CRITERIA Intro & Objective Pts Data & Hx History Definition of Diagnosis Developmental Data Physical Assessment Anatomy

& Physiology Pathophysiology Diagnostic exams Drug Studies Nsg Care Plans Discharge Planning Prognosis Bibliography Promptness TOTAL

5% 5% 5% 5% 10% 5% 10% 5% 5% 20% 5% 5% 5% 10% 100%

A Nursing Case Study

In Partial Fulfillment of the Requirements in NCM 103- RLE Oxygenation

Submitted to: Ms. Paula Gene Maniago, ST.N Mr. Nikko Jay Sulpot, ST.N Practicing Clinical Instructor And Mrs. Marilou Dela Cruz-Sawan, RN, MN Clinical Instructor Submitted by: Flauta, Reina Alyannah Jimena, Phil Anthony Lego, Roselle Carmi Loquias, Mariel Anne Mamaluba, Desiree May Saballo, Kevin Van Erick

July 12, 2010

Table of Contents

Rationale Goal and Objectives Data Base Biographical Data Clinical Data Family Health History Past Health History History of Present Illness Definition of Diagnosis Developmental Tasks Physical & Neuro Assessment Anatomy & Physiology Pathophysiology Medical Management Diagnostic Exams Management Drug Studies Nursing Care Nursing Care Plans Discharge Plan Prognosis References

1 5 7 8 9 11 11 12 18 21 24 38 45 53 55 74 86 92

Rationale
Oxygen is one of the main needs for the bodys life-supporting functions. No one can live without sufficient quantities of food, water, and oxygen. Of the three, oxygen is by far the most urgently needed. If necessary, a well-nourished person can go without food for many days or weeks, living on what are stored in the body. The need for water is more immediate but still will not become critical for several days. The supply of

oxygen in the body is limited to a few minutes. When that supply is exhausted, death is inevitable. Oxygenation is a dynamic interaction involved in the transportation of oxygen to all body parts and the removal of carbon dioxide. In this rotation we had our duty in Sta. Rosa ward at San Pedro Hospital and we conducted a study on our patients case which has UTI, CKD secondary to diabetes and hypertensive, Pleural effusion and ascites secondary to hypoalbumin secondary to CKD/liver pathology and DM type II uncontrolled. Through this, we can determine the interrelationship of kidney to other complications such as diabetes and diabetes. Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis. Recent professional guidelines classify the severity of chronic kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF). Kidney diseases rank as the number 10 killer in the Philippines causing death to about 7,000 Filipinos every year, DOH reported. The DOH stepped up the advocacy on kidney disease prevention in observance of the 25th year of Kidney month with theme "25 Taong Pangunguna sa Serbisyo para sa Kalusugan ng Bato ng Sambayanang Pilipino". The population of Filipinos aged 20 years and above in 2005 was 46,627,172. A prevalence of 2.6% means that 1,212,306 adult Filipinos have CKD. Philippines have a total of 254 dialysis centers where most of the dialysis machines are located in the

National Capital Region with 41 % while Region 6 has only 5%. Iloilo and Negros Occidental provinces have the most number of dialysis machines while the provinces of Antique and Guimaras have none. Chronic kidney disease is a worldwide public health problem. In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. There is an even higher prevalence of earlier stages of chronic kidney disease. Recent reports from the United States estimate that nearly half a million patients in the United States were treated for end-stage renal disease (ESRD) in 2004 and by 2010 this figure is expected to increase by approximately 40%. The number of people with renal replacement therapy has increased from 426,000 in 1990 to 1.5 million in 2000 and is expected to rise to 2.5 million by 2010. An Estimated 26 Million Adults in the United States have Chronic Kidney Disease (CKD). In 2006, CKD was responsible for the death of nearly 45,000 people, ranking as the ninth leading cause of death in the United States. A population survey in 1999-2000 found that 1 in 7 (13.4%) Australians adults over 25 years of age have some degree of CKD. In year 19992004 an estimated 11.5 percent of adults ages 20 or older (23 million adults) have physiological evidence of chronic kidney disease determined from data collected through the National Health and Nutrition Examination Survey. The frequency of CKD continues to increase worldwide as does the prevalence of end-stage renal disease (ESRD). Consequently, the identification and reduction of CKD has become a vital public health priority. The reported prevalence of CKD stages 1-4 in the most recent NHANES (national health and nutrition examination survey) between 1999 and 2006 was 26 million (13%) out of approximately 200 million United States residents aged 20 and older. Of these, 65.3% had CKD stage 3 or 4. The most recent report of the United States Renal Data System estimates that nearly one-half million patients in the United States were treated for ESRD in the year 2004, and by 2010 this figure is expected to increase by approximately 40%. The elderly are a growing segment of the population and at increased risk for renal disease. Additionally, males and African-Americans with

pre-existing hypertension or diabetes and CKD are also at much higher risk for ESRD. These observations have also been confirmed throughout the developed world: Europe, Asia, Australia as well as in developing regions such as China, India and Africa. Recent reports from the United States estimate that nearly half a million patients in the United States were treated for end-stage renal disease (ESRD) in 2004 and by 2010 this figure is expected to increase by approximately 40%. The economic burden for developing countries is particularly severe, partly because CKD generally occurs at a younger age. For example, in Guatemala, 40% of patients receiving RRT are under 40. In China, the economy will lose US$558 billion over the next decade due to effects on death and disability attributable to chronic cardiovascular and renal disease. More than 80% of individuals receiving renal replacement therapy (RRT) live in the developed world because in developing countries it is largely unaffordable. In countries such as India and Pakistan, less than 10% of all patients who need it receive any kind of renal replacement therapy. In many African countries there is little or no access to RRT, meaning many people simply die. Through this we have come up with ideas that this kind of disease are increasing now a days. In line with nursing implications and research, we as a student nurse should know the disease process and the possible complication that may occur if not treated; the therapies that could help lessen the disease and the medication appropriate for our client. By this we are conducting this case study so that we can upgrade our knowledge and skills on how we could render our care appropriately. It will serve as a research material in which the case is thoroughly studied. It will give the future researcher a background on the disease and a literature on this disease and basis for future studies. In Nursing Education the group will learn firsthand about the client case. The group will be the one who will learn themselves. Education and learning is not limited to the confines of a classroom but it is also achieved through effort and exposure to actual cases like in the clinical area To conclude, this case study will serve as a learning tool for nursing student and will give experiences that will broaden the groups skill in handling this condition, use of

interpersonal skills, acquire knowledge, and stimulate critical thinking.

Goal and Objective

We, the BSN 3K, Group 3 Subgroup 1, formulated the following goals that will serve as our guide towards the completion of this nursing case study. Our group aims to achieve the objectives below and come up with a well-organized and comprehensive and detailed output. General Objectives: That within 32 intermittent hours of rotation oxygenation, we, the group 3 subgroup 1 of BSN 3K would be able to do a systematic way of research about Chronic Kidney Disease with regards to our patients condition and we will be able to present this case study to our Clinical Instructor and Practicing Clinical Instructor for further discussion to be utilized by future researchers and aid in understanding the disease mentioned. Specific Objectives: At the end of our rotation at Sta. Rosa ward, the group will be able to specifically: a. Select a subject for our case study; b. establish a nurse-client relationship to the client, as well as to the family by rendering a therapeutic nurse-patient relationship;
6

c. gather adequate information to be used in the development of the study d. make a specific, measurable, attainable, realistic and time bounded objectives that will serve as a guide to have a good nursing management; e. present the clients personal data; f. illustrate the patients family tree and trace significant diseases which may be of relevance to the study;
g. trace the health history of the client and the family by collecting information

both of the past and present illnesses; h. identify the clients developmental data basing on Erik Erikson and Robert Havighursts theories; i. have a cephalocaudal assessment of the client providing relevance to changes both physically and physiologically because of the disease; j. tackle the systems involved in the development of the disease in the human anatomy and physiology; k. provide a schematic and narrative explanation of the pathophysiology in a comprehensive manner;
l.

present the predisposing factors, precipitating factors and symptomatology of the disease process and each of its rationales;

m. explain and interpret the diagnostic studies including the indication, result and their implications; n. discuss the medications given to our client which includes the classification, suggested and ordered dose, action, indication, contraindication, side effects, drug interactions and nursing responsibilities; o. formulate nursing care plans that is applicable to our patients condition; p. give health teachings to the client and to his family in relation to their needs in response to the disease process and therapy; q. evaluate the outcome of the disease and therapy whether there is good, fair or poor prognosis; and r. present and defend comprehensively our case study to the group.

Personal Data
Name: Pt. S Gender: M Age: 76 yrs old Birthday: August 27, 1933 Birthplace: Panabo City Nationality: Filipino Address: 7091 Liceralde Subdivision, Panabo City Religion: Jehovas Witnesses Education Level: High School Graduate Occupation: Farmer and Photographer No. of Dependents and Siblings: Seven siblings Marital Status: Married

Clinical Data

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

10

Family Health History (Genogram)

Apolonia Aniano

Benjamin

Raquel

Teodoro

Becaya

Susana
Rebeca Estrelieta David Jr. Levi

David Sr.

Legend:
Male Female ? Unknown Hypertension Asthma Diabetes Client Narrative: Deceased
Denis Danny Susaneth Norodine

Juceth

11

We dont have gathered data about the grandparents of our client because he cannot remember it anymore. Both parents of our client had already passed away due to old age and they had seven children named Benjamin as the eldest had experienced hypertension, Raquel as the second child experience asthma, Theodoro was the third, next to him were two siblings whom are unknown and next to them was our client David who had a diabetes and hypertension and lastly was Becaya as the youngest. Only two of them are living, David and Becaya. Our client marry Susana which they had nine offsprings. Their eldest was Rebeca, second is Estrelieta who had a hypertension, third was David Jr. who also had hypertension and diabetes, fourth was Levi, next is Denis, then Danny, then Susaneth, and then Norodine, and lastly the youngest was Juceth.

12

Past History According to our patient, in year 1996 he experienced gangrenous at the right leg which causes amputation of his right big toe. He was diagnosed to have diabetes mellitus, twenty years ago and diagnosed as hypertensive, ten years ago. Present History Eight days prior to admission, the patient had onset of body malaise and numbness of lower extremities which resulted to difficulty in walking, chills were noted and also colds and dyspnea. Consultation was done and also laboratory tests which had a result of decrease in K, which mange by giving Kalium Dumule and Insulin injection. Six days prior to admission there is a presence of symptoms of CKD which he was admitted in Panabo Polymedic Hospital. There were episodes of fever, chills, and constipation.

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Definition of Diagnosis
1. Chronic Kidney Disease (CKD) Secondary to Diabetes & Hypertensive Nephropathy

DIAGNOSIS Chronic Kidney Disease (CKD)

RATIONALE

BIBLIOGRAPHY

1. CKD is a progressive, irreversible loss of Swearingen, Pamela L., RN (2008).All-in-One Care kidney function that develops over days to Planning Resource. years. Aggressive management of Westline Industrial Drive St. Louise, hypertension and diabetes mellitus and Missouri. Mosby, Inc. avoidance of nephrotoxic agents may 2nd Ed. p.217. slow progression of CKD; however loss of glomerular filtration is irreversible and can lead to end-stage renal disease (ESDR). 2. CKD is a term that describes kidney damage or a decrease in glomerular filtration rate for 3 or more months. Untreated CKD can result in end-stage renal disease (ESRD) and necessitate renal replacement therapy. 3. Chronic renal failure represents progressive and irreversible destruction of kidney structures. It results in loss of renal cells with progressive deterioration of glomerular filtration, tubular reabsorptive capacity, and endocrine functions of the kidney.
Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). Medical- Surgical Nursing. 530 Walnut Street, Philadelphia. Wolters Kluwer Health & Lippincott Williams & Wilkins. 12th Ed. p.1313. Porth, Carol Mattson. (2005). Pathophysiology: Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. Pg. 837

http://en.wikipedia.org/wiiki/

4.

Chronic kidney disease (CKD), also Chronic_kidney_disease known as chronic renal disease, is a progressive loss of renal function over a period of months or years. Chronic kidney disease is identified by a blood test for creatinine. Higher levels of creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the kidneys to excrete waste products. DM is a group of metabolic disease Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). characterized by increased level of Medical- Surgical glucose in the blood (hyperglycemia) Nursing. 530 Walnut Street, Philadelphia. resulting from defects in insulin secretion, Wolters Kluwer health insulin action, or both. The major source
& Lippincott Williams &

Diabetes

1.

14

Wilkins. 12th Ed. p. 1196. of glucose is absorption of ingested food in the gastrointestinal tract and formation of glucose by the liver from food McCann, Judith A. Schilling, substances. RN, MSN (2005). Professional Guide to Diseases. 323 2. DM is a chronic disease of absolute or Norristown relative insulin deficiency or resistance Road, Suite 200, Ambler. characterized by disturbances in Lippincott Williams & carbohydrate, protein, and fat metabolism. Wilkins. 8th Ed. p.865. Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA & Jane Hokanson Hoaks, DNSc, RN, BC (2009). Medical- Surgical Nursing: Clinical Management for Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p.1062. Porth, Carol Mattson. (2005). Pathophysiology: Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. pg. 995

3. DM is a chronic, progressive disease characterized by the bodys inability to metabolized carbohydrates, fats, and proteins, leading to hyperglycemia (high blood glucose level).

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

adults, this means a systolic pressure that is equal to or greater than 140 mmHg & a diastolic pressure that is equal to or greater than 90 mmHg.

deWit, Susan C., MSN, RNCs (1998). Essentials of Medical- Surgial Nursing. Independence Square West Philadelphia, Pennsylvania. W.B. Saunders Company. 4th Ed. p. Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA Jane Hokanson Hoaks, DNSc, RN, BC (2009).

2. Persistent elevation of the systolic blood pressure (SBP) at a level of 140 mmHg or & higher & diastolip blood pressure (DBP) at

15

a level of 90 mmHg or above.

