CHF, CRF, BPH

1

I. Introduction

HF, often referred to as congestive heart failure (CHF), is the inability of the heart to

pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. However, the

term CHF is misleading, because it indicates that patients must experience pulmonary or

peripheral congestion to have HF, and it implies that patients with congestions have HF. The

Agency for Health Care Policy and Research (AHCPR) HF guidelines panel (1994) defined HF

as a clinical syndrome characterized by signs and symptoms of fluid overload or of inadequate

tissue perfusion. These signs and symptoms result when the heart is unable to generate a CO

sufficient to meet body’s demands. The HF guideline panel used the term heart failure because

many patients with HF do not manifest pulmonary or systemic congestions. The term HF is

preferred and indicates myocardial heart disease in which there is a problem with contraction of

the heart (systolic dysfunction) or filling of the heart (diastolic dysfunction) and which may or

may not cause pulmonary or systemic congestion. Some cases of HF are reversible, depending

on the cause. Most often, HF is a lifelong diagnosis that is managed with lifestyle changes and

medications to prevent acute congestive episodes. CHF is usually an acute presentation of HF.

Chronic renal failure or ESRD is a progressive, irreversible deterioration in renal function

in which the body’s ability to maintain metabolic and fluid and electrolytes balance fails,

resulting in uremia and azotemia. The incidence of ESRD has increased by almost 8% per year

for the past 5 years. In the U.S, more than 280,000 patients with chronic renal failure (65%) are

receiving hemodialysis; more than 120,000 (28%) have functioning renal transplant and more

than 24,000 (7%) are receiving peritoneal dialysis (United States Renal Data System [USRD] ,

2004).

Conditions that cause ESRD include systematic diseases such as diabetes mellitus

(leading cause); hypertension; chronic glomeronephritis ; pyelonephritis (inflammation of the

renal pelvis); obstruction of the urinary tract; hereditary lesions, as in polycystic kidney disease;

vascular disorders; infections; medications; or toxic agents. Comorbid conditions that develop

during chronic renal insufficiency contribute to the high morbidity and mortality among patients

with ESRD (Burrows-Hudson,2005).

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Environmental and occupational agents that have been implicated in chronic renal failure

include lead, cadmium, mercury, and chromium. Dialysis or kidney transplantation eventually

becomes necessary for patient survival; dialysis is an effective means of correcting metabolic

toxicity at any age.

Anemia-literally, “lack of blood”-is a deficiency in the amount of the red pigment

hemoglobin in the blood. Since men, women and children have different levels of hemoglobin,

anemia must also be defined in terms of what normal values for that group maybe. Thus men

have a level in the range of 13.5 to 18.5 g per 100 ml of blood; in men anemia is usually

considered to be present when the hemoglobin value drops below 13.5 g. A corresponding figure

for women would be 11.5 g and for a young child as low as 10 g. A similar lower figure would

apply to a woman in the later stages of pregnancy.

Anemia has four basic causes. There may be a loss of red blood cells from the circulation

through hemorrhage. There may be a deficiency of raw materials needed for the production of

hemoglobin and red blood cells. The bone marrow itself may be diseased and therefore unable to

produce sufficient red blood cells. Lastly, in the hemolytic anemias, production of red blood cells

by the bone marrow is normal but the cells are destroyed unusually quickly and so do not survive

for the normal period of 120 days in the circulation. Anemia may also occur as a presenting

symptom of cancer, occurring for reasons that are not clearly understood and not necessarily

related to any of these four causes.

The raw materials for the production of red blood cells include iron for hemoglobin

production and vitamin B12 and folic acid (another B group vitamin). Deficiencies of these

substances may be the result of dietary lack, failure to absorb them normally (although they are

present in normal amounts in the diet), and, more rarely, an increased demand by the body (as

when there is a need for more folic acid in pregnant women.

Anemia is very common condition and in many ways goes undetected if it is not severe.

The symptoms of anemia may be minimal; but if the condition is at all severe, the patient will be

pale, and will complain of tiredness and shortness of breath on exertion. In addition, specific

types of anemia may produce characteristic symptoms.

If a patient is found to be anemic, the fundamental problem for the doctor to resolved is

whether the anemia is the result of a specific blood diseased (such as pernicious anemia or

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leukemia) or whether it is a symptom of blood loss or an underlying diseased (such as arthritis)

or infection.

