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-insulin-

dependent 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 age-

specific 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 resistant hypertension have been

limited. Recommendations for the pharmacological treatment of resistant

hypertension remain largely empiric due to the lack of 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 long-

term 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

Mommy Mouse(Mother-deceased):

Stroke and DM

Mr. Mickey: eldest

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

 

- 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

Grandfather(deceased):

Hypertension

Grandmother(deceased):

Kidney Failure

Grandfather(deceased): Heart Attack

Grandmother(deceased): Tuberculosis

Papa Mouse(Father-deceased):

Lung Cancer

Sister 1 Brother Sister Sister Sister Sister 5 Sister

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 Normal Findings Actual Findings

1. Olfactory

Type: Sensory

Client must be able to

identify the scent of

Client was able to

identify the scent of

Fxn: Sense of smell perfume when allowed to

smell it.

perfume when allowed

to smell it.

2. Optic

Type: Sensory

Fxn: Sense of vision and

visual fields

Client must see the pen or

penlight clearly from a

certain distance; must be

able to read newspaper

print.

Client was able to see

the pen or penlight

from a certain distance,

but was not able to

read newspaper print.

Client needs to wear

eyeglasses for better

vision.

3. Oculomotor

Type: Motor

Fxn: Pupil constriction and

raising of eyelid

Eyes must follow the

direction of the movement

of the penlight;

In lightly dimmed

environment, the pupils of

the eyes will dilate but

upon the introduction of

light, pupils will constrict.

The client was able to

follow the movement of

the penlight through

her eyes.

4. Trochlear

Type: Motor

Fxn: Downward inward

eye movement

The eye must follow the

movement of a pen in

different directions with

coordination.

The client was able to

follow the pen with her

eyes without moving

her head.

5. Trigeminal

Type: Sensory and Motor

Fxn: Jaw movements,

chewing and mastication

The client must elicit

blinking reflex upon

touching the cornea with

the use of cotton.

(Corneal Sensitivity Test)

The client elicited

blinking reflex upon

touching the cornea.

6. Abducens

Type: Motor

Fxn: Lateral movements

of the eyes

Client must follow the

index finger of the

examiner and its

movements.

The client was able to

follow the index finger

of the examiner and its

movements.

7. Facial

Type: Motor and Sensory

Client must be able to

raise eyebrows, show

The client was able to

raise eyebrows, show

Fxn: Movement of

muscles of the face and

sense of taste on the

anterior two-thirds of the

tongue

teeth, frown, smile, pout

and puff out cheeks. Also,

the client must also be

able to distinguish sweet,

sour, and salty foods.

teeth frown, smile, pout

and puff out cheeks.

Also, the client was not

able to distinguish

sweet, sour, and salty

foods. Test not

performed due to

anorexia and vomiting.

8. Acoustic

(Vestibulocochlear)

Type: Sensory

Fxn: Sense of hearing

Client must be able to

hear a snap of the finger.

The client was not able

to hear the snap of the

finger.

9. Glossopharyngeal

Type: Motor and Sensory

Fxn: Pharyngeal

movements and

swallowing

Sense of taste on the

posterior one-third of the

tongue

The patient must be able

to swallow foods that were

chewed and taste bitter

foods. Also, the gag reflex

should be stimulated.

The client was not able

to taste the food. Test

not performed due to

anorexia and vomiting.

10. Vagus

Type: Motor

Fxn: Swallowing and

speaking

The patient must be able

to speak clearly.

The client was able to

speak clearly.

11. Accessory

Type: Motor

Fxn: Movement of

shoulder muscles

The patient must able to

elevate her shoulders

against resistance.

(Sternocleidomastoid and

Trapezius muscles

function test)

The client was able to

elevate her shoulders

against resistance.

12. Hypoglossal

Type: Motor

Fxn: Movement of tongue

The patient must able to

move her tongue side to

side and protrude her

The patient was able to

move her tongue side

to side and protrude

and strength of the

tongue

tongue. her tongue.

Diagnostic and Laboratory Procedures

DIAGNOSTIC OR LABORATORY PROCEDURES

DATE ORDERED AND DATE RESULTS IN

INDICATIONS OR PURPOSES

RESULTS NORMAL VALUES

ANALYSIS AND INTERPRETATION

CLINICAL CHEMISTRYFBS/RBS Date Ordered:

04-27-08

Date Results In:04-27-08

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

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

137

113.4

(70-105mg/dl)

135 – 150 mEq/L

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.

