Liceo de Cagayan University College of Nursing RN Pelaez Boulevard

Submitted as partial fulfillment in the subject N102 RLE A case study on Hypertension, Arthritis, Cataract and Non-toxic Goiter

Submitted by: Franklin Macabada April May Tolentino

Submitted to:

March 24, 2012

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TABLE OF CONTENTS

I. II. III. IV. V. VI. VII. VIII. IX. X.

INTRODUCTION DATABASE AND HISTORY NURSING SYSTEMS REVIEW CHART DEVELOPMENTAL DATA PATHOPHYSIOLOGY DRUG STUDY NURSING MANAGEMENT REFERRALS AND FOLLOW UP EVALUATIONS AND IMPLICATIONS BIBLIOGRAPHY

3 8 9 15 19 23 24 29 29 30

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I.Introduction A. Overview of the Case Client Guillerma Estonilo an 84 year old female widow from Zone 06, Baikingon, has been suffering from Non-toxic Goiter, Arthritis, Cataract and then recently hypertension. Client is also complaining of generalized weakness and easy fatigueability. Now we might think that she has so many diseases but let us look at the primary culprit, her age. Aging is a process that begins at conception and continues for as long as we live. At any given time throughout our lifespan, the body reflects:

its genetic component and Its environmental experience.

In other words, our bodies reflect our genetic capacity to adapt and repair, as well as the cumulative damage from disease processes. Aging highlights our strengths and our weaknesses. In our society we currently think of the "young old" as being around 65 to 74 years of age, the "middle old" 75 to 84 and the "old old" 85 years +. With advancing age, all of the body systems eventually demonstrate reduced efficiency, slowed building & replacement and actual loss of tissue. While an individuals aging experience is unique, there are generalizations which can be observed for each of the body systems. Skin The primary function of the skin is to protect the organism from the environment. It accomplishes this by providing a barrier that regulates temperature, retains fluid and absorbs shock and ultraviolet radiation, among other things. As we age, the dermis decreases in thickness by about 20%. As it thins out it loses vascularity, cellularity and sensitivity. Its ability to exchange or retain internal heat is diminished. The skin becomes thin, fragile and slow to
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heal. Sweat and sebaceous glands are reduced both in number and effectiveness. Sensory neurons are decreased by 30% from the age of 10 years to 90 years old. Subcutaneous fat deposition is altered in the elderly. Muscle, blood vessels and bone become more visible beneath the skin due to thinning of subcutaneous fat on the extremities. Fat deposition occurs mainly on the abdomen and thighs. Musculoskeletal Muscle mass is a primary source of metabolic heat. When muscles contract, heat is generated. The heat generated by muscle contraction maintains body temperature in the range required for normal function of its various chemical processes. As early as the third decade of life there is a general reduction in the size, elasticity and strength of all muscle tissue. The loss of muscle mass continues throughout the elder years. Muscle fibers continue to become smaller in diameter due to a decrease in reserves of ATP, glycogen, myoglobin and the number of myofibrils. As a result, as the body ages, muscular activity becomes less efficient and requires more effort to accomplish a given task. The elderly are less efficient at creating the heat necessary to drive the important biochemical reactions necessary for life. Beginning at around age 35 in both men and women, calcium is lost and bones become less dense. This can result in osteoporosis and a reduction of weight bearing capacity, leading to the possibility of spontaneous fracture. Thinning of the vertebrae also results in a reduction in height. In addition, the vertebrae calcify, resulting in postural changes and increasing rigidity, making bending difficult. The joints also undergo changes. In fact, arthritis, the degenerative inflammation of the joints, is the most common chronic condition in the elderly. The two most common forms are osteoarthritis (a wearing away of the joint cartilage), rheumatoid arthritis (a disease of the connective tissue).

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Respiratory function Lung function diminishes with age. The major contributing factors are the progressive loss of elastic recoil within lung tissue, the chest wall becomes stiff, and there is a decrease in alveolar surface area. These changes diminish the efficiency of gas exchange and make it more difficult to exercise. Cardiovascular Despite cardiovascular disease, often combined with a slowdown in the autonomic nervous response, the cardiovascular function of a resting healthy elder is usually adequate to meet the body's needs. Cardiac output of healthy exercising elders can usually be maintained, allowing moderate continued physical activity throughout their lives. People who are aging experience significant overall change by reduced blood flow to the body, which typically becomes serious in the eighth decade. This results from a number of factors including normal atrophy of the heart muscle, especially in the left ventricle which pumps oxygenated blood out to the body, calcification of the heart valves, loss of elasticity in artery walls (arteriosclerosis or "hardening of the arteries"), intra-artery deposits (atherosclerosis). The reduced blood flow results in less strength since, less oxygen is being exchanged, reduced kidney and liver function, less cellular nourishment As a consequence, the individual is more vulnerable to drug toxicity, has a slower rate of healing, a lower response to stress Other consequences of these cardiovascular changes are hypertension with an increased risk of stroke, heart attack, congestive heart failure

