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).
Environmental and occupational agents that have been implicated in chronic renal failure
include lead, cadmium, mercury, and chromium. Dialysis or kidney transplantation eventually
 2

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
leukemia) or whether it is a symptom of blood loss or an underlying diseased (such as arthritis)
or infection.
 3

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.

I. BIOGRAPHIC DATA

Name: Patient J. L.

Age: 71
 4

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

A. 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.

2. Was consultation/help sought?

-Yes

3. Medications used?

-He uses antibiotics

 5

4. How the problem has interfered with daily life?

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

A. 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

A. Family History

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

 6

-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

I. Functional Health Pattern

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
 7

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.

I. ACTIVITIES OF DAILY LIVING

Area Before Hospitalization During Analysis

Hospitalization
 8

The patient eats Now that he is The older adult requires the
whatever food he wants confined at Angono, same basic nutrition as the
to eat. He usually ate the client is under a young adult. However,
meals three times a day Low Salt Low Fat Diet fewer calories are needed by
specifically, fish and and prescribed to the older adult because of
vegetables and drank lessen the amount of the lower metabolic rate and
plenty of water. fluid intake to prevent decrease in physical
the worsening of activity. (Fundamentals of
NUTRITION edema. 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)
The patient bowel for 3 The patient defecates Normal patterns of bowel
times a week. He has no only when he takes elimination vary in relation
awareness of bladder medicine which is to the person’s regular
filling and he can’t Lactulose that helps to elimination pattern. Some
control his urine flow softens stool. An people normally defecate
due to Chronic Renal indwelling catheter is only few times a week;
Failure. applied. other people defecate more
than once a day. (page
ELIMINATION 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
 9

occur.

(Fundamentals of Nursing
by Kozier page 1121)

The patient was able to The patient wasn’t able Exercise is a type of
perform exercises such to perform exercises physical activity performed
as jumping and walking because he feels weak to improve or maintain one
to become healthy. and every time he tried or more components of
to stand his legs were physical fitness.
shaking.
( Fundamentals of Nursing
EXERCISE by Kozier page 1107)

The patient takes a bath The patient takes a Hygiene is the science
daily and apply powder bath daily and needs dealing with health and its
to refreshes his body. assistance. He needs maintenance. It is a
assistance in doing condition or practice, such
self-care activities. as cleanliness, that is
conducive to the
preservation of health.

(Blackwell’s Nursing
HYGIENE Dictionary by Maslin page
284)
The patient smoke The patient doesn’t People tend to consume less
before about 5 packs a smoke nor drink any alcohol as they get older.
week but he quit alcohol beverages. Elderly alcoholics include
smoking 3 years ago. He those who began drinking
doesn’t drink any alcohol on their youth and
alcohol beverages. those who began excessive
alcohol use later in life.
SUBSTANCE
ABUSE (Fundamentals of Nursing
by Kozier page 411)

Smoking is another type of

drug abuse that can bring
 10

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.

The patient usually Since confinement at Elderly adults tend to take

sleeps at night for 6-8 the hospital, the somewhat longer to get to
hours and takes a nap client’s sleep was not sleep. Change in
every afternoon. regular. He sleeps for environment can hinder
only 4-6 hours at night sleep where the presence of
because of noisy familiar stimuli can prevent
environment. people from sleeping.
SLEEP AND
REST (Fundamentals of Nursing
by Kozier page 1117)
 11

II. PHYSICAL ASSESSMENT

Area Normal Findings Actual Findings Interpretation Analysis

Head The head is The head is All findings are Normal
proportional to the size proportional to the normal.
1. Skull of the body, it is size of the body, it
round, with is round, with
prominences in the prominences in
frontal area anteriorly the frontal area
and the occipital area anteriorly and the
posteriorly, occipital area
symmetrical in all posteriorly,
planes and gently symmetrical in all
curved. planes and gently
curved.
2. Scalp It is white, clean and It is white, clean All findings are Normal
free from masses, and free from normal.
lumps and scar, nits, masses, lumps
dandruff and any and scar, nits,
lesions. dandruff and any
lesions.
3. Hair It is black in color and It is white in color Findings are Thinning and
thinning and thinning normal for an graying of scalp,
older adult pubic and
axillary hair
because of
 12

