Stroke In Evolution

Introduction Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to

society,

hypertension

is

an

important public health challenge. Over

the

extensive

past

several

research,

decades,

widespread

patient education, and a concerted effort on the part of health care professionals have led to decreased mortality and morbidity rates from the multiple organ damage arising from years of untreated hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population. •

Pre-hypertension - Systolic blood pressure (SBP) 120-139 or diastolic blood

pressure(DBP) 80-89 •

Stage I HTN - SBP 140-159 or DBP 90-99

•

Stage II HTN - SBP >160 or DBP >100

Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled BPs leads to progressive or impending target organ dysfunction (TOD). The clinical distinction between hypertensive emergencies and hypertensive urgencies depends on the presence of acute TOD and not on the absolute level of the BP.

Hypertensive emergencies represent severe HTN with acute impairment of an organ system (eg, central nervous system [CNS], cardiovascular, renal). In these conditions, the BP should be lowered aggressively over minutes to hours. Hypertensive urgency is defined as a severe elevation of BP, without evidence of progressive target organ dysfunction. These patients require BP control over several days to weeks. II. NURSING ASSESSMENT A. PERSONAL HISTORY Mang Jose was born on January 20, 1948 via Normal Spontaneous Delivery (NSD). He is already 60 years old, a natural born Filipino and a Roman Catholic. He was the 6th child in their family and has 5 other siblings, three girls and two boys. Presently, he lives at Brgy. Pandan, Pampanga and is already married to his wife, Aling Lucing. They have three children, one boy who is already 30 years old, and two girls aged 40 and 38. He is a purok leader, he usually works whole day. He also loves to eat fatty and salty foods. According to Mang Jose, he experienced dysuria or difficulty urinating. His wife, Aling Lucing confirmed his statement and also said that her husband sometimes had elevated blood pressure. She also said that, one week prior to his husband’s admission, Mang Jose has difficulty urinating and thus he decided to consult a doctor. Mang Jose was admitted in the morning of April 20, 2009 at Ospital ning Angeles with an admitting diagnosis of HPN I and UTI with a chief complaint of dysuria. His admitting notes/vital signs are as follows: T=36°C P=80 R=24 BP=170/100

B. PERTINENT FAMILY HISTORY

Mang Jose’s family is a nuclear type of family. They live together with his wife and youngest son, because his two daughters already have their own family. His family believes in “herbolarios” or the so-called “manghihilot”. He also uses herbal plants like “dahon ng bayabas”, whenever he has a wound. He and his family also go to the health center for consultations. The family lives in a Bungalow-type of house that is made of coco lumber and corrugated tin as their roof. The house has two rooms, one for him and his wife and the other for their youngest son. A corrugated tin serves as a wall that separates the two rooms for their own privacy. The house has a bathroom with a pail system. Their electricity is being supplied by AEC and their water source is through a faucet supplied by Angeles Water District. Mang Jose is a brgy. tanod and earns P200.00/day. His wife is a laundry woman, who works once a week with her niece and earns P2, 000.00 for a month. Mang Jose also mentioned that what they earn is not enough to sustain their needs. They usually seek financial support from their daughters when they do not have enough money to sustain their needs and in case of emergencies like what happened to him.

C. PERTINENT FAMILY HEALTH-ILLNESS HISTORY

According to Mang Jose, his grandparents on mother’s side died of CVA and hypertension while on his father’s side, died of aging. His mother died of CVA and hypertension while his father died because of appendicitis. According to Mang Jose, his father experienced severe abdominal pain and was diagnosed to have ruptured appendicitis but due to financial constraints, they were not able to afford to perform surgery for his father. His brother died of car accident, his other brother died of gastric cancer. His three sisters are hypertensive. Mang Jose loves to eat fatty and salty foods. His three children are all hypertensive also.

D. HISTORY OF PAST ILLNESS

According to Mang Jose, this was his first time to be hospitalized. He said that he is only having headaches, fever, coughs, and colds and takes medicines such as Paracetamol and Mefenamic Acid to be relieved. He also drinks calamansi juice when he has coughs and colds. It was just recently when he experienced difficulty urinating.

E. HISTORY OF PRESENT ILLNESS According to Mang Jose, a week before he was admitted at Ospital ning Angeles, he experienced difficulty urinating and an elevated blood pressure. He always asks student nurses in their barangay to take his blood pressure and his elevated blood pressure is consistent. Also, he has difficulty urinating, and his urine is dark yellow in color, and only small amount of urine is excreted. Aling Lucing decided then to bring him to the hospital. There, he was admitted on April 20, 2009. He was asked to take medications and he was given an IVF. He was also asked to undergone renal ultrasound, chest x-ray, urinalysis and CBC. They also took his total cholesterol, BUN, Crea and other electrolytes.

F. PHYSICAL EXAMINATION

Upon Admission (April 20, 2009). Lifted from the chart. Vital Signs: T=36°C P=80 R=24 BP=170/100 •

HEENT: pink palpebral conjunctiva

•

Chest, Lungs: Symmetrical Chest Expansion, normal breath sounds

•

Cardiovascular: Normal Rate Regular Rhythm (NRRR), adynamic precordium

•

Abdomen: symmetrical

April 21, 2009 (student nurse- patient interaction) General condition: Patient on a semi-fowler’s position, awake, conscious and coherent with an IVF of with an ongoing IVF of #2 D5 LRS 1Lx8° at 450cc level infusing well on the right hand; with initial VS of: T=36.6°C P=79 R=20 BP=150/90 SKIN: with edema; non-pitting HEAD and SKULL: smooth skull contour, no lumps or lesions on the head EYES: pink palpebral conjunctiva, periorbital edema EARS: no discharge, no lesions FACE: symmetrical placement of eyes and facial features and ears are symmetrical in line with the outer cantus of the eyes, facial edema NOSE: nasal septum intact and midline, no discharge, no lesions, no nasal flaring MOUTH: intact lips and palate NECK: no vein distention, no palpable lymph nodes CHEST: normal contour with symmetrical lung expansion LUNGS: normal breathing pattern, (+) adventitious breath sounds; wheezes ABDOMEN: symmetrical EXTREMITIES: bipedal edema, non-pitting April 22, 2009 (student nurse- patient interaction) General condition: Patient on a semi-fowler’s position; sleeping; with an ongoing IVF of #3 D5LRS 1Lx8° at 280ml level infusing well on the right hand; pt. appears restless; with initial VS taken and recorded as follows: T=36.6°C P=69 R=20 BP=140/90 SKIN: with good skin turgor; pale nail beds HEAD and SKULL: smooth skull contour, no lumps or lesions on the head EYES: pink palpebral conjunctiva, periorbital edema EARS: no discharge, no lesions FACE: symmetrical placement of eyes and facial features and ears are symmetrical in line with the outer cantus of the eyes, facial edema NOSE: nasal septum intact and midline, no discharge, no lesions, no nasal flaring MOUTH: intact lips and palate

NECK: no vein distention, no palpable lymph nodes CHEST: normal contour with symmetrical lung expansion LUNGS: normal breathing pattern, (+) adventitious breath sounds; wheezes ABDOMEN: symmetrical EXTREMITIES: bipedal edema, non-pitting

G. DIAGNOSTIC AND LABORATORY PROCEDURES DIAGNOSTIC/

DATE

INDICATIONS/

LABORATORY

ORDERED/

PURPOSES

PROCEDURE

PERFORMED

HOSPITAL

Date

140-180gm/L

1. Complete Blood Count

RESULTS

USED

Ordered: Hemoglobin- to determine 160

04-20-09

the

NORMAL

oxygen

VALUES ANALYSIS BY

carrying

THE INTERPRETATION

There is a normal level of

capacity of the blood.

