UNIVERSITY OF THE EAST RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

AURORA BOULEVARD, QUEZON CITY

COLLEGE OF NURSING

SUBMITTED BY:

MEMBERS: GROUP 1A CARANDANG, Russel Anne Marie CENTENA, Rose Anne Louise ENRIQUEZ, Marian Roserie ALMIRAEZ, John Paul GELERA, Hazel Marie Christel GONZALES, Aura Kay RAGASA, Mirabella MEJIA, Mary Ann JULY 1 2, 2011 JULY 8 9, 2011 JULY 15 16, 2011 DATE SUBMITTED: SUBJECT: JULY 22, 2011 RENAL NURSING ELECTIVE COURSE BSN 4 A BSN 4 A BSN 4 A BSN 4 E BSN 4 A BSN 4 A BSN 4 A BSN 4 E

GROUP 1B

SCHEDULED DAYS OF DUTY:

NURSING PROCESS

I.

ASSESSMENT A. CLIENTS PROFILE NAME: BMA AGE: 56 YEARS OLD SEX: MALE STATUS: MARRIED ADDRESS: STA. MESA, MANILA BIRTH DATE: FEBRUARY 24, 1955 BIRTH PLACE: MANILA OCCUPATIONAL HISTORY: RETIRED OFW (WORKED AS A RESTAURANT MANAGER) RELIGION: CHRISTIAN DATE STARTED FOR HD: JANUARY 04, 2011 ATTENDING PHYSICIAN: DR. HIZON CHIEF COMPLAINT: DIAGNOSIS: NEPHROPATHY SOURCE OF INFORMATION: DIFFICULTY OF BREATHING FOR 1 DAY DURATION CHRONIC KIDNEY DISEASE (CKD) STAGE V SECONDARY TO DM

PATIENT, HIMSELF

B. CURRENT HEALTH STATUS HISTORY OF PRESENT ILLNESS

One month prior to admission (PTA) to RSI Dialysis Center, patient experienced difficulty of breathing and was brought to the clinic where his daughter (who is a nurse) was working. A blood sample was then collected for laboratory exam. Based from the laboratory result, there was an increase in the creatinine level, while there was a decrease in the hemoglobin level. On the same day, he was brought to National Kidney institute. After 18 days of confinement, he was referred to RSI Dialysis Center. He was admitted for uremic symptoms; hence hemodialysis was started.

PAST HEALTH HISTORY

Patient BMA had undergone reconstructive surgical procedure in the lips when he was 17 years old (1972). He is known to have Diabetes Mellitus Type II for 25 years (from 1986 until present). He is taking Glucosol 3x/day before meals. The patient has no known allergies. He was given complete immunization in the community. He had traveled outside the country due to his job as a restaurant manager.

FAMILY HEALTH HISTORY GENOGRAM

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DM HTN CKD V

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LEGEND: - MALE - FEMALE - DECEASED MALE FAMILY MEMBER - DECEASED FEMALE FAMILY MEMBER - GONE INTO AN OPERATION FOR MYOMA - LEUKEMIA HTN DM - HYPERTENSION - DIABETES MELLITUS CKD V - CHRONIC KIDNEY DISEASE STAGE V - PATIENT

Patient is known to have Diabetes Mellitus Type II. He was also hypertensive. He was then diagnosed of having chronic kidney disease on December 2010. His eldest sister was diagnosed of having myoma, and went for an operation. His eldest brother was diagnosed of having hypertension and diabetes mellitus. The fourth sibling died of leukemia when she was 3 years old, while the fifth one died when she was 2 months.

Socio- Cultural Health

Patient is a 56-year old male, Christian. According to him, they live in a two-storey house in Sta. Mesa, Manila wherein there are four (4) occupants. Their residence is located near the highway. Transportation is readily available in the community and there are health facilities within the communitys vicinity. His wife is in abroad. His daughter and son, as well as his nephew are residing with him in the same house. His source of income is from his wife, daughter, and his cousin from Hongkong who is helping him financially.

