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I. INTRODUCTION

Overview of the Case

Chronic Kidney Disease is the failure of the kidneys to perform the function of

cleansing the blood of waste products. The primary method of cleansing the body of

waste involves the liver forming urea and the kidneys filtering this product out of the

blood to be excreted in the urine. Blood urea nitrogen and creatinine are nitrogenous

wastes, end products of protein metabolism. The amount of urea in the blood can be

measured with a blood test called blood urea nitrogen (BUN). Creatinine levels also can

be measured in the blood. BUN and creatinine levels are utilized to measure kidney

function. A high level in the blood is called uremia, literally meaning urine in the blood.

Urea is eventually converted to ammonia, leading to toxicity and related symptoms in allsystems of the body.

End Stage Renal Disease is already the 7th leading cause of death among

Filipinos? It is said that a Filipino is having the disease hourly or 120 Filipinos per million

populations per year. This shows that about 10, 000 Filipinos need to replace their

kidney function. Unfortunately though only 73% or about 7, 267 patients received

treatment. An estimate of about a quarter of the whole population probably just died

without receiving any treatment.

The kidneys play key roles in body function, not only by filtering the blood and

getting rid of waste products, but also by balancing levels of electrolyte levels in the

body, controlling blood pressure, and stimulating the production of red blood cells.

Treatment for chronic kidney failure, also called chronic kidney disease, focuses

on slowing the progression of the kidney damage, usually by controlling the underlying

cause. Chronic kidney failure can progress to end-stage kidney disease, which is fatal

without artificial filtering (dialysis) or a kidney transplant.

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Objective of the Study

As a third year (N104) nursing student of Liceo de Cagayan University, within two

days of nursing intervention on a client with Chronic Kidney Disease of Northern

Mindanao Medical Centre, I will be able to conduct a thorough and comprehensivestudy of the assigned patient according to the data that was gathered by conducting a

series of interviews. The condition of the aforementioned will augment and free of

possible complications from the disorder.

The completion of this case study enables the proponent to do the following:

1. To organize my patients data for the establishment of good background

information

2. To show the family history as well as the history of past and present illness for

the knowledge of what could be the predisposing factors that might contribute to

the patients illness

3. To trace the psychological development of the patient through the analysis of

different developmental theories with comparison of the patients data

4. To review Patients Chart and carry out Medical Orders; thus, relate these

interventions to the alleviation of the Patients health condition

5. To present the different results of the patients diagnostic exams together with

the comparison of normal values for the understanding of what changes during

the disease

6. To discuss the Anatomy, Physiology and Pathophysiology of the Patients health

condition

7. To present the data from the nursing assessment performed on the patient using

the cephalocaudal approach for the good overview of her over-all health

8. To identify Patients Clinical Manifestations as basis for a specific, measurable,

attainable, realistic and time-bounded Actual and Ideal Nursing Care Plans.

9. To impart appropriate health teachings specifically for the patient to promote

wellness and appropriate discharge plan

10. To have an over-all conclusion and recommendation about the care study

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Scope and limitation

The case presentation merely covers data that have been gathered through

interview per assessment tool and chart referral on the day of the assessment phase in

loading assigned patients and in the succeeding days of the rotation, in the care

formulated and intervened to its progress as the weeks rotation ended. Thus, it is

limited to the days in the rotation the student nurse interacted with the client in the hope

to gather the necessary data to support the presentation which is not enough to acquire

a bulk of specific details.

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II. HEALTH HISTORY

Patients Profile

Clients Name: Patient EBG

Age: 80 years old

Address: Kalinaw Dampias, Binuangan, Misamis Oriental

Civil Status: Married

Spouse: Mrs. CRG

Sex: Male

Job: Farmer

Nationality: Filipino

Religion: Roman Catholic

Birthday: May 7, 1931

Height: 167.74 cm (55)

Weight: 82 Kilogram

Allergy: No Known Food and Drug Allergies

Educational Attainment: High School Graduate

Admitting Physician: Melissa Suzanne Y. Abamongan, M.D.

Date of Admission: July 30, 2011

Time of Admission: 7:30 in the morning

Chief Complaint: Prior to admission, patient EBG from Binuangan Misamis

Oriental complains of shortness of breath. Patient then

sought consult and was admitted for the first time in Northern

Mindanao Medical Centre

Admitting Diagnosis: Chronic Kidney Disease secondary to Diabetes Mellitus

Nephropathy

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Family Health History

During the interview, there were no traced of underlying condition of her family.

Most common illness experienced by the members of the family is only mild cough and

fever, and a medication bought on a nearBotika ng Bayan was their primary source to

medicate their illness. On both maternal and paternal sides of Patient EBG, his parents

are both diabetic and hypertension. So genetically, it comes on their blood line that they

are diabetic and hypertensive.

Personal Health History

Patient EBG is married with Mrs. CRG with 2 children, a professional teacher

from an elementary school and a government employee at Binuangan.. He smokes

occasionally and can consume 3-4 sticks of cigarettes, while he is a hard drinker of

liquor and can consume 1 case of beer every 24 hours. According to patient EBG, he

drinks a lot together with his friends and there were no days that they skip from drinking.

With no known food and drug allergies. Patient EBG had tried all the skilled works, from

driving a very huge truck, go farming and working in an auto-repair shop. Because of his

stressful work and due to the influence of friends, he then became a hard liquor drinker.

Hes a diabetic for almost 15 year and did not seek medical admission and no

maintenance of medication.

Past Medical History

Patient EBG has not yet experienced any admission at the hospital since birth.

During my interview he said that its his first time to be admitted in a hospital.

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History of present health illness

5 months prior to admission, patient EBG noticed to have a decrease in urine

output and it is below 500mL/day. No consult was done and no medications given.

Aging Pallor

The condition has tolerated until 3 days prior to admission, patient EBG

complains in loss of appetite.