The treatment of anemia may be simple, as in the administration of iron tablets in iron-

deficiency anemia; in other cases it may require initial blood transfusion or other measures, or

treatment may be directed toward underlying condition of which the anemia is a symptom.

OBJECTIVES:

These case study aims:

To gain more knowledge about congestive heart failure, chronic renal failure, and

anemia through the help of our patient’s case.

To know the underlying pathophysiology of congestive heart failure, chronic

renal failure and anemia.

To be able to trace the cause of the clients illness through the help nursing health

history.

To be able to be able to develop nursing care plans and interventions on the

clients’ response to congestive heart failure, chronic renal failure and anemia.

To be able to formulate discharge plans that will help client gain wellness.

II. BIOGRAPHIC DATA

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Name: Patient J. L.

Age: 71

Sex: Male

Race: Filipino

Marital Status: Single

Occupation: None

Religious orientation: Roman Catholic

Health Care Financing and usual source of medical care: From 2nd sibling

A. Chief Complaint or Reason for visit

1. What brought you to the clinic or hospital?

-Main complaints were presence of edema on his extremities and difficulty of breathing

2. What is troubling you?

-Difficulty of breathing

B. History of present illness

1. When symptoms started?

-Symptoms started on August 7, 2009

How often?

-The edema on his extremities is always present and seldom he experience

difficulty of breathing.

Type of activity of client when problem occurred?

-Passing time in front of his house.

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2. Was consultation/help sought?

-Yes

3. Medications used?

-He uses antibiotics

4. How the problem has interfered with daily life?

-He is unable to perform certain activities because of difficulty of breathing.

C. Past History

1. Childhood disease

-None

2. Immunizations

-He has not received any vaccines.

3. Allergies

-None

4. Accidents and injuries

-None

5. Hospitalizations

-3 years ago (2006) because of renal failure

6. Medications

-antibiotics

D. Family History

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1. Health and ages of parents, siblings, children, or ages at death and causes

-His father died of Lung disease and his mother died of cancer while two of his

siblings, sisters, have hypertension

2. Illness in the family similar to the patient’s illness

-One of his sisters has the same illness as the patient.

3. Familial incidence of rheumatic fever, hypertension, tuberculosis, diabetes, mental

illness, others, especially as suggested by the present illness.

-Two of his sisters currently have hypertension

III. Functional Health Pattern

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1. Health Perception And Health Management Patterns

In spite of the patient’s present condition, he remains positive about his general health.

According to him, he feels well and good. For these past few weeks, he has cough and colds.

He just self medicate to manage his cough and colds. For him, the most important things

done to keep health are eat nutritious foods like fruits and vegetables. He also added that

visiting the doctor regularly also keeps him healthy but due to financial problem, he was

unable to do so. For the past fifty (50) years of his life, he used to smoke cigarette. He

consumed five (5) packs of cigarettes per day. He just decided to quit smoking three (years

ago). The good thing was that he never used to drink any alcoholic beverages for the entire of

his life. For him, it has been easy to find ways to follow things that the nurses and doctors

suggest because he knows that these things will contribute a lot to the improvement of his

health. Patient also believed that his vices when he was on his productive year caused his

present illness. When he was diagnosed, he then immediately quit smoking. While he is still

inside the hospital, it is important for him to recover from his illness and restore his health

before he was hospitalized. As a health care provider, we can contribute to the patient’s

recovery through supplementing all the health care needed by the patient and treat him as a

holistic one.

IV. ACTIVITIES OF DAILY LIVING

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Area Before Hospitalization During Hospitalization

Analysis

NUTRITION

The patient eats whatever food he wants to eat. He usually ate meals three times a day specifically, fish and vegetables and drank plenty of water.

Now that he is confined at Angono, the client is under a Low Salt Low Fat Diet and prescribed to lessen the amount of fluid intake to prevent the worsening of edema.

The older adult requires the same basic nutrition as the young adult. However, fewer calories are needed by the older adult because of the lower metabolic rate and decrease in physical activity. (Fundamentals of Nursing by Kozier 1181)minimizing the amount of fluid intake to prevent the accumulation of fluids in the cells, intercellular spaces, and serous cavities.(Blackwell’s Nursing Dictionary by Maslin page 408)

ELIMINATION

The patient bowel for 3 times a week. He has no awareness of bladder filling and he can’t control his urine flow due to Chronic Renal Failure.

