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A case study about patient M.G. diagnosed with Cellulitis, both lower extremities, Systemic Lupus Erythematosus with Nephritis, Chronic Venous
Insufficiency and Hypertensive Cardiovascular Disease

Submitted to:
Mrs. Cecilia Ramos RN, MAN

Submitted by:
Centino, Lady Di
Deluta, Cathy
Gruta, Justine Danillee
Zosa, Razi
Cariaga, Fredelyn
Colina, Oñin Reyjoys Love
Mangio, Aira Marie
Laput, Sean
Lauron, Queenie Ann
Salumbre, Dallas Mairi
Soco, Bianca Marie
Velez, Annette
 Cellulitis
Cellulitis is a nonnecrotizing inflammation of the skin and subcutaneous tissues, usually related to an acute bacterial infection that does not involve the fascia
or muscles. In most cases, only the surface of the skin is infected. However, the infection may spread to underlying tissues or worse, enter the bloodstream
and spread to the lymph nodes, leading to life-threatening complications.

CAUSES
Cellulitis is caused by the invasion of bacteria through a crack or break in the skin. The break does not need to be visible. Skin injuries such as cuts, insect
bites, surgical incision and burns are common portals of entry for the infection.
Streptococcal species are the most common causes of erysipelas (bacterial infection of the upper dermis) and diffuse cellulitis and nonpurulent cellulitis. In
purulent cellulitis, S. aureus is the usual causative organism, associated with faruncles, carbuncles and abscesses.

CLASSIFICATION
Eron’s Classification of Cellulitis
Class I: Healthy patient with cellulitis that is less than 15 cm in diameter, with or without fever. No signs of systemic toxicity. Patient may take oral
antibiotics at home.
Class II: Healthy patients or patients with peripheral vascular disease, diabetes or obesity with cellulitis that is greater than 15 cm in diameter, with or without
fever. This also includes patients in whom antibiotics have failed.
Class III: Patients with fever and changes in mental status. May also include confusion, tachycardia, breathlessness and hypotension. There are physical
findings of limb threatening conditions such as gangrene, bullae or open draining wounds due to vascular compromise.
Class IV: Patients with systemic complications of severe infection (e.g. septicemia, necrotizing fasciitis, hypotension, renal failure, acute respiratory distress
syndrome).

INCIDENCE AND RISK FACTORS

In 2013, around 155 million people were affected by bacterial skin infections and of those, cellulitis occured in 37 million people. In other words, 2 out of
10,000 people every year are being affected by this infection. In that same year, 30,000 deaths worldwide were the result of cellulitis.
Risk factors include the following:
 Injury. Any cut, fracture, burn or scrape gives bacteria an entry point.
  Weakened immune system. Patients with a weakened immune system as a result of conditions such as diabetes, leukemia and HIV/AIDS are
more susceptible to infections. Certain medications, such as corticosteroids, also can weaken the immune system.
 Skin conditions. Skin disorders (such as eczema, athlete's foot, chickenpox and shingles) can cause breaks in the skin and give bacteria an entry
point.
 Chronic swelling of your arms or legs (lymphedema). Swollen tissue may crack, leaving the skin vulnerable to bacterial infection.
 History of cellulitis. Patients who have had cellulitis before, especially those whose lower legs were affected, are more prone to develop another
episode of the infection.
 Intravenous drug use. People who inject illegal drugs have a higher risk of developing cellulitis.
 Obesity. Being overweight or obese increases the risk of developing cellulitis and having recurring episodes.

SIGNS AND SYMPTOMS

Symptoms include the following:
 pain and tenderness in the affected area
 redness or inflammation of your skin
 a skin sore or rash that appears and grows quickly
 a tight, glossy, swollen appearance of the skin
 a feeling of warmth in the affected area
 a central area that has an abscess with pus formation
 a fever

A more serious cellulitis infection may include:

 shaking
  chills
 a feeling of illness
 fatigue
 dizziness
 lightheadedness
 muscle aches
 warm skin
 Sweating

A spreading cellulitis infection may manifest as:

 drowsiness
 lethargy
 blistering
 red streaks

COMPLICATIONS
Cellulitis may spread to underlying tissues and enter the bloodstream and lymph nodes, leading to the following complications:
 Septicemia. An infection of the blood caused by an overwhelming immune response to infection. Chemicals released into the blood to fight
infection trigger widespread inflammation. This is a life-threatening medical emergency characterized by fever, chills, oliguria, tachycardia,
tachypnea, nausea, vomiting and diarrhea. This may further lead to organ damage and consequently, organ failure. Septic shock may also result
once the blood pressure fall to dangerous levels.
  Osteomyletis. An infection of the bone characterized by fever, irritability, nausea, fatigue, tenderness, redness and warmth at the site of infection,
swelling around the affected bone and lost range of motion. The infection may enter the bone via bloodstream.
 Lymphadenitis. An inflammation of the lymph nodes characterized by erythema, tenderness and swelling over the affected lymph node
 Necrotizing fasciitis. Commonly known as a “flesh-eating disease” by the media, it is an infection of the fascia with secondary necrosis of
subcutaneous tissues. Symptoms include skin with erythema, swelling and warmth, fever, chills, nausea, vomiting and diarrhea. It may also
damage skin, fat and tissue covering the muscle (otherwise known as gangrene) due to a critically insufficient blood supply to the tissues, and
eventually lead to organ failure and death.

DIAGNOSIS
 Physical Examination. Your doctor will check the area of the rash to see if your symptoms are consistent with cellulitis. He or she may mark the
area of the rash with a marker to track its spread. He or she may also examine your lymph nodes to check for signs of infection and test any fluid
that has accumulated at the site of the rash.
 Blood Test. Blood tests may also be ordered to rule out the possibility of a blood clot, as deep vein thrombosis and cellulitis can have similar
symptoms.
 Complete Blood Count. A complete blood count (CBC) may be used to check for an elevated white blood cell count, which indicates infection.
 Culture. A culture is done to identify the bacteria present in skin, blood, pus or tissue specimens, but usually this is not necessary unless a person
is seriously ill or has a weakened immune system or the infection is not responding to drug therapy.
TREATMENT AND PREVENTION
 Antibiotic Therapy. Prompt treatment with antibiotics can prevent the bacterial infection from spreading rapidly and reaching the blood and
internal organs. Antibiotics that are effective against both streptococci and staphylococci (such as dicloxacillin or cephalexin) are used. If doctors
suspect methicillin-resistant Staphylococcus aureus (MRSA) infection, treatment may include antibiotics such as trimethoprim with
sulfamethoxazole, clindamycin, or doxycycline by mouth. People with mild cellulitis may take antibiotics by mouth. People with rapidly
spreading cellulitis, high fever, or other evidence of serious infection are hospitalized and given antibiotics by vein (such as oxacillin or nafcillin).

Symptoms of cellulitis usually disappear after a few days of antibiotic therapy. However, cellulitis symptoms often get worse before they get better probably
because, with the death of the bacteria, substances that cause tissue damage are released. When this release occurs, the body continues to react even though
the bacteria are dead. Antibiotics are continued for 10 days or possibly as long as 14 days even though the symptoms may disappear earlier.

 Abscess Drain. The doctor makes a cut on any purulent abscesses present and allows them to drain.

In patients with recurrent cellulitis, the doctor may recommend preventive antibiotics. Other precautions that can be taken are the following:
 Washing the wound daily with soap and water.
 Applying a protective cream or ointment. For superficial wounds, an OTC antibiotic ointment provides adequate protection.
 Covering the wound with a bandage. Change bandages at least daily.
 Watching for signs of infection. Redness, pain and drainage all signal possible infection and the need for medical evaluation.

People with diabetes and those with poor circulation need to take extra precautions to prevent skin injury. Good skin care measures include the following:
 Inspecting the feet daily for signs of injury to ensure early detection.
 Moisturizing the skin regularly to prevent cracking and peeling.
 Trimming the fingernails and toenails carefully. Caution must be observed as to not damage surrounding tissue.
  Protecting the hands and feet with footwear and gloves.
 Promptly treating the superficial infections, such as athlete's foot. Superficial skin infections can easily spread from person to person.

NURSING MANAGEMENT
 Keep the affected limb elevated to facilitate venous return.
 Advise the client to observe strict compliance of antibiotics and inform them of the consequences that may result when medication is not being
taken as prescribed such as the development of methicillin-resistant S. aureus.
 Administer analgesics as needed and as prescribed by the physician.
 Encourage the client to include in their diet foods rich in vitamin C such as oranges, broccoli, guava, and red and green peppers.
 Teach the client and SOs the importance of proper hand washing in preventing the spread of microorganisms.
 Secure specimen for the laboratory identification of the bacteria present in the specimen so that the proper therapy can be employed.
 Monitor progress of any complications that may arise during the healing process
 Keep the affected area clean and dry and carefully dress wounds to assist body’s natural process of healing.
 Use appropriate dressings during wound care to protect the wound and surrounding tissues.
 For potentially serious wounds, consult with the doctor to develop an appropriate care plan.

Systemic Lupus Erythematosus

Systemic Lupus Erythematosus is a chronic autoimmune disease characterized by the production of unusual antibodies in the blood. In which the body’s
immune system mistakenly attacks the healthy tissues that later on affects the skin, joints, kidney, brain and other organs in the body. People diagnosed with
lupus produces abnormal antibodies that target the tissues within their own body instead of attacking foreign infectious agents. When only the skin is involved
by rash, the condition is called lupus dermatitis or cutaneous lupus erythematosus. A form of lupus dermatitis that can be isolated to the skin, without internal
disease, is called discoid lupus. When internal organs are involved, the condition is referred to as systemic lupus erythematosus.

CAUSES
The exact cause of SLE is unknown, but several factors have been associated with the disease.
Genetics: The disease isn’t linked to a certain gene, but people with lupus often have family members with other autoimmune conditions.
Environmental triggers can include ultraviolet rays, certain medications, viruses, physical or emotional stress, and trauma.
Gender: SLE affects women more than men. Women also may experience more severe symptoms during pregnancy and with their menstrual periods. Both
of these observations have led some medical professionals to believe that the female hormone estrogen may play a role in causing SLE. However, more
research is still needed to prove this theory.

CLASSIFICATION
1) Systemic lupus erythematosus (SLE)
When most people talk about lupus, they are referring to SLE.
"Systemic" means that the disease can affect numerous parts of the body. The symptoms of SLE can be mild or severe, and although more common in people
aged between 15-45, it can additionally occur during childhood or later in life.10
2) Discoid lupus erythematosus (DLE)
DLE is a chronic skin disorder in which a red, raised rash appears on the face, scalp or elsewhere on the body.10
The raised areas may become thick and scaly and may cause scarring. The rash may last for days or years and may recur. Small percentages of people with
DLE have or will develop SLE.
3) Subacute cutaneous lupus erythematosus
Subacute cutaneous lupus erythematosus refers to skin lesions that appear on parts of the body exposed to sun. The lesions do not cause scarring.10
4) Drug-induced lupus
There are a number of medications that can cause drug-induced lupus such as some antiseizure, high blood pressure, thyroid medications, antibiotics,
antifungals and oral contraceptive pills. The symptoms usually completely disappear once the drug has stopped being taken.

5) Neonatal lupus
Neonatal lupus is a rare disease that can occur in newborn babies of women with SLE, Sjögren's syndrome, or with no disease at all. Most babies of mothers
with SLE are healthy
Sjögren syndrome is a systemic chronic inflammatory disorder characterized by lymphocytic infiltrates in exocrine organs.

INCIDENCE AND RISK FACTORS: Lupus is not contagious, and it cannot be transmitted sexually.
 Gender - more than 90% of people with lupus are women. Before puberty, boys and girls are equally likely to develop the condition
 Age - symptoms and diagnosis of lupus often occur between the ages of 15-45. Around 15% of people who are later diagnosed with lupus,
experienced symptoms before the age of 18
 Race - in the US, lupus is more common, more severe and develops earlier in African-Americans, Hispanics/Latinos, Asian-Americans, Native
Americans, Native Hawaiians and Pacific Islanders than in the white population
 Family history - first-degree or second-degree relatives of a person with lupus have a 4-8% risk of developing lupus. One study suggests that sisters
of lupus patients have as high as a 10% chance of developing lupus. In another 10-year prospective study, researchers observed a 7% incidence of
lupus in first-degree relatives of lupus patients.
SIGNS AND SYMPTOMS
Symptoms can vary and can change over time. Common symptoms include:
 severe fatigue
 joint pain
 joint swelling
 headaches
 a rash on the cheeks and nose, which is called a “butterfly rash”
 hair loss
 anemia
 blood-clotting problems
 fingers turning white or blue and tingling when cold, which is known as Raynaud’s phenomenon
 Other symptoms depend on the part of the body the disease is attacking, such as the digestive tract, the heart, or the skin.

Lupus symptoms are also symptoms of many other diseases, which makes diagnosis tricky. If you have any of these symptoms, see your doctor. Your doctor
can run tests to gather the information needed to make an accurate diagnosis.

COMPLICATIONS
Over time, SLE can damage or cause complications in systems throughout your body. Possible complications may include:
 blood clots and inflammation of blood vessels or vasculitis
 inflammation of the heart, or pericarditis
  a heart attack
 a stroke
 memory changes
 behavioral changes
 seizures
 inflammation of lung tissue and the lining of the lung, or pleuritis
 kidney inflammation
 decreased kidney function
 kidney failure

SLE can have serious negative effects on your body during pregnancy. It can lead to pregnancy complications and even miscarriage. Talk with your doctor
about ways to reduce the risk of complications.

DIAGNOSIS
Your doctor will do a physical exam to check for typical signs and symptoms of lupus, including:
 sun sensitivity rashes, such as a malar or butterfly rash
 mucous membrane ulcers, which may occur in the mouth or nose
 arthritis, which is swelling or tenderness of the small joints of the hands, feet, knees, and wrists
 hair loss
 hair thinning
 signs of cardiac or lung involvement, such as murmurs, rubs, or irregular heartbeats
No one single test is diagnostic for SLE, but screenings that can help your doctor come to an informed diagnosis include:
1.) blood tests, such as antibody tests and a complete blood count
2.) a urinalysis
3.) a chest X-ray

Your doctor might refer you to a rheumatologist, which is a doctor who specializes in treating joint and soft tissue disorders and autoimmune diseases.