AND

hemoglobin

count

possibly because there

Date Performed:

is still enough oxygen

04-20-09

carrying

capacity

of

blood. Hematocrit- to aid in the diagnosis

of

abnormal 0.47

There is a normal level 0.40-0.54L/L

state of hydration

of

hematocrit

count

since patient did not manifest dehydration

WBC- especially helpful in the

evaluating

infection, 9.7

allergy

Normal 5-10g/L

or

may

suggest absence/alleviation

immunosuppression

Lymphocytes- stimulated in 0.21

values

of

infection

0.20-0.35

A

normal

value

chronic bacterial infections

indicates

or acute viral infections

absence/alleviation

of

infection Potassium 2. Serum electrolytes

-

Most

Date Ordered:

important determinant in 4.09mmol/L

04-20-09

maintaining

membrane

electrical

potential

Date Performed:

excitable

neuromuscular

04-20-09

tissue. -It

is

a

Result is normal due to absence of electrolyte

in

imbalance.

144.3mmol/L Sodium

K= 3.5-5.0mmol/L

Na= 137-147mmol/L

major

Result is normal due to

cation in the extracellular

absence of electrolyte

space. Sodium salts are

imbalance.

the major determinants of extracellular osmolality.

DIAGNOSTIC/

DATE ORDERED/

INDICATIONS/

LABORATORY

PERFORMED

PURPOSES

RESULTS

PROCEDURE 1. Blood

NORMAL VALUES

ANALYSIS

AND

USED BY

INTERPRETATION

THE HOSPITAL Urea Date Ordered:

Nitrogen

04-21-09

This test measures the

37.78 mg/dl

15-45 mg/dl

Normal BUN indicates

nitrogen fraction of urea,

a

the chief end product of

function.

Date Performed:

protein

04-21-09

BUN level reflects protein

normal

renal

metabolism.The

intake and renal exvretory capacity,

but

is

less

indicator of uremia than the serum creatinine level. This test was done to evaluate renal function.

2. Creatinine

Date Ordered:

Creatinine

04-21-09

directly by the kidneys. 1.3 mg/dl Therefore

is

excreted

is

Normal 0.7-1.4 mg/dl

directly

Date Performed:

proportional

to

04-21-09

excretory function. Use to

Creatinine

levels indicates normal renal function

renal

diagnose impaired renal function

3.

Lipid Profile

Date Ordered:

HDL- This is a blood test

26 mgs/dl

>35 mgs/dl

The HDL level is below

04-20-09

that measures a kind of fat

the

(lipid) in the blood. The

which

normal indicates

range that

Nursing Responsibilities (CBC test) Before: • Prepare the client • The nurse needs to know what equipment and supplies are needed for the test. • Instruct the client and family about requirements or restrictions (when and what to drink, how long and fast) • Explain to the patient the purposes of the test. • Tell the patient that the test requires blood sample. Explain who will perform the venipuncture and when. • Explain to the patient that he may experience discomfort from the needle puncture and tourniquet. • Inform the client the time period before the results will be available. • Review the client’s record for medications that may prolong bleeding such as anticoagulants. During: • The nurse focuses on specimen collection and performs or assists with certain diagnostic testing. • The nurse provides emotional and physical support while monitoring the client as needed. • The nurse ensures correct labeling, storage, and transportation of specimen to avoid invalid test results. After: • The nurse focuses on nursing care of the client and follows up activities and observations. • The nurse compares the previous and current results ad modifies interventions as needed. • The nurse also reports the results to appropriate health team members. Nursing Responsibilities (Sodium) Before: • Inform the patient that the test is used to evaluate electrolyte balance. • Obtain a history of the patient’s endocrine and genitourinary systems, as well as previously performed laboratory tests, surgical procedure, and other diagnostic procedures. • Assess patient for allergy, including list of unknown allergens (especially allergies or sensitivities to latex).

•

Obtain a list of medications the patient is taking, including herbs, and nutritional supplements. • Review the procedure with the patient. Inform the patient about the duration of the procedure and explain to the patient that there may be some discomforts during the venipuncture. During: • Instruct the patient to cooperate fully and to follow directions. • Observe Standard Precautions. • Remove the needle, and apply pressure dressing over the puncture site. • Promptly transport the specimen to the laboratory for processing and analysis. After: • Observe the venipuncture site for bleeding or hematoma formation. Apply paper tape or other adhesive to hold pressure bandage in place. • Evaluate patient for signs and symptoms of dehydration, decreased skin turgor, dry mouth, and multiple longitudinal furrows in the tongue are symptoms of dehydration • Educate the patients with low sodium levels that the major source of dietary sodium is found in table salt. • Reinforce information given by the patient’s health care provider regarding the test results. Answer any questions or address any concerns voiced by the patient or family. Nursing Responsibilities (Potassium) Before: • Check the doctor’s order • Explain the procedure • Explain the purpose and what to expect • No food or fluid restrictions During: • • • • •

Do not take the blood sample from hand or arm with receiving IVF The tourniquet should be less on a minute Do not squeeze the punctured site rightly Wipe away the first drop of blood Collect 2ml venous blood in a lavender top tube

After: • • • • • •

Observe and record vital signs. Check injection sites for bleeding, infection, tenderness or thrombosis. Report untoward reaction to the physician. Apply warm compress to ease discomfort, as ordered. Encourage relaxation by allowing client to discuss experiences and verbalize feelings. Interpret results and provide counsel appropriately. Provide health teachings regarding proper lifestyle changes and symptoms that may warrant immediate medical attention.

Nursing Responsibilities (Lipid Profile) Before: • • • •

Inform the patient that the test is used to assess and monitor risk for coronary artery disease. Obtain history of the patient’s past health history and previously performed laboratory tests, surgical procedures, and other diagnostic procedures. Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels for 12 to 24 hours before specimen collection. Fasting 6 to 12 hours before specimen collection is required if triglyceride measurements are included; it is recommended if cholesterol levels alone are measured for screening.

During: • • • • • •

Ensure that the patient has complied with the dietary restrictions and pre testing precautions. If the patient has a history of severe allergic reaction to latex, care should be taken to avoid the use of equipment containing latex. Instruct the client to cooperate fully and to follow directions. Observe Standard Precautions. Remove the needle and apply pressure dressing over the puncture site. Immediately transport the specimen to the laboratory for processing and analysis.

After:

• •

• • •

Observe venipuncture site for bleeding or hematoma formation. Instruct the patient to reduce intake of foods high in saturated fats and cholesterol and triglyceride levels. (E.g. red meats, eggs, and dairy products are major sources of saturated fats and cholesterol. Consider social and cultural beliefs and practices of the client. Recognize anxiety related to test results. Discuss the implications of abnormal test results on the patient’s lifestyle. Provide teaching and information regarding the clinical indications of the test results.

Nursing Responsibilities (Urinalysis) Before: • •

Explain the procedure to the patient’s significant others that these test assess response to treatment. Tell the patient’s significant others that specimen will be taken.

During: • • •

Plan to obtain the specimen when the patient is calm and physically still. Instruct the SO to collect urine specimen. Collect urine by clean catching.

After: •

If there is a necessary urine collection, instruct SO to collect the urine in every urination and put it in the bedside.