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Endocrine and metabolism Old age is accompanied by a generalized reduction in hormone production and activity. This reduction affects most metabolic functions of the body. Water, mineral, electrolyte, carbohydrate, protein, lipid and vitamin disorders are all more common in the elderly. Nutrition and the ability to use food for energy is seriously affected in the elder population. Diabetes is common in the elderly. There are many causes but a primary mechanism involves the inability of skeletal muscle to absorb glucose. Over time skeletal muscle becomes less responsive to insulin. Recent research indicates that the elderly are at risk for nutritional deficiencies due to anorexia. Age related anorexia has been linked to a lower satiety threshold. Elders feel "full" sooner which may be due to changes in hormone receptor or trigger mechanisms. Neurosensory Like other systems, the nervous system changes with age. There is loss of neurons in both the brain and spinal cord. There is loss of neuronal dendrites which reduces the amount of synaptic transmission. The sense of smell, taste, sight, touch and hearing are all diminished over time. Depression can be the result of impaired synaptic activity. Research indicates that as many as 25% of nursing home residents are clinically depressed. Depression is one of the most common reversible causes of weight loss. Summary Clearly elders are at a disadvantage when it comes to generating metabolic heat. They have less muscle mass and therefore less generating apparatus. They have less alveolar surface, therefore less oxidative reserve. Their skin provides less protection from heat loss. They have impaired neurotransmission, therefore less ability and/or desire to initiate activity. All of these

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factors put the elderly at risk for hypothermia if their environmental circumstances expose them to heat loss greater than their resting heat generating capacity. B. Objective The objective in making this case study is to identify and understand the problem of my patient which is Hypertension, Cataract, Arthritis and Non-toxic goiter, and to determine what are the factors that contribute to the disease so that specific actions should be done and rendered to my patient. Having this kind of case study is a privilege for me because it would be a good learning process by adding new knowledge and concept about different kinds of diseases that may be present in some patients. By making this case study I can identify the disease step by step, its nature on how this disease occur, and nursing actions that would be appropriate for the patient.

C. SCOPE and LIMITATIONS of the STUDY The study was conducted at Zone 06 Baikingon, Cagayan de Oro city in which observation, analyzing and understanding the patients condition was done. We were given four (4) days to conduct the study. The study is also limited to the condition of the patient which is hypertension, cataract, arthritis and non-toxic goiter. The study focuses only on obtaining the patients profile, health history and present health condition; assessing, recording, and gathering of pertinent data about the patient. Estimating the nursing needs and coping capacity of the patient; finding the primary health problems of the patient and the appropriate nursing interventions to solve the condition of the patient. The objectives, nursing care plans, drug study and evaluation for the patient was also done in this study.

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II. Database and History A. Database My client was Guillerma Estonilo, Female, 84 years old, Catholic and a widow from Zone 06, Baikingon. Born on June 25, 1928. A Filipina with an average income of 2,000 a month from pension. Her vitals during my visit were Temperature of 35.8 C, Pulse rate of 88 bpm, Respiratory rate of 19 cpm, and BP of 120/95 mmHg. Her height is 50 and weighs 37 kgs. Client Estonilo has 6 children all delivered through NSVD and cant recall exact dates. Health History Family Health History According to client Estonilo; Hypertension is a heredofamilial trait. Her father had suffered from it. Past Health History Client Estonilo had suffered from the regular bouts of colds and cough, but has made sure to take extra care of herself because of her old age. Present Health History Client Guillerma Estonilo an 84 year old female widow from Zone 06, Baikingon, has been suffering from Non-toxic Goiter, Arthritis, Cataract and then recently hypertension. Client is also complaining of generalized weakness and easy fatigueability.

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III. NURSING SYSTEM REVIEW CHART

Name of Patient: Guillerma F. Estonilo Body Measurements: Weight: 37 kg. Height: 5 feet Date of Assessment: July 17, 2012

Vital Signs upon Assessment: Temp: 35.9 C PR: 82 bpm RR: 19 cpm BP: 130/100 mmHg

EENT [X ] Impaired Vision [ ] Impaired Hearing [ ] Blind [ ] Deaf [ ] Pain [ ] Reddened [ ] Burning [ ] Edema [ ] Drainage [ ] Lesions [ ] Gums [ ] Teeth

Assess Eyes, Ears, Nose, and throat for any abnormalities [ ] No Problem RESPIRATORY [ ] Asymmetrical [ ] Tachypnea [ ] Apnea [ ] Rales [ ] Cough [ ] Barrel Chest