Medical- Surgical Nursing: Clinical Management for Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p. Tortora, Gerald J. & Bryan Derrickson (2007). Principles of Anatomy and Physiology. 111 River Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 798.

3. A persistently high blood pressure. It is known as silent killer bcause it can cause considerable damage to the blood vessels, heart, brain, and kidneys before it causes pain or other noticeable symptoms. This damages the kidney arterioles, causing them to thicken, which narrow the lumen; because the blood supply to the kidney is thereby reduced, the kidney secrete more renin, which elevates the blood pressure even more. 4.

Nephropathy 1. Diabetic Nephropathy is the result of an

alteration in glomerular function. There is thickening of the basement membranes of the glomerular capillaries, leading to the development of glomerular sclerosis. These changes in the glomeruli are accompanied by a small urinary loss of albumin.

Bullock, Barbara L., RN, MSN & Reet L. Henze, DSN, RN (2000). Pathophysiology. Philadelphia. Lippincott Williams & Wilkins. p. 703.

2.

Diabetic Nephropathy is the most Black, Joyce M., PhD, RN, CPSN, CWCN, FAPWCA common cause of stage 5 chronic kidney & disease, formerly known as end-stage Jane Hokanson Hoaks, DNSc, RN, BC (2009). renal disease. Nephropathy involves Medical- Surgical Nursing: damage to and obliteration of the Clinical Management for capillaries that supply the glomeruli of the Positive Outcomes. 3 kidney. Killiney Road # 08-01
Winsland House 1 Singapore. Elsevier. p.1103. Tortora, Gerald J. & Bryan Derrickson (2007). Principles of Anatomy and Physiology. 111 River Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 1030.

3. Any disease of the kidney. Nephrotic syndrome is a condition characterized by proteinuria (protein in urine) and hyperlipidemia (high blood levels of cholesterol, phospholipids, and triglycerides). Proteinuria is due to an increased permeability of the filtration membrane, which permits proteins, Porth, Carol Mattson. (2005). Pathophysiology: especially albumin, to escape from blood

16

into urine. 4. Diabetic nephropathies is used to describe the combination of lesions that often occur concurrently in diabetic kidney. The most kidney lesions in diabetic people are those that affect the glomeruli. It is the leading cause of end-stage renal failure (ESRD).

Concepts of Altered Health Science. Philippines. Wolters Kluwer Health & Lippincott Williams & Wilkins. 7th Ed. pg. 1010

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

DIAGNOSIS Pleural Effusion

RATIONALE 1. Pleural effusion is a collection of fluid in the pleural space, is rarely a disease process; it is usually secondary to other diseases. Normally, the pleural space must contain only a small amount of fluid which acts as a lubricant that allows the pleural surfaces to move without friction.

BIBLIOGRAPHY
Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). Medical- Surgical Nursing. 530 Walnut Street, Philadelphia. Wolters Kluwer health & Lippincott Williams & Wilkins. 12th Ed. p.574.

2. It is an abnormal collection of fluid or exudate in Porth, Carol Mattson. (2005). Pathophysiology: the pleural cavity. The fluid maybe a transudate, Concepts of Altered exudate, purulent drainage, chyle, or blood. I
Health Science. Philippines. Wolters Kluwer Health & Lippincot Williams & Wilkins. 7th Ed. pg. 690

Ascites

1. Accumulation of fluid in the peritoneal cavity that Black, Joyce M., PhD, RN, CPSN, CWCN, results from the interaction of several FAPWCA& pthophysologic changes. Portal hypertension, Jane Hokanson Hoaks, DNSc, RN, BC (2009). lowered plasma colloidal osmotic pressure, & Medical- Surgical Nursing: sodium retention all contribute to this condition.
Clinical Management for Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier.

2. Accumulation of serous fluid in the peritoneal cavity.

Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). Medical- Surgical Nursing. 530 Walnut Street, Philadelphia. Wolters Kluwer health & Lippincott Williams & Wilkins. 12th Ed. p.1196.

17

Hypoalbumin 1. Hypoalbuminemia (low blood albumin level) Tortora, Gerald J. & Bryan Derrickson (2007). emia happens once liver production of albumin fails to Principles of Anatomy and meet increased urinary losses. Physiology. 111 River
Street, Hoboken, USA. John Wiley & Sons, Inc. 11th ed. p. 1030.

Liver

1. A large, highly vascular organ located behind the Smeltzer, Suzanne C., EdD, RN, FAAN, et.al (2010). ribs in the upper right portion of the abdominal Medical- Surgical cavity. It is considered as a chemical factory that Nursing. 530 Walnut Street, Philadelphia. manufactures, stores, alters, and excretes large Wolters Kluwer health number of substances involved in metabolism. It & Lippincott Williams & receives nutrient-rich blood directly from the Wilkins. 12th Ed. p.1117. gastrointestinal tract (GI) and then either stores or transforms these nutrients into chemicals that are Microsoft Student 2008 [DVD]. Redmond, WA: Microsoft used elsewhere in the body for metabolic needs. Corporation, 2007. 2. Largest internal organ of the human body. Its essential functions include helping the body to digest fats, storing reserves of nutrients, filtering poisons and wastes from the blood, synthesizing a variety of proteins, and regulating the levels of many chemicals found in the bloodstream.
Microsoft Encarta 2008. 1993-2007 Microsoft Corporation. All rights reserved.

Pathology

1. Study of disease: the scientific study of the nature, origin, progress and cause of disease.

Microsoft Student 2008 [DVD]. Redmond, WA: Microsoft Corporation, 2007. Microsoft Encarta 2008. 1993-2007 Microsoft Corporation. All rights reserved.

3. Diabetes mellitus (DM) Type 2 Uncontrolled DIAGNOSIS DM Type 2 RATIONALE BIBLIOGRAPHY

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

2. Type 2 DM is previously called adult-onset diabetes mellitus, is a disorder involving both genetic and environmental factors. This Black, Joyce M., PhD, RN, CPSN, CWCN, type of DM has limited beta-cell response to FAPWCA

18

hyperglycemia. As the beta-cells are exposed to high levels of glucose, they become progressively less efficient.

3. Type 2 DM has 2 main problems and these are insulin resistance and impaired insulin secretion. Insulin resistance refers to decreased tissue sensitivity to insulin. Smeltzer, Suzanne C., EdD, Normally, insulin binds to special receptors RN, FAAN, et.al on cell surfaces and initiates a series of (2010). Medical- Surgical reactions involved in glucose metabolism. Nursing. 530 Walnut But, in type 2 DM, these intracellular Street, Philadelphia. reactions are diminished, making insulin less Wolters Kluwer health effective at stimulating glucose uptake by & Lippincott Williams & the tissues and at regulating glucose release Wilkins. 12th Ed. p.1199. by the liver. 4. Urinary Tract Infection DIAGNOSIS MEANING BIBLIOGRAPHY

& Jane Hokanson Hoaks, DNSc, RN, BC (2009). Medical- Surgical Nursing: Clinical Management for Positive Outcomes. 3 Killiney Road # 08-01 Winsland House 1 Singapore. Elsevier. p.1063.

Urinary Tract 1. Used to describe either an infection of a part Tortora, Gerald J. & Bryan Derrickson (2007). Infection of the urinary system of the presence of Principles of Anatomy (UTI) large numbers of microbes in urine. and Physiology. 111 River Symptoms include painful or burning Street, Hoboken, USA. urination, urgent and frequent urination, low John Wiley & Sons, Inc. back pain, and bed wetting. 11th ed. p. 1030. 2. UTIs are caused by pathogenic Smeltzer, Suzanne C., EdD, RN, FAAN, et.al microorganisms in the urinary tract. They are (2010). generally classified as infections involving Medical- Surgical the upper and lower urinary tract and further Nursing. 530 Walnut Street, Philadelphia. classified as uncomplicated or complicated, Wolters Kluwer health depending on other patient-related & Lippincott Williams & conditions. Wilkins. 12th Ed.
p.1359.

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Developmental Tasks of Later Maturity

Robert Havighursts Developmental Tasks Developmental Tasks
1. Adjusting to decreasing physical strength and health

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.

2. Adjusting to retirement and reduced income

Passed

Our patient is not receiving pension but gets his income from his farm (banana plantation) and his photo studio. He is a photographer by experience according to his grandchildren. His annual income at his photo studio is 200,000 pesos.

3. Adjusting to death Older adults may

Passed

When asked, the patient

20

of a spouse

become caregivers to their spouses. Some older adults have to adjust to the death of their spouses. After they have lived with a spouse for many decades, widowhood may force older people to adjust to loneliness, moving to a smaller place,and learning about business matters. Passed

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.

4. Establishing an The development of a explicit affiliation with large part of the one's aged group population into old age is historically recent phenomenon to modern cities. Thus, advancements understanding of the aging process may lead to identifying further developmental tasks associated with gains and purposeful lives for adults.

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.

5. Meeting social and Older people might civil obligations accumulate knowledge about life, and thus may contribute to the development of younger people and the society. 6. Establishing satisfactory physical living arrangements 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

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.

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Eric Eriksons Developmental Task

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

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Physical Assessment
Name: Mrs. J Bed: 304-6 Age: 56 Status: Married Vital Signs Axillary T= 37.3 C, PR= 77 bpm, RR= 22, CR= 79 bpm, BP= 110/70 mmHg. General survey Height= 5 ft and 3 inches, weight=46 kilos, head circumference=21cm, abdominal circumference= 28 inches. Mesomorph. No signs of distress noted upon assessment, able to smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show calmness during the examination. She has no IVF infused, and was asleep at initial assessment. Skin Skin is brown in color, rough, dry and warm. She has good skin turgor. Brownish discolorations that resemble freckles are observed on arms and face. Head Skull is round in shape, symmetrical (normocephalic). No masses noted. Facial movement is symmetrical. Hair is dry in texture; its color is black with mimimal streaks of gray. Scalp is clear from dandruff and lice. No scars and wounds noted. Eyes Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils constricted to light (2mm), round in shape, isocoric, shows uniform convergence. She is able to rotate eyes and has coordinated eye movements. Ears Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil, with no lesions noted. She has wet cerumen noted on both ears when pulled down and back for Ward: San Lorenzo Ward Sex: Female Civil

23

better visualization. She is able to hear on both ears. Her ears lobules have holes for jewelry. Nose Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration. Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses noted. Mouth Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light pink in color while hard palate is lighter in color. Gums are pinkish in color. Her first and second right molars of the lower teeth, and her first left molar of the upper teeth are missing. Her teeth are a little yellow in color with few plaques usually found on her remaining molars. Pharynx Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not inflamed. Neck Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. She is able to flex and extend neck and move it laterally (L and R). Chest and Lungs Breathing pattern is regular (eupnea). Anteroposterior diameter to transverse diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm). Vocal tactile fremitus is bilaterally equal. She refused to have her breasts examined. Heart and Central Vessels Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in apical area upon auscultation. Back and Extremities Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted. Calluses were observed at the tip of her fingers and toes. Her hands are a little rough. Muscle strength is equal on both sides of the upper and lower extremities. Spine is a little deviated to the left as seen when client was asked to bend

24

over. She is able to stand and walk on both feet independently, and her movements are well coordinated. Toes point straight ahead. And she is able to sit up straight. Abdomen Her abdomens color is same with the rest of the part of the body. Her umbilicus is coated with blackish dirt. She has globular abdomen and dullness was noted upon percussion. Neurologic Assessment Cranial Nerves: (CN1) able to identify aromas by smelling with eyes closed; (CN2) able to see objects; (CN3) pupil constricted to light sensation; (CN4&6) able to move eyeball downward and laterally; (CN5) able to blink eyes; (CN7) able to smile, raise eyebrows, puff cheeks and close eyes; (CN8) able to respond to questions being heard; (CN10) has rough and vibrating sound; (CN11) able to shrug shoulders, elevate and flex arms and legs against resistance; (CN12) able to protrude tongue and move it side to side.

25

Anatomy and Physiology

Function of the Urinary System: The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism and because of this, it is sometimes referred to as the excretory system. Although the urinary system has a major role in excretion, other organs contribute to the excretory function. The lungs in the respiratory system excrete some waste products, such as carbon dioxide and water. The skin is another excretory organ that rids the body of wastes through the sweat glands. The liver and intestines excrete bile pigments that result from the destruction of hemoglobin. The major task of excretion still belongs to the urinary system. If it fails the other organs cannot take over and compensate adequately.

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The urinary system maintains an appropriate fluid volume by regulating the amount of water that is excreted in the urine. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. Components System: The urinary system of the Urinary

consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. KIDNEYS The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly

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lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult, each kidney is approximately 3 cm thick, 6 cm wide and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney. The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule. The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole

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leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop. Parts of the Kidney: Renal Vein -This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get rid of excess amino-acids. Blood in the renal vein also has exactly the right amount of water and salts. This is because the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is excreted. Renal Artery - This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Medulla - The medulla is the inside part of the kidney. This is where the amount of salt and water in your urine is controlled. It consists of billions of loops of Henl. These work very hard pumping sodium ions. ADH makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine is produced. Cortex - The cortex is the outer part of the kidney. This is where blood is filtered. We call this process "ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak.

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Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours. Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials. Glomerulus and Bowman's Capsule - This is where ultra-filtration takes place. Blood from the renal artery is forced into the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which surrounds it. Proximal Convoluted Tubules - Proximal means "near to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's capsule. This is the place where all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If the glucose was not absorbed it would end up in your urine. This happens in people who are suffering from diabetes. Loop of Henl - This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low water concentration. If you remember the definition of osmosis, you will realize that water will pass from a region of high water concentration (the ultra-filtrate and urine) into a region of low water concentration (the medulla) through cell membranes which are semi-permeable. Distal Convoluted Tubules - Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate are re-absorbed. Collecting Duct - Collecting ducts run through the medulla and are surrounded by loops of Henl. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our kidneys make about 160 litres of urine every 24

30

hours, we only produce about litre of urine. It is called a collecting duct because it collects the liquid produced by lots of nephrons.