The hair strands are The hair strands progressive loss

course or fine. are fine. of pigment cells
from the hair
bulbs.
(Fundamentals
of Nursing by
Kozier pp.412)
4. Face It is heart-shaped, It is round- Findings are Progressive
symmetrical, smooth shaped, normal for an wrinkling and
and free from wrinkle, symmetrical, and older adult sagging of the
no involuntary muscle wrinkles are skin becausenof
movements. present, no loss of skin
involuntary elasticity,
muscle increased
movements. dryness and
decreased
subcutaneous
fat.

(Fundamentals
of Nursing by
Kozier pp.412)
5.Eyes Parallel and evenly Parallel and All findings are Normal
placed, symmetrical, evenly placed, normal.
non-protruding, with symmetrical, non-
scant amount of protruding, with
secretions, both eyes scant amount of
black and clear. secretions, both
eyes black and
clear.
Eyebrows Black, symmetrical, Black and some Findings are Thinning and
thick, can raise & are white, normal for an graying of scalp,
lower eyebrows symmetrical, older adult pubic and
symmetrically and thick, and evenly axillary hair
without difficulty, distributed, because of
even distributed & parallel with each progressive loss
parallel with each other, can raise & of pigment cells
other lower eyebrows from the hair
without difficulty bulbs.
(Fundamentals
of Nursing by
 13

Kozier pp.412)

Eyelashes It is black, evenly Black, evenly All findings are Normal

distributed and turned distributed and normal.
outward. turned outward.
Eyelids Inspection: Upper lids Upper lids cover a All findings are Normal
cover a small portion small portion of normal.
of the iris, cornea and the iris, cornea
the sclera when the and the sclera
eyes are open. When when the eyes are
the eyes are closed, the open. When the
lids meet completely. eyes are closed,
Symmetrical, color is the lids meet
the same as the completely.
surrounding skin. Symmetrical,
color is the same
as the surrounding
skin.

Palpation: No Not done

Palpable mass

Not done
Not done
Lid margins Clear, without scaling Clear, without All findings are Normal
or secretions, lacrimal scaling or normal.
duct opening (puncta) secretions, puncta
are evident at the nasal are evident at the
ends. nasal ends.

Lower Salmon pink, shiny, Pale, shiny, moist Deviation from Pallor is the
Palpebral moist and transparent. conjunctiva normal result of
Conjunctiva inadequate
circulating
 14

blood or
hemoglobin.

Fundamentals
of Nursing by:
Kozier (p.535)
Sclera White and clear White and clear All findings are Normal
normal.
Iris Proportional to the Proportional to Findings are Arcus Senilus
size of the eye, round, the size of the normal for an an opaque
black and eye, round, older adult grayish white
symmetrical. clouding around ring around the
the iris and edge of iris;
symmetrical. usually bilateral;
does not
interfere with
vision.
(Blackwell’s
Nursing
Dictionary by
Maslin pp. 50)
Pupils From pinpoint to Black in color, All findings are Normal
almost the size of the equal in size, normal.
iris, round, round, with
symmetrical smooth border
Eye Movement Able to move eyes in Able to move All findings are Normal
full range of motion or eyes in full range normal.
able to move in all of motion or able
direction. to move in all
direction.
Visual Acuity Eyes can read Eyes can read All findings are Normal
normal.
Field of Vision Able to see 60 degrees Not done Not done Not done
superiorly, 90 degrees
temporarily and 70
degrees inferiorly.
6.Ears Parallel, symmetrical, Parallel, All findings are Normal
 15

proportional to the size symmetrical, normal.

