A Case Study On Schistosomiasis

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ABSTRACT

We, group 1 of Level III section 1, have chosen this case to gain more knowledge
about the mechanism of Schistosomiasis that leads to Liver Cirrhosis and manifests
complications (Ascites, CVI & Edema). Our patient R.P is a 68 -year old female who
was first diagnosed of Schistosomiasis, Liver Cirrhosis and Chronic Venous
Insufficiency in the year 2010. Her disease leads to fluid accumulation to his lungs and
in the abdominal cavity and edema on her extremities. Our group chose the case
because it is also our first time to handle a case that is unusual. We also want to
improve our knowledge and skills in dealing with individuals with this kind of disease,
especially in preventing the occurrence of its complications.
Schistosomiasis (also known as bilharzia, bilharziosis or snail fever) is a
collective name of parasitic diseases caused by several species of trematodes
belonging to the genus Schistosoma. Snails serve as the intermediary agent between
mammalian hosts. Individuals within developing countries who cannot afford proper
water and sanitation facilities are often exposed to contaminated water containing the
infected snails.
This disease is most commonly found in Asia, Africa, and South America,
especially in areas where the water contains numerous freshwater snails, which may
carry the parasite.
The disease affects many people in developing countries, particularly children
who may acquire the disease by swimming or playing in infected water. When children
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come into contact with a contaminated water source, the parasitic larvae easily enter
through their skin and further mature within organ tissues. As of 2009, 74 developing
countries statistically identified epidemics of Schistosomiasis within their respective
populations
Cirrhosis is an abnormal liver condition in which there is irreversible scarring of
the liver. The main causes are sustained excessive alcohol consumption, viral hepatitis
B and C, and fatty liver disease; however, there are many possible causes. People with
cirrhosis may develop jaundice, itching and extreme tiredness. For cirrhosis to develop
long-term, continuous damage to the liver needs to occur. When healthy liver tissue is
destroyed and replaced by scar tissue the condition becomes serious, as it can start
blocking the flow of blood through the liver. Cirrhosis is a progressive disease,
developing slowly over many years, until eventually it can stop liver function (liver
failure). The liver carries out several essential functions, including the detoxification of
harmful substances in the body. It also purifies the blood and manufactures vital
nutrients.

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I. DEMOGRAPHIC DATA:

Name: R.P Date of Interview: August 01, 2013
Age: 68 years old Primary informant: Patient R.P
Birthday: September 09, 1944 Secondary Informant: Relatives
Birthplace: Tabon-Tabon Northern Leyte Other Sources: Patients Chart and Lab
Address: GMA, Cavite Date Admitted: July 21, 2013
Gender: Female Time Admitted; 07:15 am
Civil Status: Married
Religion: Roman Catholic
Highest Educational Attainment: Elementary Graduate
Occupation: Sari-sari Store Owner
Monthly Income: 25, 000
Monthly Expenses: 10, 000
Medical support: PhilHealth

II. CHIEF COMPLAINT:
One month prior to admission she noted unexpected weight gain from 59 kg to
63.2 kg and enlargement of the abdomen. Four days prior to admission, the patient had
experienced difficulty of breathing and dyspnea on exertion.
III. HISTORY OF PRESENT ILLNESS:
In the year 2010, the patient was diagnosed with Schistosomiasis and
Liver Cirrhosis in Philippine General Hospital. She was also diagnosed with Chronic
Venous Insufficiency on the said year.
Her relatives claimed that she got her disease when she had her vacation in
Leyte last 2009. When she got back in Cavite on the same year, she noticed that her
legs were edematous due to the lacerated wound she got upon farming in Leyte. After a
year, her daughter insisted on getting her mother a medical attention at the said
hospital. At the day of admission, as her wounds slowly healed, she was given the
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medication-propranolol to be taken three times a day and Praziquantel and was advised
to clean her wound properly. Her abdomen was also enlarged and an evident edema on
her lower extremities was noted. After seeking medical attention, she did not attend her
follow up consultation because she claimed that she will be fine due to the given
medication.
This 2013, four days prior to her admission, she developed productive cough with
whitish phlegm accompanied with difficulty of breathing. Two days prior to admission,
her abdomen was enlarged and evident edema on her lower extremities was noted.
IV. PAST MEDICAL HISTORY:
According to the patient, she cannot recall if she was fully immunized during her
childhood days. She perceives herself to be healthy and she claimed, Hindi naman ako
sakitin noong bata pa ako,. She also claimed that she did experience common
illnesses like fever, cough and colds. Pag may sakit si nanay kahit nung bata pa kami,
di siya mahilig uminom kaagad ng gamot mas gusto niya yung mga herbal medicine
katulad ng lagundi at oregano, as verbalized by her daughter. She didnt rely on over
the counter drugs because for her it will just make you more dependent in synthetic
remedies. She claimed that she has no known allergies in foods and in medications.
She claimed that in their family, there are no history of hereditary diseases such as
diabetes and hypertension. Also, she claimed that, Nung dinala ako sa PGH, dun
naming nalaman na tumaas na BP ko hanggang ngayon kasi di naman tumataas yun
dati hanggang 110/80 lang. RP also claimed that, Yunhg kapatid lang ng nanay ko
namatay dahil sa colon cancer at yung kapatid ko na bunso may asthma.
The patient didnt encounter any accidents or fall thus she didnt have any
fracture in the past. Di naman yan naaksidente kahit dati pa, yun lang talaga nung
nagbakasyon siya sa probinsya namin tapos pag- uwi may sugat siya at biglang
namaga na yung paa tapos ayaw niya na magpacheck-up kaya March 2010 na namin
siya nadala., as verbalized by her sibling. She was hospitalized in Philippine General
Hospital on the year 2010 for four days after she came back from their province and
was then diagnosed of Chronic Venous Insufficiency and Schistosomiasis and Liver
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Cirrhosis. Nasugatan po kasi yung paa niya sa kahoy nung nasa palyan daw sila tapos
ayan pag-uwi namaga na paa niya at marami dun sa amin ang may ganiyang sakit, as
verbalized by the daughter. They seeked medical attention because they thought that
the wound was healing slowly. Nililinis po namin ng dextrose na may zonrox yung paa
niya, yun po kasi sabi ng doktor, as verbalized by her daughter. She was then
maintained on the given medication (propranolol) and she refused her follow-up check
up because she claimed that she will become fine, knowing that she just appropriately
took her medication. Ayaw niya na magpa-check up kasi daw umiinom naman daw siya
ng gamot tapos naging okay naman siya. Ngayon lang
V. OBSTETRIC- GYNECOLOGICAL HISTORY:
Patient R.P claimed that she had her menarche during her elementary day
(Grade 6), she just dont remember the exact date. She also claimed that she had a
regular menstrual cycle and did experience dysmenorrhea but she didnt take any
analgesic. She had her last menstrual period during her late 40s.
Name of the Child Year of
Birth
AOG Place of Birth Manner of
Delivery
P. P 1973 Full Term House NSD
M. P 1975 Full Term House NSD

Interpretation:
Patient R.Ps OB score is G2P2T2A0L2. She delivered her children in their
house here in Cavite and through NSD. She claimed that she didnt experience any
complication during her pregnancies.
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VI. HEREDO- FAMILIAL HISTORY:

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Interpretation:
The genogram is a pictorial display of patients R.Ps family relationship and
medical history. It shows the three-generation family of the patient. The diagram
includes the current ages and current health status of each family member from the
three generation from the patient.
The paternal and maternal side of the patient in both of her grandparents were
dead but she was not sure for the exact cause of her death.
For the second generation, most of the family members were dead. His father
and mother both died due to a vehicular accident. Her uncle on the mothers side died
because of colon cancer.
For the third generation, her older brother died due to myocardial infarction and
her brother L.P developed asthma.

VII. DEVELOPMENTAL HISTORY:
Erik Eriksons Psychosocial Development
According to Erik Erikson, our personality traits come in opposites. We think of
ourselves as optimistic or pessimistic, independent or dependent, emotional or
unemotional, adventurous or cautious, leader or follower, aggressive or passive. Many
of these are inborn temperament traits, but other characteristics, such as feeling either
competent or inferior, appear to be learned, based on the challenges and support we
receive while growing up.
The man who did a great deal to explore this concept is Erik Erikson. Although
he was influenced by Freud, he believed that the ego exists from birth and that behavior
is not totally defensive. Based in part on his study of Sioux Indians on a reservation,
Erikson became aware of the massive influence of culture on behavior and placed more
emphasis on the external world, such as depression and wars. He felt the course of
development is determined by the interaction of the body (genetic biological
programming), mind (psychological), and cultural (ethos) influences. His developmental
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stages were based on his philosophy that: (1) the world gets bigger as we go along and
(2) failure is cumulative.
He organized life into eight stages that extend from birth to death (many
developmental theories only cover childhood). Then, since adulthood covers a span of
many years, Erikson divided the stages of adulthood into the experiences of young
adults, middle aged adults and older adults. While the actual ages may vary
considerably from one stage to another, the ages seem to be appropriate for the
majority of people.
Stage 1. Infancy: Birth to 18 Months
Ego Development Outcome: Trust vs. Mistrust
Basic strength: Drive and Hope

At this stage babies learn to trust that their parents will meet their basic needs. If
a child's basic needs aren't properly met at this age, he or she might grow up with a
general mistrust of the world. The patient grew up with her parents and siblings in their
province. Upon questioning the patient regarding on this developmental stage, she
stated that, Ang pagkakatanda ko, nanay ko ang madalas na nagaalaga sakin dahil si
tatay ang palaging nasa bukid. Breastfed din naman ako at hindi naman daw ako
mahirap padedehen. Kapag umiyak na daw ako hindi daw agad ako mapatahan,
kailangan matagal akong kinakarga para tumahan. Nung di na ako nadede, pinapakain
na ako ng magulang ko ng nilagang patatas, kalabasa na dinurog. Sabi ng nanay ko
dati, hindi daw ako ganun katakot sa mga tao hindi din naman ako nangingilala,
nasama agad ako kapag nagpapakarga. Minsan daw umiiyak ako kapag nakakakita
ako ng mga malalaking tao, lalo na yung mga tito at yung lolo ko, sa tatay ko lang ako
hindi takot. Umiiyak lang daw ako kapag naalis yung mga magulang ko lalo na nanay
ko.
An infant is helpless, totally dependent on others for his needs. During this stage,
the infant learns whether the world in which he lives can be trusted. If an infant's
physical and emotional needs are met in a consistent and caring way, she learns that
his mother or caregiver can be counted on and he develops an attitude of trust in
people. If her needs are not met, an infant may become fearful and learns not to trust
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the people around her. The implications of Erikson's first stage for parents, it is to
ensure that an infant experiences a trusting relationship with her parent (or caregiver).
For a trusting relationship to exist there must be a consistent relationship.
The most significant relationship is with the maternal parent, or whoever is our
most significant and constant caregiver. Based on our interview with the client, we can
say that she gained trust as she had a constant caregiver, which was her mother, who
made sure all his needs were met and gave her constant love.

Stage 2. Early Childhood: 18 Months to 3 Years
Ego Development Outcome: Autonomy vs. Shame
Basic Strengths: Self-control, Courage, and Will
As toddlers, children begin to develop independence and start to learn that they
can do some things on their own (such as going to the toilet). If a child is not
encouraged properly at this age, he or she might develop shame and doubt about their
abilities.
The patient states that Noong dalawang taong gulang pa lang daw ako at sa
pagkakatanda ko mabilis daw akong natutong magsalita, madaldal ako at mahilig akong
tumakbo kapag lumalabas kami ng bahay, sobrang likot at kulit ko daw noon, hindi daw
agad ako basta-basta nasasaway lalo na pagpupunta si tatay sa bukid mamimilit akong
sumama. Minsan mabait naman daw ako, pero dapat daw ibigay lang ang gusto ko para
hindi ako mangulit. Bata palang din daw ako mahilig na ako magsulat ng kung anu-ano,
basta kapag nakakita ako ng lapis bigla na lang ako guguhit. Tinuturuan din ako ni nanay
kung saan ako tatae at iihi, nagsasabi ako sa kanila na tatae ako, at kusa naman akong
pupunta sa banyo. Meron din naman minsan na pag di ko mapigilan yung pag- ihi
napapaihi din naman ako sa panty ko.
The toddler realizes that she is a separate person with her own desires and
abilities. She wants to do things for herself without help or hindrance from other people.
The toddler's favorite word "No" is a declaration of independence and a bid for
increased autonomy. It is a reflection of being made in the image of God ... with the
ability to make choices.
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This push for autonomy is enhanced by muscular maturation as toddlers try to
use their developing muscles to walk, climb, hop and jump and to explore their
environment. Potentially, toddlers can get into dangerous situations. Therefore, parents
have to balance the opposing virtues of encouragement and restraint. If a toddler's
efforts to do things on her own were frustrated by over-protective parents then she may
not have many opportunities to develop autonomy. On the other hand, if a toddler was
harshly criticized for "accidents" (e.g., wetting, soiling, spilling or breaking things) then
she may develop doubt about his own abilities to tackle new challenges.
Children need to develop a sense of personal control over physical skills and a
sense of independence. Success leads to feelings of autonomy, failure results in
feelings of shame and doubt. The most significant relationships are with parents. Based
on our interview with the client, we can say that she established autonomy. She was
also taught how to the things the correct way and was allowed to do these things by
herself.
Stage 3. Play Age: 3 to 5 Years
Ego Development Outcome: Initiative vs. Guilt
Basic Strength: Purpose
As preschoolers, children continue to develop more independence and start to do
things of their own initiative. If a child is not able to take initiative and succeed at
appropriate tasks, he or she might develop guilt over their needs and desires.

During this period, the patient experiences a desire to copy the adults around her
and take initiative in creating play situations. The patient also begins to use that
wonderful word for exploring the world "WHY?" As she verbalized, Noong mga 5 na
taon daw ako, palagi daw akong nasunod sa nanay ko tapos ang hilig ko daw
magkwento pag dumadating si tatay kinukwentuhan ko siya. Kapag wala naman daw
akong ginagawa naglalaro lang daw ako sa bakuran namin. Naalala ko din noon na
mahilig ako mangialam ng mga bagay na di akin lalo na gamit ng mga kapatid ko.
Naalala ko din na mahilig ako sumama sa mga magulang ko sa bukid kapag napipilit ko
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sila na isama ako. Sabi ng nanay ko, pipilitin ko din na magsaka ako na parang kayang
kaya ko daw, ginagaya ko pa ang ginagawa ng tatay ko kaya tuwang tuwa mga
katrabaho niya.
Increased muscular, mental and language abilities set the stage for more
activities and questions. There is a great curiosity and openness to learning. The
favorite word of a pre-school is "why." Parents who take time to answer their
preschoolers questions reinforce their intellectual initiative. But parents who see their
children's questions as a nuisance may stifle their initiative and cause them to be too
dependent on others and to be ashamed of themselves. Imaginative play is the basic
activity of this stage. The preschooler explores and reenacts the different roles and
activities of people, both real (home life) and fictional (often based on television).
Preschoolers learn through play. Play is their "work." Children who are given much
freedom and opportunity to initiate imaginative and motor play have their sense of
initiative reinforced. Parents who inhibit their children's imaginative play or deride them
as silly may cause them to develop a sense of guilt over self-initiated activities. Based
on our interview, it can be said that the patient established autonomy due to her
experiences in terms. Her experiences brought on such a powerful effect on her
personality they influenced her actions.
Children need to begin asserting control and power over the environment.
Success in this stage leads to a sense of purpose. Children who try to exert too much
power experience disapproval, resulting in a sense of guilt.

Stage 4. School Age: 6 to 12 Years
Ego Development Outcome: Industry vs. Inferiority
Basic Strengths: Method and Competence
Throughout their school years, children continue to develop self-confidence
through learning new things. If they are not encouraged and praised properly at this
age, they may develop an inferiority complex.
During this stage, often called the Latency, we are capable of learning, creating
and accomplishing numerous new skills and knowledge, thus developing a sense of
industry. This is also a very social stage of development and if we experience
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unresolved feelings of inadequacy and inferiority among our peers, we can have serious
problems in terms of competence and self-esteem.
The patient at this stage learned to read, to write and make things on her own.
She verbalized that, Six year old ako nagsimulang mag-grade1. Sabi sa akin ng nanay
ko palagi ako sumasagot sa klase, kaya tuwang-tuwa daw ang teacher ko sa akin. Kahit
hirap kami noon nairaraos pa din naman kami nila nanay. Nairaos din nila ang pag-
aaral ko hanggang magtapos ako ng elementarya. Kahit di ako ganun ka talino kahit
papaano nakapagtapos ako.
At the school-going stage, the child's world extends beyond the home to the
school. The emphasis is on academic performance. There is a movement from play to
work. Earlier the child could play at activities with little or no attention given to the quality
of results. Now, she needs to perform and produce good results.
The child soon learns that she can win recognition from parents, teachers and
peers by being proficient in her school work. The attitudes and opinions of others
become important. The school plays a major role in the resolution of the developmental
crisis of initiative versus inferiority.
If children are praised for doing their best and encouraged to finish tasks then
work enjoyment and industry may result. Children's efforts to master school work help
them to grow and form a positive self-concept ... a sense of who they are. Children who
cannot master their school work may consider themselves a failure and feelings of
inferiority may arise.
A child may also feel a sense of shame if his parents unthinkingly share her
"failures" with others. Shame stems from a sense of self-exposure, a feeling that one's
deficiencies are exposed to others.
There is a danger in "I am what I can achieve" ... children may come to believe
that they must earn love and acceptance. This thinking runs counter to the gospel of
grace (Eph. 2:8-9). Parents need to give their children "unconditional love" that no
matter what they do, they are still your children. Based on the interview, it is determined
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that the patient established industry because she received praise from his teacher. Also,
her parents showed their support in giving her better future even they are not wealthy
enough just to sustain their child.
Stage 5. Adolescence: 12 to 18 Years
Ego Development Outcome: Identity vs. Role Confusion
Basic Strengths: Devotion and Fidelity

When they reach the teenage years, children start to care about how they look to
others. They start forming their own identity by experimenting with who they are. If a
teenager is unable to properly develop an identity at this age, his or her role confusion
will probably continue on into adulthood.
The patient verbalized that, Nung nagsimula na ako maging teenager, simple
lang ako hindi ako gaanong nag-aayos. Madali akong magkaroon ng kaibigan kasi
madali naman akong makisama at pakisamahan. Hindi rin ako nagkaroon ng
karelasyon dahil bawal pa at ayaw din ng mga magulang ko. Sabi kasi nila madali lang
daw magasawa at dapat nasa tamang edad na.
Teens need to develop a sense of self and personal identity. Success leads to an
ability to stay true to yourself, while failure leads to role confusion and a weak sense of
self.
Our task is to discover who we are as individuals separate from our family of
origin and as members of a wider society. Unfortunately for those around us, in this
process many of us go into a period of withdrawing from responsibilities, which Erikson
called a "moratorium." And if we are unsuccessful in navigating this stage, we will
experience role confusion and upheaval. A significant task for us is to establish a
philosophy of life and in this process we tend to think in terms of ideals, which are
conflict free, rather than reality, which is not. The problem is that we don't have much
experience and find it easy to substitute ideals for experience. However, we can also
develop strong devotion to friends and causes.
The most significant relationships are with peer groups. Based on the interview, it
is determined that the patient established identity because as a young man, he had a lot
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of confidence and made friends easily. She was not influenced by other people and
made her own decisions as seen with his former relationship.