URETERS

Each ureter is a small tube, about 25 cm long that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface.

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The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells.

URINARY BLADDER The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue.

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There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter. URETHRA The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina. In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the

33

urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis.

LIVER

The liver is the largest internal organ in the body, and weighs about 3 pounds in an adult. The liver is located in the right upper quadrant of the abdomen, just below the diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the entire surface of the liver. The liver is divided into a large right lobe and a smaller left lobe. The falciform ligament divides the two lobes of the liver. Each lobe is further divided into lobules that are approximately 2 mm high and 1 mm in circumference.

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These hepatic lobules are the functioning units of the liver. Each of the approximately 1 million lobules consists of a hexagonal row of hepatic cells called hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a variety of metabolic functions. Between each row of hepatocytes are small cavities called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows through the sinusoids. The main functions of the sinusoids are to destroy old or defective red blood cells, to remove bacteria and foreign particles from the blood, and to detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the liver each minute, making it one of the most vascular organs in the body. Seventy-five percent of the blood flowing to the liver comes through the portal vein; the remaining 25% is oxygenated blood that is carried by the hepatic artery. Central Role of Liver in Metabolism The liver is vitally important in helping to maintain blood glucose levels within normal range. After a carbohydrate-rich meal, thousands of glucose molecules are removed from the blood and combined to form the large polysaccharide molecules called glycogen, which are then stored in the liver. This process is glycogenesis, literally, glycogen formation. Later, as body cells continue to remove glucose from the blood to meet their needs, blood glucose levels begin to drop. At this time, liver cells break down the stored glycogen, by a process called glycogenolysis, which means glycogen splitting. The liver cells then release glucose bit by bit t the blood to maintain homeostasis of blood glucose levels. If necessary, the liver can also make glucose from noncarbohydrate substances such as fats and proteins. This process is gluconeogenesis, which means formation of new sugar. Some of the fats and fatty acids picked up by the liver cells are oxidized for energy to make ATP for use by the liver cells themselves. The rest are broken down to simpler substances such as acetic acid and acetoacetic acid (two acetic acids linked together) and released into the blood, or stored as fat reserves in the liver. The liver also makes cholesterol and secretes cholesterols breakdown products in bile. All blood proteins made by the liver are built from the amino acids its cells pick up from the blood. The completed proteins are then released back into the blood to travel

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throughout the circulation. Albumin, the most abundant protein in blood, holds fluid in the bloodstream. When insufficient albumin is present in blood, fluid leaves the bloodstream and accumulates in the tissue spaces, causing edema. The liver cells also synthesize nonessential amino acids and detoxify ammonia (produced when amino acids are oxidized for energy) by converting into urea. The liver is responsible for important functions, including:

Bile production and excretion Excretion of bilirubin, cholesterol, hormones, and drugs Metabolism of fats, proteins, and carbohydrates Enzyme activation Storage of glycogen, vitamins, and minerals Synthesis of plasma proteins, such as albumin and globulin, and clotting factors Blood detoxification and purification The liver synthesizes and transports bile pigments and bile salts that are needed

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

Through the process of glycogenesis, glucose, fructose, and galactose

are converted to glycogen and stored in the liver. 36

Through the process of glycogenolysis, the liver breaks down stored

glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake.

Through the process of gluconeogenesis, the liver synthesizes glucose

from proteins or fats to maintain blood glucose levels. The liver synthesizes about 50 grams of protein each day, primarily in the form of albumin. Liver cells also chemically convert amino acids to produce ketoacids and ammonia, from which urea is formed and excreted in the urine. Digested fat is converted in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These substances are converted in the liver into glycerol and fatty acids, through a process known as ketogenesis. Prothrombin and fibrinogen, substances needed to help blood coagulate, are both produced by the liver. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. By making toxic substances more water soluble, they can be excreted from the body in the urine. The liver also has an important role in vitamin storage. High concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's vitamin A stores are concentrated in the liver. The liver also contains small amounts of Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.

PANCREAS The hormones administered by the pancreas are responsible for controlling and manipulating blood glucose levels. The pancreas houses islets responsible for production and secretion of the hormones, glucagon and insulin. Because of this, the pancreas falls under both the endocrine glandular system as well as the exocrine glandular system. The islets which produce these hormones are semi scattered throughout the pancreas and are known as the islets of Langerhans. These particular endocrine functioning structures are typically able to be located in the body and along the tail of the pancreas. Alpha cells and Beta cells are the cells that are known to secrete 37

the hormones within the islets. Glucagon is administered from the Alpha cells and insulin comes from the Beta cells. Gulcagon has an affect on insulin by providing the appropriate stimulus for the liver to convert glycogen into glucose. The Alpha cells are able to respond appropriately to the feedback provided and thus are able to self monitor. High blood sugar, which is also known as hypoglycemia, can be the result of continuous output of glucagon. Insulins function on the human physiology is opposite of its counterpart, glucagon. Insulin is designed to lower the blood sugar in the body. Insulin is the initiating factor that allows blood glucose to the necessary movement through the cell membranes. Muscular cells and adipose cells rely on this movement of glucose for their ability to function. The glucose level within the cell drops as the glucose moves throughout the cell membrane. Insulin is also an initiating factor in the conversion of glucose to glycogen by the cells of the muscles and liver. This action actually assists amino acids into the cells and provides the foundation for the creation of fats and proteins. When Beta cells are incapable of producing the appropriate amount of insulin, diseases such as diabetes occur.

The pancreas is rather soft, created from lobes, Measures about 6 inches long and 1 inch thick, and performs the functions of a mixed gland. Serving both endocrine functions and exocrine functions, the pancreas is serving dual systems. The islets of Langerhans, or pancreatic islets, are the cell clusters responsible for the pancreas endocrine functions. Insulin and glucagon are required hormones of the bloodstream to maintain optimal homeostasis. Performing the exocrine functions requires the proper ability to secrete pancreatic juices which aid in digestion. The pancreatic juice is created within the pancreas and immediately released into the pancreatic duct which empties into the duodenum. The pancreas is positioned snugly up against the greater curvature of the stomach, which runs along the posterior wall of the abdominal cavity. It head is located close to the duodenum, which is expanded over the central body. The tail tapers off near the location of the spleen.

The exocrine secretion units are tucked inside the pancreatic lobules. These

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secretion units are technically referred to as the pancreatic acini. The endocrine secretion units are found right next to the exocrine secretion units, these are referred to as pancreatic islet cells however. The pancreatic juice is secreted from the acini, and each individual acinus has only one mere layer of epithelial acinar cells which encompass a lumen.

Branches from the celiac plexus are responsible for the innervation of the pancreas. The innervation of the pancreas is segregated by function; the glandular functional innervation portion receives is held the for parasympathetic the blood innervation vessels of while the sympathetic pancreas.

The splenic artery branches off into the pancreatic branch in order to deliver the appropriate blood supply. The splenic artery is a branch from the celiac artery. The pancreatoduodenal artery is a branch derived from the superior mesenteric artery, which also serves the pancreas; blood flow demands. Venous return is naturally through the splenic and superior mesenteric veins. These veins drain into the hepatic portal vein.

Pathophysiology Diabetes Mellitus

a. Etiology: Predisposing Factors Factors Genetic

Presence (+)

Mechanism/Justification Initial decrease in beta cell mass related to genetic factors responsible for beta cell differentiation or presence of diabetogenic gene. Pancreas, similar to several

39

Age >40

(+)

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

Precipitating Factors Factors Over weight/Obesity

Presence

BMI 21.0 (Normal) (-)

Environment stage)

(intrapartal

(-)

Virus Infection Presence of Toxin

(-) (-)

Decrease potassium level

serum (-)

b. Symptomatology Symptoms Polyuria urination) Presence (excessive (+) Mechanism/Justification Glucose exceeds the amount that can be reabsorbed by renal tubules this results glycosuria. Excess glucose in the blood pulls water out of the cell causing intracellular dehydration, including those in thirst center. Results from depleation of cellular reserves of carbohydrates, fats and proteins. Lens and retina are exposed

Polydipsia thirst)

(excessive

(+)

Polyphagia hunger) Blurred Vision

(excessive

(+) (+)

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Predisposing Factors Paresthesias Genetics Age >40 Pruritus, vaginitis, chronic

Weakness and fatigue

(+) (+) (-) (-)

skin infections Weight Precipitatingloss Environment(intrapartal) Toxin/Virus Obesity Decrease Serum Potasium

Increased Osmolarity Often Asymptomatic due to Glucose

to hyperosmolar fluids Lowered plasma volume Temporary dysfunction of peripheral sensory nerves Hypergycemia and glycosuria favors growth of yeast Decrease insulinorganisms. Initial loss due to depleation production/sensitivity of water, glycogen, and triglyceride store; chronic loss secondary to decrease muscle mass as amino acid are diverted to form glucose and ketone bodies. Elevated Serum The Glucose body is able to adopt ta a slow rise of blood glucose level to a greater extent than it can to a rapid rise.

Polydipsia

Polyuria

Polyphagia

Chronic elevation of Serum Glucose

Weight loss

Diabetic neuropathy

Small vessel disease

Diabetic retinopathy

Accelerated atherosclerosis Hypertension

Impaired immune function

Symmetrical loss of sensation

Diabetic nephropathy Numbness and paresthesia

Coronary artery disease

Infection

c. Schematic Tracing Wasting of End-stage intrinsic muscles renal failure

Autonomic neuropathy

Loss of vision

Increase LDL levels

Delayed wound healing

Impotence Diabetic foot ulceration

Dry, cracked skin

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Charcot changes in joints Gastroparesis Neurogenic bladder

d. Narrative Type two Diabetes Mellitus is a heterogeneous condition that describes the presence of excess serum glucose level in association with relative insulin deficiency. Type 2 Diabetes is associated with high, normal, low insulin levels. However there is a presence of insulin resistance thus the insulin cannot function effectively and hyperglycemia will occur. Most people with this type of diabetes are older and obese, but type 2 Diabetes is becoming a more common occurrence in obese adolescent. The metabolic abnormalities that contribute in hyperglycemia in people with type 2 diabetes are 42

impaired beta cell function and insulin production, peripheral insulin resistance, and increase hepatic glucose production. Insulin is a anabolic hormone. Without insulin three major metabolic problem occur: decrease glucose uptake and utilization, increase fat and lipid mobilization and increased protein and amino acid utilization. Beta cells chronically exposed to high blood levels of glucose become progressively less efficient when responding to further glucose elevation. Insulin resistance initially produces an increase beta cell secretion of insulin as body attempt to maintain normoglycemic state. In time, however the insulin response declines because of increasing beta cell dysfunction. This results to postprandial hyperglycemia. Eventually fasting blood glucose level also rise until frank type 2 Diabetes occurs. Cells that require insulin as carrier of glucose can take only 25% of glucose they require for fuel, but nerve tissues, erythrocytes, and cells of intestine, liver, kidney tubules do not require insulin for glucose transport. However, adipose tissue, along with skeletal and cardiac muscle requires insulin for glucose transport. During severe stress such as hospitalization, the body of a type 2 diabetes patient will turn fat reserves into glucose for energy production when glucose is not available. Fat and lipid metabolism cause breakdown products called ketones to form. Ketones accumulate in the blood and excreted through kidneys and lungs. Ketones interfere with the bodys acid base balance by producing Hydrogen ions. The pH can decrease, and metabolic acidosis can result. In addition when ketone is excreted in urine, sodium is also eliminated, causing sodium depletion and further acidosis. The excretion of ketone also increases osmotic pressure, leading to increase fluid loss. In this type of Diabetes Mellitus the onset of clinical manifestation may develop gradually that clients may notice a few or no clinical manifestations for a number of year. Some of the manifestations are frequency in urination, increase thirst or fluid intake, and as the disease progresses, weight loss despite hunger and increased food intake. Clients with diabetes mellitus are living longer, with an increased risk for development of chronic complications. Chronic complication are the major cause of morbidity and mortality in client with diabetes mellitus. Diabetes mellitus-related complications are classified into two types: macrovascular, including coronary artery diseases, cerebrovascular disease, hypertension, peripheral vascular disease and infection; and microvascular, including retinopathy, nephropathy, and neuropathy.

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The very-low density lipoprotein and low density lipoprotein level are increased and high density lipoproteins are decreased, and the most characteristic of lipid abnormality in diabetes mellitus is an increase triglyceride level. Therefore the influence of diabetes in these disease are not additive, it is multiplicative. Macrovascular disease tends to occur year before the onset of clinical diabetes mellitus. Clients with DM are two to four times more likely to have coronary artery disease than those who do not have DM. In many clients with DM, often presents atypical or silent CAD, that often presents as indgestion, or unexplained heart failure, dyspnea or excretions, or epigastric pain. CAD is common in clients younger than 40 years old, of diabetes mellitus is of long duration. DM patients with history of myocardial infarction have higher chance of having second infarct than the patient who does not have DM. The incidence of cerebrovascular disease is two to three times greater in diabetic client, and is more severe. Atherothromboembolic infarction manifested by transient ischemic attracts and cerebrovascular accidents are the most commont incidence of CVD that are the complication of DM. Hypertension has increased of 40% occurrence in diabetic population. Hypertension is a major risk factor for stroke and nephropathy. Diabetis mellitus augments the process of atherosclerosclerosis by variety of mechanism thus causing peripheral vascular disease. Hyperglycemia and insulin resistance contribute to endothelial dysfunction by decreasing available nitric oxide bioavailability and altering the function of various cell mediators. Clients with diabetes are susceptible to different type of infection. Three factors may contribute to the development of infection are impaired polymorphonuclear-leukocyte function, diabetic nephropathies and vascular insufficiencies. Damaged area heals slowly because the damaged vascular system cannot carry sufficient amount of oxygen, white blood cells, nutrients and antibodies to the injured site. Infection increases the need for insulin and enhances the possibility of ketoacidosis. Urinary tract infection is the most common infection especially in women. Factors that impairs the polymorphonuclear-leukocyte is the presence of glycosuria and the development of neurogenic bladder, which results in incomplete emptying and or urinary stasis. About 80% of clients with DM have some form of retinopathy, the exact cause of retinopathy is not understood but it is probably a multifactorial and associated with protein glycosylation, ischemia, and hemodynamics mechanism that increases the permeability and decreases the elasticity of capillaries.