The patient defecates only when he takes medicine which is Lactulose that helps to softens stool. An indwelling catheter is applied.

Normal patterns of bowel elimination vary in relation to the person’s regular elimination pattern. Some people normally defecate only few times a week; other people defecate more than once a day. (page 1262)Urinary incontinence or the involuntary urination is experienced when urination is not possible due to renal failure; the bladder gradually becomes distended with urine. The bladder may stretch excessively, eventually inhibiting the urge to void. When bladder distention is considerable, some involuntary urine may occur.(Fundamentals of Nursing by Kozier page 1121)

9

EXERCISE

The patient was able to perform exercises such as jumping and walking to become healthy.

The patient wasn’t able to perform exercises because he feels weak and every time he tried to stand his legs were shaking.

Exercise is a type of physical activity performed to improve or maintain one or more components of physical fitness. ( Fundamentals of Nursing by Kozier page 1107)

HYGIENE

The patient takes a bath daily and apply powder to refreshes his body.

The patient takes a bath daily and needs assistance. He needs assistance in doing self-care activities.

Hygiene is the science dealing with health and its maintenance. It is a condition or practice, such as cleanliness, that is conducive to the preservation of health.(Blackwell’s Nursing Dictionary by Maslin page 284)

SUBSTANCE ABUSE

The patient smoke before about 5 packs a week but he quit smoking 3 years ago. He doesn’t drink any alcohol beverages.

The patient doesn’t smoke nor drink any alcohol beverages.

People tend to consume less alcohol as they get older. Elderly alcoholics include those who began drinking alcohol on their youth and those who began excessive alcohol use later in life.(Fundamentals of Nursing by Kozier page 411)Smoking is another type of drug abuse that can bring about feelings of well-being that may be highly valued by people with adjustment problems. Prolonged use can lead to physical and psychologic dependency and subsequent health problems.

SLEEP AND REST

The patient usually sleeps at night for 6-8 hours and takes a nap every afternoon.

Since confinement at the hospital, the client’s sleep was not regular. He sleeps for only 4-6 hours at night because of noisy environment.

Elderly adults tend to take somewhat longer to get to sleep. Change in environment can hinder sleep where the presence of familiar stimuli can prevent people from sleeping.(Fundamentals of Nursing

10

by Kozier page 1117)

V. PHYSICAL ASSESSMENT

Area Normal Findings Actual Findings Interpretation AnalysisHead

1. SkullThe head is

proportional to the size The head is proportional to the

All findings are normal.

Normal

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of the body, it is round, with

prominences in the frontal area anteriorly and the occipital area

posteriorly, symmetrical in all planes and gently

curved.

size of the body, it is round, with prominences in the frontal area anteriorly and the occipital area posteriorly, symmetrical in all planes and gently curved.

2. Scalp It is white, clean and free from masses,

lumps and scar, nits, dandruff and any

lesions.

It is white, clean and free from masses, lumps and scar, nits,

dandruff and any lesions.


Normal

3. Hair It is black in color and thinning

The hair strands are course or fine.

It is white in color and thinning

The hair strands are fine.

Findings are normal for an

older adult

Thinning and graying of scalp,

pubic and axillary hair because of

progressive loss of pigment cells

from the hair bulbs.

(Fundamentals of Nursing by

Kozier pp.412)4. Face It is heart-shaped,

symmetrical, smooth and free from wrinkle, no involuntary muscle

movements.

It is round-shaped,

symmetrical, and wrinkles are present, no involuntary

muscle movements.


older adult

Progressive wrinkling and sagging of the skin becausenof loss of skin elasticity, increased dryness and decreased subcutaneous fat.(Fundamentals of Nursing by Kozier pp.412)

5.Eyes Parallel and evenly placed, symmetrical, non-protruding, with

scant amount of

Parallel and evenly placed,

symmetrical, non-protruding, with


Normal

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secretions, both eyes black and clear.

scant amount of secretions, both eyes black and

clear.Eyebrows Black, symmetrical,

thick, can raise & lower eyebrows

symmetrically and without difficulty, even distributed & parallel with each

other

Black and some are white,

symmetrical, thick, and evenly

distributed, parallel with each other, can raise & lower eyebrows

without difficulty


older adult

Thinning and graying of scalp,

pubic and axillary hair because of

progressive loss of pigment cells

from the hair bulbs.


