CLIENT IN- CONTEXT PRESENT STATE INTERVENTIONS OUTCOME

L.C., 82years old, female, was admitted

for the fifth time at CVGH accompanied by
daughter per taxi per wheelchair last April
15, 2008 for complaints of fever
accompanied by headache and chills under
the services of Dr. Geselita Maambong,
under the Department of Internal Medicine,
co-managed by Dr. Clifford John Aranas, of
the Internal Medicine Department.

Previous Hospitalization:
2000- Pt was admitted at CVGH ICU
because of dyspnea due to the aspiration of
an unrecalled cause, under the services of Dr.
Maambong. Diagnostic tests include CBC,
U/A, and X-ray, as recalled by the S.O. She
was there for almost a month. Pt was
diagnosed with Diabetes Mellitus Type2 and
Essential Hypertension2. She was discharged
with improved condition with maintenance
medications: Diamicron MR 30mg/tab 1tab
OD, Imdur 60mg/tab 1/2tab BID, and
Neurontin 100mg/capsule 1capsule BID, all
taken with good compliance.
2002- Pt was admitted at CVGH for
complaints of chills and fever under the
services of Dr. Maambong. She was admitted
for 2weeks. Again, diagnostic tests include
CBC, U/A, and X-ray, as recalled by the S.O.
She was discharged with an improved
condition. No more fever and chills. With the
same set of maintenance medications taken
with good compliance.
2004- Pt was again admitted at CVGH
because of a wound in her left foot and the
surrounding area of the wound had turned
dark. It was diagnosed to be a gangrene. Pt
underwent Debridement under the services of
Dr. Busa of the surgery department. Her
July 1, 2008

ER blotter: time in 11:00 am, time out ? with the following vital signs:
BP: 110/60, PR: 64 bpm, T: 38 C/axilla, RR: 29 cpm
1. Fever 3. S/P CBG 2002
2. DM Type 2 4. ?Dyslifidemic
>CBG = HIGH 436 12:10
>IVF PNSS 1L @ 30 gtts 11:00
>PUN 200cc of ___ IVF 11:00
10 11 HR given - 11:00
ECG 12 leads 11:00
>CBG, Crea, Na-, K+, SGPT HBAIC - 12:00
>CXR PA, CBG monitor hourly relay all results
>blood culture 2 soltn n30 min apart ??
>please admit to IM Dept. under the service of Dr. Zanoria
>TPR q4
>Diet: blenderized feeding @ 1000 cal/day in 1500cc divided in 6 equal
feedings: low salt, low fat/cholesterol, diabetic @ CHO 240 CHON 80
>insert FBC and attach to urobag
>11:30 insert NGT
>monitor V/S every 2 hours and refer for ???? or HR > 100, RR > 20,
BP = 160/90
>I/O every 4 hours

PHYSICAL ASSESSMENT:
Date of Assessment: July 3, 2008 (Thursday)
Time performed: 10:00am

General Appearance:
Examined while lying on bed,, awake, conscious, unresponsive,
incoherent and afebrile, with FBC-CDU and IVF 4 D5.3NaCl @
20gtts/min infusing well at right arm with the following vital signs:
BP=130/80mmHg, PR=72bpm, RR=20cpm, T=36.8C/axilla,
Height=cm, Weight=kg; IBW=kg.

SKIN AND APPENDAGES: no lesions, brown complexion, (-)
jaundice, (-) cyanosis, (-) edema, hair evenly distributed, senile skin







































































hospitalization lasted for 3weeks and was
discharged with improved condition. S.O.
claims that the medications were still the
same but an unrecalled antibiotic was added.
S.O. reports to have let patient take these
medications with good compliance.

History of Present Illness:
3weeks PTA, patients daughter noticed a
burn on the left side part of the patients left
dorsal foot. Daughter asked pt how she got it
and patient answered napaso sa kalan
which was still hot and placed on the floor.
According to the S.O. murag ga tubig cya sa
sulod pariha adtong na una niyang samad
sauna. S.O. pricked the blister and washed
it with the water extracted from boiled guava
leaves. There was no pain felt by the patient
but there was redness and swelling around
the sides. Patient also claimed it to be rather
itchy. After, S.O. treated it with Betadine and
Tetracycline BID without prescription.
2weeks PTA, the wound was getting deep.
It looked like erosion. No consult was done
and the ritual treatment using Betadine and
Tetralcycline ointment BID continued.
1week PTA, S.O. noticed that the wound
did not show signs of healing. She then
decided to have her mother get ready for a
check-up with Dr. Maambong. Initially,
patient was hesitant. For her, there was
nothing to be worried about and its a waste
of money. With her daughters persistence,
patient agreed to go for a medical check-up.
There, she was prescribed with Bactroban
cream (Mupirocin), Betadine, and Hydrogen
peroxide to clean the wound BID. Patient was
also prescribed Ciprofloxacin (Ciprobay)
500mg OD.
4days PTA, pt experienced intermittent
turgor, warm to touch, pale nailbeds, no nail clubbing, no ingrown
toenails, presence of IV line on right arm, bruises on antecubital
area, (-) Chvosteks sign

HEAD: normocephalic, symmetric, thinning gray hair, evenly
distributed hair, no masses, no lice infestation, (-) dandruff, scalp has no
lesions and no tenderness upon palpation

EYES: symmetrical, ,anicteric sclerae, pale palpebral conjunctivae,
eyebrows and lashes present bilaterally, equal distribution of eyebrows,
(+) Pupils Equally Round and Reactive to Light and Accomodation, (+)
Cardinal gaze, no abnormal discharges

EARS: symmetrical, skin color is consistent with the facial skin color,
pinna is in line with the outer canthus of the eye, no swelling, no lesions,
no abnormal discharges, no foul odor, pinna is non-tender upon
palpation, recoils after being folded, can hear low-pitched voice at 2 ft.
distance

NOSE AND SINUSES: Nasal septum is straight and perforated, no
nasal flaring, septum located at midline, symmetrical & proportional to
other facial features, no inflammation, no lesions, no swelling, no
bleeding, clear frontal & maxillary sinuses on transillumination, nares
are patent, no congestion

MOUTH AND THROAT: lips symmetrical and red in color, dry lips,
no cracks, no lesions, gums pinkish and moist, pinkish tongue, uvula in
the midline, no swelling or redness, no masses and ulcerations, (+) gag
reflex, no tonsil inflammation, uvula at midline, pinkish gums, has 11
teeth ( 6 upper and 5 lower), presence of plaque and dental caries,
decayed teeth

NECK: supple neck, no lesions, no masses, trachea at midline, lymph
nodes not palpable

CHEST AND THORAX: equal chest expansion, RR=20cpm, no
palpable masses, no lesions, normal tactile fremitus

HEART: distinct heart sounds S1 and S2 upon auscultation, no
murmurs, HR= 72bpm with regular rhythm.









































































fever (highest at 38C) and chills. S.O.
remembered the same symptoms her mother
experienced in her previous hospitalizations
and decided to seek consult with Dr.
Maambong again. Furthermore, patient
manifested polyuria and nocturia as reported
by S.O. mukalit ra ug pangihi. Pt was
advised to undergo CBC, U/A and Lipid
panel.
Morning PTA, the results were given.
There was an increase in her creatinine level
(4.0mg/dl) which meant that the patient had
kidney failure. Aside from this, the wound
was not healed and began to become deep.
This prompted Dr. Maambong, and with the
patients consent, to let the patient admit at
CVGH for a closer observation.

Past Heath History
Pt. is diabetic and hypertensive (with
highest BP of 240/110mmHg) for 8years as
diagnosed by Dr. Maambong last 2000 with
maintenance medications: Diamicron MR
30mg 1 tab OD, Imdur 60 mg/ tablet, tablet
two times a day, and Neurontin 100 mg/
capsule 1 capsule two times a day. She is a
nonsmoker and a nonalcoholic beverage
drinker with no known food and drug
allergies.
Health-Perception Health-Management
Pattern
Patient cannot describe health and
cannot rate when asked to. She has no regular
medical checkups and would only seek
consultation to Dr. Maambong whenever the
need arises. She believes in folk medicine as
she, herself, is a licensed mananabang and
manghihilot. She uses Pau d Arco to
BREAST AND AXILLAE: symmetrical, no abnormal nipple
discharges, no masses, non-tender, non-palpable axillary lymph nodes,
areola brown in color, nipples not inverted

ABDOMEN: flat and soft, umbilicus at midline, inverted, nontender,
scars present, (-) fluid wave test, (-) shifting dullness, nonpalpable
kidneys, 14 borborygmous sounds/minute auscultated at right lower
quadrant

GENITO-URINARY: grossly female, minimal pubic hair, no
discharges, no lesions, no purulent discharges, no itching, no rashes,
?urine output=300-450cc/shift

RECTUM: no hemorrhoids, no abnormal discharges, no irritations and
itchiness

EXTREMITIES: no swelling, no lesions, (-) ROM on lower and
upper extremities (-) edema, CRT on upper extremity <2sec, CRT on
lower extremities are <2 seconds, pale nailbeds, weak and thready
pulses, (-) Trousseaus sign

NEUROLOGIC ASSESSMENT

Cognitive: Does not respond to questions Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?

Cerebellar: unable to perform finger to nose test, (-) thumb
opposition test, (-) Romberg test, (-) Tandem test, cant walk without
assistance

Sensory: Does not respond to student nurses instructions
> (-) graphesthesia: cant able to identify letter A & 2 on
her back and palm
>(-) 2point discrimination test: able to identify sharp from
dull (back of comb and tip of ballpen)
> (-) sterognosis: able to identify pen with eyes closed
>(-) kinesthesia: able to identify the directions to which
her toes and finger were moved (up and down)










































































soothe muscle pains and aches. She also
drank the water from sibukaw and
wachichaw, two glasses/day to promote
urination. She also drinks the CBW left from
dahon sa atis to cure colds. Last year, she
took Roch 1capsule per day for 15days
because daughter heard over the radio and
thought it was effective. After the 15
th
day,
the daughter stopped buying the drug because
saw that it was not effective and heard about
the damage to the liver caused by Roch
herbal medicine. She doesnt know how to
perform BSE ever since and was taught by
the student nurses on how to perform it but
no response was noted. Shes not fully
immunized and practices OTC medications
such as Paracetamol (Biogesic) 500mg for
relieving minor headaches and fever as
reported by S.O. At home, it is her daughter
who cuts her nails but in bathing and
dressing, the pt does it alone although she is
being watched by S.O.
During hospitalization, patient still
cannot rate health. She claims that she is
alright and when asked how she feels,
verbalizes ok ra or maau nako. Ganahan
nako mu-uli. S.O. further adds that her
mother is dili reklamador ug agwantador
and is very pasensyosa even if she feels
pain or is feeling unwell already. Patient is a
little bit aware of her condition because every
time the medicine or a procedure is given, it
is explained by the healthcare team about it.
However, when asked about what she
understands about her case, she only looks at
the student nurse and calls her daughter to
answer the questions instead. Her daughter is
the one who cuts her toenails and fingernails.