Stage 6. Young Adulthood: 18 to 35
Ego Development Outcome: Intimacy and Solidarity vs. Isolation
Basic Strengths: Affiliation and Love
During early adulthood most people fall in love, get married and start building
their own family. If a person is unable to develop intimacy with others at this age
(whether through marriage or close friendships), they will probably develop feelings of
isolation.
The patient stated that in this stage, Lumipat ako dito sa Cavite nung 20 years
old na ako. Kasi may kamag- anak kami dito at magtatrabaho na din ako kasi mahirap
ang buhay namin sa probinsya. Dito ko din nakilala yung asawa ko. Nagkakilala kami sa
pinagtatrabahuhan ko. Suki namin siya sa restaurant at dun na nag- umpisa yung
pagmamahalan namin hanggang sa nagkaroon kami ng dalawa anak. Masaya kami
hanggang sa nagkaroon kami ng sariling tindahan.
Young adults need to form intimate, loving relationships with other people.
Success leads to strong relationships, while failure results in loneliness and isolation.
In the initial stage of being an adult we seek one or more companions and love.
As we try to find mutually satisfying relationships, primarily through marriage and
friends, we generally also begin to start a family, though this age has been pushed back
for many couples who today don't start their families until their late thirties. If negotiating
this stage is successful, we can experience intimacy on a deep level. If we're not
successful, isolation and distance from others may occur. And when we don't find it
easy to create satisfying relationships, our world can begin to shrink as, in defense, we
can feel superior to others.
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The significant relationships are with marital partners and friends. Based on the
interview, the patient is said to have gained intimacy because he has established a
marital relationship and has a family.
Stage 7. Middle Adulthood: 35 to 55 or 65
Ego Development Outcome: Generativity vs. Self absorption or Stagnation
Basic Strengths: Production and Care
This is the longest period of a human's life. It is the stage in which people are
usually working and contributing to society in some way and perhaps raising their
children. If a person does not find proper ways to be productive during this period, they
will probably develop feelings of stagnation.
During this period, the patient is already having his own family. As we
interviewed her, she stated that, Noong nasa mga nasa 40s na ako, wala akong ibang
ginawa kundi ang magtrabaho at maghanap ng pera para sa pamilya. Hindi ko na nga
masyadong iniintindi ang sarili ko dahil ang lagi kong iniisip ay ang para sa pamilya ko.
Nakapagpundar din kami ng sari-sari store at yan nagsilbing negosyo namin.
Adults need to create or nurture things that will outlast them, often by having
children or creating a positive change that benefits other people. Success leads to
feelings of usefulness and accomplishment, while failure results in shallow involvement
in the world. Now work is most crucial. Erikson observed that middle-age is when we
tend to be occupied with creative and meaningful work and with issues surrounding our
family. Also, middle adulthood is when we can expect to "be in charge," the role we've
longer envied.
The significant task is to perpetuate culture and transmit values of the culture
through the family (taming the kids) and working to establish a stable environment.
Strength comes through care of others and production of something that contributes to
the betterment of society, which Erikson calls generativity, so when we're in this stage
we often fear inactivity and meaninglessness. As our children leave home, or our
relationships or goals change, we may be faced with major life changes the mid-life
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crisis and struggle with finding new meanings and purposes. If we don't get through
this stage successfully, we can become self-absorbed and stagnate. Significant
relationships are within the workplace, the community and the family.
Stage 8. Late Adulthood: 55 or 65 to Death
Ego Development Outcome: Integrity vs. Despair
Basic Strengths: Wisdom
As senior citizens, people tend to look back on their lives and think about what
they have or have not accomplished. If a person has led a productive life, they will
develop a feeling of integrity. If not, they might fall into despair.
Erikson felt that much of life is preparing for the middle adulthood stage and the
last stage is recovering from it. Perhaps that is because as older adults we can often
look back on our lives with happiness and are content, feeling fulfilled with a deep sense
that life has meaning and we've made a contribution to life, a feeling Erikson calls
integrity. Our strength comes from a wisdom that the world is very large and we now
have a detached concern for the whole of life, accepting death as the completion of life.
As we interviewed her, she stated that Ngayon sa kalagayan ko, aaminin ko na
hirap na ako at handa na akong mamatay. Pinagsasadiyos ko nalang ang mga
mangyayari kahit alam kong mahirap lalo na sa pamilya ko. Wala akong pinagsisihan sa
buhay ko, lahat naman naging maayos, masaya at walang naging problema, Kahit hindi
kami gaanong mayaman at naging ganito ang kondisyon ko nagpapasalamat pa din ako
sa diyos.
On the other hand, some adults may reach this stage and despair at their
experiences and perceived failures. They may fear death as they struggle to find a
purpose to their lives, wondering "Was the trip worth it?" Alternatively, they may feel
they have all the answers (not unlike going back to adolescence) and end with a strong
dogmatism that only their view has been correct. Older adults need to look back on life
and feel a sense of fulfillment. Success at this stage leads to feelings of wisdom, while
failure results in regret, bitterness, and despair. The significant relationship is with all of
mankind.
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VIII. GORDONS FUNCTIONAL HEALTH PATTERN:
1) HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN
At present, the patient perceives that her general health was compromised as
she was diagnosed with Schistosomiasis, Liver Cirrhosis, Ascites and CVI. Her relatives
claimed that it started when she had her vacation in Leyte and her legs got a wound
while farming. Also, she claimed that she was not an alcoholic drinker nor did she
practice any sort of vices while growing up. According to her before she was admitted,
she does not rely on over the counter drugs and seldom seek medical attention
whenever she got sick. The patient would rather take herbal medicines as her form of
remedy whenever she feels unwell. She believes that one should not be dependent on
certain medication in treating a disease. Also, whenever she felt something wrong or
she does not feel good, she would simply rest or go to sleep. She claimed that she
walks every morning and perform some household chores that serve as her daily
exercise.
When she first seek medical attention at Philippine General Hospital in the year
2010 due to the slow healing process of her legs as well being edematous, she was
prescribed by her doctor with propranolol to be taken three times a day and another was
Praziquentel. She was then advised to avoid fatty foods and always clean her legs with
NaCl Solution with Zonrox, thus she goes after the advice of her doctor. From then on
she did not attend her check ups believing that she will be just fine as long as she
properly took her medications.
But when RP was hospitalized due to her worsening condition, it was the only
time she finally followed the doctors order and advice, realizing that it will help her to
improve her condition. Her relatives also took good care of her especially when the
client can no longer perform a few of her ADLs (activities of daily living). RP claimed
that before her hospitalization, she was persistent to her own perspective of health and
in keeping herself well. Now, she realized the importance of following doctors orders
and check ups, because as time goes by, aging and health status changes.

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2) NUTRITIONAL- METABOLIC PATTERN
Patient R.P was instructed to limit fluid intake of less than 1 liter per day as
doctors order. Before hospitalization she consumes 5-8 glasses of water a day. Also,
her relatives claimed that, Nung pagkahospital ni nanay sa PGH sinabihan siya na
bawal siya ng malalangsa at matatabang pagkain. According to her daughter, patient
R.Ps meal before hospitalization usually includes vegetables, fruits, rice and cereals.
She also drinks coffee every morning. During hospitalization, she usually eats porridge,
biscuit, cereals, soup and vegetables. Her relatives claimed that before hospitalization,
she ate a lot and has a good appetite.
Her relatives claimed that RPs legs were really swollen and that her enlarged
abdomen made it look like she gained weight. Her weight increased from 59kg to
63.2kg prior to admission.
Upon observation, we noticed that the patients skin was dry and with poor skin
turgor. She also ha hematoma throughout both arms due to administration of
medications and switching of IV positions. Although RP did not have any problem
chewing, she wore dentures since she was 56 years old and had difficulty in swallowing
foods that are quite rigid.
5- Day Diet Recall (Hospital Setting)
Meals Sept. 29,
2013
Sept. 30,
2013
Sept. 31,
2013
Aug. 01,
2013
Aug. 02,
2013
Breakfast 1 cup Lugaw
200 ml water
1 small bowl
vegetable
soup
240 ml water
1 slice bread
grapes
240 ml water
1 cup
oatmeal
200 ml water
1 slice
bread
1 cup
oatmeal
200 ml
water
Lunch 1 cup of rice
with sabaw
ng tinola
240 ml water

1 cup of rice
Vegetables
240 ml water
1 cup of rice
Vegetables
240 ml water
1 cup of rice
Vegetables
200 ml water

1 cup of
rice
Vegetables
200 ml
water
Page 19

Snack Biscuits
Grapes
1 slice of
bread
1 cup
oatmeal
Biscuit Grapes
Dinner I cup lugaw
200 ml water
I cup lugaw
grapes
240 ml water

1 cup of rice
Vegetables
200 ml water
1 cup of rice
Vegetables
200 ml water
I cup lugaw
200 ml
water
Total Fluid
Intake
640 ml 720 ml 680 ml 600 ml 600

3) ELIMINATION PATTERN
Patient R.P claimed that before hospitalization, she usually defecates once every
two days with dark brown in color. On the other hand, she urinates 5 times a day with
yellow in color. She claimed, Normal naman yung dami ng ihi ko. She has no trouble
in holding her urine. Also, she claimed that, Di naman ako mabiilis pawisan at kung
mapawisan man ako di naman sobra-soobra.
During hospitalization, she had 2-3 bowel movements per week with a dark
brown color stool, with hard formed in consistency. She was on a catheter for accurate
monitoring of her urine output. She claimed that she is experiencing discomfort due to
the inserted catheter and has difficulty in defecating. Upon observation, she doesnt
perspire excessively.
4) ACTIVITY- EXERCISE PATTERN
According to patient R.P her usual activities before hospitalization was that upon
waking up she sometimes walk in the morning or rather swept the floor. She claimed
that this serves as her exercise and after that she watches her sari-sari store together
with her husband. Sometimes, she took a nap in the afternoon or watch television. Her
daughter claimed that she was not able to perform certain things that exert too much
effort rather than before especially because of her age and as well due to her condition.
During hospitalization, her relatives claimed that most of the time she was on her
bed. Also, she needs assistance whenever going to the bathroom or even standing up
in preventing accidents especially fall. Her relatives claimed that she usually sleeps and
sometimes became irritated when there are nurses doing their rounds. Upon
Page 20

observation, she looks very weak and was not able to perform certain things on her
own. She was placed on semi-fowlers position because she claimed that she
experience difficulty on breathing when lying on flat.
7-Day Activity Table (Hospital Setting)
TIME Days Of The Week
Sept. 27 Sept. 28 Sept. 29 Sept. 30 Sept. 31 Aug. 01 Aug. 02
1 am

Sleeping

Sleeping

Sleeping

Sleeping

Sleeping

Sleeping

Sleeping
2 am
3 am
4 am
5 am
6 am
Having
breakfast
Having
breakfast
Having
breakfast
Having
breakfast
Having
breakfast
7 am Morning
Care
Having
breakfast

Lying in bed
Having
breakfast

Morning Care

Morning Care 8 am
Having
breakfast
9 am Chatting
with her
relatives

Lying in bed
Morning
Care
10
am
Chatting
with her
relatives
Chatting with
her relatives

Chatting
with her
relatives
Chatting with
her relatives
Chatting with
her relatives
11
am
Chatting with
her relatives

Having lunch

Lying in bed
Having lunch
12 nn Having
lunch
Lying in
bed
Having lunch Chatting with
her relatives

Having
lunch

Having lunch

Chatting with
her relatives 1 pm Resting Having
lunch
Chatting with
her relatives
2 pm Chatting
with her
relatives

Resting

Resting
Resting
Having snack
3 pm
Resting

Having Snack Having
snack

Chatting with
her relatives

4 pm Having
snack

Lying on Bed

Resting
Having snack
5 pm Resting

Having
snack
Chatting with
her relatives
Page 21

6 pm Resting
Chatting with
her relatives
Lying in
bed
Lying in bed
Resting
7 pm Having dinner
Having
dinner
Having dinner
8 pm Having
dinner
Having
dinner

Resting
Having dinner

Resting

Resting
Having dinner
9 pm
Sleeping

Sleeping

Resting 10
pm
Sleeping
Lying in bed

Sleeping

Sleeping
11
pm
Sleeping Sleeping
12
mn
Katz Index of Independence in Activities of Daily Living
Activities
Points (1 or 0)
Independence
No supervision, direction or
personal assistance needed
Dependence
With supervision, direction or personal
assistance or total care
Bathing
Dressing
Toileting
Transferring
Continence
Feeding
TOTAL POINTS: 0 point 6 points

Interpretation:
As seen on the table above, patient R.P was not capable of doing the activities of
daily living without supervision, direction and personal assistance from family member
or from health care provider.

Page 22

5) SLEEP- REST PATTERN
Patient R.P claimed that before hospitalization she sleeps around 8 pm and
wakes up around 6 oclock in the morning. Her daughter claimed that sometimes she
snores and sometimes experienced dreams at night that comprised of sleep talking.
During hospitalization, she claimed that she doesnt have any enough sleep
especially when the nurses were doing their rounds. Also, she was not satisfied in her
stay in the hospital because there are also several patients in the ward. She claimed
that sometimes she feels dizzy upon awakening and doesnt feel rested.
5-Day Sleep Diary (Hospital Setting)
Constructs Sept. 27 Sept.
28
Sept. 29 Sept. 30 Sept.
31
Aug.
01
Aug.
02
Hours of
Sleep
9 hours 9 hours 9 hours 7 hours 9 hours 7hours 7 hours
Sleeping
Time
9 pm 9 pm 10 pm 11 pm 10 pm 11 pm 11 pm
Waking
Time
6 am 6 am 6 am 4 am 6 am 6 am 6 am
Bedtime
Rituals
Praying Praying Praying Praying Praying Praying Praying
Feeling
upon
Waking Up
Irritable Not
well
rested
Feels
dizzy
Irritable Not well
rested
Not
well
rested
Not
well
rested
Problem
Encountered
Body
malaise
Body
malaise
Headache Body
malaise
Body
malaise
Being
sleepy
Being
sleepy

6) COGNITIVE- PERCEPTUAL
The patient had hematoma throughout her both arm and claimed that she feels
pain in both hands due to IV insertion and when giving medications. Her relatives
massage her hands and we applied warm compress to help ease the pain. She also
Page 23

said that her abdomen is also in pain. When we asked the pain scale, she answered 6
out of 10.
Upon the interview, the patient does not wear any eyeglasses and hearing aids.
She stated that she is experiencing blurred vision in both eyes due to her age, the grade
of her eyes were 4.00 and her last opthalmoscopic examination was January, 2013.
She claimed that she cannot read small texts mainly in dim lights. She needs assistance
whenever going to the bathroom or even standing up in preventing accidents especially
from fall. She is also having difficulty in hearing. She said that she easily forgets mainly
due to her age. Medyo makakalimutin na din ako, siguro dahil narin sa katandaan, as
verbalized by the patient. When we asked her whats the date today she answered
hindi ko alam, anu nga ba neng?
7) SELF PERCEPTION-SELF CONCEPT PATTERN
The patient describes herself as a good and responsible mother, wife and a
grandmother. When she was admitted, she easily gets irritated because of the noise
and the ambiance in the hospital as well as when the nurse doing their rounds because
she cannot rest well. She claimed that she knew that her health was then compromised
and was not able to perform things like before. She claimed that, Ako na nga ngayon
yung inaalagaan ng mga anak ko na dapat gawain ko yun pero nagpapasalamat pa din
ako sa kanila at sa asawa ko.
8) ROLE RELATIONSHIP PATTERN
The patient lives with her husband while her children have their own family. As of
her condition, she claimed that her family supports her for her fast recovery. The patient
stated that she has a good relationship with the family. In regards with her children, they
have their own family as well they still have a good relationship. Matibay ang
pagsasamahan nilang mag-asawa. Syempre minsan nagkakatampuhan o nag-aaway,
pero naayos din naman agad, as verbalized by the patients relatives.
She said that her family is the most important thing for her. Her family is her
motivation and strength to fight for her condition.
9) SEXUALITY-REPRODUCTIVE PATTERN
Patient R.P claimed that she had her menarche during her elementary days, she
just dont remember the exact date. She also claimed that she had a regular menstrual
Page 24

cycle and did experience dysmenorrhea but she didnt take any analgesic. She had her
last menstrual period during her 40s. Patient R.Ps OB score is G2P2T2A0L2.
Her relatives claimed that, Masaya naman sila ni nanay at palagi na nga silang
magkasama kasi sila din ang nagbabantay sa tindahan. Siguro hanggang 2 nalang
talaga kami, mahirap na dagdagan.
10) COPING-STRESS TOLERANCE
Before she was admitted, when client R.P. feels tired, she will rest and sleep.
She claimed that when she got problems especially in terms of money, she talk with her
husband and children. Sometimes she used to have her past time activities which are
watching television and listening in a radio while into their sari-sari store. This serves as
her coping mechanisms to overcome the feeling of being stressed. Also, she talks and
sometimes plays with her granddaughter.
When she was admitted, there have been many changes occurred that made her
difficult to adjust. She cannot perform her usual activities due to her condition and she
easily gets irritated.
11) VALUE-BELIEF PATTERN
Patient R.P. is a roman catholic. Before she was admitted, she usually goes to
mass every Sunday with her husband. The patient has a strong faith in God. She said
that God helps her to get through to her problems in life. She always prays and asked
God to guide her and her family especially for her illness that she was experiencing.
She stated that she doesnt want to stay in the hospital anymore and wanted to go
home.
When she was asked about what is the most important thing in her life, she
answered her family. Her family is the reason why she wanted to live longer. The patient
does believe in superstitions and still practiced it until now specifically, Bawal maligo
pag may menstruation and Bawal magwalis pag gabi. In terms of medical
approaches, she was really into the herbal medicines and claimed that she doesnt rely
too much on the over the counter drugs.

Page 25

IX. COMPREHENSIVE PHYSICAL EXAMINATION
(Date Performed: August 01-02, 2013)
A. Vital Signs: (10:00pm to 6:00am shift)
August 01, 2013
TIME BLOOD
PRESSURE
TEMPERATURE RESPIRATORY
RATE
PULSE
RATE
10:00pm(Initial) 140/80 mmHg 36.1
0
C 21 cpm 59 bpm
12:00mn 140/80 mmHg 36.3
0
C 20 cpm 62 bpm
4:00am 130/80 mmHg 35.4
0
C 21 cpm 60 bpm
August 02, 2013
TIME BLOOD
PRESSURE
TEMPERATURE RESPIRATORY
RATE
PULSE
RATE
10:00pm(Initial) 130/80 mmHg 36.0
0
C 20 cpm 64 bpm
12:00mn 130/80 mmHg 36.1
0
C 22 cpm 62 bpm
4:00am 130/80 mmHg 35.9
0
C 20 cpm 63 bpm

ABDOMINAL GIRTH MEASUREMENT:
DATE: MEASUREMENT:
July 21, 2013 105 cm
July 23, 2013 113 cm
July 26, 2013 110 cm
July 30, 2013 107 cm
August 02, 2013
(taken & noted by the group)
100 cm

Page 26

B. Anthropometric Data:
Body Mass Index:
weight (kg) Conversion:
height (m
2
) 1ft=12 inches
1 inch=2.54 cm
1 m=100 cm
Patient RP who is a female, age of 68 years with a height of 52 and weight
of 63.2 kg
63.2 kg Ht: 5 ft= 60 inches
2.48 + 02 inches
= 62 inches x 2.54
=25.48 = 157.48 cm
= 157.48 cm / 100
= 1.5748
= 1.5748
2

= 2.479995 or 2.48

INPUT AND OUTPUT MONITORING: (10pm-6am shift)

August 01, 2013
INTAKE OUTPUT
Oral: 100 cc Urine: 300 cc
IV: 90 cc Vomitus: 0
Stool: 0
TOTAL: 190 mL TOTAL: 300 mL
August 02, 2013
INTAKE OUTPUT
Oral: 120 cc Urine: 500 cc
IV: 90 cc Vomitus: 0
Stool: 0
TOTAL: 210 mL TOTAL: 500 mL
Page 27

C. General Appearance
GENERAL
APPEARANCE
ACTUAL
FINDINGS
NORMAL FINDINGS CLINICAL
SIGNIFICANCE
Body built > Endomorph body
type
> Evident
protuberant
abdomen
> Generally soft and
shorter build with
thin arms and legs.
>Proportionate
>Varies with lifestyle
According to Webber &
Kelley Health
Assessment in Nursing
3
rd
edition that the
shorter built, round
physique is a
characteristic of
endomorphs. Normal
findings noted.
Posture and Gait >looks weak and
not relaxed
>Relaxed According to Webber &
Kelley Health
3
rd
edition that not
relaxed finding is
abnormal due to the
uncomfortable condition
experience and the
disease per se.
Over-all Hygiene
and Grooming
> neat
> with unsoiled
>Clean, neat and
well groomed.
Kelley Health
NAME HEIGHT(cm) WEIGHT(kg) BMI WHO
Classification
ASIA-
PACIFIC
Classification
Client RP (68 y/o) 157.48 cm 63.2 kg 25.48 Obese Grade
I
Obese I
Page 28

clothes Assessment in Nursing
3
rd
edition that clean and
neat must see
appropriately. Normal
findings noted.
Body and Breath
Odor
> No unusual body
and breath odor.
>No body and breath
odor.
Kelley Health
3
rd
edition that no
unusual odors should be
assess. Normal findings
noted.
Obvious Sign of
Distress/Illness
> irritable
> with body malaise