Kozier pp.412)Eyelashes It is black, evenly

distributed and turned outward.

Black, evenly distributed and turned outward.


Normal

Eyelids Inspection: Upper lids cover a small portion of the iris, cornea and the sclera when the

eyes are open. When the eyes are closed, the lids meet completely. Symmetrical, color is

the same as the surrounding skin.

Palpation: No Palpable mass

Upper lids cover a small portion of the iris, cornea and the sclera

when the eyes are open. When the eyes are closed,

the lids meet completely.

Symmetrical, color is the same

as the surrounding skin.

Not done


Not done

Normal

Not done

Lid margins Clear, without scaling or secretions, lacrimal duct opening (puncta) are evident at the nasal

ends.

Clear, without scaling or

secretions, puncta are evident at the

nasal ends.


Normal

Lower Palpebral

Conjunctiva

Salmon pink, shiny, moist and transparent.

Pale, shiny, moist conjunctiva

Deviation from normal

Pallor is the result of

inadequate circulating blood or

hemoglobin.

13

Fundamentals of Nursing by: Kozier (p.535)

Sclera White and clear White and clear All findings are normal.

Normal

Iris Proportional to the size of the eye, round,

black and symmetrical.

Proportional to the size of the

eye, round, clouding around

the iris and symmetrical.


older adult

Arcus Senilus an opaque

grayish white ring around the

edge of iris; usually bilateral;

does not interfere with

vision. (Blackwell’s

Nursing Dictionary by Maslin pp. 50)

Pupils From pinpoint to almost the size of the

iris, round, symmetrical

Black in color, equal in size, round, with

smooth border


Normal

Eye Movement Able to move eyes in full range of motion or

able to move in all direction.

Able to move eyes in full range of motion or able to move in all direction.


Normal

Visual Acuity Eyes can read Eyes can read All findings are normal.

Normal

Field of Vision Able to see 60 degrees superiorly, 90 degrees

temporarily and 70 degrees inferiorly.

Not done Not done Not done

6.Ears Parallel, symmetrical, proportional to the size

of the head, bean-shaped, helix is the

line with outer canthus of the eye; skin is same color as the surrounding area,

clean.

Parallel, symmetrical,

proportional to the size of the head,

bean-shaped, helix is the line

with outer canthus of the eye; skin is same color as the surrounding area,

clean.


Normal

Ear Canal Pinkish, clean with scan amount of

Pinkish, clean with scant amount


Normal

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cerumen and few cilia. of cerumen and few cilia.

Hearing Acuity

Able to hear whisper spoken 2 feet away.

Able to hear whisper spoken

1foot away.

Findings are normal for an older adult.

Progressive loss of hearing because of

changes in the structures and

nerve tissues in the inner ear; thickening of the eardrum.


Kozier pp.412)7.Nose Midline, symmetrical

and patentMidline,

symmetrical and patent


Normal

Internal Nares Clean, pinkish with few cilia


Septum Straight, midline Straight and in midline


Normal

8.MouthLips

Gums

Teeth

Pinkish, symmetrical, lip margin well-

defined, smooth and moist.

Pinkish, smooth, moist, no swelling, no

retraction, no discharges.

32 permanent teeth, well-aligned free from

caries or filing

No teeth at all.



older adult

Normal

Normal

Toothloss usually occurs among elders

due to inappropriate

dental hygiene. (Fundamentals of Nursing 7th ed.by Kozier pp.566)

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Tongue

Cheeks

Soft Palate

Hard Palate

Medium and pinkish color, the lateral

margin, moist, shiny and freely movable

Pinkish, moist and smooth

Pinkish, moist and smooth

Slightly pink

Medium and pinkish color, the

lateral margin, moist, shiny and freely movable

Pink in color, smooth and moist.

Pink in color, smooth and moist

Lighter pink than soft palate, more irregular texture





Normal

Normal

Normal

Normal

Frenulum Midline, straight and thin

Midline and straight


Normal

Uvula At the center, symmetrical and freely

movable.

At the center, symmetrical and freely movable.