Fever, still with decrease urine output

Until the night prior to admission, patient complains of difficulty in breathing and

unable to sleep man

Until morning prior to admission, the patient then brought to the hospital and then

admitted to have a better condition

Chief complains

Prior to admission, patient EBG an 80 years old from Binuangan Mis. Or.,

admitted for the first time in Northern Mindanao Medical Centre, complains of shortness

of breathing.

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III. DEVELOPMENTAL DATA

Robert Havighursts Developmental Tasks

DevelopmentalTasks

Description Passed orFailed

Justification

1. Adjusting todecreasing physicalstrength and health

Older adults also haveto adjust to decreasingphysical strength andhealth. The prevalenceof chronic and acutediseases increase inold age. Thus, olderadults may beconfronted with lifesituations that arecharacterized by not

being in perfecthealth,serious illnessand dependency onpeople.

Passed Our patient is aware about hishealth and is very cooperativeon the student nurses whoprovide care to him. He iscooperative in a way that hefollows the student nurses inprocedures like removing thecatheter. Also, when givingmeds, he does not refuse intaking the due meds given tohim.

2. Adjusting toretirement andreduced income

A centraldevelopmental taskthat characterized thetransition into old ageis adjustment toretirement. The periodafter retirement has tobe filled with new

projects, but ischaracterized by fewvalid culturalguidelines. Theachievement of thistask may beobstructed by themanagement ofanother task, living ina reduced incomeafter retirement.

Passed Our patient is not receivingpension but gets his incomefrom his farm (bananaplantation) and his photostudio. He is a photographerby experience according tohis grandchildren. His annualincome at his photo studio is

200,000 pesos.

3. Adjusting to death ofa spouse

Older adults maybecome caregivers totheir spouses. Someolder adults have toadjust to the death oftheir spouses. Afterthey have lived with aspouse for manydecades, widowhood

Passed When asked, the patientstated that his wife is alreadydead. He accepts that he isnow a widow. His deceasedwife's name is Susanna. Shedied on November 7, 2005due to cancer (not specified).They had 9 children.

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may force older peopleto adjust to loneliness,moving to a smallerplace,and learningabout businessmatters.

4. Establishing anexplicit affiliation withone's aged group

The development of alarge part of thepopulation into old ageis historically recentphenomenon tomodern cities. Thus,advancementsunderstanding of theaging process maylead to identifyingfurther developmental

tasks associated withgains and purposefullives for adults.

Passed Our patient is a member ofPHIC and a congregation ofJehovah's witnesses inPanabo City. According tohim, they have 7congregations in Panabo andit is composed of 100members per congregation.In their congregation, theirfocus is on teaching the goodnews of Jehovah. He also

mentioned that he has friendsof the same age groupnamely Helson Daclan whodelivers meds and OscarEmier.

5. Meeting social andcivil obligations

Older people mightaccumulate knowledgeabout life, and thusmay contribute to thedevelopment ofyounger people andthe society.

Passed Our patient tells stories abouthis childhood life to hisgrandchildren. He sharesexperiences to them whichserved as a guide andlesson.

6. Establishingsatisfactory physicalliving arrangements

Oder adults aregenerally challengedto create positivesense of their lives asa whole. The feelingthat life has order andmeaning results inhappiness.

Passed Our patient lives in asubdivision in a Panabo Citytogether with his daughter.

According to him, hisdaughter is the only one whois not married among hischildren. All eight had theirown families nonetheless hesometimes would visit them.

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Psychosocial theory (Erick Erikson)

Middle Adulthood: 65 and above

Ego Development Outcome: Integrity vs. Despair

Basic Strengths: Production and Care

Erikson felt that much of life is preparing for the middle adulthood stage and the

last stage recovering from it. Perhaps that is because as older adults we can often look

back on our lives with happiness and are contented, feeling fulfilled with a deep sense

that life has meaning and we've made contribution to life, a feeling Erikson called

integrity. On the other hand, some adults may reach this stage and despair at their

experiences and perceived failure.

This phase occurs during old age and is focused on reflecting back on life. Those

who are unsuccessful during this phase will feel that their life has been wasted and will

experience many regrets. The individual will be left with feelings of bitterness and

despair. Those who feel proud of their accomplishments will feel a sense of integrity.

Successfully completing this phase means looking back with few regrets and a general

feeling of satisfaction. These individuals will attain wisdom, even when confronting

death.

Justification:

My patient achieved happiness and contentment in his life based on his actions

and speeches. He is faithful and devoted to his religion. When asked what his principle

in life he said is, Mamatay man kun buhi, mapabilin kay Jehovah. He is ready to

accept death completely and he has shared his experiences to his beloved

grandchildren. Even though he accepted death fully but his faith and love for his

worshipped God never changed.

.

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Cognitive development theory (Jean Piaget)

Formal operational stage

The formal operational period is the fourth and final of the periods of cognitive

development in Piaget's theory. This stage, which follows the Concrete Operational

stage, commences at around 11 years of age (puberty) and continues into adulthood. In

this stage, individuals move beyond concrete experiences and begin to think abstractly,

reason logically and draw conclusions from the information available, as well as apply

all these processes to hypothetical situations. The abstract quality of the adolescent's

thought at the formal operational level is evident in the adolescent's verbal problem

solving ability. The logical quality of the adolescent's thought is when children are more

likely to solve problems in a trial-and-error fashion. Adolescents begin to think more as

a scientist thinks, devising plans to solve problems and systematically testing solutions.

They use hypothetical-deductive reasoning, which means that they develop hypotheses

or best guesses, and systematically deduce, or conclude, which is the best path to

follow in solving the problem. During this stage the adolescent is able to understand

such things as love, "shades of gray", logical proofs and values. During this stage the

young person begins to entertain possibilities for the future and is fascinated with what

they can be. Adolescents are changing cognitively also by the way that they think about

social matters. Adolescent Egocentrism governs the way that adolescents think about

social matters and is the heightened self-consciousness in them as they are which is

reflected in their sense of personal uniqueness and invincibility. Adolescent egocentrism

can be dissected into two types of social thinking, imaginary audience that involves

attention getting behavior, and personal fable which involves an adolescent's sense of

personal uniqueness and invincibility.

