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Bataan Peninsula State University
Balanga, Campus
Balanga, Campus
Diabetes Neprophaty
Prepared by:
Nuguid, Camille F.
Paragiison, Ralp Roentgen
Cunanan, Mark Joseph
Salvador, Marry Joyce
Bartolome, Dazel
Gamiao, Joebert
Mallari, Apple
Lisay, Cristine
Abalos, Leslie
Pingul, Philip
Roman, Lea
INTRODUCTION
PATIENT’S PROFILE
Client’s name: Mr. C
Age: 47
Birthday: September 15, 1962
Address: Tapulao, Orani, Bataan
Gender: Male
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Single
Occupation: Beautician
Clinical impression: To consider viral hepatitis rule out
cholecystitis vs cholelithiasis
Attending Physician: Dr. June G. Reyes
FAMILY HEALTH HISTORY
According to Mr. C regarding their herido-familial
history, his father had a hypertension and his mother had
hypotension. His parents were both deceased.
PAST HEALTH HISTORY
The patient was born on September 15, 1962. He was a
permanent resident of Tapulao, Orani Bataan.
The patient stated that he was the youngest among his
siblings. He lives together with the family of his brother under
one roof with four different partitions. He said that he was a
smoker; he takes 1-2 packs of cigarette per day. He was also an
alcohol drinker; he can take 6 to 8 bottles of beer and 1 bottle
hard in a day. He also said that he always lacks of sleep because
he enjoys night life. He enjoyed eating salty and fatty foods and
also fond of buying street foods. Being a beautician, he was
good in doing ear piercing, so after doing the piercing in his
client, he used the needle to pierce himself. He also admitted
that he was sexually active with multiple male partners.
Last 2003 he was confined at Bataan General Hospital
with the diagnosis of cholelithiasis. He wasn’t able to have the
operation because his income as a beautician is not much.
PRESENT ILLNESS:
A case OF Mr. C, 47 years old, male, confined at Orani
District Hospital with a clinical impression of viral hepatitis rule
out cholecystitis vs cholelithiasis.
SOCIAL HISTORY
Mr. C is a gay beautician with on and off income. He was
the one who sustains for the education of his niece and
nephews. Sometimes his income is not sufficient because of his
underlying disease.
ACTIVITIES OF DAILY LIVING
Activities Before
hospitalization
During
hospitalization
Cigarette
smoking
>Takes 1 to 2 packs
of cigarette per day
> Restriction of
cigarette smoking
Alcohol drinking >Drinks 6 to 8
bottles of beer and 1
> Restriction of
alcohols
to 2 bottles of hard
drinks
Nutrition >Likes to eat foods
rich in cholesterol
such as chicharon
>He wasn’t able to
eat on time
>Always eats street
foods such as “isaw
and barbecue
> Increase nutritious
foods
> Low fat diet
Exercise >Doesn’t have time
to exercise or do
physical activities
> Range of motion
Sexual activity >He used to go out
together with his
gay friends to hunt
boys and play with
them
> Abstinence
Rest and sleep >He doesn’t have
adequate rest and
sleep because he
always goes out
during the night
together with his
gay friends.
> Have adequate rest
and sleep.
Livelihood >He is a beautician
with an on and off
income
> He can’t perform
his job due to
hospitalization.