Normal

Tonsils Pinkish, non-inflamed, no exudates

Pinkish, non-inflamed, no

exudates


Normal

Voice No hoarseness and well-modulated

No hoarseness and well-modulated


Normal

9.Neck Inspection: Proportional to the

size of the body and head, symmetrical and

straight

Palpation: No palpable lumps, masses, or areas of

tenderness

Proportional to the size of the body and head, muscle equal in size, head centered

No lumps and areas of

tenderness



Normal

Normal

Range of motion

Free movable without difficulty

Free movable without difficulty


Normal

Muscular Strength

Symmetrical and able to resist force (both

muscle).


Posterior and Anterior

Inspection: The chest contour is symmetrical

Inspection: The chest contour Deviation from A barrel

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Thorax and chest is twice as wide as deep (anterior-posterior diameter in a

1:2 ratio) The spine straight. Posteriorly, the ribs tend to slope across and down. The

chest wall moves symmetrically during

respiration.

Palpation:No lumps, masses, areas of tenderness. Sides of the thorax

expand symmetrically. The examiner’s thumb

separate approximately 3-5 cm

during excursion.Vibrations are

prominent over the areas near the bronchi.

It increases with the intensity of the voice.

Vibrations are strongest between the first and second ribs along the sternum

anteriorly and between the scapulae posteriorly.

Percussion:Percussion note varies with the thickness of

the chest wall.Resonance- sound created by air filled

with lungs. It is clear,

is symmetrical and chest is as wide as deep

(anterior-posterior diameter in a 1:1 ratio) The spine is

bent forward. Posteriorly, the

ribs tend to slope across and down.

The chest wall moves

assymmetrically during respiration.

Not done

Not done

normal.

Not done

Not done

chest in which the ratio of the anteroposterior to transverse diameter is 1:1, is seen in client with thoracic kyphosis and emphysema.

Fundamentals of Nursing by: Kozier and Erbs ( p.613)

Not done

Not done

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long, low pitch. Dull- short, high pitch, soft and thudding, heard over the heart. Flat- absolute dullness;

absence of air in the underlying tissue.

Tympany- moderately loud with musical

quality with specific pitch.

Auscultation: Bronchial and tubular

sounds are normal. Bronchovesicular and

vesicular breath sounds are normal

Rales are heard over the right lower lobe.

Deviation from normal.

Rale an abnormal, non-continuous, bubbling, crackling, or gurgling sound associated with pneumonia, congestive heart failure and long periods of recumbency; heard at the base of the lungs at inspiration when fluid is present in the small air passages and alveoli. (Blackwell’s Nursing Dictionary by Maslin pp. 505)

Abdomen Inspection:Skin is unblemished,

no scar, color is uniform, flat, rounded,

or scaphoid, symmetrical

movements caused by

Skin is unblemished, no

scar, color is uniform, flat and has a symmetrical

movements


Normal

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respiration, and color is the same as the surrounding skin.

Auscultation:There are clicks and

gurgles, the frequency of which has been

estimated from 5-34 per minute.

Occasionally, borborygmic (loud

prolonged gurgles of hyperperistalsis) – the

familiar stomach growling can be heard.

Percussion:Tympany

predominates because of the presence of air in the stomach and

intestines. Percussion is dull at the liver’s

lower boarder.

Palpation:Soft abdomen, no

tenderness, no muscle guarding, no lumps or

masses.

caused by respiration, and

color is the same as the surrounding

skin.

Auscultation:There are clicks and gurgles, the

frequency of which has been 29

per minute. Occasionally, borborygmic

(loud prolonged gurgles of

hyperperistalsis) – the familiar

stomach growling can be heard.

Not done

Soft abdomen, no tenderness, no

muscle guarding, no lumps or

masses.


Not Done


Normal

Not Done

Normal

Heart Inspection and palpation:

Aortic valve- no pulsations.

Pulmonic area- no pulsations.

Tricuspid area- no

Aortic valve, pulmonic and

tricuspid area - no pulsations

Apical area-

All findings are normal

Normal

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pulsations.Apical area- pulsations

are visible and palpable.

Auscultation:Aortic valve- S1 sound

Pulmonic area- S1 sound

Tricuspid valve- S1 and S2 sounds

Apical area- S1 and S2 sounds

pulsations are visible and palpable.

Aortic valve- no sound

Pulmonic area- no sound

Tricuspid valve- S1 and S2 soundsApical area- S1 and S2 sounds

Deviations from normal

Aorticstenosis is the narrowing of the aortic valve orifice which causes an obstruction to the flow of blood from the left ventricle to the aorta. (Blackwell’s Nursing Dictionary by Maslin pp.46)

Breast Inspection:Variable in size

depending on body built. Obese clients

may have a large and pendulous. Slender-

thin and small. Young clients- firm, elastic in

consistency, cone shaped, symmetrical, smooth skin surface.

