Individual Case Study

8/4/2019 Individual Case Study

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Clinical Summary

Name: Manuel Galang Delos Santos

Sex: Male

Age: 68 years old

Address: A-A 6-20 PArola Tondo Manila

Date of Birth: May 9, 1943

Birth Place: Mindanao

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Date of Admission: September 5, 2011

Ward and Room: Medicine Ward and Rm. 621

Admitting Diagnosis: Diabetes Mellitus Type II

A. Personal DataPatient is Mr. Manuel Galang Delos Santos, a 48 years old male from A-A 6-20 Parola

Tondo Manila. He is married, they have three childrens, and they are all Roman

Catholic.

B. Chief ComplainThe patient was admitted at Gat Andres Bonifacio Memorial Medical Center last

September 5, 2011 due to the complaint of difficulty of breathing (DOB). He was

attended at the Emergency Department and had taken a clinical history and physical

assessment. He was transferred at the Medicine ward particularly in the isolation room

of the hospital for further evaluation of the complaint. He was attended by Dr. Ancheta

resident physician of the said hospital.

C. Past Medical HistoryThe patient is known hypertensive, diabetic and asthmatic since he was a child it istriggered by dust, scented products and Strong odors from paints. Last attack of

asthma he did not take any maintenance and medication. He has a history of asthma

in her family. Whenever asthma attacks he uses inhaler if available. He does not have

allergies to whatever kind of foods and medication as far as she kno

D. History of Present illnessThe patient condition started about 2 months ago prior to consultation, as onset of

cough, fatigue and difficulty of breathing.


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3/28

Nursing Care Plan

Assessmen

t

Diagnosis Planning Intervention Rationale Evaluation

Subjective:

hindi ko

na

magawa

yung mga

nagagaw

a ko dati

as

reported

by the

patient.

Objective:

Generalize

d

weakness

Polyphagi

a

Polyuria

Polydypsia

Restlessnes

s

Drowsy

Lethargy

Vital Signs:

Bp;130/90

mmHg

RR:25bpm

Pr:95bpm

Temp.:37.20C

ActivityIntolerance

related to

poor

glucose

control as

evidence

by

experienci

ng

shortness of

breathwhen

ambulating

.

Short Term

After 8 hours

of nursing

intervention,

will be able

to

participate in

physical

activity with

appropriate

changes in

heart rate,

blood

pressure, and

respirations.

Long Term:

After 3 days

of nursing

intervention,

will be ableto

demonstrate

increased

tolerance to

activity by

discharge.

1.Evaluatemedication

s the client

is taking to

see if they

could be

causing

activity

intolerance

2.Assess

nutritional

needs

associated

with activity

intolerance.

1.Medicationssuch as beta-

blockers, lipid-

lowering

agents, which

can damage

muscle, and

some

antihypertensi

ves such as

Clonedine

and loweringthe blood

pressure to

normal in the

elderly can

result in

decreased

functioning.

2.The decline

in body mass,

with physical

weakness,

inhibits

mobility,

increasing

liability to

deep vein

thrombosis,

and pressure

ulcers.

3.Fear of

breathlessness,

pain, or falling

may decrease

Short Term:

After 8 hours of

nursing

intervention,

goal met, as

evidence by

participating in

physical

activity with

appropriate

vitals changes.

Long Term:

After 3 days of

nursing

interventiongoal met, as

evidence by

demonstrating

increased

tolerance to

activity.


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3.Provide

emotional

support and

encourage

ment to the

client togradually

increase

activity.

4.Monitor

vital signs

before and

after any

activity,

noting anyabnormal

changes.

5.Assess for

pain before

activity.

willingness to

increase

activity.

4.This can be

caused by a

temporary

insufficiency of

blood supply.

5.Pain restricts

the client from

a achieving a

maximal

activity level

and if often

exacerbated

by movement.


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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

palagi ako

nagugutomkya palagi din

ako

kumakaen as

verbalized by

the patient.

Objective:

Generalized

weakness

Polyphagia

Polyuria

Polydypsia

Restlessness

Drowsy

Lethargy

Vital Signs:

Bp;130/90mmH

g

RR:25bpm

Pr:95bpm

Temp.:37.20C

Nutritional

Imbalance

more than

bodyrequiremen

t related to

intake in

excess of

activity

expenditur

es as

evidence

by

Long Term:

After 3

days ofnursing

interventio

n, will be

able to

have

nutritional

balance

between

needs and

intake.