Nursing Responsibilites (Chest X-ray) Before: • • • •

Verify doctors order Explain to the patient SO the importance and the procedure to be done Remove any jewelry prior to procedure Assist patient to go to the X-ray room to undergo procedure

During: • •

Position patient Note pertinent findings such as the presence of a pacemaker or an artificial joint on the x-ray request

After: • • •

Assist patient in removing the x-ray gown Assist patient to go back to his bed Record all procedures done

Nursing Responsibilities (Kidney-Ureter Bladder) Before: • • •

Cleanse bowel of patient Instruct patient to distend bladder by drinking 1 liter of water per orem Try to withhold voiding

During: • •

Assist physician doing the ultrasound Reassure patient that procedure is painless and relatively short.

After: • •

Assist patient to go back to his bed Record all procedures done

IV. 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

Retinal changes, papilledema

Impaired cerebral functioning

Impaired renal functioning

Altered level of consciousness, dizziness, headache

↑BUN, creatinine

↑Contractilit y

Left ↑BP ventricular Output hypertroph y

↑Preload

=

↑Cardiac

PATHOPHYSIOLOGY: Urinary Tract Infection (book based) Non-modifiable Factors Old age women Family history of hypertension

Modifiable Factors

-

Fragile soft tissues

Being sexually active sodium DM, and other chronic illness prolonged use of catheters

Damaged soft tissue lining

↓ Organ perfusion

Tissue breakdown dysuria

Inflammatory process

Bacterial multiplication

Blood – tinged urine

↓ urine output fever Urinary retention

↑ fluid volume

Fluid shifts to extracellular compartment

↑ BP ↓ preload vasoconstriction

↓ CO

edema Pulmonary congestion

-

Excess

dietary

- Kidney stones

↑ Infection susceptibility

PATHOPHYSIOLOGY: HYPERTENSION (patientcentered) 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

↑Blood pressure

-

Alcohol use sodium Lack of exercise

-

Excess

dietary

- Stress

SNS overactivity

Functional Constriction

↑Peripheral Resistance

Modifiable Factors

Renal Na retention

Venous Constriction

↑Fluid Volume

Decreased organ perfusion Impaired ocular functioning

Retinal changes, papilledema

↑Contractilit y

↑Preload

↑BP = ↑Cardiac Output

B. Synthesis of the Disease Hypertension refers to a state where a person’s blood pressure remains at an elevated level at all times. This condition is formally known as arterial hypertension and is popularly called high blood pressure. Two types of hypertension: 1. Primary Hypertension - when a patient’s chronically elevated blood pressure does not have a specific medical cause that can be identified 2. Secondary Hypertension - When high blood pressure is caused by other health conditions like tumors of the adrenal gland, kidney disease of other problems. Hypertension is a dangerous condition because it can lead to serious complications. Chronically elevated blood pressure increases the risk of developing heart failure, heart attacks, arterial aneurysm and strokes. Many cases of chronic renal failure have been linked to high blood pressure. Signs and Symptoms: Undiagnosed high blood pressure can lead to many physical problems including damage to major organs over a period of time. The symptoms of hypertension, if ignored, can lead to deterioration in kidney / liver function and cardiac problems. Hypertension can also damage vision, cause strokes and more. Here

are

some

of

the

common

hypertension symptoms to be aware of. •

Recurrent / persistent headaches

•

Vision problems including blurring of vision

•

Giddiness

•

Convulsions

•

Tremors in the hands or other body parts

•

Walking difficulties (formally called ataxia)

A urinary tract infection is an infection of any of the organs in the urinary tract, which consist of the bladder, the ureter, the urethra, and the kidneys. A urinary tract infection (UTI) may occur in the: Bladder - Cystitis is an infection of the bladder. This is the most common form of UTI; it can be aggravated if the bladder does not empty completely when you urinate. Urethra - Urethritis is infection/inflammation of the urethra. This can be due to other things besides the organisms usually involved in UTI’s; in particular, many sexually transmitted diseases (STD’s) appear initially as urethritis. Ureter - Ureteritis is infection of a ureter. This can occur if the bacteria entered the urinary tract from above or if the ureter-to-bladder valves don’t work properly and allow urine to “reflux” from the bladder into the ureters. Kidney - Pyelonephritis is an infection of the kidney itself. This can happen with infection from above, or if reflux into the ureters is so bad that infected urine refluxes all the way to the kidney. People more susceptible to UTI’s: •

Diabetics because of changes in the immune system

•

Infants who are born with abnormalities of the urinary tract

•

Women who use a diaphragm

•

Women whose partners use a condom with spermicidal foam

•

A person who has already had a UTI

•

Pregnant women

•

Post-menopausal women

•

Women on birth control pills

•

Women with lowered immunity

•

Women with prolapsed urethra or bladder

•

Women with obstructions in the urinary tract

Symptoms Symptoms depend on age of person and where the UTI is located . Symptoms of urethritis often include: •

Burning sensation at the start of urination

Symptoms of cystitis often include: •

Burning sensation in the middle of urination

•

Fever

•

Lower abdominal pain

•

Funny smell, color, or appearance (cloudy, dark, blood tinged) of urine

Symptoms of Pyelonephritis often include: •

Pain in back, flanks, or abdomen

•

Fever

•

Nausea

•

Vomiting

Other symptoms of UTI’s: •

Uncomfortable pressure above pubic bone

•

Fullness in rectum (in men only)

•

Small amount of urine, despite urge to urinate

•

Irritability (in children only)

•

Abnormal eating (in children only)

III. Anatomy and Physiology Hypertension 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. 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. Central Nervous System Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain,

and

diencephalon)

functions

in

consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter. Hypothalamus; controls and intergrates activities of the autonomic nervous system and pituitary

gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone. Cardiovascular System Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal carotid arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus reflex and the aortic reflex. Chemoreceptors, sensory receptors that monitor the xhemical composition of blood, are located close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood level of O2, CO2, and H+. Renal System Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which increases blood pressure.

Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume. Urinary tract infection One of the major functions of the Urinary system is the process of excretion. Excretion is the process of eliminating, from an organism, waste products of metabolism and other materials that are of no use. The urinary system maintains an appropriate fluid volume by regulating the amount of water that is excreted in the urine. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. Several body organs carry out excretion, but the kidneys are the most important excretory organ. The primary function of the kidneys are to maintain a stable internal environment (homeostasis) for optimal cell and tissue metabolism. They do this by separating urea, mineral salts, toxins, and other waste products from the blood. They also do the job of conserving water, salts, and electrolytes. At least one kidney must function properly for life to be maintained. Six important roles of the kidneys are: Regulation of plasma ionic composition. Ions such as sodium, potassium, calcium, magnesium, chloride, bicarbonate, and phosphates are regulated by the amount that the kidney excretes. Regulation of plasma osmolarity. The kidneys regulate osmolarity because they have direct control over how many ions and how much water a person excretes. Regulation of plasma volume. Your kidneys are so important they even have an effect on your blood pressure. The kidneys control plasma volume by controlling how much water a person excretes. The plasma volume has a direct effect on the total blood volume, which has a direct effect on your blood pressure. Salt(NaCl)will cause osmosis to happen; the diffusion of water into the blood.

