Introduction

Hypertension is one of the most

common worldwide diseases afflicting
humans. Because of the associated
morbidity and mortality and the cost
to society, hypertension is an
important public health challenge.
Over the past several decades,
extensive research, widespread
patient education, and a concerted
effort on the part of health care
professionals have led to decreased
mortality and morbidity rates from the multiple organ damage arising from years of
untreated hypertension. Hypertension is the most important modifiable risk factor for
coronary heart disease (the leading cause of death in North America), stroke (the third
leading cause), congestive heart failure, end-stage renal disease, and peripheral
vascular disease. Therefore, health care professionals must not only identify and treat
patients with hypertension but also promote a healthy lifestyle and preventive strategies
to decrease the prevalence of hypertension in the general population.

• Pre-hypertension - Systolic blood pressure (SBP) 120-139 or diastolic blood

pressure(DBP) 80-89

• Stage I HTN - SBP 140-159 or DBP 90-99

• Stage II HTN - SBP >160 or DBP >100

Hypertensive crises encompass a spectrum of clinical presentations where uncontrolled

BPs leads to progressive or impending target organ dysfunction (TOD). The clinical
distinction between hypertensive emergencies and hypertensive urgencies depends on
the presence of acute TOD and not on the absolute level of the BP.
Hypertensive emergencies represent severe HTN with acute impairment of an organ
system (eg, central nervous system [CNS], cardiovascular, renal). In these conditions,
the BP should be lowered aggressively over minutes to hours.

Hypertensive urgency is defined as a severe elevation of BP, without evidence of

progressive target organ dysfunction. These patients require BP control over several
days to weeks.

II. NURSING ASSESSMENT

A. PERSONAL HISTORY

Mang Jose was born on January 20, 1948 via Normal Spontaneous Delivery
(NSD). He is already 60 years old, a natural born Filipino and a Roman Catholic. He
was the 6th child in their family and has 5 other siblings, three girls and two boys.
Presently, he lives at Brgy. Pandan, Pampanga and is already married to his wife,
Aling Lucing. They have three children, one boy who is already 30 years old, and
two girls aged 40 and 38. He is a purok leader, he usually works whole day. He also
loves to eat fatty and salty foods.

According to Mang Jose, he experienced dysuria or difficulty urinating. His

wife, Aling Lucing confirmed his statement and also said that her husband
sometimes had elevated blood pressure. She also said that, one week prior to his
husband’s admission, Mang Jose has difficulty urinating and thus he decided to
consult a doctor. Mang Jose was admitted in the morning of April 20, 2009 at Ospital
ning Angeles with an admitting diagnosis of HPN I and UTI with a chief complaint of
dysuria. His admitting notes/vital signs are as follows: T=36°C P=80 R=24
BP=170/100
B. PERTINENT FAMILY HISTORY

Mang Jose’s family is a nuclear type of family. They live together with his wife
and youngest son, because his two daughters already have their own family.

His family believes in “herbolarios” or the so-called “manghihilot”. He also

uses herbal plants like “dahon ng bayabas”, whenever he has a wound. He and his
family also go to the health center for consultations.

The family lives in a Bungalow-type of house that is made of coco lumber and
corrugated tin as their roof. The house has two rooms, one for him and his wife and
the other for their youngest son. A corrugated tin serves as a wall that separates the
two rooms for their own privacy. The house has a bathroom with a pail system. Their
electricity is being supplied by AEC and their water source is through a faucet
supplied by Angeles Water District. Mang Jose is a brgy. tanod and earns
P200.00/day. His wife is a laundry woman, who works once a week with her niece
and earns P2, 000.00 for a month. Mang Jose also mentioned that what they earn is
not enough to sustain their needs. They usually seek financial support from their
daughters when they do not have enough money to sustain their needs and in case
of emergencies like what happened to him.

C. PERTINENT FAMILY HEALTH-ILLNESS HISTORY

According to Mang Jose, his grandparents on mother’s side died of CVA and
hypertension while on his father’s side, died of aging. His mother died of CVA and
hypertension while his father died because of appendicitis. According to Mang Jose,
his father experienced severe abdominal pain and was diagnosed to have ruptured
appendicitis but due to financial constraints, they were not able to afford to perform
surgery for his father. His brother died of car accident, his other brother died of
gastric cancer. His three sisters are hypertensive. Mang Jose loves to eat fatty and
salty foods. His three children are all hypertensive also.
D. HISTORY OF PAST ILLNESS

According to Mang Jose, this was his first time to be hospitalized. He said that he
is only having headaches, fever, coughs, and colds and takes medicines such as
Paracetamol and Mefenamic Acid to be relieved. He also drinks calamansi juice
when he has coughs and colds. It was just recently when he experienced difficulty
urinating.

E. HISTORY OF PRESENT ILLNESS

According to Mang Jose, a week before he was admitted at Ospital ning Angeles,
he experienced difficulty urinating and an elevated blood pressure. He always asks
student nurses in their barangay to take his blood pressure and his elevated blood
pressure is consistent. Also, he has difficulty urinating, and his urine is dark yellow in
color, and only small amount of urine is excreted. Aling Lucing decided then to bring
him to the hospital. There, he was admitted on April 20, 2009. He was asked to take
medications and he was given an IVF. He was also asked to undergone renal
ultrasound, chest x-ray, urinalysis and CBC. They also took his total cholesterol,
BUN, Crea and other electrolytes.

F. PHYSICAL EXAMINATION

Upon Admission (April 20, 2009). Lifted from the chart.

Vital Signs: T=36°C P=80 R=24 BP=170/100

• HEENT: pink palpebral conjunctiva

• Chest, Lungs: Symmetrical Chest Expansion, normal breath sounds
• Cardiovascular: Normal Rate Regular Rhythm (NRRR), adynamic
precordium
• Abdomen: symmetrical
 April 21, 2009 (student nurse- patient interaction)

General condition: Patient on a semi-fowler’s position, awake, conscious and coherent

with an IVF of with an ongoing IVF of #2 D5 LRS 1Lx8° at 450cc level infusing well on
the right hand; with initial VS of: T=36.6°C P=79 R=20 BP=150/90
SKIN: with edema; non-pitting
HEAD and SKULL: smooth skull contour, no lumps or lesions on the head
EYES: pink palpebral conjunctiva, periorbital edema
EARS: no discharge, no lesions
FACE: symmetrical placement of eyes and facial features and ears are symmetrical in
line with the outer cantus of the eyes, facial edema
NOSE: nasal septum intact and midline, no discharge, no lesions, no nasal flaring
MOUTH: intact lips and palate
NECK: no vein distention, no palpable lymph nodes
CHEST: normal contour with symmetrical lung expansion
LUNGS: normal breathing pattern, (+) adventitious breath sounds; wheezes
ABDOMEN: symmetrical
EXTREMITIES: bipedal edema, non-pitting
April 22, 2009 (student nurse- patient interaction)

General condition: Patient on a semi-fowler’s position; sleeping; with an ongoing IVF of

#3 D5LRS 1Lx8° at 280ml level infusing well on the right hand; pt. appears restless;
with initial VS taken and recorded as follows: T=36.6°C P=69 R=20 BP=140/90
SKIN: with good skin turgor; pale nail beds
HEAD and SKULL: smooth skull contour, no lumps or lesions on the head
EYES: pink palpebral conjunctiva, periorbital edema
EARS: no discharge, no lesions
FACE: symmetrical placement of eyes and facial features and ears are symmetrical in
line with the outer cantus of the eyes, facial edema
NOSE: nasal septum intact and midline, no discharge, no lesions, no nasal flaring
MOUTH: intact lips and palate
NECK: no vein distention, no palpable lymph nodes
CHEST: normal contour with symmetrical lung expansion
LUNGS: normal breathing pattern, (+) adventitious breath sounds; wheezes
ABDOMEN: symmetrical
EXTREMITIES: bipedal edema, non-pitting
 G. DIAGNOSTIC AND LABORATORY PROCEDURES

DIAGNOSTIC/ DATE INDICATIONS/ RESULTS NORMAL VALUES ANALYSIS AND

LABORATORY ORDERED/ PURPOSES USED BY THE INTERPRETATION
PROCEDURE PERFORMED HOSPITAL

1. Complete Date Ordered: Hemoglobin- to determine 160 140-180gm/L There is a normal level
Blood Count 04-20-09 the oxygen carrying of hemoglobin count
capacity of the blood. possibly because there
Date Performed: is still enough oxygen
04-20-09 carrying capacity of
blood.