[ ] Bradypnea [ ] Shallow [ ] Orthopnea [ ] Labored

[ ] Rhonchi [ ] Sputum [ ] Diminished [ ] Dyspnea [ ] Wheezing [ ] Pain [ ] Cyanotic

Assess respiration, rate, rhythm, depth, pattern, breath sounds, comfort. [ x ] No Problem CARDIOVASCULAR [ ] Arrhythmia [ ] Edema [ ] Tingling [ ] Tachycardia [ ] Numbness [ ] Diminished Pulse [X] Fatigue [ ] Irregular [ ] Bradycardia [ ] Mur-mur [ ] Absent Pulse [ ] Pain

Assess heart sounds, rate, rhythm, pulse, blood pressure, circulation, fluid retention, comfort [ ] No Problem GASTROINTESTINAL [ ] Obese [ ] Distension [ ] Mass[ ] Dysphagia [ ] Rigidity [ ] Pain

Assess abdomen, bowel habits, swallowing, bowel sounds, comfort. [X] No Problem GENITO URINARY and GYNE [ ] Pain [ ] Urine Color [ ] Vaginal Bleeding [ ] Hematuria [ ] Discharges [X ] Nocturia Page | 9

Assess Urine frequency, control, color, odor, comfort, Gyne Bleeding, Discharges . [ ] No Problem

NEUROLOGIC [ ] Paralysis [ ] Vertigo [ ] Stuporous [ ] Tremors [X ] Unsteady [ ] Seizure [ ] Confused [ ] Vision [ ] Lethargic [ ] Grip [ ] Comatose

Assess motor function, sensation, LOC, Strength, Grip, gait, coordination, Speech [ ] No Problem

MUSCULOSKELETAL and SKIN [ ] Appliance [ ] Prosthesis [ ] Wound [ ] Echymosis [ ] Stiffness [ ] Swelling [ ] Itching [ ] Petechiae [ ] Hot [ ] Lesions [X] Poor Turgor [X] Cool [ ] Pain [ ] Drainage [ ] Deformity

[ ] Rash [ ] Skin Color [ ] Flushed [ ] Diaphoretic [ ] Moist

[X] Atrophy

Assess mobility, motion gait, alignment, joint function, Skin color, texture, turgor, integrity [ ] No Problem Place an (X) in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure if appropriate, using (X).

Cataract Hypertension Non-Toxic Goiter Poor skin turgor Nocturia Cool skin Unsteady Gait (difficulty in prolonged walking) Arthritis (left ring finger)

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NURSING ASSESSMENT II

SUBJECTIVE COMMUNICATION: [ ] Hearing Loss Comments: na gamay

OBJECTIVE

[X] Glasses [ ] Languages akong [ ] Contact [ ] Hearing Aide [ ] Speech Difficulties

[X] Visual Changes Halap [ ] Denied

panan-aw As verbalized byLens the client.

Pupil Size: R_3mm _ L _3mm__ Bilaterally equal but sluggish Reaction: _Sluggish reaction due to cataract OXYGENATION: [ ] Dyspnea Comments: Respiration: [ x ] Regular [ ] Irregular The rise and fall of the chest is symmetric

[X] Smoking History Gapanagarilyo ko ug Tabaco Describe: Somker (Tabaco) [ ] Cough [ ] Sputum [ ] Denied CIRCULATION: [ ] Chest Pain [ ] Leg Pain [ ] Numbness of extremities [ ] Denied Comments: labi na kung maglimpyo ko sa mga sagbot kay daghan

insekto . As verbalized by R: Symmetric to left; full chest expansion the client. L: Symmetric to right; full chest expansion

Heart Rhythm: [x] Regular [ ] Irregular

Wala man magsakit akong Ankle Edema: ________________________ dughan As verbalized by the Pulse client. Right Left Car + + Rad + + DP + + Fem* + +

Comments:

Pulses on both left and right are present and palpable

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NUTRITION: Diet: Low fat & low sodium [ ]N [ ]V Comments:

[ ] Dentures

[X ] None Full Incomplete With Patient

Character _________________ [ ] Recent change in weight, appetite [ ] Swallowing difficulty [X ] Denied ELIMINATION: Usual bowel pattern: Once a day [ ] Constipation Remedy

Mukaon jud ko, labi na Upper utan kasaguran sud-an namo As Lower verbalized by the client. *Teeth are badly decayed due to poor dental hygiene together with long term effects of Tabaco use. diri

[ ] Urinary Frequency 4 x day [ ] Urgency [ ] Dysuria [ ] Hematuria

Comments: No tenderness palpation.