Nutritional Metabolic Pattern
CRANIAL NERVES

I. Olfactory: not able to distinguish any smell

II. Optic:

III. Occulomotor: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA

IV. Trochlear: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA

V. Trigeminal:
Sensory: eyelids blink bilaterally at the touch of tissue on the
temporal area, can feel touch of object on forehead, chin, and
cheeks but cant determine whether soft or hard
Motor: can masticate, can clenched teeth

VI. Abducens: (+) cardinal gaze = on lifesize objects such as
student nurse, (+) PERRLA

VII. Facial:
Sensory: can identify bitter taste by spitting the medicine
Motor: does not smile, cant frown, can raise eyebrows, cant
puff out cheeks, can wrinkle forehead

VIII. Vestibulocochlear: can hear low-pitched voice at 2ft distance

IX. Glossopharyngeal: able to swallow, (+)gag reflex, able to
distinguish taste at the posterior 1/3 of tongue because she does
not spit out delicious food like spaghetti

X. Vagus: (+) gag reflex, can swallow

XI. Spinal Accessory: cant shrug shoulders against resistance

XII. Hypoglossal: tongue at midline upon protrusion, unable to
move tongue from side to side and up and down










































































Before hospitalization, patient eats 5x/day
with snacks in between (3full meals and
snacks for morning and afternoons).
Occasionally, pt drinks softdrinks at 240ml
the most. Pt also eats fruits at least once a
week such as oranges and apples for these are
easily available at the market and do not need
special temperature conditions for it to stay
fresh. Water intake is also more than
8glasses/day before hospitalization. She
claims her body weight was normal for her.
She also takes in Musigor Vita 500mg OD as
prescribed by Dr. Maambong last year for
loss of appetite.

CLIENTS
DIET
24H
RECALL
USUAL
DIET
Breakfast Around
8am
1cup rice
30cc water
75g mashed
corned beef
6am
1pc
scrambled
egg,
75g corned
beef,
1/2cup rice
or oatmeal,
240ml
Anlene
milk
Lunch 12:30nn
1 cup rice,
1cup
mashed
sayote
guisado,
1 whole
banana,
30cc water

12noon
100g salty
paksiw, 1
small bowl
of
malunggay
soup, and
1/2cup rice.

MUSCLE STRENGTH
1/5 3/5

1/5 3/5

SCALE FOR GRADING MUSCLE STRENGTH

5 Full ROM against gravity, full resistance
4 Full ROM against gravity, some resistance
3 Full ROM with gravity
2 Full ROM with gravity eliminated
(passive motion)
1 Slight Reaction
0 No Reaction

DEEP TENDON REFLEXES

(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex


SCALE FOR GRADING REFLEX RESPONSES:

0 No Reflex Response
+1 Minimal Activity
+2 Normal Response
+3 More Active than Normal
+4 Maximal Activity (Hyperactive)


?GLASGOW COMA SCALE

Response Score
Eye-opening response Spontaneous opening 4
To verbal response 3
To pain 2
None 1

Most appropriate Oriented 5









































































Dinner 6pm
1 cup rice,
150g
shredded
chicken
with
carrots,
30cc water
6pm
1 fish inun-
unan,
1/2cup rice,
and 100g of
caldereta
with
potatoes
and carrots.
Snacks 3pm

1pc orange
2-3pm
1 pc home-
made
sandwich or
1pack
biscuits
with 100ml
milk.

During hospitalization, patient still eats 3
full meals of only soft foods (mostly with
soups) and seldom eats snacks. She has a low
salt, low fat, low cholesterol diet with no
simple sugars diet. She cannot swallow the
tablets whole as well (the student nurses
administer it to her in powdered form). Her
favorite foods consist of pork as S.O. says
pakibaboy mana si mama gud. She is
currently placed to limit her fluids at 800cc
per day. Pt has difficulty in chewing and
swallowing and prefers her foods readily
shred up for her. She doesnt have any
regular dental check-ups. She once went to
see a dentist with her daughter because she
complained of a little pain in her tooth. The
dentist, their friend, Dr. Pedro Achombre,
told them that she cannot pull the tooth unless
the pts blood sugar will go back to normal.
After a while the pts blood sugar did go
down but she no longer wanted to have her
tooth pulled for financial reasons and she
Verbal response Confused 4
Inapp. Words 3
Incoherent 2
None 1

Most appropriate Obeys commands 5
Motor response Localizes pain 4
Flexion to pain 3
Extension to pain 2
None 1
TOTAL SCORE 3-15

?Patients rating in GCS: 12points Lethargic


Date performed: July 4, 2008 (Friday
Time performed: 10:00am
General Appearance:
Examined while lying on bed,, awake, conscious, unresponsive,
incoherent and afebrile, with NGT at left nostril and IVF 5 D5.3NaCl @
20gtts/min infusing well at right arm with the following vital signs:
BP=120/70mmHg, PR=73bpm, RR=20cpm, T=36.3C/axilla,
Height=cm, Weight=kg; IBW= kg.

SKIN AND APPENDAGES: pale nailbeds, presence of IV line on
right arm, bruises on antecubital area
EYES: pale palpebral conjunctivae
NOSE AND SINUSES: presence of NGT
MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower),
presence of plaque and dental caries, decayed teeth
ABDOMEN:, scars present
Extremities: (-) ROM on lower and upper extremities, pale nailbeds,
weak and thready pulses

NEUROLOGIC ASSESSMENT

Cognitive: Does not respond to questions Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?
Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-)









































































wanted to wait for the rest of her teeth to
tangtang ug iya-iya. Furthermore, the S.O.
reports that the patient only brushes her teeth
once a day or sometimes, only when she goes
out of the house.

Elimination Pattern
Before hospitalization, patient eliminates
bowel everyday usually after she wakes up at
around 5am. Her stools are yellow-brown in
color and are well-formed. She doesnt take
in laxatives and does not claim to experience
constipation. She voids 5-6 times per day
with light yellow-colored urine having a
moderate flow approximately 20-40 ml per
episode. She claims to have no difficulty in
voiding.
During hospitalization, patient voids 3-
4times per day and her urine is dark yellow
amounting to 300-450cc/8hours. She only
experienced nocturia in the first few days of
her hospitalization as confirmed by the S.O.
Her defecation pattern changed. At initial
days of admission, pt claims to experience
constipation and S.O. claims that there was a
time the patient was not able to defecate in 2-
3days. She was given Senna concentrate
(Senokot) 2tabs OD qHS by AP. Right now,
patient seems to defecate involuntarily. Often
times, fecal matter is found staining her bed
linens. There was a time when pt was able to
verbalize kalibangun ko but when the
student nurses assisted her and checked, the
linens were already soiled with fecal matter.
Pt also defecates more than twice per day
with yellow-colored stools and irregular
timing.

Activity Exercise Pattern
Patient wakes up at 5am, walks around the
Romberg test, (-) Tandem test, cant walk without assistance
Sensory: (-) graphesthesia, (-) 2point discrimination test, (-)
sterognosis, (-) kinesthesia



CRANIAL NERVES
I. Olfactory: not able to distinguish any smell
II. Optic:
III. Occulomotor:
Motor: does not smile, cant frown, cant puff out cheeks
IV. Spinal Accessory: cant shrug shoulders against resistance
V. Hypoglossal: unable to move tongue from side to side and
up and down

MUSCLE STRENGTH
1/5 3/5

1/5 3/5

?DEEP TENDON REFLEXES
(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex

?Patients rating for GCS: 12points Lethargic


Date performed: July 5, 2008(Saturday)

Examined while lying on bed, awake, conscious, unresponsive,
incoherent and afebrile, with IVF 6 D5.3NaCl @ 10gtts/min infusing
well at right arm with the following vital signs: BP=140/90mmHg,
PR=80bpm, RR=20cpm, T=36.3C/axilla, Height=cm, Weight=kg;
IBW= kg.

SKIN AND APPENDAGES: pale nailbeds, presence of IV line on
right arm, bruises on antecubital area
EYES: pale palpebral conjunctivae
MOUTH AND THROAT: has 11 teeth ( 6 upper and 5 lower),
presence of plaque and dental caries, decayed teeth









































































house using a cane, defecates, eats breakfast
prepared by her daughter at 6am. She takes
her nap for about 2hours, eats lunch by 12nn
and takes another 2-hour nap, eats dinner by
6pm, and sleeps at 8pm. Patient has been a
manghihilot and a licensed mananabang
all her life as far as she can remember. She
only stopped working after she was
diagnosed with Essential Hypertension and
Diabetes Mellitus 2 last 2000. Patient tries to
help in performing household chores by
sweeping the floor, wiping the table and
window surfaces whenever she feels well.
Her daughter is the one who hinders the
patient from performing these things because
she fears this will worsen her mothers
condition. Patients usual leisure time
includes strolling after rising, watching TV,
sleeping and listening to drama on the
radio. To this question (patients leasure
activities), the S.O. also adds badlong sa
mga apo. Di nuon siya mangasaba pero
mubadlong siya kung nag-gara2 na.
During hospitalization, pt. is most of the
time asleep or watching TV. S.O. says di
mana siya tulog gyud. Murag hinanok mana
iya. Manokon na bya matulog pud basta
tiguwang. Sturyai lang, naminaw ramana
siya. Pt. can no longer perform her ADLs as
she did before. Now, student nurses and her
daughter facilitate in moving her from the
bed to the chair, comb her hair, assists her in
changing her diapers, clothes, and underwear.

Sleep Rest Pattern
Before hospitalization, patient usually
sleeps around 8pm and wakes up at 5am
everyday. Upon waking up, she feels ok
and that her sleep is enough. She uses a
blanket and a pillow as her sleeping aid. She
ABDOMEN:, scars present
Extremities: (-) ROM on lower and upper extremities, pale nailbeds,
weak and thready pulses

NEUROLOGIC ASSESSMENT

Cognitive: Does not respond to questions Kaila ka ani niya mam?,
Kahibaw ka asa ka karun? Kanusa imong birthday? Pila imong
edad gi-dugo ka?
Cerebellar: (-) finger to nose test, (-) thumb opposition test, (-)
Romberg test, (-) Tandem test, cant walk without assistance
Sensory: (-) graphesthesia, (-) 2point discrimination test, (-)
sterognosis, (-) kinesthesia



CRANIAL NERVES
I. Olfactory: not able to distinguish any smell
II. Optic:
III. Occulomotor:
Motor: does not smile, cant frown, cant puff out cheeks
IV. Spinal Accessory: cant shrug shoulders against resistance
V. Hypoglossal: unable to move tongue from side to side and
up and down

MUSCLE STRENGTH
1/5 3/5

1/5 3/5

?DEEP TENDON REFLEXES
(+1) biceps reflex, (+1) triceps reflex, (+1) brachioradialis reflex, (+1)
patellar reflex, (+1) Achilles Reflex

?Patients rating for GCS: 12points Lethargic

LABORATORY EXAMS:
BLOOD TYPING
(4/12/08)
Purpose: Blood typing are most commonly done to make certain that a









































































doesnt take sedatives to facilitate her sleep
and has no problems in sleeping. She prays
before sleeping. Rituals include changing of
clothes before sleeping and putting of
cologne after a bath.
During hospitalization, patient sleeps most
of the time and looks fatigued as shown in
her weary facial expression. Aside from this,
there is no more definite time as to when she
sleeps or wakes up. She also says her sleep is
ok ra. She has no rituals before sleeping.
At first, patient is disturbed by healthcare
professionals who go inside the room often.
But she says she has adjusted to them
already.

