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 client's grandparents. Hypertension is inherited by the client's
mother. On the clients paternal side are insulin dependent Diabetes
mellitus (DDM also known as Type 1 diabetes) and Chronic kidney
disease (CKD). Last 2008, the client's father died due to these health
problems. The client's sister had Pregnancy nduced Hypertension
(PH) while the client's brother is alive and well (A/W). t was shown
that the patient is now has insulin dependent Diabetes mellitus
(DDM also known as Type 1 diabetes) and Chronic kidney disease
which is the same health problem the patient's father had.

G. Socio-Economic History

FamiIy Member Occupation MonthIy Income

R.M.S.A
(pt's 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 client's father died last 2008. R.M.S.A's
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.





H. Psychosocial Assessment
Patient's Age: 46 yrs. Old
Developmental Stage: Middle Adulthood
Developmental Crisis: Generativity vs. Stagnation
Developmental Virtue: Care
Developmental Task: Being creative and productive; establishing the next
generation

n Erik Erikson's 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 patient's relatives visit him as often as they can, to show them how
much they care and love him. The patient is a graduate of nformation
Technology (T) 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 patient
wasn't 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 can't 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.

. Functional Assessment


J. Review of Systems and Physical Examination
$$%M R.O.$ P.
1. General
"Wala pa
naman
pagbabago,
pero feeling

O Awake and conscious
O Ambulatory with
minimal assistance
O With minimal
ko medyo
pumayat ako,
kasi hndi ako
masyado
kumakain

movement
O T= 36 C
O RR= 12 cpm, regular,
bilateral chest
expansion
O PR= 96, 1+
O BP= 120/80 mmHg


2. ntegument

"Eto medyo
dry ang balat
ko







"Okay naman,
wala naman
nagiba, ganun
pa din sa
dati.





Skin:

O (+)Dry skin on both
upper and lower
extremities
O Fair skin
O (-)hyperpigmentation
O (-) maculopopular
rashes
O Warm to touch
,ir:
O Color: Black
O (+) Normal hair
distribution
O (-) Presence of
parasites


,ils:
O Round, hard nails
with pink nail beds
O Capillary refill is < 3
seconds


3. Head
"Hindi naman
masakit ang
ulo ko ngayon
and haven't
experience
any head
injuries so far
O Smooth,
Symmetrical, firm
O (-) Lesions on the
scalp
O Normocephalic
O Temporomandibular
joint felt bilaterally
with full ROM

4. Eyes
"Hindi na ako
nakakakita sa
right eye ko

" don't wear
eye glasses or

O Round iris
O Bulbar conjunctiva
clear with tiny vessels
visible
O Nontender lacrimal
apparatus
contact lense
kahit dati pa


5. Ears

"Hindi naman
sumasakit
ang tenga ko

"Cotton Buds
ang gamit ko
panlinis


O Passed whisper test
O (-) tenderness
O (-) discharge on
external ear



6. Nose and Sinuses



"Wala naman
ako sipon
ngayon



O (-) nasal flaring
O (-) nasal discharge
O (-) lesion in turbinates
and septum
O Pink and moist
mucosa with no
lesions
O Sinuses clear upon
illumination

7. Mouth and Throat
"okay naman,
hindi naman
masakit o
kakaiba

O Pharyngeal tonsils
not inflamed
O Moist lips
O (-) lesions on lips
O (-) hoarseness

8. Neck
"Hindi naman
masakit
pagginagalaw
ko and aking
neck
O (+) full ROM
O (-) cervical lymph
node enlargement
O Smooth, firm and
non-tender thyroid

9. Breast and Axilla
"Pareho lang
naman
katulad dati,
hindi naman
masakit

O (-) dimpling
O (-) discoloration
O (-) axillary lymph
node enlargement
O Flat, pale brown
areola

10. Respiratory
"wala naman
ako ubo
ngayon
O (-) cough
O (-)Crepitus
O (-)wheezing
O Symmetrical thoracic

" have no
history of any
respiratory
related illness

expansion
O RR= 12 cpm, regular,
bilateral chest
expansion.
11. Cardiac
"Hindi naman
ako
nahihirapan
huminga
O PR= 96, 1+
O (+) apical pulse felt at
5
th
CS LMC line
O dentical apical and
radial pulse

12. Gastrointestinal "minsan wala
ako gana
kumain

"hindi pa ako
nakakapagba
was ngayon


O (-) rashes
O Round, flabby
abdomen
O (-) mass
O (+) slightly distended
abdomen
13. Urinary
"Eto may
Chronic
Kidney
disease ako,
hindi pa ako
nakakaihi
ngayon eh


O Urine color: amber
yellow
O (+) bladder distention

14. Genitalia
"okay naman,
wala naman
problema

O (+)rashes
O No lesions and
inflammations noted

15. Peripheral
Vascular
"Wala din
naman
problema

O (-)jaundice
O (-) Pallor
O (-) lesions
O Capillary refill <3
seconds

16. Musculoskeletal
"Hindi ko pa
masyado
nagagalaw ng
maayos yung
right arm and
leg ko, kasi
nastroke ako
last week
O (-) Weakness
O (-) full ROM on lower
extremities
O (-)full ROM on upper
extremities
O Muscle strength
grading: no. 2 or poor
ROM