Hematocrit- to aid in the There is a normal level

diagnosis of abnormal 0.47 0.40-0.54L/L of hematocrit count
state of hydration since patient did not
manifest dehydration

WBC- especially helpful in Normal values may

the evaluating infection, 9.7 5-10g/L suggest
allergy or absence/alleviation of
immunosuppression infection

Lymphocytes- stimulated in 0.21 0.20-0.35 A normal value

 chronic bacterial infections indicates
or acute viral infections absence/alleviation of
infection
Potassium - Most
2. Serum Date Ordered: important determinant in 4.09mmol/L K= 3.5-5.0mmol/L Result is normal due to
electrolytes 04-20-09 maintaining membrane absence of electrolyte
electrical potential in imbalance.
Date Performed: excitable neuromuscular
04-20-09 tissue.
144.3mmol/L Na= 137-147mmol/L
Sodium -It is a major Result is normal due to
cation in the extracellular absence of electrolyte
space. Sodium salts are imbalance.
the major determinants of
extracellular osmolality.
DIAGNOSTIC/ DATE ORDERED/ INDICATIONS/ RESULTS NORMAL VALUES ANALYSIS AND
LABORATORY PERFORMED PURPOSES USED BY INTERPRETATION
PROCEDURE THE HOSPITAL

1. Blood Urea Date Ordered: This test measures the 37.78 mg/dl 15-45 mg/dl Normal BUN indicates
Nitrogen 04-21-09 nitrogen fraction of urea, a normal renal
the chief end product of function.
Date Performed: protein metabolism.The
04-21-09 BUN level reflects protein
intake and renal exvretory
capacity, but is less
indicator of uremia than
the serum creatinine level.
This test was done to
evaluate renal function.

2. Creatinine Date Ordered: Creatinine is excreted Normal Creatinine

04-21-09 directly by the kidneys. 1.3 mg/dl 0.7-1.4 mg/dl levels indicates normal
Therefore is directly renal function
Date Performed: proportional to renal
04-21-09 excretory function. Use to
diagnose impaired renal
function

3. Lipid Profile Date Ordered: HDL- This is a blood test 26 mgs/dl >35 mgs/dl The HDL level is below
04-20-09 that measures a kind of fat the normal range
(lipid) in the blood. The which indicates that
Nursing Responsibilities (CBC test)
Before:
• Prepare the client
• The nurse needs to know what equipment and supplies are needed for the test.
• Instruct the client and family about requirements or restrictions (when and what
to drink, how long and fast)
• Explain to the patient the purposes of the test.
• Tell the patient that the test requires blood sample. Explain who will perform the
venipuncture and when.
• Explain to the patient that he may experience discomfort from the needle
puncture and tourniquet.
• Inform the client the time period before the results will be available.
• Review the client’s record for medications that may prolong bleeding such as
anticoagulants.

During:
• The nurse focuses on specimen collection and performs or assists with certain
diagnostic testing.
• The nurse provides emotional and physical support while monitoring the client as
needed.
• The nurse ensures correct labeling, storage, and transportation of specimen to
avoid invalid test results.

After:
• The nurse focuses on nursing care of the client and follows up activities and
observations.
• The nurse compares the previous and current results ad modifies interventions
as needed.
• The nurse also reports the results to appropriate health team members.

Nursing Responsibilities (Sodium)

Before:
• Inform the patient that the test is used to evaluate electrolyte balance.
• Obtain a history of the patient’s endocrine and genitourinary systems, as well as
previously performed laboratory tests, surgical procedure, and other diagnostic
procedures.
• Assess patient for allergy, including list of unknown allergens (especially allergies
or sensitivities to latex).
 • Obtain a list of medications the patient is taking, including herbs, and nutritional
supplements.
• Review the procedure with the patient. Inform the patient about the duration of
the procedure and explain to the patient that there may be some discomforts
during the venipuncture.
During:
• Instruct the patient to cooperate fully and to follow directions.
• Observe Standard Precautions.
• Remove the needle, and apply pressure dressing over the puncture site.
• Promptly transport the specimen to the laboratory for processing and analysis.

After:
• Observe the venipuncture site for bleeding or hematoma formation. Apply paper
tape or other adhesive to hold pressure bandage in place.
• Evaluate patient for signs and symptoms of dehydration, decreased skin turgor,
dry mouth, and multiple longitudinal furrows in the tongue are symptoms of
dehydration
• Educate the patients with low sodium levels that the major source of dietary
sodium is found in table salt.
• Reinforce information given by the patient’s health care provider regarding the
test results. Answer any questions or address any concerns voiced by the patient
or family.

Nursing Responsibilities (Potassium)

Before:

• Check the doctor’s order

• Explain the procedure
• Explain the purpose and what to expect
• No food or fluid restrictions
During:

• Do not take the blood sample from hand or arm with receiving IVF
• The tourniquet should be less on a minute
• Do not squeeze the punctured site rightly
• Wipe away the first drop of blood
• Collect 2ml venous blood in a lavender top tube
After:

• Observe and record vital signs.

• Check injection sites for bleeding, infection, tenderness or thrombosis.
• Report untoward reaction to the physician.
• Apply warm compress to ease discomfort, as ordered.
• Encourage relaxation by allowing client to discuss experiences and verbalize
feelings.
• Interpret results and provide counsel appropriately. Provide health teachings
regarding proper lifestyle changes and symptoms that may warrant immediate
medical attention.

Nursing Responsibilities (Lipid Profile)

Before:

• Inform the patient that the test is used to assess and monitor risk for coronary
artery disease.
• Obtain history of the patient’s past health history and previously performed
laboratory tests, surgical procedures, and other diagnostic procedures.
• Instruct the patient to withhold drugs and alcohol known to alter cholesterol levels
for 12 to 24 hours before specimen collection.
• Fasting 6 to 12 hours before specimen collection is required if triglyceride
measurements are included; it is recommended if cholesterol levels alone are
measured for screening.

During:

• Ensure that the patient has complied with the dietary restrictions and pre testing
precautions.
• If the patient has a history of severe allergic reaction to latex, care should be
taken to avoid the use of equipment containing latex.
• Instruct the client to cooperate fully and to follow directions.
• Observe Standard Precautions.
• Remove the needle and apply pressure dressing over the puncture site.
• Immediately transport the specimen to the laboratory for processing and
analysis.

After:
 • Observe venipuncture site for bleeding or hematoma formation.
• Instruct the patient to reduce intake of foods high in saturated fats and
cholesterol and triglyceride levels. (E.g. red meats, eggs, and dairy products are
major sources of saturated fats and cholesterol.
• Consider social and cultural beliefs and practices of the client.
• Recognize anxiety related to test results. Discuss the implications of abnormal
test results on the patient’s lifestyle.
• Provide teaching and information regarding the clinical indications of the test
results.

Nursing Responsibilities (Urinalysis)

Before:

• Explain the procedure to the patient’s significant others that these test assess
response to treatment.
• Tell the patient’s significant others that specimen will be taken.

During:

• Plan to obtain the specimen when the patient is calm and physically still.
• Instruct the SO to collect urine specimen.
• Collect urine by clean catching.

After:

• If there is a necessary urine collection, instruct SO to collect the urine in every

urination and put it in the bedside.

Nursing Responsibilites (Chest X-ray)

Before:

• Verify doctors order

• Explain to the patient SO the importance and the procedure to be done
• Remove any jewelry prior to procedure
• Assist patient to go to the X-ray room to undergo procedure
During:

• Position patient
• Note pertinent findings such as the presence of a pacemaker or an artificial joint
on the x-ray request

After:

• Assist patient in removing the x-ray gown

• Assist patient to go back to his bed
• Record all procedures done

Nursing Responsibilities (Kidney-Ureter Bladder)

Before:

• Cleanse bowel of patient

• Instruct patient to distend bladder by drinking 1 liter of water per orem
• Try to withhold voiding

During:

• Assist physician doing the ultrasound

• Reassure patient that procedure is painless and relatively short.