Cognitive Perceptual Pattern
Patient remembers things that happened
a long time in the past such as her menarche,
her first sexual contact, and what her work
was. She also remembers things that have
happened recently such as the food she ate
for lunch as confirmed by her S.O. Once, she
even said to the student nurse when there
were about more than 8children in the room
daghan pani sila. Gamay ra ni akong mga
apo diri karunand smiled which meant that
she is still able to remember her
grandchildren. She has an educational level
of kindergarten because at that time, her
parents did not give any importance to
education. Kindergarten at that time involved
activities such as playing, singing songs, and
dancing. Patient comprehends Bisaya and
speaks the language well. She uses
eyeglasses with unrecalled date as to when
she started using it. S.O. reports that the
patient does not know how to read at all (with
or without glasses) but is able to write her
signature when she was not hospitalized.
person who needs a transfusion will receive blood that matches (is
compatible with) his own. People must receive blood of the same blood
type; otherwise, a serious, even fatal, transfusion reaction can occur.
Blood type = B
Rh = +
Implications: the patients blood type is B+


URINALYSIS
Stanford Med and Diagnostic
(4/12/08)
Purpose: Urine provides important information about a number of
physiologic processes, including renal disease, diabetes mellitus,
hydration status, and some liver disease. Most have a routine urine
examination upon admission to a hospital, and many outpatient settings.

Macroscopic
Color: slightly cloudy
Reaction: pH 5.0
Spec.grav. : 1.015
CHON: +1 (HAc)
Glucose: negative

Microscopic
RBC/hpf: 0-1
WBC/hpf: 4-6
Epithelial cells: few
Mucus threads: moderate
a. urates: few
Bacteria: few
Coarsely granular cast: 0-1/hpf
Finely granular cast: 0-1/hpf

Implications: An increase of WBC in urine usually implies infection of
the urinary tract.

LIPID PANEL
(April 12, 2008)
Purpose: To determine if your blood glucose level is within healthy
ranges; to screen for, diagnose, and monitor hyperglycemia,









































































There are no changes before and during
hospitalization except that when asked to
write her signature, only scribbles appear.
Patient does not use hearing aids. Her sense
of smell and taste is still intact. Patients
sense of touch is diminished in the left leg.


Self-Perception Self-Concept Pattern
Patient claims that she is satisfied with her
life and that is contented as a mother. She
feels alright about her accomplishments such
as raising wonderful kids and letting them
graduate with degrees. She says that her
family is very good to her even before
hospitalization. To her, her physical outlook
is ok. She also feels good about herself and
has no complaints about herself. She says her
worry right now is her illness but she strongly
believes that she will be cured. According to
her S.O., pt is very understanding, loving,
caring, and generous. Bisan mga silingan
mangayo ug bugas, muhatag gyud na dayun
siya. As a mother, the patient is a very good
one and has raisedher children well.
According to the grandchildren, she is not
selfish. Kung mangayo gain mi ug kwarta,
hatagan dayun mi.

Role Relationship Pattern
Patient claims to have good and open
relationship with her family until now (to
those still alive). She has been a widow for
about 14 years already. She has 15 children, 2
of which are dead. They use a switchboard
type of communication. She has a lot of
friends and relatives with whom she
maintains a peaceful relationship with them.
Breadwinners of the family are her 2sons
working abroad as a licensed practical nurse
hypoglycemia, diabetes, and pre-diabetes. Total cholesterol assesses risk
of CAD and evaluates fat metabolism. Triglycerides screens for
hyperlipemia, and helps identify nephrotic syndrome. The serum
creatinine level is used to indicate the renal function specifically the
ability of the kidney to secrete urea and proteins. The BUN test is
primarily used, along with the creatinine test, to evaluate kidney
function. This test measures the nitrogen function of urea.

Glucose: 83 mg/dl (normal= 75-115 mg/dl)
Cholesterol total: 180 mg/dl (up to 200 mg/dl)
Triglyceride: 164 mg/dl (up to 150 mg/dl)
HDL: 23 mg/dl (normal = 35-60 mg/dl)
LDL: 124mg/dl (normal = 0-150 mg/dl)
VLDL: 33 mg/dl (normal = 0-40 mg/dl)
Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl)
BUN: 52.5 mg/dl (normal = 4.7 23.4 mg/dl)
BUA: 7.6 mg/dl (normal = 2.5 6.1 mg/dl)
SGOT: 25 u/L (up to 37 u/L)
SGPT: 14 u/L (up to 32 u/L)
Glycosylated Hgb: 5.7 % (normal= 4.5 6.3%)

(April 30, 2008)
Glu: 103 mg/dl (normal= 75-115 mg/dl)

Implications: Mild-to-moderate increase in serum triglyceride levels
indicates biliary obstruction, diabetes, nephrotic syndrome or
endocrinopathies. Low HDL-cholesterol levels are connected with
diabetes mellitus, and hypertension. Increased creatinine levels and BUN
in the blood suggest diseases or conditions that affect kidney function.
High creatinine may be due to reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure, atherosclerosis, or
complications of diabetes. Increased BUN may result from decreased
blood flow to the kidneys, such as shock or stress, and from conditions
that cause obstruction of urine flow.



BLOOD CHEMISTRY
Stanford Med and Diagnostic
(4/12/08)









































































and another who is a chef of a university.
They are the ones supporting the treatment of
the patient and the expenses of the household.
When asked if she is satisfied with her
relationship with her family, she says oo.
And her S.O. reinforces the question by
adding pinangga kaau ni cya sa tanan.
Contento na siya ky wa gyuy kaaway nya
nindot ra ug kahimtang iyng mga anak run
afterwhich the patient nods in affirmation to
the statement.
During hospitalization, patient can no
longer see her other grandchildren and
children as often as she used to. Her
communication with other family members is
also impaired because she does not talk much
already.
Genogram:
Maternal Side Paternal side






*heart problem
*patient
*unrecalled cancer
*lung cancer

male
female
deceased
* History of both maternal and paternal sides
are unrecalled but patient is sure that both
sides have a history of Hypertension and
Diabetes Mellitus.

Sexuality-Reproductive Pattern
Patient had her menarche at 12yrs.old as
manifested by brown spots on her underwear.
Purpose: To determine if your blood glucose level is within healthy
ranges; to screen for, diagnose, and monitor hyperglycemia,
hypoglycemia, diabetes, and pre-diabetes. Total cholesterol assesses risk
of CAD and evaluates fat metabolism. Triglycerides screens for
hyperlipemia, and helps identify nephrotic syndrome. The serum
creatinine level is used to indicate the renal function specifically the
ability of the kidney to secrete urea and proteins. The BUN test is
primarily used, along with the creatinine test, to evaluate kidney
function. This test measures the nitrogen function of urea.


Glucose: 83 mg/dl (normal= 75-115 mg/dl)
Cholesterol total: 180 mg/dl (up to 200 mg/dl)
Triglyceride: 164 mg/dl (up to 150 mg/dl)
HDL: 23 mg/dl (normal = 35-60 mg/dl)
LDL: 124mg/dl (normal = 0-150 mg/dl)
VLDL: 33 mg/dl (normal = 0-40 mg/dl)
Creatinine: 4 mg/dl (normal= 0.5-1.2 mg/dl)
BUN: 52.5 mg/dl (normal = 4.7 23.4 mg/dl)
BUA: 7.6 mg/dl (normal = 2.5 6.1 mg/dl)
SGOT: 25 u/L (up to 37 u/L)
SGPT: 14 u/L (up to 32 u/L)
Glycosylated Hgb: 5.7 % (normal= 4.5 6.3%)

Implications: Mild-to-moderate increase in serum triglyceride levels
indicates biliary obstruction, diabetes, nephrotic syndrome or
endocrinopathies. Low HDL-cholesterol levels are connected with
diabetes mellitus, and hypertension. Increased creatinine levels and BUN
in the blood suggest diseases or conditions that affect kidney function.
High creatinine may be due to reduced blood flow to the kidney due to
shock, dehydration, congestive heart failure, atherosclerosis, or
complications of diabetes. Increased BUN may result from decreased
blood flow to the kidneys, such as shock or stress, and from conditions
that cause obstruction of urine flow. Increased blood uric acid may result
from certain medications like diuretics and antihypertensive drugs. It can
lead to deposits of uric acid in the kidneys (uric acid nephropathy).


COMPLETE BLOOD COUNT
Purpose: The CBC is a basic screening test and is one of the most









































































Her menstruation lasted for 4-5 days usually
with moderate flow and consumes 2-3
pasadors/day. Her 1
st
sexual contact was
with her sole partner (husband) at the age of
17years old. No hx of STD and uses no
contraceptives ever since. Currently, pts
APGAR score is G15P150013 all
pregnancies did not undergo PNC and were
delivered via licensed mananabang. No
problems in delivery were reported. Patient
does not know how t perfor BSE and has
never tried undrergone any procdures such as
mammogram and pap smear. Patient had her
menopause at 52 years old. Personal
information about the pts sexuality is
disclosed as verbalized by the S.O. Grabiha
ninyu dae noh din a lage mo ma.uwaw
mangutana ug mga ing.ana. Pt also
verbalized mingawun ko usahay sa akng
bana.

Coping-Stress Tolerance Pattern
When asked what stress is to her, patient
only stared at the student nurse. But when
asked what kapoy is to her and if she feels
any right now and before hospitalization, she
answered with wala man but sometimes
also replies with ambot lang and shakes her
head slightly from side to side. According to
the daughter, who is the patients primary
caregiver at home, di ka makadungog ni
mama mureklamo gyud sa balay bisan
nagsakit na na siya dinha. Ako nalang
mahibung nganu lain na iyang nilihukan ug
sa ni adtong hinay na siya ug samot. Pt just
lies down to relax if she feels such and her
problems and worries are alleviated. Family
has a switchboard type of communication but
since the year 2000, her daughter is the one
deciding for the family in coordination with
frequently ordered laboratory procedures. The findings in the CBC give
valuable diagnostic information about the hematologic and other body
systems, prognosis, response to treatment and recovery.