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IV. MEDICAL MANAGEMENT

Medical orders

July 30, 2011 (7:30AM) Rationale

Please admit patient at P1F3-MRI

Secured consent to care

DAT with aspiration precaution

IVF PNSS iL + 2amp D50 Glucose at10gtts/minute

Diagnostics

CBC with platelet count

Blood typing

U/A

For confinement and in need formedical attention

For legal purposes and to ensure thatthe client understands the nature oftreatment and procedures done are inaccordance to patients will

Able to take foods as wished withaspiration precaution to prevent fromchoking

NSS is a solution of common salt indistilled water, of strength of 0.9%. It iscalled normal saline because thepercentage of salt resembles that of thecrystalloids in the blood plasma. It is anisotonic solution. It is less irritating for thebody cells. With addition of D50 glucose,this is to prevent hypoglycemia andmaintain glucose level.

To test for loss of blood,abnormalities in the production ordestruction of cells, acute andchronic infections, allergies, andproblems in blood clotting andbleeding

Done to determine persons blood

type for blood transfusion ortransplant purposes, because not allblood types are compatible with eachother

A screening to detect renal andmetabolic diseases

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Na+, K+, BUN and Creatinine

Ca, Mg, Phosphorus and Albumin

Chest X-ray PA refer

ECG 12 leads

CBG every 2H

SGPT, SPT, Total billirubin

Therapeutics

D50 water i vial IV push

Furosemide 40g IVTT every 8 hourswith blood pressure precaution

To screen for an electrolyteimbalances

To determine if there is presence ofinfection and electrolyte imbalances

Use to help find problems with theorgans and structure inside the chest

To record electrical changes in theheart and also used to evaluatesymptoms such as chest pain,shortness of breath and palpitations

Done in a regular basis for diabeticpatients to determine the glucoselevel in the blood

A test used to measure the amountof the enzyme glutamate pyruvatetransaminase (GPT) in blood.Most commonly ordered to check forproblems of the liver

Given as an intravenous bolus topatients who have hypoglycemia andincreases blood serum glucose level

Used to eliminate water and saltfrom the body. works by blocking theabsorption of sodium, chloride, andwater from the filtered fluid in the

kidney tubules, causing a profoundincrease in the output of urine

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CaCO3 i tab TID PO

NaHCO3 i tab TID PO

Ketolog 2 tabs TID PO

NaHCO3 100meq IV push

NaHCO3 side drip with D50 water500cc + NaHCO3 100meq at20cc/hour (to consume in 24 hours)

Monitor vital signs q4H and refer

Antacid. Act as an activator in thetransmission of nerve impulses andcontraction of cardiac, skeletaland smooth muscles. It is essentialfor bone formation and blood

coagulation. It is also used areplacement of calcium in deficiencystates. It controls ofhyperphosphatemia in end-stagerenal disease without promotingaluminum absorption.

Alkalinizing agent. Acts as analkalinizing agent by releasingbicarbonate ions. It is used toalkalinize urine and promote

excretion of certain drugs inoverdosage situations.

Essential Amino Acid. Normalizes

metabolic process, promotesrecycling product exchange andreduces ion concentration ofpotassium, magnesium andphosphate.

Alkalinizing agent. Acts as analkalinizing agent by releasingbicarbonate ions. It is used toalkalinize urine and promoteexcretion of certain drugs inoverdosage situations.

Acts as an alkalinizing agent byreleasing bicarbonate ions. It is usedto alkalinize urine and promote

excretion of certain drugs inoverdosage situations in addition toD50 water it prevents hypoglycemia

To monitor and identify abnormalitiesfrom the patients normal state, andto establish basis for the effect of thetreatment and medications

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Strict I&O q shift

MHBR

To secure 2 u PRBC of patientsblood type to transfuse blood onceavailable in 6H with 8H apart

Evaluate clients fluid and electrolytebalance., also influence the choice ofthe fluid therapy; document clientsability to tolerate oral fluids andrecognize significant fluid losses

Promote proper ventilation

The most commonly transfusedblood component which can restorethe bloods oxygen-carrying capacity,specially for patients with bleedingproblem and anemia

July 30, 2011 (10:25AM) Rationale Human Albumin 20% IVTT every 12hours

Insert FBC attached to urobag

Give D50 water 1amp IV bolus NOW

Titrate prevent in IVF at 20gtts/minute

Give NaHCO3 drip (NaHCO3 100meq +D50 water 200cc) to run at 10cc/hr

Infuse Furosemide 40g IVTT every 6hours

Repeat ABG once NaHCO3 amp isconsumed

Repeat CBG determination after 1 hour

10:45PM

Give D50 water 1amp IV bolus NOW Repeat CBG 1 hour after

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JULY 31, 2011 (2:30AM) Rationale

Give 2 amp D50 water NOW

Repeat CBG 1 hour after

Diagnostics

For UTZ of the whole abdomen For 24 hour urine evaluation

Therapeutics:

Give NaHCO3 100cc bolus NOW Continua NaHCO3 drip with D50 water

at 20gtts/minute Continue present meds Vital signs every 4 hours Strict I and O every shift Transfuse blood once available with

congestion precaution Refer accordingly

7:50PM

Give para 300mg IVTT NOW Give Diphenhydramine i amp IVTT

NOW

Electrolytes. Treatment for hypokalemia,prophylaxis during treatment with diuretics

To establish a diagnosis of hepatitis Binfection and to assess immune statusin naturally infected and experimentallyvaccinated individuals

Used for immunization in the preventionof tetanus

To prevent the bacteria from producingtoxins and to remove anaerobicconditions

For maximum therapeutic effects, andprevention of complications

It is indicated as a source of water andelectrolytes. In general, used for fluid

replenishment or medication administration

Laboratory results

HEMATOLOGY REPORT

TEST RESULT REFERENCE

RANGE7-10-1111:44 AM7-12-1112:18PM

WBC High WBC count often means that an

infection is present in the body, while a lownumber can mean that a specific diseaseor drug has impaired the bone marrowsability to produce new cells.

