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F. Family History
The client in the genogram depicted in the accompanying figure has
hypertension (HTN) on his maternal side; it was the cause of death
of the clients grandparents. Hypertension is inherited by the clients
mother. On the clients paternal side are insulin dependent Diabetes
mellitus (IDDM also known as Type 1 diabetes) and Chronic kidney
disease (CKD). Last 2008, the clients father died due to these health
problems. The clients sister had Pregnancy Induced Hypertension
(PIH) while the clients brother is alive and well (A/W). It was shown
that the patient is now has insulin dependent Diabetes mellitus
(IDDM also known as Type 1 diabetes) and Chronic kidney disease
which is the same health problem the patients father had.
G. Socio-Economic History
Family Member Occupation Monthly Income
R.M.S.A
(pts Mother)
Retired 2,500 dollars
R.M.S.A is 75 years old, a retired employee in a
department store in the United States of America and is
the mother of the patient. R.M.S.A is the only provider
because the clients father died last 2008. R.M.S.As
monthly income is 2500 dollars or in Philippine money,
more or less 115,000 pesos, 1500 dollars from the
retirement benefit and 1000 dollars from the Social
Security System or SSS which is a government
institution. The client said that it is not enough to provide
for their daily needs due to a lot of expenses, especially
now that the client is hospitalized.
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H. Psychosocial Assessment
Patients Age: 46 yrs. Old
Developmental Stage: Middle Adulthood
Developmental Crisis: Generativity vs. Stagnation
Developmental Virtue: Care
Developmental Task: Being creative and productive; establishing the nextgeneration
In Erik Eriksons Psychosocial Development theory, ages 40 to 65 years old or
the age of middle adulthood are more likely to have a crisis of Generativity vs.
stagnation. During this period according to Erik Erickson, most adults are
preoccupied with raising a family, and establishing themselves in their vocation
or career. Some may find themselves in position of greater influence in society,
such as in government. Adults develop a concern for the welfare of the future or
younger generations, and the need to pass on or leave a legacy regarding what
they have learned. This psychosocial need for generativity may take the form of
parenting, mentoring, teaching, or engaging in sociocivic work.
The patient seems to have a meaningful attachment to his family especially to his
mother. The patients relatives visit him as often as they can, to show them how
much they care and love him. The patient is a graduate of Information
Technology (IT) and is currently not working because of a personal problem. The
patient has no wife and kids of his own, but he has his niece and nephews that
he loves very much. The patient always gives advices and tells them stories
about his experiences in his life.
On this stage most adults are preoccupied with raising a family, but the patientwasnt able to achieve this. The patient lives with his mother and treats his
nephews and niece as his own children. The patient wants to practice his
vocation but he cant because of his current health problem but despite of it he
wants to help his family and make himself productive in his own simple way.
I. Functional Assessment
J. Review of Systems and Physical Examination
SYSTEM R.O.S P.E1. General
Wala panamanpagbabago,pero feeling
y Awake and conscious
y Ambulatory withminimal assistance
y With minimal
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ko medyopumayat ako,kasi hndi akomasyadokumakain
movement
y T= 36 C
y RR= 12 cpm, regular,bilateral chestexpansion
y PR= 96, 1+
y BP= 120/80 mmHg
2. Integument Eto medyodry ang balatko
Okay naman,wala namannagiba, ganunpa din sadati.