MANAGEMENT AND PREVENTION

No cure for SLE exists. The goal of treatment is to ease symptoms. Treatment can vary depending on how severe your symptoms are and which parts of your
body SLE affects. The treatments may include:
 anti-inflammatory medications for joint pain and stiffness
 steroid creams for rashes
 corticosteroids to minimize the immune response
 antimalarial drugs for skin and joint problems
 disease modifying drugs or targeted immune system agents for more severe cases
 your diet and lifestyle habits. eating or avoiding certain foods and minimizing stress to reduce the likelihood of triggering symptoms.
 You might need to have screenings for osteoporosis since steroids can thin your bones
 May also recommend preventive care, such as immunizations that are safe for people with autoimmune diseases and cardiac screenings
 NEPHRITIS

Nephritis is the inflammation of the kidney that leads to impaired kidney function. May be caused by infections and toxins, but most commonly caused by
autoimmune disease that affects the organs of the body like the kidneys. Nephritis is a general term to describe a group of disease that may cause the
inflammation or swelling of the kidneys. It involves the tubule, intestinal renal tissues, glomerulus, and may also affect the glomeruli called
glomerulonephritis.
TYPES OF NEPHRITIS
Acute Nephritis:
 Interstitial Nephritis - the spaces between the kidney tubules become inflamed. This inflammation causes the kidneys to swell.
 Pyelonephritis - is an inflammation of the kidney, usually due to a bacterial infection. In the majority of cases, the infection starts within the bladder
and then migrates up the ureters and into the kidneys. Ureters are two tubes that transport urine from each kidney to the bladder.
 Glomerulonephritis - this type of acute nephritis produces inflammation in the glomeruli. There are millions of capillaries within each kidney.
Glomeruli are the tiny clusters of capillaries that transport blood and behave as filtering units. Damaged and inflamed glomeruli may not filter the
blood properly.
 Lupus Nephritis - a form of glomerulonephritis occurring in some people with systemic lupus erythematosus, lead to a progressive course resulting in
renal failure. May be characterized by hematuria, proteinuria, or both, with or without associated hypertension.
 Interstitial nephritis - is an immunological adverse reaction to certain drugs, often sulfonamide or methicillin. Acute renal failure, fever, rash, and
proteinuria are characteristic of this condition. Most people regain normal kidney function when the offending drug is discontinued.

If acute nephritis cannot be controlled immediately, it may develop into chronic kidney damage.

CAUSES
Pyelonephritis is inflammation that results from a urinary tract infection that reaches the renal pelvis of the kidney.
Lupus nephritis is caused by systemic lupus erythematosus, a disease of the immune system.
Athletic nephritis is resulting from strenuous exercise. Bloody urine after strenuous exercise may also result from hemoglobinuria, which is caused by trauma
to red blood cells, causing their rupture, which leads to the release of hemoglobin into the urine

INCIDENCE AND RISK FACTORS

Certain people are at greater risk for acute nephritis. The risk factors for acute nephritis include:
 a family history of kidney disease and infection
  having an immune system disease, such as lupus
 taking too many antibiotics or pain medications
 recent surgery of the urinary tract

SIGNS AND SYMPTOMS

Symptoms will vary depending on the type of acute nephritis you have. The most common symptoms of all three types of acute nephritis are:
 pain in the pelvis
 pain or a burning sensation while urinating
 a frequent need to urinate
 cloudy urine
 blood or pus in the urine
 pain in the kidney area or abdomen
 swelling of the body, commonly in the face, legs, and feet
 vomiting
 fever
 high blood pressure
 glomerulonephritis

The chronic form can creep up without any symptoms. There may be slow development of symptoms similar to the acute form. Some symptoms include:
 blood or excess protein in your urine, which may be microscopic and show up in urine tests
 high blood pressure
 swelling in ankles and face (edema)
 frequent nighttime urination
 bubbly or foamy urine (from excess protein)
 abdominal pain
 frequent nosebleeds
COMPLICATION
 Glomerulonephritis can lead to nephrotic syndrome, where you lose large amounts of protein in your urine. This leads to a lot of fluid and salt
retention in your body. You can develop high blood pressure, high cholesterol, and swelling throughout your body. Corticosteroids treat this condition.
Eventually, nephrotic syndrome will lead to end-stage renal disease if it doesn’t come under control.

The following conditions can also occur:

 acute kidney failure
 chronic kidney disease
 electrolyte imbalances, such as high levels of sodium or potassium
 chronic urinary tract infections
 congestive heart failure due to retained fluid or fluid overload
 pulmonary edema due to retained fluid or fluid overload
 high blood pressure
 malignant hypertension, which is rapidly increasing high blood pressure
 increased risk of other infections

DIAGNOSIS
The first step is to have a urinalysis test. A routine physical exam for another condition can also lead to the discovery of GN. Blood and protein in the urine
during urinalysis are important markers for the disease.
More urine testing may be necessary to check for important signs of kidney health, including:
 creatinine clearance
 total protein in the urine
 urine concentration
 urine specific gravity
 urine red blood cells (RBCs)
 urine osmolality

Blood tests may show:

  anemia, which is a low level of red blood cells
 abnormal albumin levels
 abnormal blood urea nitrogen
 high creatinine levels

Immunology testing can also check for things, such as:

 antiglomerular basement membrane antibodies
 antineutrophil cytoplasmic antibodies
 antinuclear antibodies
 complement levels

These are all signs that your immune system may be damaging your kidneys.
A biopsy (a small sample taken with a needle) of the kidneys may be necessary to confirm the diagnosis.
To learn more about your condition, you may also have scans such as:
 CT scan
 Kidney ultrasound
 Chest X-ray

TREATMENT AND PREVENTION

 One treatment is to control high blood pressure. The doctor may prescribe blood pressure medications, including angiotensin-converting enzyme
inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs).
 Corticosteroids may also be used if immune system is attacking your kidneys to reduce the immune response.
 A doctor will typically prescribe antibiotics to treat the kidney infection. If your infection is very serious, you may require intravenous (IV) antibiotics
within the hospital inpatient setting. IV antibiotics tend to work faster than antibiotics in pill form. Infections like pyelonephritis can cause severe pain.
Your doctor may prescribe medication to relieve pain as you recover.
  Dialysis - If your kidney function is significantly impaired due to your infection, you may require dialysis. This is a process in which a special
machine acts like an artificial kidney. Dialysis may be a temporary necessity. However, if your kidneys have experienced too much damage, you may
need dialysis permanently.
 Increase your fluid intake to prevent dehydration and keep the kidneys filtering to release waste products.
 A special diet low in certain electrolytes, such as potassium. Many fruits and vegetables are high in potassium. Can also soak some vegetables in
water and drain the water before cooking them. This process, known as leaching, can remove extra potassium.

Chronic Venous Insufficiency

Chronic venous insufficiency (CVI) is a condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it
difficult for blood to return to the heart from the legs. CVI causes blood to “pool” or collect in these veins, and this pooling is called stasis. It can be caused by
several different vein disorders, but it’s most often caused by either blood clots or varicose veins.

CAUSES
Venous insufficiency is most often caused by either blood clots or varicose veins. In healthy veins, there is a continuous flow of blood from the limbs back
toward the heart. Valves within the veins of the legs help prevent the backflow of blood.
The most common causes of venous insufficiency are previous cases of blood clots and varicose veins. When forward flow through the veins is obstructed
(such as in the case of a blood clot) blood builds up below the clot, which can lead to venous insufficiency. In varicose veins, the valves are often missing or
impaired and blood leaks back through the damaged valves. In some cases, weakness in the leg muscles that squeeze blood forward can also contribute to
venous insufficiency.
INCIDENCE AND RISK FACTOR
Other risk factors include:
 blood clots
 varicose veins
 obesity
 pregnancy
 smoking
 cancer
 muscle weakness, leg injury, or trauma
 swelling of a superficial vein (phlebitis)
 family history of venous insufficiency
 inactivity (sitting or standing for long periods of time without moving can cause high blood pressure in the leg veins and increase your risk)

SIGNS AND SYMPTOMS

 Swelling in the lower legs and ankles, especially after extended periods of standing.
 Aching or tiredness in the legs.
 New varicose veins.
 Leathery-looking skin on the legs.
 Flaking or itching skin on the legs or feet.
 Stasis ulcers (or venous stasis ulcers)
  a feeling of tightness in your calves
 pain that gets worse when you stand and gets better when you raise your legs
 leg cramps
 aching, throbbing, or a feeling of heaviness in your legs
 itchy legs
 weak legs

COMPLICATION
Complications of untreated venous insufficiency include the following:
 Recruitment of veins – High venous pressures may cause the recruitment of adjacent normal veins into refluxing circuits.
 Deep Vein Thrombosis (DVT)
 Pulmonary embolism (PE)

MANAGEMENT AND TREATMENT

Treatment for venous insufficiency can include several different strategies:
Improving Blood Flow Include:
 keep your legs elevated whenever possible
 wear compression stockings to apply pressure to lower legs
 keep your legs uncrossed when seated
 exercise regularly
Medications
There are also a number of medications that may help those suffering from this condition. These include:
 diuretics: medications that draw extra fluid from your body through your kidneys
 anticoagulants: medications that thin the blood
 pentoxifylline (Trental): a medication that helps improve blood flow

Surgery
Sometimes more serious cases of venous insufficiency require surgery. Your doctor may suggest one of the following surgery types:
 surgical repair of veins or valves
 removing (stripping) the damaged vein
 minimally invasive endoscopic surgery — the surgeon inserts a thin tube with a camera on it to help see and tie off varicose veins
 vein bypass (a healthy vein is transplanted from somewhere else in your body) — this procedure is generally used only when the upper thigh is
affected and only for very severe cases after nothing else has worked
 laser surgery — this relatively new treatment uses lasers to either fade or close the damaged vein with strong surges of light in a small, specific place.
It involves no surgical cuts

If you have a family history of venous insufficiency, there are steps you can take to lessen your chances of developing the condition:
 Don’t sit or stand in one position for long stretches of time — get up and move around frequently.
 Don’t smoke and if you do smoke, quit.
 Get regular exercise.
 Maintain a healthy body weight.
 HYPERTENSIVE CARDIOVASCULAR DISEASE

Hypertensive Cardiovascular Disease refers to heart conditions caused by high blood pressure.

Types of Hypertensive Heart Disease

In general, the heart problems associated with high blood pressure relate to the heart’s arteries and muscles.

Narrowing of the Arteries- Coronary arteries transport blood to your heart muscle. When high blood pressure causes the blood vessels to become narrow,

blood flow to the heart can slow or stop. This condition is known as coronary heart disease (CHD), also called coronary artery disease. CHD makes it difficult

for your heart to function and supply the rest of your organs with blood. It can put you at risk for heart attack from a blood clot that gets stuck in one of the

narrowed arteries and cuts off blood flow to your heart.

Thickening and Enlargement of the Heart- High blood pressure makes it difficult for your heart to pump blood. Just like other muscles in your body,

regular hard work causes your heart muscles to thicken and grow. This alters the way the heart functions. These changes usually happen in the main pumping

chamber of the heart, the left ventricle. The condition is known as left ventricular hypertrophy (LVH). CHD can cause LVH and vice versa: When you have

CHD, your heart must work harder. If your heart is enlarged because of LVH, it can compress the coronary arteries
 Complications:

Both CHD and LVH can lead to:

 Heart failure
 Arrhythmia
 Ischemic heart disease
 Heart attack
 Sudden cardiac arrest
 Stroke and sudden death

Who Is at Risk for Hypertensive Heart Disease?

The main risk factor for hypertensive heart disease is high blood pressure. Your risk increases if:

 Overweight
 Lack of exercise
 Smoking
 Eating high-fat and high-cholesterol foods
 Genetics
 Gender- Men are more likely to get heart disease than women who have not gone through menopause. Men and postmenopausal women are equally at risk.
Your risk for heart disease will increase as you age, regardless of your gender.

SIGNS AND SYMPTOMS

Symptoms vary depending on the severity of the condition and progression of the disease. You may experience no symptoms, or your symptoms may include:

 Chest pain (angina)

 Tightness or pressure in the chest
 Shortness of breath
 Fatigue
 Pain in the neck, back, arms, or shoulders
 Persistent cough
 Loss of appetite
 Foot or ankle swelling

Diagnosis

 Assessment of medical history

  Physical Exam

 Lab Tests to check your kidneys, sodium, potassium, and blood count.

 Electrocardiogram

 Echocardiogram

 Coronary Angiography

 Exercise Stress Test

TREATMENT

 Nitrates to treat chest pain

 HMG CoA Reductase Inhibitor
 Beta-blockers
 Aspirin
Integumentary system
The skin is the largest organ in the body. In humans, it accounts for about 12 to 15 percent of total body weight and covers 1.5-2m2 of surface area.[4] It
distinguishes, separates, and protects the organism from its surroundings. Small-bodied invertebrates of aquatic or continually moist habitats respire using the
outer layer (integument). This gas exchange system, where gases simply diffuse into and out of the interstitial fluid, is called integumentary exchange.

The human skin (integument) is composed of a minimum of two major layers of tissue: the epidermis and dermis. (The hypodermis or subcutaneous layer is
not part of the skin.) The epidermis forms the outermost layer, providing the initial barrier to the external environment. Beneath this, the dermis comprises
two sections, the papillary and reticular layers, and contains connective tissues, vessels, glands, follicles, hair roots, sensory nerve endings, and muscular
tissue.[5] The deepest layer is the hypodermis, which is primarily made up of adipose tissue. Substantial collagen bundles anchor the dermis to the hypodermis
in a way that permits most areas of the skin to move freely over the deeper tissue layers.

Epidermis
This layer is seen on the surface of the skin. It is made up of cells called keratinocytes, which are stacked on top of each other, forming different sub-layers.
The keratinocytes develop at the bottom and rise to the top, where they are shed from the surface as dead cells. So this layer is constantly renewing itself, the
live cells changing into dead, hard, flattened cells. Melanocytes and Langerhans cells are other important cells found in the epidermis which have special
functions

 Melanocytes
These cells produce a dark pigment called melanin which contributes to skin color and provides UV protection. They are located at the bottom of the
epidermis.

 Dendritic (Langerhans) cells

These cells are involved in the epidermal immune system. They engulf foreign material that invades the epidermis and migrate out of the skin to
stimulate an immune response.
  Basal cells
Small cells found at the bottom of the epidermis. Earlier it was believed that basal cell carcinoma is derived from these cells. As of this writing basal
cell carcinoma is thought to arise from non-differentiated cells from the basal cell layer.

Dermis
The dermis consists mostly of connective tissue and is much thicker than the epidermis. It is responsible for the skin's pliability and mechanical resistance and
is also involved in the regulation of the body temperature. The dermis supplies the avascular epidermis with nutrients by means of its vascular network. It
contains sense organs for touch, pressure, pain and temperature (Meissner´s corpuscles, Pacinian corpuscles, free nerve endings), as well as blood vessels,
nerve fibres, sebaceous and sweat glands and hair follicles.

 Blood Vessels
These are tiny pipes through which blood circulates. The blood vessels supply the skin with fresh blood, which contains nutrients and oxygen, and
carry away waste products.

 Meissner's corpuscle
These touch receptors are expecially effective in detecting light touch and soft, fleeting movements.

 Pacinian corpuscles
Pacinian corpuscles function as receptors for deep pressure and vibration.
 Free Nerve Endings
Free nerve endings are sensitive to pain, temperature changes and itchiness.

 Nerve Fibers
Nerve fibres forward information.

 Sebaceous Glands
Sebaceous or oil glands are small, sacculated organs that secrete sebum. This oily substance is a natural moisturiser which conditions the hair and
skin. Sebaceos glands are found all over the body, but they are more numerous in the scalp area and around the forehead, chin, cheeks and nose.

 Sweat Glands
These are sweat-producing structures consisting of a single tube, a coiled body and a superficial duct. They are involved in thermoregulation, as they
cool the skin by sweating.

 Hair Follicles
Hair follicles are downward growths into the dermis of epidermal tissue and produce hair. They are found all over the body except on the palms of the
hands and soles of the feet as well as on the lips. When the body gets cold, the hair stands upright with the help of the arrector pili muscle, closing up
the skin's pores and keeping the warmth in.