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About 20% of diagnosed DM type 2 patients have nephropathy 5 to 10 years after diagnosis. A consequence of microangiopathy, nephropathy involves damage to and eventual obliteration of the capillaries that supply the glomeruli of the kidney. This damage leads to complex pathologic changes and manifestations such as intercapillary glomerolonecrosis, nephrosis, gross albuminuria and hypertension. Unsuccessful treatment of nephropathy will lead to stage 5 chronic kidney disease. Like retinopathy, diabetic nephropathy is irreversible. Neuropathy, the most common chronic complication of diabetes mellitus. Nearly 60% of diabetic patients experience it. Because nerve fibers do not have their own blood supply, they depend on diffusion of nutriens, and oxygen across membrane. When axon and dendrites do not receive nourishment their transmission of impulses becomes slow. Both temporary and permanent neurologic problem may develop. The neuropathy might be mild that causing minor inconveniences or severe that quality of life is affected. Clients might present mononeuropathy or polyneuropathy and may have motor or sensory impairment, depending on which nerve that are involved. Mononeuropathy usually involves single or group nerves. It produces sharp, stabbing pain and is usually caused by an infarction of blood supply. Polyneuropathy also known as diffuse neuropathy, which involves both sensory and autonomic nerves. Sensory neuropathy is most common type. It is commonly assed as bilateral, symmetrical and is affecting the lower extremity. Client may describe tingling, numbness, burning, and mild to severe sensory loss, a major factor in injuries to the legs. Autonomic neuropathy affects the nerves that regulate vital functions, including the heart muscle and smooth muscles. Autonomic neuropathy involves damage to the nerves that run through a part of the peripheral nervous system. The peripheral nervous system includes the nerves used for communication to and from the brain and spinal cord (central nervous system) and all other parts of the body, including the internal organs, muscles, skin, and blood vessels. Damage to the autonomic nerves affects the function of areas connected to the problem nerve. Some of the autonomic neuropathy are: autonomic neuropathy of the pupil which interferes with pupils ability to adapt to dark because pupils dilation is inadequate; autonomic neuropathy of the cardiovascular system is evidence by abnormal response to exercise, fixed heart maybe noted; autonomic neuropathy of gastrointestinal, client may have dysphagia, abdominal pain, nausea, vomiting, diarrhea malabsorption, post prandial hypoglycemia, constipation, or fecal incontinence and gastroparesis. Bladder hypotonisity of neurogenic bladder is

45

common manifestation of autonomic neuropathy of genitourinary organs. In male client it can contribute to erectile dysfunction and retrograde ejaculation. Women may experience painful coitus. All of these complication can be prevented by good control of blood sugar level, exercise and diet modification.

Medical Management
Legend: Red HIGH Green - LOW

1.1 ACTUAL
Date
06/26/10

Test
Chest X-

Definition and Normal Range

The chest x-ray is the most

Result
-The lungs show no

Interpretation and Significance

Left Pleural Effusion

46

Ray

commonly performed diagnostic x-ray examination. A chest x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with xrays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

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

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

06/26/10

Complete Blood Count

The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular (formed elements) of blood.

Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

121 3.88 31.1 95.0 12.1 0.70 0.17 0.08 0.05 0.00 0.37 278

Normal Values:
Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit 140-180 4.5-5.0 27-33 80-96 32-36 5-10 0.55-0.65 0.25-0.40 0.02-0.06 0.01-0.05 0.000-0..005 0.40-0.48

Decreased hemoglobin and erythrocyte -indicates anemia. If RBC is decreased, the hemoglobin decreases also. This means that exchange of gases between the alveoli, and the capillary beds are affected, and there will be less oxygenated blood circulating the body, and hypoxia results. This is caused by impaired production of erythropoietin by the kidney. Eythropoietin stimulates the bone marrow to produce blood products especially RBC. Increased Leukocytes -Increase in number indicates infection or

47

Platelelt

150-300

damage caused by bacteria, viruses, etc. The patient is diagnosed to have UTI, specifically cystitis. Increased Neutrophils -Also indicates infection. Neutrophils are avid phagocytes at sites of acute infection. Decreased Lymphocytes -Patient is prone to immunosupression since his lymphocytes are small in number. Lymphocytes play an important role in immune response (B and T lymphocytes). Increased Monocytes -Indicates chronic infection. Monocytes are active phagocytes that become macrophages in the tissues. They are called the long-term clean-up team. Decreased Hematocrit -Hemodilution or there is decreased concentration of RBC in the blood. Plasma volume is increased because of fluid shifting. For 06/28/10: Same results +

06/28/10
Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet 107 3.46 31.0 94.7 32.8 15.5 0.70 0.16 0.08 0.05 0.01 0.37 322

High Platelet -Risk for coagulation/clotting, and may lead to arteriosclerosis due to thrombus formation.

07/02/10

For 07/02/10: Same results with the first two tests except:

48

Hemoglobin Erythrocyte MCH MCV MCHC Leukocytes Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hematocrit Platelet

94 3.10 30.4 91.8 33.1 12.6 0.78 0.13 0.05 0.04 0.00 0.28 466

-Number of monocytes normalized.

06/26/10

Urine Culture and Sensitivity

A urine specimen is collected tested for growth of microorganisms. Antibiotics are also tested if the discovered microbe is sensitive to the drug. Tests that measure the concentration of electrolytes are needed for both the diagnosis and management of renal, endocrine, acid-base, water balance, and many other conditions. Their importance lies in part with the serious consequences that follow from the relatively small changes that diseases or abnormal conditions may cause. Normal:
Creatinine Albumin Sodium Potassium Calcium Magnesium Alanine Aminotransfe rase 53-115 34-50 136-145 3.5-5.1 2.12-2.52 0.79-0.99 30-65

Multiple Growth of Microorganisms

-Result proves infection of the urinary tract (cystitis).

06/26/10

Serum Electrolytes

Creatinine Albumin Sodium Potassium Calcium Magnesium Alanine Aminotransfe rase

272.8 17 126 4.7 1.81 0.87 37

07/01/10

Creatinine Albumin Sodium Potassium Calcium Creatinine Sodium Potassium

359.6 25 131 4.0 2.06 389.0 131 4.2

07/02/10

-Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. Creatinine reflects glomeruli filtration rate. Some signs and symptoms of kidney dysfunction include: Fatigue, lack of concentration, poor appetite, or trouble sleeping Swelling or puffiness, particularly around the eyes or in the face, wrists, abdomen, thighs or ankles Urine that is foamy, bloody, or coffee-colored A decrease in the amount of urine Problems urinating, such as a burning feeling or abnormal discharge during urination, or a change in the frequency of urination, especially at night Mid-back pain (flank), below the ribs, near where the kidneys are located High blood pressure -Low sodium affects the

49

neuromuscular function and water-electrolyte balance in the body. - On the cellular level,

calcium is used to regulate the permeability and electrical properties of biological membranes (such as cell walls), which in turn control muscle and nerve functions, glandular secretions, and blood vessel dilation and contraction. Ca deficiency can make the muscles or tissues spastic, therefore contractility is impaired. -Renal kidney dysfunction can cause hypoalbuminemia, since more albumin is excreted in the urine. Ascites, muscle weakness, and fatigue can be brought about by low albumin in the blood. 06/27/10 Urinalysis Tests for specific gravity (urine concentration or the amount of solutes present in the urine), and presence of abnormal constituents such as pus cells, glucose, protein, and RBC. Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine. Normal:
Color Appearance Reaction Specific gravity Chemical Characterist ics Pus Cells RBC Straw, amber Transparen t 4.5 - 8 1.0101.025 Alb- absent Sugarabsent 1-5 hpf none

Color Appearance Reaction Specific gravity Chemical Characteristics Pus Cells RBC

Yellow Cloudy 6.0 1.00 Alb- trace Sugar-+++ 20-30 1-2

-Urine is not concentrated since color is not dark. Cloudy urine indicates presence of WBC, bacteria, pus, contaminants, or prostatic fluid. Glycosuria indicates high blood glucose levels and maybe indicative of uncontrolled DM. Hematuria can be caused by irritation or injury to endothelial wall of the ureters Proteinuria indicates kidney damage. There is an increased pus cells which means infection is present.

50

06/26/10

ABG Test

The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Normal Values:
pH PCO2 PO2 HCO3 TCO2 BE O2 Sat 7.35-7.45 35-45 80-100 22-26 25-30 +/-1 95-100%

pH PCO2 PO2 HCO3 TCO2 BE O2 Sat

7.37 67 acidosis 83 15 acidosis 16 -8.3 96%

-A high PaCO2 (respiratory acidosis) indicates underventilation. Carbon dioxide is produced constantly as the body burns energy, and this CO2 will accumulate rapidly if the lungs do not adequately dispel it through alveolar ventilatio n. Alveolar hypoventilation thus leads to an increased PaCO2 (called hypercapnia). The increase in PaCO2in turn decreases the HCO3/PaCO2 ratio and decreases pH. -A low HCO2 indicates metabolic acidosis which is a condition that occurs when the body produces too much acid or when the kidneys are not removing enough acid from the body. Fully Compensated Metabolic Acidosis

06/27/10

pH PCO2 PO2 HCO3 TCO2 BE O2 Sat

7.385 27.9 alkalosis 79.8 16.3 acidosis 17.2 -6.8 95.6% 4.0 3.0 1.35 0.40 6.7 0.31

06/28/10

Lipoprotein Profile with Glucose and Uric Acid

The lipid profile is a group of tests that are often ordered together to determine risk of coronary heart disease. They are tests that have been shown to be good indicators of whether someone is likely to have a heart attack or stroke caused by blockage of blood vessels or hardening of the arteries (atherosclerois). Normal Values:
Cholesterol LDL 0.0-5.2 0.0-3.4

Cholesterol LDL TGL HDL Glucose Uric Acid

-There is very little high density lipoprotein or good cholesterol which implies that there is lesser chance for the remaining HDL to remove more cholesterol from atheromas within the arteris and transport it back to the liver for excretion or re-utilization.

51

TGL HDL Glucose Uric Acid

0.00-1.70 0.90-1.55 3.9-6.1 0.16-0.43

06/28/10

Ferritin Test

The ferritin test is ordered to assess a person's iron stores in the body. The test is sometimes ordered along with an iron test and a TIBC to detect the presence and evaluate the severity of an iron deficiency or overload. Ferritin is a protein that releases iron in a controlled fashion. Normal Values: Men: 68-236 ng/mL Women: 9.3-58 ng/mL

Ferritin = 1021.71 ng/mL

If there is damage in the liver (where ferritin is stored), ferritin levels can become elevated because livers function is affected. Also, low iron or hemoglobin coupled with increase ferritin production is a sign of a chronic illness.

06/28/10

KUB/Prosta te USD

It is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images. Normal Size in cm:
Left Kidney Right Kidney 10.8 +Length 9.7 +0.8 0.7 4.2 + Width 4.3 +-0.5 0.5 4.8 +Thick 3.9 +0.5 0.5 1.5 C. Thick 1.5

Left Kidney Right Kidney 11.3 Length 11.1 4.0 Width 4.7 4.6 Thick 4.9 1.8 C. Thick 1.6

-No significant disparity in size, shape and location of the kidneys and both show intact central echocomplexes of both renal corticomedullary differentiation. -There is an increase in the echogenecity of both renal cortices relative to the liver and spleen. -No focal lesions. -Ureters are not dilated. -Urinary bladder distends adequately. -Has smooth thickened walls with trabeculations. -Prostate gland measures: 40mm x 47 mm x 26 mm, 26 grams. -Pre void urine volume is about 437 cc. -Post void scan shows 76% (333 cc) residual urine. Impression: -Diffuse Bilateral Renal Parenchymal Disease -Cystitis -Grade 1 Prostatic Enlargement -Ultrasonographically normal ureters -Significant urinary bladder retention

52

07/2/10

Arterial Duplex Scan

Arterial duplex scan is a painless exam that uses high-frequency sound waves (ultrasound) to capture internal images of the major arteries in the arms, legs and neck.

-Intimal irregularities with occasional type III and V plaques in the bilateral popliteal arteries with normal triphasic waveform pattern with full color except the bilateral posterior tibialis arteries and bilateral dorsalis pedis arteries with monophasic waveform patterns. -No focal increase in flow velocities noted.

Peripheral Arterial Disease >50% stenosis bilateral posterior tibilais arteries & bilateral dorsalis pedis arteries. Peripheral arterial disease <50% stenosis bilateral common femoral arteries, bilateral superficial femoral arteries, bilateral popliteal arteries. Incomprehensive arteries bilaterally

07/02/10

Creatinine Clearance Test

07/04/10

A creatinine clearance test measures how well creatinine is removed from your blood by your kidneys. A creatinine clearance test gives better information than a blood creatinine test on how well your kidneys are working. A creatinine clearance test is done on both a blood sample and on a sample of urine collected over 24 hours (24-hour urine sample). Normal Values: 24 hr urine: 0.6-1.6 q/24 h Blood: 0.8-1.4 mg/dL

Crea: 1.53 q/24 hr

Creatinine in the 24 hr urine sample falls between the normal range. Due to impaired kidney function, creatinine in the blood elevates.

Crea: 14.1 mg/dL

1.2 POSSIBLE
Result (Normal Values)
Male: mg/dL 2.1-8.5

Test
Uric Acid Test

Rationale
The patient has been complaining of pain in the pelvic area. Since he has CKD, his kidneys might have broken down purine (protein) rather very fast causing accumulation to the

Interpretation and Significance

High uric acid level indicates impaired GFR and destruction of RBC to purine.