Skin:
y (+)Dry skin on bothupper and lowerextremities
y Fair skin
y (-)hyperpigmentation
y (-) maculopopular
rashesy Warm to touch
Hair:
y Color: Black
y (+) Normal hairdistribution
y (-) Presence ofparasites
Nails:
y Round, hard nails
with pink nail bedsy Capillary refill is < 3
seconds
3. HeadHindi namanmasakit angulo ko ngayonand I haventexperienceany headinjuries so far
y Smooth,Symmetrical, firm
y (-) Lesions on thescalp
y Normocephalic
y Temporomandibularjoint felt bilaterallywith full ROM
4. EyesHindi na akonakakakita saright eye ko
I dont weareye glasses or
y Round iris
y Bulbar conjunctivaclear with tiny vesselsvisible
y Nontender lacrimalapparatus
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contact lensekahit dati pa
5. Ears Hindi namansumasakit
ang tenga ko
Cotton Budsang gamit kopanlinis
y Passed whisper test
y (-) tenderness
y (-) discharge onexternal ear
6. Nose and Sinuses Wala namanako siponngayon
y (-) nasal flaring
y (-) nasal discharge
y (-) lesion in turbinatesand septum
y Pink and moistmucosa with nolesions
y Sinuses clear uponillumination
7. Mouth and Throatokay naman,hindi namanmasakit okakaiba
y Pharyngeal tonsilsnot inflamed
y Moist lips
y
(-) lesions on lipsy (-) hoarseness
8. NeckHindi namanmasakitpagginagalawko and akingneck
y (+) full ROM
y (-) cervical lymphnode enlargement
y Smooth, firm andnon-tender thyroid
9. Breast and AxillaPareho langnaman
katulad dati,hindi namanmasakit
y (-) dimpling
y (-) discoloration
y (-) axillary lymph
node enlargementy Flat, pale brown
areola
10. Respiratorywala namanako ubongayon
y (-) cough
y (-)Crepitus
y (-)wheezing
y Symmetrical thoracic
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I have nohistory of anyrespiratoryrelated illness
expansion
y RR= 12 cpm, regular,bilateral chestexpansion.
11. CardiacHindi namanakonahihirapanhuminga
y PR= 96, 1+y (+) apical pulse felt at
5th ICS LMC line
y Identical apical andradial pulse
12. Gastrointestinal minsan walaako ganakumain
hindi pa akonakakapagbawas ngayon
y (-) rashes
y Round, flabbyabdomen
y (-) mass
y
(+) slightly distendedabdomen
13. UrinaryEto mayChronicKidneydisease ako,hindi pa akonakakaihingayon eh
y Urine color: amberyellow
y (+) bladder distention
14. Genitaliaokay naman,wala namanproblema
y (+)rashes
y No lesions andinflammations noted
15. PeripheralVascular
Wala dinnamanproblema
y (-)jaundice
y (-) Pallor
y (-) lesions
y Capillary refill
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17. Neurologic Na-strokeako last weeklang
y Oriented to time,place and person
y Responds toquestions andstatementsappropriately
18. Hematologic Hindi namanako anemic
y (-) bruising
y (-)bleeding
19. Endocrinehindi namanako pawisinna tao
y (-) excessivesweating
y (+) heat and coldtolerance
20. Psychiatric ahh, hndinaman pa
naman akonagigingmakalimutinkahittumatanda naako
NO P.E.
III. PATHOPHYSIOLOGY
Diabetes Mellitus
The pathophysiology of diabetes mellitus (All types) is related to the hormone insulin, which is
secreted by the beta cells of the pancreas. This hormone is responsible for maintaining glucose
level in the blood. It allows the body cells to use glucose as a main energy source. However, in
a diabetic person, due to abnormal insulin metabolism, the body cells and tissues do not make
use of glucose from the blood, resulting in an elevated level of blood glucose or hyperglycemia.
Over a period of time, high glucose level in the bloodstream can lead to severe complications,
such as eye disorders, cardiovascular diseases, kidney damage and nerve problems.
In Type 1 diabetes, the pancreas cannot synthesize enough amount of insulin hormone as
required by the body. The pathophysiology of Type 1 diabetes mellitus suggests that it is an
autoimmune disease, in which the body's own immune system generates secretion of
substances that attack the beta cells of the pancreas. Consequently, the pancreas secretes little
or no insulin. Type 1 diabetes is more common among children and young adults (around 20
years). Since it is common among young individuals and insulin hormone is used for treatment,
Type 1 diabetes is also referred to as Insulin Dependent Dabetes Mellitus (IDDM) or Juvenile
Diabetes.