Developmental History Middle Adulthood Generativity vs. Self absorption or Stagnation Basic Strengths: Production and Care In this stage, middle-age is when we tend to be occupied with meaningful activities and with matters concerning the family. Here, we expect to be in charge. BMA is under the Generativity vs. Stagnation. Generativity is when an individual often fear inactivity and meaningless. A persons relationships or goals change, he may be faced with major life changesthe mid-life crisisand struggle with finding new meanings and purposes . If he doesnt get through this stage successfully, he can become self-absorbed and stagnate. Significant relationships are within the workplace, the community and the family.

C. GORDONS FUNCTIONAL HEALTH PATTERN

HEALTH-PERCEPTION HEALTH MANAGEMENT PATTERN Subjective: Dati, masasabi ko talagang masigla at malusog ako. Kayang kaya ko magovertime at magtrabaho ng 16 hours e. Pero ngayon hindi na. mabilis ako mapagod. Mabilis ako manghina. Lagi nang nasa bahay halos. Pero nakakalabas naman. Iba nga lang kaysa dati, ibang-iba. Umiinom ako ng vitamins. Kaso di ko alam pangalan e. Kapag may sakit ako noon, kunwari yung mga simpleng lagnat, ubo o sipon, umiinom ako ng gamot. Minsan naman tubig lang. Pero ngayon, dahil may sakit daw ako sa bato, dapat magpacheck-up lagi kasi sinusukat yung dose ng dapat kong inumin. Yung ibang gamot ko, hindi ko lagi iniinom. Tulad nung pang-high blood yata yun. Syempre hindi naman ako iinom kung hindi mataas presyon ko. Itong sugat ko, dyan sa access. Masakit pa rin kapag tinutusok para sa dialysis kahit na ilang beses na nagamit. Tapos sabi nga nila lumalakki sa katagalan. Tulad ng itsura nyan ngayon. Tapos namumula, as verbalized by the client. Objective: cannot read any letter on the jeagers chart-no glasses used; with diagnosis of cataract;cannot feel sensation on some parts of the lower extremities; has dark complexion with dark spots on right lower arm; and bilateral lower legs and feet; nails are pale and slightly brittle; prescribed with the following medication for management (lozartan; amlodipine; ferrous sulfate; calcium carbonate; Eposina Alfa; vitamin b complex; iterax); height: 175 cm weight (dry weight: 70 kg; pre-weight: 76 kg) initial vital signs (BP: 140/90 PR: 79 RR: 18 temp: 36.8 oC); with access at left upper arm for dialysis; artery and vein on venous access are bulging; with redness noted on venous access during insertion of blood lines; with bruit heard and thrill felt during hemodialysis; Neutrophils=71.2 % Diagnosis: Risk for infection related to inadequate primary defenses

NUTRITIONAL- METABOLIC PATTERN Subjective: Ang hilig kong kainin ngayon, sisig. Hindi naman sa paborito ko siya pero ewan ko, parang naghahanap lagi yung katawan ko ng sisig. Hindi talaga sya pwede lagi sa akin, pero minsan nakakatakas ako, pag may pagkakataon. Pero wala naman akong pinipili noon. Kahit ano. Gulay, karne, isda, lahat. Pero ngayon, yung lagay ng katawan ko na yung namimili, lalo na kapag bagong labas ng laboratory? Naku! Ayan na yung bawal ng masyadong maalat, yung ganito ganun. Kaya syempre, kapag walang lasa, walang gana na kumain. Sa probinsya naming sa Ilocos Norte, mahilig kainin doon yung bagnet tapos sa impluwensya ng mga pamangkin ko yung longganisa at seaweed. Uso din sa amin yung bagoong, sarap nun. Sa pag-inom ko, dapat hanggang ganito lang karami (shows water container which carries up to 1 liter of fluid). Pero minskapag nauuhaw, nasosobrahan. Wala naman akong magawa, parang mamamatay ako sa sobrang tuyo ng lalamunan ko. Ang mahirap lang, kapag bumabalik ako para sa dialysis, sobrang laki na ng binibigat ko kapag maraming nainom, tapos minsan lumalagpas pa ako sa schedule. Naninigarilyo din ako noon. Nagsimula ako binata pa ako. Pero tumigil na ako mga 20 years na. kasi 5 years old yung panganay ko nun. E 25 na sya ngayon, as verbalized by the client. Objective: skin is warm to touch on proximal area and cold to touch on hands and feet; client felt cold during assessment; no lesions noted but with black discolorations on right lower arm and bilateral lower extremities and feet; pale conjunctiva and oral mucous membrane; with upper dentures; gums are pale; tongue is slightly pale with whit spots in the middle; no jugular vein distention; gag reflex present; increase in weight (from 70kg to 76 kg); grade 2 pitting edema noted (lower extremities) Diagnosis: Extracellular Fluid Volume Excess related to retention of sodium and water in the interstitial space secondary to impaired renal function as manifested by edema.