19.4 20.0 10^3/uL (5.0-10.0)

RBC

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Decreased RBC is usually in anemia ofany cause with the possible exception ofthalassemia minor, where a mild orborderline anemia is seen with a high orborderline-high RBC. Increased RBC isseen in erythrocytotoxic state.

2.78 2.76 10^6/uL (4.2-5.4)

Hgb Decreased in various anemias, pregnancy,severe or prolonged hemorrhage withexcessive fluid intake. Increased inpolycythemia, chronic obstructivepulmonary disease failure of oxygenationbecause of CHF and normally in peopleliving at high altitudes.

7.6 7.5 g/dL(12.0-16.0)

Hct Decreased in sever anemias, anemia in

pregnancy, acute massive loss. Increasedin erythrocytosis of any cause and indehydration or hemoconcentration

associated with shock.

22.1 21.8 % (37.0-47.0)

Mean corpuscular volume Decreased in ion deficiency, thalassemia,

anemia of chronic diseas and leadpoisoning. Increased in folate deficiency,B12 deficiency and hypothyroidism

79.5 79.0 fL (82.0-98.0)

Mean corpuscular hemoglobin Levels below 27pg suggest conditions

such as anemia and iron deficiency.Levels above 33pg suggest possiblethyroid issues.

27.3 27.2 pg (27.0-31.0)

Mean corpuscular Hgb concentration Decreased MCHC values are seen in

conditions where the hemoglobin isabnormally diluted inside the red cellssuch as in iron deficiency anemia and inthalassemia. Increased MCHC calues

are seen in conditions where the Hgbis abnormally concentrated inside thered cells, such as in burn patients andhereditary spherocytosis, a relativerare congenital disorder.

34.4 34.4 g/dL (31.5-35.0)

Red cell distribution width In some anemias, such as pernicious

anemia, the amount of variation in RBCsize causes an increase in the RDW

14.3 13.8 % (12.0-17.0)

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Mean platelet volume New platelets are larger and an increase

in MPV occurs when increased numbersof platelets are being produced

9.8 9.9 fL (8.0-12.0)

Differential count 7-10-1111:44 AM

7-12-1112:18PM

Lymphocytes Increased with infections mononucleosis,

viral and some bacterial infections andhepatitis. Decreased in aplastic anemia,SLE and immunodeficiencyAIDs

6.4 6.7 (17.4-48.2)

Neutrophils Increased with acute infections, trauma, or

surgery, leukemia, malignant disease andnecrosis. Decreased with viral infections,bone marrow suspension and primarybone marrow disease.

89.3 85.3 (43.4-76.2)

Monocytes Increased with viral infections, parasitic

disease, collagen and hemolyticdisorders. Decreased with use ofcorticosteroids, RA and HIV infection

3.8 6.6 (4.5-10.5)

Eosinophils Increased in allergies, parasitic disease,

collagen disease, and subacute infections.Decreased with stress and use of meds.

0.4 1.4 (1.0-3.0)

Basophils Increase in acute leukemia and following

surgery or trauma. Decreased with allergicreactions, stress, parasitic disease anduse of corticosteroids

0.1 0.0 (0.0-2.0)

Platelet Both increases and decreases can point

to abnormal conditions of excess bleedingor clotting.

303,000 280,000 (150,000-

400,000)

BLOOD CHEMISTRY RESULT (7-10-11)

TEST RESULT REFERENCERANGE

Blood sugar (Fbs, Rbs, 2HPP)

Increased in DM, nephritis,hypothyroidism and infections.Decreased in hyperinsulinism,hyperthyroidism and hepatic damage.

309.0 mgs% (60-110)

Blood urea nitrogen Increased: renal failure, pre-renal

azotemia, shock, volume depletion,post-renal (obstruction), GI bleeding,stress, drugs (aminoglycosides, vanco

37.76 mgs% (4.6-23.4)

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etc). Decreased: starvation, liverfailure, pregnancy, infancy, nephroticsyndrome, overhydration.

Creatinine Increased: renal failure including pre-

renal, drug-induced (aminoglycosides,

vancomycin, others),acromegaly. Decreased: loss ofmuscle mass, pregnancy.

3.70 mgs% (0.6-1.2)

Potassium Increased in renal failure, acidosis, cell

lysis and hemolysis. Decreased inhyperparathyroidism, vit. D deficiency,GI losses and diuretic administration.

3.32 mmol/L (3.5-5.3)

Sodium Increased in hemoconcentration,

nephritis and pyloric obstruction.Decreased in alkali deficit, Addisonsdisease and myxedema.

127.30 mmol/L (135-145)

Note: no UA result was attached in the chart.

V. HUMAN ANATOMY and PHYSIOLOGY with PATHOPHYSIOLOGY

Anatomy and Physiology of Liver

The liver is the largest organ of the human body, weighs approximately 1500 g,

and is located in the upper right corner of the abdomen. The organ is closely associatedwith the small intestine, processing the nutrient-enriched venous blood that leaves thedigestive tract. The liver performs over 500 metabolic functions, resulting in synthesis ofproducts that are released into the blood stream (e.g. glucose derived fromglycogenesis, plasma proteins, clotting factors and urea), or that are excreted to theintestinal tract (bile). Also, several products are stored in liver parenchyma (e.g.glycogen, fat and fat soluble vitamins).

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Almost all blood that enters the liver via the portal tract originates from thegastrointestinal tract as well as from the spleen, pancreas and gallbladder. A secondblood supply to the liver comes from the hepatic artery, branching directly from theceliac trunk and descending aorta. The portal vein supplies venous blood under lowpressure conditions to the liver, while the hepatic artery supplies high-pressured arterial

blood. Since the capillary bed of the gastrointestinal tract already extracts most O2,portal venous blood has a low O2 content. Blood from the hepatic artery on the otherhand, originates directly from the aorta and is, therefore, saturated with O2. Blood fromboth vessels joins in the capillary bed of the liver and leaves via central veins to theinferior caval vein.