After:

• Assist patient to go back to his bed

• Record all procedures done
 IV. THE PATIENT AND HIS ILLNESS
A. Pathophysiology
a. Schematic Diagram

PATHOPHYSIOLOGY: HYPERTENSION (book-

centered)
Non-modifiable Factors Modifiable Factors
- Age – 35 years and older - Alcohol use - Excess dietary sodium
- Gender – men and post-menopausal women - Lack of exercise - Stress
- Race – black and brown race
- Family history of hypertension
- Obesity - Diabetes
- Kidney disease - Hormonal disorders
- Porphyria - Toxemia of pregnancy
- Oral Contraceptives - Steroids
- Decongestants - Diet pills
- Antidepressants - History of high BP during
pregnancy
- Nonsteroidal anti-inflammatory drugs

Cell membrane alteration Hyperinsu- Renin- SNS over- ↓ Filtering Renal Na

linemia Angiotensi activity surface retention
n Excess

Venous ↑Fluid
Constriction Volume
Structural Functional
hypertrophy Constriction
Decreased organ perfusion

Impaired Impaired Impaired ↑Contractilit ↑Preload

ocular cerebral renal y
↑Peripheral functioning functioning functioning
Resistance

Retinal Altered level of ↑BUN, Left ↑BP = ↑Cardiac

↑Blood pressure changes, consciousness, creatinine ventricular Output
papilledema dizziness, headache hypertroph
y
 PATHOPHYSIOLOGY: Urinary Tract Infection (book
based)
Non-modifiable Factors Modifiable Factors
- Old age
- women
- Being sexually active - Excess dietary
- Family history of hypertension sodium
- DM, and other chronic illness - Kidney stones
- prolonged use of catheters

Fragile soft tissues

Damaged soft ↓ Organ perfusion ↑ Infection
tissue lining susceptibility

Tissue breakdown

Inflammatory dysuria Blood – tinged

process Bacterial urine
multiplication

↓ urine output
fever

Urinary retention

edema
↑ fluid Fluid shifts to
volume extracellular
compartment Pulmonary
congestion
↑ BP

↓ preload ↓ CO

vasoconstriction
 PATHOPHYSIOLOGY: HYPERTENSION (patient-
centered)

Non-modifiable Factors Modifiable Factors

- Age – 35 years and older - Alcohol use - Excess dietary
- Gender – men and post-menopausal women sodium
- Race – black and brown race - Lack of exercise - Stress
- Family history of hypertension

Cell membrane alteration SNS over- Renal Na

activity retention

Venous ↑Fluid
Constriction Volume
Structural Functional
hypertrophy Constriction
Decreased organ perfusion

Impaired ↑Contractilit ↑Preload

ocular y
↑Peripheral functioning
Resistance

Retinal ↑BP = ↑Cardiac

↑Blood pressure changes, Output
papilledema
B. Synthesis of the Disease

Hypertension refers to a state where a person’s blood pressure remains at an elevated

level at all times. This condition is formally known as arterial hypertension and is
popularly called high blood pressure.

Two types of hypertension:

1. Primary Hypertension - when a patient’s chronically elevated blood pressure

does not have a specific medical cause that can be identified
2. Secondary Hypertension - When high blood pressure is caused by other health
conditions like tumors of the adrenal gland, kidney disease of other problems.

Hypertension is a dangerous condition because it can lead to serious complications.

Chronically elevated blood pressure increases the risk of developing heart failure, heart
attacks, arterial aneurysm and strokes. Many cases of chronic renal failure have been
linked to high blood pressure.

Signs and Symptoms:

Undiagnosed high blood pressure can

lead to many physical problems including
damage to major organs over a period of
time. The symptoms of hypertension, if
ignored, can lead to deterioration in kidney
/ liver function and cardiac problems.
Hypertension can also damage vision,
cause strokes and more.

Here are some of the common

hypertension symptoms to be aware of.

• Recurrent / persistent headaches

• Vision problems including blurring of vision
 • Giddiness
• Convulsions
• Tremors in the hands or other body parts
• Walking difficulties (formally called ataxia)

A urinary tract infection is an infection of any of the organs in the urinary tract, which
consist of the bladder, the ureter, the urethra, and the kidneys.

A urinary tract infection (UTI) may occur in the:

Bladder - Cystitis is an infection of the bladder. This is the most common form of UTI; it
can be aggravated if the bladder does not empty completely when you urinate.

Urethra - Urethritis is infection/inflammation of the urethra. This can be due to other

things besides the organisms usually involved in UTI’s; in particular, many sexually
transmitted diseases (STD’s) appear initially as urethritis.

Ureter - Ureteritis is infection of a ureter. This can occur if the bacteria entered the
urinary tract from above or if the ureter-to-bladder valves don’t work properly and allow
urine to “reflux” from the bladder into the ureters.

Kidney - Pyelonephritis is an infection of the kidney itself. This can happen with
infection from above, or if reflux into the ureters is so bad that infected urine refluxes all
the way to the kidney.

People more susceptible to UTI’s:

• Diabetics because of changes in the immune system

• Infants who are born with abnormalities of the urinary tract
• Women who use a diaphragm
• Women whose partners use a condom with spermicidal foam
• A person who has already had a UTI
• Pregnant women
 • Post-menopausal women
• Women on birth control pills
• Women with lowered immunity
• Women with prolapsed urethra or bladder
• Women with obstructions in the urinary tract

Symptoms

Symptoms depend on age of person and where the UTI is located .

Symptoms of urethritis often include:

• Burning sensation at the start of urination

Symptoms of cystitis often include:

• Burning sensation in the middle of urination

• Fever
• Lower abdominal pain
• Funny smell, color, or appearance (cloudy, dark, blood tinged) of urine

Symptoms of Pyelonephritis often include:

• Pain in back, flanks, or abdomen

• Fever
• Nausea
• Vomiting

Other symptoms of UTI’s:

• Uncomfortable pressure above pubic bone

• Fullness in rectum (in men only)
• Small amount of urine, despite urge to urinate
• Irritability (in children only)
 • Abnormal eating (in children only)

III. Anatomy and Physiology

Hypertension

The heart and circulatory system make up the cardiovascular system. The heart
works as a pump that pushes blood to the organs, tissues, and cells of the body. Blood
delivers oxygen and nutrients to every cell and removes the carbon dioxide and waste
products made by those cells. Blood is carried from the heart to the rest of the body
through a complex network of arteries, arterioles, and capillaries. Blood is returned to
the heart through venules and veins.
Vasoconstriction or the spasm of smooth muscles around the blood vessels
causes and decrease in blood flow but an increase in pressure. In vasodilation, the
lumen of the blood vessel increase in diameter thereby allowing increase in blood flow.
There is no tension on the walls of the vessels therefore, there is lower pressure.

Various external factors also cause changes in blood pressure and pulse rate. An
elevation or decline may be detrimental to health. Changes may also be caused or
aggravated by other disease conditions existing in other parts of the body.

Central Nervous System

Medulla Oblongata; relays motor and sensory

impulses between other parts of the brain and the
spinal cord. Reticular formation (also in pons,
midbrain, and diencephalon) functions in
consciousness and arousal. Vital centers regulate
heartbeat, breathing (together with pons) and blood
vessel diameter.

Hypothalamus; controls and intergrates activities

of the autonomic nervous system and pituitary
gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls
body temperature and regulates eating and drinking behavior. Helps maintain the
waking state and establishes patterns of sleep. Produces the hormones oxytocin and
antidiuretic hormone.

Cardiovascular System

Baroreceptor, pressure-sensitive sensory receptors, are located in the aorta, internal

carotid arteries, and other large arteries in the neck and chest. They send impulses to
the cardiovascular center in the medulla oblongata to help regulate blood pressure. The
two most important baroreceptor reflexes are the carotid sinus reflex and the aortic
reflex.

Chemoreceptors, sensory receptors that monitor the xhemical composition of blood,

are located close to the baroreceptors of the carotid sinus and the arch of the aorta in
small structures called carotid bodies and aortic bodies, respectively. These
chemoreceptors detect changes in blood level of O2, CO2, and H+.

Renal System

Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the

kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the
bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their
substrates to produce the active hormone angiotensin II, which raises blood pressure in
two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by
increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone,
which increases reabsorption of sodium ions and water by the kidneys. The water
reabsorption increases total blood volume, which increases blood pressure.

Antidiuretic hormone. ADH is produced by the hypothalamus and released from the
posterior pituitary in response to dehydration or decreased blood volume. Among other
actions, ADH causes vasoconstriction, which increases blood pressure.
Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood
pressure by causing vasodilation and by promoting the loss of salt and water in the
urine, which reduces blood volume.

Urinary tract infection

One of the major functions of the Urinary system is the process of excretion. Excretion
is the process of eliminating, from an organism, waste products of metabolism and other
materials that are of no use. The urinary system maintains an appropriate fluid volume
by regulating the amount of water that is excreted in the urine. Other aspects of its
function include regulating the concentrations of various electrolytes in the body fluids
and maintaining normal pH of the blood. Several body organs carry out excretion, but
the kidneys are the most important excretory organ. The primary function of the kidneys
are to maintain a stable internal environment (homeostasis) for optimal cell and tissue
metabolism. They do this by separating urea, mineral salts, toxins, and other waste
products from the blood. They also do the job of conserving water, salts, and
electrolytes. At least one kidney must function properly for life to be maintained. Six
important roles of the kidneys are:

Regulation of plasma ionic composition. Ions such as sodium, potassium, calcium,

magnesium, chloride, bicarbonate, and phosphates are regulated by the amount that
the kidney excretes.