 Arrector pili muscle

This small muscle is attached to the base of the follicle. When it is stimulated by cold or fright, it pulls the hair follicle up, causing it to stand upright.
Functions

The integumentary system has multiple roles in homeostasis. All body systems work in an interconnected manner to maintain the internal conditions essential
to the function of the body. The skin has an important job of protecting the body and acts as the body’s first line of defense against infection, temperature
change, and other challenges to homeostasis. Functions include:

 Protect the body’s internal living tissues and organs

 Protect against invasion by infectious organisms
 Protect the body from dehydration
 Protect the body against abrupt changes in temperature, maintain homeostasis
 Help excrete waste materials through perspiration
 Act as a receptor for touch, pressure, pain, heat, and cold (see Somatosensory system)
 Protect the body against sunburns by secreting melanin
 Generate vitamin D through exposure to ultraviolet light
 Store water, fat, glucose, vitamin D
 Maintenance of the body form
 Formation of new cells from stratum germanium to repair minor injuries
 Protect from UV rays
 The Lymphatic System and Immunity

Lymph
Lymph is the name for tissue fluid that enters lymph capillaries. Filtration in capillaries creates tissue fluid from the blood plasma, most of which returns
almost immediately to the blood by osmosis. Some tissue fluid, however, remains in interstitial spaces and must be returned by the blood by way of lymphatic
vessels.
Lymph vessels
The system of lymph vessels begin as dead-end lymph capillaries found in most tissue spaces. Lymph capillaries are very permeable and collect tissue fluid
and protein.
 Lacteal are specialized lymph capillaries in the villi of the small intestine; they absorb the fat soluble end products of digestion, such as fatty acids
and vitamin A, D, E, and K.
 Skeletal muscle pump the smooth muscle layer of the larger lymph vessel constrict and the one way valve prevent the backflow of the lymph.
Lymph vessels in the extremities, especially the legs, are compressed by the skeletal muscles that surround them.
 Respiratory pump alternately expands and compress the lymph vessels in the chest cavity and kept the lymph moving.
  Cisterna chyli the lymph vessels from the lower body unite in front of the lumbar vertebrae to form a vessel.
 Lymph vessels from the upper left quadrant of the body join the thoracic duct, which empties lymph into the left subclavian vein. Lymph vessels
from the upper right quadrant of the body unite to form the right lymphatic duct, which empties into the right subclavian vein.
Lymphatic tissue
Lymphatic tissue consists mainly of lymphocytes in a mesh-like framework of connective tissue.
 Lymphocytes are produced from the stem cell of bone marrow, then migrate to the lymph nodes and nodule, to the spleen, and to the thymus.
Become activated and proliferate in response to infection.
Lymph nodes and nodules
Lymph nodes and nodules are masses of lymphatic tissue. Nodes and nodules differ with respect to size and location.
 Lymph nodes are found in groups along the pathway of lymph vessels, and lymph flows through these nodes on its way to subclavian vein. Lymph
enters a node through several afferent lymph vessels and leaves through one or two vessels. As lymph passes through a lymph node, bacteria and
other foreign materials phagocytized by fixed macrophages. Plasma cells develop from lymphocytes exposed to pathogens in the lymph and produce
antibodies. These antibodies will eventually reach the blood and circulate throughout the body.
 Lymph nodules are small masses of lymphatic tissue found just beneath the epithelium of all mucous membranes. The body systems lined with
mucous membranes are those that have openings to the environment: respiratory, digestive, urinary, and reproductive tracts, because any natural
body opening is a possible portal of entry for pathogens.
> Peyer’s patches lymph nodes of the small intestines.
> Tonsils are those of the pharynx.
> Palatine tonsils are on the lateral walls of the pharynx.
> Adenoid (pharyngeal tonsil) is on the posterior wall.

Spleen
The spleen is located in the upper left quadrant of the abdominal cavity, just below the diaphragm, behind the stomach. The lower rib cage protects the spleen
form physical trauma.
Function of the spleen after birth:
1. Contains plasma cells that produce antibodies to foreign antigens.
2. Contain fixed macrophages (RE cells) that phagocytize pathogens or other foreign materials in the blood. The macrophages of the spleen also
phagocytize old RBC and form bilirubin. By the way of portal circulation, the bilirubin is sent to the liver for excretion in bile.
3. Stores platelet and destroy them when they are no longer useful.
 Thymus
Thymus is located inferior to the thyroid gland. The stem cells of the thymus produce T lymphocytes or T cells. The thymus is located just behind the sternum
in the upper part of the chest. It is a bilobed organ that consists of an outer, lymphocyte-rich cortex and an inner medulla. The differentiation of T cells occurs
in the cortex of the thymus. In humans the thymus appears early in fetal development and continues to grow until puberty, after which it begins to shrink. The
decline of the thymus is believed to be the reason T-cell production decreases with age. Thymic hormones are necessary for what may be called
“immunological competence”. To be competent means to be able to do something well, the thymic hormones enable the T cells to participate in the
recognition of foreign antigens and to provide immunity.

Immunity

Immunity may be defined as the ability to destroy pathogens or foreign materials and to prevent further cases of certain infectious diseases. This ability is of
vital importance because the body is exposed to pathogens from the moment of birth.
Antigens
Are chemicals marker that identify cells. Human cells have “self” antigen-the HLA types. When antigen are foreign, or “non-self”, they may be recognizes as
such destroyed. Bacteria, fungi, virus, protozoa, are all foreign antigens that activate immune response.
Innate immunity
Innate immunity has several aspects: anatomic and physiological barriers, phagocytic and other defensive cells, and chemical secretions and reactions,
including inflammation. It is not specific, responses are always the same, does not create memory, and does not become more efficient consist of barriers,
defensive cells, and chemical defenses.
 Barriers
The stratum corneum of the epidermis of the skin is non-living, and when unbroken is an excellent barrier to pathogen of all kind. The fatty acids in
sebum help limit the growth of bacteria on the skin. The living cells of the epidermis produce defensins, which are antimicrobial chemicals. The
ciliated epithelium of the upper respiratory tract is an effective barrier. The hydrochloric acid destroys most pathogens that enter the stomach.
Lysozyme, an enzyme found in saliva and tears, inhibits the growth of bacteria in the oral cavity and in the wet surface of the eyes.

 Defensive cells
 Phagocytes – macrophages, neutrophils, eosinophils; macrophages also activate the lymphocytes of adaptive immunity.
 Langerhans cells and other dendritic cells – activate lymphocytes
 Natural killer cells – destroy foreign cells by rupturing their cell membrane.
  Basophils and mast cells – produce histamine and leukotrienes (inflammation). Histamine causes vasodilation and makes capillaries more
permeable. Leukotrines also increase capillary permeability and attack phagocytic cells to the area.
 Chemical defense
Chemicals that help the body resist infection include the interferon, complement, and chemical involve in inflammation.
 Interferons (alpha-, beta-, gamma- interferons) – are protein produced by cell infected with viruses and by T cells. Interferon is probably a factor
in the self-limiting nature of many viral diseases
 Complement – is a group of more than 20 plasma protein that circulate in the blood until activated. They are involved in lysis of cellular antigens
and the labeling of noncellular antigens.
 Inflammation – is a general response of damage of any kind: microbial, chemical, or physical. Vasodilation and increased capillary permeability
bring tissue fluid and WBC’s to the area.
Adaptive immunity
Is very specific, may involve antibodies, does crate memory, and responses become more efficient.
 T lymphocytes (T cells) – are produced in the thymus and red bone marrow they require hormones of the thymus for maturation migrate to
spleen, lymph nodes, and nodules.
 B lymphocytes (B cells) – are produced in the red bone marrow: migrate to the spleen, lymph nodes, and nodules.
 The antigen must 1st be recognized as foreign; this is accomplished by B cells or by the helper T cells that compare the foreign antigen to “self”
antigens present on macrophages.
 Helper T cells strongly initiate one or both of the immune mechanism: cell-mediated immunity and antibody-mediated immunity.

Cell-mediated immunity
This mechanism of immunity does not result in the production of antibodies, but it is more effective against intracellular pathogens (such as viruses),
fungi, malignant cells, and grafts of foreign tissue. The 1st step in recognition of the foreign antigen by macrophages and helper T cells, which
becomes activated and are specific, these activated T cells, which are antigen specific divide many times to form memory T cells and cytotoxic
(killer) T cells. The memory T cell will remember the specific foreign antigen and become active if it enters the body again. Cytotoxic T cells are
able to chemically destroy foreign antigen by disrupting the cell membrane.
 Antibody-mediated immunity
This mechanism does involve the production of antibodies and is also diagrammed. The B cells, macrophages, and helper T cells will firstly
recognize the foreign antigen. The sensitized helper T cells present the foreign antigen to B cells, which provides a strong stimulus for the activation
of B cells specific for thus antigen. Some of the new B cells produced memory B cells, which will remember the specific antigen and initiate rapid
response upon second exposure. Other B cells become plasma cells that produce antibodies specific for this one foreign antigen.

Classes of antibodies
Name Location Functions
IgG Blood  Crosses the placenta to provide passive immunity for newborns
 Provides long-term immunity following recovery or a vaccine
Extracellular fluid
IgA External secretions (tears,  Present in breast milk to provide passive immunity for breast-fed
saliva, etc.) infants
 Found in the secretions of all mucous membranes
IgM Blood  Produced 1st by the maturing immune system of infants
 Produced 1st during infection ( IgG production follows)
 Part of the ABO blood group

IgD B lymphocytes  Receptor of B lymphocytes

IgE Mast cells or basophils  Important in allergic reactions (mast cells release histamine)

Types of immunity
Type Description
Genetic  Does not involves antibodies; programmed in DNA
 Some pathogens affect certain host species but not others
Acquired  Involves antibodies
Passive  Antibodies from another source

NATURAL  Placental transmission of antibodies from mother to fetus

  Transmission of antibodies from breast milk

ARTIFICIAL  Injection of performed antibodies ( gamma globulins or immune globulins ) after presumed
exposure
Active  Production of one’s own antibodies

NATURAL  Recovery from disease, with production of antibodies and memory cells

ARTIFICIAL  A vaccine stimulates production of antibodies and memory cells

RENAL SYSTEM

 It eliminates waste products such as nitrogenous wastes, toxins and drugs

from the body and maintains fluid/salt balance.

Kidneys
- Bean-shaped organs found along the posterior wall of the abdominal cavity.
- The left kidney is located slightly higher than the right kidney because the right side of
the liver is much larger than the left side.
- They remove liquid waste from the blood in the form of urine; keep a stable balance of salts and other substances in the blood
- They produce erythropoietin, a hormone that aids the formation of red blood cells. The kidneys remove urea from the blood through tiny filtering units
called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together
with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
Parts of the Kidney:
 Renal Capsule – outer membrane that surrounds the kidney; it is thin but tough and fibrous

 Renal Pelvis – basin-like area that collects urine from the nephrons, it narrows into the upper end of the ureter

 Calyx – extension of the renal pelvis; they channel urine from the pyramids to the renal pelvis
  Cortex – the outer region of the kidney; extensions of the cortical tissue, contains about one million blood filtering nephrons

 Nephron – these are the filtration units in the kidneys

 Medulla – inner region of the kidney contains 8-12 renal pyramids. The pyramids empty into the calyx.

 Medullary pyramids – formed by the collecting ducts, inner part of the kidney

 Ureter – collects filtrate and urine from renal pelvis and takes it to the bladder for urination

 Renal Artery – branches off of the aorta bringing waste-filled blood into the kidney for filtering in the nephrons; the renal artery is further
subdivided into several branches inside the kidney. Each minute, the kidneys receive 20% of the blood pumped by the heart. Some arteries
nourish the kidney cells themselves.

 Renal Vein – removes the filtered blood from the kidneys to the inferior vena cava

Function of the kidney:

Every minute 1300 mL of blood enter the kidneys, 1299 mL leave the kidney. and 1 mL leaves as urine.The kidneys have many functions. The kidneys are
the major organs that maintain homeostasis (balance of the various body functions) in the body and help control blood pressure. They maintain balance in
electrolytes, acid-base, and fluid in the blood. The kidneys remove nitrogenous waste from the body (creatinine, urea, ammonia) and keep essential substances
the body needs to function as it should. The kidneys produce the hormone erythropoietin that stimulates the production of red blood cells and enzymes.
When the kidneys aren’t working as they should, there is a failure of homeostasis which can cause death if not corrected. A panel of blood tests, called
a Kidney Function Profile, is used to monitor the kidneys, detect kidney problems or make a diagnosis.
Parts of a Nephron:
 Renal Artery – brings waste-filled blood from the aorta to the kidney for filtering in the
nephron.
 Glomerulus – each glomerulus is a cluster of blood capillaries surrounded by a
Bowman’s capsule. It looks similar to a ball of tangled yarn.
 Proximal convoluted tubule (PCT)
 Thin descending limb of the loop of Henle
o Thin Ascending limb of the loop of Henle
o Thick Ascending limb of the loop of Henle
 o Distal convoluted tubule
o Renal Vein – when filtration is complete, blood leaves the nephron to join the renal vein, which removes the filtered blood from the
kidney
o Arterioles – blood is brought to and carried away from the glomerular capillaries by two very small blood vessels—the afferent and
efferent arterioles.
o Nephron Functions:
o Bowman’s Capsule – Surrounds the glomerulus
o Glomerulus – consist of a the cluster of capillaries
o Proximal Convoluted Tubule – nearest the glomerulus; have permeable cell membranes that reabsorb glucose, amino acids,
metabolites and electrolytes into nearby capillaries and allow for circulation of water
o Loop of Henle – has an ascending and descending limb, these loops along with their blood vessels and collecting tubes for the
pyramids in the medulla. When the filtrate reaches the descending limb of the loop, water content has been reduced by 70%. The
filtrate contains high levels of salts (mostly sodium). As the filtrate moves further through the loop, more water is removed which
further concentrates the filtrate.
o Distal Convoluted Tubule – farthest from the glomerulus; helps regular potassium excretion.
o Collecting Duct – collects the filtrate
Flow of blood in the kidneys:
 The blood enters the kidney and goes to the glomerulus. Pressure forces fluid out of the blood through membrane filtration slits creating a
cell-free fluid (plasma) of water and small molecules that enters into the renal tubule. Large cells and proteins stay in the blood. This plasma
is taken to the nearest (proximal) convoluted tubule. This runs down into the medulla into the loop of Henle and then back to the farthest
(distal) convoluted tubule to join with other tubules. In the distal tubule most of the salts are reabsorbed. What is left is further modified until
it becomes concentrated urine which contains urea and other waste products at the end of the collecting duct.
 Glomerular filtration – Filtrate is made as the blood is filtered through a collection of capillaries in the nephron called glomeruli.
 Tubular reabsorption – The tubules in the nephrons reabsorb the filtered blood in nearby blood vessels.
 Tubular secretion – The filtrate passes through the tubules to the collecting ducts and then taken to the bladder.
Functions of the Kidneys:
A. Filtration
 The nephron is the functional unit of the kidney that filters blood to produce urine. Arterioles in the kidneys deliver blood to a bundle of capillaries
surrounded by a capsule called a glomerulus. As blood flows through the glomerulus, much of the blood’s plasma is pushed out of the capillaries and
into the capsule, leaving the blood cells and a small amount of plasma to continue flowing through the capillaries. The liquid filtrate in the capsule
flows through a series of tubules lined with filtering cells and surrounded by capillaries. The cells surrounding the tubules selectively absorb water
and substances from the filtrate in the tubule and return it to the blood in the capillaries.
 At the same time, waste products present in the blood are secreted into the filtrate. By the end of this process, the filtrate in the tubule has become
urine containing only water, waste products, and excess ions. The blood exiting the capillaries has reabsorbed all of the nutrients along with most of
the water and ions that the body needs to function.