1.Obtain

accurate

history of

weightchanges.

2.Record

accurate

food hstory,

including

daily intake.

3. Encourage

use of internalreward

systems when

goals are

accomplishe

d.

4. Set a

realistic plan

with Mr.

galang to

include

reducedfood intake

And

increased

energy

expenditure.

5. Encourage

attendance

at support

groups for

weight lossand/or

Refer to a

community

weight

control

program.

1.

Increases

awareness

ofactivities

and foods

that

contribute

to

excessive

intake

2.

Increases

awareness

of

activities

and foods

that

contribute

to

excessive

intake.

3. Goal

setting

providesmotivation

, which is

essential

for a

successful

weight-loss

program

4.. A

combined

plan of

caloriereduction

and

exercise

can

enhance

weight loss

since

Long Term:

After 3 days

of nursingintervention,

goal met as

manifested

by

understandin

g of

nutritional

balance

between

needs and

intake.


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exercise

increases

caloric

utilization

5.

Overweig

ht people

are often

nutritionall

y

deprived.

Intake

must

be

reduced

by 500

caloriesper day to

obtain a

one-

pound-per

week

Weight

loss.


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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:

nanghihina

ako at walang

gana kumaenas verbalized by

the patient.

Objective:

Generalized

weakness

Polyphagia

Polyuria

Polydypsia

Restlessness

Drowsy

Lethargy

Vital Signs:

Bp;130/90mmHg

RR:25bpm

Pr:95bpm

Temp.:37.20C

Risk for Injury

(hypoglycemia)

related to

effects of insulin

as evidence by

restlessness.

Long Term:

After 3 days

of nursing

intervention,will be able

to

understand

whats the

cause of his

restlessness.

1.Assess

clients level

of

disorientation

to determine

specific

requirements

for safety.

2. Obtain a

urine sample

for

laboratory

analysis of

substance

con-tent.

3. Place

client in quiet

room.

4. Institute

necessary

safety

precautions

as follows:

Observe

client

behaviors

frequently;

assign staffon one-to-

one basis if

condition is

warranted;

accompany

and assist

client when

1.Knowledge

of clients

level of

functioning is

necessary to

formulate

appropriate

plan of care.

2. Subjective

history is

often not

accurate.

Knowledge

of substance

ingestion isimportant for

accurate

assessment

of client

condition.

3. Excessive

stimuli

increase

client

agitation

4. Client

safety is a

nursing

priority.

Long Term:

After 3 days

nursing

interventiongoal, met a

evidence b

understand

the cause o

his

restlessness.


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ambulating;

use

wheelchair

for

transporting

client longdistances.

Be sure that

side rails are

up when

client is in

bed.

5. Ensure that

smoking

materials

and other

potentially

harmful

objects are

stored away

from clients

access.

6. Monitor

clients vital

signs every

15 minutesinitially and

less

frequently as

acute

symptoms

subside.

5. Client may

harm self or

others in

disoriented,confused

state.

6. Vital signs

provide the

most reliable

information

about clientcondition

and need for

medication

during acute

detoxification

period.


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Gordons

Before

Hospitalization

During

Hospitalization

Analysis and

Interpretation

HealthPerception/Management He always consulta doctor

whenever he

feels sick

He realized thegood effect of

always consulting a

doctor.

Normalconcern

regarding on

his body

strength and

capabilities.

Nutritional-Metabolic

Pattern

He usually eats 4-

5 times a day. He

loves to eat food

with high

cholesterol .And

usually drinks 6-7

glass of water aday.

He only eats 3-4

times a day; eating

food with high

cholesterol was

minimized. And

water demand was

increased due to hispresent condition,

usually 8-10 glass a

day.

Decreased due

to patients

condition.

Elimination Pattern He usually

urinates 4-5 times

a day and

defecates at

least once a day.

He urinates 5-6 times

a day and

defecates once a

day.

Patient number

of void

decreases due

to lessen

amount of oral

intake

Activity-Exercise pattern Since his a

jeepney driver he

just seat for a

longer period of

time and not

practicing any

form of exercise.

He just spends his

time talking to his

wife during

hospitalization.