Basic liver architecture

The major blood vessels, portal vein and hepatic artery, lymphatics, nerves and

hepatic bile duct communicate with the liver at a common site, the hilus. From the hilus,they branch and re-branch within the liver to form a system that travels together in aconduit structure, the portal canal. From this portal canal, after numerous branching, theportal vein finally drains into the sinusoids, which is the capillary system of the liver.Here, in the sinusoids, blood from the portal vein joins with blood flow from end-arterialbranches of the hepatic artery. Once passed through the sinusoids, blood enters thecollecting branch of the central vein, and finally leaves the liver via the hepatic vein. Thehexagonal structure with, in most cases, three portal canals in its corners draining into

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one central vein, is defined as a lobule. The lobule largely consists of hepatocytes (livercells) which are arranged as interconnected plates, usually one or two hepatocytesthick. The space between the plates forms the sinusoid. A more functional unit of theliver forms the acinus. In the acinus, the portal canal forms the center and the centralveins the corners. The functional acinus can be divided into three zones: 1) the

periportal zone, which is the circular zone directly around the portal canal, 2) the centralzone, the circular area around the central vein, and 3) a mid-zonal area, which is thezone between the periportal and pericentral zone.

Sinusoids

Sinusoids are the canals formed by the plates of hepatocytes. They areapproximately 8-10 m in diameter and comparable with the diameter of normalcapillaries. They are orientated in a radial direction in the lobule. Sinusoids are linedwith endothelial cells and Kupffer cells, which have a phagocytic function. Plasma and

proteins migrate through these lining cells via so-called fenestrations (100-150 nm) intothe Space of Disse, where direct contact with the hepatocytes occurs and uptake ofnutrients and oxygen by the hepatocytes takes place. On the opposite side of thehepatocyte plates are the bile canaliculi situated (1 m diameter). Bile produced by thehepatocytes empties in these bile canaliculi and is transported back towards the portalcanal into bile ductiles and bile ducts, and finally to the main bile duct and gallbladder tobecome available for digestive processes in the intestine. The direction of bile flow isopposite to the direction of the blood flow through the sinusoids.

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Network of branching and re-branching blood vessels in the liver

The liver lobule with portal canals (hepatic artery, portal vein and bile duct), sinusoids

and collecting central veins.

Pressure distribution

Blood pressure in afferent vessels and pressure distribution inside the liver is

essentially similar for most species. Pressure in the hepatic artery, originating from thedescending aorta and the celiac trunk, is considered to be the same as aortic pressure.This includes a high pulsatile pressure between 120 and 80 mmHg with a frequencyequal to the heart rate. Vessel compliance causes a gradual decrease in pulsation asthe hepatic artery branches and re-branches inside the liver. Once at the sinusoidallevel, pulsation amplitude decreases to virtually zero and pressure drops toapproximately 2-5 mmHg. On the other hand, pressure in the portal vein, originatingfrom capillaries of the digestive tract, has no pulsation and a pressure of 10-12 mmHg.

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In the sinusoids, both portal venous and hepatic arterial pressure is 3-5 mmHg.Consequently, the pressure drop inside the liver is much less in the portal venoussystem than in the arterial system. The pressure drop from the collecting central veinsto the vena cava is then approximately 1-3 mmHg, fluctuating slightly with respiration.

Detailed view of liver sinusoidal structure.

Flow distribution

Total human liver blood flow represents approximately 25% of the cardiac output;up to 1500 ml/min. Hepatic flow is subdivided in 25-30% for the hepatic artery (500ml/min) and the major part for the portal vein (1000 ml/min). Assuming a human liverweighs 1500 g, total liver flow is 100 ml/min per 100 g liver. Comparing this normalizedflow rate to other species, it can be concluded that total liver blood flow is 100 130ml/min per 100 g liver, independent of the species. The ratio of arterial: portal bloodflow, however, is species-dependent. The hepatic artery originates directly from thedescending aorta, and is therefore saturated with oxygen. It accounts for 65% of totaloxygen supply to the liver. The hepatic artery also plays an important role in liver blood

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vessel wall and connective tissue perfusion. It also secures bile duct integrity. The bloodfrom the portal vein is full of nutrients derived from the intestine and allows thehepatocytes to perform their tasks. Blood from the hepatic artery and the portal vein

joins in the sinusoids. However, recent studies by others as well as our ownobservations have revealed that there are both common and separate channels for

arterial and portal blood. The hepatic artery perfuses the liver vascular bed in a 'spotty'pattern, while the portal vein perfuses the liver uniformly. The liver is able to regulatemainly arterial flow by means of so-called sphincters, situated at the in- and outlets ofthe sinusoids. One of the most important triggers for sphincter function is the need forconstant oxygen supply. If the rate of oxygen delivery to the liver varies, the sphincterswill react and the ratio of arterial: portal blood flow alters.

VI. ASSESSMENT (Nursing Review Chart II)

Vital signs:

Temp.: 38.7c Pulse: 74 bpm Respi:28 cpm BP:160/90 mmHg Height: 5 5 Weight: 82 kgs.

EENT:[ ] impaired vision [ ] blind [ ] pain[ ] reddened [ ] drainage [ ] gums[ ] Hard of hearing [ ] deaf[ ] burning[x] edema [ ] lesion [ ] teeth

Assess eyes, ears, nose,throat for abnormalities.