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

retention and excretion of water.

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

3.8 3.5 – 5.2 mEq/LThe potassium electrolyte level is within normal range.

URINALYSIS Date Ordered:04-27-08

Date Results In:04-27-08

This is a measure of acidity for your urine.

This measures how dilute your urine is.

Color: Yellow

Transparency:SL cloudy

Ph: 5.0

Specific Gravity: 1.010

3.5-4.5

1.010-1.030

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

Ph is slightly basic which could indicate metabolic alkalosis.

Water would have a SG of 1.000 . Most urine is around 1.010, but it can

Microscopic Findings

Pus cells/HPF:3-6

RBC/HPF:5-8

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.

Normally there is no blood in the urine. Blood can indicate an

HEMATOLOGY:

HEMOGLOBIN Date Ordered: ▪ HGB

Albumin:Positive (3+)

Sugar:(Negative)

3.2-5.0 g/dl

M: 140-180g/l

infection, kidney stones, trauma, or bleeding from a bladder or kidney tumor. The technician may indicate whether it is hemolyzed (dissolved blood) or non-hemolyzed (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 disease, and inadequate iron intake.

WBC

HEMATOCRIT

04-27-08

Date Results In:04-27-08

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

95

14.5

0.29

F: 120-160g/l

5-10 x 109/L

M: 0.40-0.52L/LF:0. 37-0.47L/L

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.

The level of hematocrit is below normal which also indicates anemia and decrease

LMPHOCYTES

CLINICAL CHEMISTRYFBS/RBS

CHOLESTEROL

Date Ordered:04/27/08

Date Results In:04-28-08

To detect presence of infection within the body.

Bacteria:Epithelial cells:

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

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

0.5

SomeSome

88

160.7

18 - 48 %

(74-110mg/dl)

M: 123 – 270F: 150 to 250

tissue perfusion.

The number of lymphocyte is slightly elevated which indicates presence of infection.

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

The cholesterol level is within the normal range.

CLINICAL CHEMISTRYFBS

BUN

CHOLESTEROL

Date Ordered:04-28-08

Date Results In:04-29-08

death from heart attacks, cholesterol testing is considered a routine part of preventive health care.

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

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

Used to estimate risk of developing a disease — specifically heart disease. Because

117.5

93

192.5

(74-110mg/dl)

(7-18 mg/dl)

M: 123 – 270F: 150 to 250

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

The BUN value is significantly higher than the normal range. It may indicate possible kidney or liver failure.

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.

The cholesterol level is within the normal range.

LIPID PROFILE:

HDL C

LDL C

Date Ordered:04-28-08

Date Results In:04-29-08

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

- The cholesterol-containing lipid fraction most likely associated with atherogenesis (CHD). One of the enzymes most commonly used to detect myocardial infarction.

33.2

145.22

M=30-75

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 narrowing of blood vessels.

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.

70.4

17.0

19.9

36-165

0-30 U/L

0-40 U/L

The triglycerides level is within the normal range.

The SGPT level is within normal limit.

The SGOT level is within normal limit.

NURSING RESPONSIBILITIES. BLOOD TESTINGBefore the Procedure:

a. Explain the procedure to the client in order to gain cooperation.b. Inform the client that she may feel pain during needle insertion.c. Prepare the materials necessary for the test.d. 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.

URINALYSISBefore 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

cellsEndocrine product

% of islet

cellsRepresentative 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 Primary signal

Centroacinar cells bicarbonate ions Secretin

Basophilic cells

digestive enzymes

(pancreatic amylase, Pancreatic

lipase,

trypsinogen, chymotrypsinogen, etc.)

CCK

 

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: DIABETES MELLITUS TYPE II (book-centered)

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

Modifiable Factors - 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 during pregnancy - Nonsteroidal anti-inflammatory drugs

Cell membrane alteration

Structural hypertrophy

Functional Constriction

SNS over-activity

↓ Filtering surface

Renin-Angiotensin Excess

Hyperinsu-linemia

↑Contractility

Venous Constriction

Renal Na retention

↑Fluid Volume

↑Preload

↑BP = ↑Cardiac Output

↑Peripheral Resistance

↑Blood pressure

Decreased organ perfusion

Impaired ocular functioning

Impaired cerebral functioning

Impaired renal functioning

Retinal changes, papilledema

↑↑BUN, ccreatinine

Altered level of consciousness, dizziness, headache

Left ventricular hypertrop

PATHOPHYSIOLOGY: HYPERTENSION (book-centered)