Patient activity

is altered

because of

being

bedridden

Sleep-Rest Pattern He usually sleeps

2-4 hours a day.

He now has 6-7

hours of sleep a day

and can sleep very

well.

Interrupted

sleep during

hospitalization

because of

environmentalfactors and

hospital

procedure

Cognitive-Perceptual

Pattern

He was very

active, alert and

responsive. Can

understand and

He was not that

active, alert and

responsive and

slightly understands

Normal

cognitive

patterns


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speaks well. what others telling

him.

Self Perception/Concept He takes a bath

every day, always

well-groomed.Hehas a high self-

esteem

He just takes sponge

bath, slightly well-

groomed. Still hashigh self-esteem.

Patient family

was

dependent onhim.

Role-Relationship Pattern He was the father

and living with

family happily.

He cant do the

thing he used to do

at home, his wife

was very loving and

caring, his sons and

daughters visited

him often due to his

work.

Patient family

was

dependent on

him.

Sexuality-Reproductive

Pattern

Not Applicable Not Applicable Not Applicable

Coping-Stress Tolerance Whenever he

feels stressed or

has a problem,

he just wrote all

his feeling in a

piece of paperthen crampled

and throws it, to

relieve stress.

Whenever he feels

stressed or has a

problem, he just

wrote all his feeling

in a piece of paper

then crampled andthrows it, to relieve

stress.

Patients display

normal

psychosocial,

psychosexual

and cognitive

development.Emotional

stability

Value-Belief Pattern

The client goes to

church every

Sunday with his

family & always

prays.

He cant go to

church but he still

prays & has strong

faith in God.

Patient has

strong religious

belief.


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ANATOMY AND PHYSIOLOGY:

Every cell in the human body needs energy in order to function. The bodys primary

energy source is glucose, a simple sugar resulting from the digestion of foods containing

carbohydrates (sugars and starches). Glucose from the digested food circulates in the

blood as a ready energy source for any cells that need it. Insulin is a hormone orchemical produced by cells in the pancreas, an organ located behind the stomach.

Insulin bonds to a receptor site on the outside of cell and acts like a key to open a

doorway into the cell through which glucose can enter. Some of the glucose can be

converted to concentrated energy sources like glycogen or fatty acids and saved for

later use. When there is not enough insulin produced or when the doorway no longer

recognizes the insulin key, glucose stays in the blood rather entering the cells.


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PATHOPHYSIOLOGY


13/28

PHYSICAL ASSESMENT

Normal Findings Actual Findings ANALYSIS

Level of

consciousness

Conscious and coherentResponsive The client is conscious andcoherent; responsive Normal

Head (Skull,

Scalp, Hair)

Skull

Generally round, with

prominences in the frontal and

occipital area.

(Normocephalic).

No tenderness noted upon

palpation.

Scalp

Can be moist or oily.

No scars noted.

Free from lice, nits and

dandruff.

No lesions should be noted.

No tenderness nor masses on

palpation.

Hair

Evenly distributed covers the

whole scalp (No evidences of

Alopecia)

Maybe thick or thin, coarse or

smooth.

Neither brittle nor dry.

The clients head has a

round skull contour. The hair is

thick, brown (on dye), and fine

which is evenly distributed. The

scalp is smooth and firm. No

lesions noted.

Normal

Eyes

Eyebrows

Symmetrical and in line with

each other.

Maybe black, brown or blond

depending on race.

Evenly distributed. Eyes

Evenly placed and inline with

Her eyes are symmetrical,

black in color, almond shape.Pupils constrict when diverted

to light and dilates when she

gazes afar. Conjunctivas are

pink. Eyelashes are equally

distributed and skin around the

eyes is intact. The eyes

involuntarily blink.

Normal


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each other.

Non-protruding.

Equal palpebral fissure.

Eyelashes

Evenly distributed.

Ears

The ear lobes are bean

shaped, parallel, and

symmetrical.

The upper connection of the

ear lobe is parallel with the

outer canthus of the eye.

Skin is same in color as in the

complexion.

No lesions noted on

inspection.

The auricles are has a firm

cartilage on palpation.

The pinna recoils when

folded.

There is no pain or tenderness

on the palpation of the

auricles and mastoid process.

The ear canal has normally

some cerumen of inspection.

No discharges or lesions

noted at the ear canal.