Facial edema

particularly on the

eyes; non-pitting

Dyspnea (SOB)

With occasional

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[ ] no problem

RESPIRATORY:[ ] asymmetric [ ] tachypnea[ ] apnea [ ] rales [x] cough[ ] barrel chest [ ] bradypnea

[ ] shallow [ ] rhonchi[ ] sputum [ ] diminished [x] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [ ] cyanotic

Assess resp. rate, rhythm,pulse blood breath sounds,Comfort [ ] no problem

CARDIOVASCULAR:[ ] arrhythmia [ ] tachycardia[ ] numbness [ ] diminished pulses[ ] edema [ ] fatigue [ ] irregular

[ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain

Assess heart sound, rate, rhythm,pulse, blood pressure, circulation,fluid retention, comfort[x]no problem

GASTROINTESTINAL TRACT:[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] pain

Assess abdomen, bowel habits,swallowing bowel sounds,Comfort [x] no problem

GENITO-URINARY AND GYNE:[ ] pain [ ] urine color[ ] vaginal bleeding[ ] hematuria [ ] discharge[ ] nocturia

Warm to touch

Sweating

T = 38.7c

P = 74bpm

R = 28 cpm

BP = 160/90

mmHg

Edema on upper

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Assess urine frequency,control, color,odor, Comfort,gyne bleeding, discharge[x] no problem

NEURO:

[ ]paralysis [ ] stuporous[ ] unsteady [ ] seizures [x] lethargic[ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] grip

Assess motor, function,sensation, LOC,Strength, grip, gait, coordination,Speech [x] No problem

MUSCULOSKELETAL AND SKIN:[ ] appliance [ ] stiffness [x] itching[ ] petechiae [x] hot [ ] drainage

[ ] prosthesis [x] swelling [ ] lesion[ ] poor turgor [ ] cool [ ] deformity[ ] wound [ ] rash [ ] skin color[ ] flushed [ ] atrophy [x] pain[ ] ecchymosis [ ] diaphoretic [ ] moist

Assess mobility, motion, gait, alignment,joint function, skin color, texture, turgor,integrity [ ] no problem

SUBJECTIVE OBJECTIVE

Communication:[ ] hearing loss Comments: Hearing is good. Client[ ] visual changes is responsive and hears

[x] denied clearly when talked to.

[ ] glasses [ ] languages[ ] contact lens [ ] hearing aide

R LPupil size: 2-3mm [ ] speech difficultiesReaction: Pupil Equally Round and Reactive to Lightand Accommodation

Oxygenation:[x] dyspnea Comments : Mejo galisud lage ko[ ] smoking history ug ginhawa. Naa pud[x] cough koy ubo karon gamay

Resp. [ ] regular [x] irregularDescribe: Patient has difficulty in breathing

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[ ] deniedAs verbalized bythe client.

R: R lung is not symmetrical to left lungL: L lung is not symmetrical to right lung.

Circulation:

[ ] chest pain Comments: Patient did not[ ] leg pain experience any of[ ] numbness of such.extremities[x]denied

Heart Rhythm [x] regular [] irregularAnkle Edema: Edema noted; pitting grade: 4

Pulse Car. Rad. DP. FEM*R : + 74 bpm + not obtainL : + 74 bpm + not obtain

Comments: All pulse sites are palpable.*If applicable

Nutrition:Diet : Diet as tolerated Aspiration precaution.[ ] N [ ] V Comments: Wala kayo ko ganaCharacter: mukaon. Gagmay ra kaayo[x] recent change in akong kinan-an..weight, appetite As verbalized by the client.[ ] swallowing

difficulty[ ] denied

[ ] dentures [x] none

Full Partial W/ Patient

Upper [ ] [ ] [ ]

Lower [ ] [ ] [ ]

Elimination:Usual bowel pattern [ ] urinary frequency1 times a day once a day[ ] constipation [ ] urgency

remedy [ ] dysurianone [ ] hematuria

Date of Last BM [ ] incontinence

07/12/11 [ ] polyuria[ ] Diarrhea [ ] foley in place

character : [ ] denied

Comments: Bowel sounds: normo-Bowel sounds are active bowel soundsnormoractive per Abdominal distentionauscultation. Present [ ] yes [x] no

Urine:(consistency, odor)Slightly hazy and dark

yellow with aromatic odor.

MGT. of Health & Illness:[ ]alcohol ___________[ ]smoking :_____________[ ] denied (amount, frequency)[ ] SBE: N/A Last Pap Smear: Not obtained LMP: N/A

Briefly describe the patients ability to follow treatments(diet, meds, etc.) for chronic health problems (ifpresent). Patient was irritable but able to followcompliance to medication and follows the right diet tobe eaten.

SUBJECTIVE OBJECTIVE

Skin Integrity:[x] dry Comments: Sige lage ko ug panga-.[x] itching tol, ambot lang pud ug[ ] other ngano ni.[ ] denied

As verbalized by the client

[ ] dry [ ] cold [ ] pale[ ] flushed [ ] warm[ ] moist [ ] cyanotic*rashes, ulcers, decubitus (describe size, location,drainage)

Edema was noted on the lower extremities; pittinggrade 4 and a blister formation on the right calf..

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Activity/Safety:[ ] convulsion Comments: Nang hupong akong tiil.[ ] dizziness dili ko kalakaw tungod[ ] limited motion of joints tungod aning buhag sa

sa akong ti-ilan, sakititunob.Limitation in ability to

[x] ambulate As verbalized by the client[x]bathe self[ ]other[ ] denied

[ ] LOC and orientation The patient is oriented toplace, time and date.

Gait: [ ] walker [ ] cane [ ] other

[ ] steady [ ] unsteady[ ] sensory and motor losses in face or extremities:

No sensory and motor losses in face or extremities.

[] ROM limitations: The patient has normal range ofmotion.

Comfort/Sleep/Awake:[x] pain Comment: Sakit ang hubag sa akong(Location paa.

frequency) As verbalized by the client[ ] nocturia[ ] sleep difficulties[x] denied

[x] facial grimaces[x] guarding

[ ]No other signs of pain:[ ] side rail release from signed (60 + years)N/A

Coping:

Occupation: HousewifeMember of household: Husband, children and grand-

childrenMost supportive person: Aileen Gabato (Daugther)

Observed non-verbal behavior: The patient is veryactive and alert during the interview

Person(Phone number): kept confidential

VII. NURSING MANAGEMENT

Ideal Nursing Management

Nursing Diagnosis: Activity intolerance related to fatigue and body malaise

INTERVENTIONS RATIONALE

Assess level of activity intoleranceand degree of fatigue and malaisewhen performing routine activity of

Provides baseline for furtherassessment and criteria forassessment of effectiveness of

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daily living

Assist with activities and hygienewhen fatigued

Encourage rest when fatigued orwhen abdominal pain or discomfortoccurs.

