Case Study Dm Hpn Furuncle

A. Introduction Diabetes is a metabolic disorder characterized by a relative or absolute lack of the hormone insulin or insulin resistance, or both, which is impaired use of carbohydrates and altered metabolism of fats and protein. The word diabetes, from the Greek meaning “a siphon”, suggests urine formation, the word mellitus, from the Greek meaning “honey”, suggests sweetness. Type 2 diabetes was formerly known by a variety of partially misleading names, including “adult-onset diabetes,” obesity-related diabetes”, or non-insulindependent diabetes” (NIDDM). It is characterized by “insulin resistance” as body cells do not respond appropriately when insulin is present. This is more complex problem than type 1, but it is sometimes easier to treat, since insulin is still in many, especially in the initial years. Type 2 may go unnoticed for years in a patient before diagnosis, since the symptoms are typically milder and can be sporadic. The 3 cardinal signs of Type 2 DM are polyphagia (excessive hunger), polydipsia (excessive thirst), and polyuria (excessive urination). Other signs and symptoms of this disease are weight loss or gain, blurred vision, headaches lethargy, impotence, vaginal discharge, increased vaginal infection, increased wound healing time, orthostatic hypertension, decreased

pedal

pulses,

paresthesics,

and

decreased

sensations

(extremities). If these signs and symptoms were not given proper or enough attention, it may lead to the following complications” diabetic neurophatics (low of sensation in extremities), Charcot’s syndrome, Retinopathy, kidney failure, Atherosclerosis of the heart and large vessels and amputation. In 2004, according to the World Health Organization, more than 150 million people worldwide suffer from diabetes. Its incidence is increasing rapidly, and it is estimated that by the year 2025 this number will double. Diabetes mellitus occurs throughout the world, but it is common (especially Type 2) in the more developed countries. In 2002 there were about 18.2 million diabetics in the United States alone. Diabetes is in the top 10, and perhaps the top 5, of the most significant disease in the developed world, and is gaining insignificance. For at least 20 years, diabetes rates in North America have been increasing substantially. The Centers for Disease Control has termed the change an epidemic. The National Diabetes Information

Clearing house estimates that diabetes costs $132 billion in the United States alone every year. Diabetes

has

become

a

multibillion

dollar

industry

in

Europe

specifically; Type 2 Diabetes contributes to an annual economic cost of 129 billion among developed countries. Due to this, the traditional urine testing as the only method for gauging blood glucose levels of patients, a variety of devices designed to monitor glucose while easing the burden of frequent blood tests. There is a growing demand for portable glucose meters that are compact user friendly in monitoring blood glucose levels efficiently accurate. Through technological improvements, Point of Case Testing (POC) is the largest profit making segment in the market. POC testing provides simple and quick results. With this, POC testing is expected to play a key role in the fight against Diabetes and will dominate the market over clinical diagnostics Glycosylated hemoglobin (HbAlc) is another test that is expected to rise slightly and is being processed and prices for cheaper than hospital-based laboratories since it is already adopted by health Care Teams even outpatient clinics and small hospital based laboratories. Manufacturers will identify customers unmet needs and develop competent technologies that focus on dedicated systems to improve efficiency and profitability. New technologies and challenges may occur; it will remain for more patient friendly screening and treatments. The future care for Diabetes will non-invasive and make glucose regulation for more accurate and easier to manage. Current Trends CDC Criteria for Anemia in Children and Childbearing-Aged Women Hemoglobin

(Hb)

and

hematocrit

(Hct)

measurements

are

the

laboratory tests used most commonly in clinical and public health settings for screening for anemia. Because most anemia in children and women of childbearing age is related to iron deficiency (1), the main purpose of anemia screening is to detect those persons at increased risk for iron deficiency. Proper anemia screening requires not only sound laboratory methods and procedures but also appropriate Hb and Hct cutoff values to define anemia. The "normal" ranges of Hb and Hct change throughout childhood and during pregnancy, and are higher for men than women (1,2). Thus, criteria for anemia should be specific for age, sex, and stage of pregnancy. Current major

reference criteria for anemia, however, are not based on representative samples and fail to take into account the normal hematologic changes occurring during pregnancy. To address these limitations, CDC has formulated new reference criteria for use in clinical practice for public health and nutrition

programs

and

the

CDC

Pediatric

and

Pregnancy

Nutrition

Surveillance Systems. The new criteria may also be useful for defining anemia in clinical research and nutrition surveys. The anemia reference values for children, nonpregnant women, and men are derived from the most current nationally representative sample--the Second National Health and Nutrition Examination Survey, 1976-1980 (NHANES II). Because representative data are not yet available for pregnant women, anemia reference values are based on the most current clinical studies available. Adjustment values of Hb and Hct cutoffs are provided for persons who reside at higher altitudes and for those who smoke cigarettes. Anemia Cutoffs for Children, Nonpregnant Women, and Men Because hematologic values normally change as children grow older, it is necessary to use age-specific criteria for diagnosing anemia in children (1). The best hematologic reference data for the United States are available from the NHANES II. The Hb and Hct cutoffs recommended represent the agespecific fifth percentile values for "healthy" persons from NHANES II (Table 1) (3, 4). The healthy sample was defined by excluding persons who were likely to have iron deficiency based on multiple iron biochemical measures. The anemia cutoff values based on these NHANES II studies for younger children are in close agreement with the cutoff values recommended by the American Academy of Pediatrics, which were based on a sample of healthy white middle-class children (5). Even though no data are available from NHANES II to determine anemia cutoffs for infants less than 1 year of age, cutoff values for children 1-2 years can be extrapolated back to 6 months of age. In general, anemia screening to detect iron deficiency is not indicated for infants less than 6 months of age because younger infants usually have adequate iron nutritional status (6). Anemia Cutoffs during Pregnancy During a normal pregnancy, a woman's hematologic values change substantially (2). For women with adequate iron nutrition, Hb and Hct values start to decline during the early part of first trimester, reach their nadir near

the end of second trimester, then gradually rise during the third trimester (2,7-10). Because of the change of Hb and Hct during pregnancy, anemia must be characterized according to the specific stage of pregnancy. The normal range of Hb and Hct during pregnancy is based on data aggregated from four European studies of healthy iron-supplemented pregnant women (7-10). These studies provide similar findings at each specific month of pregnancy. The month-specific fifth percentile values for Hb of the pooled data have been adopted for use in the CDC Pregnancy Nutrition Surveillance System (Table 2). In addition, trimester-specific cutoffs also have been developed for use in the clinical setting (Table 2). These trimester-specific cutoffs are based on the mid-trimester values; cutoffs for the first trimester, the time at which most women are initially seen for prenatal care, are based on a late-trimester value. Adjustment of Hb and Hct Cutoffs for Altitude and Smoking Persons residing at higher altitudes ( greater than 1000 meters (3300 feet)) have higher Hb and Hct levels than those residing at sea level. This variation is due to the lower oxygen partial pressure at higher altitudes, a reduction in oxygen saturation of blood (11), and a compensatory increase in red cell production to ensure adequate oxygen supply to the tissues. Thus, higher altitude causes a generalized upward shift of the Hb and Hct distributions. This shift may be associated with the underdiagnosis of anemia for residents of higher altitudes when sea-level cutoffs are applied (CDC, unpublished data). Therefore, the proper diagnosis of anemia for those residing at higher altitudes requires an upward adjustment of Hb and Hct cutoffs. The values for altitude-specific adjustment of Hb and Hct are derived from data collected by the CDC Pediatric Nutrition Surveillance System on children residing at various altitudes in the mountain states (Table 3). Altitude affects Hb and Hct levels throughout pregnancy in a similar way (J.N. Chatfield, unpublished data). The influence of cigarette smoking is similar to that of altitude, in that smoking increases Hb and Hct levels substantially. The higher Hb and Hct of smokers is a consequence of an increased carboxyhemoglobin from inhaling carbon monoxide during smoking. Because carboxyhemoglobin has no

oxygen carrying capacity, its presence causes a generalized upward shift of the Hb and Hct distribution curves (CDC, unpublished data). Therefore, a smoking-specific adjustment to the anemia cutoff is necessary for the proper diagnosis

of

anemia

in

smokers.

The

smoking-specific

Hb

and

Hct

adjustments are derived from the NHANES II data (Table 4). The altitude and smoking adjustments are additive. For example, a woman living at 6000 feet and smoking two or more packs of cigarettes per day would have her cutoff for anemia adjusted upward by a total of 1.4 grams of Hb or 4% Hct. Reported by: Div of Nutrition, Center for Chronic Disease Prevention and Health Promotion; Div of Environmental Health Laboratory Sciences, Center for Environmental Health and Injury Control; Div of Health Examination Statistics, National Center for Health Statistics; Div of Host Factors, Center for Infectious Diseases, CDC. Hypertension is a common clinical problem faced by both primary care clinicians

and

specialists.

While

the

exact

prevalence

of

resistant

hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing,

severe

hypertension

complicated

by

multiple

other

cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic

and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well

documented;

however,

identification of

broader

mechanisms

of

treatment resistance is lacking. In particular, attempts to elucidate potential genetic

causes

of

Recommendations hypertension

for

resistant the

remain largely

hypertension

have

pharmacological

treatment

empiric

the

due

to

lack

been of of

limited. resistant

systematic

assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the longterm clinical management of this disorder. Furuncles are very common. They are caused by staphylococcus bacteria, which are normally found on the skin surface. Damage to the hair follicle allows these bacteria to enter deeper into the tissues of the follicle and the subcutaneous tissue. Furuncles may occur in the hair follicles anywhere on the body, but they are most common on the face, neck, armpit, buttocks, and thighs. Furuncles are generally caused by Staphylococcus aureus, but they may be caused by other bacteria or fungi. They may begin as a tender, red, subcutaneous nodule but ultimately become fluctuant (feel like a water-filled balloon). A furuncle may drain spontaneously, producing pus. More often the patient or someone else opens the furuncle. Furuncles can be single or multiple. Some people have recurrent bouts with abscesses and little success at preventing them. Furuncles can be very painful if they occur in areas like the ear canal or nose. A health care provider should treat furuncles of the nose. Furuncles that develop close together may expand and join, causing a condition called carbunculosis.