Regulation of plasma osmolarity. The kidneys regulate osmolarity because they have
direct control over how many ions and how much water a person excretes.

Regulation of plasma volume. Your kidneys are so important they even have an effect
on your blood pressure. The kidneys control plasma volume by controlling how much
water a person excretes. The plasma volume has a direct effect on the total blood
volume, which has a direct effect on your blood pressure. Salt(NaCl)will cause osmosis
to happen; the diffusion of water into the blood.
Regulation of plasma hydrogen ion concentration (pH). The kidneys partner up with
the lungs and they together control the pH. The kidneys have a major role because they
control the amount of bicarbonate excreted or held onto. The kidneys help maintain the
blood Ph mainly by excreting hydrogen ions and reabsorbing bicarbonate ions as
needed.

Removal of metabolic waste products and foreign substances from the plasma.
One of the most important things the kidneys excrete is nitrogenous waste. As the liver
breaks down amino acids it also releases ammonia. The liver then quickly combines
that ammonia with carbon dioxide, creating urea which is the primary nitrogenous end
product of metabolism in humans. The liver turns the ammonia into urea because it is
much less toxic. We can also excrete some ammonia, creatinine and uric acid. The
creatinine comes from the metabolic breakdown of creatine phospate (a high-energy
phosphate in muscles). Uric acid comes from the break down of necloetides. Uric acid
is insoluble and too much uric acid in the blood will build up and form crystals that can
collect in the joints and cause gout.

Secretion of Hormones The endocrine system has assistance from the kidney's when
releasing hormones. Renin is released by the kidneys. Renin leads to the secretion of
aldosterone which is released from the adrenal cortex. Aldosterone promotes the
kidneys to reabsorb the sodium (Na+) ions. The kidneys also secrete erythropoietin
when the blood doesn't have the capacity to carry oxygen. Erythropoietin stimulates red
blood cell production. The Vitamin D from the skin is also activated with help from the
kidneys. Calcium (Ca+) absorption from the digestive tract is promoted by vitamin D.

Kidneys

The kidneys are a pair of bean shaped, reddish brown organs about the size of your
fist.It measures 10-12 cm long. They are covered by the renal capsule, which is a tough
capsule of fibrous connective tissue. Adhering to the surface of each kidney is two
layers of fat to help cushion them. There is a concaved side of the kidney that has a
depression where a renal artery enters, and a renal vein and a ureter exit the kidney.
The kidneys are located at the rear wall of the abdominal cavity just above the waistline,
and are protected by the ribcage. They are considered retroperitoneal, which means
they lie behind the peritoneum. There are three major regions of the kidney, renal
cortex, renal medulla and the renal pelvis. The outer, granulated layer is the renal
cortex. The cortex stretches down in between a radially striated inner layer. The inner
radially striated layer is the renal medulla. This contains pyramid shaped tissue called
the renal pyramids, separated by renal columns. The ureters are continuous with the
renal pelvis and is the very center of the kidney.

Renal Vein

The renal veins are veins that drain the kidney. They connect the kidney to the inferior
vena cava. Because the inferior vena cava is on the right half of the body, the left renal
vein is generally the longer of the two. Unlike the right renal vein, the left renal vein
often receives the left gonadal vein (left testicular vein in males, left ovarian vein in
females). It frequently receives the left suprarenal vein as well.

Renal Artery

The renal arteries normally arise off the abdominal aorta and supply the kidneys with
blood. The arterial supply of the kidneys are variable and there may be one or more
renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena
cava and the kidneys in the body, the right renal artery is normally longer than the left
renal artery. The right renal artery normally crosses posteriorly to the inferior vena cava.
The renal arteries carry a large portion of the total blood flow to the kidneys. Up to a
third of the total cardiac output can pass through the renal arteries to be filtered by the
kidneys.

Ureters

The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter
is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters
send the urine in small spurts into the bladder, (a collapsible sac found on the forward
part of the cavity of the bony pelvis that allows temporary storage of urine). After the
urine enters the bladder from the ureters, small folds in the bladder mucosa act like
valves preventing backward flow of the urine. The outlet of the bladder is controlled by a
sphincter muscle. A full bladder stimulates sensory nerves in the bladder wall that relax
the sphincter and allow release of the urine. However, relaxation of the sphincter is also
in part a learned response under voluntary control. The released urine enters the
urethra.

Urinary Bladder

The urinary bladder is a hollow, muscular and distendible or elastic organ that sits on
the pelvic floor (superior to the prostate in males). On its anterior border lies the pubic
symphysis and, on its posterior border, the vagina (in females) and rectum (in males).
The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine,
however the desire to micturate is usually experienced when it contains about 150 to
200 ml. When the bladder fills with urine (about half full), stretch receptors send nerve
impulses to the spinal cord, which then sends a reflex nerve impulse back to the
sphincter (muscular valve) at the neck of the bladder, causing it to relax and allow the
flow of urine into the urethra. The Internal urethral sphincter is involuntary. The ureters
enter the bladder diagonally from its dorsolateral floor in an area called the trigone. The
trigone is a triangular shaped area on the postero-inferior wall of the bladder. The
urethra exits at the lowest point of the triangle of the trigone. The urine in the bladder
also helps regulate body temperature. If the bladder becomes completely void of fluid, it
causes the patient to chill.
Urethra

Male Sphincter urethrae muscle - The male urethra laid

open on its anterior (upper) surface. (Region visible, but
muscle not labeled.)

The urethra is a muscular tube that connects the bladder

with the outside of the body. The function of the urethra is
to remove urine from the body. It measures about 1.5
inches (3.8 cm) in a woman but up to 8 inches (20 cm) in
a man. Because the urethra is so much shorter in a
woman it makes it much easier for a woman to get
harmful bacteria in her bladder this is commonly called a
bladder infection or a UTI. The most common bacteria of
a UTI is E-coli from the large intestines that have been excreted in fecal matter.

Male urethra

In the human male, the urethra is about 8 inches (20 cm) long and opens at the end of
the penis.

The length of a male's urethra, and the fact it contains a number of bends, makes
catheterisation more difficult.

The urethral sphincter is a collective name for the muscles used to control the flow of
urine from the urinary bladder. These muscles surround the urethra, so that when they
contract, the urethra is closed.

• There are two distinct areas of muscle: the internal sphincter, at the bladder neck
and
 • the external, or distal, sphincter.

Human males have much stronger sphincter muscles than females, meaning that they
can retain a large amount of urine for twice as long, as much as 800mL, i.e. "hold it".

Nephrons

A nephron is the basic structural and functional unit of the kidney. The name nephron
comes from the Greek word (nephros) meaning kidney. Its chief function is to regulate
water and soluble substances by filtering the blood, reabsorbing what is needed and
excreting the rest as urine. Nephrons eliminate wastes from the body, regulate blood
volume and pressure, control levels of electrolytes and metabolites, and regulate blood
pH. Its functions are vital to life and are regulated by the endocrine system by hormones
such as antidiuretic hormone, aldosterone, and parathyroid hormone.

Each nephron has its own supply of blood from two capillary regions from the renal
artery. Each nephron is composed of an initial filtering component (the renal corpuscle)
and a tubule specialized for reabsorption and secretion (the renal tubule). The renal
corpuscle filters out large solutes from the blood, delivering water and small solutes to
the renal tubule for modification.

Glomerulus

The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole
of the renal circulation. The glomerular blood pressure provides the driving force for fluid
and solutes to be filtered out of the blood and into the space made by Bowman's
capsule. The remainder of the blood not filtered into the glomerulus passes into the
narrower efferent arteriole. It then moves into the vasa recta, which are collecting
capillaries intertwined with the convoluted tubules through the interstitial space, where
the reabsorbed substances will also enter. This then combines with efferent venules
from other nephrons into the renal vein, and rejoins with the main bloodstream.
Afferent/Efferent Arterioles

The afferent arteriole supplies blood to the glomerulus. A group of specialized cells
known as juxtaglomerular cells are located around the afferent arteriole where it
enters the renal corpuscle. The efferent arteriole drains the glomerulus. Between the
two arterioles lies specialized cells called the macula densa. The juxtaglomerular cells
and the macula densa collectively form the juxtaglomerular apparatus. It is in the
juxtaglomerular apparatus cells that the enzyme renin is formed and stored. Renin is
released in response to decreased blood pressure in the afferent arterioles, decreased
sodium chloride in the distal convoluted tubule and sympathetic nerve stimulation of
receptors (beta-adrenic) on the juxtaglomerular cells. Renin is needed to form
Angiotensin I and Angiotensin II which stimulate the secretion of aldosterone by the
adrenal cortex.