> He doesn’t have
enough money for
his hospitalization
PHYSICAL ASSESSMENT
February 11, 2010
Part to be
examine
Technique
used
Result Interpretation
Skin Inspection
Palpation
>skin color:
with jaundice
noted
>clean skin
>warm to
>increase
bilirubin level
>normal
>normal
Head
Scalp
Hair
Eyebrows
Eyes
Ears
Nose
Lips
Inspection
Palpation
Inspection
Inspection
Inspection
Inspection
Inspection
Palpation
Inspection
Palpation
Inspection
touch
>round
>no
tenderness
noted
>oily
>black
>thick
>oily
>properly
distributed
>symmetrical
and in line
with each
other
>symmetrical
>black iris
>yellow sclera
>bean-shaped
>with piercing
noted
>normal
>normal
>normal
>normal
>normal
>due to the
production of
sebum
>normal
>normal
>normal
>normal
>due to
increase
bilirubin level
>normal
>due to
lifestyle
>normal
>normal
>normal
Mouth
Teeth
Tongue
Chest
Abdomen
Upper
extremities
Inspection
Inspection
Inspection
Inspection
Palpation
Auscultation
Inspection
Auscultation
Percussion
Palpation
Inspection
>firm cartilage
>located at
the midline
>patent nares
>firm cartilage
>dry and dark
>symmetrical
>kept moist
by saliva
>yellowish to
white
>kept moist
by saliva
>sternum is at
the midline
>moves
symmetrically
when
breathing
>RR: 20bpm
>no
tenderness
>HR:72 bpm
>normal
>due to
frequent
smoking
>normal
>normal
>due to
acquired
nicotine
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to
increase
intake of
alcohol
Lower
extremities
Nails
General
appearance
Inspection
Inspection
Palpation
Inspection
>skin color is
uniform
>distended
>borborygmi
noted
>tympany
noted
>no masses
noted
>symmetrical
>proportional
>no lesions
noted
>symmetrical
>proportional
>with lesion
on the right
lower leg
>160˚ angle
>dirty
>capillary
refill: after 1
second
>normal
bowel sound
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to
previous
burns
>normal
>due to poor
hygiene
>normal
>normal
>due to
restlessness
>conscious
and coherent
>sleepy
appearance
February 12, 2010
Part to be
examine
Technique
used
Result Interpretation
Skin
Head
Scalp
Hair
Inspection
Palpation
Inspection
Palpation
Inspection
Inspection
>skin color:
with jaundice
noted
>clean skin
>warm to
touch
>round
>no
tenderness
noted
>oily
>black
>increase
bilirubin level
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to the
production of
Eyebrows
Eyes
Ears
Nose
Lips
Mouth
Teeth
Tongue
Chest
Inspection
Inspection
Inspection
Palpation
Inspection
Palpation
Inspection
Inspection
Inspection
Inspection
Inspection
>thick
>oily
>properly
distributed
>symmetrical
and in line
with each
other
>symmetrical
>black iris
>yellow sclera
>bean-shaped
>with piercing
noted
>firm cartilage
>located at
the midline
>patent nares
>firm cartilage
>dry and dark
>symmetrical
sebum
>normal
>normal
>normal
>normal
>due to
increase
bilirubin level
>normal
>due to
lifestyle
>normal
>normal
>normal
>normal
>due to
frequent
smoking
>normal
>normal
>due to
Abdomen
Upper
extremities
Lower
extremities
Palpation
Auscultation
Inspection
Auscultation
Percussion
Palpation
Inspection
Inspection
Inspection
>kept moist
by saliva
>yellowish to
white
>kept moist
by saliva
>sternum is at
the midline
>moves
symmetrically
when
breathing
>RR: 18bpm
>no
tenderness
>HR:82 bpm
>skin color is
uniform
>distended
>with
guarding
behavior
noted
>borborygmi
noted
acquired
nicotine
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to
increase
intake of
alcohol
>due to pain
>normal
bowel sound
>normal
>presence of
stones in the
gallbladder
>normal
>normal
Nails
General
appearance
Palpation
Inspection
>tympany
noted
>with masses
noted
>symmetrical
>proportional
>no lesions
noted
>symmetrical
>proportional
>with lesion
on the right
lower leg
>160˚ angle
>dirty
>capillary
refill: after 1
second
>conscious
and coherent
>weak in
appearance
>with
>normal
>normal
>normal
>due to
previous
burns
>normal
>due to poor
hygiene
>normal
>normal
>due to pain
>due to pain
>due to
restlessness
guarding
behavior in
the abdomen
>sleepy
appearance
February 13, 2010
Part to be
examine
Technique
used
Result Interpretation
Skin
Head
Scalp
Hair
Eyebrows
Inspection
Palpation
Inspection
Palpation
Inspection
Inspection
Inspection
>skin color:
with slight
jaundice
noted
>clean skin
>warm to
touch
>round
>no
tenderness
noted
>oily
>black
>thick
>oily
>properly
>increase
bilirubin level
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to the
production of
sebum
>normal
>normal
Eyes
Ears
Nose
Lips
Mouth
Teeth
Tongue
Chest
Inspection
Inspection
Palpation
Inspection
Palpation
Inspection
Inspection
Inspection
Inspection
Inspection
distributed
>symmetrical
and in line
with each
other
>symmetrical
>black iris
>slight
yellowish
sclera
>bean-shaped
>with piercing
noted
>firm cartilage
>located at
the midline
>patent nares
>firm cartilage
>dry and dark
>symmetrical
>kept moist
by saliva
>normal
>normal
>due to
increase
bilirubin level
>normal
>due to
lifestyle
>normal
>normal
>normal
>normal
>due to
frequent
smoking
>normal
>normal
>due to
acquired
nicotine
>normal
Abdomen
Upper
extremities
Lower
extremities
Nails
Palpation
Auscultation
Inspection
Auscultation
Percussion
Palpation
Inspection
Inspection
Inspection
Palpation
Inspection
>yellowish to
white
>kept moist
by saliva
>sternum is at
the midline
>moves
symmetrically
when
breathing
>RR: 17bpm
>no
tenderness
>HR:75 bpm
>skin color is
uniform
>distended
>borborygmi
noted
>tympany
noted
>no masses
noted
>normal
>normal
>normal
>normal
>normal
>normal
>due to
increase
intake of
alcohol
>normal
bowel sound
>normal
>normal
>normal
>normal
>normal
>normal
>normal
>due to
previous
General
appearance
>symmetrical
>proportional
>no lesions
noted
>symmetrical
>proportional
>with lesion
on the right
lower leg
>160˚ angle
>dirty
>capillary
refill: after 1
second
>conscious
and coherent
burns
>normal
>due to poor
hygiene
>normal
>normal
ANATOMY AND PHYSIOLOGY
A. Structures1. Liver
a. The liver is the largest organ in the body , weighing 3 pounds. It is encase in a fibrous
capsule and lies in the upper right quadrant of the abdomen.
b. The liver is composed of four lobes containing lobules that are the functioning units of the liver. The four lobes are: the right, left, caudate and quadrate.
c. Each lobule is composed of hepatocytes (liver cells) and its own blood supply called sinusoids. The phagocytic Kupffer cels are located within the sinusoids.
d. The main blood supply to the liver is transported via the hepatic artery and the portal vein emptying into the inferiof vena cava via the hepatic veins.
e. The hepatic artery receives blood directly from the aorta and the portal vein drains the blood from the spleen and intestines.
f. Fibers from the vagus (parasympathetic) and celiac plexus (sympathetic) comprise the liver’s nerve supply.
2. Biliary systema. Hepatic lobules are the functional unit of the
liver. The lobules consist of a network of small ducts called canaliculi.
b. The hepatic duct receives bile via the canaliculi that join to create larger bile ducts.
c. The common bile duct is formed by the joining of the hepatic and cystic ducts located in the liver and gallbladder respectively. The liquid contents of these ducts drain into the duodenum via the sphincter of the Oddi.
d. Relaxing of the Sphincter of Oddi permits the passage of bile into the duodenum
e. The gallbladder is a pear-shaped hollow organ, 3 to 4 inches long, located on the undersurface of the right lobe of the liver.
f. Normal bile capacity is approximately 50 to 75ml.
3. Pancreasa. The pancreas is a long, slender organ,
approximately 6 to 9 inches in length, which is situated behind the stomach and consist of three segments: head, body and tail.
b. The organ is composed of lobules that form lobes.
c. The lobules have enzyme-producing acini that release their secretions into the duct of Wirsung or pancreatic duct.
d. The pancreas produces exocrine and endocrine secretion. The exocrine secretions are via the acini cells of digestive purposes. The endocrine secretions are associated with the islets of Langerhans whose cells are involved in the regulation of carbohydrate metabolism.
A. Functions1. Liver
a. The liver is the first organ to receive blood carrying the final products of digestion and decomposition products.
b. From this blood the liver begins its enormous role in maintain normal body functions.