Regulation of plasma hydrogen ion concentration (pH). The kidneys partner up with the lungs and they together control the pH. The kidneys have a major role because they control the amount of bicarbonate excreted or held onto. The kidneys help maintain the blood Ph mainly by excreting hydrogen ions and reabsorbing bicarbonate ions as needed. Removal of metabolic waste products and foreign substances from the plasma. One of the most important things the kidneys excrete is nitrogenous waste. As the liver breaks down amino acids it also releases ammonia. The liver then quickly combines that ammonia with carbon dioxide, creating urea which is the primary nitrogenous end product of metabolism in humans. The liver turns the ammonia into urea because it is much less toxic. We can also excrete some ammonia, creatinine and uric acid. The creatinine comes from the metabolic breakdown of creatine phospate (a high-energy phosphate in muscles). Uric acid comes from the break down of necloetides. Uric acid is insoluble and too much uric acid in the blood will build up and form crystals that can collect in the joints and cause gout. Secretion of Hormones The endocrine system has assistance from the kidney's when releasing hormones. Renin is released by the kidneys. Renin leads to the secretion of aldosterone which is released from the adrenal cortex. Aldosterone promotes the kidneys to reabsorb the sodium (Na+) ions. The kidneys also secrete erythropoietin when the blood doesn't have the capacity to carry oxygen. Erythropoietin stimulates red blood cell production. The Vitamin D from the skin is also activated with help from the kidneys. Calcium (Ca+) absorption from the digestive tract is promoted by vitamin D. Kidneys The kidneys are a pair of bean shaped, reddish brown organs about the size of your fist.It measures 10-12 cm long. They are covered by the renal capsule, which is a tough capsule of fibrous connective tissue. Adhering to the surface of each kidney is two layers of fat to help cushion them. There is a concaved side of the kidney that has a depression where a renal artery enters, and a renal vein and a ureter exit the kidney.

The kidneys are located at the rear wall of the abdominal cavity just above the waistline, and are protected by the ribcage. They are considered retroperitoneal, which means they lie behind the peritoneum. There are three major regions of the kidney, renal cortex, renal medulla and the renal pelvis. The outer, granulated layer is the renal cortex. The cortex stretches down in between a radially striated inner layer. The inner radially striated layer is the renal medulla. This contains pyramid shaped tissue called the renal pyramids, separated by renal columns. The ureters are continuous with the renal pelvis and is the very center of the kidney. Renal Vein The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava. Because the inferior vena cava is on the right half of the body, the left renal vein is generally the longer of the two. Unlike the right renal vein, the left renal vein often receives the left gonadal vein (left testicular vein in males, left ovarian vein in females). It frequently receives the left suprarenal vein as well. Renal Artery The renal arteries normally arise off the abdominal aorta and supply the kidneys with blood. The arterial supply of the kidneys are variable and there may be one or more renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena cava and the kidneys in the body, the right renal artery is normally longer than the left renal artery. The right renal artery normally crosses posteriorly to the inferior vena cava. The renal arteries carry a large portion of the total blood flow to the kidneys. Up to a third of the total cardiac output can pass through the renal arteries to be filtered by the kidneys. Ureters The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters send the urine in small spurts into the bladder, (a collapsible sac found on the forward

part of the cavity of the bony pelvis that allows temporary storage of urine). After the urine enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing backward flow of the urine. The outlet of the bladder is controlled by a sphincter muscle. A full bladder stimulates sensory nerves in the bladder wall that relax the sphincter and allow release of the urine. However, relaxation of the sphincter is also in part a learned response under voluntary control. The released urine enters the urethra. Urinary Bladder The urinary bladder is a hollow, muscular and distendible or elastic organ that sits on the pelvic floor (superior to the prostate in males). On its anterior border lies the pubic symphysis and, on its posterior border, the vagina (in females) and rectum (in males). The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine, however the desire to micturate is usually experienced when it contains about 150 to 200 ml. When the bladder fills with urine (about half full), stretch receptors send nerve impulses to the spinal cord, which then sends a reflex nerve impulse back to the sphincter (muscular valve) at the neck of the bladder, causing it to relax and allow the flow of urine into the urethra. The Internal urethral sphincter is involuntary. The ureters enter the bladder diagonally from its dorsolateral floor in an area called the trigone. The trigone is a triangular shaped area on the postero-inferior wall of the bladder. The urethra exits at the lowest point of the triangle of the trigone. The urine in the bladder also helps regulate body temperature. If the bladder becomes completely void of fluid, it causes the patient to chill.

Urethra

Male Sphincter urethrae muscle - The male urethra laid open on its anterior (upper) surface. (Region visible, but muscle not labeled.) The urethra is a muscular tube that connects the bladder with the outside of the body. The function of the urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter in a woman it makes it much easier for a woman to get harmful bacteria in her bladder this is commonly called a bladder infection or a UTI. The most common bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal matter. Male urethra In the human male, the urethra is about 8 inches (20 cm) long and opens at the end of the penis. The length of a male's urethra, and the fact it contains a number of bends, makes catheterisation more difficult.

The urethral sphincter is a collective name for the muscles used to control the flow of urine from the urinary bladder. These muscles surround the urethra, so that when they contract, the urethra is closed. •

There are two distinct areas of muscle: the internal sphincter, at the bladder neck and

•

the external, or distal, sphincter.

Human males have much stronger sphincter muscles than females, meaning that they can retain a large amount of urine for twice as long, as much as 800mL, i.e. "hold it". Nephrons A nephron is the basic structural and functional unit of the kidney. The name nephron comes from the Greek word (nephros) meaning kidney. Its chief function is to regulate water and soluble substances by filtering the blood, reabsorbing what is needed and excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone. Each nephron has its own supply of blood from two capillary regions from the renal artery. Each nephron is composed of an initial filtering component (the renal corpuscle) and a tubule specialized for reabsorption and secretion (the renal tubule). The renal corpuscle filters out large solutes from the blood, delivering water and small solutes to the renal tubule for modification. Glomerulus The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation. The glomerular blood pressure provides the driving force for fluid and solutes to be filtered out of the blood and into the space made by Bowman's capsule. The remainder of the blood not filtered into the glomerulus passes into the narrower efferent arteriole. It then moves into the vasa recta, which are collecting capillaries intertwined with the convoluted tubules through the interstitial space, where the reabsorbed substances will also enter. This then combines with efferent venules from other nephrons into the renal vein, and rejoins with the main bloodstream.

Afferent/Efferent Arterioles The afferent arteriole supplies blood to the glomerulus. A group of specialized cells known as juxtaglomerular cells are located around the afferent arteriole where it enters the renal corpuscle. The efferent arteriole drains the glomerulus. Between the two arterioles lies specialized cells called the macula densa. The juxtaglomerular cells and the macula densa collectively form the juxtaglomerular apparatus. It is in the juxtaglomerular apparatus cells that the enzyme renin is formed and stored. Renin is released in response to decreased blood pressure in the afferent arterioles, decreased sodium chloride in the distal convoluted tubule and sympathetic nerve stimulation of receptors (beta-adrenic) on the juxtaglomerular cells. Renin is needed to form Angiotensin I and Angiotensin II which stimulate the secretion of aldosterone by the adrenal cortex. Glomerular Capsule or Bowman's Capsule Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus and is composed of visceral (simple squamous epithelial cells) (inner) and parietal (simple squamous epithelial cells) (outer) layers. The visceral layer lies just beneath the thickened glomerular basement membrane and is made of podocytes which send foot processes over the length of the glomerulus. Foot processes interdigitate with one another forming filtration slits that, in contrast to those in the glomeruluar endothelium, are spanned by diaphragms. The size of the filtration slits restricts the passage of large molecules (eg, albumin) and cells (eg, red blood cells and platelets). In addition, foot processes have a negatively-charged coat (glycocalyx) that limits the filtration of negatively-charged molecules, such as albumin. This action is called electrostatic repulsion. The parietal layer of Bowman's capsule is lined by a single layer of squamous epithelium. Between the visceral and parietal layers is Bowman's space, into which the filtrate enters after passing through the podocytes' filtration slits. It is here that smooth