On otoscopic examination

the tympanic membrane

appears flat, translucent and

pearly gray in

color

Ears are symmetrical with no

discharge. The clients auricles

have the same color as the

facial skin. It is mobile, firm,

and not tender. The pinna

recoils often as it is folded.

Moderate loud voice is

needed when talking with the

client.

Most of the geriatric

client has problem

with their hearing

Thus, moderate loud

voice is needed when

talking with her.

Nose

Nose

- Symmetric and straight

- No discharge or flaring

- Uniform color

External nose is symmetric

and straight. Cilia present

upon inspection. Nasal septum

is not deviated. Both nostrils

are patent as each nostril is

being occluded. No

discharge, tenderness and

lesions noted. The sinuses are

Normal


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- Not tender and no lesions

- Patent nares

- Mucosa is pink

- Clear, watery discharge

- Nasal septum intact and in

midline

Facial Sinuses

- Not tender

well outlined after trans

illumination.

Mouth

Teeth and Gums

- 32 adult teeth

- Smooth, white, shiny tooth

enamel

- Pink gums (bluish or dark

patches in dark-skinned

clients)

- Moist, firm texture to gums

- Smooth, intact dentures

Tongue/Floor of the Mouth

- Central position

- Pink color (some brown on

borders for dark-skinned

clients); moist; slightly rough;

thin whitish coating

- Moves freely; no tenderness

- No prominent veins and

palpable nodules

Uvula

- Midline

Oropharynx and Tonsils

- Pink and smooth posterior

wall

- No discharge

Has dentition. Oral mucosa

and gingival are pink in color,

moist, and there were no

lesions or inflammation noted.

Tongue is pinkish with thin

whitish coating and free of

swelling and lesions.

Normal

Neck 1.The neck is straight. The clients head is

coordinated with smooth

Normal


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2.No visible mass or lumps.

3. Symmetrical

4.No jugular venous distension

(suggestive of cardiac

congestion)

5. The trachea is palpable. It is

positioned in the line and

straight.

Lymph nodes

1.May not be palpable.

Maybe normally palpable in

thin clients.

2. Non tender if palpable.

3. Firm with smooth rounded

surface.

4. Slightly movable.

5. The thyroid is initially

observed by standing in front

of the client and asking the

client to swallow.

Thyroid

1. Normally the thyroid is non

palpable.

2. Isthmus maybe visible in a

thin neck.

movements and no

discomfort. The neck supports

the head properly. No

presence of abnormal swelling

or masses. Lymph nodes are

palpable. No nodules are

palpable.

Thorax and Lungs

Posterior Thorax

- Chest symmetric

- Spine vertically aligned

- Skin intact; uniform

temperature

- Chest wall intact; notenderness; no masses

- Full and symmetric chest

expansion (3-5cm gap)

- Bilateral symmetry of vocal

fremitus

She has a slight deviation of

respiratory rate of 22 breaths

per minute. Breath sounds are

clear on both lungs upon

auscultation. Excursion shows a

3-cm gap during inspiration.

No signs of swelling or masses

noted.

Normal; slight

deviation in respiratory

rate (22bpm) may be

possibly caused by her

present condition.


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Anterior Thorax

- Quiet, rhythmic, and effortless

respirations

- Full symmetric excursion

- Bronchial and tubular breath

sounds upon auscultation on

trachea

Heart

- Neck veinsJVD at 45

- Carotid arteries:

- Palpation (Amplitude and

contour)upstroke and

amplitude are bilateral

- Auscultaionno bruits

- Precordium

- Inspectionno lifts or

heaves

- PMI not visible

- Palpationno parasternal

impulses and no thrills

-PMIpalpable in 5th ICS,

MCL, equal size

- Auscultation:

- S1heard best at apex, nl

intensity

- S2heart best at base, nl

splitting, A2 > P2

- Extra soundsno S3, S4

- No murmurs

Pulsation in apical pulse is

visible. No lifts and heaves

noted. Cardiac rate is 76 bpm.

Blood pressure is 130/80

mmHg. Reported chest pain

frequently.

Common sign of

HCVD CASHD is chest

pain. Slight increased

blood pressure of

130/80 mmHg is stil

manageable. Norma

cardiac rate.