B. Storage and Excretion of Wastes

 Urination is the process of releasing urine from the urinary bladder through the urethra and out of the body. The process of urination begins when the
muscles of the urethral sphincters relax, allowing urine to pass through the urethra. At the same time that the sphincters relax, the smooth muscle in
the walls of the urinary bladder contract to expel urine from the bladder.
 After urine has been produced by the kidneys, it is transported through the ureters to the urinary bladder. The urinary bladder fills with urine and
stores it until the body is ready for its excretion. When the volume of the urinary bladder reaches anywhere from 150 to 400 mL, its walls begin to
stretch and stretch receptors in its walls send signals to the brain and spinal cord. These signals result in the relaxation of the involuntary internal
urethral sphincter and the sensation of needing to urinate. Urination may be delayed as long as the bladder does not exceed its maximum volume
(600-800 mL), but increasing nerve signals lead to greater discomfort and desire to urinate.
C. Maintenance of Homeostasis
 The kidneys maintain the homeostasis of several important internal conditions by controlling the excretion of substances out of the body.
 Ions. The kidney can control the excretion of potassium, sodium, calcium, magnesium, phosphate, and chloride ions into urine. In cases where these
ions reach a higher than normal concentration, the kidneys can increase their excretion out of the body to return them to a normal level. Conversely,
the kidneys can conserve these ions when they are present in lower than normal levels by allowing the ions to be reabsorbed into the blood during
filtration.
 pH. The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate ions in the blood to control blood pH. H+ ions are produced
as a natural byproduct of the metabolism of dietary proteins and accumulate in the blood over time. The kidneys excrete excess H+ ions into urine for
elimination from the body. The kidneys also conserve bicarbonate ions, which act as important pH buffers in the blood.
  Osmolarity. The cells of the body need to grow in an isotonic environment in order to maintain their fluid and electrolyte balance. The kidneys
maintain the body’s osmotic balance by controlling the amount of water that is filtered out of the blood and excreted into urine. When a person
consumes a large amount of water, the kidneys reduce their reabsorption of water to allow the excess water to be excreted in urine. This results in the
production of dilute, watery urine. In the case of the body being dehydrated, the kidneys reabsorb as much water as possible back into the blood to
produce highly concentrated urine full of excreted ions and wastes. The changes in excretion of water are controlled by antidiuretic hormone (ADH).
ADH is produced in the hypothalamus and released by the posterior pituitary gland to help the body retain water.
 Blood Pressure. The kidneys monitor the body’s blood pressure to help maintain homeostasis. When blood pressure is elevated, the kidneys can help
to reduce blood pressure by reducing the volume of blood in the body. The kidneys are able to reduce blood volume by reducing the reabsorption of
water into the blood and producing watery, dilute urine. When blood pressure becomes too low, the kidneys can produce the enzyme renin to constrict
blood vessels and produce concentrated urine, which allows more water to remain in the blood.

D. Production of Hormones
 The kidneys produce and interact with several hormones that are involved in the control of systems outside of the urinary system.
 Renin. Renin is not a hormone itself, but an enzyme that the kidneys produce to start the renin-angiotensin system (RAS). The RAS increases blood
volume and blood pressure in response to low blood pressure, blood loss, or dehydration. Renin is released into the blood where it catalyzes
angiotensinogen from the liver into angiotensin I. Angiotensin I is further catalyzed by another enzyme into Angiotensin II.
 Angiotensin II stimulates several processes, including stimulating the adrenal cortex to produce the hormone aldosterone. Aldosterone then changes
the function of the kidneys to increase the reabsorption of water and sodium ions into the blood, increasing blood volume and raising blood pressure.
Negative feedback from increased blood pressure finally turns off the RAS to maintain healthy blood pressure levels.
 Erythropoietin. Erythropoietin, also known as EPO, is a hormone that is produced by the kidneys to stimulate the production of red blood cells. The
kidneys monitor the condition of the blood that passes through their capillaries, including the oxygen-carrying capacity of the blood. When the blood
becomes hypoxic, meaning that it is carrying deficient levels of oxygen, cells lining the capillaries begin producing EPO and release it into the
bloodstream. EPO travels through the blood to the red bone marrow, where it stimulates hematopoietic cells to increase their rate of red blood cell
production. Red blood cells contain hemoglobin, which greatly increases theblood’s oxygen-carrying capacity and effectively ends the hypoxic
conditions.
 CARDIOVASCULAR SYSTEM
I. BLOOD
It is the “river of life”. It is the only fluid tissue in the body. It is a type of connective tissue since it consists of cells and cell fragments surrounded by
a liquid matrix. It functionally connects the different body organ systems.
Functions of blood:
 Transportation: it delivers oxygen from the lungs to the cells and moves carbon dioxide from the cells to the lungs. It also carries nutrients, waste
products, hormones and other substances to various destinations.
 Protection: in response to injury, it coagulates or forms seals called clots, thereby preventing blood loss and maintaining cardiovascular function. Its
several roles in inflammation are: Leukocytes, or white blood cells, destroy invading microorganisms and cancer cells. Antibodies and other proteins
destroy pathogenic substances. Platelet factors initiate blood clotting and help minimize blood loss.
 Regulation: helps maintain a steady pH of body fluids. It distributes heat, thereby adjusting body temperature. Its osmotic pressure influences the
water content of cells and tissues.

Formed Elements:
1. Red blood cells – also known as erythrocytes. It is the most abundant formed element in the blood. It delivers oxygen from the lungs and deliver it to
tissues elsewhere and carries carbon dioxide from other tissues and unload it in the lungs.
2. White blood cells – are also known as leukocytes. They can be divided into granulocytes and agranulocytes.
Granulocytes:
 Neutrophils – they kill and digest bacteria and fungi. They are the most numerous type of white blood cell and your first line of defense when
infection strikes.
 Eosinophils – they attack and kill parasites, destroy cancer cells, and help with allergic responses.
 Basophils – these small cells appear to sound an alarm when infectious agents invade your blood. They secrete chemicals such as histamine, a marker
of allergic disease, that help control the body's immune response.
Agranulocytes:
 Monocytes: they have a longer lifespan than many white blood cells and help to break down bacteria.
 Lymphocytes: they create antibodies to defend against bacteria, viruses, and other potentially harmful invaders.
1. Platelets – secrete vasoconstrictors which constrict blood vessels, causing vascular spasms in broken blood vessels. It forms temporary platelet plugs
to stop bleeding.
 II. HEART
The main function of the cardiovascular system is to transport oxygen, carbon dioxide, nutrients, waste products and other substances to the different
parts of the body.
Anatomy of the heart:
Pericardium
The heart sits within a fluid-filled cavity called the pericardial cavity. Pericardium is a type of serous membrane that produces serous fluid to lubricate
the heart and prevent friction between the ever beating heart and its surrounding organs cavity.

Chambers of the Heart

 Atria – two superior receiving or collecting chambers of the heart. It pumps their collected blood to the ventricles.
 Ventricles – two inferior chambers of the heart that pumps blood that eject blood into the arteries.
 Right atrium – collects blood from the systemic circulation through 3 veins namely the Superior vena cava, Inferior vena cava and the coronary sinus.
 Left atrium – collects blood from the lungs through the four pulmonary veins.
 Right ventricle – receives blood from the right atrium and pumps it into the lungs through the pulmonary arteries.
 Left ventricle – it forms the heart’s apex. It is the thickest chamber of the heart. It receives blood from the left atrium and pumps it into the systemic
circulation through the aorta.
Valves of the Heart:
 Atrioventricular valves – the atrioventricular (AV) valves are located in the middle of the heart between the atria and ventricles and only allow blood
to flow from the atria into the ventricles.
 Semilunar valves – the semilunar valves, so named for the crescent moon shape of their cusps, are located between the ventricles and the arteries that
carry blood away from the heart.
Great blood vessels of the heart:
 Superior vena cava & Inferior vena cava – are veins that return deoxygenated blood from circulation in the body and empty into the right atrium.
 Pulmonary artery – carries deoxygenated blood from the right ventricle into the lungs for oxygenation.
 Pulmonary veins – carry oxygenated blood from the lungs into the left atrium to be returned to systemic circulation.
 Aorta – is the largest artery in the body. It carries oxygenated blood from the left ventricle of the heart into systemic circulation.
Physiology of the heart
Coronary Systole and Diastole:
 Systole – during systole, cardiac muscle tissue is contracting to push blood out of the chamber.
 Diastole – during diastole, the cardiac muscle cells relax to allow the chamber to fill with blood.
Heart Sounds:
 S1 – the “lub” sound comes first in the heartbeat and is the longer of the two heart sounds. The “lub” sound is produced by the closing of the AV
valves at the beginning of ventricular systole.
 S2 – the shorter, sharper “dup” sound is similarly caused by the closing of the semilunar valves at the end of ventricular systole.