muscle cells and macrophages lie between the capillaries and provide support for them. Unlike the visceral layer, the parietal layer does not function in filtration. Rather, the filtration barrier is formed by three components: the diaphragms of the filtration slits, the thick glomerular basement membrane, and the glycocalyx secreted by podocytes. 99% of glomerular filtrate will ultimately be reabsorbed. The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or glomerular filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten times the blood volume daily. Measuring the glomerular filtration rate (GFR) is a diagnostic test of kidney function. A decreased GFR may be a sign of renal failure. Conditions that can effect GFR include: arterial pressure, afferent arteriole constriction, efferent arteriole constriction, plasma protein concentration and colloid osmotic pressure. Any proteins that are roughly 30 kilodaltons or under can pass freely through the membrane. Although, there is some extra hindrance for negatively charged molecules due to the negative charge of the basement membrane and the podocytes. Any small molecules such as water, glucose, salt (NaCl), amino acids, and urea pass freely into Bowman's space, but cells, platelets and large proteins do not. As a result, the filtrate leaving the Bowman's capsule is very similar to blood plasma in composition as it passes into the proximal convoluted tubule. Together, the glomerulus and Bowman's capsule are called the renal corpuscle. Proximal Convoluted Tubule (PCT) The proximal tubule can be anatomically divided into two segments: the proximal convoluted tubule and the proximal straight tubule. The proximal convoluted tubule can be divided further into S1 and S2 segments based on the histological appearance of it's cells. Following this naming convention, the proximal straight tubule is commonly called the S3 segment. The proximal convoluted tubule has one layer of cuboidal cells in the lumen. This is the only place in the nephron that contains cuboidal cells. These cells are

covered with millions of microvilli. The microvilli serve to increase surface area for reabsorption. Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily glucose and amino acids). This is driven by sodium transport from the lumen into the blood by the Na+/K+ ATPase in the basolateral membrane of the epithelial cells. Much of the mass movement of water and solutes occurs in between the cells through the tight junctions, which in this case are not selective. The solutes are absorbed isotonically, in that the osmotic potential of the fluid leaving the proximal tubule is the same as that of the initial glomerular filtrate. However, glucose, amino acids, inorganic phosphate, and some other solutes are reabsorbed via secondary active transport through cotransport channels driven by the sodium gradient out of the nephron. Loop of the Nephron or Loop of Henle

The Nephron Loop or Loop of Henle. The loop of Henle (sometimes known as the nephron loop) is a U-shaped tube that consists of a descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal convoluted tubule, extends into the medulla, and then returns to the cortex to empty into the distal

convoluted tubule. Its primary role is to concentrate the salt in the interstitium, the tissue surrounding the loop. Descending limb Its descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs. Ascending limb Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content. This hypotonic filtrate is passed to the distal convoluted tubule in the renal cortex. Distal Convoluted Tubule (DCT) The distal convoluted tubule is similar to the proximal convoluted tubule in structure and function. Cells lining the tubule have numerous mitochondria, enabling active transport to take place by the energy supplied by ATP. Much of the ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the tubule also secretes hydrogen and ammonium to regulate pH. After traveling the length of the distal convoluted tubule, only 3% of water

remains, and the remaining salt content is negligible. 97.9% of the water in the glomerular filtrate enters the convoluted tubules and collecting ducts by osmosis. Patient and his Care A. Medical Management A. Drugs Name of Drug Generic Name Brand Name

Date Ordered Route of General Date Taken/ Administration Action Given Dosage and Functional Date Frequency of Classification Changed/ D/ Administration Mechanism C of Action

Amlodipine ( Norvasc )

DO: 04-20-09 DT: 04-20-09 to 04-22-09 D/C: 04-22-09

5mg/ tab 1 tab OD

Calcium channel blocker - inhibits influx of calcium through the cell membrane resulting in depression of automaticity and conduction velocity in heart muscle.

Client’s response to the medication with actual side effects The patient’s blood pressure/ blood pressure fluctuations decreased. No other adverse effects were noted.

Nursing Responsibilities: Before: 1. Verify the doctor’s order. Determine the dosage and frequency of the drug. 2. Assess for history of sensitivity or any reactions to this or other related drugs.

During: 1. Ensure that the correct drug is being given/administered. 2. Monitor CBC, Cultures, Renal and NFT’s. 3. Monitor Urinary output and K+ levels. After: 1. Evaluate how the patient responds to the treatment physically and psychologically. 2. Report any side effects/ adverse reactions.

Name of Drug Generic Name Brand Name

Date Ordered Route of General Date Taken/ Administration Action Given Dosage and Functional Date Frequency of Classification Changed/ D/ Administration Mechanism C of Action

Paracetamol ( Aeknil )

DO: 04-20-09 DT: 04-20-09 to 04-22-09 D/C: 04-22-09

300 mg IV q 4

Analgesic/ Antipyretic - decreases fever by a hypothalamic effect leading to sweating and vasodilation and inhibits the effect of pyrogens on the hypothalamic heatregulating centers.

Client’s response to the medication with actual side effects The patient maintained body temperature within normal range.

Nursing Responsibilities: Before: 1. Verify the doctor’s order. Determine the dosage and frequency of the drug. 2. Assess for history of sensitivity or any reactions to this or other related drugs. During: 1. Ensure that the correct drug is being given/administered. 2. Monitor CBC, Cultures, Renal and NFT’s. 3. Monitor Urinary output. After: 1. Evaluate how the patient responds to the treatment physically and psychologically. 2. Report any side effects/ adverse reactions.

Name of Drug Generic Name Brand Name

Date Ordered Route of General Date Taken/ Administration Action Given Dosage and Functional Date Frequency of Classification Changed/ D/ Administration Mechanism C of Action

Ceftriaxone ( Rocephin )

DO: 04-20-09 DT: 04-20-09 to 04-21-09 D/C: 04-21-09

1 gm/ IV q 12 ANST (-)

Third generation cephalosporin - active against many enteric Gramnegative organisms,

Client’s response to the medication with actual side effects The patient complied with the treatment regimen by following the full antibiotic course. There were no adverse

including blactamase producers, Salmonella and Shigella, but have less activity against Grampositive bacteria

reactions noted after the administration.

Nursing Responsibilities: Before: 1. Verify the doctor’s order. Determine the dosage and frequency of the drug. 2. Assess for history of sensitivity or any reactions to this or other related drugs. During: 1. Ensure that the correct drug is being given/administered. 2. Monitor CBC, Cultures, Renal and NFT’s. 3. Monitor Urinary output and K+ levels. After: 1. Evaluate how the patient responds to the treatment physically and psychologically. 2. Report any side effects/ adverse reactions.

Name of Drug Generic Name Brand Name

Date Ordered Route of Date Taken/ Administration Given Dosage and Date Frequency of Changed/ D/ Administration C

Captopril ( Capoten )

DO: 04-20-09 DT: 04-20-09 to 04-22-09

25 mg/ tab SL PRN > 150 mmHg

General Action Functional Classification Mechanism of Action

Client’s response to the medication with actual side effects

Antihypertensive/ The patient’s ACE inhibitor blood pressure/

D/C: 04-22-09

- inhibits angiotensinconverting enzyme resulting in decreased plasma angiotensin II, which leads to decreased aldosterone secretion.

blood pressure fluctuations decreased. No other adverse effects were noted.

Nursing Responsibilities: Before: 1. Verify the doctor’s order. Determine the dosage and frequency of the drug. 2. Assess for history of sensitivity or any reactions to this or other related drugs. During: 1. Ensure that the correct drug is being given/administered. 2. Monitor CBC, Cultures, Renal and NFT’s. 3. Monitor Urinary output and K+ levels. After: 1. Evaluate how the patient responds to the treatment physically and psychologically. 2. Report any side effects/ adverse reactions.