>No signs of distress
>Healthy
Appearance
Kelley Health
3
rd
edition that the actual
findings in patient is a
signs of distress or
illness predispose to the
experience condition and
health status due to
present condition.
Certain findings noted
are not normal.
Attitude >expresses herself
to what she feels
>slightly
accommodating.
>Cooperative According to Webber &
Kelley Health
3
rd
edition that the
finding in patient is
normal because she can
express herself well and
Page 29

with cooperative
behavior.
Affect/Mood;
Appropriateness of
Response
>patient was slightly
irritable.
>Appropriate to
situation
Kelley Health
3
rd
edition that the
findings in patient is
abnormal due to signs of
distress or illness
predispose to the
experience condition and
health status due to
present condition.
Certain findings noted
are not normal.
Quantity and Quality
of Speech
> The voice can be
heard.
>Moderate pace
>Clear and
explicable
Kelley Health
3
rd
edition that clear and
explicable executes
chronological thought
processes.
Relevance and
Organization of
Thoughts
>Answers make
sense and concisely
> Conscious and
coherent
>The arrangements
of conversation are
comprehensible.
Kelley Health
3
rd
edition that the
arrangements of
conversation must be
comprehensible and can
be understood clearly.
Normal findings noted.
Page 30

D. Cephalocaudal Assessment:

Focused Assessment (Geriatrics)
Body Part Examined Actual Finding Normal Finding Clinical Significance
SKIN AND HAIR
Inspect and palpate
skin lesions. Wear
gloves when palpating
lesions. Note whether
lesions are flat or
raised, palpable or
nonpalpable. Also
note color, size, and
exudates, if any.
>no lesion palpated
>solar lentigenes are
noted in the skin
>hematoma on both
of the forearm
>edema on both lower
extremities (2+ pitting
for 7 seconds) 4mm
measurement
>with lacerated wound
in both crural area
>Jaundice with
associated hepatic
dysfunction
>with varicose vein at
posterior region of the
thigh

*Lentigenes: Hyper
pigmentation in sun
exposed areas
appears as brown,
pigmented, round or
rectangular patches
often called liver
spots.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the decrease in
the total number of
melanocytes, hyper
pigmentation occurs in
skin exposed to
sunlight, which
manifest as brown
pigmented areas
called lentigines that
are commonly
referred to as liver or
age spots
Hematoma formation
is an abnormal finding
due to the intravenous
insertion site and
medication.
Edema an abnormal
accumulation of fluid
in the interstitium,
Page 31

which are locations
beneath the skin or in
one or more cavities
of the body.
A wound is a break in
the outer layer of the
skin, called the
epidermis. Laceration
wounds in both crural
area are caused by
cuts or scrapes.
Jaundice is a
condition that causes
the skin, eyes, and
mucus membranes to
become yellow. It is a
disorder that results
from high levels of
bilirubin in the blood.
The condition itself is
not a fatal condition;
however, it can be a
sign of extensive liver
damage, which can be
life-threatening.
As you get older, your
veins can lose
elasticity causing
them to stretch. The
valves in your veins
may become weak,
Page 32

allowing blood that
should be moving
toward your heart to
flow backward. Blood
pools in your veins,
and your veins
enlarge and become
varicose. The veins
appear blue because
they contain
deoxygenated blood,
which is in the
process of being
recirculated through
the lungs.
Note color, texture,
integrity, and
moisture of skin and
sensitivity to heat or
cold.
>skin is dry
>with wrinkles and
tent to pinched

*Somewhat
transparent, pale, skin
with an overall
decrease in body hair
on lower extremities is
normal. Dry skin is
common.
*Skin may wrinkle and
tent when pinched.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding in
noted was normal
because dryness of
skin is cause of
decreased of
sebaceous gland
function due to aging.
Wrinkles are
prominent because
subcutaneous fat
decrease with age.
Inspect and palpate >60% black and 40% *Thinning and graying According to Weber
Page 33

hair and scalp. gray color with short
hair
>loss of hair pigment

of scalp, axillary, and
pubic hair are normal.
*Some women may
have mild hair growth
on upper lip.
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding noted
was normal because
loss of hair pigment is
the cause of graying.
NAIL
Inspect plate shape,
texture, bed color
and surrounding
tissue.
> Rounded Long and
thick nail shape of the
fingernails
> Soft tissue and
intact in skin with pink
tones
> slightly yellowish
and dull in bed color
both in fingernails and
toenails

* Round or square nail
shape according to
the cuticle.
* Nails are hard and
basically immobile.
* Pink tones should be
seen. Some
longitudinal ridging is
normal.
* Soft tissue and
without any lesions.

According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Toenails usually
thicken; but fingernails
may become thin and
split. They may also
appear yellowish and
dull. A thickened,
yellow toenail
indicates
onychomycosis, a
fungal infection.
Perform blanch test > Capillary refill at 3
seconds.
* Pink tones returns
immediately to
blanched nail beds
when pressure is
released.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding noted
was abnormal
because there is slow
(greater than 2 sec.)
capillary refill with
Page 34

those who have
respiratory or
cardiovascular
diseases that can
cause hypoxia.
HEAD AND NECK
Inspect head and
neck for symmetry
and movement.
Observe facial
expression.
>cervical curvature
> Normocephalic,
symmetric and oval in
shape
>Descent of the chin
>facial expression of
the patient was
irritable.
*Atrophy of face and
neck muscle
*Reduced range of
motion of head and
neck
*Shortening of neck
due to vertebral
degeneration and
development of
buffalo humpat top
of cervical vertebrae.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the cervical
curvature may
increase because of
kyphosis of the spine.
Moreover, fat may
accumulate around
the cervical vertebrae.
Descent of the chin is
a normal age-related
finding in elderly.
Slight Irritable is a
signs of distress or
illness predispose to
the experience
condition and health
status.
MOUTH AND THROAT
Inspect the lips for
symmetry of
contour, color,
texture, moisture,
>Symmetric in contour
>no lesion
>with dark lining in
upper and lower lips
*lips are smooth and
moist without lesions
or swelling. Pink lips
are normal in light-
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
Page 35

lesion >lips are dry

skinned clients as are
bluish or freckled lips
some dark-skinned.
that the
Dryness of lips is due
to dehydration.
Dark lining of lips is
due to excessive
consumption of
caffeine and
dehydration can all
contribute to the
darkening of the lips.
Inspect the gums
and buccal mucosa
for color and
consistency.
>decreased saliva
production
>gums and mucosa
are pink and without
swelling, bleeding, or
lesions.
*Decreased salivary
gland secretions are
commonly seen in the
elderly client.
*Gums and mucosa
should be pink and
without swelling,
bleeding, or lesions.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the findings noted
was normal,
decreased in saliva
production with aging.
However, the major
cause of xerostomia
(dry mouth) in the
elderly is from using
medications that have
anticholinergic effects.
Because saliva has
anti-bacterial, anti-
fungal, and tooth-
cleansing properties,
decreased production
may promote dental
caries.
Page 36

If the client is wearing
dentures, inspect
them for fit. Then ask
the client to remove
them for the rest of
the oral examination.
> with dentures
>no teeth at all (upper
and lower)

*Resorption of gum
ridge commonly
results in poorly fitting
dentures.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that it was considered
normal to lose your
teeth as you grew old.
But if you have
missing teeth, you
lose the ability to
chew on food and stay
healthy.
Dentures should be
removed before the
mouth is examined.
Dentures increase risk
of oral candidiasis and
resorption of the
alveolar ridges.
Inflammation of the
palatal mucosa and
ulcers of the alveolar
ridges may result from
poorly fitting dentures.
Examine the tongue.
Observe symmetry
and size.
> The tongue is color
light pink, moist, and
symmetric.

*The tongue should
be pink and moist.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the tongue must
be in the midline and
with no discharges
Page 37

found.
Observe the client
swallowing food or
fluids.
>slow motion in eating
or in swallowing the
food

*A mild decrease in
swallowing ability is
normal.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that in older adults,
esophageal motility is
slower and more
disorganized, giving
rise to dysphagia, a
swallowing
dysfunction involving
the transfer of a bolus
of food from the
mouth to the stomach.
NOSE AND SINUSES
Inspect the nose for
color and
consistency
>color is same with
the face
> symmetric in
appearance
>not inflamed but
intact
*Nose and nasal
passages are not
inflamed, and skin and
mucus membranes
are intact.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that nose may seem
more prominent on
face because of loss
of subcutaneous fat.
Evaluate the sense of
smell. Have the client
close the eyes and
smell a common
substance, such as
mint, lemon or soap.
>slow detection of the
odor

*Client has slightly
diminished sense of
smell and ability to
detect odors.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that olfactory function
gradually decreased
with aging and may
Page 38

lead to a decreased
ability to detect odors.
Diminish smell may
also lead to a decline
in appetite.
Test nasal patency by
asking the client to
breathe while blocking
one nostril at a time.
>able to breath in both
sided nose while
blocking one nostril at
a time

*Client can breathe
with reasonable ease
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that normally the
patient will be able to
exhale through the
unoccluded nares.
Nasal obstruction is
present if the patient
is unable to exhale
through the nares.
Normal with the age of
the patient
Palpate the frontal
and maxillary sinuses
for consistency and to
elicit possible pain
>no tenderness in
palpating and crepitus

*Area is free of lesions
and pain
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that negative pain in
sinuses during
percussion indicates
absence of
discomforts.
EYES AND VISION
Inspect eyes,
eyelids, eyelashes,
>periorbital darkening
edema
*The skin around the
eyes becomes thin,
According to Weber
and Kelly- Health
Page 39

and conjunctiva.
Also observe eye and
conjunctiva for
dryness, redness,
tearing, or increased
sensitivity to light and
wind
>with wrinkles
>eyelids easily close
>eyelashes turn
outward
and wrinkles appear
normally with age.
*Eyelids close easily,
and eyelashes turn
outward.
*Client may have
some dryness
resulting from
diminished tear
production that occurs
with aging.
Assessment in
Nursing; 3
rd
edition
that eyelids skin is the
thinnest skin of the
body, it tends to
stretch over time. In
the upper eye lid, this
stretch skin may limit
the peripheral field of
vision and may
produce a feeling of
heaviness and tired
appearance. In the
lower eyelid, bags
form.
Periorbital darkening
edema due to sleep
deprivation -
Interrupted sleep
cycles are common
causes of eye
puffiness. And
normal aging - As a
person grows older,
the skin around the
eyes becomes thinner
and may swell or
droop. Further a
gradual and generally
permanent increase in
the size of the
Page 40

suborbicularis oculi fat
pad along with the
thinning and
weakening of the
overlying musculature
contributes to the
apparent distention of
the lower eye lids.
Inspect the cornea
and lens. Also ask
the client when he or
she last had an eye
and vision
examination.
> slightly grayish ring
around the iris
>vision acuity of the
patient has same
grade in left and right
eyes (4.00)
>Last
opthalomoscopic
examination: Jan.
2013

*An arcus senilis, a
cloudy or grayish ring
around the iris, and
decreased pigment in
iris are age-related
changes.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding in
client ; Age-related
macular degeneration
(AMD) is an eye
disease affecting the
macula, the center of
the light sensitive
retina at the back of
the eye, causing loss
of central vision.
Although small, the
macula is the part of
the retina that allows
us to see fine detail
and colors. While
macular degeneration
causes changes in
central vision,
Page 41

peripheral or side
vision remains
unaffected.
Grayish ring around
the iris of eyes or
called arcus senilis is
results from
cholesterol deposits in
or hyalinosis of the
corneal stroma, and
may be associated
with ocular defects or
with familial
hyperlipidemia. It is
common in the
apparently healthy
middle aged and
elderly.
Inspect the pupils.
With a penlight or
similar device, test
papillary reaction to
light
>pupils are slowly
constricts
*Overall decrease in
size of pupil and
ability to dilate in dark
and constrict in light
may occur with
advanced age; this
result in poorer night
vision and decreased
tolerance to glare.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the muscles that
work to regulate the
size of the pupils
weaken with age. The
pupils become
smaller, react more
sluggishly to light, and
dilate more slowly in
the dark. Therefore,
Page 42

people older than 60
may find that objects
are not as bright, that
they are dazzled
initially when going
outdoors (or when
facing oncoming cars
during night driving),
and that they have
difficulty going from a
brightly light
environment to a
darker one. These
changes may be
particularly
bothersome when
combined with the
effects of a cataract.
Test vision. Ask the
client to read from a
newspaper or
magazine. Use only
room lighting for the
initial reading. Use
task lighting for a
second reading.
>not able to read due
to no available
reading glass

*Impaired near vision
is indicative of
presbyopia
(farsightedness), a
common finding in
older adults. Also
common are light
decreases in
peripheral vision and
difficulty in
differentiating blues
from greens.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Presbyopia is the
loss of the ability to
clearly see close
objects or small print.
It is a normal process
that happens slowly
over a lifetime, but
you may not notice
any change until
Page 43

around age 40.
Presbyopia is often
corrected with reading
glasses and contacts.
EARS AND HEARING
Inspect the external
ear. Observe shape,
color, and hair growth.
Also look for lesions
or drainage.
>same color with the
skin
>no odor and ear is
clean
> minimal amount of
cerumen
>slightly moist
>lesions-free
.>hair in ear was
slightly coarser
*Hairs may become
coarser and thicker in
the external ear,
especially in men.
*Earlobes may be
pendulous.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that structural
changes in the outer
ear begin in middle
adulthood. The
earlobes elongate,
and the pinna
increases in length
and width. The hairs
become coarser.
Cerumen production
decreases leading to
dryness and the
increased tendency
toward impaction.
Perform the voice-
whisper test, a
functional examination
to detect obvious
(conversational)
hearing loss.
Instruct the client to
put a hand over one
>patient repeats or
hear the word whisper
to her in 3 out of 5
words.
> slightly cannot hear
well

*The inability to hear
high-frequency
sounds or to
discriminate a variety
of simultaneous sound
results from
degeneration of the
hair cells of the inner
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that hearing loss
associated with aging
is called presbycusis.
It involves the
Page 44

ear and to repeat the
sentence you say.
Stand approximately 2
feet away from the
client and whisper a
sentence.
ear and is called
presbycusis.
diminished ability to
hear high-frequency
sounds and is due to
degeneration in the
hair cells of the inner
ear.
THORAX AND LUNGS
Inspect shape of
thorax. Note
respiratory rate,
rhythm, and quality
of breathing.
>Respiratory Rate:
(August 01, 2013)
10pm: 21 cpm
12mn: 20 cpm
04am: 21 cpm

(August 02, 2013)
10pm: 20 cpm
12mn: 22 cpm
04am: 20 cpm

>DOB when lying on
flat surface

*Increased in normal
respiratory rate of 16
to 25 .
*Increased reliance on
diaphragmatic
breathing and
increased work of
breathing related to
the anatomic changes
in the costal cartilage,
respiratory muscles,
and lung tissue.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the Normal
breathing is quiet and
unlabored. If it is
labored, it is important
to note respiratory
effort.
Orthopnea is due to
increased distribution
of blood to the
pulmonary circulation
while recumbent, but
usually can be
attribute to a more
fundamental cause.
Percuss lung tones
as you would in a
younger adult.
>resonant sound
>symmetric

*In general, the
normal sound to
percussion is the
same in an older adult
as it is in a younger
adult-resonant.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that air-filled lungs
create a resonant
Page 45

*However, in the
presence of structural
changes such as
kyposis or slight barrel
chest, resonance may
increase.
sound.
Auscultate lung
sounds as you
would in a younger
adult.
> crackles noted in
the left 3
rd
and 4
th

intercostals space
>with clear mucous in
respiratory tract

*Vesicular sounds
should be heard over
all areas of air
exchange. However,
because lung
expansion maybe e
diminished, it may be
necessary to
emphasize taking
deep breaths with the
mouth open during the
exam. This may be
very difficult for those
with dementia.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding in
client is abnormal
because
Rhonchi and rales
(crackles) may
indicate a number of
respiratory diseases
such as pneumonia,
bronchitis or
bronchiolitis.
HEART AND BLOOD VESSELS
Blood Pressure
Take blood pressure
to detect actual or
potential orthostatic
hypotension and,
therefore, the risk
for falling. Measure
pressure with the
client lying, sitting and
standing positions.
>Blood Pressure:
(August 01, 2013)
10pm: 140/80 mmHg
12mn: 140/80 mmHg
04am: 130/80 mmHg

(August 02, 2013)
10pm: 130/80 mmHg
12mn: 130/80 mmHg
04am: 130/80 mmHg
*An elderly persons
baroreceptor
response to positional
changes is slightly
less efficient.
*Blood pressure
increases as elasticity
decreases in arteries
with proportionately
greater increase in
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Prehypertension
is a systolic pressure
range of 120 to 139
and a diastolic
pressure range of 80
to 89. Diagnosis with
Page 46

Also measure pulse
rate. Have the client
lie down for 5 min;
take the blood
pressure; at 1 min,
take blood pressure
and pulse after client
is sitting and again at
1 min after client
stands.
-If dizziness occurs,
instruct client to sit a
few minutes before
attempting to stand up
from a supine ore
reclining position.
-Any client with
blood pressure
exceeding 160/90
mmHg should be
referred to the health
care provider for
follow up.

systolic pressure
resulting in a widening
of pulse pressure.
prehypertension
provides an
opportunity to work
hard-through physical
activity, diet, and
possibly medication-to
reduce blood pressure
to a healthy level.
Within four years of
diagnosis with
prehypertension, one
in three adults ages
35 to 64 will develop
definite high blood
pressure. One in two
adults over age 65 will
develop definite high
blood pressure.

Exercise Tolerance
Measure activity
tolerance. Evaluate,
either by reviewing
results of stress
testing or by
observing the clients
ability to move from
>evident activity
intolerance

*The maximal heart
rate with exercise is
less than in a younger
person. The heart rate
will also take longer to
return to its pre-
exercise rate.
*Normally the rise in
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that most activity
intolerance is related
to generalized
weakness and
Page 47

sitting to standing
position or to flex and
extend fingers rapidly.
pulse rate should be
no greater than 10 to
20 beats/min. the
pulse rate should
return to the baseline
rate within 2 minutes.
debilitation secondary
to acute or chronic
illness and disease
especially apparent in
elderly patients. The
aging process itself
causes reduction in
muscle strength and
function, which can
impair the ability to
maintain activity.
Activity intolerance
may also be related to
factors such as
obesity,
malnourishment, side
effects of medications
(e.g., Beta-blockers),
or emotional states
such as depression or
lack of confidence to
exert one's self.
Pulses
Determined
adequacy of blood
flow by palpating the
arterial pulses in all
locations (carotid,
brachial, radial,
femoral, and
popliteal, posterior
>Pulse Rate:
(August 01, 2013)
10pm: 59 bpm
12mn: 62 bpm
04am: 60 bpm

(August 02, 2013)
10pm: 64 bpm
12mn: 62 bpm
*Proximal pulses may
be easier to palpate
due to loss of
supporting
surrounding tissue.
However, distal lower
extremity pulses
maybe more difficult o
feel or even
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that while your pulse
rate may vary a bit as
you age, this range
changes only 1 to 2
beats a minute over
Page 48

tibial, and dorsalis
pedis) for strength
and quality.
04am: 63 bpm

nonpalpable. The
dorsalis pedis pulse is
absent in
approximately 20% of
older persons.
the years, and returns
to the 66 to 69 beat
baseline for women
65 years or older in
above-average
condition.
Inspect and palpate
veins while client is
standing.
>patient cannot stand
well due to her
edematous leg.