of the head, bean- proportional to the
shaped, helix is the size of the head,
line with outer canthus bean-shaped,
of the eye; skin is helix is the line
same color as the with outer canthus
surrounding area, of the eye; skin is
clean. same color as the
surrounding area,
clean.
Ear Canal Pinkish, clean with Pinkish, clean All findings are Normal
scan amount of with scant amount normal.
cerumen and few cilia. of cerumen and
few cilia.
Hearing Able to hear whisper Able to hear Findings are Progressive loss
Acuity spoken 2 feet away. whisper spoken normal for an of hearing
1foot away. older adult. because of
changes in the
structures and
nerve tissues in
the inner ear;
thickening of
the eardrum.
(Fundamentals
of Nursing by
Kozier pp.412)
7.Nose Midline, symmetrical Midline, All findings are Normal
and patent symmetrical and normal.
patent
Internal Nares Clean, pinkish with Not done Not done Not done
few cilia
Septum Straight, midline Straight and in All findings are Normal
midline normal.
8.Mouth

Lips Pinkish, symmetrical, All findings are Normal

lip margin well- normal.
defined, smooth and
 16

moist.

Pinkish, smooth,
moist, no swelling, no
Gums retraction, no Normal
discharges.

32 permanent teeth,
well-aligned free from
caries or filing Findings are
normal for an
Teeth No teeth at all. older adult Toothloss
usually occurs
among elders
due to
inappropriate
dental hygiene.

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

Medium and pinkish Normal

color, the lateral
margin, moist, shiny All findings are
and freely movable normal.

Tongue Medium and

pinkish color, the
 17

lateral margin,
moist, shiny and
Pinkish, moist and freely movable
smooth
Normal

Pink in color, All findings are

Pinkish, moist and smooth and moist. normal.
smooth
Cheeks Normal
Pink in color, All findings are
Slightly pink smooth and moist normal.

Soft Palate All findings are Normal

Lighter pink than
soft palate, more normal.
irregular texture

Hard Palate
Frenulum Midline, straight and Midline and All findings are Normal
thin straight normal.
Uvula At the center, At the center, All findings are Normal
symmetrical and freely symmetrical and normal.
movable. freely movable.
Tonsils Pinkish, non-inflamed, Pinkish, non- All findings are Normal
no exudates inflamed, no normal.
exudates
Voice No hoarseness and No hoarseness All findings are Normal
well-modulated and well- normal.
modulated

9.Neck Inspection: Proportional to All findings are

Proportional to the the size of the normal.
size of the body and body and head, Normal
head, symmetrical and muscle equal in
straight size, head
centered
 18

Palpation:

No palpable lumps, No lumps and

masses, or areas of areas of
tenderness tenderness All findings are Normal
normal.
Range of Free movable without Free movable All findings are Normal
motion difficulty without difficulty normal.
Muscular Symmetrical and able Not done Not done Not done
Strength to resist force (both
muscle).
Posterior and Inspection: The chest Inspection:
Anterior contour is symmetrical
Thorax and chest is twice as The chest contour Deviation from A barrel
wide as deep (anterior- is symmetrical normal. chest in which
posterior diameter in a and chest is as the ratio of the
1:2 ratio) The spine wide as deep anteroposterior
straight. Posteriorly, (anterior-posterior to transverse
the ribs tend to slope diameter in a 1:1 diameter is 1:1,
across and down. The ratio) The spine is is seen in client
chest wall moves bent forward. with thoracic
symmetrically during Posteriorly, the kyphosis and
respiration. ribs tend to slope emphysema.
across and down.
The chest wall
moves Fundamentals
assymmetrically of Nursing by:
during respiration. Kozier and Erbs
( p.613)

Palpation:

No lumps, masses, Not done

areas of tenderness. Not done
Sides of the thorax
expand symmetrically.
The examiner’s thumb
separate
 19

approximately 3-5 cm
during excursion.

Vibrations are
prominent over the Not done
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,
long, low pitch. Dull-
short, high pitch, soft
and thudding, heard
over the heart. Flat- Not done
absolute dullness;
Not done
absence of air in the
underlying tissue.