ELIMINATION PATTERN Subjective: Dati, halos palagi ako umiihi. Mga kada-inom ko, siguro may kapalit agad na ihi, pero di naman sabay. Ngayon, wala na. kung iihi man ako, parang isang kustsara na lang yung dami. Kapag parang gusto ko umihi, pero hindi ako maihi, ang sakit sakit ng dito sa may bandang pantog. Ginagawa ko, umuupo ako, yun, medyo nawawala yung sakit. Kaunting pahinga bago ako uli tumayo. Sa pagdumi ko, wala namang problema ngayong araw kasi nakabawas ako, pero may time noon na nagconstipate ako. Siguro parang bilog na longganisa yung laki. Isang lingo ata yung tinagal nun. Tapos pinainom ako ng dulcolax. Nakadumi naman ako. Minsan naman nagsusuppository ako. Sabi kasi, kulang na ako sa exercise, tapos limitado pa daw yung tubig. E paano din naman ako makakadumi, may mga oras na wala naman akong ganang kumain, as verbalized by the client. Objective: abdominal skin is warm to touch; dark complexion- color is evenly distributed; normoactive bowel sounds at 3x every 15 seconds with the exception at LUQ and LLQ which is only once every 10 secs; no tenderness noted but with small soft mass on LLQ upon palpation; increase in weight from 70 to 76 kg; presence of edema; urine and stool was not assessed because client did not urinate and did not have his bowel movement during dialysis. Diagnosis: Impaired urinary elimination r/t impaired renal function sec to CKD as manifested by clients report of very small amount or absence of urine output

ACTIVITY-EXERCISE PATTERN Subjective: Naglalakad naman ako, nang may tungkod. Dati kayak o tumakbo. Nagbabasketball pa nga ako. Pero ngayon, nahihirapan na ako. Mabilis ako mapagod. Tapos kapag napagod, umuupo ako agad. Kasi baka mamaya mahilo ako. Karaniwang layo nang nalalakad ko siguro mula dito sa RSI hanggang dun sa kanto nitong kalsada. Tapos mapapagod na ako. Dito sa bahay, minsan nagpupunas ako ng mesa, tapos mga cabinet. Pero di ko na kaya yung magbuhat. Tapos namamaga pa paa ko, kaya masakit ilakad. Kapag nasobrahan ng pagod, tapos mainit. Inuubo ako. Tapos nahihirapan huminga. Ginagawa ko lang,nagpapahinga. Tapos di ako humihiga, kasi parang nasasakal yung pakiramdam, as verbalized by the client. Objective: skin, nails and conjunctiva is pale; capillary refill at fingernails is at secs; capillary refill at the distal nails/toes is 3-4 secs; weak brachial pulses; pulses at lower extremities are difficult to locate; distal areas of skin are cold to touch; heart rate is 79 bpm, no extra heart sound noted; respiratory rate at 18 bpm, deep, accompanied by nasal flaring and use of mouth while breathing, crackles noted upon auscultation but was diminished after dialysis; able to do range of motion exercises slowly; muscle strength 5/5 on all extremities; balance was not assessed because client was on his dialysis session and goes home immediately after dialysis; unsteady gait noted due to grade 2 pitting edema; uses cane as to assist him while walking Diagnosis: Fatigue r/t anemia secondary to altered erythropoietin production