*Prominent, bulging
veins are common.
*Varicosities are
considered a problem
only if ulcerations,
signs of
thrombophlebitis, or
cords are present.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the Cords are
nontender, palpable
veins having a rubber
tubing consistency.
Heart
Inspect and palpate
the precordium
> Normal respiratory
>no tenderness
> no apical impulses
*The precordium is
still and without thrills,
heavens, or visible,
palpable pulsations
(noted exception may
be the apex of the
heart if close to the
surface)
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that no pulsation
should be palpated.
Auscultate heart
sounds.
>S1 is loud heard at
apex while S2 is
loader heard at base.
>normal heart sound
>no heart murmurs
heard

*Extra heart sounds
(low intensity,
systolic murmur and
an S4) result from
normal age-related
calcification of heart
valves and vessels
and fibrotic changes in
the heart muscle.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that there should be
no heart murmur or
any abnormalities
heard sounds in the
heart.
Page 49

BREAST
Inspect and palpate
breast and axillae.
When viewing axillae
and contour of
breasts, assist a client
with arthritis to raise
the arms over the
head. Do this gently
and without force and
only if it is not painful
for the client.
>The patient refused
to inspect her breast.
*The breast of elderly
women are often n
described as
pendulous due to the
atrophy of breast
tissue and supporting
tissue and the forward
thrust of the client
brought about by
kyphosis.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Breast can be a
variety of sizes and
somewhat round and
pendulous. One
breast may normally
be larger than the
other.
The pigmentation on
the areola varies to
the race and health
state condition.
Nipples are usually
everted, but they may
inverted or flat.
If the breast is
pendulous, assist the
client to lean slightly
so the breast hang
away from the chest
wall, enabling you to
best observe
symmetry and form.
*Decrease in fat
composition and
increase in fibrotic
tissue may make the
terminal ducts feel
more fibrotic and
palpable as linear,
spoke-like strands.
*Nipples may retract
due to loss in
musculature. Unlike
nipple retraction due
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the aged breasts,
particularly in women,
are often described as
pendulous. This is
because fat and
elastic tissue
decrease and the
existing tissue
Page 50

to a mass, nipples
retracted because of
aging can be everted
with gentle pressure.
become more fibrotic.
Overall, breast tissue
mass declines with
aging.
Inspect skin under
breast.
*Skin is intact without
lesions or rashes.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that no discharge
should be present or
noted.
ABDOMEN
Nutritional Status
Elderly clients typically
report gastrointestinal
problems related not
only to elimination but
also to diet and
nutrition. Therefore,
measure and record
the clients height and
weight, noting weight
changes and
problems with
swallowing or
chewing.
>Height: 157.48 cm
>Weight: 63.2 kg
>BMI=25.48
Obese Grade I
(WHO Classification)
Obese I (Asia-Pacific
Classification)
>slow movement in
swallowing or chewing
>DIET: Low Salt, Low
Fat Diet with Fluid
Restriction of less
than 1000 mL
*Antral cells and
intestinal villi atrophy,
and gastric production
of hydrochloric acid
decreases with age.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the Elderly
become vulnerable to
malnutrition owing to
inappropriate dietary
intake, poor economic
status and social
deprivation.

Body Mass Index
(BMI) is estimated
according to the
formula BMI = weight
(kg)/height (m)
2
. BMI
results of less than
18.5 are classified as
underweight, 18.5
Page 51

24.9 as normal,
25.029.9 as
overweight, and over
30.0 as obese (Health
Canada 2003).
Hydration Status
Because muscle mass
decreases and fatty
tissues increase, the
elderly client is at
increased risk for
dehydration. Evaluate
hydration status as
you would nutritional
status. Begin with
accurate serial
measurements of
weight, careful review
of laboratory test
findings (serial serum
sodium level, and
urine-specific gravity),
and a 2-3 day dairy of
fluid intake and
output.
>Weight: 63.2 kg
>URINE: Specific
Gravity=1.015 (normal
range 1.005-1.025)

>Input and Output:
(10pm-6am shift)
July 31, 2013
INTAKE
Oral: 210 cc
IV: 300 cc
TOTAL=510 mL
OUTPUT
Urine: 700 cc
Vomitus: 0
Stool: 0
TOTAL= 700 mL

August 01, 2013
INTAKE
Oral: 100 cc
IV: 90 cc
TOTAL= 190 mL
OUTPUT
Urine: 300 cc
Vomitus: 0
*Normal findings
include stable weight
and stable mental
status.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Fluid intake of
fewer than 1500 mL
daily (excluding
cafferine-containing
beverages) is a
possible indicator of
dehydration. Fluid
requirements for older
persons without
cardiac or renal
disease are
approximately 30
mL/kg of body weight
per day.
Page 52

Stool: 0
TOTAL= 300 mL

August 02, 2013
INTAKE
Oral: 120 cc
IV: 90 cc
TOTAL= 210 mL
OUTPUT
Urine: 500 cc
Vomitus: 0
Stool: 0
TOTAL= 500 mL

Motility
Assess GI motility
and auscultate
bowel sounds.
>25 sounds per
minute

*5-30 sounds/min is
heard.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding in
client in
GI Motility is in the
normal range.

Inspect and percuss
abdomen in same
manner as for
younger adults.
> Inspection: cirrhotic
ascites in the
abdomen-measured
of 100 centimeter
(Aug. 02)
>Protuberant
Abdomen
Previous waistline: 32
*Liver, pancreases,
and kidneys normally
decrease in size, but
the decrease is not
generally appreciable
upon physical
examination
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that Cirrhotic ascites
forms as the result of
a particular sequence
of events.
Page 53

inches(1 month prior
to admission)
>Percussion: dullness
sound heard
Development of portal
hypertension is the
first abnormality to
occur. As portal
hypertension
develops, vasodilators
are locally released.
These vasodilators
affect the splanchnic
arteries and thereby
decrease the effective
arterial blood flow and
arterial pressures. The
precise agent(s)
responsible for
vasodilation is a
subject of wide
debate; however,
most the recent
literature has focused
on the likely role of
nitric oxide.
Abnormal dullness is
heard over a
distended ascites on
percussion.
Movements of a fluid
wave against the
resting hands suggest
large amounts of fluid
are present (ascites).
Page 54

Palpate the bladder.
(Ask client to empty
bladder before
examination.) If the
bladder is palpable,
percuss from
symphysis pubis to
umbilicus. If the client
is incontinent, post
void residual content
may also need to be
measured.
>bladder is not
palpable

*Empty bladder is not
palpable or
percussable.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that distended bladder
is palpated as a
smooth, round, and
somewhat firm mass
extending as far as
the as the umbilicus. It
may further validated
by dull percussion
tones.
GENITALIA
Female
Inspect external
genitalia. Assist the
client into the
lithotomy position.
Inspect the urethral
meatus and vaginal
opening.
to inspect her external
genital.
*Pubic hair is usually
sparse, and labia are
flattened. Clitoris is
decreased in size.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that because
reproduction and
breast tissue depend
on estrogen for
growth, many atrophic
changes begin in
women at
menopause. The size
of the ovaries, uterus,
and cervix decreases.
The pubic hair
becomes more brittle.
Loss of elasticity and
Page 55

reduced vaginal
lubrication from
diminishing levels of
estrogen can cause
dyspareunia (painful
intercourse).
Ask the client to
cough, while in the
lithotomy position.
genital.
*No leakage of urine
occurs.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
no leakage of urine
occurs.
Test for prolapsed.
Ask the client to bear
down while you
observe the vaginal
opening.
genital.
*No prolapsed is
evident.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that
a stretching of the
vaginal tissue, the
thinning of tissue,
aging with estrogen
deficiency at
menopause, and
breaks in the fascia of
the vagina has a very
little is known about
the physical and
biological
manifestations of
prolapse. A potential
Page 56

cure at the molecular
level appears unlikely.
Perform a pelvic
examination. Put on
disposable gloves and
use a small speculum
if the vaginal opening
has narrowed with
age. Use lubrication
on speculum and
hand because natural
lubrication is
decreased.
genital.
*Vaginal secretion
should be white, clear,
and odorless.
*The vaginal
epithelium is thinner,
drier, and may be pale
and shiny. Atrophic
changes are
intensified by
infrequent intercourse.
*Because the ovaries,
uterus, and cervix
shrink with age, the
ovaries may not be
palpable.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that for pelvic
examination, patients
who lack hip mobility
may lie on their left
side. Postmenopausal
reduction of estrogen
leads to atrophy of the
vaginal and urethral
mucosa; the vaginal
mucosa appears dry
and lacks rugal folds.
The ovaries should
not be palpable 10
year after menopause;
palpable ovaries
suggest cancer.
Patients should be
examined for
evidence of prolapse
of the urethra, vagina,
cervix, and uterus.
They are asked to
cough to check for
urine leakage and
intermittent prolapse.
Page 57

Test pelvic muscle
tone. Ask the woman
to squeeze muscle
while the examiners
finger is in the vagina.
Assess perineal
strength by turning
fingers posterior to the
perineum while the
woman squeezes
muscles in the vaginal
area.
genital.
*The vaginal wall
should constrict
around the examiners
finger, and the
perineum should feel
smooth.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that vaginal wall
should be constrict
around the perineum.
ANUS AND RECTUM
Inspect the anus and
rectum.
to inspect her anus
and rectum.
*The anus is darker
than the surrounding
skin.

According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
that the finding in
client is normal
because if there is
Bluish, grapelike
lumps at the anus are
indication of
haemorrhoids .
Put on gloves to
palpate the anus and
rectum.
to inspect her anus
and rectum.
*No masses or
swelling should be
palpated.
According to Weber
and Kelly- Health
Assessment in
Nursing; 3
rd
edition
no abnormalities
found while
Page 58

performing the
procedure.
EXTREMITIES
Lower extremities
I: size, contour, and
movements

>with grade 2 pitting
edema in both legs of
the patient
> slight pitting/4 mm,
disappears rapidly.
>with wound in both
crural area
>with varicose vein at
posterior region of the
thigh

*equal in size
*same contour with
prominence of joints.
*no involuntary
movements.
*No edema.
*Color is even
According to Webber
& Kelley Health
Assessment in
Nursing 3
rd
edition,
Edema an abnormal
accumulation of fluid
in the interstitium,
which are locations
beneath the skin or in
one or more cavities
of the body.
A wound is a break in
the outer layer of the
skin, called the
epidermis. Laceration
wounds in both crural
area are caused by
cuts or scrapes.
As you get older, your
veins can lose
elasticity causing
them to stretch. The
valves in your veins
may become weak,
allowing blood that
should be moving
toward your heart to
flow backward. Blood
Page 59

pools in your veins,
and your veins
enlarge and become
varicose. The veins
appear blue because
they contain
deoxygenated blood,
which is in the
process of being
recirculated through
the lungs.
MUSCULOSKELETAL
INSPECTION

>has slightly difficulty
when moving
> Muscle strength-
appear weak during
routine testing

*No difficulty in
moving
According to Webber
& Kelley Health
Assessment in
Nursing 3
rd
edition
that the findings were
determined if there
are no signs of
disproportion.
Difficulty when moving
may suggests the
disease condition and
the pain felt by the
patient examined.
Sarcopenia (a
decrease in muscle
mass) is a common
age-related finding. It
is insignificant unless
accompanied by a
Page 60

decline or change in
function.
NEUROLOGIC
INSPECTION

>the client is not tense
during the
examination but
irritable due to her
condition
*cooperative actively

According to Webber
& Kelley Health
Assessment in
Nursing 3
rd
edition
that patient is no
neurological problem.
SENSORY FUNCTION
INSPECTION

>can distinguish 6
given colors
(red,green,yellow,
white, black,blue)
>numbness in both
lower extremities
>diminished sense of
smell
>altered sense of
taste
>decrease sense of
hearing
>decrease sense of
sight

*can distinguish 6
given colors
According to Webber
& Kelley Health
Assessment in
Nursing 3
rd
edition
that Aging has limited
effects on sensation.
Many elderly patients
report numbness,
especially in the feet.
It may result from a
decrease in size of
fibers in the peripheral
nerves, particularly
the large fibers.
In many elderly
people, sense of smell
is diminished because
they have fewer
olfactory neurons,
Page 61

have had numerous
upper respiratory
infections, or have
chronic rhinitis.
However, asymmetric
loss (loss of smell in
one nostril) is
abnormal. Taste may
be altered because
the sense of smell is
diminished or because
patients take drugs
that decrease
salivation.
Visual and hearing
deficits may result
from abnormalities in
the eyes and ears
rather than in nerve
pathways.
Page 62

SYSTEM: SUBJECTIVE DATA
Neurologic System Medyo makakalimutin na din ako, siguro
dahil narin sa katandaan, as verbalized by
the patient.
Pulmonary System Kaya dinala namin siya dito gawa ng
nahihirapan nga daw siyang huminga, as
verbalized by the patients sibling.
Cardiovascular System Mataas nga yung BP ko pero di naman
sumasakit yung batok ko, as verbalized
by the patient.
Hematologic System Yung pasa ko sa kamay ay dahil sa
injection ng mga gamot, as verbalized by
the patient.
Immunologic System Di naman sakitin si nanay ngayon lang
talaga, as verbalized by her daughter.
Gastrointestinal System Dito sa ospital nakaka dalawa o tatlong
beses siyang dumumi sa isang lingo
tapos., as stated by the patients sibling.
Okay lang naman yung mga kinakain ko
bawal lang talaga ako sa mamantika at
maalat, as verbalized by the patient.
Renal System Bago siya maospital nakaka limang beses
siyang umihi sa isang araw, medyo dilaw
yung kulay ng ihi niya pero dito
nakamonitor at nakacatheter siya as
verbalized by the sibling.
Musculoskeletal System May umaalalay sakin kapag tumatayo
ako o kaya kapag magbabanyo ako, kasi
nga nanghihina ako, as stated by the
patient.

Review of System
Page 63

Reproductive System Natapos yung menstruation ko mga 40s
na ako, tapos wala naman akong nagging
komplikasyon nung nagbuntis at
manganak, as verbalized by the patient.
Integumentary System Medyo madilaw si nanay, as verbalized
by the patients daughter.

HEMATOLOGY REPORT
Date: July 22, 2013
Time: 07:16 am
TEST NORMAL
FINDINGS
ACTUAL
FINDING
S
ANALYSIS
White Blood
Cells
5-10 x
10^3u/L
4.36 WBCs, which are produced in the bone
marrow, are an important part of your
immune system and your bodys natural
weapon to fight off bacteria, viruses and other
germs. When you have a low white blood cell
count you may be immunosuppressed, which
means that you are more vulnerable to
potentially serious infections that do not go
away or are hard to treat.
Red Blood
Cells
4.0-5.5x
10^6u/L

3.70 Abnormalities in lipid metabolism that occur in
liver disease can lead to changes in red blood
cell size and shape. Macrocytosis may be an
initial finding, followed by the development of
target cells and acanthocytes (spur cells)
These changes are associated with abnormal
cholesterol loading of the red blood cell
membrane. Cholesterol loading of the lipid
bilayer acts to restrict the mobility of integral
membrane proteins. The erythrocytes are
therefore unable to undergo normal
deformation as they transit the
vasculature.When cholesterol loading is
sufficiently severe, passage of such red blood
cells through the microcirculation of the
spleen leads to cytoskeletal damage and the
irreversible deformation of the red blood cell
noted morphologically as spur cells
Hemoglobin 120-160
G/L
106.0 G/L Low hemoglobin levels are usually due to
nutritional deficiency especially iron
deficiency.
Hematocrit 37.0-47.0% 31.1 The value of the hematocrit is dependent
upon the number of RBC's. If the Hct is
abnormal, then the RBC count is possibly
Page 65

abnormal. Low hematocrit may indicate:
Anemia (various types)
Blood loss (hemorrhage)
Bone marrow failure (for example, due to
radiation, toxin, fibrosis, tumor)
Hemolysis (RBC destruction) related to
transfusion reaction
Leukemia
Malnutrition or specific nutritional
deficiency
Multiple myeloma
Rheumatoid arthritis

MCV M: 81-
99femtoliter
s
84.1

The MCV (mean corpuscular volume) is an
index of the size of the RBCs. Increase or
decrease in both MCV levels are used to
determine vitamin B6 or mineral (copper or
iron) deficiencies and/or excess B12 and folic
acid.
MCH 27-31
pitogram
28.6 MCH is the average amount of hemoglobin
inside an RBC

MCHC 33.0-
37.0g/dL
34.1 The MCHC is dependent upon the size of the
RBC as well as the amount of hemoglobin in
each cell. Certain diseases and anemias will
alter the RBC count and/or the amount of
hemoglobin in the cell. The MCHC is not as
dependent upon the RBC count as the other
tests in this section.
Neutrophil 50-70% 82.0 Neutrophils are essential in protecting the
body against disease and infections by
removing and destroying some types of
bacteria, wastes, foreign substances, and
other cells. Damage or inflammation of
tissues can also lead to a high neutrophil
count.
Lymphocyte
s
25-40% 7.8 Low levels of lymphocytes can lead to
conditions such as cancer or an infection in a
person. On the other hand, low levels of
lymphocytes (T cell or B cells) can indicate a
less threatening condition (than cancer) of
infection.
Monocyte 3.0-11.0% 9.4 Normal relative (%) content of monocytes.
Monocytes are a type of white blood cell and
Page 66

are part of the innate immune
system of vertebrates including
all mammals (humans included), birds, reptile
s, and fish. Monocytes play multiple roles in
immune function. Such roles include: (1)
replenish resident macrophages and dendritic
cells under normal states, and (2) in response
to inflammation signals, monocytes can move
quickly (approx. 812 hours) to sites of
infection in the tissues and divide/differentiate
into macrophages and dendritic cells to elicit
an immune response
Eosinophils 1.0-4.0% 0.0 A lower-than-normal eosinophil count may be
due to:
Alcohol intoxication
Over production of certain steroids in
the body (such as cortisol)

Basophils 0.0-1.0% 0.0

Normal relative (%) content of basophils .
Basophils are a type of white blood cell that
are involved in inflammatory reactions in your
body, especially those related to allergies and
asthma. When stimulated, basophils release
histamine and other enzymes that can lead
to inflammation, bronchoconstriction,
and asthma symptoms.
RDW-CV 11.5-14.5% 20.4 RDW- CV is the relative distribution width of
red blood cells by volume, coefficient of
variation. MCV goes hand in hand with red
blood cell distribution width (RDW) in terms of
anemia and other hematology disorders, and
the values of both are influenced by each
other. Elevated RDW and normal MCV is
associated with the following conditions:
Early iron, vitamin B12, or folate deficiency
Dimorphic anemia (for example, iron and
folate deficiency)
Sickle cell disease
Chronic liver disease
Myelodysplastic syndrome
Platelet
Count
150-450 x
16^3 u/L
152 A platelet count is a test to measure how
many platelets you have in your blood.
Platelets help the blood clot. They are smaller
Page 67

than red or white blood cells.