In older women, breast sag, nipple lower,

stringy and nodular.

Palpation:No mass or lump, no areas of tenderness.

Warm to touch.

Not Done

Not Done

Not Done

Not Done

Not Done

Not Done

Areola Inspection:Round or oval, color

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darker than surrounding skin,

symmetrical. For dark skinned client, color is darker than other skin

surfaces.

Palpation:No masses and areas

of tenderness.

Not Done

Not Done

Not Done

Not Done

Not Done

Not Done

Nipples Inspection:Round or inverted,

equal in size, similar in color, both nipples point in one direction,

no discharge, no lesion, no dimpling, no

crusting.

Palpation:No masses, no tenderness, no

discharge.

Not Done

Not Done

Not Done

Not Done

Not done

Not Done

Upper Extremities

Arm Inspection:Skin color is Tan, symmetrical, thin

hairs, there are visible veins

Palpation:The fingers are

symmetrical

Warm, dry and elastic, there are no areas of

tenderness

Inspection:Skin color is Tan, symmetrical, thin of hairs, there are

visible veins

Palpation:The fingers are

symmetrical

Warm, dry and there is loss of elasticity, there are no areas of

tenderness



Normal

Normal

Palm Palms are pale in color, warm and rigid

Pallor, warm and rigid



21


hemoglobin.


Nails Convex curvature, angle of nail plate

about 160 °, Highly vascular and pink in light-skinned clients and intact epidermis

Convex curvature, smooth texture,

pale nailbeds and it takes 3 seconds

before it turns back to its

original color.


Delayed return of pink or usual

color may indicate

circulatory impairment


*Range of MotionArms Abduct, adduct, and

rotate - Performs with relative ease


Elbows Bend and straighten- Perform with relative

ease.

Bend and straighten elbows with relative ease


Normal

Hands and wrists

Extend and spread the fingers. Make a fist,

thumb across the knuckles- performs with relative ease.

Extend and spread the fingers. Make

a fist, thumb across the knuckles-

performs with relative ease.


Normal

Lower extremities

Legs Inspection:Skin varies (pinkish,

tan, dark, brown), skin is smooth, fine hair, evenly distributed, absence of varicose

veins, muscles symmetrical, length

symmetrical.

Inspection:Skin is tan, dry, absence of hair,

absence of varicose veins,

muscles symmetrical,

length symmetrical.


Generalized edema is most often an indication of impaired venous circulation and in some cases reflects cardiac

22

Palpation:Muscles appear equal, warm and with good

muscle tone.

There is presence of edema on feet with a scale of

2+.

Palpation:Muscles appear equal, warm and poor muscle tone.

Findings is normal for an

older adult

dysfunction or venous abnormalities. Fundamentals of Nursing by: Kozier and Erbs (p.576)

Increased skin dryness is caused by decrease in sebaceous gland activity and tissue fluid.

Fundamentals of Nursing by: Kozier and Erbs (p.412)

Loss of bone mass because bone reabsorption outpaces bone reformation. (Fundamentals of Nursing by Kozier pp.412)

Toes Inspection:Five toes in each foot: sole and dorsal surface is smooth, with pink

nail beds.

Palpation:As pressure is applied,

the nail beds appear white or blanched; pink color returns

Five toes in each foot, nail beds are pale, sole have rough surface

Not done


Not done



hemoglobin.


Not done

23

when pressure is released.

*Range of Motion

Legs Abduct, adduct, rotate, walk to and from-

performs with relative ease.

Wasn’t able to perform the task


Hypokalemia an abnormally low

level of potassium in the

blood. Symptoms are variable but may include

muscle weakness and fatigue, nausea and/or vomiting

and etc.(Blackwell’s

Nursing Dictionary by

Maslin pp. 290)

Knees Bend and extend – performs with relative

ease.

Bend and extend knees with relative ease


Normal

Ankles Flexion and extension, rotation – performs with relative ease.