Glomerular Capsule or Bowman's Capsule

Bowman's capsule (also called the glomerular capsule) surrounds the glomerulus
and is composed of visceral (simple squamous epithelial cells) (inner) and parietal
(simple squamous epithelial cells) (outer) layers. The visceral layer lies just beneath the
thickened glomerular basement membrane and is made of podocytes which send foot
processes over the length of the glomerulus. Foot processes interdigitate with one
another forming filtration slits that, in contrast to those in the glomeruluar endothelium,
are spanned by diaphragms. The size of the filtration slits restricts the passage of large
molecules (eg, albumin) and cells (eg, red blood cells and platelets). In addition, foot
processes have a negatively-charged coat (glycocalyx) that limits the filtration of
negatively-charged molecules, such as albumin. This action is called electrostatic
repulsion.

The parietal layer of Bowman's capsule is lined by a single layer of squamous

epithelium. Between the visceral and parietal layers is Bowman's space, into which the
filtrate enters after passing through the podocytes' filtration slits. It is here that smooth
muscle cells and macrophages lie between the capillaries and provide support for them.
Unlike the visceral layer, the parietal layer does not function in filtration. Rather, the
filtration barrier is formed by three components: the diaphragms of the filtration slits, the
thick glomerular basement membrane, and the glycocalyx secreted by podocytes. 99%
of glomerular filtrate will ultimately be reabsorbed.

The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or
glomerular filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten
times the blood volume daily. Measuring the glomerular filtration rate (GFR) is a
diagnostic test of kidney function. A decreased GFR may be a sign of renal failure.
Conditions that can effect GFR include: arterial pressure, afferent arteriole constriction,
efferent arteriole constriction, plasma protein concentration and colloid osmotic
pressure.

Any proteins that are roughly 30 kilodaltons or under can pass freely through the
membrane. Although, there is some extra hindrance for negatively charged molecules
due to the negative charge of the basement membrane and the podocytes. Any small
molecules such as water, glucose, salt (NaCl), amino acids, and urea pass freely into
Bowman's space, but cells, platelets and large proteins do not. As a result, the filtrate
leaving the Bowman's capsule is very similar to blood plasma in composition as it
passes into the proximal convoluted tubule. Together, the glomerulus and Bowman's
capsule are called the renal corpuscle.

Proximal Convoluted Tubule (PCT)

The proximal tubule can be anatomically divided into two segments: the proximal
convoluted tubule and the proximal straight tubule. The proximal convoluted tubule can
be divided further into S1 and S2 segments based on the histological appearance of it's
cells. Following this naming convention, the proximal straight tubule is commonly called
the S3 segment. The proximal convoluted tubule has one layer of cuboidal cells in the
lumen. This is the only place in the nephron that contains cuboidal cells. These cells are
covered with millions of microvilli. The microvilli serve to increase surface area for
reabsorption.

Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the
peritubular capillaries, including approximately two-thirds of the filtered salt and water
and all filtered organic solutes (primarily glucose and amino acids). This is driven by
sodium transport from the lumen into the blood by the Na+/K+ ATPase in the basolateral
membrane of the epithelial cells. Much of the mass movement of water and solutes
occurs in between the cells through the tight junctions, which in this case are not
selective.

The solutes are absorbed isotonically, in that the osmotic potential of the fluid leaving
the proximal tubule is the same as that of the initial glomerular filtrate. However,
glucose, amino acids, inorganic phosphate, and some other solutes are reabsorbed via
secondary active transport through cotransport channels driven by the sodium gradient
out of the nephron.

Loop of the Nephron or Loop of Henle

The Nephron Loop or Loop of Henle.

The loop of Henle (sometimes known

as the nephron loop) is a U-shaped
tube that consists of a descending
limb and ascending limb. It begins in
the cortex, receiving filtrate from the
proximal convoluted tubule, extends
into the medulla, and then returns to
the cortex to empty into the distal
convoluted tubule. Its primary role is to concentrate the salt in the interstitium, the tissue
surrounding the loop.

Descending limb
Its descending limb is permeable to water but completely impermeable to salt,
and thus only indirectly contributes to the concentration of the interstitium. As the
filtrate descends deeper into the hypertonic interstitium of the renal medulla,
water flows freely out of the descending limb by osmosis until the tonicity of the
filtrate and interstitium equilibrate. Longer descending limbs allow more time for
water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic
than shorter limbs.
Ascending limb
Unlike the descending limb, the ascending limb of Henle's loop is impermeable to
water, a critical feature of the countercurrent exchange mechanism employed by
the loop. The ascending limb actively pumps sodium out of the filtrate, generating
the hypertonic interstitium that drives countercurrent exchange. In passing
through the ascending limb, the filtrate grows hypotonic since it has lost much of
its sodium content. This hypotonic filtrate is passed to the distal convoluted
tubule in the renal cortex.

Distal Convoluted Tubule (DCT)

The distal convoluted tubule is similar to the proximal convoluted tubule in structure and
function. Cells lining the tubule have numerous mitochondria, enabling active transport
to take place by the energy supplied by ATP. Much of the ion transport taking place in
the distal convoluted tubule is regulated by the endocrine system. In the presence of
parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes
more phosphate. When aldosterone is present, more sodium is reabsorbed and more
potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to
excrete more sodium. In addition, the tubule also secretes hydrogen and ammonium to
regulate pH. After traveling the length of the distal convoluted tubule, only 3% of water
remains, and the remaining salt content is negligible. 97.9% of the water in the
glomerular filtrate enters the convoluted tubules and collecting ducts by osmosis.

Patient and his Care

A. Medical Management

A. Drugs

Name of Date Ordered Route of General Client’s

Drug Date Taken/ Administration Action response to
Generic Given Dosage and Functional the
Name Date Frequency of Classification medication
Brand Name Changed/ D/ Administration Mechanism with actual
C of Action side effects

Amlodipine DO: 04-20-09 5mg/ tab 1 tab Calcium The patient’s

( Norvasc ) DT: 04-20-09 OD channel blood
to 04-22-09 blocker pressure/
D/C: 04-22-09 blood
- inhibits influx pressure
of calcium fluctuations
through the decreased. No
cell other adverse
membrane effects were
resulting in noted.
depression of
automaticity
and
conduction
velocity in
heart muscle.

Nursing Responsibilities:

Before:
1. Verify the doctor’s order. Determine the dosage and frequency of the drug.
2. Assess for history of sensitivity or any reactions to this or other related drugs.
During:
1. Ensure that the correct drug is being given/administered.
2. Monitor CBC, Cultures, Renal and NFT’s.
3. Monitor Urinary output and K+ levels.

After:
1. Evaluate how the patient responds to the treatment physically and
psychologically.
2. Report any side effects/ adverse reactions.

Name of Date Ordered Route of General Client’s

Drug Date Taken/ Administration Action response to
Generic Given Dosage and Functional the
Name Date Frequency of Classification medication
Brand Name Changed/ D/ Administration Mechanism with actual
C of Action side effects

Paracetamol DO: 04-20-09 300 mg IV q 4 Analgesic/ The patient

( Aeknil ) DT: 04-20-09 Antipyretic maintained
to 04-22-09 body
D/C: 04-22-09 - decreases temperature
fever by a within normal
hypothalamic range.
effect leading
to sweating
and
vasodilation
and inhibits
the effect of
pyrogens on
the
hypothalamic
heat-
regulating
centers.
Nursing Responsibilities:
Before:
1. Verify the doctor’s order. Determine the dosage and frequency of the drug.
2. Assess for history of sensitivity or any reactions to this or other related drugs.

During:
1. Ensure that the correct drug is being given/administered.
2. Monitor CBC, Cultures, Renal and NFT’s.
3. Monitor Urinary output.

After:
1. Evaluate how the patient responds to the treatment physically and
psychologically.
2. Report any side effects/ adverse reactions.

Name of Date Ordered Route of General Client’s

Drug Date Taken/ Administration Action response to
Generic Given Dosage and Functional the
Name Date Frequency of Classification medication
Brand Name Changed/ D/ Administration Mechanism with actual
C of Action side effects

Ceftriaxone DO: 04-20-09 1 gm/ IV q 12 Third The patient

( Rocephin ) DT: 04-20-09 ANST (-) generation complied with
to 04-21-09 cephalosporin the treatment
D/C: 04-21-09 regimen by
- active following the
against many full antibiotic
enteric Gram- course. There
negative were no
organisms, adverse
 including b- reactions
lactamase noted after the
producers, administration.
Salmonella
and Shigella,
but have less
activity
against Gram-
positive
bacteria

Nursing Responsibilities:
Before:
1. Verify the doctor’s order. Determine the dosage and frequency of the drug.
2. Assess for history of sensitivity or any reactions to this or other related drugs.