HEMATOLOGY REPORT
Date: July 27, 2013
Time: 07:40 am

TEST NORMAL
FINDINGS
ACTUAL
FINDING
S
ANALYSIS
White Blood
Cells
5-10 x
10^3u/L
weapon to fight off bacteria, viruses and other
germs. When you have a low white blood cell
count you may be immunosuppressed, which
means that you are more vulnerable to
potentially serious infections that do not go
away or are hard to treat.
Red Blood
Cells
M: 4.0-5.5x
10^6u/L

3.77 Abnormalities in lipid metabolism that occur in
liver disease can lead to changes in red blood
cell size and shape. Macrocytosis may be an
initial finding, followed by the development of
target cells and acanthocytes (spur cells)
These changes are associated with abnormal
cholesterol loading of the red blood cell
membrane. Cholesterol loading of the lipid
bilayer acts to restrict the mobility of integral
membrane proteins. The erythrocytes are
therefore unable to undergo normal
deformation as they transit the
vasculature.When cholesterol loading is
sufficiently severe, passage of such red blood
cells through the microcirculation of the
spleen leads to cytoskeletal damage and the
irreversible deformation of the red blood cell
noted morphologically as spur cells
Page 68

Hemoglobin M: 120-160
G/L
111.0 G/L Low hemoglobin levels are usually due to
deficiency.
Hematocrit 37.0-47.0% 32.3 The value of the hematocrit is dependent
Leukemia
deficiency
Multiple myeloma

MCV M: 81-
99femtoliter
s
85.7 The MCV (mean corpuscular volume) is an
iron) deficiencies and/or excess B12 and folic
acid.
MCH 27-31
pitogram
inside an RBC

MCHC 33.0-
37.0g/dL
34.4 The MCHC is dependent upon the size of the
RBC as well as the amount of hemoglobin in
each cell. Certain diseases and anemias will
alter the RBC count and/or the amount of
hemoglobin in the cell. The MCHC is not as
dependent upon the RBC count as the other
tests in this section.
Page 69

count.
Lymphocyte
s
conditions such as cancer or an infection in a
person. On the other hand, low levels of
infection

Monocyte 3.0-11.0% 07.4

Normal relative (%) content of monocytes.
all mammals (humans included), birds, reptile
s, and fish. Monocytes play multiple roles in
immune function. Such roles include: (1)
replenish resident macrophages and dendritic
cells under normal states, and (2) in response
to inflammation signals, monocytes can move
quickly (approx. 812 hours) to sites of
infection in the tissues and divide/differentiate
into macrophages and dendritic cells to elicit
an immune response
Eosinophils 1.0-4.0% 0.0

A lower-than-normal eosinophil count may be
due to:


are involved in inflammatory reactions in your
body, especially those related to allergies and
asthma. When stimulated, basophils release
histamine and other enzymes that can lead
other. RDW- CV is the relative distribution
Page 70

width of red blood cells by volume, coefficient
of variation. MCV goes hand in hand with red
other. Elevated RDW and normal MCV is
associated with the following conditions:
folate deficiency)
Sickle cell disease

Platelet
Count
150-450 x
16^3 u/L
44 A lower-than-normal number of platelets
(thrombocytopenia) may be due to:
Cancer chemotherapy
Certain medications
Disseminated intravascular
coagulation (DIC)
Hemolytic anemia
Hypersplenism
Idiopathic thrombocytopenic
purpura (ITP)
Leukemia
Massive blood transfusion
Prosthetic heart valve
Thombotic thrombocytopenic purpura
(TTP)
Celiac disease
Vitamin K deficiency

Page 71

HEMATOLOGY REPORT
Date: July 28, 2013
Time: 04:48 am

TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
White Blood
Cells
5-10 x
10^3u/L
weapon to fight off bacteria, viruses and
other germs. When you have a low white
blood cell count you may be
immunosuppressed, which means that you
are more vulnerable to potentially serious
infections that do not go away or are hard to
treat.
Red Blood
Cells
M: 4.0-5.5x
10^6u/L

3.53 Abnormalities in lipid metabolism that occur
in liver disease can lead to changes in red
blood cell size and shape. Macrocytosis may
be an initial finding, followed by the
development of target cells and
acanthocytes (spur cells) These changes
are associated with abnormal cholesterol
loading of the red blood cell membrane.
Cholesterol loading of the lipid bilayer acts
to restrict the mobility of integral membrane
proteins. The erythrocytes are therefore
unable to undergo normal deformation as
they transit the vasculature.When
cholesterol loading is sufficiently severe,
passage of such red blood cells through the
microcirculation of the spleen leads to
cytoskeletal damage and the irreversible
deformation of the red blood cell noted
morphologically as spur cells
Hemoglobin 120-160 G/L 103.0 G/L Low hemoglobin levels are usually due to
deficiency.
Hematocrit 37.0-47.0% 29.7% The value of the hematocrit is dependent
Page 72

Leukemia
deficiency
Multiple myeloma

MCV : 81-
99femtoliter
s
84.1

The MCV (mean corpuscular volume) is an
iron) deficiencies and/or excess B12 and
folic acid.
MCH 27-31
pitogram
inside an RBC

MCHC 33.0-
37.0g/dL
34.7 The MCHC is dependent upon the size of
the RBC as well as the amount of
hemoglobin in each cell. Certain diseases
and anemias will alter the RBC count and/or
the amount of hemoglobin in the cell. The
MCHC is not as dependent upon the RBC
count as the other tests in this section.
count.
Lymphocyte
s
conditions such as cancer or an infection in
a person. On the other hand, low levels of
infection

Page 73

Monocyte 3.0-11.0% 7.8

Normal relative (%) content of monocytes.
all mammals (humans included), birds, reptil
es, and fish. Monocytes play multiple roles
in immune function. Such roles include:
(1) replenish
resident macrophages and dendritic
cells under normal states,
(2) in response to inflammation signals,
monocytes can move quickly (approx. 812
hours) to sites of infection in the tissues and
divide/differentiate into macrophages and
dendritic cells to elicit an immune response
Eosinophils 1.0-4.0% 0.0 A lower-than-normal eosinophil count may
be due to:


are involved in inflammatory reactions in
your body, especially those related to
allergies and asthma. When stimulated,
basophils release histamine and other
enzymes that can lead
blood cell distribution width (RDW) in terms
of anemia and other hematology disorders,
and the values of both are influenced by
each other. RDW- CV is the relative
distribution width of red blood cells by
volume, coefficient of variation. MCV goes
hand in hand with red blood cell distribution
width (RDW) in terms of anemia and other
hematology disorders, and the values of
both are influenced by each other. Elevated
RDW and normal MCV is associated with
Page 74

the following conditions:
folate deficiency)
Sickle cell disease

Platelet
Count
150-450 x
16^3 u/L
55 A lower-than-normal number of platelets
(thrombocytopenia) may be due to:
Cancer chemotherapy
Certain medications
Disseminated intravascular
coagulation (DIC)
Hemolytic anemia
Hypersplenism
Idiopathic thrombocytopenic
purpura (ITP)
Leukemia
Massive blood transfusion
Prosthetic heart valve
Thombotic thrombocytopenic purpura
(TTP)
Celiac disease
Vitamin K deficiency

Page 75

PROTIME/ PARTIAL THROMBOPLASTIN TIME
Date: July 21, 2013
Time: 6:00 am
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
PROTIME: 11-15.5 secs. 26.2 secs.
Control: --- 13.3 secs.
Activity: --- 32.4%
INR: --- 2.60
APPT: 22-35 secs. 61.4 secs.
Control: --- 31.3 secs.

According to http//webmd.com, Prothrombin Time 100% or 1216 seconds
Prothrombin time may be prolonged in liver disease. It will not return to normal with
vitamin K in severe liver cell damage. A partial thromboplastin time (PTT) test measures
how long it takes for a clot to form in a blood sample. A clot is a thick lump of blood that
the body produces to seal leaks, wounds, cuts, and scratches and prevent excessive
bleeding. The blood's ability to clot involves platelets (also called thrombocytes) and
proteins called clotting factors. Platelets are oval-shaped cells made in the bone
marrow. Most clotting factors are made in the liver. When a blood vessel breaks,
platelets are first to the area to help seal off the leak and temporarily stop or slow the
bleeding. But for the clot to become strong and stable, the action of clotting factors is
required.

Page 76

CLINICAL CHEMISTRY
Date: July 27, 2013

TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Creatinine 44-80 umol/L 120.97umol/L High creatinine
levels often indicate
serious kidney
damage, which may
be due to low blood
flow, shock, cancer
or a life-threatening
infection. Conditions
that often produce
high creatinine
levels consist of
urinary tract
blockages, cardiac
problems, thyroid
problems or
dehydration.

Potassium 3.6-5.5 mmol/L 3.91mmol/L Potassium is
another of the
important
electrolytes in the
body. Our body is
quite sensitive to
abnormal levels of
potassium. The
finding in the test of
Potassium is
normal.

Page 77

CLINICAL CHEMISTRY
Date: July 30, 2013
Time: 10:20 am
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Total Protein 84-93 o/L 62.02 A total serum
protein test
measures the total
amount of protein in
the blood. It also
measures the
amounts of two
major groups of
proteins in the
blood: albumin and
globulin
Albumin 35-52 o/L 17.60 Albumin is the major
form of protein in
the
blood. Abnormal
albumin levels are
associated with
protein issues.
Low blood albumin
levels
(hypoalbuminemia)
can be caused by:
Liver
disease; cirrhosi
s of the liver is
most common
Excess
excretion by
the kidneys (as
in nephrotic
syndrome)
Excess loss in
bowel (protein-
losing
enteropathy,
e.g., Mntrier's
Page 78

disease)
Burns (plasma
loss in the
absence of skin
barrier)
increased
vascular
permeability or
decreased
lymphatic
clearance)
Acute disease
states (referred
to as a
negative acute-
phase protein)
Mutation
causing
analbuminemia

Globulin 23-35 o/L 44.50
High serum globulin
causes can be
anything starting
from really serious
cases such as
cancer to nothing
more than a little
dehydration, it
causes the blood to
thicken, causing the
concentration of its
elements.
A/G ratio 1.1-2.5 0.39 A low A/G ratio can
be due to
overproduction of
gamma-globulin due
to an autoimmune
disease. A low A/G
ratio can also be
due to a low
albumin level
caused by liver
Page 79

cirrhosis or kidney
nephritis.

CLINICAL CHEMISTRY
Date: August 1, 2013
Time: 11:00 am

TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Potassium 3.6-5.5 mmol/L 2.27 mmol/L

Low potassium levels
(hypokalaemia) can cause
weakness as cellular processes
are affected. Low potassium
causes are:
Dehydration, diarrhoea, excessive
sweating (hyperhidrosis) and
laxative abuse are common
causes of low potassium levels.
It may also be caused by a lack of
potassium in the diet; however,
this is uncommon.
Other causes
include medicines that affect the
amount of potassium in the body,
such as water pills.

Page 80

CLINICAL CHEMISTRY
Date: August 1, 2013
Time: 8:40 pm
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Creatinine 44-80 umol/L 112.88 umol/L Creatinine level temporarily
increase if dehydrated, have a
low blood volume, eat a large
amount of meat or take certain
medications. The dietary
supplement creatine can have the
same effect.
Potassium 3.6-5.5 mmol/L 1.88 mmol/L
Low potassium levels
(hypokalaemia) can cause
weakness as cellular processes
are affected. Causes of it are:
Dehydration, diarrhoea, excessive
sweating (hyperhidrosis) and
laxative abuse are common
causes of low potassium levels.
It may also be caused by a lack of
potassium in the diet; however,
this is uncommon.
Other causes
include medicines that affect the
amount of potassium in the body,
such as water pills.

Page 81

BODY FLUID EXAMINATION
July 30, 2013
Quali/Quanti Analysis (CSF/Body)
Microscopic:
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Fluid Normally clear Pleural Fluid CSF should be clear as the
water.
Color Clear and
Colourless
Yellow The yellow appearance is
caused by red blood
cells entering the CSF during
the bleeding. The cells are
eventually destroyed by the
body, releasing their oxygen-
carrying molecule heme,
which is degraded
by enzymes into the yellow-
green pigmentbilirubin.
Character Clear Cloudy If the CSF looks cloudy, it
could mean there is an
infection or a build up of white
blood cells or protein.

Specific Gravity 1.0061.009 1.010 specific gravity (SG) were
determined at two or more
temperatures between 23 and
37 C for 15 samples of normal
human cerebrospinal fluid
(CSF) and CSF mixed with
tetracaine, and for tetracaine
solutions commonly used for
spinal anesthesia
pH 7.35-7.45 8.0 High CSF pH may
causes dizziness and syncope

Microscopic:
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
WBC count 0-5mm
3
144/cumm Increased white blood cells in the
CSF may be a sign of
Page 82

meningitis, acute infection,
beginning of a chronic illness,
tumor, abscess, stroke, or
demyelinating disease (such as
multiple sclerosis) and intracranial
hemorrhage
Lymphocytes Approximately
70%
96%
Lymphocytes normally make up 25
percent or more of the total WBC count.
There are two forms: B cells, which make
antibodies, and T cells, which recognize
and remove foreign substances.

RBC count Not present 3,600/cumm Red blood cells in the CSF sample
may be a sign of bleeding into the
spinal fluid or the result of a
traumatic lumbar puncture.
Normally, there are no red blood
cells in the CSF unless the needle
passes through a blood vessel on
route to the CSF.

Chemistry:
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Sugar 16.7 mmol/L 9.33 mmol/L Chemical
meningitis,
inflammatory
conditions,
subarachnoid
hemorrhage,
and
hypoglycemia
also cause
hypoglycorrha
chia (low
glucose level
in CSF)
Protein 0.18 to 0.58 g/L 31 g/L Elevated CSF
protein is seen
Page 83

in infections,
intracranial
hemorrhages,
multiple
sclerosis,
Guillain Barr
syndrome,
malignancies,
some
endocrine
abnormalities,
certain
medication
use, and a
variety of
inflammatory
conditions

FECALYSIS EXAMINATION
Date: July 22, 2013
Time: 11:00 am
TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Color Brown Brown Color such as clay
or white may
indicate bile
pigment or
diagnostic study
using barium
Consistency Form, Soft,
Semisolid, Moist
Soft Hard and dry
consistency may
cause of
dehydration:
decreased intestinal
motility resulting
from lack of fiber in
diet, lack of
Page 84

exercise, emotional
upset and laxative
abuse
Occult Blood Not present Negative
blood in stool can
refer to multiple
conditions:
Melena, with
more blackish
appearance,
originating in
upper parts of
the
gastrointestinal
tract
Hematochezia,
with more red
color, originating
in latter parts of
the
gastrointestinal
tract

Microscopic Negative No ova or parasite
seen
Parasites may
indicated infection

URINALYSIS
Date: July 26, 2013
Time: 07:10 pm

TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Macroscopic
Color
Yellow

Dark Yellow Some drugs can
change the color of
the urine. Normal
Page 85

urine color is a light
yellow to a dark
amber color.
Inflammation may
also cloud the urine
as well as other
pathological
conditions.
Transparency Clear Slightly Turbid The turbidity of the
urine is gauged
subjectively and
reported as clear,
slightly cloudy,
cloudy, opaque or
flocculent. Normally
fresh urine is clear
to very slightly
cloudy. Excess
turbidity results from
the presence of
suspended particles
in the urine
Reaction Slightly Acidic(4.5 -
8.0. Average is 6.0)

Acidic A highly acidic urine
pH occurs in:
Respiratory
diseases in which
carbon dioxide
retention occurs and
acidosis develops

Specific Gravity 1.005 to 1.025

1.015 Specific Gravity will
increase with the
amount of dissolved
particles
(concentrated) in it.
Specific gravity will
decrease when the
water content is
high and the
dissolved particles
are low (less
concentrated). Low
specific gravity
(<1.005) is
characteristic of
Page 86

diabetes insipidus,
nephrogenic
diabetes insipidus,
acute tubular
necrosis, or
pyelonephritis.
Fixed specific
gravity, in which
values remain 1.010
regardless of fluid
intake, occurs in
chronic
glomerulonephritis
with severe renal
damage. High
specific
gravity(>1.035)
occurs in nephrotic
syndrome,
dehydration, acute
glomerulonephritis,
heart failure, liver
failure, or shock.
Albumin none

+ 1 Albumin is a type of
protein found in
large amounts in the
blood. Because it is
a small molecule in
size, it is one of the
first proteins able to
pass through the
kidneys into the
urine when there
are kidney
problems. This
presence of small
amounts of albumin
in the urine is the
condition called
microalbuminuria.
Sugar none

Negative Sugar in urine is an
abnormal finding.
Normally, the kidney
filters blood in such
a way that it holds
on to blood sugar,
Page 87

keeping it in the
blood. No glucose
should be present in
the urine under
normal
circumstances.
Sugar can be found
in urine in
conditions where
the blood glucose
levels are high,
hyperglycemia, as
occurs with diabetes
mellitus.
Microscopic
Pus cells 0-5/hpf 2-3/hpf Finding a few pus
cells or white blood
cells (WBCs) in
urine is quite
normal. But too
many of them may
signal a problem
somewhere in
your urinary tract,
the commonest of
which is a urinary
tract infection (UTI).
Lab will usually
report the result as
number of cells
counted per high
power field of the
microscope (hpf) or
number of
WBCs/mL of urine.
Usually, 5 to 10 pus
cells/hpf or 105
WBCs/mL of urine
is considered
normal. A high
number of pus cells
in urine is called
pyuria. When a
large number of
WBCs are present
in urine, they may
Page 88

also be detected on
a urine dipstick test
for leukocyte
esterase.
RBC <5/hpf 0-1 /hpf Gross bleeding into
the urine is usually
obvious. On lab
exam of the urine,
numerous, many,
and gross are terms
used to describe the
amount of blood in
gross bleeding.
However, all
bleeding is not that
obvious. In order to
detect slower
bleeding and
inflammation in the
urinary tract, the
microscopic exam is
needed. In some
normal conditions, a
very few RBC's may
get into the urine.
When a level of
more than 3 RBC's
are found, a disease
condition is often
present. One of the
most common
causes of RBC's in
the urine, is
infection or
inflammation of the
urinary tract itself
(i.e., cystitis).
Trauma and several
other conditions
may also cause
bleeding into the
urine
Ephitelial cells --- Many Epithelial cells often
are present in the
urinary sediment.
Squamous epithelial
Page 89

cells are large and
irregularly shaped,
with a small nucleus
and fine granular
cytoplasm; their
presence suggests
contamination. The
presence of
transitional epithelial
cells is normal.
These cells are
smaller and rounder
than squamous
cells, and they have
larger nuclei. The
presence of renal
tubule cells
indicates significant
renal pathology
(Figure 2).
Erythrocytes are
best visualized
under high-power
magnification.
Dysmorphic
erythrocytes, which
have odd shapes
because of their
passage through an
abnormal
glomerulus, suggest
glomerular disease.
Amorphous Urates -- Few Uric acid crystallizes
in the orthorombic
system. Uric acid
crystals can appear
under several
shapes. The classic
crystals are thin
rhombus shaped
plates with more or
less eroded tops.
The other forms are
the hexagonal plate,
the needle and the
rosette. Uric acid
Page 90

crystals usually
have a
characteristic yellow
color. The intensity
of the color depends
on the thickness of
the crystal, thus
very thin plates
seem colorless,
while the massive
crystals have a
color that tends to
be brown. Under
polarized light, uric
acid shows a
polarization color,
and with thicker
crystals, a series of
concentric black
lines. The color
variation seen under
polarized light is
quite typical of uric
acid. With rare
exceptions, uric acid
crystals are of little
clinical value and
represent a
punctual situation.
Mucus Threads none Few Mucus forming cells
are found scattered
all over the urinary
tract from the
ascending section
of the Loop of Henle
in the kidney
tubules (the filtering
system of the
kidney) to the
bladder.
Consequently,
mucus can originate
from the kidney or
from the lower
urinary tract. Mucus
originating from the
Page 91

kidney is made of
Tamm-Horsfall
protein. This
explains the
frequent association
of mucus threads
and casts. In elderly
patients, mucus is a
frequent finding and
seems to originate
from the lower
urinary tract.

URINALYSIS
Date: July, 25, 2013
Time: 09:30 am

TEST NORMAL
FINDINGS
ACTUAL
FINDINGS
ANALYSIS
Macroscopic
Color
Yellow

Dark Yellow Some drugs can
change the color of
the urine. Normal
urine color is a light
yellow to a dark
amber color.
Inflammation may
also cloud the urine
as well as other
pathological
conditions.
Transparency Clear Slightly Turbid The turbidity of the
urine is gauged
subjectively and
reported as clear,
slightly cloudy,
cloudy, opaque or
flocculent. Normally
fresh urine is clear
to very slightly
cloudy. Excess
turbidity results from
Page 92

the presence of
suspended particles
in the urine
Reaction Slightly Acidic(4.5 -
8.0. Average is 6.0)

Acidic A highly acidic urine
pH occurs in:
Respiratory
diseases in which
carbon dioxide
retention occurs and
acidosis develops

Specific Gravity 1.005 to 1.025

1.015 Specific Gravity will
increase with the
amount of dissolved
particles
(concentrated) in it.
Specific gravity will
decrease when the
water content is
high and the
dissolved particles
are low (less
concentrated). Low
specific gravity
(<1.005) is
characteristic of
diabetes insipidus,
nephrogenic
diabetes insipidus,
acute tubular
necrosis, or
pyelonephritis.
Fixed specific
gravity, in which
values remain 1.010
regardless of fluid
intake, occurs in
chronic
glomerulonephritis
with severe renal
damage. High
specific
gravity(>1.035)
occurs in nephrotic
syndrome,
Page 93

dehydration, acute
glomerulonephritis,
heart failure, liver
failure, or shock.
Albumin None

Negative Albumin is a type of
protein found in
large amounts in the
blood. Because it is
a small molecule in
size, it is one of the
first proteins able to
pass through the
kidneys into the
urine when there
are kidney
problems. This
presence of small
amounts of albumin
in the urine is the
condition called
microalbuminuria.
Sugar None

Negative Sugar in urine is an
abnormal finding.
Normally, the kidney
filters blood in such
a way that it holds
on to blood sugar,
keeping it in the
blood. No glucose
should be present in
the urine under
normal
circumstances.
Sugar can be found
in urine in
conditions where
the blood glucose
levels are high,
hyperglycemia, as
occurs with diabetes
mellitus.
Microscopic Microscopic
Pus cells 0-5/hpf 0-1/hpf Finding a few pus
cells or white blood
cells (WBCs) in
urine is quite
Page 94

normal. But too
many of them may
signal a problem
somewhere in
your urinary tract,
the commonest of
which is a urinary
tract infection (UTI).
lab will usually
report the result as
number of cells
counted per high
power field of the
microscope (hpf) or
number of
WBCs/mL of urine.
Usually, 5 to 10 pus
cells/hpf or 105
WBCs/mL of urine
is considered
normal. A high
number of pus cells
in urine is called
pyuria. When a
large number of
WBCs are present
in urine, they may
also be detected on
a urine dipstick test
for leukocyte
esterase.
RBC <5/hpf 0-2 /hpf Gross bleeding into
the urine is usually
obvious. On lab
exam of the urine,
numerous, many,
and gross are terms
used to describe the
amount of blood in
gross bleeding.
However, all
bleeding is not that
obvious. In order to
detect slower
bleeding and
inflammation in the
Page 95

urinary tract, the
microscopic exam is
needed. In some
normal conditions, a
very few RBC's may
get into the urine.
When a level of
more than 3 RBC's
are found, a disease
condition is often
present. One of the
most common
causes of RBC's in
the urine, is
infection or
inflammation of the
urinary tract itself
(i.e., cystitis).
Trauma and several
other conditions
may also cause
bleeding into the
urine. Of course, the
nurse will carefully
observe the patient
with gross bleeding.
Ephitelial cells Occasional Epithelial cells often
are present in the
urinary sediment.
Squamous epithelial
cells are large and
irregularly shaped,
with a small nucleus
and fine granular
cytoplasm; their
presence suggests
contamination. The
presence of
transitional epithelial
cells is normal.
These cells are
smaller and rounder
than squamous
cells, and they have
larger nuclei. The
presence of renal
Page 96

tubule cells
indicates significant
renal pathology

RADIOLOGY REPORT
Date: July 28, 2013

ROENTGENOLOGICAL FINDINGS:

Examination done: Chest AP (Port)
Chest; The latest study since 7-20-2013 shows development of pleural effusion at
the left
The rest is unchanged.