Stanford Med and Diagnostic
(4/12/08)
Hgb = 10 g/dl (normal = 12-16 g/dl)
Hct = 30 vol% (normal = 37-47 vol%)
WBC = 10.8 10^9/L (normal= 5.0-10.0 10^9/L)
Platelet count = 245,000 (normal= 150,000- 450,000/cumm)
RBC count = 7.70 10^12/L (normal= 4.0-5.5 10^12/L)

Differential count
Segments = 0.70 (normal: 0.5-0.7)
Lymphocytes = 0.30 (normal: 0.2-0.4)

RBC morphology
Anisocytosis rare
Red Cell Indices
MCV = 81 fl (normal: 80-96 fl)
MCH = 27.0 pg (normal: 27.0-33.0 pg)
MCHC = 33.3% (normal: 31.0-36.0%)




Cebu Velez General Hospital
DATE 4/23/08 4/24/08 4/28/08 5/2 NORMAL
VALUES
WBC 13 16.3 11.1 8.74 4.10-10.9 k/uL
NEU 10.4
80%
13.1
80.7%
8.71 6.46
78.2% 73.9%
2.50-7.50
47-80%N
LYM 1.37
10.5%
1.49
9.16%
1.14 1.49
10.2% 17.1%
1-4
13-14%L
MONO .884
6.78%
1.27
7.83%
1.06 0.477
9.52% 5.46%
.100-1.20
2-11%M
EOS .276
2.07%
.308
1.89%
.162 0.237
1.45% 2.71%
0.00-.5
0-5%E
BASO .078 .062 .063 0.74 0-.100









































































her brothers and sisters. Pts support system
is her family.

Value Belief Pattern
Patient has faith in God because she
values masses highly. She watches TV on
Sundays because she can no longer tolerate
the walking to get to church to hear mass.
She also prays every night before going to
sleep. She has no religious organizations. She
has superstitious beliefs such as not taking a
bath after having fever because
makabughat. There is no difference with
her values and beliefs before and after
hospitalization. Values in the family include
close family ties, helping one another, being
sensitive to one anothers needs. During
hospitalization, the sons of the patient calls
during weekends to ask about their mothers
condition. They also send money from time
to time to finance their mothers
hospitalization. Magtinabangay gyud mi
was what the S.O. said.

Environmental History
Pt. is currently residing in a one storey
house in Suba, Lilo-an, Cebu for three years
with her eldest daughters family. House and
lot is rented and financed by the patients
eldest son abroad. There are a total of 7
people living in the house including the
patient with 2 bedrooms and 8windows. Pt
sleeps with her 2grandchildren and daughter.
While the other room is occupied by her 2
older grandchildren and son-in-law. They
have no pets in the household but there are
chickens from the neighbors that go to their
backyard. Location of the house is accessible
to their basic necessities. It is a 10-15minute
walk away from the Healthcare center,
.598% .379% .565% 0.846% 0-2.10%B
RBC 3.04 3.71 3.67 3.74 4-5.20
HGB 9.03 10.6 10.7 10.7 12-16g/dL
HCT 25.4 30.8 30.8 31.3 36-46%
MCV 83.5 83 84.0 83.3 80-100fL
MCH 29.1 28.5 29.1 28.4 24-36pg
MCHC 35.6 34.4 34.7 34.1 31-36g/dL
RDW 14.7 13.9 14.5 14.7 11.6-18%
PLT 372 355 306 340 140-440k/uL
MPV 7.56 7.37 7.16 7.71 0-100gfL


Remarks:
4/23/08:few hypochromic red cells noted
4/24/08: low hypochromic RBCs noted.
Implications:.
An increase in WBC and neutrophil count is the bodys
reaction in response to the invading organism to fight off the
infection (foot debridement) and defend the body. An
elevated number of monocytes results from viral infection
A decrease in RBC production, Hgb and Hct level is a result
of damage of kidney (CKD) that results in the decrease in
the production of the hormone erythropoietin that stimulates
red blood cell production in the bone marrow.

BLOOD CHEMISTRY
(4/15/08)
Purpose: Serum or plasma tests for potassium levels are routinely
performed in most patients when they are investigated for any type of
serious illness. Also, because potassium is so important to heart function,
it is usually ordered. Sodium test is a part of the routine lab evaluation of
most patients. It is one of the blood electrolytes, which are often ordered
as a group. Ionized Calcium is the calcium found in blood. This test
measures serum levels of phosphates. It helps store and utilize body
energy and help regulate calcium levels, carbohydrate and lipid
metabolism, and acid-base balance. It is also essential for bone
formation. Magnesium is the most abundant intracellular cation after









































































market and Barangay Health Center (BHC),
and church. The main road is a 5minute walk
away from the house. The location of the
house is accessible to public transportation
such as their trysikads. Water is supplied
by MCWD and electricity is supplied by
Visayan Electric Company(VECO). Pt.
describes neigborhood as peaceful and not
congested. Garbage is disposed via motorized
collection system every other day and toilets
are flush-type.

potassium. Vital to neuromuscular function, this helps regulate
intracellular metabolism, and activates many essential enzymes.

Creatinine is the byproduct of the breakdown of muscle creatine
phosphate resulting from energy metabolism. It is produced at a constant
rate depending of the muscle mass of the person and is removed from the
body by the kidney. This test diagnoses impaired renal function

BUN: Urea forms in the liver and along with CO2, constitutes the final
product of protein metabolism. The amount excreted urea varies directly
with protein intake. The test for Bun, which measure the nitrogen portion
of urea, is used as an index of glomerular function in the production and
excretion of urea.


Implications:
Elevated serum Creatinine levels may indicate renal disease that
has seriously damaged the nephrons. Increased creatinine levels in the
blood suggest diseases or conditions that affect kidney function or
reduced blood flow to the kidney due to atherosclerosis.
Increase in BUN levels indicates impaired function of the
kidneys (Chronic Kidney Disease) to filter and excrete urea leading to its
accumulation in the blood.
Abnormally low serum sodium levels may result from
inadequate sodium intake or excessive sodium loss due to profuse
sweating, diuretic therapy, adrenal insufficiency, or chronic renal
insufficiency
Below-normal potassium levels often result from loss of body
Normal V
15-
Apr
19-
Apr
23-
Apr
25-
Apr
28-
Apr
30-
Apr
2-
May
Crea 0.6.-1.6 mg/dl 4.7 5.3 4.2 3.7
BUN 7-18 mg/dl 75.5 58 57
K
4.0-5.6
mmol/L 4.5 5 4.8 4 3.7
Na
136-142
mmol/L 135 132 131 138 139
Mg 1.2-2.2 mg/dl 2.3
P
2.70-4.50
mg/dl 4.67 3.6
Ionized 4.5-5.16 mg% 4.76
Ca









































































fluids (as in diuretic therapy). It may also result from chronic renal
insufficiency.
Elevated serum magnesium levels (hypermagnesemia) most
commonly occur in renal failure, when the kidneys excrete inadequate
amounts of magnesium.
Elevated levels of phosphorus (hyperphosphatemia) may result
from renal failure. Hyperphosphatemia is rarely clinically significant;
however, if prolonged, it can alter bone metabolism by causing abnormal
calcium phosphate deposits.


(4/18/08)
Purpose: Amylase helps digest starch and glycogen in the mouth,
stomach, and intestine. It distinguishes between acute pancreatitis and
other causes of abdominal pain. Phosphates aids in diagnosis of renal
disorders and acid-base imbalance.

amylase = 89 u/L (normal = 25-100 u/L)
SGPT = 15 u/L (normal = 0-46.0 u/L)
Phosphates = 76 u/L (40 129 u/L)
Implications: Results are within normal limits.



ARTERIAL BLOOD GAS ANALYSIS
Purpose: ABG Analysis is a measurement of oxygen, carbon dioxide, as
well as the pH of the blood that provides a means of assessing the
adequacy of ventilation (PaCO2), oxygenation (PaO2) and it also allows
assessment of the acid-base (pH) status of the body whether acidosis or
alkalosis is present, whether acidosis or alkalosis is respiratory or
metabolic in origin and to what degree (compensated or
uncompensated). This test is important because patient was having
dyspnea so the oxygenation of the body cells must be noted.



DATE 4/15/08
2:59
pm
4/26/08 4/29
2:17 pm 10:24am
Normal
values
temp 35.3 C 36.8 C 36.3 C 36.4-37.4C









































































Hgb 9.2 9.0 10.7 12-16 g/dl
pH 7.370 7.461 7.45 7.35 7.45
pCO2 25.6 28.1 36.2 32-42
mmHg
pO2 78.7 56.1 39.1 75-100
mmHg
HCO 14.8 19.8 25.0 20-24
mmol/L
TCO 21 20.7 26.2 21-
25mmol/L
ABE -9.4 -2.9 1.4 -3.3(+)1.2
mmol/L
SatO2 97.8 91.1 78.4 95-98%
Reticulocyte
count
1.8% 0.5-1.5%


Implications:
(4/15/08)Results imply a fully compensated respiratory alkalosis with
adequate oxygenation. It is fully compensated because the pH is normal.
It may also be caused by respiratory stimulation by drugs, disease,
hypoxia, or fever. A high reticulocyte count indicates a bone marrow
response to anemia caused by hemolysis or blood loss.
(4/26/08) Results imply a partially compensated respiratory alkalosis
with mild hypoxemia. This is due to the impaired function of the kidneys
to excrete the hydrogen ions to maintain pH homeostasis. As a
compensatory mechanism, when more hydrogen ions are released in the
blood, the respiratory control centers are activated in breathing rate and
depth increases to exhale carbon dioxide to maintain pH homeostasis.
(4/29/08) Results show an acid-base balance with severe hypoxemia.

RESCREENING TEST RESULTS
(4/23/08)
HBsAg MEIA = 0.79
Cut off = 2.0
Interpretation = non-reactive










































































Anti HIV-MEIA = 0.37
Cut off = 1.0
Interpretation = non-reactive

Anti HIV-MEIA = 0.28
Cut off = 1.0
Interpretation = non-reactive

Remarks: VDRL and malarial smears not done due to technical reasons
and limitations.
ELECTROCARDIOGRAM
Purpose: to detect heart problems or blockages in the coronary arteries;
to draw a graft of the electrical impulses moving through the heart; to
record heart rate and the regularity of heart beats; to diagnose a possible
heart attack or other heart diseases.