Electrolytes are salts that conduct electricity and are found in the body fluid, tissue, and blood. Examples are chloride, calcium, magnesium, sodium, and potassium. Sodium (Na+) is concentrated in the extracellular fluid (ECF) and potassium (K+) is concentrated in the intracellular fluid (ICF). Proper balance is essential for muscle coordination, heart function, fluid absorption and excretion, nerve function, and concentration. The kidneys regulate fluid absorption and excretion and maintain a narrow range of electrolyte fluctuation. Normally, sodium and potassium are filtered and excreted in the urine and feces according to the body's needs. Too much or too little sodium or potassium, caused by poor diet, dehydration, medication, and disease, results in an imbalance. Too much sodium is called hypernatremia; too little is called hyponatremia. Too much potassium is called hyperkalemia; too little is called hypokalemia. B. Reasons for choosing such case for Presentation One of the formidable parts in doing a case study is choosing what case is to present. We had this unanimous decision of choosing our patients case, first and foremost because with our initial contact we already established harmonious relationship with the patient and his significant others. We had established the “trust” we yearn from them and that makes it easy for us to ask certain questions we need for our case and interact with them properly. Another thing is because we find them kind and humorous that is why our previous interaction with them is smooth and conventional. Most importantly, our patient’s case is very critical because he has five diagnoses. With that thought alone, we want to further enhance our knowledge about the disease such as to ensure appropriate evaluation of the etiology, reassess and address the course of the illness takes in its progression. Also, to have an experience in handling and providing humanitarian health services to a patient who has it and provide any intervention or treatment indicated based on the specific etiology and the

course it follows in that specific patient. With that scenario, it is not only the knowledge that was enhanced but also our skills as health care practitioners. II. NURSING ASSESSMENT A. Personal History 1. Demographic Data Mr. Mickey (not his real name) is a 52 years old married male, Filipino who was born on February 16, 1954 in Angeles City. He is the eldest among the eight siblings of Disney family (not their real family name) and has 5 unmarried sisters. He, together with Mrs. Minnie (not her wife’s real name) and their eight children, currently resides near main road in Robinson’s mall, Angeles City, Pampanga. He is religiously affiliated as a Roman Catholic. He is presently working as a Barangay Tanod. He was admitted at Ospital Ning Angeles (ONA) on April 27, 2008 because of hypertension and Diabetes Mellitus type 2. 2. Socio-economic and cultural factors Mr. Mickey was able to finish a full course of elementary until second year college but had not gone to school to continue his studies due to financial constraints. Mr. Mickey was a construction worker before and now he is presently working as a barangay tanod. He doesn’t earn much, he just earn 2000 per month that’s why he cannot able to support his family. They spend about 300 pesos a day through the financial support of his children. Mr. Mickey, does not like having exercises, he has a sedentary lifestyle. He gets easily stressed because of their financial status plus his job as a barangay tanod. He usually comes home at 2 am in the morning. He does not engage in any vices such as drinking alcoholic beverages nor smoking cigarettes. As for the foods he eats before he acquired hypertension and diabetes mellitus type 2, Mr. Mickey preferred fatty and salty foods and also those glucose rich or sweets. Mr. Mickey and his family also believe in consulting the “herbolaryos or manghihilot” for any problems or illness that would occur. They also use

herbal medicines as alternative in treating illnesses like guava decoction. The family of Mr. Mickey lived in one of those small concrete houses, situated near main road of Robinson’s Mall in Angeles. They have a one storey house but cemented. It has only three bedrooms though they are ten in the family living in that house. Some of them are sleeping in the sala at night. Their sala serves both as a receiving and recreational area for the family; a kitchen at the back portion of the house, and a comfort room. Their residence is fortunately, nearby the community market. So everyday, his wife buys fresh foodstuffs like meat, fish, and vegetables to cook. There are also clinics and health center but not close to the proximity. There are also no factories near their house. B. Family Health Illness History Grandfather (deceased): Hypertension

Grandmother (deceased): Kidney Failure

Mommy Mouse (Mother-deceased): Stroke and DM

Mr. Mickey: eldest

Sister 1

Brother

Sister

Grandfather (deceased): Heart Attack

Grandmother (deceased): Tuberculosis

Papa Mouse (Father-deceased): Lung Cancer

Sister

Sister

Sister 5

Sister

- Normal - With diabetes - With hypertension - With Diabetes type 2, Hypertension 2 C. History of Past illnesses Mrs. Minnie mentioned that it was actually her husbands first time to be confined in a hospital. According to Mrs. Minnie, her husband had Measles when he was in grade five. Mr. Mickey had Arthritis; he used “katingko” as a pain remedy. He took Mefenamic acid and Biogesic for his arthritis and Headache. He also had cough and colds and he used to drink lots of water as

self medication. He also suffered from hypertension and was diagnosed when he was still single, it was just starting then (mild hypertension). He didn’t take any medications nor consult any health care provider. Five years ago, Mr. Mickey noticed that he has an insatiable appetite for food, excessive thirst, and at the same time he urinates frequently. He easily gets fatigue and feels weak or lethargic that’s why he used to sleep most of the time.

D. History of Present Illness Two years ago, Mr. Mickey went to the clinic and consulted the Doctor. He complained of pain and loss of hearing in his left ear. The Doctor prescribed him antibiotic (eardrops) and advised him to wear hearing aid. One year after, two ears became affected. In January 2008 when he went to health center, his blood pressure was increased, it was 140/90. Last April 23, morning, when he sought medical help in the OPD of ONA. During that time, he has no appetite in eating and his furuncle was still small. The Doctor prescribed him to take Amoxicillin, Appebon with Iron and Cetrizine Dihydrochloride. On the night of April 27, 2008, he was admitted to the hospital for the first time with admitting diagnosis of intractable vomiting, Electrolyte

imbalance,

Anemia,

furuncle,

Diabetes

Mellitus

type

2,

Hypertension 2.

The following doctor’s orders were given: (lifted from the Mr. Mickey’s chart): Initial V/S were, T-36.0 PR-84 RR-21 BP-170/100  Pls admit to medical ward  Secure consent from admin and management  NPO temporarily except meds

 IVF PNSS 1L x 30 gtts/min  Dxtic: CBC-done RBC-done 

U/A-done



Na, K-done



Creatinine-Requested



BUN



FBS



Lipid profile



CXR-PA



12 lead ECG

 Tx: Ceftriaxone 1g/IV q 12 

Metformin 500mg 1 tab BID



Plasil tab TID PRN for Vomiting



FeSO4 tab BID

 Monitor VS q4  Refer accordingly  Amlodipine (Lopicard) 5g I tab OD E. Physical Examination Physical Assessment/Doctor’s Notes: April 27, 2008 (admission-lifted from the chart) Diagnosis: Intractable Vomiting, Electrolyte Imbalance, Anemia, Furuncle, DM type 2, Hypertension 2 •

Vomiting, three times

•

Body weakness

•

BP= 170/100 mmHg

•

Pulse Rate= 84 beats per minute

•

Respiratory Rate= 21 cycles per minute

•

Temperature= 36.6 ˚C

*** for Lipid profile, triglycerides, BUA, CXR posterior-anterior view, ECG

Physical Assessment: April 28, 2008 Vital Signs: T- 37°C

RR- 17 cpm

PR- 74 bpm

BP- 150/90 mmHg

1. General Appearance a. Body built is ectomorphic b. Presence of halitosis for the breath odor c. Attitude is cooperative d. Affect or mood is appropriate for the situation 2. Skin a. There is good skin turgor b. Skin is dry, pale on the palms and soles of the feet, with scars on lower extremities c. Absence of facial and periorbital edema d. (+) 3-cm-diameter furuncle on left upper arm, draining purulent secretion 3. Head a. Skull is round in shape and has normal contour, with no palpated depressions b. Hair is thick, with fine strands; scalp is excessively oily with no masses palpated c. Facial features are symmetrical with no noted abnormalities 4. Eyes a. Pupils are equally round and reactive to light and accommodation b. Palpebral conjunctiva are pale

c. Eyebrows are symmetrically aligned, hair is thick, evenly distributed; skin is intact d. Eyelashes are equally distributed and curled slightly outward e. No discharges present f. Absence of periorbital edema g. Cornea is transparent, smooth and shiny h. Details of the iris are visible, color brown i. Sclera appears white 5. Ears a. Ears are symmetrical and aligned with the outer canthus of the eye, with no lesions noted. b. Color is same as facial skin c. Ears have no foul smelling discharges, with impacted cerumen on the middle ear d. Pinna recoils after being folded 6. Nose a. Nose has no discharge, no lesions, not occluded & with patent airway b. Color is same as facial skin 7. Throat and Mouth a. Throat & mouth have no sores and swellings/inflammation b. Lips are dry and pinkish c. There is slight difficulty in swallowing d. Grade of (+) 1 for tonsils-normal; pale, smooth, with no inflammation e. Tongue is positioned at the center, furry, white, moist, rough, with fissures f. Gums are pale and with firm texture 8. Neck a. Color is slightly darker than facial skin b. Absence of enlarged thyroid area c. Absence of jugular vein distention

d. Movement is coordinated and smooth 9. Chest a. Breasts are not enlarged, with no lesions b. No masses assessed upon palpation 10. Cardiovascular a. Absence of chest pain and murmurs b. Normal heart rhythm, PR = 74 bpm 11. Respiratory a. Chest is symmetric; anteroposterior to transverse diameter ratio is 1:2 b. Chest expansions are symmetrical c. Absence of rales on both lung fields 12. Gastrointestinal a. Presence of bowel sounds 5/min, presence of flatus b. Absence of bowel movement c. Absence of organomegaly 13. Extremities a. Upper- symmetrical, absence of edema; capillary refill >2 seconds; (+) 3-cm-diameter furuncle on left upper arm, draining purulent secretion b. Lower- symmetrical, absence of edema 14. Urogenital a. Urine output: approximately 30cc per hour, amber yellow in color, cloudy b. Genitals- no foul smelling discharges

Neurological Assessment

Cranial Nerve 1. Olfactory

Normal Findings Client must be able to

Actual Findings Client was able to

Type: Sensory

identify the scent of

identify the scent of

Fxn: Sense of smell

perfume when allowed to perfume when allowed

2. Optic

smell it. to smell it. Client must see the pen or Client was able to see

Type: Sensory

penlight clearly from a

Fxn: Sense of vision and

certain distance; must be from a certain distance,

visual fields

able to read newspaper

but was not able to

print.

read newspaper print.

the pen or penlight

Client needs to wear eyeglasses for better vision. The client was able to

3. Oculomotor

Eyes must follow the

Type: Motor

direction of the movement follow the movement of

Fxn: Pupil constriction and of the penlight;

the penlight through

raising of eyelid

her eyes.

In lightly dimmed environment, the pupils of the eyes will dilate but upon the introduction of

4. Trochlear

light, pupils will constrict. The eye must follow the The client was able to

Type: Motor

movement of a pen in

follow the pen with her

Fxn: Downward inward

different directions with

eyes without moving

eye movement 5. Trigeminal

coordination. The client must elicit

her head. The client elicited

Type: Sensory and Motor

blinking reflex upon

blinking reflex upon

Fxn: Jaw movements,

touching the cornea with

touching the cornea.

chewing and mastication the use of cotton. 6. Abducens

(Corneal Sensitivity Test) Client must follow the

The client was able to

Type: Motor

index finger of the

follow the index finger

Fxn: Lateral movements

examiner and its

of the examiner and its

of the eyes 7. Facial

movements. Client must be able to

movements. The client was able to

Type: Motor and Sensory

raise eyebrows, show

raise eyebrows, show

Fxn: Movement of

teeth, frown, smile, pout

teeth frown, smile, pout

muscles of the face and

and puff out cheeks. Also, and puff out cheeks.

sense of taste on the

the client must also be

Also, the client was not

anterior two-thirds of the able to distinguish sweet, able to distinguish tongue

sour, and salty foods.

sweet, sour, and salty foods. Test not performed due to

8. Acoustic

Client must be able to

anorexia and vomiting. The client was not able

(Vestibulocochlear)

hear a snap of the finger.

to hear the snap of the

Type: Sensory

finger.

Fxn: Sense of hearing 9. Glossopharyngeal

The patient must be able

Type: Motor and Sensory

to swallow foods that were to taste the food. Test

Fxn: Pharyngeal

chewed and taste bitter

movements and

foods. Also, the gag reflex anorexia and vomiting.

swallowing

should be stimulated.