According to Brunner and Suddarths Textbook of Medical-Surgical Nursing
twelfth edition, Pleural effusion is a collection of fluid in the pleural space is rarely a
primary disease process; it is usually secondary to other diseases. Normally, the pleural
space contains a small amount of fluid (5 to 15 mL) which acts a lubricant that allows
the pleural surfaces to move without friction. Pleural effusion may be a complication of
heart failure, TB, pneumonia, Cirrhosis with Ascites, pulmonary infections, nephrotic
syndrome, connective tissue disease, pulmonary embolus, and neoplastic tumors.

Ultrasound Report
Date: July 30, 2013
Sonographic Findings:

Massive Pleural effusion is noted in the left hemithorax measuring 684.3 cc
No pleural effusion noted at the right hemithorax
Analysis: According to http//:webmed.com, Cirrhosis with ascites (hepatic
hydrothorax) are common in Right-sided effusions in 70%; left-sided in 15%; and
Page 97

bilateral in 15%.
Ascitic fluid migration to the pleural space through diaphragmatic defects causes
Pleural effusion. Effusion present in about 5% of patients with clinically apparent
ascites.

Page 98

Case Management
Page 99

Drug Features Mechanism of
Actions
Indication Contraindication Adverse Effects Nursing Responsibility
Generic
Name:
FUROSEMIDE
Brand Name:
Lasix
Classification:
Loop Diuretic
Dosage:
20 mg
Route:
IV
Frequency:
OD
Form:
Liquid
Color:
White

Inhibits the
reabsorption of
sodium and
chloride from
the loop of
Henle and
distal renal
tubule.
Increases
renal excretion
of water,
sodium,
chloride,
magnesium,
potassium, and
calcium.
Effectiveness
persists in
impaired renal
function.
Edema
in CHF,
nephritic
syndrome,
ascites,
caused by
hepatic
disease,
hepatic
cirrhosis.

Hypersensitivity
Cross-
sensitivity with
thiazides and
sulfonamides may
occur
Hepatic coma
or anuria
Some liquid
products may
contain alcohol,
avoid in patients
with alcohol
intolerance.
CNS: blurred
vision, dizziness,
headache,
vertigo.
EENT: hearing
loss, tinnitus.
CV: hypotension.
GI: anorexia,
constipation,
diarrhea, dry
mouth,
dyspepsia,
nausea,
pancreatitis,
vomiting.
GU: excessive
urination.
Derma:
photosensitivity,
pruritis, rash.
Assess fluid status. Monitor
daily weight, intake and output
ratios, amount and location of
edema, lung sounds, skin
turgor, and mucous
membranes. Notify physician or
other health care professional if
thirst, dry mouth, lethargy,
weakness, hypotension, or
oliguria occurs.
Monitor blood pressure and
pulse before and during
administration. Monitor
frequency of prescription refills
to determine compliance in
patients treated for
hypertension.
Assess patients receiving
digoxin for anorexia, nausea,
vomiting, muscle cramps,
A. Pharmacologic Intervention
Page 100

Endo:
hyperglycemia,
hyperuricemia. F
and E:
dehydration,
hypocalcemia,
hypochloremia,
hypokalemia,
hypomagnesemia
, hyponatremia,
hypovolemia,
metabolic
alkalosis.
Hema: anemia,
Agranulocytosis,
hemolytic anemia,
leukopenia,
thrombocytopenia
MS: muscle
cramps.
Neuro:
paresthesia.
paresthesia, and confusion.
Patients taking digoxin are at
increased risk of digoxin toxicity
because of the potassium-
depleting effect of the diuretic.
Potassium supplements or
potassium-sparing diuretics
may be used concurrently to
prevent hypokalemia.
Assess patient for tinnitus
and hearing loss. Audiometry is
recommended for patients
receiving prolonged high-dose
IV therapy. Hearing loss is most
common after rapid or high-
dose IV administration in
patients with decreased renal
function or those taking other
ototoxic drugs.
Assess for allergy to
sulfonamides.
Lab Test Considerations:
Page 101

Misc: fever,
increased BUN,
nephrocalcinosis
Monitor electrolytes, renal and
hepatic function, serum
glucose, and uric acid levels
before and periodically
throughout therapy. Commonly
serum potassium. May cause
serum sodium, calcium, and
magnesium concentrations.
May also cause BUN, serum
glucose, creatinine, and uric
acid levels.
Page 102

Drug Features Mechanism
of Actions
Indication Contraindication Adverse Effects Nursing Responsibility
Generic
Name:
HYDROCORTI
SONE
Brand Name:
Hydrocortone
Classification:
Short acting
glucocorticoids
Dosage:
100mg
Route:
IV
Frequency:
q5
Form:
Liquid
Color:
White
Decrease
inflammation
by
suppressing
migration of
polymorphonu
clear
leukocytes
and fibroblast
and reversing
increased
capillary
permeability
and lysosomal
stabilization
(systemic),
antipruritic,
anti-
inflammatory.
Severe
inflammati
on, septic
shock,
adrenal
insufficienc
y,ulcerative
colitis,
collegen
disorder,
pruritus.
Psychosis,
hypersensitivity,
idiopathic
thrombocytopenia
, acute
glomerulonephriti
s, fungal infection.
AIDS, TB.
CNS: depression,
euphoria, headache,
increased intracranial
pressure (children
only), personality
changes, psychoses,
restlessness.
EENT: cataracts,
increased intraocular
pressure.
CV: hypertension.
GI: PEPTIC
ULCERATION,
anorexia, nausea,
vomiting.
Derma: acne,
decreased wound
healing, ecchymoses,
fragility, hirsutism,
petechiae.
Assess patient for signs
of adrenal insufficiency
(hypotension, weight loss,
weakness, nausea,
vomiting, anorexia,
lethargy, confusion,
restlessness) before and
periodically during therapy.
Monitor intake and
output ratios and daily
weights. Observe patient
for peripheral edema,
steady weight gain,
rales/crackles, or dyspnea.
Notify health care
professional if these occur.
Cerebral Edema: Assess
patient for changes in level
of consciousness and
headache during therapy.
Page 103

Endo: adrenal
suppression,
hyperglycemia. F and
E: fluid retention (long-
term high doses),
hypokalemia,
hypokalemic alkalosis.
Hema:
THROMBOEMBOLIS
M, thrombophlebitis.
Metabolism: weight
gain.
MS: muscle wasting,
osteoporosis, aseptic
necrosis of joints,
muscle pain.
Misc: cushingoid
appearance (moon
face, buffalo hump),
increased susceptibility
to infection.
Monitor serum electrolytes
and glucose. May cause
hyperglycemia, especially
in persons with diabetes.
May cause hypokalemia.
Patients on prolonged
therapy should routinely
have CBC, serum
electrolytes, and serum and
urine glucose evaluated.
May WBCs. May cause
hyperglycemia, especially
in persons with diabetes.
May serum potassium
and calcium and serum
sodium concentrations.

Page 104

of Actions
Indication Contraindication Adverse
Effects
Nursing Responsibility
Generic Name:
POTASSIUM
CHLORIDE
Brand Name:
KALIUM
DURULES
Classification:
Potassium
sparing diuretic
Dosage:
100mg
Route:
Oral
Frequency:
TID
Form:
Tablet
Color:
Orange
Needed for
adequate
transmission
of nerve
impulses and
cardiac
contraction,
renal function,
intracellular
ion
maintenance.
Prevention
and
treatment
for
hypokalemia
Renal disease,
severe hemolytic
disease,
Addisons
disease,
hyperkalemia,
acute
dehydration,
extensive tissue
breakdown
CNS:
confusion,
restlessness,
weakness.
CV:
ARRHYTHMIA
S, ECG
changes.
GI: abdominal
pain, diarrhea,
flatulence,
nausea,
vomiting
GU: oliguria
INTEG: rash
Assess for signs and
symptoms of hypokalemia
(weakness, fatigue, U wave on
ECG, arrhythmias, polyuria,
polydipsia) and hyperkalemia
(see Toxicity and Overdose).
Monitor pulse, blood pressure,
and ECG periodically during IV
therapy.
Monitor serum potassium before
and periodically during therapy.
Monitor renal function, serum
bicarbonate, and pH. Determine
serum magnesium level if patient
has refractory hypokalemia;
hypomagnesemia should be
corrected to facilitate
effectiveness of potassium
replacement. Monitor serum
Page 105

chloride because hypochloremia
may occur if replacing potassium
without concurrent chloride.
Toxicity and Overdose:
Symptoms of toxicity are those of
hyperkalemia (slow, irregular
heartbeat; fatigue; muscle
weakness; paresthesia;
confusion; dyspnea; peaked T
waves; depressed ST segments;
prolonged QT segments;
widened QRS complexes; loss of
P waves; and cardiac
arrhythmias).
Treatment includes
discontinuation of potassium,
administration of sodium
bicarbonate to correct acidosis,
dextrose and insulin to facilitate
passage of potassium into cells,
calcium salts to reverse ECG
effects (in patients who are not
Page 106

receiving digoxin), sodium
polystyrene used as an exchange
resin, and/or dialysis for patient
with impaired renal function.

Page 107

Actions
Effects
Generic
Name:
PROPRANOL
OL
Brand Name:
NovoPranol
Classification:
Antihypertensiv
e
Dosage:
40mg
Route:
Oral
Frequency:
BID
Form:
Tablet
Color:
Blue
Blocks
stimulations of B-
adrenergic
receptor within
vascular smooth
muscle;
producechronotr
opic, inotropic
activity
(decrease SA
node discharge,
increase
recovery time),
slows conduction
of AV node,
decrease heart
rate, which
decreases
oxygen
consumption in
Chronic
stable
angina
pectoris,
hypertension
, MI,
dysrhtmias,
cyanotic
spells
related to
hypertrophic
subaortic
stenosis.
Hypersensitivity
to this drug, heart
failure,
cardiogenic
shock,
bronchospatic
disease, sinus
bradycardia, CHF
CNS: fatigue,
weakness,
anxiety,
dizziness,
drowsiness,
insomnia,
memory loss,
mental
depression,
mental status
changes,
nervousness,
nightmares.
EENT: blurred
vision, dry
eyes, nasal
stuffiness.
Resp:
bronchospasm
, wheezing.
Monitor blood pressure and
pulse frequently during dose
adjustment period and
periodically during therapy.
Abrupt withdrawal of
propranolol may precipitate life-
threatening arrhythmias,
hypertension, or myocardial
ischemia. Drug should be
tapered over a 2 week period
before discontinuation. Assess
patient carefully during tapering
and after medication is
discontinued. Consider that
patients taking propranolol for
non-cardiac indications may
have undiagnosed cardiac
disease. Abrupt discontinuation
or withdrawal over too-short a
period of time (less than 9
Page 108

myocardium. CV:
ARRHYTHMI
AS,
BRADYCARDI
A, CHF,
PULMONARY
EDEMA,
orthostatic
hypotension,
peripheral
vasoconstricti
on.
GI:
constipation,
diarrhea,
nausea.
GU: erectile
dysfunction,
decreased
libido.
Derm: itching,
rashes.
days) should be avoided.
Patients receiving
propranolol IV must have
continuous ECG monitoring and
may have pulmonary capillary
wedge pressure (PCWP) or
central venous pressure (CVP)
monitoring during and for
several hours after
administration. .
Assess for orthostatic
hypotension when assisting
patient up from supine position.
Monitor intake and output
ratios and daily weight. Assess
patient routinely for evidence of
fluid overload (peripheral
edema, dyspnea,
rales/crackles, fatigue, weight
gain, jugular venous distention).
Angina: Assess frequency
and characteristics of anginal
Page 109

Endo:
hyperglycemia
hypoglycemia
(increased in
children).
MS: arthralgia,
back pain,
muscle
cramps.
Neuro:
paresthesia.
Misc: drug-
induced lupus
syndrome.
attacks periodically during
therapy.
PTSD: Assess frequency of
symptoms (flashbacks,
nightmares, efforts to avoid
thoughts or activities that may
trigger memories of the trauma,
and hypervigilance) periodically
throughout therapy.
May cause BUN, serum
lipoprotein, potassium,
triglyceride, and uric acid levels.
May cause ANA titers.
May cause or in blood
glucose levels. In labile diabetic
patients, hypoglycemia may be
accompanied by precipitous
of blood pressure. .
Toxicity and Overdose:
Monitor patients receiving beta
blockers for signs of overdose
Page 110

(bradycardia, severe dizziness
or fainting, severe drowsiness,
dyspnea, bluish fingernails or
palms, seizures). Notify
physician or other health care
professional immediately if
these signs occur.
Hypotension may be treated
with modified Trendelenburg
position and IV fluids unless
contraindicated. Vasopressors
(epinephrine, norepinephrine,
dopamine, dobutamine) may
also be used. Hypotension
does not respond to beta
agonists.
Glucagon has been used to
treat bradycardia and
hypotension.

Page 111

Actions
Effects
Generic
Name:
SPIRONOLAC
TONE
Brand Name:
ALDACTONE
Classification:
Potassium-
sparing diuretic
Dosage:
50mg
Route:
Oral
Frequency:
BID
Form:
Tablet
Color:
Yellow
Competes with
aldosterone at
receptor sites
in the distal
tube in the
renal system,
resulting in
excretion of
sodium
chloride, water
bicarbonate
and calcium;
potassium,
phosphate and
hydrogen are
retained.
Edema of
CHF,
hypetension,
diuretic-
induced
hypokalemia
, edema of
nephritic
syndrome,
liver cirrhosis
with ascites
Pregnancy D,
hypersensitivity,
anuria, severe
renal disease,
hyperkalemia
CNS:
dizzinessspi
ronolactone
only:
clumsiness,
headache.
CV:
arrhythmias
GI:
amiloride:
constipation
, nausea,
vomiting.
GU:
spironolacto
ne-: erectile
dysfunctiont
riamterene-:
nephrolithia
sis.
Monitor intake and output ratios
and daily weight during therapy.
If medication is given as an
adjunct to antihypertensive therapy,
monitor blood pressure before
administering.
Monitor response of signs and
symptoms of hypokalemia
(weakness, fatigue, U wave on
ECG, arrhythmias, polyuria,
polydipsia). Assess patient
frequently for development of
hyperkalemia (fatigue, muscle
weakness, paresthesia, confusion,
dyspnea, ECG changes, cardiac
arrhythmias). Patients who have
diabetes mellitus or kidney disease
and geriatric patients are at
increased risk of developing these
symptoms.
Page 112

Derma:
triamterene:
photosensiti
vity.
Endo:
hyperkalemi
a,
hyponatrem
ia.
Hema:
spironolacto
ne:
agranulocyt
osistriamter
ene-:
hemolytic
anemia,
thrombocyt
openia.
MS: muscle
cramps.
Misc:
Periodic ECGs are recommended
in patients receiving prolonged
therapy.
Lab Test Considerations: Serum
potassium levels should be
evaluated before and routinely
during therapy. Withhold drug and
notify physician or other health care
professional if patient becomes
hyperkalemic.
Monitor BUN, serum creatinine,
and electrolytes before and
periodically during therapy. May
cause serum magnesium, BUN,
creatinine, potassium, and urinary
calcium excretion levels. May also
cause sodium levels.
Discontinue potassium-sparing
diuretics 3 days before a glucose
tolerance test because of risk of
severe hyperkalemia.
Spironolactone may cause false
Page 113

allergic
reactions.

of plasma cortisol concentrations.
Spironolactone should be
withdrawn 4-7 days before test.
Monitor platelet count and total
and differential leukocyte count
periodically during therapy in
patients taking triamterene.

Page 114

Drug Features Indication Mechanisms of
Action
Contraindication Adverse Effects Nursing
Responsibilities
Generic name:
Omeprazole

Brand name:
Omepron

Classification:
Anti-
ulcer/Proton-
Pump Inhibitor

Dosage: 20 mg

Route: Oral

Frequency: OD
Form: Tablet

Color:
White
Symptomatic
gastroesopha
geal reflux
disease
(GERD)
without
esophageal
lesions
Short-term
therapy of
active benign
gastric ulcer
Erosive
esophagitis
Pathologic
hypersecretor
y conditions,
including
Zollinger-
Ellison
Inhibits proton
pump activity
by binding to
hydrogen-
potassium
adenosine
triphosphatase
, located at
secretory
surface of
gastric parietal
cells, to
suppress
gastric acid
secretion

Contraindicate
d in patients
with
hypersensitivity
to drug or its
components.
Use cautiously
in patients with
Bartter
syndrome,
hypokalemia,
and respiratory
alkalosis and in
patients on a
low-sodium
diet.
CNS:
headache,
dizziness,
asthenia
GI: abdominal
pain,
constipation,
diarrhea, dry
mouth,
flatulence,
nausea,
vomiting
Musculoskele
tal: back pain
Respiratory:
cough, upper
respiratory
tract infection
Skin: rash
Tell patient to
swallow tablets
whole and not to
open, crush or
chew them.
Instruct patient to
take drug at least
1 hour before
meals.
Caution patient to
avoid hazardous
activities if he
gets dizzy.
Page 115

syndrome
Duodenal
Ulcer (short-
term
treatment)
Helicobacter
pylori infection
and duodenal
ulcer disease,
to eradicate H.
pylori with
clarithromycin
and amoxicillin
(triple therapy)
Frequent
heartburn (2
or more days
a week)

Page 116

Action
Indications Contraindications Adverse Effects Nursing
Responsibilities
Generic Name:
Vitamin K1

Brand Name:
Phytonadione

Classification:
fat-soluble
vitamin

Dosage: 10
mg/ml

Route: IV

Frequency: BID

Form: Ampule
Color:
Pale yellow
Needed for
adequate blood
clotting.
Vitamin K
malabsorption,
hypoprothrombinemia,
prevention of
hypoprothrombinemia
caused by oral anti-
coagulants,
prevention of
hemorrhagic disease
of the newborn.
Hypersensitivity,
severe hepatic
disease, last few
week of
pregnancy.
CNS: headache,
brain damage
(large doses)
GI: nausea,
decrease liver
function tests
Hema: hemolytic
anemia,
hemoglobinuria,
hyperbilirubinemia
Integ: rash,
urticuria
Monitor for
bleeding,
pulse, and
blood
pressure.
Assess
nutritional
status: liver
(beef),
spinach,
tomatoes,
coffee,
asparagus
Assess for
bleeding or
bruising:
hematuria,
back tarry
stool,
hematemesis

Page 117

of Action
Indications Contraindications Adverse Effects Nursing
Responsibilities
Generic Name:
Albumin
(Normal Serum
5-25%)
Brand Name:
Albuminar 5%
Classification:
Blood derivative,
volume
expander
Dosage:
1000-2000 ml(5-
10 ml/min)
Route:
IV
Frequency:
OD
Form:
Liquid
Color:
Light Amber
Normal blood
protein;
maintains
plasma
osmotic
pressure and
is important in
maintaining
normal blood
volume.
Emergency
treatment of shock
due to burns,
trauma, surgery and
infections
Acute liver failure
(20% or 25%)
Hyperbilirubinemia
and erythroblastosis
fetalis: adjunct in
exchange
transfusion.
Contraindicated
with allergy to
albumin; severe
anemia cardiac
failure, normal
or increased
intravascular
volume current
use of
cardiopulmonar
y bypass
Use cautiously
with hepatic or
renal failure.
CV: hypotension,
heart failure,
pulmonary edema
after rapid
infusion
Hypersensitivity:
fever, chills,
changes in blood
pressure,
flushing, nausea,
vomiting, changes
in respiration,
rashes
Monitor blood
studies: Hct,
Hgb; if serum
protein
declines,
dyspnea,
hypoxemia
can result;
check for
decrease
blood
pressure,
erratic pulse,
respiration.
Monitor CVP:
pulmonary
wedge
pressure will
increase if
overload
occurs; I & O
Page 118

ratio: urinary
output may
decrease;
shortness of
breath,
anxiety and
respiratory
crackles.
Assess for
allergy: fever,
rash, itching,
chills, flushing
nausea,
vomiting.
Page 119

action
Indication Contraindication Side Effects Nursing
Responsibilities
Generic Name:
Acetylcysteine

BrandName:
Flumucil

Classification:
Mucolytic

Dosage: 60 mg

Route: oral

Frequency: BID

Form: tablet

Color: white

Acetylcysteine
solution is a
mucolytic. It works
by thinning out
mucus secretions,
making them
easier to move
through the lungs.
Treatment of
respiratory
affections
characterized by
thick and viscous
hypersecretions:
acute bronchitis,
chronic bronchitis
and its
exacerbations;
pulmonary
emphysema,
mucoviscidosis
and
bronchiectasis.
Known
hypersensitivity to
acetylcysteine. As
Acetylcystein
(Fluimucil)
granules and
tablets contain
aspartame, it is
contraindicated in
patients suffering
from
phenylketonuria.
GI: nausea,
vomiting, diarrhea,
heartburn,
dyspepsia, rectal
bleeding,
epigastric pain.
CNS: dizziness,
drowsiness,
lightheadedness,
asthenia
RESPI:
bronchospasm,
Others: urticarial
rash, pruritus,
flushing, a warm
feeling of the skin,
occasional
bronchospasm or
hypotension,
angioedema,
dyspnea,
Monitor
effectiveness
of therapy and
advent of
adverse/
allergic effects.
Instruct patient
in appropriate
use and
adverse effects
to report.