April 18, 2008 (3:40pm)
Rate: atrial: 83/minute
ventricular: 83/minute
Rhythm: sinus
Axis: +33 degrees
PR interval: 0.16 seconds QRS: .06 seconds QT interval: .36 seconds
P wave: gen. upright
QRS: normal R wave progression
Transitional zone: V4
T wave: flat in II, depressed III, AVF
ST segment: isoelectric

Interpretation: Sinus rhythm
Inferior wall ischemia
Probable old anteroseptal myocardial infarction


April 19, 2008
Rate: atrial: 71/minute
ventricular: 71/minute
Rhythm: sinus
Axis: +32 degrees
PR interval: 0.28 seconds QRS: .04 seconds QT interval: .36 seconds
P wave: upright









































































QRS: normal R wave progression q II, AVF, II
Transitional zone: V2 V3
T wave: flat II, AVF, V4, V5-V6
ST segment: isoelectric
Interpretation: sinus rhythm within normal limits. Consider an old
inferior wall scar.
LEFT FOOT APO
(4/15/08) DR. BULLO
Left foot APO: examination reveals the bones are normal in density,
texture, and modeling. The joint space is well maintained. There is no
evidence of a fracture, bone erosion nor bone destruction.
Conclusion: (-) left foot

CHEST PA
(4/15/08) DR. MAAMBONG
Purpose: To evaluate respiratory status and heart size.
Result: Examination reveals the lung fields are clear. The cardiac
silhouette is not enlarged. There are no bony abnormalities.

(4/16/08) DR. MAAMBONG
Result: examination reveals there are reticular densities noted in both
lungs. The cardiac silhouette is not enlarged. There are no bony
abnormalities.
Conclusion: pneumonitis both lungs

(4/22/08) DR. MAAMBONG
Chest AP: examination reveals there is hazy density noted in the right
lower lung and the right costrophrenic angle is obliterated.
Conclusion: pleural effusion right (hazy density)

(4/29/08) DR. MAAMBONG
Chest PA: examination reveals there are hazy densities noted in both
lower lungs. The diaphragm is obliterated. The cardiac silhouette is
enlarged. The pulmonary vessels in the upper lung fields are prominent.
There are no bony abnormalities.
Conclusion: cardiomegaly, associated with pulmonary edema or
congestion

Chest Right Lateral Decubitus: examination of the right lateral
decubitus of the chest with horizontal beam reveals there is homegenous









































































density noted along the right lateral chest wall. The right hemidiaphragm
is obliterated
Conclusion: Pleural Effusion RIGHT

Chest PA: Examination reveals there is hazy density noted on both lung
bases. The pulmonary vessels are prominent. The cardiac silhouette is
difficult to evaluate
Conclusion: Pulmonary edema and congestion, pulmonary edema
secondary to heart failure

(4/30/08) DR. MAAMBONG
Chest PA: Examination reveals there is hazy density noted on both lung
bases. The pulmonary vessels are prominent. The cardiac silhouette is
enlarged
Conclusion: Cardiomegaly, associated with pulmonary edema or
congestion

PERIPHERAL SMEAR EVALUATION
(4/15/08) DR. MAAMBONG
Result: The peripheral blood smears shows a dimorphic population of
normocytic and microlytic normocromic to mildly hypocromic RBC. No
significant poikilocytosis is noted. No nucleated RBCs seen; WBC are
heterogeneous lot and show basically normal adult morphology. A
relative predominance of segmentors is present. There are o blast cells
identified.
Platelets are within normal limits in number and morphology.

ARTERIAL DUPLEX SCAN
(4/15/08)
Conclusion: atherosclerotic and heavily calcified lower extremity
arterial segments
: severe (50-99%) arterial occlusive disease of the bilateral
posterior tibial and anterior tibial arteries
: moderate (20-49%) arterial occlusive disease of the mid-
segments of the right superficial femoral artery.

VENOUS DUPLEX SCAN: LOWER EXTREMITY
(4/15/08) DR. MAAMBONG
Venous duplex result: the visualized lower extremity venous segments
are compressible with adequate phasic.









































































Interpretation: no evidence of acute approximal deep vein thrombosis
bilaterally
: deep venous insufficiency involving the right common
femoral, superficial femoral and popliteal veins
: superficial venous insufficiency involving the right
greater saphenous vein and lesser saphenous vein.


WOUND DISCHARGE/ CULTURE
(4/16/08)
Gram staining: no microorganisms seen
P.R. No growth after 1 day

(4/17/08)
P.R. no growth after 2 days of incubation

(4/19/08)
P.R. smear of culture: Gram (+) bacillus
Culture: bacillus spp.

(2/20/08)
F.R remarks: no other pathogens isolated

(4/21/08)
F.R remarks: sensitivity testing of culture:
Bacillus spp was not done since there is no definitive CLSI or NCCLS
guidelines for susceptibility testing. However, vancomycin,
ciprofloxacin, imiperum, and aminoglycosides may be effective.
Whenever isolated from clinical specimens, the potential for the isolate
to be a contaminant must be strongly considered.


2 D ECHO
(4/16/08) DR. MAAMBONG
Conclusion: concentric left ventricular hypertrophy with regional
hypokinesia with borderline fan and Doppler evidence of stage 2
diastolic dysfunction.
: dilated left atrium
: mitral sclerosis with mitral regurgitation, mild, mitral
annular, calcification









































































: aortic sclerosis with aortic annular calcification
: tricuspid regurgitation, mild
: moderate pulmonary hypertension





ULTRASOUND
(4/19/08) DR. MAAMBONG
Ultrasound upper abdomen
Purpose: to evaluate the kidneys, liver, gallbladder, pancreas, spleen,
abdominal aorta and other blood vessels of the abdomen; to help
diagnose a variety of conditions, such as abdominal pains, inflamed
appendix, enlarged abdominal organ, stones in the gallbladder or kidney;
to assist in the assessment of damage caused by illness.

Ultrasound upper abdomen:
Exam reveals the liver is normal in size and echopattern. There are no
dilated intrahepatic ducts or masses noted. The gallbladder is normal in
size. The gallbladder wall is not thickened. The common duct is not
dilated. There are no intraluminal stones noted.
The Pancreas is normal.
The Spleen is normal in size with transverse diameter of 6.3 cm.
Incidentally, there is fluid in the left hemithorax.

Conclusion: normal liver, gallbladder, pancreas, and spleen
Right pleural effusion

Ultrasound K.U.B
(4/16/08) DR. MAAMBONG
Right kidney 7.4 x 4.2 cm
Cortical thickness 1.5 cm
Left kidney 8.2 x 4.5
Cortical thickness 1.9 cm
Examination reveals both kidney are in Normal in size, shape,
echogenicity and echopattern. There is no evidence of a stone, mass or
hynephrosis. The ureters are unremarkable. The urinary bladder is
normal.
Conclusion: normal K.U.B ultrasound. Examination reveals both









































































kidneys are normal in size, shape, echogenicity, and echopattern


DEBRIDEMENT
Purpose: Debridement speeds the healing of pressure ulcers,
burns, and other wounds. Wounds that contain non-living
(necrotic) tissue take longer to heal. The necrotic tissue may
become colonized with bacteria, producing an unpleasant
odor. Though the wound is not necessarily infected, the
bacteria can cause inflammation and strain the body's ability
to fight infection. Necrotic tissue may also hide pockets of
pus called abscesses. Abscesses can develop into a general
infection that may lead to amputation or death.

(4/26/08)
Debridement of left foot under local anesthesia at 9:30 AM under cardiac
monitor

LIVER FUNCTION TEST (April 30, 2008)
Purpose: Lactate dehydrogenase catalyzes the reversible conversion of
muscle lactic acid into pyruvic acid. This test aids in differential
diagnosis of MI, pulmonary infarction, and hepatic diseases.
LDH (lactate dehydrogenase): 212u/L (normal=0-247 u/L)
Total CHON: 6.6 g/dl (normal=6.6-8.8 g/dl)

Pleural fluid
LDH (lactate dehydrogenase): 76u/L (normal=0-247 u/L)
CHON: 1.8 g/dl (normal=6.6-8.8 g/dl)

Implications: Low total protein levels may result from essential
hypertension, uncontrolled diabetes mellitus, and malnutrition. Low
protein levels can suggest a kidney disorder, or a disorder in which
protein is not digested or absorbed properly.

CBG
Purpose: CBG consisting in measuring the glucose (sugar) content in
the blood is done on a regular basis in diabetes patients to determine
their glucose level (Normal = 70 120mg/dl). The purpose is to find out









































































if the doses of medicine which the patient is taking are correct and if his
diet is right or if corrections should be made.
Highest (4/16/08 9pm) 269 mg/dl
Lowest (4/17/08 5am) 84 mg/dl







KEY ISSUES:
1. Impaired gas exchange related to alveolar-capillary membrane
changes secondary to inflammation of lung parynchema as manifested
by shortness of breath, use of accessory muscles in breathing, (+)
wheezes, crackles heard upon auscultation, decreased Sat O2= 91.1
(mild hypoxemia) as of 04/26/08, hazy density noted in the right lower
lung and right pleural eff) on chest x-ray result as of 04/22.

SB:
Ventilation is impaired because of secretions of exudates from alveoli.
Secretions noted to be mobilized, loosened and expectorated in order to
provide an adequate gas exchange. Unless secretions are removed, the
alveoli becomes remained filled with exudates causing consolidation of
lung tissues and further interfering with gas exchange. (Nursing Care
Planning Guidelines by Caine Bufalino p.497)

In pleural effusion, lung expansion may be restricted, and the client may
experience dyspnea primarily on exertion, and a dry non-productive
cough caused by bronchial irritation or mediastinal shift. (Black, Joyce,
et. al, Medical-Surgical Nursing, 7
th
edition, Volume 2, p. 1873)







April 28, 2008
2. Decreased cardiac output related to increased viscosity of the blood










































































secondary to abnormally high blood sugar and impaired heart
contractility secondary to elevated blood pressure as manifested by skin
is dry and cold to touch, weak and thready peripheral pulses, 2D Echo
results as of April 16, 2008 that reveal left ventricular hypertrophy
dilated left atrium, mitral sclerosis with mitral regurgitation, aortic
sclerosis with aortic annular calcification, mild tricuspid regurgitation,
and moderate pulmonary hypertension, cardiomegaly on chest x ray
(april 29, 2008)

SB: The increased thickness of the heart muscle reduces the size of the
ventricular cavities and causes the ventricles to take longer time to relax,
making it more difficult for the ventricles to fill with blood during the
first part of diastole and making them more dependent on atrial
contraction for filling (Medical-Surgical Nursing, 10
th
Ed., Vol.1 p.773)
The left ventricle of the heart may become enlarged as it works to pump
blood against elevated pressure due to systemic vascular resistance and
excessive intravascular volume. Eventually, stroke volume, preload and
afterload are affected
(Brunner and Suddarths Textbook on Medical-Surgical Nursing 10
th

edition pg. 856)





















Independent Interventions:
1. Auscultated breath sounds and assessed
air movements.
R: To ascertain status and note progress.
2. Elevated head of bed and complied to
positioning schedule of patient.
R: To take advantage of gravity decreasing
pressure on the diaphragm and enhancing
drainage and ventilation to different lung
segments.
3. Positioned head midline.
R: To open or maintain open airway.
4. Encouraged deep breathing exercises.
R: To maximize effort.
5. Encouraged to expectorate sputum.
R: To clear secretions.
6. Promoted adequate rest periods.
R: To lessen fatigue.