SLEEP-REST PATTERN Subjective: walang eksaktong oras ng gising at tulog ko e. kahit sa hapon, hindi naman ako lagi natutulog. Minsan sa hapon nakakapagpahinga lang ako kapag nagdadialysis kasi walang ginagawa, malamig, at nakakaantok talaga. Masarap ang tulog ko kapag bagong dialysis. Kasi parang walang bumabara sa daluyan ng hangin ko. Pero kapag di pa ako nagdadialysis o kaya kapag matagal tagal bago ako bumalik dito(RSI), grabe ang hirap. Paputol-putol ang tulog ko, kasi hirap akong huminga. Lalo na kapag yung naiinom ko sobra-sobra sa sinabi sa akin ng doctor. Mga tatlong unan ginagamit ko sa pagtulog. Alisin mo lang ang isa, pakiramdam ko nalulunod na ako. Bago matulog, ayun

nagdadasal ako, yun lang naman. Syempre nanonodd ng tv. Pero hindi naman ako yung nanonood ng matagal kasi Malabo din naman, as verbalized by the client Objective: client yawns from time to time; slowed reaction to questions but is able to answer Diagnosis: Insomnia r/t difficulty of breathing sec to excessive body fluids as manifested by clients report of disrupted sleep, yawning COGNITIVE-PERCEPTUAL PATTERN Subjective: Malabo na yung mata ko. Kasi may katarata ako. Pag ganyan ka kalayo (3 seats apart) nakikita ko yung hugis ng mukha mo pero yung mata mo hindi malinaw. Pero pag nilapit mo yung kamay mo(1 seat apart) nakikita ko kung ilan yang daliri na pinapakita mo. Hindi pa naman ako nabibingi sa awa ng Diyos. Pero syempre hindi ko naman alam kung talagang hindi pa humihina pandinig ko, binase ko lang sa kasi naririnig ko kayo kahit mahina boses nyo. Yung sa panlasa ko, minsan hindi ko nalalasahan. Sabi naman ng pamangkin ko o nung anak ko, may lasa naman. Hindi nga lang ganun kalasa kasi medyo bawas yung alat. Pero ako, wala talaga akong nalalasahan. Pero hindi naman lagi. Kapag may sipon ako o parang may nakabara sa paghinga ko, parang medyo nawawala din pang-amoy ko. Syempre, kahit sino naman siguro. Sa pangdamdam, wala naman. Minan lang sa paa, di ko maintindihan kung namamanhid ba o nananakit, na parang nangangawit, as verbalized by the client. Objective: cannot read any letter on the jaegers chart-no glasses used; with diagnosis of cataract; pupil size equal on both sides (estimated at 3-4mm); pupils equal and reactive to light and accommodation; both eyes move bilaterally in all directions; pain or tingling sensation felt on feet accompanied by facial grimaces but according to client, pain is tolerated at a pain scale of 2/10 and is not radiating Diagnosis: Disturbed sensory perception: visual perception r/t altered status of sense organ (cataract) SELF-PERCEPTION SELF-CONCEPT PATTERN Subjective: Kung kilala nyo ako dati pa, makikitang ang laki ng pagkakaiba ko noon kaysa ngayon. Dati napakalakas ko. Ang dami ko pa ngang napuntahan na lugar kasi kung saan-saan ako nagtrabaho. Pero ngayon, ang dami nang bawal sa akin. Kung hindi bawal, hindi ko na kayang gawin. Parang wala ka nang magagawa kundi umupo, kumain, uminom ng gamot araw-araw. Sa bagay tumatanda na rin. Pero syempre, mas maganda pa rin yung malusog ka kahit tumatanda na. pero hindi naman ako yung pinanghihinaan ng loob kasi alam ko pinabayaan ko din sarili ko, as verbalized by the client. Objective: cannot maintain eye contact when topics about self and health comes in; frowns on sad statements Diagnosis: Situational low self-esteem r/t functional impairment sec to CKD as manifested by clients verbalization of helplessness and gestures associated with it ROLE-RELATIONSHIP PATTERN Subjective: sa bahay, ang kasama ko yung dalawa kong anak, at isa kong pamangkin. Wala pa naman silang mga sariling pamilya. Yung asawa ko, nasa ibang bansa, nagtatrabaho siya. Tapos nagpapadala dito ng panggastos ko at dito sa bahay. Pero umuuwi naman paminsan-minsan para magbakasyon. Tinutulungan din pala ako ng pinsan ko na nasa Hongkong para sa mga gamot ko. Sa lugar naming, president ako ng sonny Belmonte volunteer movement. Yun yung parang samahan na

