KABALE UNIVERSITY

NAME: Natukunda Dianah

REG NO: 15/A/BNS/0561/W

COURSE: Bachelor of Nursing Science

COURSE UNIT: Health assessment

YEAR: One

SEMESTER: One

LECTURER: Dr. Sam Tumwesigire

DATE OF SUBMISSION: 2nd October 2015

QUESTION;

Give the nursing assessment management of patients presenting with the

following conditions
a) Hypertension
b) Convulsions
c) Tuberculosis
d) Diabetes mellitus
e) Hyperpyrexia
f) Malaria
g) Dehydration

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 A. HYPERTENSION
Hypertension is defined as systolic blood pressure of 140mmHg or greater,
diastolic pressure of 90mmHg or greater.
Blood pressure is the force exerted by blood on the arterial walls.
Types of hypertension
Essential / primary hypertension
 The cause is idiopathic, accounts for 95% of all cases.
Secondary hypertension
 This is secondary to other conditions accounts for 5% of all the cases.
Causes/predisposing factors
 Renal failure
 Obesity
 Conn’s syndrome; over secretion of aldosterone.
 Diabetes mellitus
 Family history of hypertension
 Cigarette smoking
 Sedentary life style
 High consumption of alcohol
 Stress
 Idiopathic
Assessment and management
History of the presenting complaint;
 Elevated systolic and/or diastolic blood pressure
 Morning occipital headache
 Dizziness
 Fatigue
 Epitaxis
 Blurred vision
 Palpitations

Family history; any members that might have had similar complaints.
Social history; patient’s life style and what a patient does for a living.

Examination;
 Blood pressure
systolic (mmHg) diastolic (mmHg)
Stage 1 hypertension 140-159 / 90-99
Stage 2 hypertension >160 / > 100
 Pulse ; rapid
Inspection
 Distended jugular vein
 Edema
Auscultation
 Palpitations
Investigations;
 Electrocardiogram; indicates enlarged left ventricle

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  Urinalysis; show proteinuria
 Blood glucose; 200mg/dL

Initial diagnosis
 Secondary hypertension
Management
Goals of therapy
 To reduce blood pressure to the normal range.
 To modify the patient’s life style
Objectives
 Strengthen the activity of the heart.
 Ensure medicine compliance
 Weight reduction
 Ensure proper nutrition
 Follow up and monitoring
Strategies
Non pharmacological treatment of hypertension
 Avoid harmful habits such as smocking and alcohol
 Reduce salt and high fat diets
 Lose weight if obese
 Regular exercise
Pharmacologic treatment
 Antihypertensive drugs
 Diuretics
 Beta blockers
 Calcium channel blockers
 ACE inhibitors
 Angiotensive II receptor inhibitors.

B. HYPERPYREXIA

Hyperpyrexia is defined as the core body temperature of 38oc or greater.

Causes / predisposing factors.

 Increased heat load

– Heat absorption from environment
– Metabolic heat
 Diminished heat dissipation
– Obesity, anhidrosis, drugs
 Sepsis
 Thyrotoxicosis
 Pheochromocytoma
 Cerebral hemorrhage
 Status epilepticus,

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  Hypothalamic injury
 Infections
– Malaria
– Typhoid
– Osteomyelitis
Differential diagnoses
 Drug toxicity: anticholinergic toxicity, stimulant toxicity (phencyclidine,
cocaine, amphetamines, ephedrine), salicylate toxicity
 Drug withdrawal syndrome: ethanol withdrawal
Serotonin syndrome
 Neuroleptic malignant syndrome
 Generalized infections: bacterial sepsis, malaria, typhoid fever, tetanus
 Central nervous system infections: meningitis, encephalitis, brain abscess
 Endocrine derangements: diabetic ketoacidosis, thyroid storm
 Neurologic: status epilepticus, cerebral hemorrhage.
Assessment and management
History of the presenting complaint;
 Cramps in big muscles – spasms
 Weakness, dizziness, headache, syncope
 Nausea, vomiting
 Temperature 39-41.1oC
 Profuse sweating
 Coma, seizures, confusion
 Convulsions
 Oliguria
Past medical history – any acute or chronic illnesses that may worsen situation.
– history of trauma
Physical exammination
Temperature > 38oc
Other vitals ; blood pressure
respiration; rapid
pulse; rapid
Investigations

 Electro Cardio Gram

 Imaging guided by history
 Complete blood count
 Renal function test
 Liver Function Tests
 Urinalysis – myoglobin
 Pan-cultures
Treatment
Goals of therapy
 To restore effective thermoregulation

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  To treat the underlying cause.
Objectives
 To reduce high temperatures to normal 36oc.
 Offer treatment according to the underlying cause.
Strategies
 Remove to cool environment
 Perform tepid sponging
 Administer antipyretics such as paracetamol.
 Correct fluid and electrolyte imbalances
 Treat the underlying cause according to laboratory findings.