Blood Flow through the Heart

Deoxygenated blood returning from the body first enters the heart from the superior and inferior vena cava. The blood enters the right atrium and is
pumped through the tricuspid valve into the right ventricle. From the right ventricle, the blood is pumped through the pulmonary semilunar valve into the
pulmonary trunk. The pulmonary trunk carries blood to the lungs where it releases carbon dioxide and absorbs oxygen. The blood in the lungs returns to the
heart through the pulmonary veins. From the pulmonary veins, blood enters the heart again in the left atrium. The left atrium contracts to pump blood through
the bicuspid (mitral) valve into the left ventricle. The left ventricle pumps blood through the aortic semilunar valve into the aorta. From the aorta, blood enters
into systemic circulation throughout the body tissues until it returns to the heart via the vena cava and the cycle repeats.
III. BLOOD VESSELS
Blood circulates inside the blood vessels, which form a closed transport system or the vascular system. As the heart beats, blood is propelled into the
large arteries leaving the heart. It moves into successively smaller and smaller arteries and then into the arterioles which feed the capillary beds in the tissues.
Capillary beds are drained by venules, which in turn empty into veins that finally empty into the great veins the venae cavae entering the heart.
3 coats:
 Tunica intima – which lines the lumen, or interior of the vessels, is a thin layer of endothelium or simple squamous epithilium resting on a basement
membrane. Its cells fit closely together and form a slick surface that decreases friction as blood flows through the vessel lumen.
 Tunica media – is the bulky middle coat. It is mostly smooth muscle and elastic fibers. Some of the larger arteries have “elastic laminae”, sheets of
elastic tissue, in addition to the scattered elastic fibers. The smooth muscle, which is controlled by the sympathetic nervous system, is active in
changing the diameter of the vessels. As the vessels constrict or dilate, blood pressure increases or decreases, respectively.
 Tunica externa – is the outermost tunic. This layer is composed largely of fibrous connective tissue, and its function is basically to support and protect
the vessels.
The blood vessel has 3 types namely the arteries, capillaries and veins.
  Arteries – which are closer to the pumping action of the heart, they have higher pressures since they directly arise from the heart. It carries blood from
the heart to the capillaries. As the arteries branch out, they usually anastomose or connect with one another to provide alternate routes for the flow of
blood called “collateral circulation,” if one vessel becomes obstructed.
 Aorta – is the largest artery which has the highest hydrostatic pressure and where the large, medium and small arteries of the systemic circulation
arise from.
 Arterioles – are the smallest, almost microscopic, arteries that branch off the small arteries into capillaries. Its smooth muscle controls the amount of
blood reaching the capillaries.
 Capillaries – are the smallest of the blood vessels, are thin-walled, microscopic vessels which connect the arterioles and venules is slow to permit
sufficient time for the exchange of substances.
 Veins – conduct blood from the capillaries to the heart.
Blood Pressure
is the pressure exerted by blood as it pulsates through the blood vessel, generated by the contraction of the left ventricles. It is highest in the aorta and
large systemic vessels that progressively falls as the distance from the left ventricle increases. The normal range for systolic in adults is 90-120 mmHg,
diastolic is 60-80 mmHg. The hypertension refers to a systemic BP consistently higher than the normal range and the hypotension is lower than the normal
systemic BP.
The determinants of blood pressure are the following:
1. Blood Volume – the blood pressure depends greatly on the blood volume or the cardiac output which is normally about 5 liters and any change in
blood volume consequently increase or decreases the blood pressure.
2. Pumping action of the heart – if the contraction is weak the BP will decrease and if the contraction is strong the BP will increase.
3. Blood Viscosity – the more the formed elements, the greater the blood viscosity and if the thickness of blood increase the BP also increases.
4. Peripheral Resistance – it refers to the opposition to blood flow due to friction between blood and the walls of the blood vessels.
Systemic Circulation
Major peripheral arteries:
 Superficial temporal artery – is where the temporal pulse could be palpated located in front of the ear.
 Common Carotid artery – is located lateral to the larynx, where the carotid pulse could be palpated and should not be palpated together as doing so
many interrupt blood flow to the brain.
 Brachial artery – is where brachial pulse could be palpated located on medial portion of antecubital space and commonly used for assessing blood
pressure.
 Radial artery – is commonly used for assessing pulse rate and for withdrawing an arterial blood specimen. Where the radial pulse could be palpated
located on thumb side of the wrist.
  Femoral artery – arises from the abdominal aorta, which is commonly used for entry side for cardiac catheterization to gain access to the coronary
arteries. Where the femoral pulse could be palpated located on the inguinal area.
 Popliteal artery – is where the popliteal pulse could be palpated located at the back of the knee.
 Posterior tibial artery – is where the posterior tibial pulse could be palpated located behind the medial malleolus.
 Dorsalis pedis artery – arises from the abdominal aorta, where the dorsalis pedis pulse could be palpated located on top of the foot over the first
metatarsal and medial cuneiform.
Major veins:
 Superior Vena Cava - arises from the union of the left and right brachiocephalic veins which returns blood from the head, neck, thorax, and upper
limbs to the right atrium of the heart.
 Inferior Vena Cava – returns blood from the abdomen, pelvis and lower limbs to the right atrium.
 External Jugular Vein - is a tributary of the superior vena cava which is a superficial vein that descends vertically through the neck on the surface of
the sternocleidomastoid muscle that drains blood to the subclavian vein before it reaches the superior vena cava.
 Median Cubital Vein - is a superficial vein on the upper limb specifically on the antecubital space, and commonly used site for administering
substances intravenously or for withdrawing venous blood specimen.
 Great Saphenous Vein - is the longest vein in the body, it ascends along the medial side of the entire limb to empty into the common iliac vein which
is a direct tributary of the inferior.
 CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS EVALUATION
Client in Context: Physical Examination
ER Blotter
Patient M.G., 44 years old, ER No.: 2016-7927
female, Filipino, single, Roman Date: 11/20/16
Catholic, currently residing in Vital Signs:
Consoacion Cebu City was admitted BP: 130/80 mmHg
for the 3rd time at CVGH on PR: 98 bpm
November 20, 2016 at 11:00pm via RR: 20 cpm
private vehicle accompanied by her O2 saturation: 94%
helper and mother due to fever and
chills under the service of Dr. M. Day 1: November 23, 2016
Chua from the department of Internal General Survey: Patient is awake, alert, afebrile,
Medicine with a case number of coherent and responsive with an IVF of PNSS 1L
39425 and hospital number of 15- infusing well at left arm.
65920. VITAL SIGNS:
BP: 120/80 mmHg
History of Present Illness: PR: 107 bpm
RR: 20 cpm
1 Day PTA, client had onset of Temp: 36.7 C/tympanic
fever with a temperature of 37.7 O2 saturation: 94%
°C/axilla with no associated cough, Height: 5’0
headache and abdominal pain. Client Weight: 71 kg
took Paracetamol 500mg/tab 1 tab Anthropometric Measurements:
for relief. Height: 5’0 BMI Categories:
Weight: 71kg <18.5: Underweight
Hours PTA, fever persisted with BMI: 30.60 18.5-24.9: Normal
a temperature of 37.8°C/axilla Interpretation:
associated with chills and difficulty Obese Class 1 25-29.9: Overweight
in breathing. No management was IBW: 110% 30-34.9: Obese class 1
done. Client and her S.O then Interpretation: Mild 35-39.9: Obese class 2
decided to go to CVGH for Obesity
consultation thus, present admission. >40: Obese class 3
IBW Categories:
PAST HEALTH HISTORY >200%: Morbid
obesity
Patient was diagnosed to have SLE 140-200%: Moderate
last 1996. Maintenance medication Obesity
was taken with good compliance. 110-140%: Mild
Patient was admitted last January Obesity
2015 at CVGH due to presence of 90-110%: Ideal Weight
desquamation on both leg and was 80-90%: Mild
diagnosed to have cellulitis. Patient malnutrition
underwent debridement last April 70-80%:Moderate
2015. After which, no follow up malnutrition
check up was done. On September <70%: Severe
2015, she was again admitted at malnutrition
CVGH due to Urinary Tract
Infection. She stayed for 6 days at
the hospital with unrecalled
medications taken. SKIN: There are skin discolorations noted on the skin
of the patient especially on the upper and lower
I. Health Perception – Health extremities. The skin is smooth and even. Some parts
Management Pattern of the skin have thin calluses due to the exposure of
friction. The skin of the patient is moist to dry. Skin is
Client defines health as “health is warm to touch and mobile with elasticity and returns to
wealth” and illness as “God’s will or
original shape quickly. There is a presence of
genetics that it is not planned.” The
desquamation noted on both lower extremities. There
client rates her health as 5/10 with 10
as the highest and 1 is the lowest is a presence of grade 2 pitting edema on the lower
because of what she is experiencing extremities.
right now. The client ’s perception SCALP & HAIR: Scalp is clean and dry. Hair is
of her general state of health as
smooth and firm, somewhat elastic.
present, which varied from the usual
as “very different” but still the client NAILS: Upper and lower extremities have transparent
remains hopeful and positive of nail beds with slightly pink color. Finger nails are
whatever God plans for her. clean, short & are firmly attached to their nailbeds.
CRT is less than 2 seconds on upper extremities and
Heredofamilial diseases include CRT is more than 3 seconds in lower extremities. No
hypertension and diabetes mellitus clubbing noted.
on both side and rheumatoid artritis
on mother’s side. Patient’s childhood HEAD & FACE: Head is symmetric, erect and round.
illnesses include chicken pox and The patient has a moon face appearance. No
german measles. The client does not involuntary movements noted and no swelling,
smoke but lives with someone who tenderness/crepitation with movement. Mouth opens
smokes. The client does not drink and closes fully.
alcoholic beverages and denies the
use of any recreational drug. The
client does not use any herbal EYES & VISION: Eyeballs are symmetrically aligned
medicines and does not do self- in sockets without protruding or sinking. Eyelids of the
medication practices. patient is quite puff due to the moon face appearance
Patient is a known hypertensive but overall both upper and lower lids close easily and
since 2013. Highest BP recording meet completely when closed. Bulbar conjunctiva is
150/100 mmHg and casual BP of clear, moist and smooth. Underlying structures are
130/90 mmHg. Maintenance
clearly visible. Sclera is white. The lower and upper
medication includes Losartan 50
mg/tab 1 tab OD taken with good palpebral conjunctivae are clear and free of swelling or
compliance. The client owns a BP lesions. The puncta is visible without swelling and
apparatus and monitors BP regularly. redness and is turned slightly toward the eye and no
She is not a known diabetic nor drainage noted from the puncta when palpating the
asthmatic. No known food as drug nasolacrimal gland. The cornea is transparent, with no
allergies. opacities. The oblique view shows a smooth and
overall moist surface; the lens is free of opacities. The
The client goes for regular health iris is round, flat and evenly colored and the pupil is
check-up every four months and had round with a regular border, is centered in the iris.
undergone complete physical Pupils are normally equal in size. The reflection of
examination last January 2015. The light on the corneas is in exact same spot on each eye.
client is a fully immunized child and The uncovered eye remains fixed straight ahead and
only had a vaccine for Influenza/Flu, the covered eye is remain fixed straight ahead after
Hep B, which date was unrecalled, being uncovered. The eye movement is smooth and
and Pneumonia last October 2016 for symmetric throughout all six directions. The patient
adult immunizations. can read the name on the nameplate. The patient
squints her eyes when reading. For the near vision, the
The client stopped working when she
patient can’t still read. She still needs her corrective
was diagnosed with SLE twenty
years ago. The client lives in a lenses.
detached housing unit, which is
made of strong materials for 19 years
already. Her sister owns their house. EARS: Equal in size bilaterally about 5cm. Pinna is in
It is a one-storey house with 10 line with lateral canthus of both eyes and within a 10°
windows and 1 door that has a direct angle of vertical position. External ears are smooth
access outside. The house has 4 without lesions, color consistent with the facial color
rooms with a crowding index of 1.25 and no discharges noted. Small amount of moist,
and has complete housing facilities
yellow cerumen was noted on both ears. Able to hear
present with an antipolo type toilet.
whispered word “food and drinks” on right ear and
The drainage facility is closed and
has a covered water disposal. The “book and pen” on left ear within 2 ft. Repeats hearing
client’s method of garbage disposal watch tick within 5 inches from the ear.
is it is collected by a garbage truck NOSE & SINUSES: Color is the same as the rest of
every Saturday. The client’s source
the face; the nasal structures is smooth and symmetric
of water for general household use is
MCWD and uses mineral water for and no tenderness noted. Px is able to sniff through
drinking. The client’s electricity each nostril while other is occluded. The nasal mucosa
provider is VECO. The client’s is dark pink, moist and free from exudate. The nasal
storage of medications, household septum is intact and free from ulcers or perforations.
chemicals, matches and knives are Turbinates are dark pink, moist and free of lesions. No
out of reach from children but only tenderness and crepitus is noted upon palpation on the
the medications has a lock and key. frontal and maxillary sinuses.
The client owns a pet cat and is kept
outside the house but is not tied. The
client’s mode of transportation is MOUTH & PHARYNX: Lips are smooth and moist
public vehicle. The distance from the without lesions or swelling. Thirty-two yellowish teeth
main road is a 3 minute walk, the with dental carries but still have smooth surfaces and
grocery store is a 5 minute walk edges. The buccal mucosa is pinkish tone in color free
away from the house and the hospital from lesions. Tongue is pink, moist and a moderate
is a 15 minute walk. There are no size with papillae present and no lesions present. The
factories nearby and generally the ventral surface is smooth, shiny, pink with visible
client feels safe in her neighborhood. veins and no lesions noted. No unusual or foul odor is
The client’s major source of income noted. The uvula is fleshy, solid structure that hangs
is from her pension and the client freely in the midline, no redness or exudate is noted.
stated that her income is not enough
The tonsils are pink and symmetric and enlarged (+1 in
for her medications The client does
not have a medical insurance and she healthy clients). Throat is pink without exudate or
is not satisfied with her economic lesions. The gag reflex is still present.
status since she stated “if wa pa joy
skit dili ta ko maglisod”.
NECK: The thyroid cartilage, cricoid cartilage move
upward symmetrically as the patient swallows. The
II. NUTRITIONAL - neck movement is smooth and controlled. Trachea is in
METABOLIC PATTERN the midline. Landmarks are positioned in the midline.
No enlargement or tenderness is present.
Usual Diet & 24- Hour Diet Recall:
Appendix 3

The client does not mix condiments
with food. The client’s water intake
per day is 1 liter and she drinks 1 cup
of coffee every morning but does
not drink any carbonated beverage.
The client’s appetite is fair and she
CHEST & LUNGS: Scapulae are symmetric and non-
protruding. Shoulders and scapulae are ate equal
horizontal positions. The px does not use accessory
muscles to assist breathing. px reports no tenderness,
pain or unusual sensations, temperature is equal
bilaterally. No palpable crepitus. Fremitus is
follows a strict diet of only eating
minimal green leafy vegetables. The
client is restricted to eat dried fish.
The client’s food preference is
vegetable and pork and she dislikes
chicken. The client often eats home
cooked meals usually with her
caretaker. The client’s caretaker buys
the food at the grocery and prepares
and cooks for her. The client stores
her food in a refrigerator. The client
takes the dietary supplement Caltrate
Plus 1 tab OD PC BF. The client
described a healthy diet as “eating
natural raw food” and stated that she
reads the food labels since she has to
have a limit on the food she eats due
to her illness. The client brushes her
teeth thrice a day and does not floss
nor use oral antiseptic. The client
visits a dentist and claimed that her
last dental checkup was year 2014.
The client has a denture. Before
hospitalization, patient’s usual body
weight was approximately 70-55kg
and was not satisfied with her
present weight for the reason that she
felt fat. During hospitalization, the
client weighs 71kg.
III. Elimination Pattern
symmetric and easily identified in the upper regions of
the lungs. Thumbs move 5-10 cm apart symmetrically.
Resonance tone is noted upon percussing the lung area.
Excursion is equal bilaterally and measure 3-5cm. The
normal breath sounds are heard directly where they are
supposed to be heard and no adventitious sounds such
as crackles or wheezes noted upon auscultated.
Bronchophony: voice transmission of is soft, muffled
and indistinct. Egophony: voice transmission is soft
and muffled but the letter “E” is distinguishable.
Whispered pectoriloquy: transmission of sound is very
faint, muffled and inaudible.
HEART & PERIPHERAL VASCULATURE: The
apical pulse is not visible. The apical impulse is
palpated in the mitral area. No pulsations or vibrations
are palpated in the areas of the apex, left sternal border
or base. the radial and apical pulse rates are identical.
S1 sound: distinct sound in each area but loudest at the
apex. S2 sound: distinct sound is heard in each area but
is loudest at the base. No extra heart sounds and
murmurs are noted. No distended, bulging or
protruding, blowing/swishing or other sounds noted.
Pink coloration returns to the palms within 3-5 secs,
ulnar and radial artery is patent. No varicosities noted.
Peripheral Pulses:
Before hospitalization, patient Rate Strength/Amplitude
usually defecates at least 4 times a
week, early in the morning. His (Right) (Left) (Right) (Left)
usual stool is a well-formed stool Temporal 79 70 Strong Strong
and brown in color. She urinates 4
times a day amounting to 1 cup or Carotid 92 98 Strong Strong
180 mL per episode. Urine is
characterized as clear and yellow in Brachial 76 80 Strong Strong
color. She has experienced
Radial 71 82 Strong Strong
constipation and the last occurrence
was unrecalled. Patient also Femoral 70 74 Strong Strong
experienced urinary tract infection 2
months ago. Popliteal 61 — Weak cannot be
palpated
During hospitalization, patient
defecates once a day with a well- Posterior tibialis — — cannot be palpated
formed stool and black in color.
Dorsalis pedis — — cannot be palpated
Patient urinates 3-4 times a day
approximately 1 cup per elimination
with a yellow usual urine color. It’s
clear in characteristic and odorless. ABDOMEN: The abdomen of the patient is evenly
After a bowel movement or rounded and symmetric. Their are striae present on the
urination, she wipes her genitalia abdomen of the patient. The umbilical skin tones are
from front to back. similar to surrounding abdominal skin tones.
Umbilicus is in the midline and inverted not more than
0.5cm. No aorta pulsation noted due to thick fat
IV. Activity- Exercise Pattern deposits in the abdomen. No peristaltic waves noted.
There is series of intermittent, soft clicks and gurgles
Patient’s typical day from the time
bowel sounds heard in the abdomen. Bruits are not
she woke up was to pray, drink
guyabano leaves, defecates, take a heard over abdominal aorta, renal, iliac or femoral
bath, eat breakfast, wound dressing, arteries. No friction rub over the liver or spleen is
go out and read newspaper or bible,
eat lunch, rest in bed, read novena,
walk outside, eat dinner and sleep.
Her usual weekend activities were
going to church and mall. Patient is
without assistive device and
performs all activities with no
supervision, direction or personal
assistance. Patient is not enrolled in a
formal exercise program. Zumba is
her usual type of exercise and
perfom this exercise when her body
is feeling well. She spent 5 minutes
per session and light intensity of
exercise routine. Patient didn’t
include warm up and cool down
exercises. Patient’s usual hobbies
were reading and sewing dresses.
She read books for 4 hours everyday.
She recently stopped window
shopping because of her health
condition. Patient experienced chest
pain, joint stiffiness or limitation of
movement and joint swelling or joint
pain. In general, her condition
affected her activity and exercise
pattern in a way that she couldn’t
wear slippers and jump like before.
During hospitalization she now Elbows: the patient has full ROM against resistance.
needs assistance in bathing, toileting,
transferring and dressing but she is Wrist, hands & fingers: full ROM resistance.
present. In general, tympany predominates over the
abdomen because of air in the stomach and intestines
while dullness is heard over the liver and spleen. no
tenderness is elicited over the liver and kidneys upon
blunt percussion. abdomen is nontender and soft. There
is no guarding upon palpating. No palpable masses are
present. Liver and kidneys are not palpable. Spleen is
slightly palpable at the left costal margin. Empty
bladder is not palpable and tender. The borders
between tympany and dullness remain relatively
constant throughout position changes. No fluid wave is
transmitted and no rebound tenderness is present. No
abdominal pain present upon doing the psoas sign and
obturator sign.
BACK & EXTREMITIES: Uneven weight bearing is
evident.
Range of Motion (ROM):
Upper extremities: Flexion of the cervical spine is 45
degrees and extension of the cervical spine is 45
degrees. Patient has full ROM against resistance.
Smooth movement, lumbar concavity flattens our and
the spinal processes are in alignment. Shoulders: the
patient can flex, extend, adduct, abduct, rotate and
shrug shoulders against resistance.
still able to eat by herself. She Lower extremities: Hips & Knees: full ROM
appears tired and she prefers to stay resistance; Ankles and Feet: decreased strength against
in bed. resistance.
Overall muscle strength in the upper extremities is 5/5
while in the lower extremities is 3-4/5.
V. Sleep- Rest Pattern Muscle strength: Scale:
5/5 5 – Full ROM against
Patient’s usual bedtime is 7:00 pm 5/5 gravity, full resistance
and wakes up at 6:00 am. She 4 – Full ROM against
usually took daytime naps for 30 gravity, some resistance
minutes. She slept for 8-9 hrs and is 3/5 4/5 3 – Full ROM with gravity
usually disturbed because of the urge 2 – Full ROM with gravity
to urinate. Patient’s environment in eliminated (passive motion)
sleeping is quiet with a temperature 1 – Slight Reaction
of 24°C with little light together with 0 – No Reaction
her 2 pillows and 2 blankets. She
prays before sleeping.