Collaborative Interventions:
1. Administered supplemental oxygen at
4L per minute.
R: To increase oxygen available to tissues.




Independent Intervention:
1. Determined baseline v/s including
peripheral pulses; and reviewed laboratory
values and diagnostic studies.
R: provides opportunities to track changes
2. Assessed mental status
R: cerebral perfusion is directly related to
cardiac output and aortic pressure
perfusion and is influenced by electrolyte
and acid-base variations.
3. Provided adequate rest by decreasing
stimuli and providing quiet environment

Desired Outcome:
Within 8 hours of nurse-client
interaction, patient will be able to
maintain patent airway, demonstrate
good respiration and improved oxygen
exchange.

Actual Outcome:
04/28-30/08
After 8 hours of nurse-client interaction,
patient was able to maintain a patent
airway still uses accessory muscle in
breathing, crackles still heard on both
lung fields, constant use of supplemental
O2. Sat O2 as of april 29 has decreased
to 78. 4 (moderate hypoxemia)

05/2/08
After 8 days of nurse-client interaction,
patient still uses accessory muscles in
breathing, O2 level has decreased from
4 to 2 L/min. supplemental O2 was also
used when difficulty in breathing rises.





Desired Outcome:
Within 8 hours of nursing intervention,
the patient will display stability in blood
pressure and participate in activities that
reduce the workload of the heart such as
balanced activity/rest plan.

Actual Outcome:
05/28-29/08
After 8 hours of nursing intervention,
the patients BP= 130/80 mmHg. Patient















April 28, 2008
3. Ineffective Tissue Perfusion related to interruption of arterial and
venous flow and decreased HGB concentration as manifested by pale
nailbeds and pale palms of the hand and soles of the feet, pale palpebral
conjunctiva, weak and thready pulse on both upper and lower
extremities, CRT < 3secs on lower extremities, deep venous on venous
duplex scan result as of 04/15 and atherosclerotic and heavily calcified
lower extremity on Arterial duplex scan result as of 04/15; decreased
Hgb= 10.7 m/ul (04/28) and Hct = 30.8% (04/28)
SB:
The delivery of oxygen to the muscle cells throughout the body depends
not only on the lungs but also on the ability of the blood to carry oxygen
and on the ability of the circulation to transport it. (Merck Manual of
Medical Information, 2
nd
Home Ed., M. Beers et. al, p. 221)
The amount of blood flow needed by body tissues constantly changes.
The percentage of blood flow received by individual organs or tissues is
determined by the rate of tissue metabolism, the availability of oxygen
and function of tissues.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 977)





R: To maximize sleep periods
4. Elevated legs
R: to promote venous return
5. Monitored I/O
R: To maintain adequate fluid balance
6. Encouraged changing positions slowly.
R: Reduce risk of orthostatic hypotension.
7. Assisted in performing self-care
activities.
R: to decrease energy consumption.
8. Altered environment such as decreasing
temperature of air conditioner.
R: to maintain body temperature in normal
range.
9. Explained fluid restrictions.
R: to promote cooperation of patient and
SO.
10. Assisted with frequent position
changes.
R: to avoid the development of pressure
sores.

Collaborative Intervention:
1. Administered oxygen inhalation at
4L/min as indicated.
R: To increase oxygen available to tissues.
2. Administered ISMN/ Isosorbide
mononitrate (Imdur) 60mg/tab tab twice
a day by mouth
R: relaxes vascular smooth muscles with a
resultant decrease in venous return
3. Administered Amlodipine 5 mg 1 tablet
once a day after breakfast by mouth
R: to depress myocardial contractility,
dilate coronary arteries and arterioles and
peripheral arterioles
3. Administered Aluminum Hydroxide
(Alutab) 1 tablet twice a day by mouth
R: binds with phosphate ions in the
intestine to form insoluble aluminium-
needs assistance in rising from bed and
transferring to bedside commode.
Patient is cold to touch, peripheral
pulses are weak and not easy to palpate

05/2/08
After 8 hours of nursing intervention,
the patients BP= 130/80 mmHg. Patient
was able to sit on bed with little
assistance, and alert at this time.





























































April 28, 2008
4. Fluid Volume Overload r/t excess fluid in pleural spaces secondary
to inability of the kidney to excrete fluid efficiently as manifested by use
of accessory muscles upon breathing, (+) wheezes, crackles heard on
both lung fields, hazy density noted in the right lower lung and pleural
effusion, right on chest x-ray result as of 04/22.

SB:Pleural effusion is the accumulation of fluid in the pleural space.
Nomally only a thin layer of fluid separates the 2 layers of the pleura. An
phosphate complexes, lowering phosphate
in hyperphospatemia


Independent Interventions:
1. Interviewed and reviewed patients
history and determined the nature of the
problem.
R: to assess causative factor
2. Established baseline vital signs, weight,
and laboratory values.
R: provide comparison with current
findings.
3. Measured capillary refill time; palpated
for presence or absence and quality of
pulses.
R: To note degree of impairment.
4. Assessed for Homans sign
R: to determine proper blood circulation
3. Encouraged sleep and rest
R: decreases oxygen consumption.
4. Provided comfort and warmth through
covering the patients feet and hands with
blanket during cold temperatures.
R: Increase blood circulation to the
peripheral areas.
5. Positioned patient in moderate high
back rest
R: Promoted optimum lung expansion
6. Performed assistive or passive range-of-
motion exercises
R: To maximize tissue perfusion.
7. Discouraged sitting or lying down for
long periods, wearing constrictive
clothing.
R: To maximize tissue perfusion.
8. Encouraged patient to elevate the legs,
but avoid sharp angulation of the hips and
or knees.
R: To maximize tissue perfusion.





Desired Outcome:
Within the course of nursing
intervention, patient will be able to be
free from the signs and symptoms of
infection like swelling, fever, redness,
pain

Actual Outcome:
After the course of nursing intervention,
no signs of infection such as fever,
redness, swelling, itchiness were noted;
wound was kept clean and dry; HGB
and HCT level were still low; 3.74 m/uL
(05/02) and 31.3% (05/2), respectively.
Patient was still pale, cold to touch and
peripheral pulses are still weak.



















excessive amount of fluid may accumulate for many reasons, depending
on the cause.the most common symptoms are shortness of breath and
chest/ pleuritic pain.there are many causes of pleuritic pain including
viral and bacterial infections. (merck manual of medical information,
2nd ed., p.226,283.)

Pleural effusions may also be associated with the leakage of fluid due to
higher than normal pressures in the lung circulation, such as with
congestive heart failure (CHF) or from low protein in the blood, as in
liver disease, severe malnutrition, and in certain kidney conditions when
protein is filtered into the urine.
(http://www.pcca.net/PleuralEffusion.html)


























April 20, 3008
5. Imbalanced Nutrition, less than body requirements related to

Collaborative Intervention:
1. Administered Diosmin + Hesperidin
(Daflon) 500 mg I tab twice a day by
mouth
R: significantly improves disabling
symptoms of venous insufficiency which
affect everyday active life
2. Administered Losartan (Lifezar) 50 mg
I tab once a day after supper by mouth
R: blocks the vasoconstricition effect of
the RAA system as well as the release of
aldosterone
3. Administered Amlodipine 5 mg I tab
OP PO pc bfast
R: to depress myocardial contractility,
dilate coronary arteries and arterioles and
peripheral arterioles



Independent Interventions:
1) Assessed skin, face and dependent areas
for edema
R: to evaluate degree of fluid volume
excess
2) Monitored input and output
R: to determine renal function and fluid
replacement and reducing risk of fluid
overload
3) Monitored Vital signs
R: tachycardia and hypertension can occur
because of failure of kidneys of excrete
urine, changes in RAA mechanism
4) Auscultated lung and heart sounds
R: Fluid overload may lead to pulmonary
edema and heart failure
R: to assess precipitating factors
5) Assessed level of consciousness
R: may reflect fluid shifts, accumulation























Desired Outcome:
Within 4 hours of nursing intervention,
the patient will maintain an appropriate
urinary output, vital signs within normal
range, a stable weight, clear lung fields,
and absence of edema

Actual Outcome:
05/28-30/08
After 4 hrs of nursing intervention,
patient maintained a normal output of
30-60 cc/hour, blood pressure was
within her normal range of 130/80, no
edema was noted, but heard crackles on
both lung fields upon auscultation.

045/02/08
increased metabolic rate and fatigue as manifested by body weight is not
ideal to her height: wt: 98 lbs; ht: 52, poor muscle tone, dry skin

SB: Undernutrition refers to an intake of nutrients insufficient to meet
daily energy requirement because of inadequate foot intake or improper
digestion and absoption of food. An inadequate food intake may be
caused by the inability to acquire and prepare food, balanced diet,
discomfort during or after eating. Improper digestion and absorption of
nutrients may be caused by an inadequate production of hormones or
enzymes or by medical contions resulting in inflammation or obstruction
of GI tract
(Kozier, Barbara. Fundamentals of Nursing 7
th
edition. pg 1190)




























of toxins, acidosis, electrolyte imbalances
or developing hypoxia
7) Measured abdominal girth
R: to identify changes that may indicate
increasing fluid retention
7) Positioned patient in semi-fowlers
position
R: to facilitate movement of diaphragm
improving respiratory effort
8) Limited oral fluids as ordered to 300ml
in the 7-3 shift, 300 ml in the 3-11 shift,
and 200 ml in the 11-7 shift
R: to allow timely alterations in
therapeutic regimen

Collaborative interventions:
1) administered Furosemide 40mg/tab ii
tabs OD PO pc bfast
R: to promote elimination of excess fluid
3) administered O2 via nasal cannula @
4L/min
R: facilitates patient in breathing
4) Assisted in performing Thoracentesis
R: to remove the excess fluid found in
pleural


Independent Interventions:
1. Assessed weight, age, body build,
strength, and activity/rest level
R: to provide comparative baseline
2. Determined ability to chew, swallow,
and taste
R: to identify the factors that can affect
digestion of nutrients.
3.Encouraged bed rest and/or limited
activities.
R: decrease metabolic needs aids in
preventing caloric depletion and conserves
energy.
After 4 hrs of nursing intervention,
patient urinated 150cc/4hrs, no edema
was noted, still crackles were heard on
both lung fields.

