Assist with selection and pacing ofdesired activities and exercise

Provide diet high in carbohydrateswith protein intake consistent withliver function

Encourage supplemental vitamins AB-complex, C and K

interventions.

Promotes exercise and hygienewithin patients level of tolerance

Conserves energy and protects theliver

Stimulates patients interest inselected activities.

Provides calories for energy andprotein for healing

Provides additional nutrients

Nursing Diagnosis: Imbalance nutrition; less than body requirements related to

abdominal discomfort and anorexia

INTERVENTIONS RATIONALE

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Assess dietary intake and nutritional

status through diet history and diary,daily weight measurements andlaboratory data.

Assist patient in identifying lowsodium foods.

Elevate the head of bed duringmeals

Provide oral hygiene before mealsand pleasant environment for mealsat mealtime

Offer smaller, more frequent meals

Identifies deficits in nutritional intakeand adequacy of nutritional state

Reduces edema and ascitesformation

Reduces discomfort from abdominaldistention and decreases sense offullness produced by pressure ofabdominal contents and ascites on

the stomach

Promotes positive environment andincreased appetite; reducesunpleasant taste.

Decreases feeling of fullness andbloating

Nursing Diagnosis: Fluid volume excess related to decrease renal function and

inability to excrete fluids and electrolytes

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INTERVENTIONS RATIONALE

Restrict sodium and fluid intake ifprescribed

Record intake and output regularlydepending on response tointerventions and on patient acuity

Measure and record abdominal girthand weight daily

Explain rationale for sodium and fluidrestriction

Elevate edematous extremities

Minimizes formation of ascites andedema

Indicates effectiveness of treatmentand adequacy of fluid intake

Monitors changes in ascitesformation and fluid accumulation

Promotes patients understanding ofrestriction and cooperation with it

To reduce edema and promotevenous return

S O A P I ES Sakit kau akong hubag sa paa. as verbalized by the client

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O redness, pain scale 7/10 pallor guarding Temp 38.7c

irritable warm to touch restless

A Acute pain related to inflammation of the dermal and subcutaneous layerof the skin

P Long term:Within eight hours of clinical rotation client will be alleviatedfrom discomforts brought about by pain

Short term:At the end of fifteen minutes client will verbalize reductionand or controlled pain

I 1.Asses level of pain through pain scale

To obtain baseline data and measure amount of pain.

2.Assist client to a comfortable position and provide a non irritatingenvironmentHelps reduce pain and provides conducive environment

3.Assist into non pharmacological pain managementDiverts attention to pain causing relief

4. Monitor vital signs-usually altered during pain assist into relaxationexercises

To reduce aggravation of pain.

5. assist into relaxation exercisesTo reduce aggravation of pain.

E Long term: At the end of eight hours client experienced relief ofdiscomforts thus long term goal is met

Short term: At the end of fifteen minutes client verbalized reduction ofpain per cooperation and participation during the implementation phase

S O A P I ES Mejo galisod lage ko ug ginhawa as verbalized by the client

O Respiratory Rate 28

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shallow breathing lip pallor gasps for air nasal flaring weak

lethargic

A Ineffective breathing pattern related to abdominal distention andcompression of lungs.

P Long term: Within fifteen minutes client will obtain an o2 sat of 99-100%

Short term: At the end of five minutes client will manifest normal breathingcycle 12-20 cpm

I 1.Assess v/s especially RRTo obtain baseline data and determine the nursing action toimplement

2. Raise the head of bed or place in high fowlers positionTo increase lung expansion

3. Monitor Abg levelsTo determine level of o2 saturation

4. Encourage breathing techniques, purse lip breathingTo facilitate breathing and allows sufficient flow of oxygen to lungs

5. Encourage adequate rest

To limit fatigue

E Long term: At the end of fifteen minutes client obtained an o2 sat of99%, therefore goal is met.

Short term: At the end of five minutes, client obtained and showednormal breathing pattern, with an RR of 17cpm, therefore goal is met

S O A P I ES Naghupong ang ako mga tiil. as verbalized by the client

O pitting edema on lower extremities; grade four

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increase in size of the gastrocnemeus region increase in weight skin warm to touch tightness of skin

A Fluid volume excess related to localized retention of fluids at theextremities

P Long term: Within two days of clinical rotation client will display reducededema on site

Short term:At the end of eight hours clinical rotation client willdemonstrate understanding of the necessary interventions.

I 1. Restrict sodium and fluid intake if prescribedMinimizes formation of edema and reduce fluid retention

2. Record intake and output regularly depending on response to

interventions and on patient acuityIndicates effectiveness of treatment and adequacy of fluid intake

3. Measure and record abdominal girth and weight dailyMonitors changes in ascites formation and fluid accumulation

4. Explain rationale for sodium and fluid restriction.Promotes patients understanding of restriction and cooperation withit

5. Provided with adequate activity, positive changes as able and assist

with repositioning every 2HTo prevent accumulation in dependent areas

E Long term: At the end of two days clinical rotation client displayeddecrease in size of edema.

Short term: At the end of eight hours intervention client demonstratedunderstanding and significance to adherence to instructions.

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Drug Study

Name of DrugGeneric/Brand

DateOrdered

Classification Dose/Frequency/

Route

Mechanism ofAction

SpecificIndication

Contraindication

Essentialeforte

7-10-11 Hepaticprotectors

Icap TIDPO

Normalizesthe metabolismof lipids andproteins,improvesthe detoxification function ofthe liver,restores thecellularstructure of the

liver andretards theproducing ofconjunctivetissue.

Indicated forthe treatmentof fattydegenerationof theliver, hepatitis(including toxichepatitis, liverdamagecaused bymedicines or

alcoholabuse), cirrhosis of the liver,disturbancesin liver functionassociatedwith differentillnesses.