During hospitalization, her sleep - SPECIAL TESTS:

rest pattern changed, as she
verbalized “ mag.sige ko ug mata-
mata kay mag.sige ug kuha ang mga
nurse ug vital signs, kana sad mag.pa
tumar sila ug tambal nga pukawon
gyud ko nila, ug ang mga doctor
(interns) kay daghan ug pangutana
mao nga dili ko katulog ug udto”.
Homan’s Sign: Not assessed because patient refused.
Phalen’s and tinel’s test was not assessed due to splint
on the left hand of the patient.
No bulge of fluid appears on medial side of knee. No
movement of the patella is noted, patella rests firmly
over the femur. There is a clicking sound on the left
knee of the patient.
NEUROLOGIC ASSESSMENT:
VI. Cognitive- Perceptual Pattern
Patient is able to read, write,
comprehend instructions, recall long-
term and short-term memories and
able to make independent decisions.
Patient speaks Visaya and can
understand English and Tagalog. She
is a college graduate and describes
herself as a good student. Patient’s
preferred learning style is either
visual, written or demonstration.
Patient is satisfied with her vision
with corrective lenses. She used
glasses and her last eye exam was on
2015. Patient experienced blind spots
and trouble seeing at night. Patient is
satisfied with her ability to hear. She
cleans it once a week using cotton
buds. Her last ear exam was 1997
due to ear pain. Patient is satisfied
with her ability to taste and smell
and didn’t change ever since.
VII. Self-Perception – Self-
Concept Pattern
CN I (olfactory): Patient correctly identifies scent
Patient describes herself as a
presented to each nostril.
beautiful person. Her strength is God
and her family is her weakness. CN II (optic): The patient squints her eyes when
MENTAL STATUS/CEREBRAL FUNCTION: The
patient is alert and awake as I do the physical exam.
The patient is clean and well groom. Desire facial
expression is presented well. The patient can talk
clearly and understands every question I ask. The
patient is oriented well in time, person and place.
Patient claimed that she can remember when she was
diagnosed of her condition and she is fully aware that
she is confined in the hospital.
MOTOR/CEREBELLAR FUNCTION: Patient
touches each finger to the thumb rapidly and rapidly
turns palms up and down. Patient is able to run each
heel smoothly down each skin. Tandem walk: the
patient has difficulty in performing the walk. Patient
stands less than 10 secs with minimal swaying. No
involuntary movements noted.
SENSORY FUNCTION: Patient correctly identifies
light touch, sensation, differentiates between dull and
sharp and hot and cold temperature on the upper
extremities. BUT FOR THE LOWER EXTREMITIES,
the patient can’t feel any sensation unless heavy
pressure is applied. Patient correctly identifies object,
area touched and number written on the hand.
CRANIAL NERVE TESTING:
Others describe her as naughty,
beautiful and confident woman. Her
major life accomplishment was
passing the nursing board exam.
Patient wished to have a different
kind of life and is not satisfied to it
because of her disease. She got angry
when the person is dumb and when
food is not delicious. Not having
money was what made her
depressed. Patient feels sad, low,
down, depressed or hopeless and lost
interest or pleasure in the things she
usually likes to do. She feels that she
is a failure and feels guilty about
things that happened in her life.
Patient had no thought of killing
herself.
VIII. Role- Relationship Pattern
Client Ecomap: Appendix 4
Patient had a nuclear family type and
assumed to be the coordinator in the
family. F.I.G. is the one who usually
decide for household expenses while
F.I. for the social activities and
would discipline the family. These
decisions were made by talking and
resolves conflict by meeting each
reading the print from the student nurse’s nameplate.
For the near vision, the patient still squints her eyes,
she still needs her corrective lenses.
CN III, IV & VI (oculomotor, trochlear &
abducens): Eyelids covers entirely the eye. eye moves
in a smooth, coordinated motion in all directions.
Bilaterally and opposite illuminated pupils constrict
simultaneously.
CN V (trigeminal): Temporal and masseter muscles
contract bilaterally. Patient correctly identifies light
touch, sensation, differentiates between dull and sharp
and hot and cold temperature on the upper extremities.
BUT FOR THE LOWER EXTREMITIES, the patient
can’t feel any sensation unless heavy pressure is
applied. Patient correctly identifies object, area
touched and number written on the hand.
CN VII (facial): Patient smiles, frowns, wrinkles
forehead, shows teeth, puffs out cheeks, purses lips,
raises eyebrows and closes eyes against resistance and
movements are symmetric.
CN VIII (vestibulocochlear): Able to correctly repeat
the two-syllable word as whispered. The patient can
hear the tick of the watch. Vibrations are heard equally
well in both ears. No lateralizations of sound to either
ear. Air conduction is heard longer than bone
conduction sound (AC>BC).
CN IX & X (glossopharyngeal & vagus): Uvula &
other in the house. She describes her soft palate rise bilaterally and symmetrically on
family’s communication as good phonation. Gag reflex is intact. Patient swallows
because they still make time to talk without difficulty and no hoarseness noted.
to each other.
Patient was a member of Catholic CN XI (spinal accessory): There is symmetric, strong
Women League, Word Apostolate contraction of the trapezius muscles. There is strong
Fatima and Sagrada Corazon De contraction of sternocleidomastoid muscle on the side
Jesus which she was elected as a opposite the turned face.
secretary. She describes her
relationship with her friends, CN XII (hypoglossal): Tongue movement is
neighbors and co-members in the symmetric, smooth and bilateral strength is apparent.
organization as a very good person.
She had a recent problem with her Pathogenic reflexes:
friends because they got mad Brudzinki’s sign: Hips and knees remain relaxed and
whenever she couldn’t text or call motionless.
them. She believed that her
contribution in the society was to be Kernig’s sign: No pain felt by the patient.
able to serve the church. She
considered her mother as an
important person because she had no
DAY 2: November 24, 2016
children and her mother was the only
one that she can lean on in life. General Survey: Patient is awake, alert, afebrile,
coherent and responsive with an IVF of PNSS 1L
infusing well at left arm.
IX. SEXUALITY-
REPRODUCTIVE PATTERN VITAL SIGNS:
BP: 110/70 mmHg
Patient’s sexual preference was
heterosexual. She had a regular PR: 102 bpm
menstrual cycle for about 28 days. RR: 22 cpm
She uses 4 pads per day, which is
partially soaked. Patient stopped O2 saturation: 96%
menstruating because she is now in
menopausal period. Patient had her Temp: 36.2 C/tympanic
breast-self examination with the date SKIN:There are skin discoloration noted on the skin of
unrecalled.
the patient especially on the upper and lower
extremities. There is a presence of desquamation noted
X. COPING- STRESS on both lower extremities. There is a presence of grade
TOLERANCE PATTERN 2 pitting edema on the lower extremities.
NAILS: CRT is less than 2 seconds on upper
extremities and CRT is more than 3 seconds in lower
Patient described stress as a part of
extremities.
life. She could recognize when she
became stress when she feels weak.
HEAD & FACE: Patient has a moon face
These stressor means for her as
appearance..
difficult obstacles in life and it
affects her emotionally. She usually
talks to God or to her helper when EYES & VISION: Eyelids of the patient is quite puff
problems come. To relieve her stress, due to the moon face appearance but overall both
she just talks to somebody to express upper and lower lids close easily and meet completely
all of it.
when closed. The patient squints her eyes when
reading. For the near vision, the patient can’t still read.
XI. VALUE- BELIEF PATTERN She still needs her corrective lenses.

The value that she learned as a child

was to be honest. Her life goal is to
travel abroad and God was her
sources of hope, strength, comfort
and peace. Patient’s cultural belief
was to “mano” as a sign of respect
for the older people and they
MOUTH & PHARYNX: Thirty-two yellowish teeth
with dental carries but still have smooth surfaces and
edges.
Peripheral Pulses:
Rate Strength/Amplitude
practiced celebrating fiesta in their (Right) (Left) (Right) (Left)
town. She described her relationship
to God as her “everything” and Temporal 75 76 Strong Strong
worshiped Him as open as possible. Carotid 80 83 Strong Strong
Her present illness influenced her
values and faith because it made her Brachial 75 79 Strong Strong
changed her perspective in life and
to understand other people. Radial 74 79 Strong Strong
Femoral 68 72 Strong Strong
Popliteal 60 — Weak cannot be
palpated
Posterior tibialis — — cannot be palpated
Dorsalis pedis — — cannot be palpated

BACK & EXTREMITIES: Uneven weight bearing is

evident.
Range of Motion (ROM):
Overall muscle strength in the upper extremities is 5/5
while in the lower extremities is 3-4/5.

Muscle strength: Scale:

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

There is a clicking sound on the left knee of the

patient.
MOTOR/CEREBELLAR FUNCTION: Tandem
walk: the patient has difficulty in performing the walk.
Patient stands less than 10 secs with minimal swaying.
SENSORY FUNCTION: Patient can’t feel any
sensation unless heavy pressure is applied on both
lower extremities.
CRANIAL NERVE TESTING:
CN II (optic): Patient still squints her eyes when
reading the print both from far and near vision without
using her corrective lenses.
CN V (trigeminal): Patient can’t feel any sensation
unless heavy pressure is applied on both lower
extremities.

DAY 3: November 25, 2016

General Survey: Patient is awake, alert, afebrile,
coherent and responsive with an IVF of PNSS 1L
infusing well at left arm.
VITAL SIGNS:
BP: 120/70 mmHg
PR: 92 bpm
RR: 17 cpm
Temp: 36.4 C/tympanic
O2 saturation: 95%
SKIN: There are skin discoloration noted on the skin
of the patient especially on the upper and lower
extremities. There is a presence of desquamation noted
on both lower extremities. There is a presence of grade
2 pitting edema on the lower extremities.

HEAD & FACE: The patient has a moon face

appearance.

EYES & VISION: Eyelids of the patient is quite puff

due to the moon face appearance. The patient squints
her eyes when reading. For the near vision, the patient
needs her corrective lenses to be able to clearly read.
MOUTH & PHARYNX: Thirty-two yellowish teeth
with dental carries.
Peripheral Pulses:
Rate Strength/Amplitude
 (Right) (Left) (Right) (Left)
Temporal 85 80 Strong Strong
Carotid 87 88 Strong Strong
Brachial 76 73 Strong Strong
Radial 85 82 Strong Strong
Femoral 75 75 Strong Strong
Popliteal 58 — Weak cannot be
palpated
Posterior tibialis — — cannot be palpated
Dorsalis pedis — — cannot be palpated

BACK & EXTREMITIES: Uneven weight bearing is

evident.
Range of Motion (ROM):

Muscle strength: Scale:

5/5 5 – Full ROM against
5/5 gravity, full resistance
4 – Full ROM against
gravity, some resistance
4/5 4/5 3 – Full ROM with gravity
2 – Full ROM with gravity
eliminated (passive motion)
1 – Slight Reaction
0 – No Reaction
There is a clicking sound on the left knee of the
patient.
NEUROLOGIC ASSESSMENT:
MOTOR/CEREBELLAR FUNCTION: Tandem
walk: the patient still has difficulty in performing the
walk. Patient stands less than 10 secs with minimal
swaying.
SENSORY FUNCTION: Patient still can’t feel any
sensation unless heavy pressure is applied oon both
lower extremities.
CN II (optic) : Patient still squints her eyes when
reading the print both from far and near vision without
using her corrective lenses.
CN V (trigeminal): Patient can’t feel any sensation
unless heavy pressure is applied on both lower
extremities.

Laboratory Examinations
CBC (Complete Blood Count)
Is a basic screening test in order to diagnose
information about the hematologic changes within the
body system
And also it can help determine the number, variety,
percentage, concentration, and quality of blood cells.
 Results Results Normal
Blood
11/20/16 11/21/16 Values
WBC 12.9 4.09 4.10-
10.9
NEU 11.4 3.69 2.50-
7.50
LYM .539 .240 1.00-
4.00
MONO .695 .101 .100-
1.20
EOS .155 .037 0.00-
.500
BASO .076 .021 0.00-
.100
RBC 3.82 3.59 4.00-
5.20
HGB 10.6 9.69 12.0-
16.0
HCT 30.7 28.4 36.0-
46.0
MCV 80.4 79.2 80.0-
100.
MCH 27.8 27.0 26.0-
34.0
MCHC 34.6 34.1 31.0-
36.0
RDW 11.2 11.3 11.6-
18.0
PLT 254. 223. 140.-
440.
 MPV 5.71 5.25 0.00-
99.9

Implications: It implies that there is an infection going

on in the system due to the increase in WBC count as
of 11/20/16 and also it is expected that there would be
an increase or decreased in WBC count since the active
problem of the patient is SLE(Systemic Lupus
Erythematosus) in which the immune system is
suppress and also accompanied to that the patient is
taking Azathioprine and it is an immunosuppressive
agent. Low RBC, HGB and HCT indicates anemia.
Anemia is a frequent occurrence in systemic lupus
erythematosus (SLE), affecting most patients at some
time in the course of their disease.
(www.uptodate.com)

X-Ray
Is a common imaging test that views the inside of the
body without having to make an incision especially the
bony structures within the body and also the silhouette
of the different organ in the body.

11/20/16
Radiologic Findings:
Examination reveals the lung fields are clear. The
cardiac silhouette is not enlarge.
Conclusion: Normal heart and lungs.

Urinalysis:
Is a set of screening tests that can detect some common
diseases. It may be used to screen for and/or help
diagnose conditions such as a urinary tract infections,
kidney disorders, liver problems, diabetes or other
metabolic conditions.

11/20/16
Macroscopic
Color Yellow
Appearance Slightly
Cloudy
PH 6.0
Specific 1.015
Gravity
Glucose Negative
Ketone Negative
Blood +++
Protein +++
Bilirubin Negative
Urobilinogen Normal
Nitrite Negative

Microscopic
RBC/HPF 10-12/HPF
WBC/HPF 25-30/HPF
Pathologic Negative
Cast(PAT)
 Hyaline Negative
Cast(HYA)
Non 1/HPF
Epithelial
Cell(NEC)
Squamous 1-2/HPF
Epithelial
Cell(SEC)
Yeast Negative
Mucous Negative
Bacteria Negative
Others Negative

Implication: Since the patient has SLE(Systemic

Lupus Erythematosus) secondary to nephritis it is
expected that there would be renal problems as seen in
the results of the patients urinalysis there is a positive
for protein(Proteinuria) and blood(Hematuria).

Immunology-Serology
It is a laboratory diagnostic that focuses on identifying
antibodies (proteins made by a type of white blood cell
in response to an antigen, a foreign substance, in the
body).