Page 120

action
Indication Contraindication Side Effects Nursing
Responsibilities
Generic Name:
Silymarin

Brand Name:
Legalon

Classification:
Liver supplement,
antioxidant
Dosage: 140 mg

Route: oral

Frequency: bid

Form: capsule

Color: brown
Hepatic protector.
It reduces the
turnover of
membrane
phospholipids and
stabilises the cell
membranes of
hepatocytes. It
has potent
antioxidant action
and prevents lipid
peroxidation
Supportive
treatment of
chronic
inflammatory
diseases of
the liver and
hepatic
cirrhosis.
Regenerate
liver cells
damaged by
alcohol or
drugs
Decongest the
liver (A liver
decongestant
stimulates bile
flow through
the liver and
gallbladder,
thus reducing
Hypersensitivity to
any component of
product.
GI: dyspepsia,
bloating, nausea,
diarrhea, stomach
upset

CNS:Weakness, H
eadache, Joint
pain,
Tell the
patient that
the drug may
be taken with
regard for
meals.

Page 121

stagnation and
preventing
gallstone
formation and
bile-induced
liver damage.)
Complement
the treatment
of viral
hepatitis
.
Page 122

Overview
Thoracentesis

Also known as thoracocentesis or pleural tap is an invasive procedure to
remove fluid or air from the pleural space for diagnostic or therapeutic purposes.
A cannula, or hollow needle, is carefully introduced into the thorax, generally
after administration of local anesthesia
Should be done in almost all patients who have pleural fluid that is 10 mm in
thickness on CT, ultrasonography, or lateral decubitus x-ray and that is new or of
uncertain etiology. In general, the only patients who do not require thoracentesis
are those who have heart failure with symmetric pleural effusions and no chest
pain or fever; in these patients, diuresis can be tried, and thoracentesis avoided
unless effusions persist for 3 days.
Thoracentesis and subsequent pleural fluid analysis often are not necessary for
pleural effusions that are chronic, have a known cause, and cause no symptoms.
Ultrasonography is helpful for identifying the site for thoracentesis when the
amount of pleural fluid is small, the fluid is loculated, or blind thoracentesis is
unsuccessful.
The most common causes of pleural effusions are cancer, congestive heart
failure,pneumonia, and recent surgery.
Page 123

Pleural fluid analysis is done to diagnose the cause of pleural effusion. Analysis
begins with visual inspection, which can
Distinguish bloody and chylous (or chyliform) from other effusions
Identify purulent effusions strongly suggestive of empyema
Identify viscous fluid, which is characteristic of some mesothelioma.

Indwelling Foley Catheter

A urinary catheter is a tube placed in the body to drain and collect urine from the
bladder.
An indwelling catheter collects urine by attaching to a drainage bag. A newer
type of catheter has a valve that can be opened to allow urine to flow out.
An indwelling catheter may be inserted into the bladder in two ways:
1. Most often, the catheter is inserted through the urethra. This is the tube that
carries urine from the bladder to the outside of the body.
2. Sometimes, the health care provider will insert a catheter into your bladder
through a small hole in your belly. This is done at a hospital or health care
provider's office.

An indwelling catheter has a small balloon inflated on the end of it. This prevents
the catheter from sliding out of your body. When the catheter needs to be
removed, the balloon is deflated.
Everyday care of catheter and drainage bag is important to reduce the risk of
infection. Such precautions include:
a. Cleansing the urethral area (area where catheter exits body) and the catheter itself.
b. Disconnecting drainage bag from catheter only with clean hands
c. Disconnecting drainage bag as seldom as possible.
Page 124

d. Keeping drainage bag connector as clean as possible and cleansing the drainage
bag periodically.
e. Use of a thin catheter where possible to reduce risk of harming the urethra during
insertion.
f. Drinking sufficient liquid to produce at least two liters of urine daily
g. Sexual activity is very high risk for urinary infections, especially for catheterized
women.

Nasal Cannula

The nasal cannula (NC) is a device used to deliver supplemental oxygen or
airflow to a patient or person in need of respiratory help.
This device consists of a lightweight tube which on one end splits into two prongs
which are placed in the nostrils and from which a mixture of air and oxygen flows.
The other end of the tube is connected to an oxygen supply such as a portable
oxygen generator, or a wall connection in a hospital via a flowmeter.
The cannula is generally attached to the patient by way of the tube hooking
around the patient's ears or by elastic head band.
The earliest, and most widely used form of adult nasal cannula carries 15 litres
of oxygen per minute.
Cannulae with smaller prongs intended for infant or neonatal use can carry less
than one litre per minute. Flow rates of up to 60 litres of air/oxygen per minute
can be delivered through wider bore humidified nasal cannula.
Oxygen therapy is the administration of oxygen at concentrations greater than
that in room air to treat or prevent hypoxemia (not enough oxygen in the blood).
Oxygen delivery systems are classified as stationary, portable, or ambulatory.
Oxygen can be administered bynasal cannula, mask, and tent. Hyperbaric
Page 125

oxygen therapy involves placing the patient in an airtight chamber with oxygen
under pressure.

Chest X-ray

is a painless, noninvasive test that creates pictures of the structures inside your
chest, such as your heart, lungs, and blood vessels.
They use ionizing radiation to create pictures of the inside of your body.
A chest x ray takes pictures of the inside of your chest. The different tissues in
your chest absorb different amounts of radiation.
A chest X-ray, which is almost always done to check for changes in the lungs
that may mean pneumonia and to look for other causes of your symptoms. But
an X-ray does not always show whether you have pneumonia, especially if it is
done when you first get sick. In some cases, the X-ray results may:
Suggest the type of organism (bacterial, viral, or fungal) causing
pneumonia.
Show complications of pneumonia.
Show conditions that may occur with pneumonia, such as fluid in the chest
cavity or a collapsed lung.
Reveal another condition, such as heart failure, lung cancer, or acute
bronchitis.

Page 126

B. Dietary Prescription/ Restriction
According to the doctors order, Patient R.P was maintained on Low Salt Low
Fat Diet and with fluid restriction of below 1L a day due to her abnormal accumulation of
fluid in the abdomen since admission.
C. Procedures
Oxygenation
Patient R.P was given an oxygen delivery system as a relief for breathing. The
patient was given oxygen inhalator via nasal cannula as needed prior to admission. The
nasal cannula delivers 10% to 40% at 4-5L per minute.
Intravenous Fluids
Patient R.P was given 1L of PNSS KVO to run for 8 hours upon admission, July
21, 2013 and was hooked at 6:45pm. Last IV fluid of PNSS no. 12 without incorporation
was given at July 31, 2013. When the above IVF was consumed, it was replaced with
No. 13 PNSS 90cc incorporated with medication of 20 meqs KCL to run for 2 hours and
was hooked August 01, 2013 at 10:00 pm in treating low blood levels of potassium
(hypokalemia) as doctors order. Intravenous fluid is necessary to supply fluid especially
to the elders with fluid restriction because the patient cannot attain enough nutrients for
her body.
Intravenous Catheterization
Patient R.P was catheterized with PNSS on her right metacarpal vein (July 21,
2013 started at 6:45pm). The IV line was infusing well and no air and back flow seen. It
was monitored and regulated on appropriate drops/min.
Blood Transfusion
The patient was undergone Blood Transfusion of 2 units of Packed Red Blood
Cells infused for 6 hours last July 22, 2013 due to low RBC count , low plasma volume
Page 127

and prolong APTT. Her blood type was B and Rh positive. The patient doesnt show any
allergic reaction.
Indwelling Foley Catheter
Patient R.P was inserted of Indwelling Foley Catheter July 23, 2013. The patient
had slightly orange in color urine and no blood was seen. The urine output was
recorded every end of the shift. The measurement of urine output was 300cc at August
1, 2013 and 500cc at August 2, 2013 in our 10pm-6am shift. The patient used to change
diapers 2-3 times a day and does perineal hygiene. Indications for IFC are sudden and
complete inability to void, need for immediate and rapid bladder decompression and
monitoring of intake and output.

Thoracentesis
Patient R.P undergone thoracentesis which an invasive procedure that remove
fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or
hollow needle, is carefully introduced into the thorax, generally after administration
of local anesthesia. This procedure is indicated when unexplained fluid accumulates in
the chest cavity outside the lung. Patient R.P was diagnosed of Pleural effusion and the
cause of it was cirrhosis with ascites because ascitic fluid migrates to the pleural space
through diaphragmatic. It was performed July 30, 2013 and the findings were yellowish
in color and cloudy in character, with specific gravity of 1.010; pH was 6.0; protein of 31
g/L and the volume was approximately 20mL.

Page 128

Overview
Anatomy and Physiology

Page 129

ANATOMY AND PHYSIOLOGY OF LIVER
The liver, the largest internal organ, is located in the upper right quadrant of the
abdominal cavity, just inferior to the diaphragm. It is partially surrounded by the ribs and
extends from the level of the fifth intercostals space to the lower margin of the ribs.

The liver is a roughly triangular organ that extends across the entire abdominal cavity
just inferior to the diaphragm. Most of the livers mass is located on the right side of the
body where it descends inferiorly toward the right kidney. The liver is made of very soft,
pinkish-brown tissues encapsulated by a connective tissue capsule. This capsule is
further covered and reinforced by the peritoneum of the abdominal cavity, which
protects the liver and holds it in place within the abdomen.
The peritoneum connects the liver in 4 locations: the coronary ligament, the left and
right triangular ligaments, and the falciform ligament. These connections are not true
ligaments in the anatomical sense; rather, they are condensed regions of peritoneal
membrane that support the liver.
The wide coronary ligament connects the central superior portion of the liver to the
diaphragm.
Located on the lateral borders of the left and right lobes, respectively, the left and
righttriangular ligaments connect the superior ends of the liver to the diaphragm.
Page 130

The falciform ligament runs inferiorly from the diaphragm across the anterior edge of
the liver to its inferior border. At the inferior end of the liver, the falciform ligament
forms the round ligament (ligamentum teres) of the liver and connects the liver to
the umbilicus. The round ligament is a remnant of the umbilical vein that carries
blood into the body during fetal development.
The liver consists of 4 distinct lobes the left, right, caudate, and quadrate lobes.
The left and right lobes are the largest lobes and are separated by the falciform
ligament. The right lobe is about 5 to 6 times larger than the tapered left lobe.
The small caudate lobe extends from the posterior side of the right lobe and wraps
around the inferior vena cava.
The small quadrate lobe is inferior to the caudate lobe and extends from the posterior
side of the right lobe and wraps around the gallbladder.
Bile Ducts
The tubes that carry bile through the liver and gallbladder are known as bile ducts and
form a branched structure known as the biliary tree. Bile produced by liver cells drains
into microscopic canals known as bile canaliculi. The countless bile canaliculi join
together into many larger bile ducts found throughout the liver.
These bile ducts next join to form the larger left and right hepatic ducts, which carry bile
from the left and right lobes of the liver. Those two hepatic ducts join to form the
common hepatic duct that drains all bile away from the liver. The common hepatic duct
finally joins with the cystic duct from the gallbladder to form the common bile duct,
carrying bile to the duodenum of the small intestine. Most of the bile produced by the
liver is pushed back up the cystic duct by peristalsis to arrive in the gallbladder for
storage, until it is needed for digestion.
Blood Vessels
The blood supply of the liver is unique among all organs of the body due to the hepatic
portal vein system. Blood traveling to the spleen, stomach, pancreas, gallbladder, and
intestines passes through capillaries in these organs and is collected into the hepatic
Page 131

portal vein. The hepatic portal vein then delivers this blood to the tissues of the liver
where the contents of the blood are divided up into smaller vessels and processed
before being passed on to the rest of the body. Blood leaving the tissues of the liver
collects into the hepatic veins that lead to the vena cava and return to the heart. The
liver also has its own system of arteries and arterioles that provide oxygenated blood to
its tissues just like any other organ.
Lobules
The internal structure of the liver is made of around 100,000 small hexagonal functional
units known as lobules. Each lobule consists of a central vein surrounded by 6 hepatic
portal veins and 6 hepatic arteries. These blood vessels are connected by many
capillary-like tubes called sinusoids, which extend from the portal veins and arteries to
meet the central vein like spokes on a wheel.
Each sinusoid passes through liver tissue containing 2 main cell types: Kupffer cells and
hepatocytes.
Kupffer cells are a type of macrophage that capture and break down old, worn out red
blood cells passing through the sinusoids.
Hepatocytes are cuboidal epithelial cells that line the sinusoids and make up the majority of
cells in the liver. Hepatocytes perform most of the livers functions metabolism, storage,
digestion, and bile production. Tiny bile collection vessels known as bile canaliculi run parallel
to the sinusoids on the other side of the hepatocytes and drain into the bile ducts of the liver.
Functions of the Liver
1. Glucose Metabolism
The liver plays a major role in the metabolism of glucose and the regulation of blood
glucose concentration. After a meal, glucose is taken up from the portal venous blood
by the liver and converted into glycogen, which is stored in the hepatocytes.
Subsequently, the glycogen is converted back to glucose (glycogenolysis) and released
as needed into the bloodstream to maintain normal levels of blood glucose.
Page 132

However, this process provides a limited amount of glucose. Additional glucose can be
synthesized by the liver through a process called gluconeogenesis. For this process, the
liver uses amino acids from protein breakdown or lactate produced by exercising
muscles. This process occurs in response to hypoglycemia (Shils, Shike, Ross, et al.,
2006).
2. Ammonia Conversion
It is a use of amino acids from protein for gluconeogenesis results in the formation of
ammonia as a by-product. The liver converts this metabolically generated ammonia into
urea. Ammonia produced by bacteria in the intestines is also removed from portal blood
for urea synthesis. In this way, the liver converts ammonia, a potential toxin, into urea, a
compound that is excreted in the urine (Porth & Matfin, 2009).
3. Protein Metabolism
The liver also plays an important role in protein metabolism. It synthesizes almost all of
the plasma proteins (except gamma-globulin), including albumin, alpha-globulins and
beta-globulins, blood clotting factors, specific transport proteins, and most of the plasma
lipoproteins. Vitamin K is required by the liver for synthesis of prothrombin and some of
the other clotting factors. Amino acids are used by the liver for protein synthesis (Porth
& Matfin, 2009).
4. Fat Metabolism
The liver is also active in fat metabolism. Fatty acids can be broken down for the
production of energy and ketone bodies (acetoacetic acid, beta-hydroxybutyric acid, and
acetone). Ketone bodies are small compounds that can enter the bloodstream and
provide a source of energy for muscles and other tissues. Breakdown of fatty acids into
ketone bodies occurs primarily when the availability of glucose for metabolism is limited,
as in starvation or in uncontrolled diabetes. Fatty acids and their metabolic products are
also used for the synthesis of cholesterol, lecithin, lipoproteins, and other complex lipids
(Porth & Matfin, 2009). In some conditions, lipids may accumulate in the hepatocytes,
resulting in the abnormal condition called fatty liver.
Page 133

5. Vitamin and Iron Storage
Vitamins A, B, and D and several of the B-complex vitamins are stored in large amounts
in the liver. Certain substances, such as iron and copper, are also stored in the liver.
Because the liver is rich in these substances, liver extract have been used for therapy
for more than a century for a wide range of nutritional disorders; however, the U.S. Food
and Drug Administration (FDA) has urged caution regarding the use of any animal
organ extract because of possible risk of exposure to pathogenic organisms.
6. Bile Formation
Bile is continuously formed by the hepatocytes and collected in the canaliculi and bile
ducts. It is composed mainly of water and electrolytes such as sodium, potassium,
calcium, chloride, and bicarbonate, and it also contains significant amounts of lecithin,
fatty acids, cholesterol, bilirubin, and bile salts. Bile is collected and stored in the
gallbladder and is emptied into the intestine when needed for digestion. The functions of
bile are excretory, as in the excretion of bilirubin; bile also serves as an aid to digestion
through the emulsification of fats by bile salts. Bile salts are synthesized by the
hepatocytes from cholesterol. After conjugation or binding with amino acids (taurine and
glycine), bile salts are excreted into the bile. The bile salts, together with cholesterol and
lecithin, are required for emulsification of fats in the intestine, which is necessary for
efficient digestion and absorption. Bile salts are then reabsorbed, primarily in the distal
ileum, into portal blood for return to the liver and are again excreted into the bile. This
pathway from hepatocytes to bile to intestine and back to the hepatocytes is called the
enterohepatic circulation. Because of the enterohepatic circulation, only a small fraction
of the bile salts that enter the intestine are excreted in the feces. This decreases the
need for active synthesis of bile salts by the liver cells (Porth & Matfin, 2009).
7. Bilirubin Excretion
Bilirubin is a pigment derived from the breakdown of haemoglobin by cells of the
reticuloendothelial system, including the Kupffer cells of the liver. Hepatocytes remove
bilirubin from the blood and chemically modify it through conjugation to glucuronic acid,
which makes the bilirubin more soluble in aqueous solutions. The conjugated bilirubin is
Page 134

secreted by the hepatocytes into the adjacent bile canaliculi and is eventually carried in
the bile into the duodenum.
In the small intestine, bilirubin is converted into urobilinogen, which is partially excreted
in the feces and partially absorbed through the intestinal mucosa into the portal blood.
Much of this reabsorbed urobilinogen is removed by the hepatocytes and secreted into
the bile once again (enterohepatic circulation). Some of the urobilinogen enters the
systemic circulation and is excreted by the kidneys in the urine. Elimination of bilirubin in
the bile represents the major route of its excretion.
The bilirubin concentration in the blood may be increased in the presence of liver
disease, if the flow of bile is impeded (eg, by gallstones in the bile ducts), or if there is
excessive destruction of red blood cells. With bile duct obstruction, bilirubin does not
enter the intestine; as a consequence, urobilinogen is absent from the urine and
decreased in the stool (Porth & Matfin, 2009).
8. Drug Metabolism
The liver metabolizes many medications, such as barbiturates, opioids, sedatives,
anesthetics, and amphetamines. Metabolism generally results in drug inactivation,
although activation may also occur. One of the important pathways for medication
metabolism involves conjugation (binding) of the medication with a variety of
compounds, such as glucuronic acid or acetic acid, to form more soluble substances.
These substances may be excreted in the feces or urine, similar to bilirubin excretion.
Bioavailability is the fraction of the administered medication that actually reaches the
systemic circulation. The bioavailability of an oral medication (absorbed from the GI
tract) can be decreased if the medication is metabolized to a great extent by the liver
before it reaches the systemic circulation; this is known as first-pass effect. Some
medications have such a large first-pass effect that their use is essentially limited to the
parenteral route, or oral doses must be substantially larger than parenteral doses to
achieve the same effect.