The client was not able not performed due to

Sense of taste on the posterior one-third of the tongue 10. Vagus

The patient must be able

The client was able to

Type: Motor

to speak clearly.

speak clearly.

speaking 11. Accessory

The patient must able to

The client was able to

Type: Motor

elevate her shoulders

elevate her shoulders

Fxn: Movement of

against resistance.

against resistance.

shoulder muscles

(Sternocleidomastoid and

Fxn: Swallowing and

Trapezius muscles function 12. Hypoglossal

test) The patient must able to

The patient was able to

Type: Motor

move her tongue side to

move her tongue side

Fxn: Movement of tongue side and protrude her

to side and protrude

and strength of the

her tongue.

tongue.

tongue

Diagnostic and Laboratory Procedures DIAGNOSTIC OR LABORATORY PROCEDURES CLINICAL CHEMISTRY FBS/RBS

DATE ORDERED AND DATE RESULTS IN

INDICATIONS OR PURPOSES

RESULTS

NORMAL VALUES

ANALYSIS AND INTERPRETATIO N

Date Ordered: 04-27-08

A test that is routinely done in all clients with possible cardiovascular disorders to determine blood glucose levels.

137

(70-105mg/dl)

A fasting blood sugar level of 126 mg/dL or higher is consistent with either type 1 or type 2 diabetes. Patient’s FBS is exceeds the normal limits indicating the patient has diabetes.

113.4

135 – 150 mEq/L

Date Results In: 04-27-08

•

SODIUM - To monitor the electrolytes and check for imbalances any imbalance in the fluid and electrolytes. Sodium plays a major role in homeostasis in a variety of ways including the renal

The sodium electrolyte level is below normal range. It indicates that the patient has hyponatremia.

retention and excretion of water. 3.8

3.5 – 5.2 mEq/L

•

The potassium electrolyte level is within normal range.

POTASSIUM - While, Potassium is checked in order to assess a known and suspected disorder associated with renal disease, glucose metabolism, trauma or burns.

URINALYSIS

Date Ordered: 04-27-08

Color: Yellow

Date Results In: 04-27-08

Transparency : SL cloudy

It indicates that there is impaired kidney function due to decrease organ perfusion. 3.5-4.5

Ph: 5.0 This is a measure of acidity for your urine.

Ph is slightly basic which could indicate metabolic alkalosis.

This measures how dilute your urine is.

1.010-1.030 Specific Gravity: 1.010

Microscopic Findings

Pus cells/HPF: 3-6

Water would have a SG of 1.000 . Most urine is around 1.010, but it can vary greatly depending on when you drank fluids last, or if you are dehydrated. This means that the value in the result is within normal range. Normally negative. Leukocytes are the white blood cells (or pus cells). This looks for white blood cells by reacting with an enzyme in the white cells. White blood cells in the urine suggests a urinary tract infection.

RBC/HPF: 5-8

3.2-5.0 g/dl Albumin: Positive (3+)

Sugar:

Normally there is no blood in the urine. Blood can indicate an infection, kidney stones, trauma, or bleeding from a bladder or kidney tumor. The technician may indicate whether it is hemolyzed (dissolved blood) or nonhemolyzed (intact red blood cells). Rarely, muscle injury can cause myoglobin to appear in the urine which also causes the reagent pad to falsely indicate blood. Albumin is slightly below normal. Lower levels indicate infection, kidney

(Negative)

disease, and inadequate iron intake.

HEMATOLOGY: HEMOGLOBIN

Date Ordered: 04-27-08 Date Results In: 04-27-08

WBC

HEMATOCRIT

▪ HGB - to monitor Hgb value in the RBC - to suggest the presence of body fluid deficit due to elevated Hgb level To detect infection or inflammation. This blood test evaluates the number of condition and differentiates causes of alteration in the total WBC count including inflammation, infection and tissue necrosis.

to aid diagnosis of abnormal states of hydration, polycythemia and anemia. - It measures the

M: 140-180g/l F: 120-160g/l 95

5-10 x 109/L 14.5

The level of hemoglobin is below normal which indicates anemia and decrease tissue perfusion. The WBC count exceeds the normal range which indicates presence of infection.

M: 0.40-0.52L/L F:0. 37-0.47L/L 0.29 The level of

concentration of RBC within the blood volume and is expressed as a percentage.

hematocrit is below normal which also indicates anemia and decrease tissue perfusion. 18 - 48 %

LMPHOCYTES To detect presence of infection within the body.

Bacteria: Epithelial cells: CLINICAL CHEMISTRY FBS/RBS

Date Ordered: 04/27/08 Date Results In: 04-28-08

A test that is routinely done in all clients with possible cardiovascular disorders to determine blood glucose levels.

0.5

Some Some

The number of lymphocyte is slightly elevated which indicates presence of infection. (74-110mg/dl)

88

CHOLESTEROL

M: 123 – 270 F: 150 to 250 Used to estimate risk of developing a disease — specifically heart disease. Because

160.7

A fasting blood sugar level of 126 mg/dL or higher is consistent with either type 1 or type 2 diabetes. Patient’s FBS is within normal range

high blood cholesterol has been associated with hardening of the arteries, heart disease and a raised risk of death from heart attacks, cholesterol testing is considered a routine part of preventive health care. CLINICAL CHEMISTRY FBS

Date Ordered: 04-28-08 Date Results In: 04-29-08

BUN

The cholesterol level is within the normal range.

(74-110mg/dl) A test that is routinely done in all clients with possible cardiovascular disorders to determine blood glucose levels.

117.5

This calculation is a good measurement of kidney and liver function.

(7-18 mg/dl)

Patient’s FBS is exceeds the normal limits indicating the patient has diabetes.

M: 123 – 270

The BUN value is significantly higher than the normal range. It

93

CHOLESTEROL

F: 150 to 250 Used to estimate risk of developing a disease — specifically heart disease. Because high blood cholesterol has been associated with hardening of the arteries, heart disease and a raised risk of death from heart attacks, cholesterol testing is considered a routine part of preventive health care.

LIPID PROFILE:

Date Ordered: 04-28-08

HDL C

Date Results In: 04-29-08

-It has the lowest concentration of cholesterol and transport endogenous cholesterol to body cells.

LDL C - The cholesterolcontaining lipid fraction most likely associated with atherogenesis

192.5

may indicate possible kidney or liver failure. The cholesterol level is within the normal range.

33.2

M=30-75

145.22

M=66-178

The HDL is within normal limit which indicates a healthy metabolic system.

The LDL is within normal limit which indicates there is no

(CHD). One of the enzymes most commonly used to detect myocardial infarction. TRIGLYCERIDES

- A test to determine the cholesterol level circulating in the bloodstream. SGPT/ALT - used to determine if there is any condition necrosis of hepatocytes, myocardial cells, erythrocytes, or skeletal muscle cells. SGOT/AST - used o determine any condition involving necrosis of hepatocytes, myocardial cells, or skeletal muscle cells.

NURSING RESPONSIBILITIES . BLOOD TESTING Before the Procedure:

narrowing of blood vessels.

70.4

36-165 The triglycerides level is within the normal range.

17.0

0-30 U/L The SGPT level is within normal limit.

19.9

0-40 U/L The SGOT level is within normal limit.

a. b. c. d.

Explain the procedure to the client in order to gain cooperation. Inform the client that she may feel pain during needle insertion. Prepare the materials necessary for the test. Practice aseptic technique by cleaning the area of blood extraction with alcohol in an outward circular motion.

During the Procedure: a. Provide comfort to the client. b. Encourage the patient to relax and refrain from unnecessary movements. After the Procedure: a. Apply pressure on the site of puncture to prevent bleeding. b. Handle the blood sample carefully to prevent hemolysis. URINALYSIS Before the Procedure: a. Explain the procedure to the client in order to gain her b. Inform the client that there is no need for NPO. c. Educate the patient on the proper way of collecting urine (clean catch midstream specimen). d. Prepare the container for the urine. During the Procedure: a. Provide privacy. b. Assist the patient if unable to get her urine sample on her own. c. Instruct the patient to prevent contamination of the urine and not to add water to the urine specimen , to prevent alteration of reslts. After the Procedure: a. Refrigerate the specimen. b. Continue taking the medications that were stopped prior to the procedure.

III . ANATOMY AND PHYSIOLOGY The Cardiovascular System The heart and circulatory system make up the cardiovascular system. The heart works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste products made by those cells. Blood is carried from the heart to the rest of the body through a complex network of arteries, arterioles, and capillaries. Blood is returned to the heart through venules and veins. The one-way circulatory system carries blood to all parts of the body. This process of blood flow within the body is called circulation. Arteries carry oxygen-rich blood away from the heart, and veins carry oxygen-poor blood back to the heart. In pulmonary circulation, though, the roles are switched. It is the pulmonary artery that brings oxygen-poor blood into the lungs and the pulmonary vein that brings oxygen-rich blood back to the heart. Twenty major arteries make a path through the tissues, where they branch into smaller vessels called arterioles. Arterioles further branch into capillaries, the true deliverers of oxygen and nutrients to the cells. Most capillaries are thinner than a hair. In fact, many are so tiny, only one blood cell can move through them at a time. Once the capillaries deliver oxygen and nutrients and pick up carbon dioxide and other waste, they move the blood back through wider vessels called venules. Venules eventually join to form veins, which deliver the blood back to the heart to pick up oxygen. Vasoconstriction or the spasm of smooth muscles around the blood vessels causes and decrease in blood flow but an increase in pressure. In vasodilation, the lumen of the blood vessel increase in diameter thereby allowing increase in blood flow. There is no tension on the walls of the vessels therefore, there is lower pressure. Various external factors also cause changes in blood pressure and pulse rate. An elevation or decline may be detrimental to health. Changes may also be caused or aggravated by other disease conditions existing in other parts of the body.

The blood is part of the circulatory system. Whole blood contains three types of blood cells, including: red blood cells, white blood cells and platelets. These three types of blood cells are mostly manufactured in the bone marrow of the vertebrae, ribs, pelvis, skull, and sternum. These cells travel through the circulatory system suspended in a yellowish fluid called plasma. Plasma is 90% water and contains nutrients, proteins, hormones, and waste products. Whole blood is a mixture of blood cells and plasma. Red blood cells (also called erythrocytes) are shaped like slightly indented, flattened disks. Red blood cells contain an iron-rich protein called hemoglobin. Blood gets its bright red color when hemoglobin in red blood cells picks up oxygen in the lungs. As the blood travels through the body, the hemoglobin releases oxygen to the tissues. The body contains more red blood cells than any other type of cell, and each red blood cell has a life span of about 4 months. Each day, the body produces new red blood cells to replace those that die or are lost from the body. White blood cells (also called leukocytes) are a key part of the body's system for defending itself against infection. They can move in and out of the bloodstream to reach affected tissues. The blood contains far fewer white blood cells than red cells, although the body can increase production of white blood cells to fight infection. There are several types of white blood cells, and their life spans vary from a few days to months. New cells are constantly being formed in the bone marrow. Several different parts of blood are involved in fighting infection. White blood cells called granulocytes and lymphocytes travel along the walls of blood vessels. They fight bacteria and viruses and may also attempt to destroy cells that have become infected or have changed into cancer cells. Certain types of white blood cells produce antibodies, special proteins that recognize foreign materials and help the body destroy or neutralize them. When a person has an infection, his or her white cell count often is higher than when he or she is well because more white blood cells are being produced or are entering the bloodstream to battle the infection. After the body has been challenged by some infections, lymphocytes remember how to make the specific antibodies that will quickly attack the same germ if it enters the body again.