During:
1. Ensure that the correct drug is being given/administered.
2. Monitor CBC, Cultures, Renal and NFT’s.
3. Monitor Urinary output and K+ levels.

After:
1. Evaluate how the patient responds to the treatment physically and
psychologically.
2. Report any side effects/ adverse reactions.

Name of Date Ordered Route of General Action Client’s

Drug Date Taken/ Administration Functional response to
Generic Given Dosage and Classification the
Name Date Frequency of Mechanism of medication
Brand Name Changed/ D/ Administration Action with actual
C side effects

Captopril DO: 04-20-09 25 mg/ tab SL Antihypertensive/ The patient’s

( Capoten ) DT: 04-20-09 PRN > 150 ACE inhibitor blood
to 04-22-09 mmHg pressure/
 D/C: 04-22-09 - inhibits blood
angiotensin- pressure
converting fluctuations
enzyme resulting decreased. No
in decreased other adverse
plasma effects were
angiotensin II, noted.
which leads to
decreased
aldosterone
secretion.

Nursing Responsibilities:
Before:
1. Verify the doctor’s order. Determine the dosage and frequency of the drug.
2. Assess for history of sensitivity or any reactions to this or other related drugs.

During:
1. Ensure that the correct drug is being given/administered.
2. Monitor CBC, Cultures, Renal and NFT’s.
3. Monitor Urinary output and K+ levels.

After:
1. Evaluate how the patient responds to the treatment physically and
psychologically.
2. Report any side effects/ adverse reactions.
 Name of Date Ordered Route of General Action Client’s
Drug Date Taken/ Administration Functional response to
Generic Given Dosage and Classification the
Name Date Frequency of Mechanism of medication
Brand Name Changed/ D/ Administration Action with actual
C side effects

Ciprofloxacin DO: 04-21-09 500 mg/ tab Fluoroquinolone The patient

( Cipro ) DT: 04-21-09 BID x 3 days ( antibiotic ) was not able
to 04-22-09 to finish the
D/C: 04-22-09 full antibiotic
- kill bacteria or course. There
prevent their were no
growth. adverse
Bacteria are reactions
one-celled noted after the
disease- administration.
causing
microorganisms
that commonly
multiply by cell
division.

Nursing Responsibilities:
Before:
1. Verify the doctor’s order. Determine the dosage and frequency of the drug.
2. Assess for history of sensitivity or any reactions to this or other related drugs.

During:
1. Ensure that the correct drug is being given/administered.
2. Monitor CBC, Cultures, Renal and NFT’s.
3. Monitor Urinary output and K+ levels.

After:
1. Evaluate how the patient responds to the treatment physically and
psychologically.
 2. Report any side effects/ adverse reactions.

B. Diet

Type of Date General Indication(s Specific Client’s

Diet Ordered Description ) or foods response
Date Purpose(s) taken and/ or
Started reaction to
Date the diet
Changed

Low fat, DO: 04-20- This type of It is indicated Fruits, This type of
low sodium 09 diet has a for persons vegetables, diet
diet DS: 04-20- limited total with elevated fruit juice, contributed
09 to 04- amount of serum chicken to the
22-09 fat, salt and cholesterol decrease in
cholesterol levels or the
to reduce those who patient’s
serum lipid are high-risk blood
levels and candidates pressure.
avoid for heart The patient
excessive disease and had good
sodium for elevated appetite
retention. blood and was
pressure able to
since it tolerate the
prevents food given.
excessive
sodium
retention.

Nursing Responsibilities:
Before:
1. Check physician’s order about the diet.
2. Identify patient, instruct SO or patient when diet is changed
1. Provide comfort measures such as offering extra cloth and napkin when eating.
During:
1. Give foods in small frequent meals to check for tolerance.
2. Assist patient when eating.
3. Observe for aspiration precaution.

After:
1. Encourage the patient to follow the diet regimen.
2. Encourage verbalization of feelings about the diet.
3. Involve the patient in the preparation of the menu according to the patient’s
preferences.
4. Assess for patient’s condition, how she responds to the diet.
5. Be sure that the patient is taking or eating food she can tolerate.

C. Activity/ Exercise

Type of Date Ordered General Indication(s) Client’s

Activity/ Date Started Description or response
Exercise Date Purpose(s) and/ or
Changed reaction to
the activity/
exercise

Exercise/s There were no It may include It prepares the The patient

and activites orders made ambulation, patient to go was able to
as tolerated for activity/ strengthening back to his tolerate the
exercise. exercises, activities of exercise/s
active or daily living activities
passive range and it planned for
of motion promotes him.
exercises. optimal level
of functioning.
Nursing Responsibilities:
Before:
1. Check physician’s order about the activity.
2. Identify patient before the activity.
3. Explain to the patient the need for the said activity/exercise.

During:
1. Provide safety precautions like raising the side rails when necessary.
2. Promote a quiet environment conducive for rest.

After:
1. Monitor the position/activity of the client every 2 hours
2. Obtain initial assessment about the progress of the activity.
B. Nursing Management

Problem No.1 : Acute Pain

Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome
Short-term: Short-term:
S>“Masakit Acute pain Not everyone >Observe or >Some people
kapag umiihi with a UTI has After 3-4 hours monitor signs deny the After 3-4 hours
ako.” symptoms, but of nursing and symptoms experience of of nursing
O>the patient most people get interventions, associated with pain when it is interventions, the
manifested: at least some the patient’s pain pain. present. patient’s pain
facial symptoms. will be relieved shall have been
grimaces These may or controlled. >Assess for >Different relieved or
marked include a probable cause etiological controlled.
irritability frequent urge to Long-term: of pain. factors respond
and urinate and a better to different Long-term:
impatience painful, burning After 2-3 days of therapies.
decreased feeling in the nursing After 2-3 days of
urinary area of the interventions, >Assess > Some patient nursing
output bladder or the patient will patient’s may be unaware interventions, the
insomnia urethra during demonstrate use knowledge of or of the patient shall
restlessnes urination. It is of techniques as preference for effectiveness of have
s not unusual to indicated for the array of pain- non- demonstrated
feel bad all over individual relief strategies pharmacological use of
The patient may —tired, shaky, situation. available. methods and techniques as
manifest: washed out— may be willing to indicated for
and to feel pain try them, either individual
changes in
even when not with or instead of situation.
appetite
urinating. Often traditional
narrowed women feel an analgesic
focus uncomfortable medications.
autonomic pressure above
alteration the pubic bone, >Evaluate >It is important
in muscle and some men patient’s to help patients
tone experience a response to pain express as
fullness in the and medications factually as
rectum. It is or therapeutics possible the
common for a aimed at effect of pain
person with a abolishing or relief measures.
urinary infection relieving pain.
to complain that,
despite the urge >Assess >Some patients
to urinate, only a patient’s will feel
small amount of willingness or uncomfortable
urine is passed. ability to explore exploring
The urine itself a range of alternative
may look milky techniques methods of pain
or cloudy, even aimed at relief. However,
reddish if blood controlling pain. patients need to
is present. be informed that
Normally, a UTI there are
does not cause multiple ways to
fever if it is in the manage pain.
bladder or
urethra. A fever >Eliminate >Patients may
may mean that additional experience an
the infection has stressors or exaggeration in
reached the sources of pain or a
kidneys. Other discomfort decreased ability
symptoms of a whenever to tolerate
kidney infection possible. painful stimuli if
include pain in environmental,
the back or side intrapersonal, or
below the ribs, intrapsychic
nausea, or factors are
vomiting. further stressing
them.

>Provide rest >The patient’s

periods to experiences of
facilitate comfort, pain may
sleep and become
 relaxation. exaggerated as
the result of
fatigue. A quiet
environment, a
darkened room
are some of the
measures
geared toward
facilitating rest.