tumutulong sa nangangailangan sa lugar naming. Hindi naman eksaktong ako yung tatakbo, maglalakad pero ako yung namumuno sa samahan. Kahit noon pa man. Maganda naman yung samahan naming sa komunidad. Cooperative naman lahat, as verbalized by the client Objective: Client came in the dialysis area with nephew; talks without hesitation about family relationships and smiles when talking about them Diagnosis: Readiness for enhanced family processes SEXUALITY-REPRODUCTIVE PATTERN Subjective: Lalaki ako, may asawa ako nasa America at may dalawa akong anak. Oo na-circumcise na ako, wala naman ako napapansin na paglaki o secretion sa penis ko. Hindi naman kami gumagamit ni misis ng contraceptives kahit noon. Hindi naman kasi kami madalas magkasama, lalo na ngayon. Noon kapag andito sa bansa yung asawa ko, kapag gusto naming gawin, gagawin naming. Pero parang hindi na rin naming nagagawa yun kasi matanda na kami, lalo na ako madali na ako mapagod the client verbalized when asked about his reproductive pattern. The daughter of the client verbalized, Minsan naicocomplain at naijojoke nya samin nab aka hindi na nya kaya gumawa ng isa pang anak. Pero tanggap naman na nya yon. Objective: Client is married for 19 years and has 2 children who accompany him during his therapy. Client is circumcised. Penile discharge is absent. Folds present around scrotal sac. Diagnosis: Ineffective sexuality pattern related to physical exhaustion as manifested by report of decreased sexual performance. COPING-STRESS TOLERANCE PATTERN Subjective: Hindi naman na ako namamasyal masyado ngayon. Nahihirapan nga ako lumakad e. ginagawa ko lang sa bahay. Nanonood, tumutulong magpunas-punas ng maabot habang nakaupo. Naglalakad din pero, mas marami ang pahinga. Minsan nagbabasa ako ng dyaryo. Hindi ako mahilig sa mga scrabble o chess. Hihiga na lang ako. Kahit di makatulog, at least makapagpahinga kahit puro pahinga na lang kayang gawin halos, as verbalized by the client. Objective: client is relaxed but yawns from time to time; no other signs or evidence of stress is noted Diagnosis: Readiness for enhanced coping VALUES-BELIEF PATTERN Subjective: Bilang tao, parang abnormal talaga yung may ganitong kondisyon, sa pisikal, sa pakikitungo sa iba. Pero wala naman ako magagawa, si Lord God na bahala. Pumupunta ako sa church para magworship o bible study. Tuwing linggo yun. Sa mga weekdays, bihira ako pumunta. Parang din a nga ako nakakapunta ngayon e. busy kasi mga kasama ko sa bahay. E hindi ko naman kayang ako lang mag-isa. Pero minsan sa bahay sila pumupunta para doon kami magsstudy. Born Again Christian kami. Kasam ko mga anak ko, nagshe-sharing. Tapos nagdadasal. Pinepray over din nila ako. Tapos kapag gabi, nagbabasa din ako minsan ng bible. Tapos bago matuog, sabi ko din kanina, nagdadasal ako, as verbalized by the client. Objective: no signs of mood alterations are noted Diagnosis: readiness for enhanced religiosity