Breast

- Rounded shape, slightly

unequal in size

- Same skin color as abdomen

- Skin smooth and intact

The clients breast is

rounded in shape, slightly

unequal in size, and generally

symmetric. The skin color of the

breast was the same color as

of the abdomen. The breast

nipples are erect and not

Normal


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Areola

- Round/oval or bilaterally the

same

- Color varies (pink to dark

brown)

Nipples

- Round, everted, and equal in

size

- Discharge for lactating

mother

Axilla

- No tenderness, masses, or

nodules

inverted. No tenderness noted.

Abdomen

Inspection

- Unblemished skin

- Uniform color

- Flat, rounded (convex), or

scaphoid (concave)

- Symmetric contour

- Symmetric movements

caused by respiration

- No visible vascular pattern

Auscultation

- Audible bowel sounds

Palpation

- No tenderness; relaxed

abdomen with smooth,

consistent tension

The abdomen is uniform in

color. Its rounded and has a

symmetric contour. No

tenderness was palpated

Normal

Upper Extremities

- No edema

- Skin texture resilient and moist

- Capillary refill test: immediate

return of color (2-3 sec)

The client has a brownishcomplexion. A capillary refill of

3 seconds was noted. No

lesions and scars noted. Able

to extend arms in front or push

them out to the side.

Normal


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- Limbs not tender

- Symmetric in size

Lower Extremities

- No edema

- Skin texture resilient and moist

- Capillary refill test: immediate

return of color (2-3 sec)

- Limbs not tender

- Symmetric in size

With bipedal edema, dry

skin and with some lesions and

bruises on legs. With colordeviation, darker brown

complexion compared to

upper extremities.

Edema on the

lower extremities may

indicate increasedfluid retention on the

body. Color deviation

(darker) may indicate

altered circulation of

blood/oxygen

throughout the body.

Neurologic

Assessment

- Conscious and coherent

- Able to respond to reflex tests

- Able to distinguish different

sensory functions.

The patient is conscious and

responsive upon interaction.

But sometimes, she cannot

directly and clearly answer all

questions rendered. Reflexes

such as Blinking reflex and

deep tendon reflex are

present. She was able to

distinguish touch, pain, hot,

and cold.

Due to old age and

present condition, her

ability to answer

clearly and directly is

altered.


20/28

ISMN Nitrate

Vasodilator

60mg

tab/ OD

Relaxes vascular

smooth muscle

with a resultant

decrease in

venous return and

decrease arterial

BP, which reduces

left ventricular

workload anddecreases

myocardial

oxygen

consumption.

CNS: headache

CV: tachycardia,

retrosternal discomfort,

palpitations, hypotension,

syncope, collapse,

orthostatic hypotension,

angina, rebound

hypertension, atrialfibrillation

GI: nausea, vomiting,

abdominal pain,

incontinence

GU: dysuria, urinary

frequency

Give

sublingual

preparations

under the

tongue or in

the buccal

pouch;

discourage

patient fromswallowing.

Give oral

preparation

on empty

stomach, 1

hour before

or 2 hours

after meals;

take with

meals ifsevere,

uncontrolled

headache

occurs

Capt

opril

Angiotensin

converting

enzyme

(ACE)

inhibitor

25mg/

tab/ OD

Blocks ACE from

converting

angiotensin I to

angiotensin II

leading to

decreased blood

pressure,decreased

aldosterone

secretion, a small

increase in serum

potassium levels,

and sodium and

fluid loss;

increased

prostaglandin

synthesis also may

be involved in theantihypertensive

action.

CV:

Tachycardia

Angina ,MI, CHF

Raynaud's

syndrome

Hypotension in

salt- or volumedepletedpatients

GI:

Gastric irritation

Aphthous ulcers

Peptic ulcers

Cholestatic

Jaundice

Hepatocellular

injury, Anorexia

Constipation

GU:Proteinuria

Renal insufficiency

Renal failure

Polyuria,oliguria

Urinary frequency

Hematologic:

Neutropenia

Assess for

history of

allergy to

captopril and

history of

angioedema.

Use

cautiously in

patients

with CHF,

impaired

renal

function, salt

or fluid

volume

depletion, or

inpregnant or

lactating

women.

Administer 1

hr before or

Or 2 hrs.


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Agranulocytosis

Thrombocytopenia

Hemolytic anemia

Pancytopenia

before meals.