HYPERGLYCEMIA

↑BloodOsmolarity

Fluid shifting fromintracellular 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

Excretion of excess glucose in the urine

Glucosuria

Glucose attracts water

Glucose uptakeby the cells

Cellular starvation

Hunger due to the stimulation of Satiety Center

of Hypothalamus

↓Energy Level

Polyphagia

Body malaise

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

PATHOPHYSIOLOGY: ELECTROLYTE IMBALANCE - HYPONATREMIA (book-centered)

↑Urine Output: Polyuria

Polydipsia

Sluggish blood flow

Decreased organ perfusion

Blurred vision, retinopathy

Dry, itchy skin

ConfusioNephropat

Numbness and tingling sensation

Slow-healing cuts or sores

Neuropat

Delayed biochemical mediation

↓Renal perfusion/ ineffective blood supply to the kidneys

Non-modifiable Factors- Age - Old age- Sex - female

modifiable Factors:- 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 tissue hypoxia

Impairment in renal functioning

↓ tubular reabsorption

↑ Sodium excretion

Albuminuri

Excretion of albumin

↓ serum Na levels:

Greater proportion of water in the blood

compared to sodiumFluid shifting from

Intravascular to intracellular esp. in the brain which is

sensitive to serum Na changes

↓ interstitial

fluid volumeDry skin

Alteration in brain functioning

Lethargy

↓impulse transmission to

the musclesWeakness

Nausea, vomiting, abdominal cramping, hyperactive bowel sounds

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

Crackles

Fluid accumulation in the alveoli

Tachypnea

↓ BP

PATHOPHYSIOLOGY: IRON DEFICIENCY ANEMIA (book-centered)

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

Non-modifiable Factors:- Sex - females- - Pregnant women - Age - Young Children - Infants and toddlers 6-

24 months of age; Premature and low-birth-weight babies

PATHOPHYSIOLOGY: FURUNCLE (patient-centered)

Impaired hemoglobin and red blood cell synthesis

Decrease circulating red

blood cell along with its hemoglobin

Pallor

Fatigue

Shortness of breath,

tachypnea

Decreased oxyen supply to the body

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

Decrease in hemoglobin

Decrease oxygenation and circulating blood that provides heat

Cold hands and feet, brittle nails

Decrease oxygen supply to the integument

Swelling or soreness of the tongue and cracks

Enlarged Spleen

decreased perfusion to any affected part causing delay in biochemical mediation

Frequent Infectio

PATHOPHYSIOLOGY (patient-centered)

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

Development of wound

Enlargement of wound, turning red, firm and swollen

Development of a single, small, firm, swollen,

red/pink, tender nodule (furuncle) draining purulent secretions

↑Biochemical mediation through ↑

blood flow

Non-modifiable Factors - Age – 54 y/o- Gender – male- Race – brown race - Family history of hypertension

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

Cell membrane alteration

Functional Constriction

SNS over-activity

Renin-Angiotensin Excess

Ineffective utilization of insulin

↑Contractility

Venous Constriction

Renal Na retention

↑Fluid Volume

↑Preload

↑↑Cardiac Output

↑Peripheral Resistance

↓Perfusion to the pancreas

Impairment in thefunctioning of the pancreas

Impaired insulin secretion

Hyperglycemia

↓Renal perfusion/ ineffective blood supply to the kidneys

Non-modifiable Factors- Age – 54 years old

Modifiable Factors- Diabetes mellitus;- active electrolyte loss from

vomiting; current low Na intake

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

140/100 mmHg: April 29, 2008

↓Renal perfusion/ ineffective blood supply to the kidneys

Non-modifiable Factors- Age – 54 years old

Modifiable Factors- Diabetes mellitus;- active electrolyte loss from

vomiting; current low Na intake

Non-modifiable Factors- Age - Older than 40

years- Family history of DM

Modifiable Factors - History of previous impaired fasting

glucose - Hypertension (>140/90 mm Hg);

dyslipidemia (HDL level <40 mg/dl) - Stress: hormones at times of stress

may block the effectiveness of

↑BloodOsmolarity

Fluid shifting from

intracellular to extracellular

Intracellular dehydration

/ volume depletion

Thirst sensation due to the stimulation of Thirst Center of hypotha-

lamus

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

↑Urine Output: polyuria

Glucose uptakeby the cells

Cellular starvation

Hunger due to the stimulation of Satiety

Center of Hypothalamus

Polyphagia

↓Energy

Level

Body malaise, Fatigue: April 27-

30, 2008

Renal tissue

hypoxia

Impairment in

renal functioning

↓ tubularreabsorption

↑ Sodiumexcretion

↓ serum Na levels: 113.4 mEq/l: April

27, 2008

Anorexia: April 23-30,

2008 Modifiable Factor: ↓ Iron intake & low socio-economic status

Sluggish blood

Albuminuria : +3 :