Dengue Test:
Troponin-I: ***
***
CK-MB: Thyphidot
*** Test: ***
CEA: Syphilis Tp
*** Test: ***
 Coombs Test:

Direct:
AFP:
Positive
***
Indirect:
Positive
Urine
TPSA:
Pregnancy
***
Test: ***
ASO:
-
***
Glycosylated
Hemoglobin: -
***
ANA:
-
***
HBsAg.iC:
-
***
Implication: It implies as seen in the patients results it
is confirmed that the patient has SLE(Systemic Lupus
Erythematosus) since there is a positive for Coombs
Test and it is one way to identify if there are antibodies
specifically proteins that are found in the WBC of the
clients serum and blood.

Clinical Chemistry
Is the area of clinical pathology that is generally
concerned with analysis of bodily fluids for diagnostic
and therapeutic purposes.

Chong Hua Hospital

11/21/16
Test Result Reference
Creatinine, Urine
11.07 11-26
24hrs
Protein, Total
884.0 28.0-141
Urine 24hrs
Remarks: Urine Total Volume: 2000ml
Implication: In the 24hr urine collection it was found
out that there are proteins present in the clients urine. It
implies that due to her condition which is
SLE(Systemic Lupus Erythematosus) secondary to
nephritis the kidneys is unable to filter the proteins
thus leading to an increased in protein levels in the
urine.

CVGH
11/21/16
Clinical Normal
Results
Chemistry Range
Blood Urea
20.9 7.0-18.0
Nitrogen
Creatinine 1.31 0.60-1.50
GFR=<49
Implication: It implies that due to the clients kidney
problems which is nephritis it is expected that there
would be an elevation of BUN because the kidneys are
not anymore working properly.

11/20/16
 Clinical Normal
Results
Chemistry Range
Sodium 135 136-142

Potassium 3.9 4.0-5.6

Implication: There is only a slight decreased in

sodium and potassium levels however if there is a
greater decreased in the potassium levels there would
be cardiac dysrhythmias.

11/20/16
Clinical Reference
Result
Chemistry Range
Uric Acid 5.74 2.30-7.00
Creatinine 1.8 0.6-1.5
Glucose 84.40 75.00-115.00
ALT/SGPT 40 0-39
TQ a
Complement 87.68 -
C3C ver.2
Implication: There is only a slight elevation of the
ALT/SGT and creatinine of the patient results.

11/20/16
Test Results Reference
CRP(C-
178.60 0-5
Reactive
 Protein)
Implication: Since the patient’s active problems is
SLE(Systemic Lupus Erythematosus) it is expected
that there is an increased in CRP(C-Reactive Protein)
since it is an autoimmune disease and it is also
associated with the inflammatory process.

Diagnostic Microbiology/Culture and Sensitivity

Test
Is a branch of medical science concerned with the
prevention, diagnosis and treatment of infectious
diseases, In addition this field of science studies
various clinical applications of microbes for the
improvement of health.

Date Findings
No growth after 1 day of
11/21/16
incubation
No growth after 2 days of
11/22/16
incubation
No growth after 3 days of
11/23/16
incubation
No growth after 4 days of
11/24/16
incubation
No growth after 5 days of
11/25/15
incubation

Blood of right arm

Date Findings
11/21/16 No growth after 1 day of
 incubation
No growth after 2 days of
11/22/16
incubation
No growth after 3 days of
11/23/16
incubation
No growth after 4 days of
11/24/26
incubation
No growth after 5 days of
11/25/16
incubation

Urine
Date Findings
Smear of Specimen:
Gram Staining:
11/21/16 No Microorganisms Seen

Pus Cells: Few/OIF

Preliminary Result:
No growth after 1
day of incubation
No growth after 2 days of
11/22/16
incubation
Implication: The results as seen above there are no
microorganisms present from 1-5 days of incubation
from left arm, right arm, and urine.

Clotting Factors
Prothrombin time (PT) is a blood test that measures
how long it takes blood to clot. A prothrombin time
test can be used to check for bleeding problems.
11/20/16
Test Reference Results

Patient:
Control(100% 19.5sec
Prothrombin
Activity): %Activity:
Time
11.6sec 32.3%
INR: 1.64

Erythrocyte
Female:0-
Sedimentation 84 mm/hr
20mm/hr
Rate
Implication: As seen in the results there is an
increased in ESR(Erythrocyte Sedimentation Rate)
because it is associated with the clients active
problems which SLE(Systemic Lupus Erythematosus)
that there is an inflammation process that is going on
in the patients body.

DRUG STUDY
1. Fucidin hydrocortisone ointment @ right foot lesions BID
C: corticosteroid ( hyrodrocortisone ) , Fucidin ( antibacterial)
A: Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences
protein, fat, and carbohydrate metabolism.
I: For the treatment of dermatitis, cellulitis, including atopic dermatitis and contact dermatitis, where an infection with bacteria sensitive to fusidic acid is
suspected or confirmed.
C: Known hypersensitivity to any component of Fucidin H. Primary bacterial, viral and fungal skin infections.
A: Mild stinging, irritation and hypersensitivity reactions to fusidic acid and hydrocortisone acetate in the form of skin rashes have rarely been reported.
N:
• Always adjust to lowest effective dose.
• Monitor patient’s weight, blood pressure, and electrolyte level.
• Monitor patient for cushingoid effects, including modn face, buffalo hump, central obesity, thinning hair, hypertension, and increased susceptibility to
infection.
• Unless contraindicated, give a low-sodium diet that is high in potassium and protein. Give potassium supplements.
• Stress (fever, trauma, surgery, and emotional problems) may increase adrenal insufficiency. Increase dosage.
• Watch for depression or psychotic episodes, especially during high-dose therapy.
• Inspect patient’s skin for petechiae..
• Periodic measurement of growth and development may be needed during high-dose or prolonged therapy in children.
• Gradually reduce dosage after long-term therapy.

2. Prednisone 30 mg/ tab 1 tab OD PC BF

C: Corticosteroid (intermediate acting), Glucocorticoid, Hormone
A: It decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the
immune system by reducing activity and vol of the lymphatic system; suppresses adrenal function at high doses.
I: Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg, SLE), dermatologic diseases
(eg, pemphigus), status asthmaticus, and autoimmune disorders
C: Hypersensitivity, serious infections (except tuberculous meningitis), varicella, systemic fungal infections.
A: Insomnia, nervousness, increased appetite, indigestion, dizziness/lightheadedness, headache, hirsutism, hypopigmentation, diabetes mellitus, glucose
intolerance, hyperglycaemia, arthralgia, cataracts, glaucoma, epistaxis, diaphoresis, Cushing’s syndrome, edema, fractures, hallucinations, hypertension,
muscle-wasting, osteoporosis, pancreatitis, pituitary-adrenal axis suppression, seizures.

N:
 Administer once-a-day doses before 9AM to mimic normal peak corticosteroid blood levels.
 Increase dosage when patient is subject to stress.
 WARNING: Taper doses when discontinuing high-dose or long-term therapy to avoid adrenal insufficiency.
 Do not give live virus vaccines with immunosuppressive doses of corticosteroids.
 Do not stop taking the drug without consulting your health care provider; take once-daily doses at about 9 AM.
 Avoid exposure to infections.
 Report unusual weight gain, swelling of the extremities, muscle weakness, black or tarry stools, fever, prolonged sore throat, colds or other infections,
worsening of the disorder for which the drug is being taken.

3. Daflon 1 tab BID PO

C: multivitamins
A: protects the microcirculation by fighting the microcirculation-damaging process; it combats venous inflammation by decreasing leukocyte activation, and
as a consequence, by inhibiting the release of inflammatory mediators, principally free radicals and prostaglandins. Thus, Daflon 500 normalizes capillary
permeability and strengthens capillary resistance.
I: Treatment of the symptoms and signs of organic and idiopathic chronic venous disease of the lower limbs eg, heavy legs, pain, heat sensation, edema,
functional impairment and nocturnal cramps.
C: Hypersensitivity to the active substance or to any of the excipients of Daflon.
A: Mild diarrhea; nausea; stomach upset. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth,
face, lips, or tongue); feeling of swelling of the entire body; numbness or tingling of the skin.
N:
 Apply as prescribed
 Assess for any signs of infections such as erythema, pain, warmth, odor.
  Clean thoroughly with sterile water on gauze, tap dry and apply on the site.
 Protect by applying bandage.

4. Cefipime + tazobactam ( saptan) 1 gm/125mg 1gm q 12h

C: Cefepime is a 4th generation cephalosporin; Tazobactam is a antibacterial penicillin
A: In general, this drug is highly toxic and has a low therapeutic index; thus a clinically effective response is likely to be accompanied by some evidence of
toxicity. Inhibits DNA synthesis in both bacterial and mammalian cells and prevents progression of cells into mitosis, affecting all phases of the cell cycle
(cell-cycle nonspecific). Appears to have minimal effects on RNA or protein synthesis. Delays repair of DNA damaged by nitrosourea-induced alkylation.
Unlike other nitrosoureas, has markedly significant specificity for pancreatic beta and exocrine cells.
I: Cefepime / Tazobactam is a medicine that is used for the treatment of Pneumonia, Urinary tract infections, Pyelonephritis, Skin and soft tissue infections,
Intra-abdominal infections, Febrile neutropenia and other conditions.
C: Hypersensitivity to Cefepime / Tazobactam is a contraindication. In addition, Cefepime / Tazobactam should not be taken if you have the following
conditions:
 Breastfeeding
 History of allergy to cephalosporins
 Hypersensitivity
 Kidney, liver or blood clotting disorder
 Poor nutrition
 Pregnant
 Stomach or bowel problems
 Taking drugs like aminoglycosides and diuretics

A: Hypersensitivity to Cefepime / Tazobactam is a contraindication. In addition, Cefepime / Tazobactam should not be taken if you have the following
conditions:
 Breastfeeding
 History of allergy to cephalosporins
 Hypersensitivity
 Kidney, liver or blood clotting disorder
 Poor nutrition
 Pregnant
 Stomach or bowel problems
 Taking drugs like aminoglycosides and diuretics

N:

 Drink fluids liberally (2000–3000 mL/d). Hydration may protect against drug toxicity effects.
 Report S&S of nephrotoxicity (see Appendix F).
 Do not take aspirin without consulting physician.Report to physician promptly any signs of bleeding: Hematuria, epistaxis, ecchymoses, petechial.
 Report symptoms that suggest anemia: Shortness of breath, pale mucous membranes and nail beds, exhaustion, rapid pulse.
 Monitor for S&S of superinfection (see Appendix F).
 Monitor and record temperature pattern to promptly recognize impending sepsis.

5. Azathioprine (imuran) 500 mg/tab i tab TID

C: Immunosuppressant
A: Azathioprine is an immunosuppressant, which inhibits DNA, RNA and protein synthesis and antagonises purine synthesis. It also inhibits mitosis and
interferes with cellular metabolism of susceptible organisms. Azathioprine inj should be discontinued as soon as oral therapy can be introduced

I: Autoimmune disease (e.g., SLE)

C: Hypersensitivity; previous treatment with alkylating agents; pregnancy, lactation.

A:
 Fever, chills; bone marrow depression characterised by leucopenia, thrombocytopenia or anaemia; anorexia, nausea, diarrhoea; arthralgias; secondary
infections; hepatotoxicity, rash, alopoecia.
 Potentially Fatal: Myelosuppression, mutagenicity and carcinogenicity; veno-occlussive liver disease.

N: History: Allergy to azathioprine; rheumatoid arthritis patients previously treated with alkylating agents; pregnancy or male partners of women trying to
become pregnant; lactation
 Physical: T; skin color, lesions; liver evaluation, bowel sounds; LFTs, renal function tests, CBC
  Interventions
 Give drug IV if oral administration is not possible; switch to oral route as soon as possible.
 Administer in divided daily doses or with food if GI upset occurs.
 BLACK BOX WARNING: Monitor blood counts regularly; severe hematologic effects may require the discontinuation of therapy; increases risk of
neoplasia.
 Teaching points
 Take drug in divided doses with food if GI upset occurs.
 Avoid infections; avoid crowds or people who have infections. Notify your physician at once if you are injured.
 Notify your health care provider if you think you are pregnant or wish to become pregnant, or if you are a man whose sexual partner wishes to
become pregnant.
 You may experience these side effects: Nausea, vomiting (take drug in divided doses or with food), diarrhea, rash.
 Report unusual bleeding or bruising, fever, sore throat, mouth sores, signs of infection, abdominal pain, severe diarrhea, darkened urine or pale stools,
severe nausea and vomiting.

6. PCM 500mg 1 tab

C: Non-narcotic analgesic, Antipyretic

A:

 Decreases fever by a hypothalamic effect leading to sweating and vasodilation

 Inhibits pyrogen effect on the hypothalamic-heat-regulating centers
 Inhibits CNS prostaglandin synthesis with minimal effects on peripheral prostaglandin synthesis
 Does not cause ulceration of the GI tract and causes no anticoagulant action.

I: Control of pain, reduce fever in viral and bacterial infections

C: Renal Insufficiency
Anemia
A: Minimal GI upset. Methemoglobinemia,Hemolytic Anemia, Neutropenia, Thrombocytopenia, Pancytopenia, Leukopenia, Urticaria, CNS stimulation,
Hypoglycemic coma, Jaundice, Drowsiness
Liver Damage

N:
 Extended-Release tablets are not to be chewed.
 Monitor CBC, liver and renal functions.
 Assess for fecal occult blood and nephritis.
 Avoid using OTC drugs with Acetaminophen.
 Take with food or milk to minimize GI upset.
 Report N&V. cyanosis, shortness of breath and abdominal pain as these are signs of toxicity.
 Report paleness, weakness and heart beat skips
 Report abdominal pain, jaundice, dark urine, itchiness or clay-colored stools.
 Report pain that persists for more than 3-5 days
 Avoid alcohol.
 This drug is not for regular use with any form of liver disease.

7. Clindamycin (Dalacin C) 600mg IV infusion q8H,NST

C: Antibiotic, lincosamide
A: Suppresses protein synthesis by microorganisms by binding to ribosomes. Prevents peptide formation and does not diffuse adequately to the CSF
I: Treatment of serious skin and soft tissue infections, septicemia and abdominal infections
Serious infections caused by Streptococci/ Staphylocicci/ Pneumococci

C: Hypersensitivity;Use in treating minor bacterial infections Use in clients with a history of regional enteritis, ulcerative colitis, meningitis, antibiotic-
associated colitis Use for treating viral infections

A: Diarrhea,pseudomembranous colitis ,tinnitus, nausea and vomiting ,rashes , dry skin , burning, itching, skin erythema ,peeling, oily skin, cardiopulmonary
arrest, anaphylaxis, agranulocytosis, aplastic anemia
N:
 Reduce dosage in severe renal impairment
 Administer IV over 20-60 minutes
  Assess for diarrhea and possible colitis
 Assess extent of infections and if improvement occurs
 Monitor liver and renal function
 With IV, keep in bed for 30 min. following infusion to prevent hypotension
 If diarrhea occurs, do not use antiperistaltic agents
 If using vaginal cream, it weakens latex-containing condoms due to the mineral oil content
 Do not use peeling agents on affected acne areas


8. losartan K ( Cozaar) 50mg/tab 1tab OD PC BF

C: Angiotensin II receptor blocker (ARB);Antihypertensive
A : Selectively blocks the binding of angiotensin II to specific tissue receptors found in the vascular smooth muscle and adrenal gland; this action blocks the
vasoconstriction effect of the renin-angiotensin system as well as the release of aldosterone leading to decreased blood pressure.
I: Treatment of hypertension, alone or in combination with other antihypertensive agents · Treatment of diabetic neuropathy with an elevated serum
creatinine and proteinuria in patients with type 2 diabetes and a history of hypertension
C : hypersensitivity to losartan
A: Headache, dizziness, syncope, insomnia, Hypotension, Rash, urticaria, pruritus, alopecia, dry skin, Diarrhea, abdominal pain, nausea, constipation, dry
mouth, URI symptoms, cough, sinus disorders, Cancer in preclinical studies, back pain, fever, gout, muscle weakness.
N:

 Monitor BP at drug trough (prior to a scheduled dose).