Bowel sounds: abdominal_normoactive_5x_ uponAbdominal Distention: Present: [ ]Yes [X ]No

Date of last BM July 17, 2012 [ ] Diarrhea Character

[ ] Incontinence [ ] Polyuria [ ] Foly in place [X] Denied

Urine: Color: Odor: Yellowish Non-foul Fluid

Consistency:

MGT. OF HEALTH & ILLNESS: [ ] Alcohol [X] Denied Briefly describe the patients ability to follow

Amount & Frequency

treatments (diet, meds, etc.) for chronic problems (if

Dili ko ga inom. Hate jud naku na present). .as verbalized by the client SBE Last Pap Smear: Client was keen to ask questions about her disease

and Client does not do describe it as well. She follows the regimen given to her. ___ SBE or pap smear anymore

LMP: Not applicable

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SKIN INTEGRITY: [X] Dry [ ] Itching [ ] Other [ ] Denied Comments: [X] Dry [X] Cold [ ] Warm [ ] Cyanotic [ ] Pale

Usahay uga kayo akong panit [ ] Flushed . As verbalized by the client. [ ] Moist

*Rashes, ulcers, decubitus (describe size, *location, drainage): No rashes, ulcers, or decubitus noted; Poor skin turgor due to loss of elasticity accompanying aging.

ACTIVITY/SAFETY : [ ] Convulsion [ ] Dizziness [X] motion of joints Comments: Maglisod nako ug lakaw [ ] Level of Consciousness and Orientation The client is awake and coherent X Cane __ Other

dodong. Mao mugamit ko ug __ Gait: __ Walker

Limitedcane or usahay magpatabang __ Gait: __ Steady ko sa akong apo. Sakit pod __ Gait: __ Unsteady: Needs assistance especially if akong tudlo, maglisod ko ugwalking for quite some distance lihok niya As verbalized by the [ ] Sensory and motor losses in face or

Limitation ability to: [X] Ambulate [ ] Bathe Self [ ] Other [ ] Denied

inclient.

extremities: No sensory and motor loses on face and extremities noted. [ ] Range of Motion Limitations: Client is ambulant but has a hard time especially for long walks

COMFORT/SLEEP/AWAKE: [ X ] Pain Location: Left ring finger Frequency: Daily Remedies: Comments: [ ] Facial Grimaces

Wa man ko maglisod [ ] Guarding ug tulog. Maglisod ko [ ] Other Signs of Pain: ug lakaw ko. by mao as the [ ] Siderail release form signed (60+ years) None (N/a) Page | 13 No signs of pain, guarding or facial grimaces observed

magsungkod verbalized

Warm compress and client._________ massage

[X ] Nocturia [ ] Sleep Difficulties [ ] Denied COPING: Occupation: House keeper and nanny at times Observe non-verbal behavior: to her grandchildren. Members of household: 9 Members The person and his phone number that can Most supportive person: (Daughter) Jane Melo Be reached anytime: Client declined to release any number Client is very jolly and receptive during the Interview

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) __NA____Daily Weight __ NA _____BP q Shift ___ NA ____Neurovs ___ NA ____CVP/SG. Reading Date ordered Diagnostic/ Laboratory Exams NA NA NA NA NA NA __ NA______PT/OT__________ __ NA _____Irradiation ___ NA _____Urine Test_________ __ NA ____24 hour Urine Collection I.V. Blood Fluids/ Date Disc.

Date Done Date Ordered

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IV. DEVELOPMENTAL DATA The term growth and development both refers to dynamic process. Often used interchangeably, these terms have different meanings. Growth and development are interdependent, interrelated process. Growth generally takes place during the first 20 years of life; development continues after that. Growth: 1. Physical change and increase in size. 2. It can be measured quantitatively. 3. Indicators of growth include height, weight, bone size, and dentition. 4. Growth rates vary during different stages of growth and development. 5. The growth rate is rapid during the prenatal, neonatal, infancy and adolescent stages and slows during childhood. 6. Physical growth is minimal during adulthood. Development: 1. Is an increase in the complexity of function and skill progression. 2. It is the capacity and skill of a person to adapt to the environment. 3. Development is the behavioral aspect of growth.

Eriksons Stages of Psychosocial Development Theory

Erikson's psychosocial crisis stages (syntonic v dystonic) 1. Trust v Mistrust infant / mother / feeding and being comforted, teething, sleeping toddler / parents / bodily functions, toilet training, muscular control, walking preschool / family / exploration and discovery, adventure and play schoolchild / school, teachers, friends, neighbourhood / achievement and accomplishment Hope and Drive life stage / relationships / issues basic virtue and second named strength (potential positive outcomes from each crisis) maladaptation / malignancy (potential negative outcome - one or the other - from unhelpful experience during each crisis) Sensory Distortion / Withdrawal Impulsivity / Compulsion