17. Neurologic

"Na-stroke
ako last week
lang


O Oriented to time,
place and person
O Responds to
questions and
statements
appropriately
18. Hematologic "Hindi naman
ako anemic
O (-) bruising
O (-)bleeding
19. Endocrine
"hindi naman
ako pawisin
na tao
O (-) excessive
sweating
O (+) heat and cold
tolerance

20. Psychiatric

"ahh, hndi
naman pa
naman ako
nagiging
makalimutin
kahit
tumatanda na
ako


NO P.E.



III. PA%OP$IOLOG
Diabetes MeIIitus

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. t 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.

n 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 nsulin Dependent Dabetes Mellitus (DDM) or Juvenile
Diabetes.
erebrovascuIar accident
Cerebrovascular accident or stroke (also called brain attack) results from sudden interruption of
blood 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 vessel
by cerebral thrombosis or embolism or hemorrhage. Hemorrhage may occur outside the dura
(extradural), beneath the dura mater (subdural), in the subarachnoid space (subarachnoid), or
within the brain substance itself (intracerebral).
Risk factors for stroke include transient ischemic attacks (TAs) warning sign of impending
stroke hypertension, arteriosclerosis, heart disease, elevated cholesterol, diabetes meIIitus,
obesity, carotid stenosis, polycythemia, hormonal use, .V., drug use, arrhythmias, and cigarette
smoking. 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 a
single 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 natural
variations 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).
hronic 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 kidney
has an innate ability to maintain GFR by hyperfiltration and compensatory hypertrophy of the
remaining healthy nephrons. This nephron adaptability allows for continued normal clearance of
plasma solutes so that substances such as urea and creatinine start to show significant
increases 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 in
a patient, although still within the reference range, actually represents a loss of 50% of
functioning nephron mass.
The residual nephron hyperfiltration and hypertrophy, although beneficial, has been
hypothesized to represent a major cause of progressive renal dysfunction. This is believed to
occur because of increased glomerular capillary pressure, which damages the capillaries and
leads initially to focal and segmental glomerulosclerosis and eventually to global
glomerulosclerosis





IV. LABORA%OR $%&DI$ AND DIAGNO$%I$
Procedure/
Date
ndications Normal
Values/Findi
ngs
Actual
Findings/
nterpretation
Nursing
Responsibilitie
s



Hematology
(January
27, 2011)

The complete blood
count (CBC) is a
screening test,
used to diagnose
and manage
numerous
diseases. t can
reflect problems
with fluid volume
(such as
dehydration) or loss
of blood. t can
show abnormalities
in the production,
life span, and
destruction of blood
cells. t can reflect
acute or chronic
infection, allergies,
and problems with
clotting.
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
O WBC

O RBC


O Hemoglobin


O Hematocrit


Differential
Count

O Segmenters


O Lymphocytes


O Platelet
Count

O 5.0-10.0

O 4.6-6.2

O 123-
153G/L

O 0.37-
0.48%

O 0.55-0.65


O 0.25-0.35



O 150-450x
10
9/L


O 9.3x10
9/L

(Normal)
O 4.4x10
12/L

(Normal)

O 127g/c
(Normal)


O 38%
(Above
normal)



O 0.83
(Above
normal)
O 0.17
(Below
normal)

O 249x10
9/L

(Normal)


Monitor the
condition
of the
patient
Monitor
vital signs



V. MDIAL-$&RGIAL MANAGMN%
1. Procedures
Procedure and
Date
Indication Nursing
ResponsibiIities
(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 or
acute Kidney
Disease



-Monitor Vital signs
especially the BP of
the Patient

chemotherapy
decisions.


January 27,
2011
O Blood Urea
Nitrogen

O Creatinine

O Potassium

O Cholesterol

O Triglycerides

O HDL

O LDL
O 7.0-23.0
mgs/dl

O 0.5-
1.7mgs/dl
O 3.6
mmol/L
O 150-
200mg/dl
O 44-
148mg/dl
O 26.63
mgs/dl

O <150


O 30.6 mgs/dl
(Above
normal)
O 5.4 mg/dl
(Above
normal)
O 3.61mmol/L
(Normal)
O 190.3 mg/dl
(Normal)
O 65.8 mg/dl
(Normal)
O 35.7 mg/dl
( Above
normal)
O 141.4mgs/d
l


Monitor the
condition
of the
patient
Monitor
vital signs



. Pharmacotherapeutics/medicines
Generic Name
(Brand name)
Iassification
Indication(Iient
$pecific)
Dosage
Frequency
Nursing
ResponsibiIities/ImpIication
(pre, Intra, Post)

Furosemide
(Lasix)
Loop Diuretic

-Hypertension
-80mg, V
-Ever 6 hours (q6)