Wasn’t able to perform








Maslin pp. 290)

24

Toes Spread and wiggles – perform with relative

ease

Has difficulty in performing








Maslin pp. 290)

VI. LABORATORY EXAMINATIONS

ELECTROCARDIOGRAM (ECG)

Date: August 20, 2009

25

Impression:

Sinus Rhythm Non-specific ST-T Wave changes Left Ventricular Hyperthrophy by voltage Intraventricular Conduction Delay

BLOOD CHEMISTRY


PARAMETER ACTUAL FINDINGS

NORMAL FINDINGS

ANALYSIS

Protein Specific Antigen (PSA)

7.8 <4 ng/mL Increase due to enlargement of the

prostate

HEMATOLOGY



NORMAL FINDINGS

ANALYSIS

White Blood Cells

9.4 x 10^g/L 5-10 x 10^g/L Normal

Hemoglobin 9.2 g/dL M: 14 -18 g/dL Decreased due to decrease RBC and

malnutritionHematocrit 28 % 40-54 % Decreased due to

decrease RBC andMalnutrition

Neutrophils 75% 50-70% Increased due to Infection

Lymphocytes 25% 25-40% Normal

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KIDNEY, URETER, AND BLADDER STUDIES (KUB)

Date: August __, 2009

Impression:

Cortical Cyst, Right Small sized kidneys with normal Corticomedullary border and Cortical Echogenicity Thickened Urinary Bladder w/ Trabeculations – Consider Cystitis Enlarged Prostate Glands as Described

BLOOD CHEMISTRY



NORMAL FINDINGS

ANALYSIS

Glucose/ FBS 5.49 mmol/L 3.89-5.89 mmol/L Normal

BUN 15.18 mmol/L 2.49-6.42 mmol/L Increased due to impaired kidney function and decreased blood flow

to the kidneys

Creatinine 230.86 mmol/L 61.88-132.6 mmol/L Increased due to impaired kidney function and decreased blood flow

to the kidneys

Total Cholesterol 3.76 mmol/L <5.2 mmol/L Normal

Triglycerides 0.84 mmol/L 0.4-1.88 mmol/L Normal

Enzymes:

SGOT 35 U/L 8-33 U/L Increased due to

SGPT 58 U/L 0-49 U/L Increased due to____

Other Tests:

27

HDL Chole 0.20 mmol/L 0-0.91 mmol/L Normal

LDL Chole 3.14 mmol/L 0-4.9 mmol/L Normal

VLDL Chole 0.21 mmol/L 0.31-0.85 mmol/L Decreased due to malnutrition

Sodium 135.35 mmol/L 135-145 mmol/L Normal

Potassium 2.11 mmol/L 3.5-5.3 mmol/L Decreased due to malnutrition

URINALYSIS



NORMAL FINDINGS

ANALYSIS

Physical Exam:Color Yellow Yellow Normal

Transparency Turbid Clear Turbidity or cloudiness may be

caused by excessive cellular material in

urine

Chemical Exam:

PH (Reaction) 6.0 4,8-7,8 Normal

Specific Gravity 1.010 1.015-1.025 Decreased due to chronic renal failure

Glucose Negative Negative Normal

Protein (Albumin) Trace Trace Normal

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Microscopic Exam:

WBC 2-6 M: 0-2/ HPF Increase due to infection

RBC 15-22 M: 0-1/ HPF Presence of RBC due to impaired

kidney function and decreased blood

flow to the kidneys

Epithelial Cells Rare Rare Normal

Bacteria Few Few Normal

VII. ANATOMY AND PHYSIOLOGY

The Urinary System

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The Urinary system consists of the kidneys, ureters, urinary bladder and urethra. The kidneys remove waste products, many of which are toxic, from the blood and play a major role in controlling the volume, red blood cell concentration, ion concentration and pH of the blood. Although the kidneys are the major organs of excretion, the skin, liver, lungs and intestines also eliminate wastes. If the kidneys fail to function, however, the other structures cannot compensate adequately.

Kidneys

The kidneys are located in the abdominal cavity, with the right kidney just below the liver, and the left kidney below the spleen. The ureters, extend from the kidneys to the urinary bladder within the pelvic cavity. An adrenal gland is located at the superior pole of each kidney.

The kidneys are located behind the peritoneum. Surrounding each kidney is the renal fat pad. The renal arteries extend from the abdominal aorta to each kidney, and the renal veins extend from the kidneys to the inferior vena cava.

Urinary Bladder

The Urinary Bladder is a hollow muscular container that lies in the pelvic cavity just posterior to the pubic symphysis.