Name of Drug Generic Name Brand Name

Date Ordered Route of General Action Date Taken/ Administration Functional Given Dosage and Classification Date Frequency of Mechanism of Changed/ D/ Administration Action C

Ciprofloxacin ( Cipro )

DO: 04-21-09 DT: 04-21-09 to 04-22-09 D/C: 04-22-09

500 mg/ tab BID x 3 days

Client’s response to the medication with actual side effects

Fluoroquinolone The patient ( antibiotic ) was not able to finish the full antibiotic - kill bacteria or course. There were no prevent their adverse growth. reactions Bacteria are noted after the one-celled administration. diseasecausing microorganisms that commonly multiply by cell division.

Nursing Responsibilities: Before: 1. Verify the doctor’s order. Determine the dosage and frequency of the drug. 2. Assess for history of sensitivity or any reactions to this or other related drugs. During: 1. Ensure that the correct drug is being given/administered. 2. Monitor CBC, Cultures, Renal and NFT’s. 3. Monitor Urinary output and K+ levels. After: 1. Evaluate how the patient responds to the treatment physically and psychologically.

2. Report any side effects/ adverse reactions. B. Diet Type of Diet

Date Ordered Date Started Date Changed

General Description

Indication(s ) or Purpose(s)

Specific foods taken

Client’s response and/ or reaction to the diet

Low fat, low sodium diet

DO: 04-2009 DS: 04-2009 to 0422-09

This type of diet has a limited total amount of fat, salt and cholesterol to reduce serum lipid levels and avoid excessive sodium retention.

It is indicated for persons with elevated serum cholesterol levels or those who are high-risk candidates for heart disease and for elevated blood pressure since it prevents excessive sodium retention.

Fruits, vegetables, fruit juice, chicken

This type of diet contributed to the decrease in the patient’s blood pressure. The patient had good appetite and was able to tolerate the food given.

Nursing Responsibilities: Before: 1. Check physician’s order about the diet. 2. Identify patient, instruct SO or patient when diet is changed 1. Provide comfort measures such as offering extra cloth and napkin when eating.

During: 1. Give foods in small frequent meals to check for tolerance. 2. Assist patient when eating. 3. Observe for aspiration precaution.

After: 1. Encourage the patient to follow the diet regimen. 2. Encourage verbalization of feelings about the diet. 3. Involve the patient in the preparation of the menu according to the patient’s preferences. 4. Assess for patient’s condition, how she responds to the diet. 5. Be sure that the patient is taking or eating food she can tolerate.

C. Activity/ Exercise Type of Activity/ Exercise

Date Ordered Date Started Date Changed

General Description

Indication(s) or Purpose(s)

Exercise/s and activites as tolerated

There were no orders made for activity/ exercise.

It may include ambulation, strengthening exercises, active or passive range of motion exercises.

It prepares the patient to go back to his activities of daily living and it promotes optimal level of functioning.

Client’s response and/ or reaction to the activity/ exercise The patient was able to tolerate the exercise/s activities planned for him.

Nursing Responsibilities: Before: 1. Check physician’s order about the activity. 2. Identify patient before the activity. 3. Explain to the patient the need for the said activity/exercise. During: 1. Provide safety precautions like raising the side rails when necessary. 2. Promote a quiet environment conducive for rest. After: 1. Monitor the position/activity of the client every 2 hours 2. Obtain initial assessment about the progress of the activity.

B. Nursing Management Problem No.1 : Acute Pain Assessment Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

>Observe or monitor signs and symptoms associated with pain.

>Some people deny the experience of pain when it is present.

Short-term: S>“Masakit Acute pain kapag umiihi ako.” O>the patient manifested: facial grimaces marked irritability and impatience decreased urinary output insomnia restlessnes s The patient may manifest: changes in appetite narrowed focus autonomic alteration in muscle tone

Not everyone with a UTI has symptoms, but most people get at least some symptoms. These may include a frequent urge to urinate and a painful, burning feeling in the area of the bladder or urethra during urination. It is not unusual to feel bad all over —tired, shaky, washed out— and to feel pain even when not urinating. Often women feel an uncomfortable pressure above the pubic bone, and some men experience a fullness in the

After 3-4 hours of nursing interventions, the patient’s pain will be relieved or controlled. Long-term: After 2-3 days of nursing interventions, the patient will demonstrate use of techniques as indicated for individual situation.

>Assess probable of pain.

Expected Outcome Short-term: After 3-4 hours of nursing interventions, the patient’s pain shall have been relieved or controlled.

for >Different cause etiological factors respond better to different Long-term: therapies. After 2-3 days of >Assess > Some patient nursing patient’s may be unaware interventions, the knowledge of or of the patient shall preference for effectiveness of have the array of pain- nondemonstrated relief strategies pharmacological use of available. methods and techniques as may be willing to indicated for try them, either individual with or instead of situation. traditional analgesic medications. >Evaluate patient’s response to pain and medications

>It is important to help patients express as factually as

rectum. It is common for a person with a urinary infection to complain that, despite the urge to urinate, only a small amount of urine is passed. The urine itself may look milky or cloudy, even reddish if blood is present. Normally, a UTI does not cause fever if it is in the bladder or urethra. A fever may mean that the infection has reached the kidneys. Other symptoms of a kidney infection include pain in the back or side below the ribs, nausea, or vomiting.

or therapeutics possible the aimed at effect of pain abolishing or relief measures. relieving pain. >Assess patient’s willingness or ability to explore a range of techniques aimed at controlling pain.

>Eliminate additional stressors sources discomfort whenever possible.

>Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.

>Patients may experience an or exaggeration in of pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.

>Provide rest periods to facilitate comfort, sleep and

>The patient’s experiences of pain may become

relaxation.

exaggerated as the result of fatigue. A quiet environment, a darkened room are some of the measures geared toward facilitating rest.

Problem No. 2: Decreased Cardiac Output r/t altered preload 2 HTN Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Short Term: S> The patient may verbalize fatigue and weakness O>the patient manifested: Edema Restlessne ss and fidgeting Marked irritability and impatience Insomnia Crackles Increased

Decreased Cardiac Output r/t altered preload 2° HTN

In hypertension, there is the imminent possibility that there is inadequate pumping of blood by the heart due to constriction of the vascularities of such organ. This would predispose altered preload, resulting to decreased cardiac output which would

After 4 hours of nursing interventions, patient will demonstrate techniques to increase activity tolerance

> establish rapport

> to gain patient’s trust and cooperation

> monitor and record VS

> to serve as baseline data

> assess patient’s condition

> to provide appropriate interventions immediately

>determine baseline vital signs /hemodynamic parameters

> provide opportunities to track changes

>promote

>maximize sleep

Long Term: After 2-3 days of nursing interventions, patient will display hemodynamic stability AEB

Expected Outcome Short Term: Patient shall have demonstrated techniques to increase activity tolerance Long Term: Patient shall have displayed hemodynamic stability AEB normal CBCs, vital signs and urinary output.