Page 135

ANATOMY AND PHYSIOLOGY OFSPLEEN
organ shaped like a shoe that lies relative to the 9th and 11th ribs and is located
in the left hypochondrium and partly in the epigastrium
between the fundus of the stomach and the diaphragm
very vascular and reddish purple in color
its size and weight vary
A healthy spleen is not palpable.
Development
The spleen develops in the cephalic part of dorsal mesogastrium (from its left layer;
during the sixth week of intrauterine life) into a number of nodules that fuse and form a
lobulated spleen. Notching of the superior border of the adult spleen is evidence of its
multiple origin .
Gross Anatomy
The spleen's 2 ends are the anterior and posterior end.
The anterior end of the spleen is expanded and is more like a border; it is
directed forward and downward to reach the midaxillary line.

The posterior end is rounded and is directed upward and backward; it rests on
the upper pole of the left kidney.
Page 136

The spleen's 3 borders are the superior, inferior, and intermediate.
The superior border of the spleen is notched by the anterior end.
The inferior border is rounded.
The intermediate border directs toward the right.
The 2 surfaces of the spleen are the diaphragmatic and visceral. The
diaphragmatic surface is smooth and convex, and the visceral surface is irregular and
concave and has impressions. The gastric impression is for the fundus of the stomach,
which is the largest and most concave impression on the spleen. The renal impression
is for the left kidney and lies between the inferior and intermediate borders. The colic
impression is for the splenic flexure of the colon; its lower part is related to the
phrenicocolic ligament. The pancreatic impression for the tail of the pancreas lies
between the hilum and colic impression .

Spleen anatomy. This image shows different surfaces and impressions caused by
different organs in relation to the spleen's hilum.

Hilum
Page 137

The hilum can be found on the inferomedial part of the gastric impression. The hilum
transmits the splenic vessels and nerves and provides attachment to the gastrosplenic
and splenorenal (lienorenal) ligaments.

Peritoneal relations
The spleen is surrounded by peritoneum and is suspended by multiple ligaments, as
follows:
The gastrosplenic ligament extends from the hilum of the spleen to the greater
curvature of the stomach; it contains short gastric vessels and associated lymphatics
and sympathetic nerves.
The splenorenal ligament extends from the hilum of the spleen to the anterior surface
of the left kidney; it contains the tail of the pancreas and splenic vessels.
The phrenicocolic ligament is a horizontal fold of peritoneum that extends from the
splenic flexure of the colon to the diaphragm along the midaxillary line; it forms the
upper end of the left paracolic gutter.

Visceral relations
The visceral surface of the spleen contacts the following organs:
Anterior surface of the left kidney
Splenic flexure of the colon
The fundus of the stomach
Tail of the pancreas
The diaphragmatic surface is related to the diaphragm; the diaphragm separates the
spleen from the pleura and the lung.
Vascular supply
The splenic artery supplies blood to the spleen. This artery is the largest branch of the
celiac trunk and reaches the spleen's hilum by passing through the splenorenal
Page 138

ligament. It divides into multiple branches at the hilum. It divides into straight vessels
called penicillin, ellipsoids, and arterial capillaries in the spleen.
The splenic circulation is adapted for the separation and storage of the red blood cells.
The spleen has superior and inferior vascular segments based on the blood supply. The
2 segments are separated by an avascular plane.
Its terminal branches aside, the splenic artery also gives off branches to the pancreas,
5-7 short gastric branches, and the left gastro-omental (gastroepiploic) artery.

Spleen anatomy. Hilum of the spleen along with anatomy of the splenic artery (a) and
the splenic vein (v).

Nerve supply
Sympathetic fibers are derived from the celiac plexus.

Surface marking
Page 139

The spleen is marked on the left side of the back with the long axis of the 10th
rib.
The upper border is marked along the upper border of the ninth rib; the lower
border, along the 11th rib.
The medial end lies 5 cm from the midline.
The lateral extension ends at the midaxillary line.
Venous drainage
The splenic vein provides the principal venous drainage of the spleen. It runs behind the
pancreas (after forming at the hilum) before joining the superior mesenteric vein behind
the neck of the pancreas to form the portal vein. The short gastric, left gastro-omental,
pancreatic, and inferior mesenteric veins are its tributaries.
Lymphatic drainage
Proper splenic tissue has no lymphatics; however, some arise from the capsule and
trabeculae and drain to the pancreaticosplenic lymph nodes.
Microscopic Anatomy
The spleen is made up of the following 4 components:
Supporting tissue
White pulp
Red pulp
Vascular system
Supporting tissue is fibroelastic and forms the capsule, coarse trabeculae, and a fine
reticulum.
The white pulp consists of lymphatic nodules, which are arranged around an eccentric
arteriole called the Malpighian corpuscle.
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The red pulp is formed by a collection of cells in the interstices of the reticulum, in
between the sinusoids. The cell population includes all types of lymphocytes, blood
cells, and fixed and free macrophages. The lymphocytes are freely transformed into
plasma cells, which can produce large amounts of antibodies and immunoglobulins .

Spleen anatomy. This section shows the spleen's red pulp and the white pulp and its
relation to the liver and diaphragm.

The vascular system traverses the spleen and permeates it.
Natural and Pathophysiologic Variants
Accessory spleens or splenunculi are natural anatomic variants formed from nodules
that fail to fuse during development. These are found in various locations such as the
gastrosplenic ligament, splenorenal ligament, gastrophrenic ligament, and gastrocolic
ligament. They have also been reported to have been found in the broad ligament of the
uterus and in the spermatic cord.
Pathophysiologic anatomic variants include splenomegaly, asplenia, and
autosplenectomy. Splenomegaly is the enlargement of the spleen. It occurs due to
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various conditions, such as infections (eg, malaria, kala azar), malignancies (eg,
lymphomas, leukemias), and other conditions (eg, portal hypertension). The spleen then
projects toward the right iliac fossa in the direction of axis of the 10th rib.
Asplenia is a rare condition in which a congenital absence of the spleen occurs.
Autosplenectomy is a condition in which splenic infarction occurs due to sickle cell
anemia.

Functions of the Spleen
Immune responses
After antigenic stimulation, increased formation of plasma cells for humoral responses
and increased lymphopoiesis for cellular responses occurs.
Phagocytosis
One of the spleen's most important functions is phagocytosis. The spleen is a
component of the reticuloendothelial system. The splenic phagocytes include reticular
cells, free macrophages of the red pulp, and modified reticular cells of the ellipsoids.
Phagocytes in the spleen remove debris, old and effete red blood cells (RBCs), other
blood cells, and microorganisms, thereby filtering the blood. Phagocytosis of circulating
antigens initiates the humoral and cellular immune responses.
Hematopoiesis
The spleen is an important hematopoietic organ during fetal life; lymphopoiesis
continues throughout life. The manufactured lymphocytes take part in immune
responses of the body. In the adult spleen, hematopoiesis can restart in certain
diseases such as chronic myeloid leukemia and myelosclerosis.
Storage of red blood cells
The RBCs are stored in the spleen. Approximately 8% of the circulating RBCs are
present within the spleen; however, this function is seen better in animals than humans.

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ANATOMY AND PHYSIOLOGY OF KIDNEY
The most basic structures of the kidneys are nephrons. Inside each kidney there are
about one million of these microscopic structures. They are responsible for filtering the
blood... removing waste products.
The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of
blood pass through the kidneys every day. When this blood enters the kidneys it is
filtered and returned to the heart via the renal vein.
The kidneys are full of blood vessels. Blood vessels are integral to efficient kidney
function. Every function of the kidney involves blood; it therefore, requires a lot of blood
vessels to facilitate these functions. Together, the two kidneys contain about 160 km of
blood vessels.

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Hepatic Portal Circulation
The liver is unusual in that it receives the majority of its metabolic requirements from a
venous source. The normal liver gets about 70% of its O
2
requirement via the portal
vein. The portal vein also delivers the dietary carbohydrates used to fuel liver
activityThe portal system begins in the capillaries and venules of the digestive system. It
collects venous blood from the lower esophagus, stomach, duodenum, jejunum, ileum,
colon, spleen and delivers it to the liver via portal vein. Consequently, portal blood
contains the substances absorbed by the digestive tract.
Normal portal flow and pressure vary depending upon: cardiac output, intra-abdominal
pressure, disease process, positioning, feeding schedule, time of day, etc. Circadian
variations begin to increase portal pressure around 19:00 hours, reaching peak
pressures around 09:00. Portal pressure decreases from 09:00 to about 19:00 hours.
Interestingly, peak reports of bleeding varies correspond with 09:00 and 23:00 hours.
Normal hepatic circulation is a high flow - low resistance system. Branches of the portal
vein deliver 1000-1500 ml/min of blood into the sinusoids of the hepatic lobules. Normal
portal venous pressure is 5-10 mm Hg. The blood passes through the sinusoids and
drains into the inferior vena cava. Inferior vena cava pressure ranges from -5 to +5
mmHg.* Portal pressure >10mm Hg may indicate portal hypertension.
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The cardiovascular system is composed of two circulatory paths: pulmonary circulation,
the circuit through the lungs where blood is oxygenated; and systemic circulation, the
circuit through the rest of the body to provide oxygenated blood.
Pulmonary Circulation
Pulmonary circulation is the movement of blood from the heart to the lungs for
oxygenation, then back to the heart again. Oxygen-depleted blood from the body leaves
the systemic circulation when it enters the right atrium through the superior and inferior
venae cava. The blood is then pumped through the tricuspid valve into the right
ventricle. From the right ventricle, blood is pumped through the pulmonary valve and
into the pulmonary artery. The pulmonary artery splits into the right and left pulmonary
arteries and travel to each lung. At the lungs, the blood travels through capillary beds on
the alveoli where respiration occurs, removing carbon dioxide and adding oxygen to the
blood. The alveoli are air sacs in the lungs that provide the surface for gas exchange
during respiration. The oxygenated blood then leaves the lungs through pulmonary
veins, which returns it to the left atrium, completing the pulmonary circuit. Once entering
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the left heart, the blood flows through the bicuspid valve into the left ventricle. From the
left ventricle, the blood is pumped through the aortic valve into the aorta to travel
through systemic circulation, delivering oxygenated blood to the body before returning
again to the pulmonary circulation.

Systemic Circulation
Systemic circulation is the movement of blood from the heart through the body to
provide oxygen and nutrients, and bringing deoxygenated blood back to the heart.
Oxygen-rich blood from the lungs leaves the pulmonary circulation when it enters the
left atrium through the pulmonary veins. The blood is then pumped through the mitral
valve into the left ventricle. From the left ventricle, blood is pumped through the aortic
valve and into the aorta, the body's largest artery. The aorta arches and branches into
major arteries to the upper body before passing through the diaphragm, where it
branches further into arteries which supply the lower parts of the body. The arteries
branch into smaller arteries, arterioles, and finally capillaries. Waste and carbon dioxide
diffuse out of the cell into the blood, while oxygen in the blood diffuses out of the blood
and into the cell. The deoxygenated blood continues through the capillaries which
merge into venules, then veins, and finally the venae cava, which drain into the right
atrium of the heart. From the right atrium, the blood will travel through the pulmonary
circulation to be oxygenated before returning gain to the system circulation. Coronary
circulation, blood supply to the heart muscle itself, is also part of the systemic circulation
Page 146

Page 147

SCHISTOSOMIASIS
Schistosomiasis (also known as bilharzia, bilharziosis or snail fever) is a collective name
of parasitic diseases caused by several species of trematodes belonging to the genus
Schistosoma. Snails serve as the intermediary agent between mammalian hosts.
Individuals within developing countries who cannot afford proper water and sanitation
facilities are often exposed to contaminated water containing the infected snails.
Although it has a low mortality rate, schistosomiasis often is a chronic illness that can
damage internal organs and, in children, impair growth and cognitive development. The
urinary form of schistosomiasis is associated with increased risks for bladder cancer in
adults. Schistosomiasis is the second most socioeconomically devastating parasitic
disease after malaria.
This disease is most commonly found in Asia, Africa, and South America, especially in
areas where the water contains numerous freshwater snails, which may carry the
parasite.
The disease affects many people in developing countries, particularly children who may
acquire the disease by swimming or playing in infected water. When children come into
contact with a contaminated water source, the parasitic larvae easily enter through their
skin and further mature within organ tissues. As of 2009, 74 developing countries
statistically identified epidemics of Schistosomiasis within their respective populations.
Species of Schistosoma that can infect humans:
Schistosoma mansoni and Schistosoma intercalatum cause intestinal schistosomiasis
Schistosoma haematobium causes urinary schistosomiasis
Schistosoma japonicum and Schistosoma mekongi cause Asian intestinal
schistosomiasis. Avian schistosomiasis species cause swimmer's itch and clam digger
itch

Page 148

LIFE CYCLE
The life cycles of all five human schistosomes are broadly similar: parasite eggs are
released into the environment from infected individuals, hatching on contact with fresh
water to release the free-swimming miracidium. Miracidia infect freshwater snails by
penetrating the snail's foot. After infection, close to the site of penetration, the
miracidium transforms into a primary (mother) sporocyst. Germ cells within the primary
sporocyst will then begin dividing to produce secondary (daughter) sporocysts, which
migrate to the snail's hepatopancreas. Once at the hepatopancreas, germ cells within
the secondary sporocyst begin to divide again, this time producing thousands of new
parasites, known as cercariae, which are the larvae capable of infecting mammals.
Cercariae emerge daily from the snail host in a circadian rhythm, dependent on ambient
temperature and light. Young cercariae are highly mobile, alternating between vigorous
upward movements and sinking to maintain their position in the water. Cercarial activity
is particularly stimulated by water turbulence, by shadows and by chemicals found on
human skin.
The most common way of getting schistosomiasis in developing countries is by wading
or swimming in lakes, ponds and other bodies of water that are infested with the snails
usually of the genera Biomphalaria, Bulinus, or Oncomelania that are the natural
reservoirs of the Schistosoma pathogen.
Penetration of the human skin occurs after the cercaria have attached to and explored
the skin. The parasite secretes enzymes that break down the skin's protein to enable
penetration of the cercarial head through the skin. As the cercaria penetrates the skin it
transforms into a migrating schistosomulum stage.
The newly transformed schistosomulum may remain in the skin for two days before
locating a post-capillary venule; from here the schistosomulum travels to the lungs
where it undergoes further developmental changes necessary for subsequent migration
to the liver. Eight to ten days after penetration of the skin, the parasite migrates to the
liver sinusoids. S. japonicum migrates more quickly than S. mansoni, and usually
reaches the liver within eight days of penetration. Juvenile S. mansoni and S. japonicum
Page 149

worms develop an oral sucker after arriving at the liver, and it is during this period that
the parasite begins to feed on red blood cells. The nearly-mature worms pair, with the
longer female worm residing in the gynaecophoric channel of the shorter male. Adult
worms are about 10 mm long. Worm pairs of S. mansoni and S. japonicum relocate to
the mesenteric or rectal veins. S. haematobium schistosomula ultimately migrate from
the liver to the perivesical venous plexus of the bladder, ureters, and kidneys through
the hemorrhoidal plexus.
Parasites reach maturity in six to eight weeks, at which time they begin to produce
eggs. Adult S. mansoni pairs residing in the mesenteric vessels may produce up to
300 eggs per day during their reproductive lives. S. japonicum may produce up to 3,000
eggs per day. Many of the eggs pass through the walls of the blood vessels, and
through the intestinal wall, to be passed out of the body in feces. S. haematobium eggs
pass through the ureteral or bladder wall and into the urine. Only mature eggs are
capable of crossing into the digestive tract, possibly through the release of proteolytic
enzymes, but also as a function of host immune response, which fosters local tissue
ulceration. Up to half the eggs released by the worm pairs become trapped in the
mesenteric veins, or will be washed back into the liver, where they will become lodged.
Worm pairs can live in the body for an average of four and a half years, but may persist
up to twenty years. Trapped eggs mature normally, secreting antigens that elicit a
vigorous immune response. The eggs themselves do not damage the body. Rather it is
the cellular infiltration resultant from the immune response that causes the pathology
classically associated with schistosomiasis.
Page 150

Embryonated eggs (ova) of adult schistosomes are expelled together with the feces of an infected
person in fresh water, those eggs then hatch due to the lower osmolarity of the fresh water. Though
the nature of hatching is poorly understood, current information suggests that miracidium inside the
egg increases in its ciliary activity then, due to the osmosis, a vent opens in the side of the egg and
the miracidium is released. In the process, some eggs do not hatch and others hatch
prematurely. As the miracidia are released in the water, they immediately swim ceaselessly
thereby increasing the chances of encountering an important host. There are different hosts
depending upon the type of schistosoma. Particularly for SchistosomaJaponicum, the snail
Oncomelaniaquadrasi is the typical host. Upon contact of a miracidium into the snail host, it
penetrates into the snail. Immediately after penetration, it sheds its epithelium and then develops
into a mother sporocyst which continues to produce daughter sporocysts, asexually, that will
migrate into other parts of the snailsbody. Production continues from 6-7 weeks. The daughter
sporocysts will transform into theinfective stage called cercaria. These cercarias are then released
by the snail into thewater where they sink toward the bottom and can remain in this state for 1-3
days. They can potentially enter the skin of a man and other warm blooded animals like dogs,
cows, carabaos, that wade in the water.
Page 151

Pathophysiology

Page 152

Precipitating Factor:
Actual contact with infected
water
Cercaria penetrated and attached to the skin
Schistosomules enters peripheral circulation of the blood
Flows to the systemic circulation
Distributed to the liver via hepatic artery
Predisposing Factor:
Geographical Location (Leyte)
Age (68 years old)
Educational Status

Schistosomules will grow and mature
Lodges in the sinusoids (small vessels in the liver) Some schistosomules trapped in the spleen
Distributed t the spleen via spleen via splenic artery
Phagocytic cells activation (Macrophage)
Inflammation of the spleen
Splenomegaly
Some schistosomes travel to
intestinal vein and
undergone sexual
reproduction
Inflammation and
destruction of the
hepatocytes
Page 153

Signs and Symptoms:
Risk for bleeding
Clotting factor affected (coagulation
factor) APPT: 61.4 secs
Distended abdomen
Palpable mass (Left upper quadrant)
Pain
Egg released by
schistosomes to the
intestine (later on
expelled with the feces)
Hepatic abscess
formation and increase
collagen in falciform
ligaments
Fibrotic regeneration of
hepatocytes

Irreverversible scarring
formation
Compression of portal
veins
Liver cirrhosis
Signs and Symptoms:
Early
Anorexia
Nausea & vomiting
Diarrhea
Abdominal pain
Late
Pleural Effusion
Limited thoracic
expansion
Lethargy
Jaundice
Anemia
Portal hypertension
Edema
Intrahepatic obstruction
occurs
Result to backing up blood
to the liver and spleen
Splanchnic artery dilated
to compensate increasing
pressure
Circulatory of blood to the
kidney will decrease
Portal Hypertension

Contributes to the fluid
shifting
Ascites
Liver tissue necrosis
Inability to synthesize
albumin
Decrease albumin
formation
Decrease osmotic
pressure
Accumulation of fluid in
the third space
Increased venous
pressure
Page 154

Stimulates of ADH by posterior pituitary
gland to change osmolality to blood
Decrease urine
output
Increased sodium and water
retention by the kidney
Edema
Venous valve
damage
Blood backflows
Chronic Venous
Insufficiency
Signs and Symptoms:
- Edema
- Ankle Swells
- Calve feels tight
- Associated with
Varicose veins
Causes diaphragmatic
defects
Pleural Effusion
Negative intrathoracic
pressure draws ascitic
fluid into the pleural
space

A Case Study On Schistosomiasis

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