Platelets (also called thrombocytes) are tiny oval-shaped cells made in the bone marrow. They help in the clotting process. When a blood vessel breaks, platelets gather in the area and help seal off the leak. Platelets survive only about 9 days in the bloodstream and are constantly being replaced by new cells. Blood also contains important proteins called clotting factors, which are critical to the clotting process. Although platelets alone can plug small blood vessel leaks and temporarily stop or slow bleeding, the action of clotting factors is needed to produce a strong, stable clot. Platelets and clotting factors work together to form solid lumps to seal leaks, wounds, cuts, and scratches and to prevent bleeding inside and on the surfaces of our bodies. The process of clotting is like a puzzle with interlocking parts. When the last part is in place, the clot is formed. When large blood vessels are cut the body may not be able to repair itself through clotting alone. In these cases, dressings or stitches are used to help control bleeding. In addition to the cells and clotting factors, blood contains other important substances, such as nutrients from the food that has been processed by the digestive system. Blood also carries hormones released by the endocrine glands and carries them to the body parts that need them. Blood is essential for good health because the body depends on a steady supply of fuel and oxygen to reach its billions of cells. Even the heart couldn't survive without blood flowing through the vessels that bring nourishment to its muscular walls. Blood also carries carbon dioxide and other waste materials to the lungs, kidneys, and digestive system, from where they are removed from the body.

The Urinary System The components of the urinary system are: two kidneys, two ureters, urinary bladder and urethra. The kidneys process blood and form urine by filtering blood plasma (glomerular filtration) and returning most of the water and

solutes to the bloodstream (tubular reabsorption). The remaining water and solutes constitute the urine (secretion) which passes through ureters, are stored in the urinary bladder, then excreted from the body through the urethra. The main functions of the kidneys are to regulate blood volume and composition, help regulate blood pressure, synthesize glucose, release erythropoietin, participate in vitamin D synthesis and excrete wastes in the urine. The nephron is functional unit of the kidney. The parts of the nephron are: renal corpuscle- where blood plasma is filtered and renal tubule- into which filtered fluid passes. The renal corpusclelies within the renal cortex and consists of two components: glomerulus and the glomerular (Bowman's) capsule- a double-walled epithelial cup that surrounds the glomerulus. The parts of a renal tubule are: proximal convoluted tubule- lies within the renal cortex, loop of Henle (nephron loop)- extends into the renal medulla, distal convoluted tubule- lies within the renal cortex, distal convoluted tubules of several nephrons empty into a single collecting duct. Malfunctioning of one of the small portions that make up the nephron will cause impairment in the functioning of the kidneys. Glomerular filtration rate may decrease, and as a result, large molecules are drained out and secreted in the urine. Examples of which are RBC and protein molecules. Likewise, accumulation of sodium causes formation of crystals, which, when dislodged, may either block passageways of urine, or be excreted and seen as crystals in the urine.

The Endocrine System The endocrine system is made up of glands that produce and secrete hormones. These hormones regulate the body’s growth, metabolism (the physical and chemical processes of the body), and sexual development and

function. The hormones are released into the bloodstream and may affect one or several organs throughout the body. The role of the endocrine system is to maintain the body in balance through the release of hormones which transfer information and instructions from one set of cells to another. Many different hormones move through the bloodstream, but each type of hormone is designed to affect only certain cells. Hormones are chemical messengers created by the body. They transfer information from one set of cells to another to coordinate the functions of different parts of the body. Hormones can act on some specific cells because they themselves do not actually cause an effect. It is only through binding with a receptor (part of the cell specifically designed to recognize the hormone) like a key into a lock - that causes a chain reaction to occur, changing the activity of the cells. If a cell does not have a receptor for a hormone then there will be no effect. Also, there can be different receptors for the same hormone, and so the same hormone can have different effects on different cells. The major glands of the endocrine system are the pituitary, thyroid, parathyroids, adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The pancreas is also a part of this system; it has a role in hormone production as well as in digestion. A gland is a group of cells that produces and secretes chemicals. A gland selects and removes materials from the blood, processes them, and secretes the finished chemical product for use somewhere in the body. The endocrine gland cells release a hormone into the blood stream for distribution throughout the entire body. These hormones act as chemical messengers and can alter the activity of many organs at once. The hypothalamus controls all the processes undergone by the anterior and posterior pituitary glands. It initiates the production of hormones by the APG. The APG is controlled by releasing hormones which are chemical signals

produced by the nerve cells of the hypothalamus, causing either stimulation or inhibition of hormone production. Secretion of hormones by the PPG is controlled by nervous system stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid hormone which is essential for the regulation of blood calcium levels. Adrenal glands produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare the body for vigorous physical activity. Testes and ovaries produce hormones that are responsible

for

secondary

sex

characteristics,

spermatogenesis,

and

oogenesis. The thymus gland secretes thymosin which aids in the synthesis of WBC for fighting infection. This gland decreases in size in some older adults. The pineal body releases melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the release of hypothalamic-releasing hormones. The thyroid gland, located on either side of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior pituitary gland, which was initially stimulated by the TSH releasing hormone from the hypothalamus. The pancreas is also part of the body's hormone-secreting system, even though it is also associated with the digestive system because it produces and secretes digestive enzymes. The pancreas produces two important hormones, insulin and glucagon. They work together to maintain a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain stores of energy. The pancreas completes the job of breaking down protein, carbohydrates, and fats using digestive juices of pancreas combined with juices from the intestines, secretes hormones that affect the level of sugar in the blood, and produces chemicals that neutralize stomach acids that pass from the stomach into the small intestine by using substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered throughout the organ. In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the abdomen adjacent to the small intestine and lies toward the back. It has

three regions: a head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail (extends toward the spleen). The pancreatic duct (also called the duct of Wirsung) runs the length of the pancreas and empties into the second part of the duodenum at the ampulla of Vater. The common bile duct usually joins the pancreatic duct at or near this point. Many people also have a small accessory duct, the duct of Santorini, which extends from the main duct more upstream (towards the tail) to the duodenum, joining it more proximal than the ampulla of Vater. The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the splenic artery: the splenic artery supplies the neck, body, and tail of the

pancreas;

the

superior

mesenteric

artery

provides

the

inferior

pancreaticoduodenal artery; and the gastroduodenal artery provides the superior pancreaticoduodenal artery. Venous drainage is via the pancreaticoduodenal veins which end up in the portal vein. The splenic vein passes posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is formed by the union of the superior mesenteric vein and splenic vein posterior to the neck of the pancreas. In some people (some books say 40% of people), the inferior mesenteric vein also joins with the splenic vein behind the pancreas (in others it simply joins with the superior mesenteric vein instead). The pancreas is a compound gland in the sense that it is composed of both exocrine and endocrine tissues. The exocrine function of the pancreas involves the synthesis and secretion of pancreatic juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans) embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the action of insulin.

There are four main types of cells in the islets of Langerhans. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by their secretion:

Name

of

cells

Endocrine product

%

of

cells

islet

Representative function

beta cells

Insulin and Amylin

50-80%

lower blood sugar

alpha cells

Glucagon

15-20%

raise blood sugar

delta cells

Somatostatin

3-10%

inhibit endocrine pancreas

PP cells

Pancreatic polypeptide 1%

inhibit exocrine pancreas

The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes or by direct apposition. There are two main types of exocrine pancreatic cells, responsible for two main classes of secretions:

Name of cells

Exocrine secretion

Centroacinar cells bicarbonate ions

Primary signal Secretin

digestive enzymes Basophilic cells

(pancreatic amylase, Pancreatic lipase, CCK trypsinogen, chymotrypsinogen, etc.)

THE INTEGUMENTARY SYSTEM Integumentary System The skin is the largest organ in the body: 12-15% of body weight, with a surface area of 1-2 meters. Skin is continuous with, but structurally distinct from mucous membranes that line the mouth, anus, urethra, and vagina. Two

distinct layers occur in the skin: the dermis and epidermis. The basic cell type of the epidermis is the keratinocyte, which contain keratin, a fibrous protein. Basal cells are the innermost layer of the epidermis. Melanocytes produce the pigment melanin, and are also in the inner layer of the epidermis. The dermis is a connective tissue layer under the epidermis, and contains nerve endings, sensory receptors, capillaries, and elastic fibers. The integumentary system has multiple roles in homeostasis, including protection, temperature regulation, sensory reception, biochemical synthesis, and absorption. All body systems work in an interconnected manner to maintain the internal conditions essential to the function of the body. Follicles and Glands Hair follicles are lined with cells that synthesize the proteins that form hair. A sebaceous gland (that secretes the oily coating of the hair shaft), capillary bed, nerve ending, and small muscle are associated with each hair follicle. If the sebaceous glands becomes plugged and infected, it becomes a skin blemish (or pimple). The sweat glands open to the surface through the skin pores. Eccrine glands are a type of sweat gland linked to the sympathetic nervous system; they occur all over the body. Apocrine glands are the other type of sweat gland, and are larger and occur in the armpits and groin areas; these produce a solution that bacteria act upon to produce "body odor". The Digestive System The human digestive system, as shown in Figure 2, is a coiled, muscular tube (6-9 meters long when fully extended) stretching from the mouth to the anus. Several specialized compartments occur along this length: mouth, pharynx, esophagus, stomach, small intestine, large intestine, and anus. Accessory digestive organs are connected to the main system by a series of ducts: salivary glands, parts of the pancreas, and the liver and gall bladder (bilary system).

III. THE PATIENT AND HIS ILLNESS A. Pathophysiology a. Schematic Diagram PATHOPHYSIOLOGY: HYPERTENSION (bookcentered) Modifiable Factors

Non-modifiable Factors Age – 35 years and older Gender – men and post-menopausal women Race – black and brown race Family history of hypertension

-

-

Cell membrane alteration

Structural hypertrophy

Hyperinsulinemia

Functional Constriction

↑Peripheral Resistance ↑Blood pressure

Alcohol use - Excess dietary sodium Lack of exercise - Stress Obesity - Diabetes Kidney disease - Hormonal disorders Porphyria - Toxemia of pregnancy Oral Contraceptives - Steroids Decongestants - Diet pills Antidepressants - History of high BP pregnancy Nonsteroidal anti-inflammatory drugs

ReninAngiotensi n Excess

SNS overactivity

↓ Filtering surface

during

Renal Na retention

Venous Constriction

↑Fluid Volume

Decreased organ perfusion Impaired ocular functioning

Impaired cerebral functioning

Impaired renal functioning

↑Contractilit y

Retinal Altered level of Left ↑↑BUN, ↑BP = changes, consciousness, ventricular Output ccreatinine papilledema dizziness, headache hypertroph PATHOPHYSIOLOGY: DIABETES MELLITUS TYPE II (book-centered ) y

↑Preload

↑Cardiac

Non-modifiable Factors Age - Older than 40 years Family history of type 2 diabetes - Hispanic, Native American, African American, Asian American, or Pacific Islander descent, Asian

Modifiable Factors History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) Obesity - Weight >20% of desirable body weight (true for approximately 90% of patients with type 2 diabetes) Hypertension (>140/90 mm Hg) or dyslipidemia (high-density lipoprotein [HDL] cholesterol level <40 mg/dL or triglyceride level >150 mg/dL) History of GDM or of delivering a baby with a birth weight of > 9 lbs Polycystic ovarian syndrome (which results in insulin resistance) Viruses: certain viruses may destroy beta cells Faulty Immune System: multiple factors may cause the immune system to destroy beta cells, such as infection Physical Trauma: injury or trauma may destroy the ability of the pancreas to produce insulin Drugs: drugs used for other conditions could cause the development of diabetes Stress: hormones at times of stress may block the effectiveness of insulin Pregnancy: hormones produced during pregnancy can block the effectiveness of insulin