2. Autonomy v Shame & Doubt 3. Initiative v Guilt 4. Industry v Inferiority

Willpower and SelfControl Purpose and Direction Competence and Method

Ruthlessness / Inhibition Narrow Virtuosity / Inertia

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5. Identity v Role Confusion 6. Intimacy v Isolation 7. Generativity v Stagnation

adolescent / peers, groups, influences / resolving identity and direction, becoming a grown-up young adult / lovers, friends, work connections / intimate relationships, work and social life mid-adult / children, community / 'giving back', helping, contributing

Fidelity and Devotion Love and Affiliation

Fanaticism / Repudiation

Promiscuity / Exclusivity

Care and Production

Overextension / Rejectivity

Client Estonilo is on the 7th stage. Generativity vs Stagnation. She is on the point where she has the need to be productive even with her old age. As was indicated in her database even though she was having a hard time walking around but still she choose to keep her store so as to contribute to her family.

Havinghurst Developmental Stages Havighurst identified Six Major Stages in human life covering birth to old age.

Infancy & early childhood (Birth till 6 years old) Middle childhood (613 years old) Adolescence (1318 years old) Early Adulthood (1930 years old) Middle Age (30-60years old) Later maturity (60 years old and over)

From there, Havighurst recognized that each human has three sources for developmental tasks. They are:

Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine, behaving in an acceptable manner to opposite sex, adjusting to menopause. Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical outlook. Tasks that have their source in the pressures of society: Learning to read, learning to be responsible citizen.

The developmental tasks model that Havighurst developed was age dependent and all served pragmatic functions depending on their age. (60 and over)

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Adjusting to decreasing physical strength and health. Adjusting to retirement and reduced income. * Adjusting to death of a spouse. * Establishing an explicit affiliation with ones age group. * Adopting and adapting social roles in a flexible way. * Establishing satisfactory physical living arrangements.

Client Estonilo has adapted very well to her current age and status. It was evident during the interview because she was very jolly and didnt really mind being interviewed and sharing parts of her life as well. Piagets Stage Theory of Cognitive Development Swiss biologist and psychologist Jean Piaget (1896-1980) observed his children (and their process of making sense of the world around them) and eventually developed a four-stage model of how the mind processes new information encountered. He posited that children progress through 4 stages and that they all do so in the same order. These four stages are:

Sensorimotor stage (Birth to 2 years old). The infant builds an understanding of himself or herself and reality (and how things work) through interactions with the environment. It is able to differentiate between itself and other objects. Learning takes place via assimilation (the organization of information and absorbing it into existing schema) and accommodation (when an object cannot be assimilated and the schemata have to be modified to include the object. Preoperational stage (ages 2 to 4). The child is not yet able to conceptualize abstractly and needs concrete physical situations. Objects are classified in simple ways, especially by important features. Concrete operations (ages 7 to 11). As physical experience accumulates, accommodation is increased. The child begins to think abstractly and conceptualize, creating logical structures that explain his or her physical experiences. Formal operations (beginning at ages 11 to 15). Cognition reaches its final form. By this stage, the person no longer requires concrete objects to make rational judgments. He or she is capable of deductive and hypothetical reasoning. His or her ability for abstract thinking is very similar to an adult.

Client Estonilo has already passed this stage and her cognitive abilities are starting to revert already. Its as if what they are saying as you grow older you start to revert to your younger days.

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Freudian psychosexual development Stage Age Range Erogenous zone Consequences of psychologic fixation Orally aggressive: chewing gum and the ends of pencils, etc. Orally Passive: smoking, eating, kissing, oral sexual practices. Oral stage fixation might result in a passive, gullible, immature, manipulative personality. Anal retentive: Obsessively organized, or excessively neat Anal expulsive: reckless, careless, defiant, disorganized, coprophiliac Oedipus complex (in boys and girls); according to Sigmund Freud. Electra complex (in girls); according to Carl Jung. Sexual unfulfillment if fixation occurs in this stage. Frigidity, impotence, unsatisfactory relationships

Oral

Birth1 year

Mouth

Anal

13 years

Bowel and bladder elimination

Phallic

36 years

Genitalia Dormant sexual feelings Sexual interests mature

Latency 6puberty Genital Puberty death

Genital stage The fifth stage of psychosexual development is the genital stage that spans puberty and adult life, and thus occupies most of the life of a man and of a woman; its purpose is the psychologic detachment and independence from the parents. The genital stage affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts. As in the phallic stage, the genital stage is centered upon the genitalia, but the sexuality is consensual and adult, rather than solitary and infantile. The psychological difference between the phallic and genital stages is that the ego is established in the latter; the person's concern shifts from primary-drive gratification (instinct) to applying secondary process-thinking to gratify desire symbolically and intellectually by means of friendships, a love relationship, family and adult responsibilities. Actually Estonilo has already passed this stage with grace. She has built a good relationship with her deceased partner, her offsprings together with her apos.