Nursing Responsibilities
Evaluate or continuously monitor degree of joint inflammation or pain. Level of activity or exercise depends on progression and resolution of inflammatory process.

Female: 2.0-7.0 mg/dL

53

joints. It has to be checked to know if the patient is suffering from gout,

Some patients with high levels of uric acid have a disease called gout, which is an inherited disorder that affects purine breakdown. Patients with gout suffer from joint pain, most often in their toes but in other joints as well.

Maintain bed rest or chair rest when indicated. Schedule activities providing frequent rest periods and uninterrupted night time sleep. Systemic rest during acute attacks and important throughout all phases of disease to reduce fatigue and improve strength. Encourage adequate fluid intake. To assist with excretion of uric acid and decrease likelihood of stone formation. Assist with active or passive range of motion. Maintains or improves joint function, muscle strength, and general stamina. Encourage patient to maintain upright and erect posture when sitting, standing, or walking. Maximizes joint function, maintains mobility. Encourage the patient to avoid alcohol. Alcohol precipitates acute attacks. Review foods that are rich in purines like sardines, anchovies, shell fish and organ meats. These foods are rich in purine. Uric acid is by product of purine metabolism in the liver. Provide safety needs. Prevents injuries and falls. Administer antiinflammatory drugs and also colchicines as prescribed. These medications relieve pain and

54

swelling during acute attacks.

Management Therapuetics
Date
06/27/10

Order
Venoclysis of PNSS1L to run at KVO rate.

Rationale
NSS is a solution of common salt in distilled water, of strength of 0.9%. It is called normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. It is an isotonic solution. It is less irritating for the body cells. It is used to patients with salt and water deprivation. KVO rate is ordered for prophylactic access. This measures how much fluids are taken and how much has been excreted. This also indicates any problem in the kidneys. Vital signs are done every 4 hours to monitor the clients well being such as temperature which is indicative of hyperthermia. Diet for diabetic patients must be accurately weighed or gauged. Too many carbohydrates mean too much glucose; too much protein and fats may overwork the liver and kidneys. To minimize formation of crystals in the urine. These laboratory tests measures the body chemistry such lipoproteins, blood products, nitrogenous wastes, and presence of infection in the urinary system. To determine adequate blood flow in the extremities and to rule out any obstruction. To monitor any weight gain due to edema or increased extra-cellular fluid.

06/27/10

I & O q shift and VS q 4

O6/27/10

Calibrated diabetic diet

06/27/10 06/27/10

Increase oral fluid intake Lipid profile, CBC, serum uric acid, KOH and urine culture

06/27/10

Doppler scan the left extremity

06/27/10

Weighing once a day

55

06/27/10

Nebulization q 6 with Berodual

Berodual is a bronchodilating and anticholinergic agent which gives of parasympatholytic effects. It relieves bronchospasms. To monitor any fluctuations in the blood glucose levels and evaluate effectiveness of insulin taking. To combat dehydration. Promotes thoracic facilities breathing. expansion and

06/27/10

Hgt q 6

06/28/10 06/30/10 06/30/10 07/04/10 07/05/10 07/07/10

IVF rate to 60 cc/hr Moderate high back rest Abdominal girth measurement Physical therapy session 3x Insertion of foley catheter Removal of foley catheter

Measures extent of ascites Promotes well being of an elderly client; facilitates fast recovery To relieve urinary retention For discharge

Drug Study
Domperidone Motilium (1 tab, 100 mg) Classification: Anti-emetic and anti-vertigo Desired Dosage and Directions for use: Acute conditions (mainly nausea, vomiting, hiccup) Adults: Two tablets (20 mg) 3 to 4 times per day, 15 to 30 minutes before meals and, if necessary, before retiring.

56

Chronic conditions (mainly dyspepsia) Adults: One tablet (10 mg) taken 3 times per day, 15 to 30 minutes before meals and, if necessary, before retiring. The dosage may be doubled. Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopamine-receptors in the chemo-emetic trigger zone produces an anti-emetic effect. Interactions: Concomitant administration of anti-cholinergic drugs may inhibit the antidyspeptic effects of MOTILIUM. Anti-muscarinic agents and opioid analgesics may antagonize the effect of MOTILIUM MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and vomiting) of dopaminergic agonists. Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of concomitant orally administered medicines, particularly those with sustained release or enteric coated formulations. As MOTILIUM interferes with serum prolactin levels, it may interfere with other hypoprolactinaemic agents and with some diagnostic tests. Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be taken after meals and not before meals, i.e. they should not be taken simultaneously with MOTILIUM. Reduced bicarbonate Side Effects: Allergic reactions, such as rash or urticaria, have been reported. Abdominal cramps have been reported. Dystonic reactions (extrapyramidal phenomena) may occur. Reversible raised serum prolactin levels have been observed which may lead to galactorrhoea and gynaecomastia. Hypertensive crises in patients with phaeochromocytoma may occur with administration of domperidone. gastric acidity impairs the absorption of domperidone. Oral bioavailability is decreased by prior administration of cimetidine or sodium

57

Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the possible occurrence of neurological side-effects cannot be totally excluded

Nursing Responsibilities: 1. Assess for extra-pyramidal effects such as jerking and tongue protrusion. 2. Check for hypotension. Imdur Durule (60 mg tab OD @ HS) Classification: Anti-anginal Desired Dosage: 60 mg once daily in the morning, may be increased to 120 mg daily in the morning. If headache occurs, the dose may initially be reduced to 30 mg daily for the 1st 2-4 days. Mode of Action: The principal pharmacological action of isosorbide-5-mononitrate, an active metabolite of isosorbide dinitrate, is relaxation of the vascular smooth muscle, producing vasodilatation of both arteries and veins, with the latter effect predominating. The effect of the treatment is dependent of the dose. Low plasma concentrations lead to venous dilatation, resulting in peripheral pooling of blood, decreased venous return and reduction in left ventricular end-diastolic pressure (preload). High plasma concentrations also dilate the arteries reducing systemic vascular resistance and arterial pressure leading to a reduction in cardiac afterload. Isosorbide-5-mononitrate may also have a direct dilating effect on the coronary arteries. By reducing the end-diastolic pressure and volume, the preparation lowers the intramural pressure, thereby leading to an improvement in the sub-endocardial blood flow. The net effect when administering isosorbide-5-mononitrate is therefore a reduced workload of the heart and an improved oxygen supply/demand balance in the myocardium. Interactions: Concomitant administration of Imdur and phosphodiesterase type 5 inhibitors can potentiate the vasodilatory effect of Imdur with the potential results of serious side effects as syncope or myocardial infarction. Side Effects:

58

Most of the adverse reactions are pharmacodynamically mediated and dose dependent. Headache may occur when treatment is initiated, but usually disappears during continued treatment.

Hypotension with symptoms eg, dizziness and nausea with syncope in isolated cases, has occasionally been reported. These symptoms generally disappear during continued treatment.

Cardiovascular System: Common: Hypotension, tachycardia Central Nervous System: Common: Headache, dizziness. Rare: Fainting. Gastrointestinal: Common: Nausea. Uncommon: Vomiting, diarrhea. Musculoskeletal: Very Rare: Myalgia. Skin: Rare: Rash, pruritus.

Nursing Responsibilities: 1. Check for hypotension. 2. Put patient on bed rest because of fainting. Provide supervision when ambulating. 3. Perform nonpharmacologic measures for nausea and vomiting such as letting client to drink weak tea, Gatorade, carbonated beverages, pedialyte and eat gelatin, crackers and dry toast. Calcium Carbonate (1 tab tid) Classification: Electrolyte replacement or supplements. Antacid Desired Dosage: 500 mg (200 mg Ca), 600 mg (240 mg Ca), 650 mg (260 mg Ca), 667 mg (266.8 mg Ca), 1 g (400 mg Ca), 1.25 mg (500 mg Ca), 1.5 mg (600 mg Ca) Mode of Action: Essential for nervous, muscular, and skeletal systems. Maintain cell membrane and capillary permeability. Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal and smooth muscles. It is essential for bone formation and blood coagulation. It is also used a replacement of calcium in deficiency states. It controls of hyperphosphatemia in end-stage renal disease without promoting aluminum absorption.

59

Interactions: Hypercalcemia increases the risk of digoxin toxicity. Chronic use with antacids in renal insufficiency may lead to milk-alkali syndrome. Ingestion by mouth may decrease the absorption of orally administered tetracyclines, fluoroquinolones, phenytoin, and iron salts. Excessive amounts may decrease the effects of calcium channel blockers, atenolol. Concurrent use with diuretics may result in hypercalcemia. Side Effects: CNS: syncope, tingling CV: cardiac arrest, arrythmias, bradycardia GI: constipation, nausea, vomting GU: calculi, hypercalciuruia Local: phlebitis (IV only)

Nursing Responsibilities: 1. Monitor VS especially BP and PR. 2. Obtain ECG result. 3. Asses for heartburn, indigestion, abdominal pain. 4. Monitor serum calcium before treatment. 5. Assess for nausea and vomiting, anorexia, thirst, severe constipation.

Metoprolol Beloc, Betaloc Durules, Lopresor, Metoprol (100 mg 1 tab q 12 hrs) Classification: Anti-anginal and Anti-hypertensive: Beta-blockers Desired Dosage: (PO) 25-100 mg/day as a single dose initially divided or 2 divided doses; maybe increased q 7 days as needed up to 450 mg/day. Mode of Action: Blocks stimulation of beta1 (myocardial)-adrenergic receptors. It does not usually affect beta2 (pulmonary, vascular, uterine)-adrenergic receptor sites. It also decreases blood pressure and heart rate. It decreases frequency of attacks of angina

60

pectoris, and decreases rate of cardiovascular mortality and hospitalization in patients with heart failure. Interaction:

Additive effect with catecholamine-depleting drugs e.g. reserpine and MAOIs. May antagonise 1-adrenergic stimulating effects of sympathomimetics. Additive negative effects on SA or AV nodal conduction with cardiac glycosides, nondihydropyridine calcium-channel blockers.

Increased oral bioavailability with aluminium/magnesium-containing antacids. Paradoxical response to epinephrine with may occur. Increased plasma inhibitors

concentrations

CYP2D6

(e.g. bupropion, cimetidine,diphenhydramine, fluoxetine, hydroxycholoquine, paroxetine, propafenone, quinidine,ritonavir, terbinafine, thioridazine). Increased risk of hypotension and heart failure with myocardial depressant general anaesthetics (e.g. diethyl ether). Risk of pulmonary hypertension with vasodilators e.g. hydralazine in uraemic patients.

Reduced plasma levels with rifampicin. May increase negative inotropic and negative dromotropic effect of antiarrhythmic drugs e.g. quinidine and amiodarone. Propafenone may increase serum levels of metoprolol. Concurrent use with indomethacin may reduce the antihypertensive efficacy of blocker. May reduce clearance of lidocaine. May increase effects of hypoglycemics. Efficacy may be reduced by isoprenaline. Concurrent use with digoxin may lead to additive bradycardia.

Nursing Responsibilities: 1. Monitor blood pressure, and pulse frequently.

61

2. Monitor intake and output ratios and daily weight. 3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight gain, peripheral edema, jugular venous distention) 4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold medication and notify health care professional. 5. Administer metoprolol with meals or directly after eating. 6. Caution patient minimize activities that require alertness because metoprolol can cause dizziness. 7. Caution patient that this medication can increase sensitivity to cold. 8. Instruct to avoid caffeinated drinks like teas and colas. 9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue occurs. 10. Reinforce the need to continue additional therapies for hypertension such as sodium restriction, stress reduction, regular exercise) 11. Emphasize compliance to the medication.

Prednisone Sterapred (5000 u 2x/week SC) Classification: asthmatics Desired Dosage: (PO) 5-60 mg/day as single dose or in divided doses. Mode of Action: It suppresses inflammation and the normal immune response. Prednisone is biologically inert and converted to the predominantly prednisolone in the Systemic corticosteroids, anti-

62

liver. It decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and vol of the lymphatic system; suppresses adrenal function at high doses. Interaction: Increase risk of hypokalemia with thiazide and loop diuretics, or amphotericin B. May increase requirement for insulin or oral hypoglycemic agents. Pheytoin, Phenobarbital, and rifampin increase metabolism; may decrease effectiveness. At chronic cases, may decrease antibody response to and increase risk of adverse reactions from live-virus vaccines. Antacids decrease absorption of it. Increase risk of GI ulceration with NSAIDs.

Side Effects: Insomnia, nervousness, increased appetite, indigestion, dizziness/lightheadedness, headache, hirsutism, hypopigmentation, diabetes mellitus, glucose intolerance, hyperglycaemia, arthralgia, cataracts, glaucoma, epistaxis, diaphoresis, Cushing's syndrome, edema, fractures, hallucinations, hypertension, muscle-wasting, osteoporosis, pancreatitis, pituitary-adrenal axis suppression, seizures Nursing Responsibilities. 1. Assess for adverse effects 2. Implement safety measures to prevent falls and fractures. 3. Monitor clients with diabetes for hyperglycemia. 4. Assess for fluid and electrolyte imbalance. 5. Assess stools for melena. 6. Administer with food to minimize gastric irritation.

63

7. Instruct to avoid people with active infection because resistance is low. 8. Instruct to avoid activities that could cause bone fracture. 9. Not to take NSAIDs unless directed. 10. Increase intake of protein, calcium, and potassium.

Albumin 25% Albuminar, Albutein, Buminate, Normal Human Serum Albumin, Plasbumin (50cc + Furosemide 20 mg x 4 to OD) Classification: Volume expanders, blood products, colloids Desired Dosage: (IV) 12.5-50 g/day in 3-4 divided doses. (Availability Injection: 250 mg/mL) Mode of Action: It provides colloidal oncotic pressure, which serves to mobilize fluid from extravascular tissues back into intravascular space. It increases intravascular fluid volume. Interactions: Do not mix with protein hydrolysates, amino acid solution and alcohol. Side Effects: CNS: Headache CV: Pulmonary edema, fluid overload, hypertension, hypotension, tachycardia GI: Vomiting, increased salivation, nausea Derm: Rash, urticaria MS: Back pain Chills, fever, flushing

Nursing Responsibilities: 1. Monitor vital signs, and intake and output.