Desired Outcome:
Within 1 hour of nursing intervention,
patient will demonstrate demonstrate
behavior and lifestyle changes to
maintain weight at a satisfactory level
for height, body build, age and gender
and patients SO will verbalize
understanding of the health teachings
given

Actual Outcome











April 28, 2008
6. Ineffective Protection related to inadequate primary defense: break in
skin and secondary body defenses: decreased haemoglobin level as
manifested by 2 cm in dm and 1x1/2 in of open wounds on left foot,
decreased Hgb= 10.7 m/ul (04/28) and 3.74 m/uL (05/02) and Hct =
30.8% (04/28) and 31.3% (05/2).
SB: Any site in the body is susceptible to infection by organisms when
skin and tissue barriers are compromised by surgery, trauma or there is
tissue ischemia or necrosis. These infections are frequently caused by
post surgical wound infection, intra-abdominal abscess among others. (
Harrisons Principles of Internal Medicine 9
th
Ed. Pg. 694-695)


















4.Recommended rest before meals.
R: quiets peristalsis and increases
available energy for eating.
5.Provided oral hygiene.
R: a clean mouth can enhance the taste of
the food.
6.Served food in a therapeutic
environment.
R: pleasant environment aids in reducing
stress and is more conducive to eating.
7.Encouraged patient to verbalize feelings
concerning resumption of diet.
R: hesitation to eat may be result of fear
that food will cause exacerbation of
symptoms.
8. Emphasized importance of well-
balanced, nutritious intake
R: to provide information regarding
individual nutritional needs
9. Instructed SO to serve soft foods to the
patient
R: to masticate food easily

Collaborative Intervention:
1. Administered Sodium bicarbonate Gr X
2 tablet thrice a day by mouth
R: to neutralize or reduce gastric acidity,
resulting in an increase in the gastric pH,
which inhibits the proteolytic activity of
pepsin
2. Administered Mucosta 100mg/tab 1
tablet thrice a day by mouth
R: exhibits a gastric cytoprotective effect
by inhibiting mucosal damage induced by
ethanol, strong acid and strong base





4/30/08
After 1 hour of nursing intervention,
patient has a good appetite, was able to
finish one serving of every meal served..
Patients SO expressed understanding of
the health teaching given as verbalized
ako man jud na dugmokon ang
pagkaon ni mama para humok ug sayon
nya matulon ang pagkaon
5/2/08
After 1 hour of nursing intervention,
patient was able to finish one serving of
meal. She still has poor muscle tone and
weight is decreased from 98lbs to 95lbs
(not accurate)




































April 28, 2008
7. Impaired Skin Integrity related to mechanical factors such as trauma
to the skin secondary to S/P debridement on left foot as manifested by 2
cm in dm and 1x1/2 in of open wounds on left foot

SB: The skin serves as the primary defense against bacterial invasion.
When skin is incised for surgical procedure, this important line of
defense is lost. Strict adherence to aseptic technique during surgery and
in the days following the procedure is necessary to compensate for
impaired defense. (Maternal and Child Health Nursing, 4
th
edition by
Adele Pillitteri, p 613)


















Independent Interventions:
1. Noted signs and symptoms of infection
R: fever, chills, diaphoresis, altered level
of consciousness, and positive blood
cultures may indicate infection
2. Encouraged proper hand washing
techniques to client and SO
R: a first line of defense against
nosocomial infection or cross-
contamination
3. Encouraged to check wound for signs of
inflammation and drainage.
R: may indicate hematoma formation and
developing infection
4. Encouraged and assisted in ambulation
R: promotes wound healing
5. Instructed patient to keep incision dry
and clean
R: to prevent risk for infection
6. Encouraged SO to let patient eat food
high in iron and vitamin c such as green
leafy vegetables, organ meat, orange,
citrus fruit
R: to boost immunity and enhance proper
blood circulation


Collaborative Interventions:
1. Assisted in wound dressing with
Mupirocin (Bactroban)
R: to keep the wound are clean and dry
2. Administered Ciprofloxacin 500 mg/tab
1 tablet once a day by mouth
R: promotes breakage of double-stranded
DNA in susceptible organisms and inhibits
DNA gyrase, which is essential in
reproduction of bacterial DNA.






Desired Outcome:
Within 8 hours of nursing intervention
px will be able to be free from the signs
and symptoms of infection like
swelling, fever, redness, pain

Actual Outcome:
After the course of nursing intervention,
no signs of infection such as fever,
redness, swelling, itchiness and warmth
on incision site were noted; wound was
kept clean and dry; hgb and hct level
were still low; 3.74 m/uL (05/02) 31.3%
(05/2), respectively.


































April 30, 2008
8. Acute Pain related to surgical operation secondary to S/P left food
debridement as manifested by gnawing pain on left foot lasting for 30
seconds with a facial, relieved by rest, aggravated by stepping on the
floor, with a verbalization of sakit kaayo.
SB: Pain is an unpleasant sensory and emotional experience associated
with actual or potential tissue damage. It occurs with many disorders,
diagnostic tests and treatments and invasive procedures. (Medical
Surgical Nursing by Smeltzer and Bare, vol. 1, p. 217)




]















Independent Interventions:
1. Assessed wound for presence of
inflammation and drainage.
R: Development of infection delays
wound healing.
2. Assessed wound for unusualities such
as discoloration and swelling.
R: Infection is characterized by a black
discoloration of the wound.
3. Monitored vital signs especially
temperature elevation.
R: A rise in temperature indicates presence
of inflammation, pyrogens, or infection.
4. Kept area clean and dry.
R: To avoid infection.
5. Avoided use of plastic materials and
removed wet and wrinkled linens
promptly.
R: Moisture potentiates skin breakdown.
6. Complied with the positioning schedule
of the patient.
R: To prevent development of pressure
sores.
7. Avoided use of constricted clothings.
R: To promote circulation to the lower
extremities.
8. Encouraged to eat food high in Vitamin
C such as orange, citrus fruit and green
leafy vegetables
R: to promote wound healing

Collaborative Interventions:
1. Assisted in wound dressing with
Mupirocin (bactroban) once a day
R: to keep the wound are clean and dry
2. Administered Ciprofloxacin 500 mg/tab
once a day by mouth
R: promotes breakage of double-stranded
DNA in susceptible organisms and inhibits
DNA gyrase, which is essential in



Desired Outcome:
After 30 minutes of nursing
intervention, patient will display timely
healing of skin wounds without
complications and prevent development
of pressure sores.

Actual Outcome:
5/28/2008
After 30 minutes of nursing
intervention, patients wound was
covered with a clean and dry gauze.
Wound is watery but there was no pus
noted.
5/29/08
After 30 minutes of nursing
intervention, patients SO understood
the health teachings given with a
verbalization of salamat kayo,
maintenahon lang nako ug pakaon si
mama ug prutas, wound dressing
remained dry, intact and presence of
blood on the edge was noted.

4/30 and 5/2 /08
After 30 minutes of nursing
intervention, patients dressing was
clean, dry and intact. Wound is dry and
no purulent discharges noted.










April 28, 2008
9. Fatigue related to decreased metabolic production, poor physical
condition and decreased hemoglobin level secondary to impairment of
kidney function as manifested by lethargy, disinterest in surroundings,
inability to perform ADLs, verbalization of kapoy sigeg higda and
decreased Hgb= 10.7 m/ul (04/28) and and Hct = 30.8% (04/28)
Scientific Basis:
Fatigue, nausea, vomiting and overall itching of the skin commonly
develop in people who have kidney failure. These symptoms result from
the accumulation of metabolic waste including acids, which the diseased
kidneys are unable to excrete. Fatigue may also result from decreased
production of red blood cells, a frequent problem in chronic kidney
failure (Merck Manual of Medical Information, 2
nd
Home Ed., M. Beers
et. al, p. 748)
























reproduction of bacterial DNA.
Independent Intervention:
1) Monitored vital signs.
R: Alteration in vital signs could indicate
pain.
2) Frequently assessed pain scale.
R: To rule out development of
complications.
3) Provided comfort measures such as
assuming patient position (semi-Fowlers
position) of comfort.
R: To provide non-pharmacological pain
management.
4) Encouraged adequate rest periods.
R: To prevent fatigue.
5) Taught how to do deep breathing
exercise and stressed to perform it every
time pain occurs.
R: To promote relaxation.
6) Encouraged expression of feelings.
R: Helpful in establishing individualized
treatment needs
7) Taught diversional activities like
watching television.
R: to divert attention from pain

Collaborative:
1. Administered Paracetamol 500mg/itab
1tablet as needed
R: for fever and pain


Independent Intervention:
1) Obtained a history of condition
including date of onset, and significant
findings of present condition.
R: To provide a baseline data for future
comparisons.
2) Determined ability to participate in
activities or level of mobility.






Desired Outcome:
Within 30 mins. of nurse-client
interaction, the patient will be able to
demonstrate methods that provide relief,
report that pain is relieved and
controlled, and pain scale is reduced.

Actual Outcome:
04/30/08
After 30 mins. of nursing interventions,
pain was still noted with a verbalization
of sakit gamay

5/2/08
After 2 days of nursing interventions,
the patient still reported pain with a
verbalization of sakit kung tumban
nako, sakit kaayo pero ako lang
antuson














Desired Outcome:
April 28, 2008
10, Partial Self Care Deficit (dressing, feeding, bathing, grooming and
toileting.) related to fatigue and developmental age of 82 years old as
manifested by inability to wash body parts, inability to get in and out of
the bathroom, inability to pick up clothing, and inability to handle
utensils.

SB: People with disabilities frequently experience fatigue. Physical and
emotional weariness may be caused by discomfort and pain associated
with a chronic health problems, deconditioning associated with
prolonged periods of bed rest and immobility, impaired motor function
requiring excessive expenditure of energy to ambulate, the frustrations of
performing ADLs.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 218)

With aging comes gradual reduction in the speed and power of skeletal
or voluntary muscle contraction and sustained muscular effort. Thus
elders often complain about their lack of strength and how they quickly
they tire.
(S: Smeltzer, Suzanne C. and Brenda G. Bare. Medical-Surgical
Nursing. p 402)












April 28, 2008
11. Impaired Physical Mobility related to decreased strength and
endurance as manifested by inability to get out of bed without assistance
and poor gait
Scientific Basis:
Paralysis, extreme weakness, pain, or any cause of decreased activity can
R: To assess patients degree of fatigue.
3) Provided environment conducive for
rest and sleep.
R: To relieve fatigue.
4) Assisted with self-care needs.
R: To limit occurrence of fatigue.
5) Scheduled activities according to
clients ability.
R: To maximize participation.
6) Instructed SO to maintain a quiet
environment conducive for rest and
sleep.
R: temperature and level of humidity are
known to affect exhaustion
7) Instructed SO to minimize number of
visitors in the room or to schedule visits.
R: to provide a calm and quiet
environment
8) Encouraged SO to let the patient eat
foods high in iron such as liver, green
leafy vegetables, fish, beans, nuts, eggs,
raisins.