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V. Pathophysiology
Pathophysiology of Hypertension Hypertension (HTN) or high blood pressure, sometimes arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is elevated. This requires the heart to work harder than normal to circulate blood through the blood vessels.

Predisposing Factors Age Genetics

Precipitating Factors High Salt Intake Low Potassium Intake Obesity Excessive alcohol intake Smoking Stress Changes in arteriolar bed Increased Vascular Resistance Increased Afterload Decreased Blood Flow to the Organs

Decreased Renal Perfusion Hyponatremia Angiotensinogen

Increased Blood Pressure Juxtaglomerular Cells Renin

Beta-Receptor Activation Hypovolemia Angiotensin 1

Angiotensin Converting Enzyme ACE Arteriolar Vasoconstriction Increased Peripheral Resistance Increased Blood Pressure

Angiotensin 2 Adrenal Cortex Stimulation Increased Aldosterone Increased Na reabsorption Increased H2O Reabsorption Page | 19

Increased Plasma Volcano (ECF)

Pathophysiology of Nontoxic goiter 45 A nontoxic goiter is a diffuse or nodular enlargement of the thyroid gland that does not result from an inflammatory or neoplastic process and is not associated with abnormal thyroid function. Endemic goiter is defined as thyroid enlargement that occurs in more than 10% of a population, and sporadic goiter is a result of environmental or genetic factors that do not affect the general population.

Predisposing Factor Sex: Female Age: over 40 years old Family history of goiter Etiology: Unknown

Precipitating Factors History of radiation therapy to head or neck, especially during childhood Regular intake of substances (goitrogens) Excessive amounts of iodine or lithium Iodine deficiency

Presence of uniform follicular epithelial hyperplasia Development of areas of involution and fibrosis interspersed with areas of focal hyperplasia Thyroid architecture loses uniformity Development of nodules

Thyroid gland increases in size Causes pressure to surrounding organs

Development of functional autonomy May lead to thyrotoxicosis

Swelling on the neck Difficulty swallowing

Feeling of pressure on the neck Breathing difficulties, coughing or wheezing

Hoarseness

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Pathophysiology of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks flexible (synovial) joints. The process produces an inflammatory response of the capsule around the joints (synovium) secondary to swelling (hyperplasia) of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus) in the synovium.

Genetic predisposition (HLA type) Plus Immunologic Trigger

T-cell mediated Immune response

RF antigen / IgG Interaction

Cytokine Production TNF, IL - 1

Complement Fixation

Inflammatory Response

Angiogenesis in synovium

Recruitment of Inflammatory cells

Synovial Proliferation

Release of enzymes and prostaglandins

Pannus Invasion

Destruction of articular cartilage and underlying bone Page | 21

Pathophysiology of Cataract
A cataract is a clouding that develops in the crystalline lens of the eye or in its envelope (lens capsule), varying in degree from slight to complete opacity and obstructing the passage of light. Early in the development of age-related cataract, the power of the lens may be increased, causing near-sightedness (myopia), and the gradual yellowing and opacification of the lens may reduce the perception of blue colors. Cataracts typically progress slowly to cause vision loss, and are potentially blinding if untreated. The condition usually affects both eyes, but almost always one eye is affected earlier than the other. A Senile cataract, occurring in the elderly, is characterized by an initial opacity in the lens, subsequent swelling of the lens and final shrinkage with complete loss of transparency

Predisposing Factor: (+) Family History of: Glaucoma Hypertension DM Aging, usually above 40 Genetics Sex (Females)

Precipitating Factor: Smoking Excessive drinking of Alcohol Unhealthy Diet Lack of Execise Job Work Usage of corticosteroid and Ezetimibe Secondary to other eye disease like Uveitis or inflammation of the inner layer of the eye.

Signs and Symptoms Gradual, painless onset of blurry, firmly, or fuzzy vision; poor central vision, frequent changes in glass prescription; changes in color vision; increase glare from lights, especially oncoming headlights when driving at night;; second sight improvement in near vision (no longer needing reading glasses), but a decrease in distance vision; poor vision in sunlight; presence of milky whiteness in the pupil as the cataract progress.

Soluble Membrane Proteins Condense and form (proteolysis) Lumps

Separation of Lens Cell Cytoplasm (a jelly like substance) into protein rich and protein poor liquid

-Damage to the fiber cell plasma -Loss of protective molecules such as glutathione -Excessive breakdown of protein -Damage to the systems responsible for calcium homeostasis

Cataract Formation Page | 22

VI. Drug Study

DRUG ORDERED NURSING RESPONSIBILITIES/ PRECAUTIONS Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 69 h following oral doses. Monitor for S&S of doserelated peripheral or facial edema that may not be accompanied by weight gain; rarely, severe edema may cause discontinuation of drug. Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional antihypertensives or diuretics are added. Monitor heart rate; doserelated palpitations (more common in women) may occur.