Problem No. 2: Decreased Cardiac Output r/t altered preload 2 HTN

Nursing Scientific Expected

Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
Short Term: Short Term:
S> The patient Decreased In hypertension, > establish > to gain patient’s
may verbalize Cardiac Output there is the After 4 hours of rapport trust and Patient shall
fatigue and r/t altered imminent nursing cooperation have
weakness preload 2° HTN possibility that interventions, demonstrated
there is patient will > monitor and > to serve as techniques to
O>the patient inadequate demonstrate record VS baseline data increase
manifested: pumping of techniques to activity
Edema blood by the increase activity > assess > to provide tolerance
Restlessne heart due to tolerance patient’s appropriate
ss and constriction of condition interventions Long Term:
fidgeting the vascularities Long Term: immediately
Marked of such organ. Patient shall
irritability This would After 2-3 days of >determine > provide have displayed
and predispose nursing baseline vital opportunities to hemodynamic
impatience altered preload, interventions, signs track changes stability AEB
Insomnia resulting to patient will /hemodynamic normal CBCs,
Crackles decreased display parameters vital signs and
cardiac output hemodynamic urinary output.
Increased
which would stability AEB >promote >maximize sleep
 BP lead ultimately, normal CBCs, adequate rest periods
Decreased underachievem vital signs and by decreasing
urinary ent of satiation urinary output. stimuli and
output of the metabolic providing quiet
demands of the environment.
> The patient body. This will Schedule
may manifests: then precipitate activities and
Weight perfusion assessment
gain problems that
JVD may worsen > provide > to minimize
patient’s patient enough patient’s anxiety
condition. time to perform when doing tasks
activities

> increase > to avoid

activity level overexertion
gradually

> provide quiet > to regain

environment strength
suitable for rest

>provide for diet >maintain

restrictions and adequate nutrition
fluids as and fluid balance
indicated

>elevate >promote venous

edematous return
extremities and
avoid restrictive
clothing

>encourage >reduce anxiety

relaxation and
 stress
management
techniques

Problem No. 3: Excess Fluid Volume

Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome
Short-term: Short-term:
S> Ø Excess fluid Excess fluid > Obtain patient > To ascertain
O> the patient volume r/t volume or After 3-4 hours history. probable cause After 3-4° of
manifested: compromised hypervolemia of nursing of the fluid nursing
periorbital regulatory occurs from an interventions, disturbance. interventions, the
edema mechanisms increase in total the patient will patient shall
restlessnes AEB presence of body sodium demonstrate > Monitor and > Sinus have
s edema 2° UTI content and an alleviation of document vital tachycardia and demonstrated
facial increase in total signs and signs. increased blood alleviation of
edema body water. This symptoms of pressure are signs and
bipedal fluid excess fluid excess AEB seen in early symptoms of
edema usually results stable VS and stages. fluid excess AEB
( non- from free signs of stable VS and
pitting ) compromised edema. > Auscultate for > These are free signs of
wheezes regulatory a third sound, signs of fluid edema.
heard on mechanisms for Long-term: and assess for overload.
BLF sodium and bounding Long-term:
water as seen in After 2-3 days of peripheral
The patient may CHF, kidney and nursing pulses. After 2-3 days of
manifest: liver failure. It interventions, nursing
may also be the patient will > Assess for > These are interventions, the
shortness
caused by demonstrate crackles in early signs of patient shall
of breath
excessive intake behaviors to lungs, changes pulmonary have
oliguria in respiratory congestion.
of sodium from maintain demonstrated
jugular vein foods, IV adequate fluid pattern, behaviors to
distention solutions and volume and shortness of maintain
medications. reduce breath and adequate fluid
occurrence of orthopnea. volume and
fluid excess. reduce
> Monitor input > Shifting of fluid occurrence of
and output out of the fluid excess.
closely. intravascular to
the
extravascular
spaces may
result in
dehydration.

> Elevate > This increases

edematous venous return
extremities. and, in turn,
decreases
edema.

> During > Monitoring

therapy, monitor prevents
for signs of complications
hypovolemia. associated with
therapy.

> Assess for > These are

presence of manifestations of
edema by fluid excess/
palpating over overload.
tibia, ankles, feet
and sacrum.

> Evaluate > Poor nutrition

weight in relation and decreased
to nutritional appetite over
status. time result in a
decrease in
weight, which
 may be
accompanied by
fluid retention
even though the
net weight
remains
unchanged.

Problem No. 4: Impaired Urinary Elimination

Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis Explanation Outcome
Short-term: Short-term:
S> Ø Impaired urinary UTI is > Note physical > To assess
O> the patient elimination r/t considered to be After 3-4 hours diagnosis that causative/ After 3-4 hours
manifested: fluid volume present when of nursing may be involved. contributing of nursing
periorbital excess AEB there are interventions, factors. interventions, the
edema decreased underlying the patient will patient shall
restlessnes urinary output factors that demonstrate >Review > To check for have
s predispose to behaviors/ laboratory tests. presence of demonstrated
facial ascending techniques that infection that behaviors/
edema bacterial prevent may be the techniques that
bipedal infection. aggravation of cause of the prevent
edema Predisposing condition. condition. aggravation of
( non- factors include condition.
pitting ) urinary Long-term: >Determine >To assess
wheezes instrumentation client’s previous degree of Long-term:
heard on (eg, After 2-3 days of pattern of interference/
BLF catheterization, nursing elimination and disability. After 2-3 days of
cystoscopy), interventions, compare with nursing
decreased
anatomic the patient will current situation. interventions, the
urinary
abnormalities, achieve normal Note reports of patient shall
output
and obstruction elimination frequency, have achieved
increased of urine flow or pattern or urgency, normal
BP poor bladder participate in burning, elimination
emptying. measures to incontinence, pattern or
The patient may Bacterial UTIs correct/ nocturia/ participate in
manifest:
weight gain can involve the compensate for enuresis, size measures to
jugular vein urethra, defects. and fore of correct/
distention prostate, urinary stream. compensate for
bladder, or defects.
kidneys. >Palpate > To assess for
Symptoms may bladder. retention.
be absent or
include urinary >Determine > To help
frequency and client’s usual determine level
urgency, dysuria, daily fluid intake. of hydration.
lower abdominal Note condition of
pain, and flank skin and mucous
pain. Systemic membranes and
symptoms and color of urine.
even sepsis may
occur with >Encourage >Open
kidney infection. client to expression
verbalize fears/ allows client to
concerns. deal with
feelings and
begin problem
solving.

>Monitor > To note client’s

medication response, need
regimen, to modify
antimicrobials treatment.
and others.
>To reduce risk
>Check of infection and/
frequently for or autonomic
bladder hyperreflexia.
distention and
observe for
overflow.
>To reduce risk
 >Emphasize of infection and/
importance of or skin
keeping area breakdown.
clean and dry .

Problem No. 5 : Mild Anxiety

Nursing Scientific Expected
Assessment Objectives Interventions Rationale
Diagnosis Explanation Outcome
Short Term: Short-Term:
S> The patient Mild anxiety r/t Patient is quite > Be aware of >These may
may verbalize unmet needs apprehensive After 4 hours of defense interfere with Patient shall
concerns due to and regarding his nursing mechanisms ability to deal with have
change in life psychological health thereby interventions, used by the problem verbalized
events and may factors such as increasing patient will client awareness of
appear ruminative stress levels verbalize feelings of
distressed and thoughts on leading to mild awareness of >Identify coping > Evaluate what anxiety and will
apprehensive health anxiety. feelings of anxiety skills the else can be identify healthy
and will identify individual is improved with the ways to deal
O>the patient healthy ways to using currently current use of and express
manifested: deal and express coping anxiety
Impaired anxiety mechanisms
attention
Restlessne Long Term: >Review coping > Determine those
ss and skills used in that might be
fidgeting After 2-3 days of past helpful in the Long-Term:
Marked nursing current situation
irritability interventions,
and patient will Patient shall
impatience appear relax and >Establish a >Assist client to have appeared
insomnia report anxiety therapeutic identify feelings relaxed and
was reduced to a relationship, and begin to deal reported
> The patient manageable conveying with problems. anxiety was
may manifests: level. empathy and reduced to a
decreased unconditional manageable
perceptual positive regard level.
field >Be available to >Help alleviate
Increased client for anxiety by
wariness listening and providing support
Anguish talking
forgetfulnes
s
>Encourage >Help relieve
expression of anxiety by not
feelings and aggravating undue
allow behavior stress the client
to belong to the already feels
client. Do not
be sympathetic
and respond
personally

>Assist client to >Promote

learn wellness
precipitating
factors and new
methods of
coping with
disabling
anxiety

>ascertain >assess coping

clients abilities/ skills of
understanding client to generate
of current better plan of care
situation and its
impact. Active
listen and
identify her
perception of
what is
happening

>determine >to identify

previous successful
method of techniques in
dealing with life dealing with
problems current situation

>provide for a >comfort

quiet measures may
environment, help in alleviating
soft music, anxiety
warm bath,
back rub.
Actual SOAPIE’s
SOAPIE #1