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Cerebrovascular accident
Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption ofblood supply to the brain, which precipitates neurologic dysfunction lasting longer than 24 hours.Stroke are either ischemic, caused by partial or complete occlusions of a cerebral blood vesselby cerebral thrombosis or embolism or hemorrhage. Hemorrhage may occur outside the dura(extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), orwithin the brain substance itself (intracerebral).
Risk factors for stroke include transient ischemic attacks (TIAs) warning sign of impendingstroke hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes mellitus,obesity, carotid stenosis, polycythemia, hormonal use, I.V., drug use, arrhythmias, and cigarettesmoking. Complications of stroke include aspiration pneumonia, dysphagia, constractures, deep
vein thrombosis, pulmonary embolism, depression and brain stem herniation.
An ischemic stroke may be caused by a thrombosis, embolism, or lacunar infarct. Blockage of asingle artery can often be compensated for by other arteries in the blood vessel network, call
collaterals. Artherosclerosis (hardening of the arteries), other damage to arteries, and naturalvariations in the collateral network can prevent the collateral system from compensating fully.The result is a loss of perfusion, or blood supply, to an area of the brain (ischemia).
Chronic Kidney Disease
Approximately 1 million nephrons are present in each kidney, each contributing to the total GFR.Regardless of the etiology of renal injury, with progressive destruction of nephrons, the kidneyhas an innate ability to maintain GFR by hyperfiltration and compensatory hypertrophy of theremaining healthy nephrons. This nephron adaptability allows for continued normal clearance ofplasma solutes so that substances such as urea and creatinine start to show significantincreases in plasma levels only after total GFR has decreased to 50%, when the renal reserve
has been exhausted. The plasma creatinine value will approximately double with a 50%reduction in GFR. A rise in plasma creatinine from a baseline value of 0.6 mg/dL to 1.2 mg/dL ina patient, although still within the reference range, actually represents a loss of 50% offunctioning nephron mass.
The residual nephron hyperfiltration and hypertrophy, although beneficial, has beenhypothesized to represent a major cause of progressive renal dysfunction. This is believed tooccur because of increased glomerular capillary pressure, which damages the capillaries andleads initially to focal and segmental glomerulosclerosis and eventually to globalglomerulosclerosis
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IV. LABORATORYSTUDIES AND DIAGNOSTICS
Procedure/
Date
Indications Normal
Values/Findi
ngs
Actual
Findings/
Interpretation
Nursing
Responsibilitie
s
Hematology
(January
27, 2011)
The complete bloodcount (CBC) is ascreening test,used to diagnoseand managenumerousdiseases. It can
reflect problemswith fluid volume(such asdehydration) or lossof blood. It canshow abnormalitiesin the production,life span, anddestruction of bloodcells. It can reflectacute or chronic
infection, allergies,and problems withclotting.
This test is used to
evaluate anemia,
leukemia, reaction
to inflammation and
infections,
peripheral blood
cellular characters,
State of hydration
and dehydration,
Polycythemia,
Hemolytic disease
of the newborn, to
manage
y WBC
y RBC
y Hemoglobin
y Hematocrit
DifferentialCount
y Segmenters
y Lymphocytes
y PlateletCount
y 5.0-10.0
y 4.6-6.2
y 123-153G/L
y 0.37-
0.48%
y 0.55-0.65
y 0.25-0.35
y 150-450x109/L
y 9.3x109/L(Normal)
y 4.4x1012/L(Normal)
y 127g/c(Normal)
y 38%
(Abovenormal)
y 0.83(Abovenormal)
y 0.17(Belownormal)
y 249x109/L(Normal)
Monitor theconditionof thepatient
Monitorvital signs
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V. MEDICAL-SURGICAL MANAGEMENT
1. Procedures
Procedure and
Date
Indication Nursing
Responsibilities(pre, intra, post)
Peritoneal dialysis
Started Last
January 24, 2011
-Primarily used is to
provide an artificial
replacement for lost
kidney function in
people with renal
failure.