C. DEHYDRATION

Dehydration is a condition that occurs with excess loss of water and electrolytes
in liquid or loose stools and vomitus.
Causes
 Decreased fluid intake
 Increased fluid output (renal, gastrointestinal or insensible losses),
 A shift of fluid (e.g. ascites, effusions),
 Capillary leak of fluid (e.g. burns and sepsis).
Types of dehydration
 Isotonic (isonatremic) dehydration; this is the most common result of
acute watery diarrhea (more than 75% of cases). Deficits of water and
sodium are balanced.
 Hypertonic (hypernatremic) dehydration; the net loss of water is greater
than that of sodium. The condition is more common in young infants who
can't verbally ask for water. It results from the intake of large amounts of
hypertonic fluids (high content of sodium or sugar) during diarrhea.
 Hypotonic (hypontremic) dehydration: it is less common and the net loss
of sodium is greater than that of water. This result from the intake of large
amounts of water or hypnotic fluids during diarrhea

Assessment and management of dehydration

Demographic data of the patient

Name: Agaba John Age: 11 months Sex: Male Weight: 8kg
History of the presenting complaint
 Diarrhea for 4 days
 Vomiting x2
 Fever
 Unable to drink

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Physical examination

Severe Mild to moderate No dehydration

dehydration dehydration
Look at
General condition Lethargic or Restless, irritable Well, alert
unconscious,
floppy
Eyes Very sunken and Sunken Normal
dry
Tears Absent Absent Present
Mouth and tongue Very dry Dry Moist
Thirst Drinks poorly or Drinks eagerly Drinks normally
not able to drink
Respiration Fast and deep fast Normal
Feel
Skin pinch Goes back very Goes back slowly Goes back quickly
slowly after
Pulse Very fast and Fast ,low volume Normal
thready

Investigations

 Complete blood count

 Blood film for malaria parasites
 Stool for culture and sensitivity
 Blood urea and creatnine analysis
Initial diagnosis
 Severe dehydration
Treatment
Goal of therapy
 Correct existing fluid and electrolyte deficit.
 Prevent further fluid losses.

Objectives
 To replace lost fluids
 To maintain nutrition
 To maintain personal hygiene.
 To eliminate infecting organisms
Strategies
Non pharmacological
 Keep the surrounding clean
 Improve personal hygiene of the mother eg hand washing after toilet.
 Home based fluid intake
 Maintaining a well balanced diet

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Pharmacological
Management of severe dehydration (IV fluid therapy-Plan C) Ringer’s lactate
Age (11 months) First give 30mls/kg in Then 70ml/kg in:
Weight 8kg I hour 7 hours
240ml in 1 hour 420 ml in 7hours

Re assessment every 1-2 hours

If child able to drink, is given oral rehydration salts (5ml/kg/hour)
Anti infective therapy;
If bacterial
 Oral ciprofloxacin
15mg/kg/dose 12 hourly for 3 days
Or
 Oral cotrimoxazole
240mg 12 hourly for 5 days.

D. CONVULSIONS
Convulsion is a sudden, violent, irregular movement of a limb or of the body,
caused by involuntary contraction of the muscles and associated especially with
brain disorders.

Causes of convulsion
 Seizure disorders
 Fever
 Meningitis
 Drug or alcohol abuse
 Poisoning
 Hypoglycemia
 Head injury
Assessment and management of convulsions
History of the presenting complaint
 Fever
 Prolonged neurological conditions
 Signs of central nervous system infection
 Bacterial infection
 Stiffness of neck
 Perinatal injury(infants)
Past medical/social history
 History of convulsions
 Head injury
 Chronic illnesses such as epilepsy
 Alcohol or drug abuse
Examination
 Vital signs temperature of 38oc or greater
 Conscious level using Glasgow coma scale

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  Bulging Fontanels (infants)
 Meningism
 Potential (non blanching) rash
 Tongue biting.
Investigations
 Blood tests: complete blood count, erythrocyte sedimentation rate,
glucose, blood slide for malaria parasites.
 Urine microscopy/ culture
 Lumbar puncture; cerebral spinal fluid culture
Diagnosis
 Febrile convulsions
Treatment
Goals of therapy
 Restore the cerebral functioning to normal.
Objectives
 To stop the convulsions
 To treat the underlying cause
 To prevent physical and neurological injury to the patient
Strategies
Non pharmacological
Immediate emergency measures: If patient is seen convulsing:
 Ensure that the patient does not harm himself (moving person away from
sharp objects etc), clothing about the neck should be loosened
 Ensure the airway is clear, remove any secretions or vomitus from the
mouth or nose. Don't force a spoon or tongue depressor into mouth
 Remove false teeth if present
 After convulsions cease, turn the patient into semi-prone position by
turning the patient on the side, with one leg bent and the other leg straight
Pharmacological
 Immediate emergency measures: If patient is seen convulsing:
 Oxygen, intranasal or by face mask, high concentration, to offset cerebral
hypoxia
 Diazepam, IV, Adults10 mg slowly over23 minutes (approximately 2.5
mg every 30 seconds)
 Children200-300 microgram/kg slowly over 23 minutes or if not possible
given the same injectable form (directly from the syringe) into the rectum
after removing the needle. This may be repeated 10 minutes later if the fit
continues.