Generic: amlodipine besylate

Brand:

Norvasc
Dose: 5 mg Frequency: OD Route: Per Orem

MECHANISM OF ACTION Amlodipine belongs to a class of drugs known as calcium channel blockers. It works by relaxing blood vessels so blood can flow more easily.Amlodipine is also used to prevent certain types of chest pain (angina).

INDICATION Amlodipine is used with or without other medications to treat high blood pressure. Lowering high blood pressure helps prevent strokes, heart attacks, and kidney problems.

CONTRAINDICATIONS Before taking amlodipine, tell your doctor or pharmacist if you are allergic to it; or to other dihydropyridine calcium channel blockers (such as nisoldipine, nifedipine) or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. .Before using this medication, tell your doctor or pharmacist your medical history, especially of: a certain structural heart problem (aortic stenosis), very low blood pressure, disease. This drug may make you dizzy. Limit alcoholic beverages

ADVERSE EFFECTS OF THE DRUG Dizziness, lightheadedness, swelling ankles/feet, flushing, or headache may occur. Tell your doctor immediately if any of these unlikely but serious side effects occur: fast/irregular/pounding heartbeat, fainting. A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing

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VII. NURSING MANAGEMENT NURSING CARE PLAN

Cues Nursing Diagnoses Deficient knowledge; Nature of and Complications of hypertension or management regimen. Objectives Interventions Rationale Evaluation

Subjective Date: Taas man akong BP ug usahay galabad akong ulo as verbalized by the patient. Objective Data: BP 120/95 mmHg Headaches Dizziness Blurred Vision

Short Term: At the end of 30 mins, effectively lower the BP of the client Long Term: At the end of 1 hour the client will understand the preventative and management of the disease

Independent: Instruct the patient to self measure BP and suggest home monitoring equipment as appropriate Involve family or significant others

This provides sense of control to seek prompt medical attention They can effectively provide support with the treatment regimen Knowledge serves correct faulty ideas to

Short Term: After 30 mins BP will be stabilzed Long Term: After 1 hour the patient is able to verbalize increase knowledge about the disease and its management

Encourage questions about hypertension and prescribed treatment Plan teaching for the signs and symptoms to report to health care provider

Information enables the client to take control

Dependent: Administration of anti-hypertensive drugs: Norvase 5 mg OD per orem

For immediate management of hypertension

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Cues Subjective Data: Klaro man akong goiter pero dili man siya dagko hinuon as verbalized by the patient. Objective Data: Mass directly observable at the lower neck Generalized weakness or fatigue Abnormal heart rate or blood pressure response to activity

Nursing Diagnoses Activity intolerance; related to generalized weakness

Objectives Long term: After 1 hour of health teaching the patient understand how to complete desired activities without fatigue and with normal heart rate and blood pressure responses

Interventions Independent: Asses the patients energy level, and muscle strength and tone.

Rationale Slowing metabolism results in decreased energy level. Muscles may be weaker and joints stiffer. Activities that are important to the client should be planned during times with high energy level. Frequent rest periods will promote energy conservation This energy conservation technique will help the patient participate in and complete desired activities. A record of energy levels and activities will help the patient identify periods of peak energy

Evaluation Long Term: After 1 hour the patient will verbalize understanding of her condition together with the management

Help the patient identify desired activities and responsibilities

Teach the patient to alternate periods of rest with periods of activity Encourage the patient to ask for assistance with activities

Encourage the patient to keep a daily log of energy levels and activities for at least a week

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Cues Subjective Data: Sakit akong tudlo, maglisod ko ug piko. as verbalized by the patient. Objective Data: Joint swelling Muscle spasms, limited movement, and joint instability

Nursing Diagnoses Acute Pain r/t joint degeneration

Objectives Long Term: At the end of 1 hour the client would be able to understand the preventative and management of the disease

Interventions Dependent: Assess the patients description of pain.

Rationale The patient may manifest any or part of the defining characteristics, so focused assessment is important. Pain may be associated with specific movements, especially repetitive movements.

Evaluation Long Term: After 1 hour the patient will verbalize understanding of her condition together with the management

Identify factors or activities that seem to precipitate acute episodes or aggravate a chronic condition. Develop a pain-relief regimen based on the patients identified aggravating and relieving factors. Instruct the client to apply hot or cold pack. Provide for adequate rest periods Dependent: Take prescribed analgesics and or anti-inflammatory medication and provide instruction in impotant side effects: NSAIDs (Flanax) 50 mg TID PO

Some patients prefer hot therapy over cold therapy to provide comfort

Fatigue impairs ability to cope with discomfort

These drugs are antiinflammatory, antipyretic and analgesic agents. They are usually used for their anti-inflammatory action to relieve mild to moderate pain. Side effects include mild GI disturbances and fluid retention.