Watch out for

excessive

perspiration,

or diarrhea;may cause

hypotension

Trime

tazidi

ne

Vasodilator

Anti-angina

35mg/1tab/

BID

Improves

myocardial

glucose utilization

through inhibition

of fatty acid

metabolism

CNS: headache,vertigo

GI: nausea, vomiting

Assess

location,

duration and

intensity of

anginal pain

Monitor BP

and PRbefore and

after

administering

the drug.

Ome

prazo

le

Anti- Ulcer 20mg/tab/B

ID

It inhibits transport

of hydrogen ions

into the gastric

lumen.

Omeprazole

increases the

gastric pH and

reduces gastric

acid formation.

Headache Diarrhea Abdominal pain Nausea Dizziness Asthenia (loss of

strength)

Vomiting Constipation Upper respiratory

tract infection

Back pain Rash Cough

Give before

meals

Do not crush

or chew

tablets,

swallow

whole

Evaluate for

therapeutic

response like

relief of

Gastrointestin

al symptoms

Question ifGastrointestin

al discomfort,

nausea, and

diarrhea

occurs.


22/28

Metf

ormin

Anti-

diabetic

drug

500mg/tab/

OD

Metformin

improves

hyperglycemia

primarily by

suppressing

glucose

production by the

liver (hepatic

gluconeogenesis)

Lactic acidosis occurs

rarely (0.03 cases/ 1,000

patients) but s a serious,

often fatal (50%)

complication.

Characterized by

increase in blood lactate

levels (more than 5

mmol/L), decrease in

blood pH, electrolyte

disturbances. Symptoms

include unexplained

hyperventilation,

myalgia, malaise, and

somnolence. May

advance tocardiovascular collapse

(shock), acute CHF,

acute MI, and prerenal

azotemia.

Inform the

patient of

potential

risks/advanta

ges of

therapy and

of alternative

modes of

therapy.

Monitor

fasting blood

glucose,

hemoglobin

a, and renal

function.

Monitor renal

function test

for evidence

of early lactic

acidosis.

Be alert to

conditions

that alter

glucoserequirements:

fever,

increased

activity or

stress, surgical

procedure.

Salbu

tamo

lNeb.

Bronchodila

tor

(therapeutic);

adrenergics

(pharmacol

ogic)

Neb./q6 It relieves nasal

congestion and

reversiblebronchospasm by

relaxing the

smooth muscles of

the bronchioles.

The relief from

nasal congestion

and

1. Nervousness2. Restlessness3. Tremor4. Headache5. Insomnia6. Chest pain7. Palpitations8. Angina9. Arrhythmias10.Hypertension

sounds, PR

and BPbefore drug

administratio

n and during

peak of

medication.

fore
http://en.wikipedia.org/wiki/Gluconeogenesishttp://en.wikipedia.org/wiki/Gluconeogenesis


23/28

bronchospasm is

made possible by

the following

mechanism that

takes place when

Salbutamol isadministered.

11.Nausea andvomiting

12.Hyperglycemia13.Hypokalemia

paradoxical

spasm and

withhold

medication

and notify

physician ifcondition

occurs.

Administer

PO

medications

with meals to

minimize

gastric

irritation.

-

release tabletshould be

swallowed-

whole. It

should not be

crushed or

chewed.

administering

medication

through

inhalation,allow at least

1 minute

between

inhalation of

aerosol

medication.


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Laboratory

Diagnostic/

laboratory

procedure

Date

ordered

and date

result/s in

Indication or

purposes

Result Normal

used values

(units in the

hospital)

Significance

and

Interpretation

Reports

Electrolytes

Na

K

Date

ordered:

9/6/11

Date

Received:

9/7/11

Tests that

measure the

concentration

of electrolytes

are needed

for both the

diagnosis and

management

of renal,

endocrine,acid-base,

water

balance, and

many other

conditions.

134.6

3.25

135-145

3.4-4.0

The result is

within normal

values.

Clinical

Chemistry

ALP (Alkaline

Phosphates)

ALT/SGPT

Cholesterol

Creatinine

FBS (Glucose)

Total Protein

Albumin

Globulin

A/g Ratio

Uric Acid (BUA)

Date

ordered:

8/1/11

Date

Received

8/2/11

It is the area

of pathology

that is

generally

concerned

with analysisof bodily

fluids.