S:Φ
O: received pt. on a semi-fowler’s position; conscious and coherent; with an ongoing
IVF of #2 D5 LRS 1Lx8° at 450cc level infusing well on the right hand; with periorbital
edema; pt. appears restless; wheezes heard on BLF; with facial edema; with bipedal
edema,non-pitting; with initial VS of: T=36.6°C P=79 R=20 BP=150/90

A: Excess Fluid Volume r/t compromised regulatory mechanism 2° UTI

P: After 3-4° of N.I., pt. will demonstrate alleviation of signs and symptoms of fluid
excess AEB stable VS and free signs of edema

I:
- established rapport
- monitored and recorded VS
- noted fluid intake
- reviewed intake of sodium
- auscultated breath sounds
- noted presence of edema
- evaluated mentation
- reviewed laboratory data
- encouraged low fat and low sodium diet as ordered
- changed position frequently to provide comfort measures
- placed client on a semi-fowler’s position to facilitate movement of diaphragm for
respiratory movement
- promoted early ambulation
- provided quiet environment
- administered medication as ordered
E: Goal met AEB pt. demonstrated alleviation of signs and symptoms of fluid excess
AEB stable VS and free signs of edema

SOAPIE #2

S:Φ
O: received pt. on a semi-fowler’s position; sleeping; with an ongoing IVF of #3 D5LRS
1Lx8° at 280ml level infusing well on the right hand; with facial edema; with bipedal
edema, non-pitting; pt. appears restless; with periorbital edema; with pail nailbeds; with
initial VS taken and recorded as follows: T=36.6°C P=69 R=20 BP=140/90

A: Imbalanced fluid volume r/t rapid fluid shifts from intravascular compartment to
interstitial circulation 2° UTI

P: After 2-3° of N.I., pt. will demonstrate adequate fluid volume AEB stable VS.

I:
- established rapport
- monitored and recorded VS
- monitor BP responses to activities
- assessed clinical signs of fluid imbalance
- noted increased lethargy/restlessness
- reviewed laboratory data
- emphasized importance of low fat and low salt diet
- administered IVF and regulated as appropriate
- discussed individual risk factors and specific interventions
- monitored urine output, noting color and amount
- identified signs and symptoms indicating need for prompt evaluation

E: Goal met AEB pt. demonstrated adequate fluid volume AEB stable VS.
VI. Client’s Daily Progress Chart (From Admission to Discharge)

Admission
NSG PROBLEMS 04-21-09 04-22-09 Discharge
04-20-09
Acute Pain ♣
Decreased Cardiac
♣ ♣ ♣ ♣
Output
Excess Fluid Volume ♣
Impaired Urinary
♣ ♣
Elimination
Mild Anxiety ♣ ♣

Admission
VITAL SIGNS 04-21-09 04-22-09 Discharge
04-20-09
1. Temperature 36 36.8 36.6 36.5
2. Pulse Rate 80 76 69 72
3. Respiratory Rate 24 20 20 18
4. Blood Pressure 170/100 140/90 140/90 130/80

Admission
DIAGNOSTICS 04-21-09 04-22-09 Discharge
04-20-09

BLD CHEMISTRY ♣
>>BUN 37.38
>>Creatinine 1.3
>>Sodium 144.3
>>Potassium 4.09

CXR-AP ♣
>> Normal Chest

URINALYSIS ♣ ♣
>>Color Yellow Light Yellow
>>Transparency Turbid Clear
>>pH 6.0 6.0
>>Specific Gravity 1.030 1.005
>>Albumin 1+ Negative
>>Sugar Negative Negative
>>Pus Cells/hpf 1-2 1-2
>>Bacteria/hpf Few
>>RBC/HPF 8-10 12-15

CBC ♣
>>Hgb 160
>>WBC 9.7
>>Hct 0.47
>>RBC 6.06
>>Platelet 280
>>Segmenters 0.75
>>Lymphocytes 0.21

KUB-UTZ ♣
Sonically normal
>>
kidneys and bladder

LIPID PROFILE ♣
>>Cholesterol 140
>>Triglycerides 160
>>HDL-C 26
>>LDL-C 82

Admission
MEDICAL MGMT 04-21-09 04-22-09 Discharge
04-20-09

IVF
>>D5LRS ♣ ♣ ♣

DRUGS
>>Norvasc 5mg ♣ ♣ ♣
>>Paracetamol
♣ ♣ ♣
300mg
>>Captopril 25 mg ♣ (PRN)
>>Ceftriaxone 1gm ♣ ♣ (D/C)
>>Ciprofloxacin
♣ ♣
500 mg

DIET
>>Low salt/Low fat ♣ ♣ ♣ ♣
DISCHARGE PLANNING

General Condition of the Client Upon Discharge

O> Patient good skin turgor and moist mucous membranes, with verbal
reports of slight dizziness. VS as follows: T=36.5 PR=72 RR=18
BP=130/80

M> Instructed client to continue meds as instructed by the physician.

Norvasc 5 mg/tab OD
E> Instructed client to continue ADL as tolerated.
T> Reiterated importance of compliance to medical regimen.
H> Increase intake of foods rich in iron.
> Increase fluid intake.
> Increase Intake of foods rich in Vitamin C.
> Instructed to have adequate rest periods.
> Instructed to avoid smoking, alcoholic beverages and fatty and salty foods.
O> Instructed patient to go back for follow-up check up after 1 week.
D> Low-fat, low-salt diet

VII. CONCLUSION

With this case study presentation, the researchers basically got a first-hand
experience in caring for a patient afflicted with hypertension and urinary tract infection.
Though these disorders are disorders too common for study, many still haven't
understood by heart the pathophysiologic mechanisms of such diseases. Ergo, the
essentiality of supplemental learning on these cases is very beneficial.

Hypertension is one of the most common worldwide diseases afflicting humans.

Because of the associated morbidity and mortality and the cost to society, hypertension
is an important public health challenge. Over the past several decades, extensive
research, widespread patient education, and a concerted effort on the part of health
care professionals have led to decreased mortality and morbidity rates from the multiple
organ damage arising from years of untreated hypertension. Hypertension is the most
important modifiable risk factor for coronary heart disease (the leading cause of death in
North America), stroke (the third leading cause), congestive heart failure, end-stage
renal disease, and peripheral vascular disease. Therefore, health care professionals
must not only identify and treat patients with hypertension but also promote a healthy
lifestyle and preventive strategies to decrease the prevalence of hypertension in the
general population.

A urinary tract infection is a bacterial infection that affects any part of the urinary
tract. Although urine contains a variety of fluids, salts, and waste products, it usually
does not have bacteria in it, when bacteria get into the bladder or kidney and multiply in
the urine, they cause a UTI. The most common type of UTI is a bladder infection which
is also often called cystitis. Another kind of UTI is a kidney infection, known as
pyelonephritis, and is much more serious. Although they cause discomfort, urinary tract
infections can usually be quickly and easily treated with a short course of antibiotics.
Studies have shown that breastfeeding can reduce the risk of UTIs in infants. They are
so common that infections are so common and typically easy to treat that most people
don't realize they can be deadly. An untreated UTI can spread to the kidneys, which can
lead to septicemia (a bacterial infection of the blood), decreased blood pressure,
decreased blood flow, shock and organ failure.

These two disease, though quite mundane and trite, still has bearing because if
left unmananaged, they might progress to a more critical circumstance that may cost
their life. As aspiring nurses, the researchers should everything they can to prevent
occurrence of such by adapting a healthy lifestyle with regular exercise, a balanced diet,
increased fluid intake and good mental hygiene.

“Prevention is better than cure”. A cliché quotation if one will look at it, but
somehow still applies to the present health problems. Everyone is challenged to repress
to the accustomed habits that are indeed detrimental to one’s health and to regress to
the forgotten practices that promote health.

VIII. BIBLIOGRAPHY:

Black, Joyce. Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, W.B. Saunders Company; 6th edition (January 15, 2001)

http://www.nytimes.com/2008/07/08/health/research/08prev.html?_r=1&adxnnl=1&or
ef=slogin&ref=health&adxnnlx=1218207884-CQVCmFnvr2UuI+xLmepYdw

Microsoft ® Encarta ® 2007. © 1993-2006 Microsoft Corporation. All rights reserved.

 Angeles University Foundation
Angeles City

College of Nursing

A Case study:

“Stroke in Evolution”
In partial fulfillment of the requirements in

Related Learning Experience NCM103

Submitted by:

Ano, Carl Elexer

Submitted to:

Robby Roque, RN, MN

april 27, 2009