2. Major liver functiona. Maintains normal serum glucose levels by means
of glycogenesis, glycogenelysis, and glucogenesis.
b. Deaminizes amino acids, forming ammonia that is then converted into urea. Synthesizes nonessential amino acids, plasma proteins (albumin0, vitamin a, and coagulation factors (fibrinogen, prothrombin), and is the source of heparin, an anticoagulant.
c. Breaks down triglycerides and fatty acids and stores and synthesizes excess fats. Also synthesizes cholesterol, lipoprotein, phospholipid and excess fat.
d. Serves as a storage place for the fat-soluble vitamins A, D, E, K and B12, iron, and trace elements.
e. Detoxifies potentially harmful substances, eg., alcohol, poisons, and various toxic substances produced by the body. Metabolizes drugs and excretes their breakdown products.
f. Continuously secretes and excretes bile.3. Bile components:
a. Bile is composed of bilirubin, cholesterol, mucin, electrolytes, bile salts, fatty acids, lecithin, water and various inorganic and organic substances.
b. Biliverdin: oxidation of bilirubin forming the greenish color in the bile.
c. Bilirubin: pigment from phagocytosed haemoglobin removed from the blood and chemically modified by conjugation to glucoronic acid and formed by the hepatocytes into the bile.
d. Bile salts: synthesized from cholesterol, conjugated with amino acid for fat emulsification; recycling is achieved by reabsorption through the ileal mucosa and into the portal circulation for transport to the liver.
4. Biliary systema. Bile from the hepatocytes is transported to the
gallbladder via an intricate drainage system.b. Cholecystokinin, a duodenal hormone,
stimulates the gallbladder to contract, thereby relaxing the sphincter Oddi and releasing bile for digestion.
5. The pancreas is composed of two basic cell types, endocrine and exocrine. Functions of the pancreatic exocrine cells (acini) include: a. Production of a watery pancreatic juice rich in
enzymes for digestion and bicarbonate to neutralize the acidic chime.
b. Production of enzymes for digestion, consisting of amylase (hydrolyzes starch), trypsin (proteolytic enzyme that catalizes the hydrolysis of the petite bonds), and lipase (breaks triglycerides into fatty acids and glycerol).
PATHOPHYSIOLOGY OF HEPATITIS B
Non- modifiable factor Modifiable factors
>Age >sexually active with multiple partners
>Gender >cigarette smoking
>alcoholic
>ear piercing
> Unhealthy diet
Exposure to Hepa B virus
HBV enters the liver through the blood
Inflammatory & immune response initiated
Invasion of HBV in the liver
Deterioration & necrosis of the hepatocytes
Enlargement of the Kuffer cells
Pain at the RUQ of the abdomen
Formation of the fibrous scar tissue in the liver
Enlargement of the liver causing stomach compression
Obstruction of the vascular & biliary networks
Nausea and vomiting
Impaired Carbohydrate, lipids & protein metabolism
Impedes excretion of bilirubin
Fatigue, Malaise
Reduction of the amount of bile entering the intestine
LABORATORY EXAMINATIONS
Laboratory Tests: HematologyName: Mr. CAge: 47 y/oDate examined: February 10, 2010Test CBC
Result Normal Values
Interpretation
Hemoglobin 162.5 gm/l 140-170gm/l
normal
Hematocrit 0.49 0.37-0.47 High hematocrit level can be seen in people living at high altitudes and chronic smokers. It causes lung disease tumors, and disorder of the bone marrow.
WBC Count 7.9x10⁹/l 5-10x10⁹/l normalSegmenters 0.48 0.55-0.65 normalLymphocytes 0.52 0.25-0.35 Indicates a viral
infectionBlood type: ORh: (+)
UrinalysisDate examined: February 10, 2010
ResultColor yellowGlucose negativepH 5.0
Jaundice, stool becomes light in color, urine becomes darker Indigestion, anorexia
HEPATITIS B
Specific gravity 1.015Protein negativeRBC 0-2WBC 1-3Calcium oxalate few
DRUG STUDY
Generic Name
Classification Action Dosage/Route Indication Ingredients Nursing Consideration
Sylmarine Herbal anti-oxidant
Protects the liver by strengthening the outer membranes of the liver cells, thereby preventing the toxins from entering the cells.
1cap PO TID Nutritionally support healthy liver function
Each capsule contains 125mg of pure Milk Thistle extract, Lecithin, Bees wax, Capsule-Gelatin.
>Administer to right person, time, route and dosage
NURSING CARE PLANS
Assessment Diagnosis Planning Interventions Rationale Evaluation
S:” Masakit tagiliran ng tiyan ko” as verbalized.>pain scale of 6 (where 0 is the lowest and 10 is the highest)
O:>conscious>coherent>distended abdomen>facial grimace>weak and pale in appearance>guarding behavior
Pain related to distended abdomen secondary to hepatic disease as evidenced by a pain scale of 6 (where 0 is the lowest and 10 is the highest)
After series of nursing interventions, the patient will decrease pain from a pain scale of 6 to2 (where 0 is the lowest and 10 is the highest)
>Assess patient for signs and symptoms of pain.