BP Decreased urinary output > The patient may manifests: Weight gain JVD

lead ultimately, underachievem ent of satiation of the metabolic demands of the body. This will then precipitate perfusion problems that may worsen patient’s condition.

normal CBCs, vital signs and urinary output.

adequate rest by decreasing stimuli and providing quiet environment. Schedule activities and assessment

periods

> provide patient enough time to perform activities

> to minimize patient’s anxiety when doing tasks

> increase activity level gradually

> to avoid overexertion

> provide quiet environment suitable for rest

> to regain strength

>provide for diet >maintain restrictions and adequate nutrition fluids as and fluid balance indicated >elevate edematous extremities and avoid restrictive clothing

>promote venous return

>encourage relaxation and

>reduce anxiety

stress management techniques

Problem No. 3: Excess Fluid Volume Assessment Nursing Scientific Diagnosis Explanation

Objectives

Interventions

Rationale

Short-term: S> Ø O> the patient manifested: periorbital edema restlessnes s facial edema bipedal edema ( nonpitting ) wheezes heard on BLF The patient may manifest: shortness of breath oliguria jugular vein distention

Excess fluid volume r/t compromised regulatory mechanisms AEB presence of edema 2° UTI

Excess fluid volume or hypervolemia occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in CHF, kidney and liver failure. It may also be caused by excessive intake of sodium from foods, IV solutions and medications.

After 3-4 hours of nursing interventions, the patient will demonstrate alleviation of signs and symptoms of fluid excess AEB stable VS and free signs of edema. Long-term: After 2-3 days of nursing interventions, the patient will demonstrate behaviors to maintain adequate fluid volume and reduce

> Obtain patient history.

> To ascertain probable cause of the fluid disturbance.

> Monitor and document vital signs.

> Sinus tachycardia and increased blood pressure are seen in early stages.

> Auscultate for a third sound, and assess for bounding peripheral pulses.

> These are signs of fluid overload.

> Assess for crackles in lungs, changes in respiratory pattern, shortness of breath and

> These are early signs of pulmonary congestion.

Expected Outcome Short-term: After 3-4° of nursing interventions, the patient shall have demonstrated alleviation of signs and symptoms of fluid excess AEB stable VS and free signs of edema. Long-term: After 2-3 days of nursing interventions, the patient shall have demonstrated behaviors to maintain adequate fluid

occurrence of fluid excess.

orthopnea. > Monitor input and output closely.

> Shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration.

> Elevate edematous extremities.

> This increases venous return and, in turn, decreases edema.

> During therapy, monitor for signs of hypovolemia.

> Monitoring prevents complications associated with therapy.

> Assess for presence of edema by palpating over tibia, ankles, feet and sacrum.

> These are manifestations of fluid excess/ overload.

> Evaluate weight in relation to nutritional status.

> Poor nutrition and decreased appetite over time result in a decrease in weight, which

volume and reduce occurrence of fluid excess.

may be accompanied by fluid retention even though the net weight remains unchanged. Problem No. 4: Impaired Urinary Elimination Assessment Nursing Scientific Diagnosis Explanation

Objectives Short-term:

S> Ø O> the patient manifested: periorbital edema restlessnes s facial edema bipedal edema ( nonpitting ) wheezes heard on BLF decreased urinary output increased BP The patient may manifest:

Impaired urinary elimination r/t fluid volume excess AEB decreased urinary output

UTI is considered to be present when there are underlying factors that predispose to ascending bacterial infection. Predisposing factors include urinary instrumentation (eg, catheterization, cystoscopy), anatomic abnormalities, and obstruction of urine flow or poor bladder emptying. Bacterial UTIs

After 3-4 hours of nursing interventions, the patient will demonstrate behaviors/ techniques that prevent aggravation of condition. Long-term: After 2-3 days of nursing interventions, the patient will achieve normal elimination pattern or participate in measures to correct/

Interventions

Rationale

Expected Outcome Short-term:

> Note physical > To assess diagnosis that causative/ After 3-4 hours may be involved. contributing of nursing factors. interventions, the patient shall >Review > To check for have laboratory tests. presence of demonstrated infection that behaviors/ may be the techniques that cause of the prevent condition. aggravation of condition. >Determine >To assess client’s previous degree of Long-term: pattern of interference/ elimination and disability. After 2-3 days of compare with nursing current situation. interventions, the Note reports of patient shall frequency, have achieved urgency, normal burning, elimination incontinence, pattern or nocturia/ participate in

weight gain jugular vein distention

can involve the compensate for enuresis, size urethra, defects. and fore of prostate, urinary stream. bladder, or kidneys. >Palpate Symptoms may bladder. be absent or include urinary >Determine frequency and client’s usual urgency, dysuria, daily fluid intake. lower abdominal Note condition of pain, and flank skin and mucous pain. Systemic membranes and symptoms and color of urine. even sepsis may occur with >Encourage kidney infection. client to verbalize fears/ concerns.

>Monitor medication regimen, antimicrobials and others. >Check frequently bladder distention observe overflow.

measures correct/ compensate defects. > To assess for retention. > To help determine level of hydration.

>Open expression allows client to deal with feelings and begin problem solving. > To note client’s response, need to modify treatment.

>To reduce risk of infection and/ for or autonomic hyperreflexia. and for >To reduce risk

to for

>Emphasize of infection and/ importance of or skin keeping area breakdown. clean and dry . Problem No. 5 : Mild Anxiety Assessment

Nursing Diagnosis

Scientific Explanation

Objectives

Interventions

Rationale

Short Term: S> The patient may verbalize concerns due to change in life events and may appear distressed and apprehensive O>the patient manifested: Impaired attention Restlessne ss and fidgeting Marked irritability and impatience insomnia > The patient may manifests: decreased perceptual

Mild anxiety r/t unmet needs and psychological factors such as ruminative thoughts on health

Patient is quite apprehensive regarding his health thereby increasing stress levels leading to mild anxiety.

After 4 hours of nursing interventions, patient will verbalize awareness of feelings of anxiety and will identify healthy ways to deal and express anxiety Long Term: After 2-3 days of nursing interventions, patient will appear relax and report anxiety was reduced to a manageable level.

> Be aware of defense mechanisms used by the client

>These may interfere with ability to deal with problem

>Identify coping skills the individual is using currently

> Evaluate what else can be improved with the current use of coping mechanisms

>Review coping skills used in past

> Determine those that might be helpful in the current situation

>Establish a therapeutic relationship, conveying empathy and unconditional positive regard

>Assist client to identify feelings and begin to deal with problems.

Expected Outcome Short-Term: Patient shall have verbalized awareness of feelings of anxiety and will identify healthy ways to deal and express anxiety

Long-Term: Patient shall have appeared relaxed and reported anxiety was reduced to a manageable level.

field Increased wariness Anguish forgetfulnes s

>Be available to client for listening and talking

>Help alleviate anxiety by providing support

>Encourage expression of feelings and allow behavior to belong to the client. Do not be sympathetic and respond personally

>Help relieve anxiety by not aggravating undue stress the client already feels

>Assist client to learn precipitating factors and new methods of coping with disabling anxiety

>Promote wellness

>ascertain clients understanding of current situation and its impact. Active listen and identify her perception of

>assess coping abilities/ skills of client to generate better plan of care

what is happening >determine previous method of dealing with life problems

>to identify successful techniques in dealing with current situation

>provide for a quiet environment, soft music, warm bath, back rub.