HYPERGLYCEMIA

↑Blood Osmolarity

Fluid shifting from intracellular to extracellular

Intracellular dehydration / volume depletion Thirst sensation due to the stimulation of Thirst Center of hypothalamus

Blood Sugar Level exceeds renal threshold Normal = 180mg/dl

Glucose uptake by the cells

Cellular starvation Excretion of excess glucose in the urine

Glucosuria

Hunger due to the stimulation of Satiety Center of Hypothalamus

Glucose attracts water

Polyphagia

↓Energy Level

Body malaise

↑Urine Output: Polyuria Polydipsia

Sluggish blood flow

Delayed biochemical mediation

Decreased organ perfusion

Dry, itchy skin

Nephropat

Neuropath Numbness and tingling sensation

Slow-healing cuts or sores

Confusio

Blurred vision, retinopath y

PATHOPHYSIOLOGY: ELECTROLYTE IMBALANCE - HYPONATREMIA (book-centered)

modifiable Factors: -

Non-modifiable Factors -

-

Age - Old age Sex - female

-

Diet – low Na intake Climate – acclimatization to warm weather Intensive physical activities Conditions that impair the body's water excretion including chronic conditions that cause organ failure

↓Renal perfusion/ ineffective blood supply to the kidneys Renal tissue hypoxia

Impairment in renal functioning ↓ tubular reabsorption

↑ Sodium excretion

Excretion of albumin

Albuminuria

↓ serum Na levels:

Greater proportion of water in the blood compared to sodium Fluid shifting from ↓impulse to intracellular Intravascular Alteration in brain transmission esp. in thetobrain which is Weakness functioning thesensitive muscles to serum Na Lethargy

fluid shifting from intravascular to intracellular space causing an urge to expel excess water ↓ BP

↓ interstitial fluid volume Dry skin

Nausea, vomiting, abdominal cramping, hyperactive bowel sounds

Fluid accumulati on in the alveoli

Crackles

Tachypnea

PATHOPHYSIOLOGY: IRON DEFICIENCY ANEMIA (book-centered)

Non-modifiable Factors: - Sex - females - - Pregnant women - Age - Young Children - Infants and toddlers 624 months of age; Premature and low-birthweight babies

Modifiable Factor: - Diet low in iron - Children with poor nutrition, including low-income children, Children with lead in their blood, Infants fed cow's milk before 1 year of age, Breastfed infants older than 4 months who are not receiving iron-rich solid foods or iron supplements - Adults With Intestinal Bleeding - It also includes people who use medicines that can cause intestinal bleeding (for example, aspirin). - People who are on kidney dialysis, vegetarians, with low socioeconomic status and older adults who have poor diets.

↓ Iron absorption at the intestines

↓ Iron available to the tissues (red blood cells)

Depletion of iron stores at the bone marrow to compensate for decreased availability

Impaired hemoglobin and red blood cell synthesis

Decrease circulating red blood cell along with its hemoglobin

Enlarged Spleen

Decrease in hemoglobin

Decrease oxygen supply to the integument

Swelling or soreness of the tongue and cracks

Pallor

Decrease oxygenation and circulating blood that provides heat

Decreased oxyen supply to the body

Fatigue

Increased need for the heart to pump more blood to meet oxygen demand

Cold hands and feet, brittle nails

decreased perfusion to any affected part causing delay in biochemical mediation

Frequen t Infectio Shortness of breath, tachypnea

PATHOPHYSIOLOGY: FURUNCLE (patient-centered)

Modifiable Factors  Poor hygiene  Insect bite  Excessive perspiration  Increased pressure  Increased friction

Development of wound

↑Biochemical mediation through ↑ blood flow

Enlargement of wound, turning red, firm and swollen

Development of a single, small, firm, swollen, red/pink, tender nodule (furuncle) draining purulent secretions

PATHOPHYSIOLOGY (patient-centered)

Non-modifiable Factors -

Age – 54 y/o Gender – male Race – brown race Family history hypertension

Modifiable Factors - Excess dietary sodium - Lack of exercise - Stress - Diabetes

of

Cell membrane alteration

Ineffective utilization of insulin

ReninAngiotensi n Excess

SNS overactivity

Renal Na retention

Venous Constriction

Functional Constriction

↑Fluid Volume

↑Peripheral Resistance ↑Contractility

↑BP: 170/100 mmHg: April 27, 2008; 150/90mmHg: April 28, 2008, 140/100 mmHg: April 29, 2008

↓Perfusion to the pancreas

↑↑Cardiac Output

Non-modifiable Factors -

Impairment in the functioning of the pancreas Impaired insulin secretion

Hyperglycemia

↑Preload

Age – 54 years old

Modifiable Factors - Diabetes mellitus;

-

active electrolyte loss from vomiting; current low Na intake

↓Renal perfusion/ ineffective blood supply to the kidneys

Modifiable Factors

Non-modifiable Factors - Age - Older than 40 years - Family history of DM

-

↑Blood Osmolarity

Fluid shifting from intracellular to extracellular

Intracellular dehydration / volume depletion

Thirst sensation due to the stimulatio n of Thirst Center of hypothalamus

Blood Sugar Level exceeds renal threshold : 137 mg/dl: April 27, 2008, 117.5mg/dl: April 28, 2008

Excretion of excess glucose in the urine

Glucose attracts water

History of previous impaired fasting glucose Hypertension (>140/90 mm Hg); dyslipidemia (HDL level <40 mg/dl) Stress: hormones at times of

Glucose uptake by the cells

Cellular starvation

↓Energy Level

Renal tissue hypoxia

Impairment in renal functioning

Body malaise, Fatigue: April 27-30, 2008

Hunger due to the stimulation of Satiety Center of Hypothalamus

↓ tubular reabsorption

Excretion of albumin

Polyphagia

↑ Sodium

↑Urine Output: polyuria Sluggish blood Modifiable Factor: ↓ Iron intake & low Depletion of iron stores socio-economic status at the bone marrow to ↓ Iron available to compensate for ↓ Iron absorption the tissues (red decreased availability atblood the intestines cells)

BUN: 93 mg/dl – April 29, 2008

Anorexia: April 23-30, 2008

excretion ↓ serum Na levels: 113.4 mEq/l: April 27, 2008

Albuminuria : +3 : U/AApril 27, 2008

↓organ perfusio n

Polydipsi a

Dry skin: April 2830, 200 8

Delayed biochemical mediation

↓ sodium intake

Modifiable Factor: -Insect bite

Development of wound

↓ Iron available to the tissues (red blood cells)

Depletion of iron stores at the bone marrow to compensate for decreased availability

↑Biochemic al mediation through ↑ blood flow

Greater proportion of water in the blood compared to sodium: Hemodilution: Hct – 0.29: April 27, 2008

↓ Iron absorption at the intestines

↓ ↓ interstitial interstitial fluid fluid volume volume

Dry skin: April 28-30, 2008

Enlargement of wound, turning red, firm and swollen

Impaired hemoglobin and red blood cell synthesis

Development of a single, red, swollen firm furuncle (approx. 3cm diameter, located at the left upper arm) draining purulent secretions: April 27-30, 2008

Pallor: April 28-

Decreased Fatigue oxyen April 27-30, supply to the

Weakness: April 27-30, 2008 Increased need for the heart to pump more of Shortness blood to meet breath, oxygen demand tachypnea

↓cerebral perfusion/ ineffective blood supply to the brain

Alteration in brain functioning

↓impulse transmission to the muscles

Decrease circulating red blood cell along with its hemoglobin

Decrease in hemoglobin: 95 g/l: April 27, 2008

Fluid shifting from Intravascular to intracellular esp. in the brain which is sensitive to serum Na changes

Lethargy: April 29, 2008

b. Synthesis of the Disease b.1 Hypertension b.1.1 Definition Hypertension is defined as systolic pressure greater than 140 mmHg and a diastolic pressure greater thank 90 mmHg based on the average of two or more accurate blood pressure measurements taken during two or more contacts with a health care provider. Blood pressure of less than 120/80 mmHg diastolic as normal, 120 to 129/80 to 89 mmHg as pre-hypertension, and 140/90 mmHg or higher as hypertension. (Bare, B. et. al. , 2008)

High blood pressure or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre–hypertension", and a blood pressure of 140/90 or above is considered high. An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac)

disease,

kidney

(renal)

disease,

hardening

of

the

arteries

(atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end–organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications.

b.1.2 Non-modifiable and Modifiable Risk Factors ***factors specific to the patient are highlighted Non-modifiable Risk Factors:

 Age – 35 years and older

 Gender – men and post-menopausal women  Race – black and brown race  Family history of hypertension Modifiable Risk Factors:  Alcohol use  Excess dietary sodium

 History of high blood pressure during pregnancy

 Lack of exercise

 Toxemia of pregnancy

 Stress

 Oral Contraceptives (Birth Control Pills)

 Obesity

 Steroids

 Diabetes  Kidney disease  Hormonal disorders  Porphyria

 Nonsteroidal anti-inflammatory drugs  Decongestants  Diet pills  Antidepressants

b.1.3 Signs and Symptoms, Complications with Rationale ***factors specific to the patient are highlighted

 high blood pressure – due to vasoconstriction and increase in circulating fluid (↑BP: 170/100 mmHg: April 27, 2008; 150/90mmHg: April 28, 2008, 140/100 mmHg: April 29, 2008)

 retinal changes and papilledemea (swelling of the optic disk) –due to increased pressure exerted by the walls of the vessels supplying the eye and increased intraocular pressure related to cranial nerve II affectation

 increased blood urea nitrogen (93mg/dl: April 29, 2008) and serum creatinine levels – due to poor oragn (kidney) perfusion which alters renal processes and causes destruction and release of substances (i.e. creatinine)

 left ventricular hypertrophy – may occur in response to increased workload placed on the ventricle as it tries to contract against higher systemic pressure  cerebrovascular involvement which may be manifested by dizziness, headache and impaired level of consciousness – related to ineffective blood supply to the brain which causes impairment in the functioning of brain structures 

impairment in organ function – occurs to the organs being supplied by the narrowed vessels; takes place due to decreased perfusion brought about by narrowed arteries

b.2 Diabetes Mellitus b.2.1 Definition Diabetes mellitus type 2 (diabetes mellitus type II, non insulindependent diabetes (NIDDM), obesity related diabetes, or adult-onset diabetes) is a metabolic disorder that is primarily characterized by insulin resistance, relative insulin deficiency, and hyperglycemia. It is often managed by engaging in exercise and modifying one's diet. It is rapidly increasing in the developed world, and there is some evidence that this pattern will be followed in much of the rest of the world in coming years. It is a non-ketosis prone hyperglycemia and glucose intolerance due to defects in insulin secretion and peripheral insulin action. DM type 2 comprises 80% of diabetic cases. Type 2 diabetes often goes undetected for long periods of time, since symptoms are usually not pronounced. Insulin is produced, but it is not enough, or it does not work properly to transport glucose through the receptor cells. Type 2 diabetics can often be controlled with a carefully planned diet, an exercise program, oral medication, or insulin, used as necessary.Uncontrolled Type 2 diabetes results in hyperglycemia. Since symptoms have an insidious onset, the patient may not recognize that there

is any difficulty. Left uncontrolled for a long period of time, Type 2 diabetics develop more serious symptoms such as severe hyperglycemia, dehydration, confusion, and shock. This is called “hyperglycemic hyperosmolar non-ketotic coma.” These symptoms are most common in the elderly population and people suffering from illness or infection. The following are the criteria for the diagnosis of DM Type 2:

o Symptoms of diabetes (polyuria, polydipsia, weight loss) plus casual (random) plasma glucose ≥ 200 mg/dL (11.1 mmol/L) o

Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L) on 2 occasions

o

2 hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during OGTT with 75 g glucose load

o

LFTs, amylase, lipase - abd pain b.2.2 Non-modifiable and Modifiable Risk Factors ***factors specific to the patient are highlighted

Non-modifiable Factors:  Age - Older than 40 years  Family history of type 2 diabetes

 Hispanic, Native American, African American, Asian American, or Pacific Islander descent, Asian Modifiable Factors:

 History of previous impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) – FBS:137 mg/dl: April 27, 2008; 117.5mg/dl: April 28, 2008

 Obesity - Weight >20% of desirable body weight (true for approximately 90% of patients with type 2 diabetes)

 Hypertension (>140/90 mm Hg)(↑BP: 170/100 mmHg: April 27, 2008; 150/90mmHg: April 28, 2008, 140/100 mmHg: April 29, 2008), or dyslipidemia (high-density lipoprotein [HDL] cholesterol level <40 mg/dL or triglyceride level >150 mg/dL)

 History of GDM or of delivering a baby with a birth weight of > 9 lbs

 Polycystic ovarian syndrome (which results in insulin resistance)  Viruses: certain viruses may destroy beta cells  Faulty Immune System: multiple factors may cause the immune system to destroy beta cells, such as infection  Physical Trauma: injury or trauma may destroy the ability of the pancreas to produce insulin  Drugs: drugs used for other conditions could cause the development of diabetes  Stress: hormones at times of stress may block the effectiveness of insulin  Pregnancy:

hormones

produced

during

pregnancy

can

block

the

effectiveness of insulin b.2.3 Signs and Symptoms, Complications with Rationale  Polyuria – due to excretion of excess glucose that causes more water attraction in the urine  Polydipsia – due to the stimulation of

the thirst center of the

hypothalamus brought about by intracellular dehydration  Polyphagia – due to the stimulation of the satiety center of the hypothalamus which brought about by cellular starvation from inadequate glucose uptake  Weight loss – due to cellular starvation from inadequate glucose uptake

 Weakness – due to cellular starvation which causes decreased energy levels (April 27-30, 2008)

 Fatigue – due to cellular starvation which causes decreased energy levels (April 27-30,2008)  Blurred vision, retinopathy – related to poor organ perfusion brough about by sluggish blood flow  Slow-healing cuts or sores – related to poor peripheral perfusion due to sluggish blood flow

 Dry, itchy skin – related to poor organ perfusion due to sluggish blood flow(April 28-30, 2008-manifested by dry skin)

 Frequent infections – related to poor perfusion due to sluggish blood flow thereby decreasing number and speed of readily available WBC; delay in biochemical mediation

 Hyperglycemia – related to inadequate insulin production FBS:137 mg/dl: April 27, 2008; 117.5mg/dl: April 28, 2008

 Dehydration – due to increased blood osmolarity leading to fluid shifting from

intracellular

to

extracellular

compartment(April

28-30,

2008-

manifested by dry skin)  Confusion – related to inadequate cerebral perfusion due to sluggish blood flow  Numbness and tingling sensation – related to poor peripheral perfusion due to sluggish blood flow  Nephropathy, neuropathy – common to older patients – related to poor organ perfusion due to sluggish blood flow, causing impairment in organ function

b.3 Electrolyte Imbalance: Hyponatremia b.3.1 Definition Hyponatremia refers to a serum level that is below normal (<135 mEq/l). (Bare, B. et. al. , 2008) When the blood sodium is too low, the cells malfunction — causing swelling. In chronic hyponatremia, sodium levels drop gradually over several days or weeks — and symptoms are typically moderate. In acute hyponatremia, sodium levels drop rapidly — resulting in potentially dangerous effects, such as rapid brain swelling, which can result in coma and death. Hyponatremia (hypervolemic) occurs when the sodium in the blood is diluted by excess water. Hyponatremia (euvolemic, hypervolemic) may result from medical conditions that impair excretion of water from your body, or by a significant increase in water consumption(hypovolemic), such as by athletes competing in marathons and other high-endurance events.

b.3.2 Non-modifiable and Modifiable Risk Factors ***factors specific to the patient are highlighted Non-modifiable Factors:

 Age. Low blood sodium is more common in older adults. This is due to age-related changes and increased prevalence of chronic disease that may impair the body's normal sodium balance.

 Sex. Hyponatremia is more common in women than in men. Non-modifiable Factors:

 Diet. Patient may be at an increased risk of hyponatremia if following a low-sodium diet, especially if combined with diuretic intake.

 Intensive physical activities. People who take part in marathons, ultramarathons,

triathlons

and

other

long-distance,

high-intensity

activities are at an increased risk of hyponatremia.

 Climate. Not being acclimated to hot weather can increase the amount of sodium you lose through sweating during exercise.

 Conditions that impair the body's water excretion. Medical conditions that may increase your risk of hyponatremia include kidney disease, syndrome of inappropriate anti-diuretic hormone (SIADH) and heart failure, and other chronic diseases that cause organ failure.

b.3.3 Signs and Symptoms, Complications with Rationale

 Serum sodium level that is below normal (<135 mEq/l): 113.4 meQ/l:April 27

 Neurologic manifestations such as headache, lethargy (April 29, 2008), confusion, apprehension – due to fluid shifting from intravascular to intracellular space in an attempt to raise the proportion of Na with water

 Decreased BP, orthostatic hypotension – due to decreased vascular volume secondary to water and sodium loss  Tachycardia – compensatory response which is a direct result of triggering sympathetic catecholamine  Sympathetic

responses

of

the

heart

–

due

to

stimulation

of

chemoreceptors on the aortic and carotid bodies  Crackles in the lungs – due to fluid shifting to the pulmonary alveoli secondary to increased pressure of circulating fluids in the pulmonary capillaries  Greater blood volume (water component>serum Na) – Hct of 0.29: April 27

 Tachypnea (April 27, 2008), dyspnea, othopnea, shortness of breath – fluid accumulation in the alveoli alters oxygen-carbon dioxide exchange transport  Nausea, vomiting, abdominal cramping, hyperactive bowel sounds – due to fluid shifting from intravascular to intracellular space causing an urge to expel excess water

 Dry skin (April 28-30, 2008), tongue and mucous membranes – due to decrease in interstitial fluid caused by sodium deficit in the blood b.4 Anemia (Iron Deficiency) b.4.1 Definition Iron-deficiency anemia typically results when the intake of dietary iron is inadequate for hemoglobin synthesis. (Bare, B. et. al. , 2008) It is the most common type of anemia. A lack of iron in the body can come from bleeding, not eating enough foods that contain iron, or not absorbing enough iron from food

that

is

eaten.

(Retieved

at

http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.html accessed on May 1, 2008, 8:22 pm) The term anemiais used for a group of conditions in which the number of red blood cells in the blood is lower than normal, or the red blood cells do

not have enough hemoglobin. Hemoglobin—an iron-rich protein that gives the red color to blood—carries the oxygen from the lungs to the rest of the body. In people with anemia, the blood does not carry enough oxygen to the rest of the body. Red blood cells also remove carbon dioxide, a waste product, from cells and carry it to the lungs to be exhaled. There are many types of anemia. The three major causes of anemia are blood loss, decreased production of red blood cells, or increased destruction of red blood cells. White blood cells and platelets are the two other kinds of blood cells. White blood cells help fight infection. Platelets help blood to clot. In some kinds of anemia, there are low amounts of all three types of blood cells. The most common symptom of all types of anemia is feeling tired because the body is not receiving enough oxygen. In iron-deficiency anemia, the body does not have enough iron to form hemoglobin, which means there is not enough hemoglobin to carry oxygen to the whole body. The body gets its iron from food. The main foods that contain iron are meat and shellfish as well as iron-fortified foods. A steady supply of iron is needed to form hemoglobin and healthy red blood cells. The four main causes of IDA include: Blood loss, either from disease or injury, Not getting enough iron in the diet, Not being able to absorb the iron in the diet. Iron-deficiency anemia also can develop when the body needs higher levels of iron, such as during pregnancy b.4.2 Non-modifiable and Modifiable Risk Factors ***factors specific to the patient are highlighted Non-modifiable Factors:

 Sex - Women - Women who lose a lot of blood during their monthly periods are at higher risk of developing iron-deficiency anemia. About 1 in 5 women of childbearing age has iron-deficiency anemia. - Pregnant women need twice as much iron in their diet than women who are not

pregnant. If a pregnant woman doesn't get enough iron for herself and the growing baby, she can develop iron-deficiency anemia. About half of all pregnant women have this type of anemia.

 Age - Young Children - Infants and toddlers 6-24 months of age need a lot of iron to grow and develop. Premature and low-birth-weight babies are at even greater risk for iron-deficiency anemia because they don't have as much iron stored in their bodies. Modifiable Factors:

 Diet low in iron – decreased intake of Iron-rich foods  Blood loss – causes decrease in blood volume  Other children at risk for anemia are: Children with poor nutrition, including low-income children, Children with lead in their blood, Infants fed cow's milk before 1 year of age, Breastfed infants older than 4 months who are not receiving iron-rich solid foods or iron supplements

 Adults With Intestinal Bleeding - Adults who bleed in their intestinal tract are at risk for iron-deficiency anemia. This includes people who have bleeding ulcers or colon cancer. It also includes people who use medicines that can cause intestinal bleeding (for example, aspirin).

 Other Adults - Other adults who are at risk for iron-deficiency anemia include those who are on kidney dialysis, vegetarians, with low socioeconomic status and older adults who have poor diets. b.4.3 Signs and Symptoms, Complications with Rationale

 Fatigue (April 27-30, 2008) is caused by having too few red blood cells to carry oxygen to the body. This lack of oxygen in the body can cause people to feel weak or dizzy, have a headache, or even pass out when changing position (for example, standing up).

 Shortness of breath, tachypnea (April 27, 2008) and chest pain - Since the heart must work harder to move the reduced amount of oxygen, signs and

symptoms may include shortness of breath and chest pain. This can lead to a fast or irregular heartbeat or a heart murmur.

 Pallor (April 28-30, 2008) - In anemia, the red blood cells don't have enough hemoglobin. Common signs of lack of hemoglobin include pale skin, tongue, gums, and nail beds.  Cold hands and feet as well as brittle nails – due to decrease oxygenation and circulating blood that provides heat to the body  Swelling or soreness of the tongue and cracks in the sides of the mouth – due to decrease oxygen supply to the integument causing easy bruising  An enlarged spleen – due to increased number of dead RBC

 Frequent infections – due to compromised immune system and decreased perfusion to any affected part causing delay in biochemical mediation  Some of the signs and symptoms of iron-deficiency anemia are related to its causes, such as blood loss. Blood loss is most often seen with very heavy or long lasting menstrual bleeding or vaginal bleeding in women after menopause. Other signs of internal bleeding are bright red blood in the stool or black, tarry-looking stools.  Decreased hemoglobin on lab exams – 95g/l: April 27, 2008 b.5 Furuncle b.5.1 Definition A furuncle or boil is an acute inflammation arising deep in one or more hair follicles and spreading in the surrounding dermis. It is a deep form of follliculitis. Furunculosis refers to multiple or recurrent lesions. Furuncles may occur anywhere in the body but are more prevalent in areas subjected to irritation, pressure, friction and excessive perspiration, such as the buttocks, back of the neck and the axilla. (Bare, B. et. al., 2008) A furuncle may start as a small, red, raised, painful pimple. Frequently the infection progresses and involves the skin and subcutaneous fatty tissue, causing tenderness, pain and surrounding cellulites. The area of redness and induration represents and effort of the body to keep the infection localized.