E. TUBERCULOSIS

This is a disease caused by the bacterium Mycobacterium tuberculosis.

It may affect any part of the body but the commonest site is the lung. When the
lung is affected, the patient is said to have pulmonary TB.

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Causes
 Mycobacterium tuberculosis
 Mycobacterium bovis (bovine TB)
 Mycobacterium africanumI and II

Assessment and management

History of the presenting complaint
 Productive cough that for more than 2 weeks
 Chest pain
 Loss of weight
 Loss of appetite
 Blood stained sputum
 Fever
 Evening or nocturnal sweating
Past medical history
 HIV status
 History of tuberculosis exposure
 Past tuberculosis treatment
 Demographic risk factors for tuberculosis
 Other chronic diseases like diabetes mellitus
Examination
 Weight loss
 Clinical signs of pneumonia, pleural effusion, lung collapse/ fibrosis
 Lympadenopathy-matted / discharging

Investigations
 2 sputum tests for the presence of acid fast bacilli (AFB)
 Chest X-ray
 FBC
 ESR
 Mantoux test-ulcerates, of >10mm in children and >15-20mm in adults
 Mycobacterial culture and drug sensitivity test
 Sputum
 CSF
 Specimen from other extra pulmonary sites
 HIV screening
 CD4 count and viral load in HIV positive patients
Treatment
 Treatment objectives
 To cure the disease
 To prevent further transmission
 To prevent the development of drug resistance
 To offer psychosocial support
 To investigate close contacts

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Non-pharmacological treatment
 Counseling
 Good nutrition
 Adequate rest -give them at least a month off work
 Admission for severely ill patients
Pharmacological treatment
There are two main types of treatment regimes:
Standard/Initial regimen
 Adults; 2EHRZ/4RH
 Children; 2HRZ/4HR

Retreatment regimen
 3EHRZ + streptomycin for the first two months.

F. MALARIA
Malaria is a febrile infectious disease caused by protozoan parasites of the
plasmodium family.
Causes
There are 4 species:
 plasmodium falciparum
 plasmodium vivax
 plasmodium ovale
 plasmodium malariae
Assessment and management
History of the presenting complaint

Uncomplicated malaria

 Fever
 Chills
 Rigors
 Sweating
 Headache
 Generalized body and joint pain
 Nausea and or vomiting
 Loss of appetite
 Abdominal pain (especially in children)
 Irritability and refusal to feed (in infants

Examination
 Pyrexia ( axillary temperature 38oc )
 Jaundice
 Pallor

Complicated malaria

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History of presenting complaint
 Inability to take in fluids (or breast milk in children)
 Repeated profuse vomiting
 Dark or 'cola-colored' urine
 Passing of very little urine
 Difficulty in breathing
 Generalized weakness, inability to walk or sit without assistance
 Altered consciousness (change of behavior, confusion, delirium, coma)
 Repeated generalized convulsions

Examination

 Hyperpyrexia (axillary temperature >38.5°C)

 Extreme pallor (severe anaemia)
 Marked jaundice
 Circulatory collapse or shock (cold limbs, weak rapid pulse)
 Tachypnoea (Rapid breathing)
 Crepitations on chest examination
 Sweating (due to hypoglycemia)
 Haemoglobinuria (dark or 'cola-coloured' urine)
 Oliguria
 Spontaneous unexplained heavy bleeding (disseminated intravascular
coagulation)
 Altered consciousness (change of behaviour, confusion, delirium, coma

Investigations
 Complete blood count
 Blood film for malaria parasites - thick and thin blood films
 Rapid diagnostic tests (only in exceptional cases, if microscopy is not
available)
 Random blood glucose
 Blood grouping and cross-matching
 Lumbar puncture in the convulsing or comatose patient to exclude other
conditions

Treatment
Goal of therapy
 To eliminate malaria parasites
 To restore the functioning of the body systems to normal
Uncomplicated malaria.
Treatment objectives
 To avoid progression to severe malaria
 To limit the duration of the illness
 To minimize the development of drug resistant parasites