64

2. Assess for signs of vascular overload such as elevated CVD, rales/crackles, dyspnea, hypertension, jugular venous distention) during and after administration. 3. Monitor serum sodium levels because it may cause increase concentrations. 4. Solution should be clear amber, and do not administer solutions that are discolored or contain particulate matter.

Sodium Bicarbonate Baking Soda, Bell-Ans, Citrocarbonate, Neut, Soda Mint (650 mg 1 tab tid) Classification: Anti-ulcer agent and alkalinizing agent Desired Dosage: Alkalinization of urine: (PO) 48 mEq or 4 g initially. Then 1-2 g q4 hr or 1 tsp of powder q4 hr as needed. Metabolic acidosis: >4.8 g/day as needed. Mode of Action: Acts as an alkalinizing agent by releasing bicarbonate ions. It is used to alkalinize urine and promote excretion of certain drugs in overdosage situations. Interactions: Increase toxicity of amphetamins, ephedrine, pseudoephedrine, flecainide, quinidine and quinine. It decreases effects of lithium, chlorpropamide and salicylates due to increased clearance. It may affect the absorption of certain drugs due to raised intragastric pH. Side Effects: Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatraemia, hyperosmolality, hypocalcaemia, hypokalaemia; stomach cramps, flatulence. Nursing Responsibilities: 1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea, hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed

65

skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria, polydypsia) 2. Assess fluid balance (intake and output, daily weight, edema, lung sounds) 3. Take med with full glass of water. 4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and renal function prior to and periodically through out the therapy.

Clonazepam Rivotril (1/4 tab daily) Classification: Anticonvulsant Desired Dosage: 0.5 mg 3x daily Mode of Action: It produces sedative effects in the CNS, probably by stimulating inhibitory GABA receptors. It prevents seizures and decreases manifestations of panic disorder. Interactions: CNS depression with alcohol, antidepressants, disulfiram, antihistamines, fluoxetine, other benzodiazepines, and opioid analgesics. Cimetidine, hormonal contraceptives, isoniazid, ketoconazole, metoprolol, propoxyphene, propanolol, or valproic acid may decrease metabolism of clonazepam. Sedative effects with theophylline.

Side Effects: Fatigue, somnolence, muscular hypotonia, coordination disturbances, aggressiveness, irritability or agitation. Nursing Responsibilities:

66

1. Assess for drowsiness, unsteadiness, and clumsiness. These symptoms are dose related and most sever during initial therapy. 2. Administer with food to minimize gastric irritation. 3. Have CBC and liver function test results evaluated periodically because it may cause increase in serum bilirubin, AST and ALT.

Epoetin B Recormon (5000 u SC) Classification: Hematopoeitic Agent Desired Dosage: 50-100 u/kg 3x weekly initially, then adjust dose base on Hct.

Anemia w/ CRF: Correction phase SC inj Initially, 3 x 20 iu/kg/wk, may be

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

Maintenance phase In SC inj, to maintain a PCV of 30-35%, initially reduce to

of the previously administered amount. Subsequently, adjust dose at 1-2 wk intervals individually for the patient. Patient stable on a once-wkly dosing regimen may be switched to once every 2 wk administration.

Prevention of anaemia of prematurity SC inj 3 x 250 iu/kg/wk for 6 wk. Increasing the amount of autologous blood SC or IV inj Twice wkly over 4 wk.
Max IV Dose: 1,600 iu/kg/wk. Max SC Dose: 1,200 iu/kg/wk.

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Symptomatic anaemia in cancer SC inj 1 inj/wk or 3-7 divided doses/wk.

Recommended Dose: Initially, 30,000 iu/wk (approx 450 iu/kg body wt/wk based on ave wt). Treatment is indicated if haemoglobin value is 11 g/dL (6.83 mmol/L), should not exceed 13 g/dL (8.07 mmol/L). After 4 wk therapy, if haemoglobin value increased by at least 1 g/dL (0.62 mmol/L), continue therapy; if not, double the wkly dose. After 8 wk, if value has not increased by at least 1 g/dL, discontinue therapy. After the end of chemotherapy, continue therapy up to 4 wk. Max: 60,000 iu/wk. When therapeutic objective has been achieved, reduce dose by 25-50% to maintain haemoglobin at that level, may reduce further to ensure haemoglobin level does not exceed 13 g/dL. If >2 g/dL (1.3 mmol/L) haemoglobin rise in 4 wk, reduce dose by 25-50%. Mode of Action: Epoetin beta is identical in its amino acid and carbohydrate composition to erythropoietin that has been isolated from the urine of anemic patients. Erythropoietin is a glycoprotein that stimulates the formation of erythrocytes from precursors of the stem cell compartment. It acts as a mitosis-stimulating factor and differentiation hormone. After administration of epoetin beta, the number of erythrocytes, the Hb values and reticulocyte counts increase as well as the 59Fe-incorporation rate. An increased 3Hthymidine incorporation in the erythroid-nucleated spleen cells has been found in vitro (mouse spleen cell culture) after incubation with epoetin beta. Interaction: The clinical results obtained so far do not indicate any interaction of Recormon with other substances. Incompatibilities: To avoid incompatibility or loss of activity, do not mix with other drugs or infusion solutions. Side Effects: CNS: Seizures, headache CV: Hypertension, thrombotic events such as MI or stroke Derm: Transient rashes

Nursing Responsibilities: 1. Monitor blood pressure before and after therapy. Additional antihypertensive drug maybe required during initiation of therapy.

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2. Monitor Hct and other hematopoietic parameters (CBC with differential and platelet count) 3. Monitor renal function studies and electrolytes closely. Increase in BUN, creatinine, uric acid, phosphorus, and potassium may occur. 4. Do not shake vial because inactivation of medication may occur. 5. Discard vial immediately after withdrawing dose from single-use 1-ml vial. Refrigerate multi-dose 2-ml vial; stable for 21 days after initial entry. 6. Stress importance of compliance with dietary restrictions, medications, and dialysis. Foods high in iron and low in potassium include liver, pork, veal, beef, mustard and turnip greens, etc

Gabapentin Neurontin (300 mg 1 tab @ night) Classification: Analgesic adjuncts, anticonvulsants, mood stabilizers Desired Dosage: CCr 30-60 mL/min300 mg 2x daily; 1530 mL/min300 mg 1x daily. Mode of Action: Mechanism of action is not known. It may affect transport of amino acids across and stabilize neuronal membranes. It can decrease incidence of seizures. Gabapentin is structurally related to the neurotransmitter GABA but is neither a GABA agonist nor antagonist. Gabapentin-binding sites have been identified throughout the brain tissues e.g. neocortex and hippocampus. However, the exact mechanism of action is still unknown. Interactions: Antacids may decrease absorption of gabapentin.

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Increase risk of CNS depression with other CNS depressants like alcohol, antihistamines, opioids, and sedatives. Morphine may increase level of gabapentin and increase risk of toxicity.

Side Effects: Somnolence, dizziness, ataxia, weakness, paraesthesia, fatigue, headache; nystagmus, diplopia; nausea, vomiting, wt gain, dyspepsia; rhinitis; tremor; leucopenia; altered LFTs; Stevens-Johnson syndrome Nursing Responsibilities: 1. Caution patient to avoid activities that require alertness to prevent injury d/t dizziness. 2. Provide supervision when patient is ambulating. 3. Monitor for side effects and instruct patient to refer if adverse effects are felt.

Sennosides Senokot Classification: Laxative Desired Dosage: 12-50 mg 1-2x daily Mode of Action: Active components of senna (sennosides) alter water and electrolyte transport in the large intestine, resulting in accumulation of water and increased peristalsis. Interactions: May decrease absorption of other orally administered drugs because of decreased transit time. Side Effects: GI: cramping, diarrhea, nausea GU: pink-red or brown-black discoloration of urine

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F & E: electrolyte abnormalities Misc: laxative dependence

Nursing Responsibilities: 1. Asses patient for abdominal distention, presence of bowel sounds, and usual pattern of bowel function. 2. Assess for color, consistency, and amount of stool produced. 3. Take with full glass of water. Ideally, administer at bedtime for evacuation 6-12 hours later. Administer on an empty stomach for a rapid result. 4. Advise patient that laxatives should be used only for short-term therapy. Long-term therapy may cause electrolyte imbalance and dependence, 5. Encourage patient to use other forms of bowel regulation such as increasing bulk in the diet, increasing fluid intake, and increasing mobility. 6. Inform that medication may cause change in his urines color to pink, red, violet, yellow or brown.

Berodual (neb) Ipratropnium Br, Fenoterol HBr Classification: Anticholinergic Indication: Acute prevention and treatment of symptoms of chronic obstructive airway disorders with Contraindication: tachyarrhythmia. Precaution: Diabetic patient with unstable metabolism, recent myocardial infarction, severe organic heart or vascular disorder; transient dose dependent doer in serum K+; hyperthyroidism; narrow-angle glaucoma; urinary outflow obstruction d/t prostatic hypertrophy. Hypertrophic reversible obstructive bronchospasm cardiomayopathy, (e.g.bronchial asthma schronic bronchitis with or without emphysema)

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Side effects: Tremor, restlessness, palpitation, tachycardia, dizziness, head ache, potentially serious hypokalemia, dryness of mouth, throat irritation, allrergic reactions, cough. Interactions: B2 adrenergics, systematically absorbed anticholinergics, xanthine derivatives and corticosteroids may increase in effect and may occur on concurrent administration of B2 blocker. Availability & Prize: UDV solution for inhalation 4ml (58.85) Inhalation solution 20 ml (932.00) Metered aerosol 10ml (1,253.00)

Norgesic Forte Per norgesic tab- Ophenadrine citrate 35 mg + Paracetamol 450mg. Per norgesic forte tab- Ophenadrine citrate 50 mg + Paracetamol 659mg. Indication: For the relief of painful skeletal muscle spasm associated with chronic low back pain, spasms and strains, prolapsed intervertebral disc, muscle injury, non-articular rheumatism (fibrisitis, myositis, & myalgia) whiplash injuries, tension head ache, dysmenorrhea, and other acute or chronic painful muscular condition. Dosage: Norgesic tab 1-2 tab TID. Contraindications: Glaucoma; prostatic hypertrophy or bladder neck obstruction. Precaution: Cardiac arrhythmias, tachycardia, cardiac decompensation, coronary insuffiency, pregnancy. Side effects: Nausea, dry mouth, blurred vision, rarely rash, drowsiness, dizziness, and restlessness. Prize: Norgesic Forte tab (21.00); Norgesic tab (14.00) Cilostazol Pletal

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Classification: Antiplatelet Action: Inhibits the enzyme cyclic adenosine monophosphate (cAMP) phosphodiesterase III, which results in increased cAMP in platelets and blood vessels, producing inhibition of platelet aggregation and vasodilation. Indication: Reduction of symptoms of intermittent claudication allowing increased walking distance. Contraindications: Hypersensitivity, heart failure, active bleeding, hemostatic disorders. Use cautiously with renal dysfunction. Availability: 50,100 mg tablets Dosage: 100 mg po BID @ least 30 minute before or 2 hours post breakfast and dinner. Adverse effects: CNS dizziness, head ache CV heart failure, tachycardia, palpitations GI diarrhea, nausea, flatulence, dyspepsia Respiratory cough, pharyngitis, rhinitis Others peripheral edema, infection, back pain Nursing Responsibilities: 1. Assess patient for intermittent claudication 2. Administer on an n empty stomach, 1 hour before of 2 hours post meal. 3. Do not administer with grapefruit juice. May increase cilostazol levels. 4. Caution patient to avoid driving or other activities requiring alertness. 5. Advise patient to avoid smoking; nicotine constricts blood vessels. 6. Prevent injury which may cause bleeding. - use soft bristled toothbrush. - avoid sharp objects. - instruct patient not to strain too much while defecating to avoid perforating the rectal muscle. Humulin 70/30 Insulin (mixtures) Classification: Antidiabetics, hormones Action: Lowers blood glucose by: stimulating glucose uptake in skeletal muscle and fat, inhibiting hepatic glucose production. Contraindications: Hypoglycemia; allergy or hypersensitivy.

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Precautions: In patient with real/hepatic impairment (may decrease insulin requirements) Adverse effects: Endo Hypoglycemia Local Erythema, lipodystrophy, pruritus, swelling Misc Allergic reactions including anaphylaxis Drug-Drug interactions: B-blockers, clonidine and reserpine may mask some of the signs andsymptoms of hypoglycemia. Corticosteroids, thyroid supplements, estrogens, isoniazid,niacin, phenothiazines and rifampin increase insulin requirements. Alcohol, ACE inhibitors, MAO inhibitors, oral hypoglycemic agents and salicylates decrease insulin requirements Availability: (100 units/ml total) in 10 ml vials and 3 ml disposable delivery devices. Nursing Interventions: 1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet, lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration, drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea, tachycardia, tremor, weakness, unsteady gait. 2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst. 3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose. 4. Monitor blood glucose every 6 hours during therapy. 5. Note for toxicity and overdose: HYPOGLYCEMIA - let patient ingest oral glucose - if severe hypoglycemia: administer IV glucose, glucagon or epinephrine. 6. viscous. 7. 8. 9. 10. Rotate site of infection. Instruct patient on proper techniques for administration. Explain to the patient that this medication controls hyperglycemia but does Emphasize the importance of compliance with nutritional guidelines and Store insulin in refrigerator. Do not use if cloudy, discolored or unusually

not cure diabetes. regular exercise as directed.