The bacteria, usually staphylococci, produce necrosis of invaded tissue. The characteristic pointing of a boil follows in a few days. When this occurs, the character becomes yellow or black, and the boil is said to have “come to a head.” b.5.2 Non-modifiable and Modifiable Risk Factors ***factors specific to the patient are highlighted Non-modifiable Factors – no particular non-modifiable factors Modifiable Factors  Poor hygiene  Insect bite  Excessive perspiration  Increased pressure  Increased friction b.4.3 Signs and Symptoms, Complications with Rationale

 The lesions themselves are the primary symptoms: -

Small firm tender red nodule in skin (early)

-

Fluctuant nodule (later)

-

Located with hair follicles

-

Tender, mildly to moderately painful

-

May be single or multiple

-

Usually pea-sized, but may be as large as a golf ball

-

Swollen

-

Pink or red

-

May grow rapidly

-

May develop white or yellow centers (pustules)

-

May weep, ooze, crust

-

May join together or spread to other skin areas and progress into a carbuncle

-

Decreasing pain as the area drains

The above-mentioned are characteristics of a furuncle. The furuncle is the symptom itself. Its characteristics are changes in the site of indurations due to biochemical mediation. Whenever there is an injury or any break in the skin integrity, the body attempts to localize the infection by increasing blood flow to the affected part in order to supply necessary chemicals that will aid in controlling infection. Localized infection is generally characterized by the following:

-

Increasing pain as pus and dead tissue fills the area – due to release of prostaglandins

-

Skin redness or inflammation around the lesion

-

Swollen, tender – due to increased blood flow and accumulation of dead bacteria and WBC that engulf them

-

Pink or red – due to increased blood flow

V. The Patient and His Care A. Medical Management a. IVFs, NGT feeding, BT, Nebulization, TPN, Oxygen therapy, etc... Medical management or treatment D5LRS

D5NM

Date ordered / Date performed: D.O.: 04-27-08 04-28-08 04-29-08 D.P.: 04-27-08 04-28-08 04-29-08 D.O. 04-30-08 D.P. 04-30-08

General Description

Indication(s) or purposes

Client’s Reponse to the treatment

Lactated Ringer’s Injection, USP is a sterile, nonpyrogenic solution containing isotonic concentrations of electrolytes in water for injection. It is administered by intravenous infusion for parenteral replacement of extracellular losses of fluid and electrolytes Hypertonic solutions draw fluid

This medication is an intravenous (IV) solution used to supply water and electrolytes (e.g., calcium, potassium, sodium, chloride), either with or without calories (dextrose), to the body. It is also used as a mixing solution (diluent) for other IV medications. It is a sterile, nonpyrogenic solution for fluid and electrolyte replenishment and caloric supply.

The patient was supplied with adequate fluid. No adverse responses were noted.

out of the intracellular and interstitial compartments into the vascular compartment, expanding vascular volume.

Nursing Responsibilities: Prior to: 1. Prepare the equipment 2. Verify doctor’s order 3. Use strict aseptic technique 4. Explain the procedure to the S0 and give formation about the purpose of IVF to be inserted 5. Identify the client

The patient was supplied with adequate fluid. No adverse responses were noted.

6. Assess vital signs for baseline data 7. Assess skin turgor, allergy to tape 8. Check the status or veins to determine appropriate venipuncture site During: 9. Use the smallest gauge needle possible. 10.Check for patency of the tubing 11.Spike the solution container 12.Cleanse the fluid to be given, make sure it is the same with the prescribed fluid. 13.Partially fill the drip chamber gently with solution. 14.Select a suitable vein for venipuncture 15.Dilate the vein 16.Put on clean gloves and clean the venipuncture site. After: 17.Label the IVF (name, date started, number) 18.Ensure appropriate infusion flow. 19.Adjust the rate of fluids appropriate to the needs f the patient as ordered. If there is any question with the flow rate ordered, check with the physician who gave the order. 20.Monitor IV flow and patient’s response 21.Monitor patient for evidence of IV infiltrations 22.Check for presence of air in the tubing, if air is present, remove immediately 23.Check for the patency of the line always. 24.Regulate and monitor the IV rate of fluid. 25.Document relevant data. b. Drugs Name of Drugs:

Generic Name: ceftriaxone

Date ordered, performed , D.O. 04-27-08

Brand Name: Rocephin

D.P. 04-27-08

Route Indication(s) or Dosage Purpose(s) and Frequency 1g/IV q 12 Treatment of: Skin and skin structure infections, bone and joint

Client’s Response to the Treatment No adverse reaction with Ceftriaxone was noted.

Nursing Responsibilities

1.Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.

04-28-08 04-29-08 04-30-08

Generic Name: Metformin

D.O. 04-27-08

Brand Name: Fortamet

D.P. 04-28-08 04-29-08 04-30-08

Generic Name: Metoclopramide

D.O. 04-27-08

Brand Name:

D.P.

500mg 1 tab BID

1 tab TID for Vomiting

infections, urinary and gynecologic infections including gonorrhea, resp. tract infections, intra-abdominal inmfections, septicemia, meningitis. Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral hypoglycemics.

Disturbances of GI motility. Nausea & vomiting of

2.IV: Monitor injection site frequently for phlebitis (pain, redness, swelling) 3.Advise patient to report signs of superinfection (furry overgrowth on the tongue, loose or foul smelling stools) and allergy. The patient’s blood glucose decreased from 137 to 88 on April 28, 2008 AEB lab results (FBS/RBS).

1. Observe for signs and symptoms of hypoglycemic reactions (abdominal pain, sweating, hunger, weakness,dizziness, h/a,tremor,tachycardia,anxi ety) when combined with oral sulfonylureas. 2. PO: Administer metformin with meals to minimize GI effects. 3. Explain to explain that metformin helps control hyperglycemia but does not cure diabetes. Treatment is usually long term.

No adverse reaction with Plasil was noted.

1. Assess pt. for nausea, vomiting, abdominal distention, and bowel sounds before and after

Plasil

04-28-08 04-29-08 04-30-08

Generic Name: FeSO4

D.O. 04-27-08

Brand Name: Feosol

D.P. 04-28-08 04-29-08 04-30-08

Generic Name: Amlodipine

D.O. 04-27-08

Brand Name: Norvasc

D.P. 04-28-08 04-29-08 04-30-08

1 tab BID

5g 1 tab OD

central & peripheral origin associated w/ surgery, metabolic diseases, infectious & drug-induced diseases. Facilitate small bowel intubation & radiological procedures of GIT Simple Fe deficiency & Fedeficiency anemia. Patient intolerant to conventional Fe & those prone to GI upsets

Hypertension, angina, myocardial ischemia. Reduce the risk of coronary revascularizatio n.

administration. 2. PO: Administer doses 30min. before meals and at bedtime. 3. Advise pt. to avoid concurrent use of alcohol and other CNS depressants while taking this medication.

The patient responded well with the medication and no adverse reaction was noted.

The patient’s blood pressure decreased from 170/100 to 150/100 on April 28,

1. Assess nutritional status and dietary history to determine possible cause of anemia and need for patient teaching. 2. Discontinue oral iron preparations prior to parenteral administration. 3. Advise patient that stools may become dark green or black and that this change is harmless. 1. Monitor BP and pulse before therapy, during dose titration, and periodically during therapy. 2. PO: May be administered without regard to meals. 3. Advise pt. to take medication as directed, even if feeling well.

Generic Name: Clindamycin

D.O. 04-28-08

Brand Name: Clindal

D.P. 04-28-08 04-29-08 04-30-08

Generic Name: Pizotifen

D.O. 04-29-08

Brand Name: Mosegor Vita cap

D.P. 04-30-08

300 mg/tab q 12

Treatment of serious anaerobic infections esp those caused by Bacteroides fragilis. Alternative to penicillin in some severe Staph & Strep infections, including Staph osteomyelitis.

1 cap OD

Underwt due to lack of appetite associated w/ vit B deficiency secondary to impaired dietary intake or absorption; nervous disorders in puberty (anorexia nervosa) old age when prevention of deficiency of Bgroup vit is indicated.

2008. No adverse reaction with Clindamyci n was noted.

The patient’s appetite was enhanced as verbalized by himself.

1. Assess for infection (vital signs; appearance of wound, sputum, urine, and stool; WBC) at beginning of and during therapy. 2. PO: administer with a full glass of water. May be given with meals. Do not refrigerate. 3. Instruct pt. to notify HCP immediately if diarrhea, abdominal cramping, fever, or bloody stools occur and not to treat with antidiarrheals without consulting HCP. 1. May be taken with or without food (May be taken w/ meals to reduce GI discomfort.). 2. Timed-release tablets and capsules should be swallowed whole, without crushing, breaking or chewing. 3. Emphasize the importance of follow-up examinations to evaluate progress.

Nursing Responsibilities: Prior: 1. Check the written medication order for completeness. It should include the drug name, dosage, frequency, and duration of the therapy. 2. Check if IV in. 3. Check to see if there are any special circumstances surrounding administration of the dose to the patient. 4. Be certain that you know the expected action, safe dosage range, special instructions for administration and adverse effects associated with drug orders. 5. Prepare the necessary equipment. 6. Wash your hands. 7. Check the label on the medications three times before administering any drug. 8. Prepare the dosage as ordered. 9. Explain the procedure to the patient. The action of the drug and its side effects. During: 10.Identify the patient. 11.Identify if the patient expresses any doubt about the medication; always recheck the order, drug label and dosage on the medication card. 12.For oral meds do special regulation and precaution to avoid or prevent aspiration. After: 13.Following administration, be certain that the patient is comfortable, then immediately record the procedure. 14.Maintain patient’s safety 15.Monitor patient for side effects 16.Instruct the patient to report signs of superinfection and allergy. 17.Inspect IV insertion sites for sign of phlebitis. 18. Document and assess the patient's reaction to the given drug c. Diet Type of Diet

Date

General

Indications

Specific

Client’s

ordered,

Description

or Purposes

foods taken

response

date

and

performed

reaction to

the diet

D.O.

The low fat

Indicated for

Low salt and

04-27-08

and salt diet

bed patients

low fat

is designed

whose

foods.

D.P.

to limit the

condition

Low Fat, Low

04-27-08

total

requires

Salt Diet

04-28-08

amount of

modified

04-29-08

fat, salt and

diet in order

04-30-08

cholesterol

to prevent

in the diet

further

to reduce

aggravation

serum lipid

of condition.

levels and avoid excessive sodium retention Nursing Responsibilities: Prior to: 1. Check the doctor’s order for the type of diet prescribed 2. Explain the importance of the diet given.

The client complied with the prescribed diet.

3. Explain the importance of compliance to the diet given. 4. Inform dietary department on the patient’s diet During: 5. Give appropriate foods to the patient. 6. Enumerate the foods that the patient may or may not take. 7. Emphasize strict compliance to diet 8. Reiterate diet frequently After: 9. Document the patient’s tolerance to the diet given.