 Monitor drug effectiveness, especially in African-Americans when losartan is used as monotherapy.
 Inadequate response may be improved by splitting the daily dose into twice-daily dose.
 Lab tests: Monitor CBC, electrolytes, liver & kidney function with long-term therapy.
 Notify physician of symptoms of hypotension (e.g., dizziness, fainting).
 Notify physician immediately of pregnancy.
 Do not breast feed while taking this drug.
 Administer without regard to meals.

9. carvedilol ( Carvid ) 25mg/tab ½ tab OD BID PC

C: antihypertensive

A: Adrenergic receptor blocking agent that combines selective alpha activity and nonselective beta-adrenergic blocking actions. Both activities contribute to
blood pressure reduction.

I: Hypertension

C: Patients with class IV decompensated cardiac failure, bronchial asthma, or related bronchospastic conditions (e.g., chronic bronchitis and emphysema),
second- and third-degree AV block, cardiogenic shock or severe bradycardia.

A: increased sweating, fatigue, chest pain, pain, arthralgia, bradycardia, hypotension, syncope, hypertension, AV block, angina, diarrhea, nausea, abdominal
pain, vomiting, sinusitis, bronchitis. thrombocytopenia, hyperglycemia, weight increase, gout, dizziness, headache, paresthesias.

N:

Take drug with meals.

Do not stop taking drug unless instructed to do so by a health care provider.
Avoid use of OTC medications.
You may experience these side effects: Depression, dizziness, light-headedness (avoid driving or performing dangerous activities; getting up and
changing positions slowly may help ease dizziness).
Report difficulty breathing, swelling of extremities, changes in color of stool or urine, very slow heart rate, continued dizziness.

10. febuxostat (Atenurix) 40mg/tab 1tab OD PC BF

C: Xanthine oxidase inhibitor

A: is a xanthine oxidase inhibitor. It works by blocking an enzyme in the body (xanthine oxidase), which lowers levels of uric acid in the blood.

I: sudden attack for redness, swelling, pain and heat in one or more joint

C: Coadministration with azathioprine, mercaptopurine, or theophylline.

A: Dizziness, Rash, Nausea, Abnormal LFTs, Arthralgia

N:

 Drink enough fluid to produce urinary output of at least 2000 mL/d (fluid intake of at least 3000 mL/d). (Note that 1000 mL is approximately equal to
1 quart.) Report diminishing urinary output, cloudy urine, unusual color or odor to urine, pain or discomfort on urination.
 Report promptly the onset of itching or rash. Stop drug if a skin rash appears, even after 5 or more wk (and reportedly as long as 2 y) of therapy.
 Minimize exposure of eyes to ultraviolet or sunlight which may stimulate the development of cataracts.
 Instruct patients to contact health care provider if they experience chest pain, rash,
 shortness of breath, or neurologic symptoms suggesting a stroke.
 Advise patients that product may be taken without regard to meals.

11. rosuvastatin ( Crestor ) 20mg/tab 1tab OD qHS

C:Anti- hyperlipi demic HMG-CoA reductase inhibitor

A: Reduces total cholesterol and LDL cholesterol, and also lowers plasma triglycerides and apolipoprotein B while increasing HDL.

I: an adjunct to diet in the treatment of elevated total cholesterol, mixed dyslipidemia, atherosclerosis; for prevention in patients with SLE has higher risk in
developing athrosclerosis

C: hypersensitivity, impaired hepatic function, alcoholism, renal impairment, advanced age, hypothyroidism

A: Nausea, dyspepsia, diarrhea, constipation, vomiting, rhinitis, sinusitis, cough, dyspnea, pneumonia
N:
• Administer drug at bed time
• Monitor patient closely for signs of muscle injury, especially higher doses
• Provide comfort measures to deal with headache, muscle cramps, or nausea
• Offer support and encouragement to deal with disease, diet, drug therapy, and follow-up care
• Arrange for proper consultation about need for diet and exercise changes
• Do not take antacids within 2 h of taking this drug

12. multivitamins + iron 1tab OD PC BF

C: vitamins and minerals
A: Elevates the serum iron concentration
I: Prevention and treatment of iron deficiency anemias. Dietary supplement for iron and treat or prevent vitamin deficiency .
C: Hypersensitivity and severe hypotension.
A: Dizziness, nasal congestion, dyspnea , hypotension, muscle cramps, flushing

N:

• Advise patient to take medicine as prescribed.

• Caution patient to make position changes slowly to minimize orhtostatic hypotension.
• Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician.
• Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs.
• Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle changes and stress management.

13. Caltrate Plus 1tab OD PC BF

C: dietary supplement
A: help maintain bone health, and may assist in the prevention or treatment of osteoporosis
I: It is used to prevent conditions of low calcium and vitamin D.
C: Hypercalcaemia and severe hypercalciuria

A: severe allergic reactions, loss of appetite, constipation, nausea and vomiting,arrythmias, bradycardia
N:
•Monitor VS especially BP and PR.
• Asses for heartburn, indigestion, abdominal pain.
• Monitor serum calcium before treatment.
• Assess for nausea and vomiting, anorexia, thirst, severe constipation

14. dabigatran ( Pradaxa) 110mg/cap 1cap BID PC

C: thrombin inhibitor

A: prevents the development of a thrombus. Both free and clot-bound thrombin and thrombin-induced platelet aggregation are inhibited by the active moieties

I: treatment of DVT and PE; Reduction in Risk of Stroke andSystemic Embolism in Non-valvular AF

C: Active pathological bleeding; mechanical prosthetic heart valve.

A: Gastritis-like symptoms (eg, GERD, esophagitis, erosive gastritis, gastric hemorrhage, ulcer), bleeding.
N:
 Monitor for bleeding, GI adverse reactions, hypersensitivity reactions, and other adverse events.
 Periodically monitor renal function as clinically indicated.
 Monitor for signs/symptoms of neurological impairment (eg, midline back pain,numbness, tingling, weakness in lower limbs, bowel/bladder dysfunction)
frequently in patients receiving neuraxial anesthesia or undergoing spinal puncture.

15. hydroxylchloroquine 200mg/tab 1tab OD PC BF

C: antimalarials; antirheumatic drug
A: The precise mechanism of action is not known.
I: Acute and chronic rheumatoid arthritis; mild systemic and discoid lupus erythematosus; the suppression and treatment of malaria.
C: patients with pre-existing maculopathy of the eye ; patients with known hypersensitivity to 4-aminoquinoline compounds, and ; long-term therapy in
children ; children under 6 years of age.

A: muscle weakness, twitching, or uncontrolled movement;loss of balance or coordination;blurred vision, light sensitivity, seeing halos around lights;pale
skin, easy bruising or bleeding;confusion, unusual thoughts or behavior; or seizure
N:

 Monitor for therapeutic effectiveness; may not appear for several weeks, and maximal benefit may not occur for 6 mos.
 Do baseline and periodic ophthalmoscopic examinations and blood cell counts on all patients on long-term therapy.
 Discontinue drug if weakness, visual symptoms, hearing loss, unusual bleeding, bruising, or skin eruptions occur

DISCHARGE PLAN
May go home was ordered by:
 Dr. M Chua on 11/28/16
 Dr. Tee 11/28/16

M:
 Losartan K 50 mg/tab 1 tab once a day after breakfast
 Carvedilol 25mg/tab ½ tab twice a day
 Dabigatran 110 mg/cap 1 cap twice a day after meal
 Rosuvastatin 20 mg/tab 1 tab once a day every before sleeping
 Febuxostat 40 mg/tab 1 tab once a day after breakfast
 Combiderm ointment twice a day until 11/27/16
 Fucidin ointment twice a day for 4 more days
 Prednisone 30 mg/tab 1 tab once a day
 Azathioprine (imuran) 500mg/tab thrice a day
 CaCO3 + vit. D ( caltrate plus) 1 tab once a day
 Hydroxyl chloroquine ( plaqueuil) 200 mg/tab once a day

E:
  Advised S.O to vigorously clean home and surroundings to avoid reinfection or infection of other individuals.
 Encouraged S.O and patient to maintain a pleasant and therapeutic environment such as cleaning the surroundings and arranging things.
 Encouraged to maintain a clean area especially in places where food is kept.
 Instructed to keep the surroundings safe by keeping sharp and pointed objects at their right places to avoid any accidents or injuries
 Encouraged to maintain a calm and peaceful environment to promote rest periods
 Advised to maintain environment conducive for resting and sleeping
 Instructed to put the patient away to those who have colds, cough or any crowded places.

T:


H:
 Rest: Rest when you feel it is needed. Slowly start to do more each day. Return to your daily activities as directed.
 Protect your skin from UV light: Sunlight can make your lupus symptoms worse. Avoid the sun between 10 am and 4 pm, when the rays are strongest.
Apply sunscreen with a SPF of 30 or more every 2 hours when you are outside. Do this even on cloudy days. Wear pants and long sleeves to cover
your body. A hat with a wide brim can protect your face, head, and neck.
 Heat: Heat helps decrease joint pain or swelling. Apply heat on the painful joint for 20 to 30 minutes every 2 hours for as many days as directed.
 Ice: Ice helps decrease swelling and pain. Ice may also help prevent tissue damage. Use an ice pack, or put crushed ice in a plastic bag. Cover it with a
towel and place it on the painful area for 15 to 20 minutes every hour as directed.
 Avoid others who are sick: You are at increased risk of a severe infection.

O:
 Instructed client to contact health care provider if following signs and symptoms are felt: have a flare of your lupus symptoms, have a fever or
headache, feel like you are starting to get sick, start to urinate less than usual, are bleeding from your nose or gums, and bruise easily.
 Instructed to seek care immediately if the following signs and symptoms are felt: have blood in your urine, bowel movement, or vomit, have severe
abdominal pain, are confused or feel dizzy or faint, have numbness or weakness of your face or limbs, or have trouble seeing or speaking, have a
seizure, have new, sudden vision changes, have trouble breathing, have chest pain, pressure, or discomfort that may spread to your arms, jaw, or back,
 leg feels warm, tender, and painful. It may look swollen and red, suddenly feel lightheaded and short of breath, have chest pain when you take a deep
breath or cough, cough up blood.

D:
 Increased consumption of omega-3 fatty acids are found in fatty fish such as salmon, sardines and tuna because Omega-3s are polyunsaturated fatty
acids that help protect against heart disease and stroke. They can also reduce inflammation in the body.
 Eat foods that are high in calcium and vitamin D. These nutrients strengthen your bones. Good foods include: low-fat milk, cheese, yogurt, tofu,
beans, calcium-fortified plant milks, dark green leafy vegetables such as spinach and broccoli. Because steroid drugs you may take to control lupus
can thin your bones as a side effect. This makes you more vulnerable to fractures.
 Limit saturated and trans fats such as pork, chicken with skin, whole milk, cream, butter, cheese and ice cream. Steroids can increase your appetite
and cause you to gain weight, so it’s important to watch what you eat. Try to focus on foods that will fill you up without filling you out, such as raw
vegetables, air-popped popcorn, and fruit.
 Instructed to watch alcohol intake. The occasional glass of red wine or beer isn’t restricted. However, alcohol can interact with some of the medicines
you take to control your condition. Drinking while taking NSAID drugs such as ibuprofen (Motrin) or naproxen(Naprosyn), for example, could
increase your risk of stomach bleeding or ulcers. Alcohol can also reduce the effectiveness of warfarin (Coumadin) and methotrexate.
 Eat less sodium instead Substitute other spices to enhance food flavor, such as: lemon, herbs, and pepper.

S:
 Advised patient and mother to always trust in God and believe that He always has wonderful plans for each and every one.
 Advised to always be strong and optimistic in facing changes that she might encounter in life.
 Encouraged patient to always stay faithful to God.
 Encourage to pray when waking up, before eating and before going to sleep to practice grace.
 Encourage to lean on God in times of distress so stress stress (which usually triggers inflammation) will be avoided.
 APPENDICES

Appendix 1
Maintenance Medications:
Generic Name Brand Name Dosage/Frequency Purpose

to maintain bone
calcium carbonate Caltrate Plus 1 tab OD PC BF
health
febuxostat Atenurix 40mg 1 tab OD PC BF decrease uric acid

dabigatran Pradaxa 110mg 1 cap BID PC prevents thrombus

treat idiopathic chronic

diosmin+hesperidin Daflon 50mg tablet BID venous disease of the
lower limbs
blocks the binding of
50mg/tab 1 tab OD PC angiotensin II to
losartan K Cozaar
BF specific tissue
receptors
Appendix 2

Family Genogram
Appendix 3
Usual Diet & 24- Hour Diet Recall
Meal of Day 24-Hour Diet Recall
Time last taken: 8 am
Breakfast Meal taken at: Hospital
Components of Meal: fish,rice
Time last taken: 12 pm
Meal taken at: Hospital
Lunch
Components of Meal:
potatoes, rice, banana
Time last taken: 6 pm
Dinner Meal taken at: Hospital
Components of Meal: fish, rice
Time last taken: 5 am
AM Snacks Meal taken at: Hospital
Components of Meal: bread
Time last taken: 3 pm
PM Snacks Meal taken at: Hospital
Components of Meal: banana
Usual/Typical Diet
Usual Time Taken: 8 am
Usual Components of Meal:
egg,fish,vegetables,rice
Usual Time Taken: 12 pm
Usual Components of Meal:
fish,vegetables,rice
Usual Time Taken: 5-6 pm
Usual Components of Meal:
fish/pork, vegetables, rice
Usual Time Taken: None
Usual Components of Meal:
None
Usual Time Taken: 3 pm
Usual Components of Meal:
fruits(apple, pineapple)
Appendix 4
A. Client Ecomap

CHURCH

Family
GOD Client
Family

Friends

ATTACHMENTS:

Strongly attached -

Moderately attached-

Slightly attached-

Very slightly attached

Negatively attached- -----------

Appendix 5

Name of Family Member Relationship with Family Describe said family

Member member, his/her role in the
family and your relationship
with him/her
F.I. Father Breadwinner
P.I. Mother Breadwinner
M.I. Brother Harmonizer/child-rearer
G.I. Sister Coordinator
H.I. Brother Coordinator
R.O. Brother Homemaker
F.I.G. Brother Child-rearer