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Loperamide Diar-aid caplets, Imodium, Imodium A-D, Kaopectate II caplets, Maalox antidiarrheal caplets, Neo-Diaral, Pepto Diarrhea control Classification: Antidiarrheals Indications: Adjunctive therapy of acute diarrhea. Chronic diarrhea associated with inflammatory bowel disease decrease the volume of ileostomy drainage. Action: Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the intestinal muscle wall. Reduces fecal volume, increases fecal viscosity and bulk while diminishing loss of fluid and electrolytes. Therapeutic effects: Relief of diarrhea. Contraindications: Hypersensitivity; patients in whom constipation must be avoided; abdominal pain of unknown cause, especially if associated with fever; alcohol intolerance(liquid only). Precautions: Hepatic dysfunction Side effects: CNS drowsiness , dizziness GI constipation, abdominal pain/distention/discomfort, dry mouth, nausea and vomiting. Misc allergic reactions Drug-Drug interactions: Increase CNS depression with other CNS depressants including alcohol, antihistamines, opioid analgesics, and sedatives. Increase anticholinergic properties with the other drugs having anticholinergic properties including antidepressants and antihistamines. Nursing Management: 1. Assess frequency and consistency of stools and bowel sounds prior to and during therapy. 2. Assess skin turgor for dehydration. 3. Administer with clear fluids to help prevent dehydration which may accompany diarrhea. 4. Instruct patient to take medication as directed. In acute diarrhea, medication may be ordered after each unformed stool.

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5. Advise patient that frequent mouth rinses and good oral hygiene may relieve dry mouth. 6. Instruct patient to notify health care professional if diarrhea persist or if fever, abdominal pain, or distention occurs. Furosemide Novosimide; PMS-Furosimide Classification: Loop diuretics Indications: Edema d/t heart failure, hepatic impairment or renal disease. Hypertension. Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal renal tubule. Increases renal excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in impaired renal function. Decreased blood pressure. Dosage: 1 tablet, 200 mg Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol intolerance. Precautions: Severe liver disease; electrolyte depression Side effects: CNS blurred vision, dizziness, head ache, vertigo EENT hearing loss, tinnitus CV hypotension GI anorexia, constipation, diarrhea, dry mouth, nausea, vomiting GU excessive urination Derm photosensitivity, rash F and E dehydration Nursing Responsibilities: 1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth, hypotension, or oliguria occurs. 2. Monitor blood pressure and pulse before and during administration. 3. Monitor blood glucose closely; may cause increased blood glucose level. 4. Caution patient to change positions slowly to minimize orthostatic hypotension.

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5. Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness and numbness occurs. 6. Caution older patients or their caregivers about increased risk for falls. Lactulose Duphalac Classification: Laxatives Indications: Treatment of chronic constipation in adults and geriatric patients. Adjunct in the management or portal- systemic (hepatic) encephalopathy. Action: Increases water and softens the stool. Lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levels. Contraindication: Patients on low-galactose diets. Precautions: Diabetes mellitus; excessive use may lead to dependence. Side effects: GI belching, cramps, distention, diarrhea Endo hyperglycemia Drug-Drug interactions: should not be used with other laxatives in the treatment of hepatic encephalopathy (leads to inability to determine optimal dose of lactulose). Antiinfectives may diminish effectiveness in treatment of hepatic encephalopathy. Dosage: 30 cc PO Nursing Interventions: 1. Assess patient for abdominal distention, presence of bowel sounds, and normal pattern of bowel function. 2. Assess color, consistency, and amount of stool produced. 3. May cause increased blood glucose levels in diabetic patients. 4. Encourage patient to increased oral fluid intake. 5. Caution patients that this medication may cause belching, flatulence, or abdominal cramping. Health care professional should be notified if this becomes bothersome or if diarrhea occurs.

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78

Date

Cues

Need

Nursing Diagnosis Excess fluid volume related to compromised regulatory mechanism. Fluid volume excess or hypervolemia occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in CHF, kidney failure, and liver failure.
Bibliography: Gulanick, Meg, PhD, RN, et.al (2003).Nursing Care Plan: Nursing Diagnosis &

Goal of Care

Intervention Plan

Evaluation

07/0 5/10 @ 9:15 am

Subjective: Paminaw nako kay puno kaayo diri, stated by Mr. S. Objective: -with IVF of PNSS1L @ 60 cc/hr -abdominal girth: 90 cm -ascitis -bipedal edema -weak and sleepy -CXR shows pleural effusion -(+) crackles -decreased Hb (94) and Hct (0.28) -increase glucose in the blood. -Furosemide

N U T R I T I O N A L M E T A B O L I C P A T T E R N

At the end of 5 hours of nursing interventions, the patient will be able to stabilize fluid volume as evidenced by: a. Balanced intake and output; b. Vitals signs within normal limits and; c. Drain at least 1 liter of urine at foley catheter.

1. Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum. Pitting edema is manifested by a depression that remains after ones finer is pressed over an edematous area and then removed. 2. Monitor daily weight of the patient. Any change in weight is indicative of increase extracellular fluid volume.

3. Monitor VS of the patient.

Tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines, thus their response to fluid overload may be blunted, with less rise in heart rate.

4. Auscultate for a 3rd sound.

S3 sound is an early sign of pulmonary congestion.

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Interpretation. Westline Dive St. Louise. Mosby Inc. 5th ed, p. 65

5. Monitor for distended neck veins and ascites. Distended neck veins mean increase pressure in the jugular veins brought about by increased circulating fluid. 6. Monitor abdominal girth daily. 7. Monitor input an output Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to extravascular spaces may result in dehydration. 8. Evaluate urine output in response to diuretic therapy. Focus on monitoring the response to the diuretics, rather than the actual amount voided. Fluid volume excess in the abdomen may interfere with the absorption of oral diuretic medications.

9. Check urinary catheter for

presence of urine. Treatment focuses on diuresis of excess fluid

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10. Instruct patient regarding fluid restrictions as appropriate. Facilitates reduction of extracellular volume. 11. Instruct patient to take diuretics as prescribed. Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem. 12. Note medications that may cause fluid retention, such as non-steroidal antiinflammatory agents, vasodilators, and steroids. 13. Instruct to avoid crossing of legs Reduce constriction of vessels thus preventing pooling. 14. Assist patient in repositioning every 2 hours Prevent accumulation of fluid in dependent areas.

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Date

Cues Subjective: Kapoy kaayo ang paminaw, Mr. S said. Daghan kaayo na siyag ma-ihi, as verbalized by the watcher. Objective: -with IVF of PNSS 1L infusing well @ R metacarpal vein running @ 60cc/hr @ 400 cc level. -with good skin turgor -with capillary refill time of 2 seconds - VS taken result of: T= PR= CR= RR= 17 BP= 130/80 -drowsy & weak -urine output of approx. 4000 mL

Need

Nursing Diagnosis Fluid & electrolyte imbalance related to excessive urination Excessive urination coupled by impaired glomerular filtration rate can affect reabsorption of sodium in the distal renal tubule, excretion of creatinine in the urine and wastage of calcium which will result to muscular spasms if not corrected.

Goal of Care

Intervention Plan

Evaluation

07/0 6/10 @ 9:15 AM

N U T R I T I O N A L M E T A B O L I C P A T T E R

At the end of 5 hours of nursing interventions, the patient will be able to show negative signs of dehydration as evidenced by: d. Vital signs within normal range;

1. Assess capillary refill time of the patient regularly including the mucus membrane and skin turgor. These are indicators of dehydration, adequacy of circulating volume. 2. Monitor intake and output

GOAL PARTIALLY MET @ 07/06/20 2:15 PM After 5 hours of nursing interventions, the patient showed no signs of dehydration as evidence by: a. able to consume 950 mL of fluids; b. had good appetite and consumed entire meal; c. maintained good skin turgor and capillary refill time of less than 2 seconds and;

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

Provide ongoing estimation of volume replacement needs, kidney function, & effectiveness of therapy. 3. Instruct patient to increase oral fluid intake to at least 2.5 L/day or above depending on the amount determined by the health care provider. Maintains hydration and circulatory volume. 4. Promote comfortable environment: cover patient with light sheets.

g. maintain good

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-abnormal serum electrolyte result of: Sodium=126 (low) Creatinine=272.8 (high) Calcium=1.81 (low) -with medications of: Furosemide NaHCO3 CaCO3 Lactulose

N Avoid overheating which could promote further fluid loss. 5. Continue to administer fluids Type and amount of fluids depends on the degree of deficit and individual patient response 6. Instruct patient to take highwater content foods like watermelon and soup if not contraindicated. Replace fluid loss in the body due to excessive urination 7. Administer medications as ordered. 8. Monitor serum electrolytes and urine osmolarity Elevated hemoglobin and elevated blood urea nitrogen suggest fluid deficit. Urinespecific gravity is likewise increased. 9. Instruct to eat the whole meal

d. alert and responsive to any stimuli

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serve.

Date

Cues

Need

Nursing Diagnosis Fatigue r/t increase decrease insulin production An imbalance in blood sugar is the main cause of diabetes-related fatigue. Cells use glucose - sugar for fuel. The hormone insulin controls the distribution and use of glucose in the body. In diabetics, due to poor production of insulin, the glucose is not properly utilized by the cells; instead, it's floating around

Goal of Care

Intervention Plan

Evaluation

07/0 5/10 @ 8 AM

Subjective: Kapoy ang paminaw! answered by the client when asked about how hes doing. Objective: -always sleeping or drowsy -(+) sleep disturbances such as administration of drugs during days and repeated medical procedures done early in the morning -irritable -answers questions crossly and

A C T I V I T Y E X E R C I S E P A T T E R

After 21 hours of care, Mr. S will be able to improve sense of energy as evidenced by: a. lessened or diminished irritability; b. ability to answer questions or communicate with high spirits; c. ability to sit independently on chair and; d. having greater time being awake.

1. Assess vital signs. To evaluate fluid status and cardiopulmonary response to activity. 2. Determine presence/degree of sleep disturbances. Fatigue can be a consequence of, and/or exacerbated by, sleep deprivation. 3. Obtain clients description of fatigue (i.e. lacking energy or strength, tiredness, weakness over length of time) To assist in evaluating impact on clients life. 4. Ask client to rate fatigue (110 scale). To assess level of fatigue based on clients perception.

GOAL MET @ 07/07/10 12 nn After 21 hours of care, Mr. S was able to improve sense of energy as evidenced by: a. welcomes visitors and gives jokes; b. open to questions and answers patiently, and initiates communication to student nurse;

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impatiently -gives inadequate answers -needs supervision from watcher -weak -in bed rest -blood glucose level of: 278 mg/dL -takes Humulin 70/30 SC

in the bloodstream, where it can't be used as energy. As a result, diabetic people will feel drained.

5. Encourage use of assistive devices (e.g. wheeled walker or crutches). Conserves energy for other tasks. 6. Assist with self-care need like ambulation, as indicated. 7. Avoid or limit exposure to temperature and humidity extremes. Temperature extremes can negatively impact energy level. 8. Provide diversional activities like open and jovial communication. Participating in pleasurable activities can refocus energy and diminish feelings of unhappiness, sluggishness, and worthlessness that can accompany fatigue. 9. Encourage to drink fluids. It is important to keep up fluid intake as even mild dehydration can cause fatigue. Dehydration can also lead to an increase in blood sugar. Calming herbal teas are more beneficial than caffeine based drinks.

c. able to sit on the chair without maximum supervision and; d. is awake most of the time during the day.

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

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enough sleep at night. Research shows that not having enough sleep may contribute to insulin resistance. One reason is that poor sleepers often experience sleep apnea; this is a condition that interferes with normal breathing and has been linked to diabetes.

Date

Cues

Need

Nursing Diagnosis Activity intolerance r/t muscular weakness as evidenced by high serum creatinine level Creatinine can cause dehydration and fatigue. medicinenet.com

Goal of Care

Intervention Plan

Evaluation

07/0 6/10 @ 7:00 AM

Subjective: Dili nako makatindog ug ako ra, stated by the client. Objective:

-creatinine levels of:

272.8 (06/26/10) 359 (07/01/10) 389 (07/02/10) -needs assistance

A C T I V I T Y A N D E X E R C

At the end of 2 days of care, Mr. S. will be able to demonstrate a decrease in physiological signs of intolerance as evidenced by: a) able to perform a specific task with improved strength; b) able to seek help in performing activities of daily living;

1. Establish guidelines and goals of activity with the patient and the caregiver Motivation is enhanced if the patient participates in goal setting.

GOAL MET @ 07/07/10 12:00 nn At the end of 2 days of care, Mr. S was able to demonstrate a decrease physiological signs of intolerance as evidenced by: a. had great strength on lower

2. Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation Rest between activities provides time for energy

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-PT 2 sessions -complained of pain in pelvic area

I S E P A T T E R N

conservation and recovery. c) verbalize acceptance of decreased activity level and; d) experience less discomfort when transferring, or performing other activities.

3. Refrain from performing nonessential procedures Patients with limited activity tolerance need to prioritize tasks.

extremities; observed during draping for removal of catheter b. asked help from student nurse or watcher in changing positions; c. Ana jud ng mutiguwang ka, he joked. d. Nagasakit gihapon diri dapita (arthritis) pag mulihok, pero gamay gamay na lang.

4. Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self Assisting the patient with ADLs allows for conservation of energy. Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patients activity tolerance and self-esteem.

5. Assist patient to plan activities for times when he has the most energy

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 Not all self-care and hygiene activities need to be completed in the morning. Likewise, not all housecleaning needs to be completed in 1 day.

6. Improvise in adapting environment Appropriate aids will enable the patient to achieve optimal independence for selfcare.