-Pt with Chronic oracute Kidney
Disease
-Monitor Vital signs
especially the BP of
the Patient
chemotherapy
decisions.
January 27,2011
y Blood Urea
Nitrogen
y Creatinine
y Potassium
y Cholesterol
y Triglycerides
y
HDL
y LDL
y 7.0-23.0
mgs/dl
y 0.5-1.7mgs/dl
y 3.6mmol/L
y 150-200mg/dl
y 44-148mg/dl
y 26.63
mgs/dl
y
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2. Pharmacotherapeutics/medicines
Generic Name
(Brand name)Classification
Indication(Client
Specific)Dosage
Frequency
Nursing
Responsibilities/Implication(pre, Intra, Post)
Furosemide
(Lasix)
Loop Diuretic
-Hypertension-80mg, IV-Ever 6 hours (q6)
-Observed 10Rs in givingmedications to the patient-ensuring it is prescribedbefore administration andrecording patientobservations for any adverseeffects, a rise in heart ratecan be fairly common-Asses pt for any allergy toFurosemide-Monitor Vital sign.-Readjust dosage graduallyas BP responds-Give early in the day so thatincreased urination will notdisturb sleep-Do not exposed to light,which may discolor solution-discard diluted solution after
24 hours.-Measure and record weightto monitor fluid changes.-Arrange to monitor serumelectrolytes, hydration, liverand renal function.-Arrange for potassium-richdiet or supplementalpotassium as needed.
Calcium
Carbonate
(Apo-Cal)
Antacid
-Symptomatic relief of
upset stomach
associated with
hyperacidity;
-Dietary supplement
when calcium intake
-Observed 10Rs in givingmedications to the patient-Assess pt for any allergy tocalcium-Monitor Vital signs-Do not administer oral drugswithin 1-2 hour of antacid
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is inadequate
-1 tablet, P.O
-TID
administration.-Have patient chew antacidtablets thoroughly beforeswallowing; following with aglass of water or milk
-Give calcium carbonateantacid 1 and 3 hours aftermeals and at bedtime
Acetylcysteine
(Mucomyst)
Mucolytic
-Mucolytic adjuvant
therapy for abnormal,
viscid, or inspissated
mucus secretions.
-200mg sachet, PO
-Every 12 hours (q12)
- Observed 10Rs in giving
medications to the patient
- assess pt for any allergy to
Acetylcysteine.
-Monitor Vital signs
-Inform patient that he may
experience these side effects:
increased productive cough,
nausea, GI upset.
-Instruct patient to reportdifficulty of breathing ornausea
Ferrous Sulfate(Feosol)
Iron Preparation
-Prevention andtreatment of iron
deficiency anemia
-1 tablet, PO
-OD
- Observed 10Rs in givingmedications to the patient
- assess pt for any allergy to
ingredient, sulfite;
hemochromatosis,
hemosiderosis, hemolytic
anemia; normal iron balance.
-Monitor Vital signs
-Give drug with meals
-Warn patient that stool may
be dark or green-Inform patient that he may
experience these side effects:
GI upset, nausea, vomiting,
diarrhea or constipation.
-Instruct patient to report GI
upset, lethargy, rapid
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respirations and constipation
Aliskiren(Tekturna)
Antihypertensive
-Treatment ofhypertension, alone or
with other
antihypertensives
-150 mg, PO
-OD
- Observed 10Rs in givingmedications to the patient
- assess pt for any allergy to
any content of the drug.
- Monitor Vital signs
- Monitor serum potassium
level periodically
- Monitor Patient also
receiving furosemide for
possible loss of diuretic
effects.