Tympany- moderately
loud with musical
quality with specific
pitch.
 20

Not done

Auscultation:
Bronchial and tubular
sounds are normal.
Bronchovesicular and
vesicular breath
sounds are normal

Rales are heard

over the right
lower lobe. Rale an
abnormal, non-
continuous,
bubbling,
crackling, or
gurgling sound
associated with
pneumonia,
Deviation from congestive heart
normal. failure and long
periods of
recumbency;
heard at the base
of the lungs at
inspiration when
fluid is present
in the small air
 21

passages and
alveoli.
(Blackwell’s
Nursing
Dictionary by
Maslin pp. 505)

Abdomen Inspection:

Skin is unblemished, Skin is All findings are Normal

no scar, color is unblemished, no normal.
uniform, flat, rounded, scar, color is
or scaphoid, uniform, flat and
symmetrical has a symmetrical
movements caused by movements
respiration, and color caused by
is the same as the respiration, and
surrounding skin. color is the same
as the surrounding
skin.

Auscultation:
Auscultation: There are clicks
There are clicks and and gurgles, the
gurgles, the frequency frequency of
of which has been which has been 29
estimated from 5-34 per minute.
per minute. Occasionally,
borborygmic All findings are
Occasionally, Normal
(loud prolonged normal.
borborygmic (loud
prolonged gurgles of gurgles of
hyperperistalsis) – the hyperperistalsis) –
familiar stomach the familiar
growling can be heard. stomach growling
can be heard.
 22

Not done

Percussion:

Tympany
predominates because
of the presence of air
in the stomach and
intestines. Percussion
is dull at the liver’s
lower boarder.

Palpation:
Not Done
Soft abdomen, no
tenderness, no muscle Soft abdomen, no Not Done
guarding, no lumps or tenderness, no
masses. muscle guarding,
no lumps or
masses.

All findings are

normal.
Normal

Heart Inspection and

 23

palpation:

Aortic valve- no Aortic valve, All findings are Normal

pulsations. pulmonic and normal
tricuspid area - no
Pulmonic area- no pulsations
pulsations.
Apical area-
Tricuspid area- no pulsations are
pulsations. visible and
Apical area- pulsations palpable.
are visible and
palpable.

Auscultation:
Aortic valve- no
Aortic valve- S1 sound sound
Pulmonic area- S1 Pulmonic area- no
sound sound Deviations from
normal Aorticstenosis is
Tricuspid valve- S1 Tricuspid valve- the narrowing of
and S2 sounds S1 and S2 sounds the aortic valve
orifice which
Apical area- S1 and S2 Apical area- S1 causes an
sounds and S2 sounds obstruction to
the flow of
blood from the
left ventricle to
the aorta.
(Blackwell’s
Nursing
Dictionary by
Maslin pp.46)
 24

Breast Inspection:

Variable in size
depending on body
built. Obese clients
may have a large and Not Done Not Done Not Done
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

Areola Inspection:

Round or oval, color

darker than
surrounding skin, Not Done Not Done Not Done
symmetrical. For dark
skinned client, color is
darker than other skin
surfaces.
 25

Palpation:

No masses and areas

of tenderness.

Not Done Not Done Not Done

Nipples Inspection:

Round or inverted,
equal in size, similar
in color, both nipples Not Done Not Done Not done
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

Upper
Extremities
Arm Inspection: Inspection:

Skin color is Tan, Skin color is Tan, All findings are Normal
symmetrical, thin symmetrical, thin normal.
hairs, there are visible of hairs, there are
veins visible veins
 26

Palpation: Palpation:

The fingers are The fingers are

symmetrical symmetrical
All findings are Normal
normal.

Warm, dry and elastic, Warm, dry and

there are no areas of there is loss of
tenderness elasticity, there
are no areas of
tenderness

Palm Palms are pale in Pallor, warm and Deviations from Pallor is the
color, warm and rigid rigid normal result of
inadequate
circulating
blood or
hemoglobin.

Fundamentals
of Nursing by:
Kozier (p.535)

Nails Convex curvature, Convex curvature, Deviations from Delayed return

angle of nail plate smooth texture, normal of pink or usual
about 160 °, Highly pale nailbeds and color may
vascular and pink in it takes 3 seconds indicate
light-skinned clients before it turns circulatory
and intact epidermis back to its impairment
original color.