Collaborative Intervention:
1) Administered O2 @ 4L/min via nasal
cannula
R: to facilitate breathing and promote ease
in respiration.



Independent Interventions:
1. Assessed emotional and psychologic
factors affecting the current situation such
as stress
R: to note any changes in emotional status
2. Evaluated current limitations or degree
of deficit in the light of usual status
R: provides comparative data
Within 30 minutes nursing intervention,
patient will be able to perform ADLs
and display improved ability to
participate in desired activities.

Actual Outcome:
4/28-30/08
After 30 minutes of nursing
intervention, patient still appeared weak
and lethargic, needed assistance in
perfoming ADLs and decreased activity
was still noted.
5/2/08
After 30 minutes of nursing intervention
, patient demonstrated
improvement in muscle strength from
poor ROM to average weakness. She
was able to sit on bed with little
assistance and interactive with the
health care provider. Patients HGB and
HCT level are still low with 3.74 m/uL,
31.3% respectively

















Desired Outcome:
hinder a persons ability to change positions independently and relieve
the pressure, even if the person can perceive pressure. (Kozier, et al,
Fundamentals of Nursing, 7
th
Ed., p 857)



























April 28, 2008
12. Risk for injury: falls related to poor physical condition
Cues: 82 years old, tremors on upper extremities, unable to do ADLs
alone, impaired balance, difficulty with gait, s/p left foot debridement,
hyperphosphatemia

SB: Weakness can occur when any part of the musculoskeletal system
is abnormal. If the muscle itself cannot contract, weakness occurs. If a
nerve does not adequately stimulate the muscle, the muscle contractions
are weak. If a joint is frozen and unable to move normally, the muscle
3. Established rapport with patient and
S.O.
R: To foster trust between the nurse, the
patient & S.O
4. Collaborated with the SO of the client
in caring for and assisting the client.
R: Enhances coordination and continuity
of care, optimizing outcomes
5. Planned care with rest periods between
activities
R: to reduce fatigue
6. Promoted comfort measures
R: to enhance ability to participate in
activities
7. Provided positive reinforcement when
client complies to nursing interventions
R: Encourages continuation of efforts.
8. Taught S.O safety concerns such as
raising of siderails at all times, keeping
away sharp objects
R: to prevent injuries
9. Encouraged S.O to stay at patients
bedside at all times
R: To ensure safety and attend patients
needs


Independent Interventions:
1. Assessed emotional and behavioural
responses to problems of immobility.
R: Feelings of frustrations and
powerlessness may impede attainment of
goals.
2. Determined functional level of
classification.
R: Assess the functional ability.
3. Positioned safely on bed and raised side
rails.
R: To promote safety.
4. Assisted with the activities of ADL like
After 8 hrs of nursing interventions,
patient will be able to perform self-care
activities such as dressing bathing,
toileting, feeding and grooming, within
the level of her own ability and
demonstrate techniques to meet self-care
needs.


Actual Outcome:
4/28-30/08
After 8 hrs of nursing interventions, the
patient still needed assistance of the care
provider and SO in performing ADLs
such as dressing, bathing, toileting,
feeding, and grooming.
5/2/08
After 8 hrs of nursing interventions,
patient was able to stand up from bed to
bedside commode with assistance for
defecation and urination. She was still in
need of assistance in performing her
ADLs.










Desired Outcome:
Within 8 hours of nursing interventions,
patient will be able to demonstrate
progressive changes in her mobility as
tolerated, and at the same time SO will
be able to provide the necessary needs
of the patient such as changing position
may not be adequately able to cause movement. (The Merck Manual of
Medical Information, 2
nd
Home Ed., M. Beers et. al, p. 305)



















April 30, 2008
13. Bowel Incontinence related to self-care deficit: inefficient toileting,
general decline in muscle tone secondary to increasing age as manifested
by inability to delay defecation, fecal staining on clothing, and inability
to recognize urge to defecate.
SB: Fecal Incontinence describes the involuntary passage of stool from
the rectum. Factors that influence fecal continence include the ability of
the rectum to sense and accommodate the stool, the amount and
consistency of stool, the integrity of the anal sphincter and musculature,
and rectal motility. It can result from neurologic disorders such as
diabetic neuropathy, or advancing age. Patients may have minor soiling,
occasional urgency, and loss of control.
(Smeltzer, Bare, Textbook of Medical-Surgical Nursing, 11
th
edition,
Lippincott Williams and Wilkins, 2008, page 1236)





transferring from bed to bedside
commode.
R: prevent complications.
5. Assisted in ambulation
R: to promote wellness
6. Promoted SO participation in patient
care.
R: Enhances coordination and continuity
of care.
7. Assisted in positioning patient every
2hrs.
R: To prevent pressure sores and promote
comfort.
8. Supported affected body part with a
pillow.
R: To maintain position of function and
reduce risk of pressure sores.
9. Promoted adequate rest periods.
R: To reduce fatigue
10. Assisted in performing active assistive
ROM exercises to the patient.
R: To stimulate peripheral circulation.


Independent Interventions:
1. Assessed age.
R: to evaluate degree of risk in the
individual situation.
2. Assessed clients cognitive status.
R: Affects ability to perceive own
limitations and risk for falling.
3. Assessed mood, behaviour, and
personality styles.
R: Individuals temperament and typical
behaviour can affect attitude towards
safety issues.
4. Provided rails, pillows and chair at sides
of patients bed.
R: to prevent from falls
5. Visited frequently
and transferring from bed to bedside
commode for toileting

Actual Outcomes:
4/28-30 and 5/2/08
After 8 hours of nursing interventions,
patient cannot change position and
ambulate without assistance





















Desired Outcome:
Within 8 hours of nursing intervention,
the patient will be safe and free from
injury and patients SO will verbalize
understanding of the safety measures
being taught by the HC provider.

Actual Outcome:
04/28/07
Patient was free from injury and SO
expressed understanding of the


































April 30, 2008
14, Impaired dentition related to poor oral hygiene and lack of
knowledge regarding dental health and aging process as manifested by
presence of dental cavities, yellow-colored teeth, 6 lower and 4 upper
teeth

R: to promote patient safety
6. Discussed to SO the need for constant
supervision
R: to maintain patients safety


Collaborative Interventions
1. Administered Gabapentin
(Reinin/Nevrontin) 100mg/cap 1capsule
twice a day by mouth
R: treatment for tremors; depresses
abnormal neuronal changes in the CNS



Independent Interventions
1. Noted times of incontinent
occurrence.
R: Provides baseline data.
2. Palpated abdomen.
R: to determine presence of
distention, masses, and tenderness.
3. Auscultated bowel sounds, noting
locations and characteristics.
R: To note presence, location,
characteristics of bowel sounds.
4. Observed for abdominal distention if
bowel sounds are decreased.
R: Loss of peristalsis paralyzes the
bowel, creating bowel distention.
5. Recorded frequencies, characteristics,
and amount of stool.
R: Identifies degree of impairment/
dysfunction and level of assistance
required.
6. Encouraged SO to record times at
which incontinence occurs.
R: To note relationship to meals,
activity, and clients behavior.
7. Determined presence of impaction.
importance of safety measures as
verbalized by naa man jud permi kuyog
si mama, bantayan nako permi si mama
04/29-30/07
Patient was free from injury. There were
no signs of local infection such as
swelling, redness, purulent discharges
noted on left foot; slight tremor was
noted on upper extremities.
05/02/08
Patient was free from injury. Patients
wound is dry and covered properly with
a clean gauze. A tremor on the upper
extremities was very noticeable.






Desired Outcome
Within 30 mins. of student nurse-patient
interaction, the patient will re-establish
satisfactory bowel elimination pattern.

Actual Outcome
04/30
After 30 mins of nursing intervention,
the patient defecated on her bed.

05/2
After 30 mins of nursing intervention,
patient felt the urge to defecate. She was
able to control it and satisfactorily
defecated in the bedside commode





Scientific Basis:
Healthy teeth must be conscientiously and effectively cleaned on a daily
basis. The normal movement of the muscles of mastication and the
normal floe of saliva aid gently in keeping the teeth clean. Because many
ill patients do not eat adequate amounts of foods, they produce less
saliva, which in turn reduces the natural cleaning process of the teeth.
(Medical Surgical Nursing by Brunner & Suddarths p. 810.)
Tooth enamel tends to wear away with age, making the teeth vulnerable
to damage and decay. Periodontal disease, however, is the major cause
of tooth loss. Periodontal disease is more likely to occur in people with
poor oral hygiene, smoker and poor nutrition. (Merck Manual of Medical
2
nd
ed. p.602)
R: Early intervention is necessary to
effectively treat constipation or
retained stool and reduce risk of
complications.
8. Taught to lean forward on commode.
R: To increase intra-abdominal
pressure during defecation.
9. Encouraged fruit juices such as apple
and
pineapple juice.
R: Improves consistency of stool for
transit through the bowel.
10 Encouraged activity within individual
ability
and up in bedside commode as
tolerated.
R: Improves appetite and muscle tone,
enhancing GI motility.
8. Restricted intake of grapefruit juice
and caffeinated beverages such as tea,
coffee, and chocolates.
R: Diuretic effect can reduce fluid
available in the bowel, increasing risk
of dry/hard formed stool.
9. Provided skin care.
R: loss of sphincter control potentiates
risk of skin irritation/ breakdown.


Independent Intervention:
1) Noted presence or absence of teeth and
ascertain its significance in terms of
nutritional needs.
R: to assess causative or contributing
factors
2) Evaluated current status of dental
hygiene and oral health
R: to assess causative or contributing
factors
3) Discussed the importance of having

































Desired Outcome:
Within the 30 mins. of nursing
intervention, SO and patient will be able
to demonstrate effective dental hygiene
skills and gain knowledge on the
importance and benefits of having a
good oral hygiene.
dental check up
R: to minimize oral or dental tissue
damage
4) Discussed the importance of having
good dental hygiene.
R: to increase patients awareness on
dental care.
5) Instructed to use warm saline gargle.
R: to promote good oral hygiene.
Actual Outcome:
04/30/08
After 30 mins. of nursing intervention,
SO and client was able to understand
and gain knowledge of health teachings
given to SO by nodding her head and
verbalizing o sige, salamat kaayo
Patient also showed understanding by
nodding her head.
05/2/08
After 30 mins. of nursing intervention,
patients teeth is still yellow in color;
presence of cavities were noted.