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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


9/16

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


10/16

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


11/16

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.


-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


ingredient, sulfite;

hemochromatosis,

hemosiderosis, hemolytic

anemia; normal iron balance.


-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


12/16

respirations and constipation

Aliskiren(Tekturna)

Antihypertensive

-Treatment ofhypertension, alone or

with other

antihypertensives

-150 mg, PO

-OD

- Observed 10Rs in givingmedications to the patient


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


13/16

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




-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



-Monitor renal studies:

urinalysis, protein, blood, BUN,


14/16

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


15/16

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.


16/16

@ 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

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