Fundamentals
of Nursing by:
 27

Kozier (p.543)
*Range of
Motion
Arms Abduct, adduct, and
rotate - Performs with
relative ease Not done Not done Not done

Elbows Bend and straighten- Bend and

Perform with relative straighten elbows
ease. with relative ease All findings are Normal
normal.

Hands and Extend and spread the Extend and spread

wrists fingers. Make a fist, the fingers. Make
thumb across the a fist, thumb All findings are Normal
knuckles- performs across the normal.
with relative ease. knuckles-
performs with
relative ease.

Lower
extremities
Legs Inspection: Inspection:

Skin varies (pinkish, Skin is tan, dry, Deviations from Generalized

tan, dark, brown), skin absence of hair, normal edema is most
is smooth, fine hair, absence of often an
evenly distributed, varicose veins, indication of
absence of varicose muscles impaired venous
veins, muscles symmetrical, circulation and
symmetrical, length length in some cases
symmetrical. symmetrical. reflects cardiac
dysfunction or
venous
There is presence abnormalities.
of edema on feet Fundamentals
with a scale of of Nursing by:
 28

2+. 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
Palpation:
of Nursing by
Palpation: Muscles appear Kozier pp.412)
equal, warm and
Muscles appear equal, poor muscle tone.
warm and with good
muscle tone.

Findings is
normal for an
older adult
 29

Toes Inspection: Five toes in each Deviations from Pallor is the

foot, nail beds are normal result of
Five toes in each foot: pale, sole have inadequate
sole and dorsal surface rough surface circulating
is smooth, with pink blood or
nail beds. hemoglobin.

Fundamentals
of Nursing by:
Kozier (p.535)

Palpation:

As pressure is applied,
the nail beds appear Not done
white or blanched;
pink color returns Not done
when pressure is
released. Not done

*Range of
Motion
Legs Abduct, adduct, rotate, Wasn’t able to Deviation from Hypokalemia an
walk to and from- perform the task normal abnormally low
performs with relative level of
ease. potassium in the
blood.
Symptoms are
variable but
may include
muscle
 30

weakness and
fatigue, nausea
and/or vomiting
and etc.

(Blackwell’s
Nursing
Dictionary by
Maslin pp. 290)

Knees Bend and extend – Bend and extend

performs with relative knees with
ease. relative ease All findings are Normal
normal.

Ankles Flexion and extension, Wasn’t able to Deviation from Hypokalemia an

rotation – performs perform normal abnormally low
with relative ease. 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)

Toes Spread and wiggles – Has difficulty in Deviation from Hypokalemia an

perform with relative abnormally low
 31

ease performing normal 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)

III. LABORATORY EXAMINATIONS

ELECTROCARDIOGRAM (ECG)

Date: August 20, 2009

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Impression:

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

BLOOD CHEMISTRY

Date: August 14, 2009

PARAMETER ACTUAL NORMAL ANALYSIS

FINDINGS FINDINGS
Protein Specific 7.8 <4 ng/mL Increase due to
Antigen (PSA) enlargement of the
prostate

HEMATOLOGY

Date: August 16, 2009

PARAMETER ACTUAL NORMAL ANALYSIS

FINDINGS FINDINGS
White Blood 9.4 x 10^g/L 5-10 x 10^g/L Normal
Cells
Hemoglobin 9.2 g/dL M: 14 -18 g/dL Decreased due to
decrease RBC and
malnutrition
Hematocrit 28 % 40-54 % Decreased due to
decrease RBC and
Malnutrition
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

Date: August 14, 2009

PARAMETER ACTUAL NORMAL ANALYSIS

FINDINGS FINDINGS
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:
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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

Date: August 12, 2009

PARAMETER ACTUAL NORMAL ANALYSIS

FINDINGS FINDINGS
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
Microscopic Exam:
WBC 2-6 M: 0-2/ HPF Increase due to
 35

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

I. 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

 37

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
 38

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.
 39

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.

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

 57

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