Urethra

The urethra is a tube that exits the urinary bladder inferiorly and anteriorly near the entrance of the two ureters.

Ureters

Each Ureter runs behind the peritoneum from the hilus of a kidney to the posterior aspect of the bladder, which it enters as a slight angle. The superior end of each ureter is continuous with the pelvis of the kidney. And it’s mucosa lining is continuous with that lining the renal pelvis and the bladder below.

The Cardiovascular System

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The heart contracts forcefully to pump blood through the blood vessels of the body. The heart is actually two pumps in one. One pump propels blood to the lungs(the pulmonary circulation), and the other propels blood to all other tissues of the body(the systemic circulation). The heart of a healthy adult pumps about 5 liters of blood per minute. For most people the heart continuous to pump at about the rate for more than 75 years. During short periods of vigorous exercise, the amount of blood pumped per minute increases several fold. If the heart loses its pumping ability for even a few minutes, however, the life of the individual is in danger.

The heart is located within the bony thorax and is flanked on each side by the lungs. Its more pointed apex is directed toward the left hip and rests on the diaphragm, approximately at the level of the fifth intercostal space. Its broader posterosuperior aspect or base, from which the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib.

External Anatomy

The thin walled atria are located at the base of the heart, and the thick walled ventricles extend from the base of the heart to the apex.

Six large veins carry blood to the heart: The superior and inferior vena cavae carry blood from the body to the right atrium; four pulmonary veins carry blood from the lungs to the left

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atrium. Two arteries, the pulmonary trunk and the aorta, exit the heart. The pulmonary trunk, arising from the right ventricle splits into the right and left pulmonary arteries, which carry blood to the lungs. The aorta carries blood from the left ventricle to the body.

A large coronary sulcus runs around the heart, separating the atria from the ventricles. In addition, two sulci extend inferiorly from the coronary sulcus, indicating the division between the right and left ventricles. The anterior interventricular sulcus is on the anterior surface of the heart, and the posterior interventricular sulcus is on the posterior surface of the heart.

The coronary arteries and their branches, which supply blood to the tissue of the heart, lie primarily within the coronary sulcus and interventricular sulci on the heart’s surface. The right and left coronary arteries exit the aorta near the point where the aorta leaves the heart, and they lie within the coronary sulcus.

The major veins draining the tissue of the heart converge toward the posterior portion of the coronary sulcus and empty into a cavity called the coronary sinus. The coronary sinus, in turn, empties into the right atrium.

The Circulatory System

The blood is important in the maintenance of homeostasis in several ways: [1] It transports oxygen, nutrients, enzymes and hormones to tissues, [2] It carries carbon dioxide and waste products away from tissues, [3] It plays a central role in temperature, fluid, electrolyte, and pH regulation, [4] It protects the body from disease-causing microorganisms, foreign substances, and tumors, and [5] It clots to prevent blood loss when blood vessels are damaged.

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Blood is classified as a connective tissue, consisting of cells and cell fragments surrounded by a liquid matrix. The cells and cell fragments are the formed elements (red blood cells, white blood cells and platelets) , and the fluid matrix is the plasma. The total blood volume in the average adult is about 4 to 5 liters in females and 5 to 6 liters in males. Blood makes up about 8% of the body’s total weight.

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X. DISCHARGE PLAN

MEDICATION

Advice/instruct the client to continue medication that are prescribed by the physician and their actions. Instruct the patient or the significant others for any observable alterations on the patient condition.

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EXERCISE

Instruct the patient to perform leg exercise as tolerated such as walking to facilitate mobilization on lower extremities.

THERAPY

Instruct the patient to continue medication. Also, activities of daily living and self-care training are important to encourage maintenance of hygiene.

HEALTH TEACHING

Encourage the patient to increase fluid intake Encourage the patient to eat foods rich in vitamins and minerals/ nutritious food Encourage the patient to avoid salty and fatty foods Encourage the patient to have enough rest

OUT-PATIENT CARE

Instruct the client to come back for follow-up check-up as scheduled by the attending physician.

DIET

Advised the patient to a Diet as Tolerated but preferably avoiding salty and fatty foods.

SPIRITUAL/ SEXUAL ADVICE

Encourage the patient learn to accept responsibility for their own physical, emotional, mental, and spiritual healing.

CHF, CRF, BPH

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