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Non-pharmacological treatment
 Tepid sponging to reduce body temperature
Pharmacological treatment
 Artesunate-Amodiaquine, oral,
Alternative Treatment (Reserved for patients not tolerating Artesunate-
Amodiaquine)
 Artemather-Lumefantrine, oral
Or
 Dihydroartemisinin-Piperaquine, oral.
Complicated malaria
Treatment objectives
 To give specific anti-malarial treatment parenterally to ensure adequate
blood-serum concentrations of the drug and rapid clearance of
parasitaemia
 To provide urgent treatment for life threatening problems e.g.
convulsions, hypoglycaemia, dehydration, renal impairment
 To provide appropriate supportive care
Non-pharmacological treatment
 Place patient in a position to prevent aspiration in unconscious patients
and during seizures.
 Tepid sponging to reduce body temperature
Pharmacological treatment
 Quinine, IM, 10 mg/kg
Or
 Artmether, IM, 3.2 mg/kg as a loading dose (to be completed)
Or
 Artesunate, rectal.

G. DIABETES MELLITUS
Is a group of metabolic disorders characterized by hyperglycemia resulting from
defects in insulin secretion, insulin action or both.
Types
 Type 1 diabetes - formerly called insulin-dependent diabetes mellitus or
juvenile diabetes
 Type 2 diabetes - formerly called non-insulin - dependent diabetes
mellitus or maturity onset diabetes
 Gestational diabetes-diabetes developing during pregnancy in previously
non-diabetic individuals.
 Diabetes in Pregnancy
Causes
 A defect in the action or secretion of insulin
 Environmental factors e.g. excessive calorie intake and lack of physical
activity
 Genetic factors

History of presenting complaint

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  Passage of large amounts of urine
 Thirst and excessive drinking of water
 Unexplained weight loss
 Blurred vision
 Recurrent boils
 Recurrent itching of the vulva
 Symptoms related to chronic complications (e.g. 'pins and needles'
sensation or numbness in the hands or feet, foot gangrene, poor vision)
Examination
 Lack of sensation in the feet or hands
 Foot gangrene
 Pedal edema
 Impaired visual acuity
 Cataract
 Retinal changes

Investigations
 Fasting or random blood glucose
 Urine protein
 Blood urea, electrolytes and creatinine.
 Fasting blood lipid profile (adults)
 Full Blood Count
 ECG (adults)

TREATMENT
Treatment objectives
 To relieve symptoms
 To prevent acute hyperglycemic complications i.e. ketoacidosis and the
hyperosmolar state.
 To prevent treatment-related hypoglycemia
 To achieve and maintain appropriate glycogenic targets(fasting blood
glucose between 4 - 6 mmol/L ,2-hour post-meal blood glucose between 4
- 8mmol/L,Glycated haemoglobin 6.5 % or less)
 To ensure weight reduction in overweight and obese individuals
 To prevent chronic complications of diabetes by maintaining
– The glycaemic targets noted above
– Blood pressure less than 130/80 mmHg
– LDL-cholesterol less than 2.5 mmol/L
Non-pharmacological treatment
Diet:
 All patients with diabetes require diet therapy
 All patients (and close relations who cook or control their meals) must be
referred to a dietician or diet nurse for individualized meal plans. In
general, patients must;

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  Avoid refined sugars as in soft drinks, or adding sugar to their beverages.
Artificial sweeteners and 'diet' soft drinks, which do not contain glucose,
may however be used.
 Be encouraged to have complex carbohydrates instead.
 A day's diet must generally consist of;
 Carbohydrates (60%), protein (15%) and fat (25%) mostly of plant-origin
and low in animal fat.
 A reduced total caloric content (portions) and an increase in the amount
of fibre e.g. vegetables, fruits and cereals.
 Exercise Regular, simple exercise e.g. 30 minutes brisk walking at least 3
days a week in ambulant patients
 All advice on exercise must give consideration to the patient's age and the
presence of complications and other medical conditions.
Pharmacologic treatment
Anti diabetic drugs.

Sulphonylureas
 Glibenclamide oral, 2.5-10 mg as a single dose in the morning
(If required, not more than 5 mg of Glibenclamide could additionally be given in
the evening maximum total dose 15 mper day)
Or
 Gliclazide, oral, 40-160 mg 12 hourly
Or
 Glimepiride, oral, 2-6 mg as a single dose in the morning
Or
 Tolbutamide, oral, 250 mg-1 g 8-12 hourly
Biguanides
 Metformin, oral, 500 mg-1 g 12 hourly with, or soon after, meals
Thiazolidinediones
 Pioglitazone, oral, 15-45 mg, as single daily dose
Or
 Rosiglitazone, oral, 4-8 mg, as single daily dose
Insulin
Rapid-acting Insulin
 Insulin aspart
 Insulin lispro
Short-acting Insulin
 Regular insulin
 Intermediate-acting Insulin
 Isophane (NPH) insulin
Long-acting Insulin
 Insulin glargine
 Insulin detemir

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