>Encourage verbalization of pain>Include client and significant others in establishing pattern of discussing pain>Provide comfort measures such as repositioning and deep breathing exercise.>Encourage diversional activities such as reading magazines or texting>Encourage adequate rest periods.
>Assessment allows for care plan modification as needed.>To assist client in dealing with pain>To limit focusing on pain
>To provide non pharmacologic pain management.
>To divert client’s attention to pain.
>To prevent fatigue.
The patient will decrease pain from a pain scale of 6 to2 (where 0 is the lowest and 10 is the highest)
Assessment Diagnosis Planning Interventions Rationale Evaluation
S:” Nanlalambot ang aking katawan” as verbalized.
O:>weak in appearance>irritable at times>limited body movements
Limited body movements related to body weakness as evidence by verbal report of fatigue or weakness.
After series of nursing interventions the patient will perform self care activities to tolerance level.
>Discuss with patient the need for activity.
>Identify activities that patient considers desirable and meaningful.>Encourage patient to help plan activity progression, being sure to include activities he considers essential.>Encourage to increase foods rich in carbohydrates.>Instruct and help to alternate periods of rest and activity.>Teach the patient exercises for increasing strength and endurance.>Perform active or passive ROM exercise to all extremities every 2 to 4 hours.
>Which will improve physical and psychosocial well-being.>To enhance their positive impact.
>Participation in planning helps ensure patient compliance.
>Carbohydrate is energy- giving.
>To reduce body’s oxygen demand and prevent fatigue.>which will improve breathing and gradually increase activity.>This exercise foster muscle strength and tone, maintain joint mobility and prevent contractures.
The patient will perform self care activities to tolerance level.
Assessment Diagnosis Planning Interventions Rationale Evaluation
S:” Parang wala na akong silbi dahil sa dumapong sakit sa akin” as verbalized.
O:>weak in appearance>irritable at times>poor concentration>difficulty making decisions>agitated
Situational low self-esteem related to unexpected change in health status.
>After series of nursing interventions the patient will verbalize feelings related to current situation and its effect on self-esteem.
>Encourage patient to express feelings about self (past and present).>Assess patient’s mental status through interview and observation at least once per day.
>Involve patient in decision making.
>Provide patient with positive feedback for verbal reports or behavior that indicate a return to positive self appraisal.
>Self exploration encourages patient to consider future change.>If anxiety resulting from self rejection becomes severe, patient may experience disorientation and psychotic symptoms.>To combat ambivalence and procrastination associated with low self esteem.>This gives patient feelings of significance, approval and competence, which can help him core effectively with stressful situations.
>The patient will voice feelings related to current situation and its effect on self-esteem.
Assessment Diagnosis Planning Interventions Rationale Evaluation
S: “Di ko masyadong maintindihan ang sinasabi ng mga doctor at nurses tungkol sa sakit ko” as verbalized.
O:>weak in appearance>irritable at times>poor concentration>poor eye to eye contact
Knowledge deficit: Hepatitis related to difficulty understanding disease process and its effect on self-care.
After series of nursing interventions the patient will express understanding of disease process.
>Provide a quiet, calm environment for learning.
>encourage patient to ask questions to the doctors regarding his disease>Advise the patient that his condition can be transmitted to other so that preventive measures should be practice such as: avoid sharing of toothbrush, nailcutter and other instruments and utensils; use handkerchief when coughing or sneezing.
>To enable the patient to process information without distraction from background noise and stress.>for further understanding of his disease
>To avoid spreading of heap virus.
The patient will express understanding of disease process..
Bataan Peninsula State University
Dinalupihan Campus
Dinalupihan, Bataan
A case Study of
Hepatitis B
Presentedby:
BSN Group J
Marie John Cabrera
Dhonalyn May Campo
Romina Joyce Canlas
Elaine Casupanan
Jim Francis Cayanan
Mark Joseph Cunanan
Katrina de Jesus
Philip Pingul
~February 2010~