April 28, 2008 7am – 7pm shift S>Ø O>received supine on bed; asleep; with an ongoing IVF #1 0.9 NaCl 1L @ 550 ml level, regulated @ 30gtts/min, infusing well on right hand; appears weak; with 3cm-diameter open wound on left upper arm, with erythematous, inflamed surroundings, draining purulent secretions; with dry, scaly skin on left upper arm; with difficulty hearing; (+) pallor; with cold, clammy skin; capillary refill in 3 seconds; with VS taken and recorded as follows: T=37°C, PR=74bpm, RR=17cpm, BP=150/90mmHg. A>Decreased cardiac output related to decreased afterload as evidenced by blood pressure elevation, cold, clammy skin, prolonged capillary refill >2 seconds, and pallor. P>After 4 hours of nursing interventions, patient will display hemodynamic stability as evidenced by decrease in blood pressure from 150/90 to 130/80mmHg. I>Established rapport >Assessed patient’s condition >VS taken and recorded >Assessed character of wound and wound drainage >Reviewed laboratory data for any deviations from the normal range >Assessed for capillary refill through blanch test >Assisted in position changes >Maintained aseptic technique during wound care >Advised to inform health care provider should vomiting occur >Instructed to dangle feet first before standing and walking >Emphasized the importance of hand washing technique before and after would cleaning >Instructed SO on the proper and aseptic method of doing wound cleaning

>Encouraged rest periods >Encouraged to avoid sweet, fatty and salty foods >Seen on rounds by Dr. Delmas @ 7am with orders made and carried out - FBS, lipid profile SGPT, SGOT, BUN, Creatinine – requested - daily wound cleaning – done - IVF to FF D5LRS 1 liter x 30gtts - start Clindamycin 300mg/tab q 12 hrs – prescribed - refer >Monitored and regulated IVF as ordered >Due meds given as prescribed >Needs attended >Refer accordingly >Endorsed E>Goal met; patient will displayed hemodynamic stability as evidenced by decrease in blood pressure from 150/90 to 130/80mmHg. _______________________________________________Kathleen Kaye D. Tobias, AUFSN April 29, 2008 S>Ø O>received lying on bed; awake, unconscious and incoherent; with an ongoing IVF #53 D5LRS 1L @ 350 ml level, regulated @ 30gtts/min, infusing well on right hand; appears weak, pale and lethargic; with dry skin; inflamed 3-cm-diameter furuncle with purulent secretion @ left upper arm noted; with pale conjunctiva; vomitus noted, thick in consistency, approximately 50 cc within the shift; with VS taken and recorded as follows: T=37.1°C, PR=80bpm, RR=19cpm, BP=140/100mmHg. A> Impaired Skin Integrity related to presence of inflamed 3-cm-diameter eruption (wound) on left upper arm.

P> After 4 hours of nursing interventions, the patient will understand and cooperate to the health teachings and interventions given. I> Established Rapport > Assessed condition > Monitored and Recorded Vital Signs > Assessed presence of cyanosis > Assessed Skin Turgor > Instructed on proper and aseptic wound care > Instructed to increase fluid intake > Instructed to eat foods rich in protein and vitamin C once DAT >Emphasized the importance of hand washing especially before and after wound care >Reinforced low salt, low fat diet >Practiced aseptic technique in wound cleaning >Due meds given >Regulated IVF as ordered >Needs attended >Refer accordingly >Endorsed E> Goal met. Patient cooperated in nursing interventions given and verbalized understanding of the health teachings. ___________________________________________Kathleen Kaye D. Tobias, AUF-SN

April 30, 2008 7am – 7pm shift S>Ø

O>received sitting on bed; awake, conscious and coherent; with an ongoing IVF #5 D5LRS 1L @ 900 ml level, regulated @ 30gtts/min, infusing well on right hand; appears weak; (+) pallor; with purulent secretion draining from inflamed 3-cm-diameter furuncle @ left upper arm; with dry, scaly skin; with vomiting 2x, vomitus is thick in consistency, yellowish color, approximately 100cc within the shift; with difficulty hearing; with pale conjunctiva; capillary refill within 2 seconds; with VS taken and recorded as follows: T=36.2°C, PR=73bpm, RR=20cpm, BP=110/70mmHg. A>Risk for deficient fluid volume related to loss of fluid through normal route (vomiting). P>After 4 hours of nursing interventions, patient will not manifest evidences of fluid volume deficit such as poor skin turgor, dry mucous membranes, increased PR and temperature, and decreased BP. I>Established rapport >Assessed patient’s condition >Monitored and recorded vital signs >Determined ability to chew, swallow, taste >Assessed skin turgor and capillary refill >assessed body built, activity, rest level >Reviewed laboratory results >Auscultated bowel sounds >Practiced aseptic technique in wound cleaning >Promoted relaxing environment to enhance intake >Encouraged small frequent feedings >Reinforced low salt, low fat diet >Instructed SO on the proper way of doing wound care >Emphasized the importance of hand washing before and after wound care >Seen on rounds by Dr. Bondoc @ 9:00 am with orders made and carried out - continue meds - D5NM 1L x 8hrs

- change dressing OD – done - refer >Due meds given as prescribed >Regulated IVF as ordered >Needs attended >Refer according ly >Endorsed E>Goal met; patient did not manifest evidences of fluid volume deficit such as poor skin turgor, dry mucous membranes, increased PR and temperature, and decreased BP. _______________Charmaigne Hazelyn Cruz, AUF-SN/Kathleen Kaye Tobias, AUFSN

VI. CLIENT’S DAILY PROGRESS CHART 1. Client’s Daily Progress Chart

April 27 (Admission)

April 28

April 29

April 30

Nursing Diagnosis >

*

Decreased cardiac output related

to

decreased afterload

as

evidenced

by

blood pressure elevation, cold,

clammy

skin, prolonged capillary >2

refill

seconds,

and pallor.

*

> Impaired Skin Integrity. * > Risk for deficient

fluid

volume related to loss of

fluid

through normal

route

(vomiting). April 27

April 28

April 29

April 30 Vital Signs Temperature (degrees Celsius) Pulse Rate (beats per minute) Respiratory Rate (cycles per minute) Blood Pressure (mmHg)

7am to 7pm

7pm to 7 am

7am to 7pm

7pm to 7 am

7am to 7pm

7pm to 7 am

7am to 7pm

36.6

37

36.6

37.1

37.2

36.2

84

74

82

80

78

73

21

17

21

19

22

20

170100

15090

14090

140100

11060

11070

7pm to 7 am

Diagnostic/ Laboratory procedures 27 30 FBS/RBS (70-100mg/dl) Na (135-150 mg/dl) K (3.5-5.2 mg/dl) Urinalysis

137

88

117.5

3.8 * 95

WBC (5-10 x 10 ^9/L)

14.5

Hct. (0.40-0.54 L/L)

.29

Seg. 0.90

.90 .10

BUN= 93 (7-18 mg/dl) Cholesterol= 192.5 (150-250 mg/dl)

29

113.4

Hgb (140-180 gm/L)

Lymph.= 0.10

28

93 160.7

192.5

Creatinine= 18 (0.4-1.4)

18.0

HDL C=33.2 (30-75)

33.2

LDL C= 145.22 (66-178)

145.22

Triglycerides= 70.4 (36165)

70.4

SGPT/ALT= 17 (up to lu/ml)

17.0

SGOT/AST= 19.9 (up to 40 lu/ml)

19.9

Medical Management IVF’S

27

28

29

D5LRS

*

*

*

30

D5NM

MEDICATIO NS

*

April 27 7am7pm7pm 7am

Ceftriaxone 1g/IV q 12

*

April 28 7am7pm7pm 7am

April 29 7am7pm7pm 7am

April 30 7am7pm7pm 7am

*

*

*

*

*

Metformin 500mg 1 tab BID

*

*

*

*

*

Plasil tab TID for Vomiting

*

*

*

*

FeSO4 tab BID

*

*

*

*

Amlodipine 5g 1 tab OD

*

Clindamycin 300 mg/tab q 12

*

* *

*

*

* *

Mosegor Vita cap Diet Low fat, low salt

* *

am

pm

am

pm

am

pm

am

*

*

*

*

*

*

pm

Conclusion:

The Groups’ Goal in this study is to at least help the patient deal with the situation in order to prevent further complications and gain cooperation with the nurses and to somewhat help in stabilizing and improve the patient’s

health and well-being because the patient is still responsible in achieving his health goal. Many Interventions were done according to the level of knowledge and understanding of the student nurses about the diseases he is afflicting right now in order to meet the said Goal. Through constant monitoring of his Vital Signs, laboratory results and checking the patient’s Daily Progress chart, the Group was able to identify if their Goals were achieved. During the first day of handling the patient, his vital signs were monitored and blood pressure appeared to be elevated and at the same time he feels weak. Vital signs were normal during the second day except for the blood pressure same with the third day. On the last day that the group handled the patient, Vital Signs were normal and the patient was still appeared weak, pale and lethargic. Medications were given on time at the desired dose. Other records such as laboratory results show that there are still complications particularly the Random Blood Sugar, however, some laboratory findings show within normal range. The Goal was not totally met because there are still abnormalities presented during the first until the last day that the group handled him though he is cooperative when it comes to medical regimen.

VIII. BIBLIOGRAPHY Bare, B. et. al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia:Lippincott-Williams & Wilkins Deglin, J. and Velerand, A. (2007). Davis’s Drug Guide for Nurses. Pensylvania: E.A. Davis Company. Doenges, Marilynn E. Nursing Care Plans: Guidelines for Planning Patient Care Seely, R., Stephens, T., Tate, P. (2005). Essentials of Human Anatomy & Physiology. New York: McGrw-Hill. Wolff L: Fundamentals of Nursing, 7th edition, JB Lippincott Co.

Retrieved at http://www.medicinenet.com/high_blood_pressure/article.htm accessed on April 29, 2008 at 5:30 pm Retrieved at http://www.emedicinehealth.com/anatomy_of_the_endocrine_system/ar ticle_em.htm accessed on April 29, 2008 9:37 pm Retrieved at http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 accessed on April 29, 2008 9:37 pm Retrieved at http://www.nurseslearning.com/courses/nrp/NRP1605/course/diabetes. pdf accessed on April 30, 2008 at 7:05 pm Retrieved at http://webpages.charter.net/saabrio/ENDO_Diabetes_mellitus.htm, accessed on April 30, 2008 at 7:05 pm Retieved at http://www.nhlbi.nih.gov/health/dci/Diseases/anemia/anemia_whatis.ht ml accessed on May 1, 2008, 8:22 pm Retrieved at http://en.wikipedia.org/wiki/Pancreas accessed on May 2, 2008 11:03 pm Retrieved at http://www.mayoclinic.com/health/hyponatremia/DS00974/DSECTION= 1 accessed on May 2, 2008, 11:50am Retrieved at http://health.allrefer.com/health/furuncle-symptoms.html accessed on May 2, 2008, 3:46pm Retrieved at http://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 accessed on April 30, 2008 at 7:05 pm) Retrieved at http://health.discovery.com/diseasesandcond/encyclopedia/2935.html. Retrieved athttp://webpages.charter.net/saabrio/ENDO_Diabetes_mellitus.htm, Retrieved at http://www.mayoclinic.com/health/hyponatremia/DS00974/DSECTION=1 accessed on May 2, 2008, 11:50am) Retrieved at http://www.medicinenet.com/high_blood_pressure/article.htm Retrieved at http://www.nurseslearning.com/courses/nrp/NRP1605/course/diabetes.pdf,

ANGELES UNIVERSITY FOUNDATION Angeles City College of Nursing

CASE STUDY: HYPERTENSION II DIABETES MELLITUS TYPE II ELECTROLYTE IMBALANCE (HYPONATREMIA) IRON DEFICIENCY ANEMIA FURUNCLE