-Observed 10Rs in giving
medications to the patient
-ensuring it is prescribed
before administration and
recording patient
observations for any adverse
effects, a rise in heart rate
can be fairly common
-Asses pt for any allergy to
Furosemide
-Monitor Vital sign.
-Readjust dosage gradually
as BP responds
-Give early in the day so that
increased urination will not
disturb sleep
-Do not exposed to light,
which may discolor solution
-discard diluted solution after
24 hours.
-Measure and record weight
to monitor fluid changes.
-Arrange to monitor serum
electrolytes, hydration, liver
and renal function.
-Arrange for potassium-rich
diet or supplemental
potassium as needed.



aIcium
arbonate
(Apo-aI)
Antacid

-Symptomatic relief of
upset stomach
associated with
hyperacidity;
-Dietary supplement
when calcium intake

-Observed 10Rs in giving
medications to the patient
-Assess pt for any allergy to
calcium
-Monitor Vital signs
-Do not administer oral drugs
within 1-2 hour of antacid
is inadequate
-1 tablet, P.O
-TD

administration.
-Have patient chew antacid
tablets thoroughly before
swallowing; following with a
glass of water or milk
-Give calcium carbonate
antacid 1 and 3 hours after
meals and at bedtime



AcetyIcysteine
(Mucomyst)
MucoIytic

-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
-nform patient that he may
experience these side effects:
increased productive cough,
nausea, G upset.
-nstruct patient to report
difficulty of breathing or
nausea

Ferrous $uIfate
(FeosoI)
Iron Preparation


-Prevention and
treatment of iron
deficiency anemia
-1 tablet, PO
-OD
- Observed 10Rs in giving
medications 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
-nform patient that he may
experience these side effects:
G upset, nausea, vomiting,
diarrhea or constipation.
-nstruct patient to report G
upset, lethargy, rapid
respirations and constipation


AIiskiren
(%ekturna)
Antihypertensive

-Treatment of
hypertension, alone or
with other
antihypertensives
-150 mg, PO
-OD
- Observed 10Rs in giving
medications 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. f a dose
is miss, take it as soon as
remembered; then resume
the usual schedule the next
day. 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.
-nform the patient that he
may experience low blood
pressure if also taking
diuretics, if become
dehydrated, or if the patient
has dialysis treatments.
-nstruct patient to report
difficulty breathing; swelling of
face, lips, or tongue;
dizziness or light headedness
-nstruct patient to report
difficulty breathing; swelling of
face, lips, or tongue;
dizziness or light
headedness.


%ramadoI
(%ramaI)
AnaIgesic


-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. t also synergizes
with SSR's and tricyclics, and
may have a stronger effect on
epileptics. Ergo, seizure
warning



Renogen
(pogen o)
ematopoietic


-Treatment of anemia
associated w/ chronic
renal 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,




VI. N&R$ING AR PLAN
CUES NURSNG
DAGNOSS
OBJECTVES OF
CARE
PLAN OF
NTERVENTON

RATONALE
EVALUATON
SCHEME

$ubjective:
"Hindi pa
ako nakaka-
ihi simula


A1:
mpaired
Urinary

P1:
Within the shift,
the pt will able

- Will Establish
rapport with the
patient




G1:
Reassess the
urinary
creatinine; input-output ratio;
report drop in output to
<50mL/hr.
-Assess for CNS symptoms:
coldness, sweating, pain in
long bones
-Assess CV status: BP and
dur|rg lrealrerl; ryperlers|or
ray occur rap|d|y ;|ead|rg lo
ryperlers|or ercepra|opalry,
arl|ryperlers|ves ray oe
reeded
-Vor|lor serur |ror |eve|s,
lerr|l|r, lrarslerr|rg |eve|s; |ror
lrerapy ray oe reeded lo
preverl recurr|rg arer|a
-Vor|lor o|ood slud|es: 8uN,
creal|r|re, ur|c ac|d, p|ale|els,
w8C, prosprorus, polass|ur,
o|eed|rg l|re; lcl, lgo,
R8Cs,rel|cu|ocyles srou|d oe
crec|ed |r crror|c rera| la||ure



kaninang 12
am

Objectives:
-Received pt
on bed in a
semi-fowlers
position
-Conscious,
coherent and
communicati
ve, oriented
to time,
place and
person
-with O
2
via
nasal
cannula @
2Lpm
-with VF of
#8 D5 0.3
Nacl x KVO
hooked @
left
metacarpal
vein
received @
290 cc level
running at a
rate of 3
gtts/min.,
intact and
infusing 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 or
induction 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 and
precautions
needed.

-Will monitor
and record vital
signs
-Will assess the
patient's
abdomen
-Will keep the
linens clean and
wrinkle free
-Will advice the
patient to ask all
visitors and
personnel to
wash 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 of
the patient
G2:
Reassess the
patients
learning
related to the
risk factors
associated
with the
infection and
precautions
needed.

@ patient's
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