U/A- April 27, 2008

Excretion of albumin

Modifiable Factor: ↓ Iron intake & low socio-economic status

↓ 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

BUN: 93

mg/dl – April

29,

Polydipsia

Greater proportion of water in the blood

compared to sodium: Hemodilution: Hct – 0.29: April 27, 2008

Fluid shifting fromIntravascular to

intracellular esp. in the brain which is sensitive to serum

Na changes

Alteration in brain functioning

Lethargy: April 29,

2008

↓cerebralperfusion/ineffective

blood supplyto the brain

↓impulse transmission to

the muscles

Weakness: April 27-30, 2008

↓ interstitialfluid

volume

↓ interstitial

fluid volume

Dry skin: April 28-30,

2008

↓ sodium intake

↓ 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

Delayed biochemical mediation

Development of wound

Enlargement of wound, turning red, firm and swollen

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 28-30, 2008

Fatigue - April 27-30, 2008

Shortness of breath, tachypnea (April 27, 2008)

Decreased oxyen supply to the body

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

Decrease in hemoglobin: 95

g/l: April 27, 2008

↓organ perfusi

on

Dry skin:

April

28-30,

Modifiable Factor:-Insect bite

↑Biochemical mediation through ↑ blood flow

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

Lack of exercise

Stress

Obesity

Diabetes

Kidney disease

Hormonal disorders

Porphyria

History of high blood pressure

during pregnancy

Toxemia of pregnancy

Oral Contraceptives (Birth Control

Pills)

Steroids

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 insulin-

dependent 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 change s 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

Date ordered/ Date performed:

General Description Indication(s) or purposes Client’s Reponse to the treatment

D5LRS D.O.: 04-27-0804-28-0804-29-08

D.P.:04-27-0804-28-0804-29-08

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

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.

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

D5NM D.O.04-30-08

D.P.04-30-08

Hypertonic solutions draw fluid

out of the intracellular and

interstitial compartments into the

vascular compartment, expanding

vascular volume.

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.

Nursing Responsibilities:Prior to:

1. Prepare the equipment2. Verify doctor’s order3. Use strict aseptic technique4. Explain the procedure to the S0 and give formation about the purpose of IVF to be inserted 5. Identify the client

6. Assess vital signs for baseline data7. Assess skin turgor, allergy to tape8. Check the status or veins to determine appropriate venipuncture site

During:9. Use the smallest gauge needle possible. 10.Check for patency of the tubing11.Spike the solution container12.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 venipuncture15.Dilate the vein16.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 response21.Monitor patient for evidence of IV infiltrations 22.Check for presence of air in the tubing, if air is present, remove immediately23.Check for the patency of the line always.24.Regulate and monitor the IV rate of fluid.25.Document relevant data.

b. DrugsName of Drugs: Date

ordered, performed,

Route Dosage and Frequency

Indication(s) or Purpose(s)

Client’s Response to the Treatment

Nursing Responsibilities

Generic Name:ceftriaxone

D.O.04-27-08

1g/IV q 12 Treatment of: Skin and skin structure

No adverse reaction with

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

Brand Name:Rocephin

D.P.04-27-0804-28-0804-29-0804-30-08

infections, bone and joint infections, urinary and gynecologic infections including gonorrhea, resp. tract infections, intra-abdominal inmfections, septicemia, meningitis.

Ceftriaxone was noted.

beginning of and throughout therapy.

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.

Generic Name:Metformin

Brand Name: Fortamet

D.O.04-27-08

D.P.04-28-0804-29-0804-30-08

500mg 1 tab BID

Management of type 2 diabetes mellitus; may be used with diet, insulin, or sulfonylurea oral hypoglycemics.

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,anxiety) 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.