Date/ Time

Cues

Need

Nursing Diagnosis

Objective of Care

Nursing Interventions

Evaluation

89

Subjective: 07/05/ - Doc, kani dinhi 10 ba(holding the right leg, pelvic area) sakit man @ kaayo, kaning bukog-bukog, 10 maglisod ko ug AM lakaw, wala man gud koy kusog, naunsa naman ni? Dili man ko ing ani pag-abot diri, as verbalized by the patient. - rated the intensity of pain as 7 in the pain scale of: 1 - no pain 2 less 3 pain 4 slightly
moderate

C O G N I T I V E P E R C P T U A L P A T T E R N

Acute pain related to inflammation of the joints

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

That within the 2-hour span of care, my patients comfort condition will improve as evidenced by: - decreased pain intensity as 1 in pain scale - no grimaced face noted - no withdrawal when there is physical contact with the joint - verbalization of feeling of comfort

1. Assess pain characteristics. Assessment of the pain experience, is the first step in planning pain management strategies. 2. Accept clients description of pain. Pain is subjective experience and cannot be felt by others. 3. Respond immediately to complaint of pain Prompt responses to complaints may result in decrease anxiety in the patient. Demonstrated concern for the patients welfare and comfort fosters the development of a trusting relationship. 4. Instruct the patient to report pain. Relief measures may be instituted . 5. Position the patient comfortably on bed. Comfortable position will aid in relaxing the muscle and it will help to lessen the pain.

GOAL MET @ 07/05/10 12pm After 2-hour span of care, the patients condition is improved as evidenced by: - pain scale of 1 - grimaced face not noted - no withdrawal when there is physical contact with the joint - di naman sakit akong mga joints karon(holding the right leg), as verbalized by the patient.

5 pain 6 7 moderate pain 8 9 severe

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Discharge Planning

Categories
Medication

Plan
Instruct patient to take prescribed medications regularly and comply with the treatment regimen prescribed by the physician.

Rationale
-Compliance to appropriate medication and treatment prevents further complications and resistance to antibiotics and promote continuous recovery of optimal health. -The patient has the right to know his drugs therapeutic effects as well as its adverse effects. He also has the right to gain awareness about why is it given to him. -Drug interactions may occur

the

Teach patient regarding the names of drug, its dosage, time of

administration, its contraindication and side effects.

Inform patient and significant others

which may be fatal to patients current situation. -Checking for the expiration date

not to take drugs not prescribed by the physician, especially OTC drugs. it. Instruct the patient to check for the

of the drug before administering it ensures it potency and safety. It also prevents any unwanted reactions like hypersensitivity. -Non-prescription drug may have

expiration date of the drug before taking

Do not administer any other drug with

antagonistic or synergistic effects if taken with other drugs.

same action without the physicians prescription. Educate the patient and the

-To be geared up of enough information that may lead to immediate medical responses.

significant others about the expected responses of drug to the body, side effects, adverse effects that may possibly seen into the patient.

-For immediate remedial action

91

Instruct the significant others to

response and to prevent any complicated reactions.

report any remarkable adverse reactions or any appearance of side effects noted.

Exercise

Explain to patient the significance of regular exercise like walking and stretching. If unable to mobilize alone, instruct the watcher to give assistance all the time. Encourage to use crutches or any device for support. Stretching upper extremities also promote healthy living. Also instruct patient to perform passive range of motion. Teach patient to wait for 1 to 2 hours eating before performing any

-Exercises promote proper blood circulation and prevent arterial and venous stasis thus lessens platelet coagulation to aged people. Older people have weakened blood vessel walls which can cause any alteration in blood flow. Also exercise prevents atrophy of the muscles. -Older people has slower digestion rate, thus they need to conserve more oxygen which will be necessary for digestion of food. Activities must be limited to decrease oxygen demand by organs and tissues other than the digestive system.

after

physical activities.

If patients pleural effusion worsens,

-Deep breathing exercises promote thoracic expansion which allows air to enter the respiratory tract and provide oxygen to the alveoli to avoid atelectasis or lung collapse due to increase fluid pressure in the pleural space. -Maintenance meds should not be forgotten to achieve highest therapeutic effect.

instruct the patient to practice deep breathing exercise.

Treatment

Instruct patient to comply with his

medication treatment like the continuous use of beta blocker Metoprolol for control of hypertension and Insulin for diabetes mellitus. Instruct client to seek medical help if

-These unusualties may be indicative of worsening condition.

any unusualties are felt such as tingling

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sensation or paresthesia, fatigue and body malaise, dizziness, headaches, irritability, tremors, diaphoresis, etc. As part of long-time treatment, advise -Medical alert bracelet provides basic information about the client in case of accidents. patient to wear medical alert bracelet all the time and wherever he goes. It contains the patients name, disease condition, address and contact person. Advise to have a family member take -Monitor of blood pressure is significant for evaluating the medications effectiveness. Since the client has his own glucose monitor, tell client to continue monitoring blood glucose level, and immediately seek Hygiene for medical help if level is -Proper foot care prevents injury to feet and toes. abnormally high. Instruct patient to practice foot care to prevent ulceration and formation of gangrenous extremities. - Check and carefully wash your feet every day. -Do not wear shoes that are too small or socks that do not fit right inside your shoes. -Soak your feet in warm soapy water for 10 minutes before cutting your nails. Trim your toenails straight across to prevent ingrown toenails. You may also file down your toenails. Do not cut your nails into the corners or close to the skin. You should not dig under or around the nail. Emphasize the importance of bathing tissues to the lower -Glucose monitoring is a big factor in the management of diabetes mellitus. your blood pressure to check if youre maintaining a stable blood pressure.

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-Proper bathing eliminates everyday. Wash genitals with mild soap. proliferation of germs and bacteria in the body. Mild soap does not irritate the skin and the genitals. Instruct client to maintain good oral Instruct to wear clean clothes and -Tooth brushing prevents build up of plaques and cavities. -Dirty or improperly washed underwear may become a sanctuary for microbial growth. Microbes may enter the genitals and might worsen the clients Out-Patient Referral Encourage patient to undergo physical therapy sessions. UTI/Cystitis. -A Physical Therapist is a source of information to understand agerelated changes and offer assistance for regaining lost abilities or develop new ones. Physical therapy can be applied to the clients condition: arthritis, urinary and fecal incontinence, amputation, and cardiac and pulmonary disorders. It can : a). increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance b.) aids adaptations to make the home accessible and safe teach positioning, transfers, and walking skills c.) promote maximum function and independence within an individual's capability d.) increase overall fitness through exercise programs e.) prevent further decline in functional abilities through

hygiene. underwear.

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education, energy conservation techniques, joint protection, and use of assistive devices to promote independence f.) improve sensation, joint proprioception g.) reduce pain Advise to have check-ups after discharge. -Serves as an evaluation process to note if condition has progressed to better or worse. Advise to have regular laboratory exams for creatinine, albumin, sodium, potassium and calcium. Encourage to undergo ABG Test every Diet month or once every 2 months. Instruct client to avoid simple sugars. Take energy from complex carbohydrates like unpolished rice, bread and vegetables. -Simple sugars easily break down and enter the blood stream. Complex carbohydrates can sustain the bodys energy requirement for a longer time because they are not broken down easily. Encourage patient to eat fibrous foods like fruits and vegetables. But do not eat too much as it can irritate the GI tract and causes bleeding. Other examples of sources of fiber are: whole grains, cereals and legumes. Limit intake of purine rich foods such as sardines, liver, beef kidneys, brains and meat extracts. Encourage to eat in moderate amount: asparagus, cauliflower, spinach, mushrooms, green peas, dried peas and beans. Instruct patients family to prepare foods low in fat and cholesterol. Also have moderate amount of sodium in the diet. -Accumulation of uric acid in the joints causes arthritis. Uric acid is the by product of purine break down in the liver. Because of renal malfunction, uric acid is retained in the blood stream and is shunted to connective tissues. -Cholesterol build up can cause atherosclerosis. Since elder people have weakened blood vessel walls, -A diet rich in fiber relieves constipation. It adds bulk to the excreta and facilities expulsion. -To assess for renal function.

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

Prognosis

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Diabetes needs to be considered a very serious condition. It is a chronic condition for which we have no cure. About 2/3 of people with diabetes die of heart disease. It is the leading cause of adult blindness, the leading cause of kidney failure, and the leading cause of lower extremity amputation. It is also the second most common chronic condition seen by American doctors. Although diabetes is a serious and chronic condition, early diagnosis and proper patient self-management can reduce and possibly eliminate the majority of the chronic complications. Meticulous control of blood glucose (HbA1c below 7% which would correlate to an average blood glucose below 150 mg/dL), good blood pressure control (below 130/80), low LDL (low density lipoprotein) cholesterol levels (below 100 mg/dL), one daily aspirin (either adult or children's), and daily foot inspection can make a major impact on improving one's risk for all diabetes-related problems. Pain High blood glucose levels do not cause pain. However, having high glucose levels for many years can lead to nerve damage in the feet (called neuropathy), which can be painful. It is estimated that 25% of newly diagnosed patients with type 2 diabetes have pain or numbness in their feet from neuropathy. Client can take analgesics for pain. Debilitation Diabetes can be debilitating, and there are many reasons for this. It is not uncommon for people with diabetes to experience advanced neuropathy to the point that he or she cannot walk. For Mrs. Js case, she sometimes stoops while walking, but still does not need supervision. The good news is that debilitation can be prevented if treatment is started early and aggressively. This treatment includes meticulous control of blood glucose (average glucose below 150 mg/dL), blood pressure (below 130/80), LDL cholesterol (bad cholesterol below 100 mg/dL), daily aspirin, and smoking cessation. Research also has shown that one particular type of blood pressure medication, called ACE (angiotensin converting enzyme) inhibitors, has an additional protective effect on complications besides lowering blood pressure. ACE inhibitors appear to stabilize or even reverse diabetic kidney disease if it is caught early enough. These drugs also have been found useful for people who have had heart attacks or have heart failure. One study even showed these drugs reduced the risk of heart attack or stroke by 25%. Finally, there is a 97

growing body of research suggesting ACE inhibitors may protect against diabetic eye disease. Comfort Diabetes usually does not cause discomfort. In fact, one of the biggest public health problems in America is that there are over 5 million Americans who have asymptomatic diabetes and do not know it. The most common reason for any discomfort is the neuropathy noted above. Another common reason people have discomfort is from the finger sticks to measure blood glucose. Fortunately, this technology is quickly improving so that discomfort is minimal. Curability Diabetes is currently not curable. Type 1 diabetes is defined as no requirement for insulin with normal blood sugars. Scientists are working on this so that the cells that make insulin ("islets") may be able to be transplanted to result in a cure. To date these experiments are not quite ready and are still in the research phases. For type 2 diabetes, there is no "cure" but often it can be treated early in its course with a strict diet, exercise, and weight loss. However, it is rare for the diabetes to "disappear" even with these measures. The main focus of research now is to prevent both types of diabetes. Independence In the vast majority of cases patients with diabetes should have no problems with independence. But for elderly, fatigue and neuropathies can occur, so strict supervision is needed. Family members should also make sure that their home environment is free from injury causing objects. Mrs. J still belongs in the middle adulthood, thus she can experience independence more than elders without causing harm to self. Mobility Again, in the vast majority of cases, diabetes should have no impact on someone's ability to move about. The exceptions to this are those people who suffer from advanced neuropathy or vascular disease. A complication involving the foot, such as a foot ulcer or amputation can impact one's ability to move around. Visual problems also will impact one's ability to move about. These are true to young diabetic patients. Mrs. J has complained of blurry vision, thus her ability to move about is readily and always affected. But she said that she uses eye glasses which aids her sight. But complications brought about by aging should not be neglected. Senile people are mostly at risk for injury.

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Daily activities For most people however, small amounts of time should be reserved for selfmanagement. This would include time for home blood glucose monitoring (although our current meters take as little as 5 seconds) and extra time to ensure the proper medication is received. Exercise is encouraged for people with diabetes, although for those over the age of 40 years old it is recommended a stress test is performed to rule out early heart disease (claudication). Rest is always a necessity. Energy Extremes in blood glucose levels can cause fatigue. Although it is difficult to give exact levels since it differs with the person, many people note fatigue when the blood glucose exceeds 400 mg/dL. Although hypoglycemia often presents with a tremor, fast heart rate, a sweating, it may be noted only as fatigue. This often occurs when the blood glucose drops below 60 mg/dL. Mrs. J can have some time for rest. Though she has to baby sit for her grand son Benedict, and perform all the house chores, she can have a bit of time in the afternoon while her grandson is at school to rest and sleep. Diet In general, it is recommended that one eats a low-fat diet with less than 10% of the calories coming from saturated fat. For people with high levels of LDL-cholesterol (the "bad" cholesterol) the January 2002 guidelines from the ADA suggest only 7% of total calories from saturated fat. The most confusion about diet for people with diabetes has to do with carbohydrates, which are the types of foods most quickly broken down to glucose (such as breads, potatoes, pasta, fruit, and simple sugar). Research has clearly shown that table sugar (sucrose) does not increase blood sugar any more than breads, pasta or other carbohydrates AS LONG AS THE SAME NUMBER OF CALORIES ARE CONSUMED. For example, putting table sugar into coffee (about 15 grams of carbohydrate) would not change blood glucose any more than 1 piece of bread (about 15 grams of carbohydrate). Therefore, simple sugars ("sweets") do not need to be restricted by people with diabetes, but rather need to be substituted for other carbohydrate sources. For people using insulin, it is much easier since additional insulin can be administered to "cover" additional carbohydrate.

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Relationships The interactions between relationships and diabetes are greatly underappreciated. Communication becomes particularly important for people in their early adult years, as issues pertaining to marriage and family planning are discussed. It is critical that concerns be discussed in the open with the assistance from a health care provider with understanding about the disease. For older adults, the impact of both the daily living of diabetes and its complications becomes even more important. Again, one needs to talk to a healthcare provider knowledgeable about diabetes to explore its complications and how it affects everything from work performance to driving or sexual function. Everyone living with an individual who has diabetes needs to have some knowledge about how to treat emergencies (hypoglycemia). Finally, psychological support can be extremely effective for many individuals due to the extreme challenges this condition presents for many individuals.

References

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