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Cues Subjective Data: Maglisod ko lakaw nga layo. as verbalized by the patient. Objective Data: Decreased muscle strength Use of cane when walking or seeking assistance Muscle spasms, limited movement, and joint instability

Nursing Diagnoses Impaired physical mobility muscle weakness

Objectives Long Term: At the end of 1 hour the client would be able verbalize and demonstrate ability to move purposefully

Interventions Dependent: Assess ROM in all joints.

Rationale Pain on motion or joint deformity may cause progressive loss of range Pain may be associated with specific movements, especially repetitive movements.

Evaluation Long Term: After 1 hour the patient will verbalize understanding of her condition together with the management

r/t

Identify factors or activities that seem to precipitate acute episodes or aggravate a chronic condition. Provide for adequate rest periods Instruct the patient on how to perform isometric, and active and passive ROM exercises to all extremities.

Fatigue impairs ability to cope with discomfort Muscular exertion through exercise promotes circulation and free joint mobility, strengthens muscle tone, develops coordination, and prevents nonfunctional contracture. Rest periods are necessary to conserve energy. The patient must learn to respect the limitations of his/her joints; pushing beyond the joint of pain will only increase the stress on the joint.

Encourage the patient to rest between activities that are tiring. Suggest strategies for getting out of bed, rising from chairs, and picking up objects from the floor to conserve energy

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Cues Subjective Data: Halap na akong pananaw, labi na kung magbasa ko. as verbalized by the patient. Objective Data: Unable to read objects even up close Gray opacities in eyes Reported changes in visual acuity

Nursing Diagnoses Disturbed sensory perception:Vis ual r/t cataracts

Objectives Long Term: At the end of 1 the client will verbalize optimal functioning within limits of visual impairment as evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities.

Interventions Dependent: Assess age

Rationale The incidence of macular degeneration, cataracts and glaucoma increases with age.

Evaluation Long Term: After 1 hour the patient will verbalize understanding of her condition together with the management

Determine nature of visual symptoms, onset, and degree of visual loss. Inquire about history of visual complaints, eye trauma, or ocular pain.

Recent loss, loss over a long period, or longstanding loss have different implications for nursing intervention and the patients level of adaptation or resource use.

Do not make unnecessary changes in the environment

This ensures safety and maintains what the patient has arranged

Recommend use of visual aids when appropriate

Visual aids such as magnifying glass or large-printed books and magazines encourage reading.

Remove environmental barriers to ensure safety.

If furniture or wastebaskets are moved, notify patient of changes

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VIII. REFERRALS AND FOLLOW-UP: Outpatient (check-up): Instructed the patient to abide to her routine check-up with Dr. Duero at Bacal Clinic. Encouraged client as well to have her goiter and cataracts checked at medical city for possible intervention. Encouraged the patient as well to report any unusual findings that she might have observed.

IX: EVALUATION AND IMPLICATIONS: This care study enables us to further our learning association with disease condition of the patient. From it, we have gained knowledge in the progression of the disease and the reaction of the body to maintain homeostasis and how eventually it causes harm. Through this, we actually improved our understanding and skills in the management of the patient through the experiences weve had in implementing our care. It also enhanced our confidence in intervening because of the input gained form our research. Case studies are a way of getting familiar or get acquainted not only with the patient but also on his or her condition. It provides concrete examples of how the theoretical knowledge learned during lectures was applied. How the concepts of the various disease condition were manifested through the client. It allows the opportunity to facilitate the acquisition of knowledge through the experiences gained in management and in caring for the patient. As a result, it is a must that case studies should be made not just for requirement purposes but also for the pursuit of knowledge. In general, the case study promoted learning through the research and actual experiences and made us more knowledgeable in caring for the patient and that can really be used in our chosen field.

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X. Bibliography Books: 120 Diseases (The essential Guide to more than 120 Medical Conditions, syndromes, and diseases) by Prof. Peter Abrahams 2007 pp. 46-47; 74-75; 190-195 Essentials of pathophysiology by Carol Mattson Porth Rn, MSN, PhD pp. 366-399; 705-721; 1034-1037 Manual of Nursing Practice by Lippincott 10thed. pp. 454-462; 910-932; 1087-1088 Portable Rn 3rd edition by Lippincott 2006 pp. 214-216; 226-228; 236-238 Nursing Care Plans, Nursing diagnosis and intervention by Gulanick/Myers 6 th ed pp. 301-305; 777-782; 1050-1062

Internet: WWW.MEDSCAPE.COM WWW.WIKIPEDIA.ORG WWW.DRUGSCAPE.COM

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