Continue other hypertensive
drug as needed to control
blood pressure
-Advice patient to take drug
once a day, at about the
same time each day. If a dose
is miss, take it as soon as
remembered; then resume
the usual schedule the nextday. Do not make up missed
doses. Do not take more than
one dose each day
-Store the drug at a room
temperature in a dry place.
-Inform the patient that he
may experience low blood
pressure if also taking
diuretics, if become
dehydrated, or if the patienthas dialysis treatments.
-Instruct patient to report
difficulty breathing; swelling of
face, lips, or tongue;
dizziness or light headedness
-Instruct patient to report
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difficulty breathing; swelling of
face, lips, or tongue;
dizziness or light
headedness.
Tramadol
(Tramal)
Analgesic
-For patients with
moderate to moderately
severe chronic pain not
requiring rapid onset of
analgesic effect.
-50mg,PO
-Every 8 hours (q8)
- Observed 10Rs in giving
medications to the patient
- assess pt for any allergy to
any content of the drug.
- Monitor Vital signs
-While not nearly as
dangerous a respiratory
depressant as other opioids
or opiates, at high doses, this
may be a consideration.
-Tramadol is metabolized in
the liver. Nurses are
cautioned to doublecheck for
meds that inhibhit liver
function, or watch for
adminstration on hepatic
compromised patients.
-Tramadol lowers the seizure
threshold. It also synergizeswith SSRI's and tricyclics, and
may have a stronger effect on
epileptics. Ergo, seizure
warning.
Renogen
(Epogen )Hematopoietic
-Treatment of anemia
associated w/ chronicrenal failure (CRF)
-4000u, SQ
-once a week
-Observed 10Rs in giving
medications to the patient- assess pt for any allergy to
any content of the drug.
- Monitor Vital signs
-Monitor renal studies:
urinalysis, protein, blood, BUN,
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VI. NURSING CARE PLAN
CUES NURSING
DIAGNOSIS
OBJECTIVES OF
CARE
PLAN OF
INTERVENTION RATIONALE
EVALUATION
SCHEME
Subjective:
Hindi pa
ako nakaka-
ihi simula
A1:
Impaired
Urinary
P1:
Within the shift,
the pt will able
- Will Establish
rapport with the
patient
G1:
Reassess th
urinary
creatinine; input-output ratio;
report drop in output to
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kaninang 12
am
Objectives:
-Received pton bed in a
semi-fowlers
position
-Conscious,
coherent and
communicati
ve, oriented
to time,
place andperson
-with O2 via
nasal
cannula @
2Lpm
-with IVF of
#8 D5 0.3
Nacl x KVOhooked @
left
metacarpal
vein
received @
290 cc level
running at a
rate of 3
gtts/min.,
intact andinfusing well
-with
Tenckhoff
catheter
connected
Elimination
related to
incompetent
bladder
distention
secondary to
chronic kidney
disease
A2:
Risk for
infection
related to
retention of
urine orinduction of
urinary catheter
able to void 20
to 30 cc per
hour.
P2:
Within the shift
the pt will report
the risk factors
associated with
infection andprecautions
needed.
-Will monitor
and record vital
signs
-Will assess the
patientsabdomen
-Will keep the
linens clean and
wrinkle free
-Will advice the
patient to ask all
visitors and
personnel towash their
hands before
approaching
him
-Will advice the
patient to limit
visitors
-Will instruct the
patient and the
family members
the signs and
symptoms of
infection
-Will assess the
patient on the
clinical
manifestation of
infection such
as fever,
through vital
signs.
elimination o
the patient
G2:
Reassess thpatients
learning
related to th
risk factors
associated
with the
infection and
precautions
needed.
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@ patients
umbilical
area of the
abdomen,
potent for
peritoneal
dialysis
-(+) slightly
distended
abdomen
-with initial
vital signs as
of February
3, 2011,4pm:
Temp: 36C
PR: 96, 1+
RR: 12 cpm,
regular,
bilateral chest
expansion.
BP: 120/80
mmHg