Do not useEssentialein hypersensitivi-ty or allergy toany ingredientsof thepreparation. Theapplication ofEssentiale innewborn childrenis not safe.

Duringpregnancywomen arerecommended toconsult theirhealth careprovider prior totaking Essentiale

Inccapdarera

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Drug StudyName of Drug

Generic/Brand

DateOrdered

Classification Dose/Frequency/

Route

Mechanism ofAction

SpecificIndication

Contraindication

Spironolactone(Aldactone)

7-10-11 Potassium-sparing diuretic

25mg itabBID PO

Spironolactoneinhibits theaction ofaldosteronethereby causingthe kidneys toexcrete salt andfluid in the urinewhile retainingpotassium.Therefore,spironolactoneis classified as

a potassium-sparing diuretic,a drug thatpromotes theoutput of urine(diuretic) whileallowing thekidneys to holdonto potassium.

Removesexcess fluidfrom the bodyin congestiveheart failure,cirrhosis of theliver,and kidneydisease and totreat elevatedblood pressureand for treating

diuretic-induced lowpotassium(hypokalemia)

Anuria, acuterenalinsufficiency;progressingimpairment ofkidney function,hyperkalemia;pregnancy andlactation.

Ssinhdcdravimirm

pirg

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VIII. Referrals and Follow-up

Referral and Follow-up Ra

Medication Instruct the patient and the family to followthe home medications as prescribed by thephysician

Explain each purpose of the medication Instruct the client not to take over-the-counter

drugs without doctors knowledge Explain the side effects or adverse reaction

on each medication. Report immediately assoon as there is an occurrence or such

Inculcate to the mind of the patient to complyall the medications prescribed at the ordereddosage, route and at the ordered time

Let the patient complete the whole course ofdrug therapy

Treatment regimen is

Knowledge about thebecome aware of whato participate in patien

Non-prescribed drugsynergistic effect in an

Explaining the side ethe family identify wha

Taking the drugs at thlimits the chance effectiveness

This can help the patiable to experience thmedication

Exercise Encourage early ambulation

Promote exercise to the patient especiallyROM

Instruct client to avoid strenuous activities forat least a week or month until fully recovered

Advise patient to have adequate rest andsleep

Practice deep breathing exercise

Walking is a good circulation, hence, pro

This will promote good

Activities that requirebe avoided to prevent

To gain back the lost normal state thus allo

This will help alleviapatient will encounter

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Treatment Explain the need of treatment after dischargeand must take it seriously to prevent suchcomplication to the patient

Explain to the family the condition of the

patient and give them factual informationabout the illness

To make the clientreatment does not onto be continued aresponsible towards m

To have better un

condition and to be should they give andtherapy

Hygiene Encourage having proper hygiene like takinga bath, meticulous hand washing, andbrushing of teeth every after meal

Encourage patient to continue hygienicmeasures practiced at present such aschanging of clothes everyday and changing

of underwear as often as necessary, keepingthe nails neatly trimmed, maintaining ownsupplies/items for personal necessities

Provide a calm and accepting

Hygiene provides copatient. It also increabeing, which is veryprocess

Keeping all practiceconsistent maintenanc

Calm, clean and nooccurrence of possiblplace for healing

Out Patient Inform the patient that follow-up check-up isimportant to have a continuous monitoringand care even after attainment of the coursemedical therapy

Advice the patient and the family to carry outfollow-up diagnostic examinations Instruct the family to report any unusual signs

and symptoms experienced by the patient

Through constant viswould still monitor thintervention availed by

This is to evaluate tpatient to the treatme This will help detect e

recurrence of disease

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Diet Encourage the client to eat variety of

nutritious foods like fruits and vegetables

once instructed by the physician

Instruct client to take vitamins as ordered

Advise client not to skip meals and have a

regular eating pattern/schedule

Tell the patient not to take foods

contraindicated by the client

To maintain and prom

To boost the bodys im

Regular interval of m

good dietary plan

To prevent the occurr

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IX. Evaluation and Implication

Category Poor

(1)

Fair

(2)

Good

(3)

Justification

1. Duration of illness

x

It has been six months since he

has been having lower extremityedema

2. Onset of illnessx

Having edema could have beenavoided by having good hygiene

3. Predisposing factorx

Race and location predisposePatient R to getting cirrhosis

4. Precipitating factor

x

Economic status and lifestyleprecipitates Patient R in getting

cirrhosis, these could have beenprevented by simple hygiene andprevention methods

5. Willingness to takethe medications orcompliance totreatment

xPatient R is very willing to take hermedications. She knows the goodeffects of drug and intravenoustherapy

6. Environmentx

Patient R was admitted at P1F3female reverse isolation ward

7. Family support

x

There were only 2 members of thefamily were present in the ward.Her sister and her daughter werethe only supportive persons thattime

Calculations 3x1

=3

3x2

=6

3x1

=3

3 + 6 + 3 = 12

12/7 = 1.7

Ranges:

1.0 - 1.5 = Poor

1.5 2.5 = Fair

2.5 3.0 = Good

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Patient R condition has been with her for 6 months before she choose to seek

treatment. She took for granted the worsening of her condition. She could have been

prevented the complications brought about by her condition if she had consulted a

health care professional immediately. Also simple observance of good hygiene could

have been to prevent him from contracting the infection of Liver Cirrhosis. On the other

hand, patient and other members of the family seek medical care; family support and

good compliance of medication were observed. Through this, the prognosis has come

up to the fair category.

The entire two days exposure at pediatric ward assigned to a client with Pediatric

Community Acquired Pneumonia has thought me a lot of things. That is, understanding

the entire pathogenesis of the disorder its affectation and what approach are to be

implemented. Thus, consequently an improvement of clients condition is achieved with

the help and assistance of the team of caregivers implementing effective plan of care

including active participation of the client and significant other. Therapeutic relationship

and communication between the caregivers and the client with the significant others

contributed to the achievement of the set goal. Personally my nursing skills and

interpersonal relationship with the people Ive worked with has improved accordingly in

the experience of the exposure.