>comfort measures may help in alleviating anxiety

Actual SOAPIE’s SOAPIE #1 S:Φ O: received pt. on a semi-fowler’s position; conscious and coherent; with an ongoing IVF of #2 D5 LRS 1Lx8° at 450cc level infusing well on the right hand; with periorbital edema; pt. appears restless; wheezes heard on BLF; with facial edema; with bipedal edema,non-pitting; with initial VS of: T=36.6°C P=79 R=20 BP=150/90 A: Excess Fluid Volume r/t compromised regulatory mechanism 2° UTI P: After 3-4° of N.I., pt. will demonstrate alleviation of signs and symptoms of fluid excess AEB stable VS and free signs of edema I: -

established rapport

-

monitored and recorded VS

-

noted fluid intake

-

reviewed intake of sodium

-

auscultated breath sounds

-

noted presence of edema

-

evaluated mentation

-

reviewed laboratory data

-

encouraged low fat and low sodium diet as ordered

-

changed position frequently to provide comfort measures

-

placed client on a semi-fowler’s position to facilitate movement of diaphragm for respiratory movement

-

promoted early ambulation

-

provided quiet environment

-

administered medication as ordered

E: Goal met AEB pt. demonstrated alleviation of signs and symptoms of fluid excess AEB stable VS and free signs of edema SOAPIE #2 S:Φ O: received pt. on a semi-fowler’s position; sleeping; with an ongoing IVF of #3 D5LRS 1Lx8° at 280ml level infusing well on the right hand; with facial edema; with bipedal edema, non-pitting; pt. appears restless; with periorbital edema; with pail nailbeds; with initial VS taken and recorded as follows: T=36.6°C P=69 R=20 BP=140/90 A: Imbalanced fluid volume r/t rapid fluid shifts from intravascular compartment to interstitial circulation 2° UTI P: After 2-3° of N.I., pt. will demonstrate adequate fluid volume AEB stable VS. I: -

established rapport

-

monitored and recorded VS

-

monitor BP responses to activities

-

assessed clinical signs of fluid imbalance

-

noted increased lethargy/restlessness

-

reviewed laboratory data

-

emphasized importance of low fat and low salt diet

-

administered IVF and regulated as appropriate

-

discussed individual risk factors and specific interventions

-

monitored urine output, noting color and amount

-

identified signs and symptoms indicating need for prompt evaluation

E: Goal met AEB pt. demonstrated adequate fluid volume AEB stable VS.

VI. Client’s Daily Progress Chart (From Admission to Discharge) NSG PROBLEMS Acute Pain Decreased Cardiac Output Excess Fluid Volume Impaired Urinary Elimination Mild Anxiety

Admission 04-20-09

04-21-09

04-22-09

Discharge

♣

♣

♣

♣ ♣

♣ ♣

♣

♣

♣

VITAL SIGNS

Admission 04-20-09

04-21-09

04-22-09

Discharge

1. Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood Pressure

36 80 24 170/100

36.8 76 20 140/90

36.6 69 20 140/90

36.5 72 18 130/80

DIAGNOSTICS

Admission 04-20-09

04-21-09

04-22-09

Discharge

BLD CHEMISTRY >>BUN >>Creatinine

♣ 37.38 1.3

>>Sodium >>Potassium CXR-AP >> URINALYSIS >>Color >>Transparency >>pH >>Specific Gravity >>Albumin >>Sugar >>Pus Cells/hpf >>Bacteria/hpf >>RBC/HPF CBC >>Hgb >>WBC >>Hct >>RBC >>Platelet >>Segmenters >>Lymphocytes KUB-UTZ >> LIPID PROFILE >>Cholesterol

144.3 4.09 ♣ Normal Chest ♣ Yellow Turbid 6.0 1.030 1+ Negative 1-2 Few 8-10 ♣ 160 9.7 0.47 6.06 280 0.75 0.21 ♣ Sonically normal kidneys and bladder ♣ 140

♣ Light Yellow Clear 6.0 1.005 Negative Negative 1-2 12-15

>>Triglycerides >>HDL-C >>LDL-C MEDICAL MGMT IVF >>D5LRS DRUGS >>Norvasc 5mg >>Paracetamol 300mg >>Captopril 25 mg >>Ceftriaxone 1gm >>Ciprofloxacin 500 mg DIET >>Low salt/Low fat

160 26 82 Admission 04-20-09

04-21-09

04-22-09

♣

♣

♣

♣

♣

♣

♣

♣

♣

♣ (PRN) ♣

♣ (D/C)

♣

♣

♣

♣

♣

Discharge

♣

DISCHARGE PLANNING General Condition of the Client Upon Discharge O> Patient good skin turgor and moist mucous membranes, with verbal reports of slight dizziness. VS as follows: T=36.5

PR=72

RR=18

BP=130/80 M> Instructed client to continue meds as instructed by the physician. Norvasc 5 mg/tab OD E> Instructed client to continue ADL as tolerated. T> Reiterated importance of compliance to medical regimen. H> Increase intake of foods rich in iron. > Increase fluid intake. > Increase Intake of foods rich in Vitamin C. > Instructed to have adequate rest periods. > Instructed to avoid smoking, alcoholic beverages and fatty and salty foods. O> Instructed patient to go back for follow-up check up after 1 week. D> Low-fat, low-salt diet

VII. CONCLUSION With this case study presentation, the researchers basically got a first-hand experience in caring for a patient afflicted with hypertension and urinary tract infection. Though these disorders are disorders too common for study, many still haven't understood by heart the pathophysiologic mechanisms of such diseases. Ergo, the essentiality of supplemental learning on these cases is very beneficial. Hypertension is one of the most common worldwide diseases afflicting humans. Because of the associated morbidity and mortality and the cost to society, hypertension is an important public health challenge. Over the past several decades, extensive research, widespread patient education, and a concerted effort on the part of health

care professionals have led to decreased mortality and morbidity rates from the multiple organ damage arising from years of untreated hypertension. Hypertension is the most important modifiable risk factor for coronary heart disease (the leading cause of death in North America), stroke (the third leading cause), congestive heart failure, end-stage renal disease, and peripheral vascular disease. Therefore, health care professionals must not only identify and treat patients with hypertension but also promote a healthy lifestyle and preventive strategies to decrease the prevalence of hypertension in the general population. A urinary tract infection is a bacterial infection that affects any part of the urinary tract. Although urine contains a variety of fluids, salts, and waste products, it usually does not have bacteria in it, when bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The most common type of UTI is a bladder infection which is also often called cystitis. Another kind of UTI is a kidney infection, known as pyelonephritis, and is much more serious. Although they cause discomfort, urinary tract infections can usually be quickly and easily treated with a short course of antibiotics. Studies have shown that breastfeeding can reduce the risk of UTIs in infants. They are so common that infections are so common and typically easy to treat that most people don't realize they can be deadly. An untreated UTI can spread to the kidneys, which can lead to septicemia (a bacterial infection of the blood), decreased blood pressure, decreased blood flow, shock and organ failure. These two disease, though quite mundane and trite, still has bearing because if left unmananaged, they might progress to a more critical circumstance that may cost their life. As aspiring nurses, the researchers should everything they can to prevent occurrence of such by adapting a healthy lifestyle with regular exercise, a balanced diet, increased fluid intake and good mental hygiene. “Prevention is better than cure”. A cliché quotation if one will look at it, but somehow still applies to the present health problems. Everyone is challenged to repress

to the accustomed habits that are indeed detrimental to one’s health and to regress to the forgotten practices that promote health.

VIII. BIBLIOGRAPHY: Black, Joyce. Medical-Surgical Nursing: Clinical Management for Positive Outcomes, W.B. Saunders Company; 6th edition (January 15, 2001) http://www.nytimes.com/2008/07/08/health/research/08prev.html?_r=1&adxnnl=1&or ef=slogin&ref=health&adxnnlx=1218207884-CQVCmFnvr2UuI+xLmepYdw

Microsoft ® Encarta ® 2007. © 1993-2006 Microsoft Corporation. All rights reserved.

Angeles University Foundation Angeles City

College of Nursing

A Case study:

“Stroke in Evolution” In partial fulfillment of the requirements in Related Learning Experience NCM103

Submitted by: Ano, Carl Elexer Submitted to: Robby Roque, RN, MN april 27, 2009