Generic Name:Metoclopramide

D.O.04-27-08

1 tab TID for

Disturbances of GI motility.

No adverse reaction

1. Assess pt. for nausea, vomiting, abdominal

Brand Name:Plasil

D.P.04-28-0804-29-0804-30-08

Vomiting Nausea & vomiting of central & peripheral origin associated w/ surgery, metabolic diseases, infectious & drug-induced diseases. Facilitate small bowel intubation & radiological procedures of GIT

with Plasil was noted.

distention, and bowel sounds before and after 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.

Generic Name:FeSO4

Brand Name:Feosol

D.O.04-27-08

D.P.04-28-0804-29-0804-30-08

1 tab BID Simple Fe deficiency & Fe-deficiency anemia. Patient intolerant to conventional Fe & those prone to GI upsets

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

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.

Generic Name:Amlodipine

Brand Name:Norvasc

D.O.04-27-08

D.P.04-28-0804-29-0804-30-08

5g 1 tab OD

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

The patient’s blood pressure decreased from 170/100 to

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

n. 150/100 on April 28, 2008.

medication as directed, even if feeling well.

Generic Name:Clindamycin

Brand Name:Clindal

D.O.04-28-08

D.P.04-28-0804-29-0804-30-08

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.

No adverse reaction with Clindamycin was noted.

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.

Generic Name:Pizotifen

Brand Name:Mosegor Vita cap

D.O. 04-29-08

D.P.04-30-08

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 B-

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

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.

group vit is indicated.

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 safety15.Monitor patient for side effects16.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

ordered,

date

General

Description

Indications

or Purposes

Specific

foods taken

Client’s

response

and

performed reaction to

the diet

Low Fat,

Low Salt

Diet

D.O.

04-27-08

D.P.

04-27-08

04-28-08

04-29-08

04-30-08

The low fat

and salt diet

is designed

to limit the

total

amount of

fat, salt and

cholesterol

in the diet

to reduce

serum lipid

levels and

avoid

excessive

sodium

retention

Indicated for

bed patients

whose

condition

requires

modified

diet in order

to prevent

further

aggravation

of condition.

Low salt and

low fat

foods.

The client complied with the

prescribed diet.

Nursing Responsibilities:

Prior to:

1. Check the doctor’s order for the type of diet prescribed

2. Explain the importance of the diet given.

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, AUF-

SN

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, AUF-

SN

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 refill

>2 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 Signs7am to 7pm

7pm to 7 am

7am to 7pm

7pm to 7 am

7am to 7pm

7pm to 7 am

7am to 7pm

7pm to 7 am

Temperature (degrees Celsius)

36.6 37 36.6 37.1 37.2 36.2

Pulse Rate (beats per minute)

84 74 82 80 78 73

Respiratory Rate (cycles per minute)

21 17 21 19 22 20

Blood Pressure (mmHg)170-100

150-90

140-90

140-100

110-60

110-70

Diagnostic/ Laboratory procedures

27 28 29 30FBS/RBS(70-100mg/dl) 137 88 117.5

Na (135-150 mg/dl) 113.4

K(3.5-5.2 mg/dl) 3.8

Urinalysis *

Hgb(140-180 gm/L) 95

WBC(5-10 x 10 ^9/L) 14.5

Hct.(0.40-0.54 L/L) .29

Seg. 0.90 .90

Lymph.= 0.10.10

BUN= 93(7-18 mg/dl) 93

Cholesterol= 192.5 (150-250 mg/dl) 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 (36-165) 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 30

D5LRS * * *

D5NM *

April 27 April 28 April 29 April 30MEDICATIO

NS7am-7pm

7pm-7am

7am-7pm

7pm-7am

7am-7pm

7pm-7am

7am-7pm

7pm-7am

Ceftriaxone 1g/IV q 12

* * * * * *

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 am pm am pm am pm am pm

Low fat, low salt

* * * * * *

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, 7 th edition , JB Lippincott Co.

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Retrieved at http://en.wikipedia.org/wiki/Pancreas accessed on May 2, 2008 11:03 pm

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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

at http://webpages.charter.net/saabrio/ENDO_Diabetes_mellitus.htm ,

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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 FOUNDATIONAngeles City

College of Nursing

CASE STUDY:

HYPERTENSION II

DIABETES MELLITUS TYPE II

ELECTROLYTE IMBALANCE

(HYPONATREMIA)

IRON DEFICIENCY ANEMIA

FURUNCLE