77.9

28.4

56.3

1.19

80.1

8.7

3.3

5.4

1.6

9.72

35-129

10-50

0-38

44-106

64-83

4.11- 5.9

3.4-4.8

3.0-3.5

1.1-1.8

0.14-0.41

Some of the

result is

below or

above

normal range

whichindicated

that there is

something

wrong in the

release or

secretion of

body fluids.

Urinalysis Dateordered:

Urinalysis are

performed for


25/28

Color

Transparency

Reaction

Specific Gravity

Albumin

Sugar

RBc

Pus cells

Squamous cells

Bacteria

9/7/11

Date

Received

9/7/11

several

reasons:

general

evaluation of

health

diagnosis of

metabolic or

systemic

diseases that

affect kidney

function

Diagnosis of

endocrine

disorders.

Twenty-four-

hour urine

studies are

often ordered

for these tests

diagnosis of

diseases or

disorders of

the kidneys or

urinary tract

monitoring of

patients with

diabetes

testing for

pregnancy

screening for

drug abuse

Orange

Hazy

5.0

1.016

Positive

Negative

0-1

1-3

Few

Few

Few

Pale yellow

Straw to

amber

Clear to

slightly hazy

Acidic

1.016- 1.022

Negative

Negative

Negative

Negative

Negative

Normal

Normal

Glycosuria

and

Proteinuria

due toincreased

glomerular

permeability

and

presence of

bacteria and

pus cells for

infection.

Hematology

Hemoglobin

Date

ordered:

9/7/11

Date

Received

It measures

the total

amount of

hemoglobin

151g/ml 120-180

gm/l

The result is

within normal

values.


26/28

Hematocrit

Leukocyte

Platelet count

9/8/11 in the blood ,

to determine

the oxygen

carrying

capacity of

the blood.

It measures

the

percentage

of RBCs in the

total blood

volume.

It determines

the number of

circulating

WBCs of the

whole blood.

To evaluate

platelet

production. to

assist in the

diagnosis of

bleeding

disorders and

to monitorpatients who

are being

treated for

any disease

involving

bone marrow

failure

.467

8.2

271

0.370-0.540

4.6-10.0

150-450

The result is

within normal

values.

The result is

within normalvalues.

The result is

within normal

values.

DISCHARGE PLANNING


27/28

Medicine:

Ceftazidime 1g/IV/Q8 Aminoleban 1sachet/BID Kalium Duruyle 1tab/PO/TID Furosemide 40mg/IV/Q8 ISMN 60mg tab/PO/OD Captopril 25mg tab/ PO/OD Trimetazidine 35mg/tab/PO/BID Omeprazole 20mg/tab/PO/OD Metformin 500mg/tab/PO/OD Salbutamol neb Q6 Encouraged to take medications on time as prescribed by his physician. Report any adverse effect when taking the prescribed drug such as nausea and

vomiting or skin allergies.

Instruct not to take other medications without consulting with the physician toprevent any harmful drug-drug interactions.

Exercise:

Encouraged patient to have adequate rest periods and sleep to promote fasterrecovery.

Encourage client to do deep breathing exercise to promote circulation of blood andrelaxations.

Avoid lifting heavy objects. Advised client and family members to try to have or maintain safe, clean, comfortable and

calm environment.

Treatment:

Advised client or significant others to take in time prescribedmedicines especially for high blood pressures.

Health Teaching:

Encouraged to elevate the part where there is edema Teach the client to follow all the instructions including medications, diet regimen

and dos and don'ts that was instructed to him by the physician.

Teach the patient to ensure rest for himself as much as possible. Encouraged the patient to comply with the medication as ordered by his

physician.

Explain the importance of adhering to his treatment regimen.Out- patient referral:


28/28

Inform the patient to have follow-up check-ups to prevent further complicationsand to update the medical team concerning the progress of the patients

condition and to promote continuity of care.

Encourage him to comply with all the modifications and instructions given to her. Advised significant others to immediately consult her physician if signs and symptoms of the

diseases occurs or persist.

Diet:

Emphasized limit fluid of intake. Keep on low fat, low sodium, full-diabetic diet. Encouraged to eat fruits and vegetables. Instructed to eat meals on time with proper diet.

SPIRITUAL

Instruct client to attend mass every Sunday. Advised relatives or significant others to provide moral support and widen their understanding. Also tell them to pray for the client to help with the recovery.

Documents

Individual Case Study