A CASE PRESENTATION ON TYPE 2 DIABETES, CHRONIC KIDNEY DISEASE

SECONDARY TO DIABETIC NEPHROPATHY AND SEPSIS SECONDARY TO

FOURNERS GANGRENE

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

Chinchuntic, Joan

JANUARY 21, 2019

 TABLE OF CONTENTS

I. TITLE PAGE

II. TABLE OF CONTENTS

III. LIST OF TABLES

IV. LIST OF FIGURES

V. OBJECTIVES 1

General Objective

Specific Objectives

VI. INTRODUCTION 2-4

VII. NURSING HEALTH HISTORY

Vital information 5

History of present health concern 6

Past history 6

Genogram 7

Physical assessment and review of systems 8-11

Gordons assessment 12-13

Diagnostic tests 14-15

VIII. NORMAL ANATOMY AND PHYSIOLOGY 16-20

IX. PATHOPHYSIOLOGY 21-22

X. NURSING CARE PLANS 23-28

XI. DISCHARGE PLAN 28-36

XII. REFERENCES 27
 LIST OF TABLES

1 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 8-11

2 GORDONS ASSESSMENT 12-13

3. DIAGNOSTIC TEST 14-15

4. NORMAL ANATOMY AND PHYSIOLOGY 16-20

5. NURSING CARE PLAN 27-33

 LIST OF FIGURES

1 GENOGRAM 9

2 PATHOPHYSIOLOGY 25-26
 OBJECTIVES

General Objectives:

At the end of one and a half hour of case presentation, the participants will be able to learn
about the disease process of ESRD SECONDARY TO DIABETIC NEPHROPHATY, TYPE 2
DIABETES MELLITTUS.

Specific Objectives:

At the end of one and a half hour of case presentation, the participants will be able to:

1. Relate the health history of the patient to DM 2, CKD, diabetic nephrophaty, and
fourners gangrene.
2. Categorize the physical assessment and review of system involved to DM 2, CKD,
diabetic nephrophaty, and fourners gangrene.
3. Numerate at least 5 diagnostic tests related to to DM 2, CKD, diabetic nephrophaty, and
fourners gangrene.
4. Discuss the anatomical structure and functions involved in to DM 2, CKD, diabetic
nephrophaty, and fourners gangrene.
5. Summarize the pathophysiology, risk factors and manifestations of to DM 2, CKD,
diabetic nephrophaty, and fourners gangrene.
6. Formulate appropriate nursing process for the client with DM 2, CKD, diabetic
nephrophaty, and fourners gangrene.

1
 INTRODUCTION

Diabetes is a group of metabolic disease characterized by increased levels of glucose in the

blood resulting from defects in insulin secretion, action, or both. Diabetes is a common lifelong
behavioral and lifestyle changes, it is a major public health problem worldwide and its complications
cause many devastating health problems. In the United States, diabetes is the leading cause of new
cases of blindness, end-stage renal disease requiring dialysis or transplantation, and foot or leg
amputations. The classifications of diabetes are Type 1 diabetes which affects approximately 5% to
10% of people with the disease. It is characterized by destruction of the pancreatic beta cells. People
do not inherit Type 1 diabetes itself but rather a genetic predisposition, or tendency, toward
development of Type 1 diabetes. This genetic tendency has been found in people with certain human
leukocyte antigen types. There is also evidence of an autoimmune response in Type 1 diabetes. There
is an abnormal response in which antibodies are directed against normal tissues of the boy, responding
to these tissues as if they were foreign. The second classification of diabetes is Type 2 diabetes which
affects 90% to 95% of people with the disease. It occurs more commonly among people who are older
than 30 years old and above, and obese, although its incidence is rapidly increasing in younger people
because of the growing epidemic of obesity in children, adolescent, and young adults. The two main
problems related to insulin Type 2 diabetes are insulin resistance and impaired insulin secretion.
Insulin resistance refers to a decreased tissue sensitivity to insulin. In Type 2 diabetes, these
intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by
the tissues and regulating glucose release by the liver. The exact mechanisms that lead to insulin
resistance and impaired insulin secretion are unknown, although genetic factors are thought to play a
role. And the last classification of diabetes is, Gestational diabetes which occurs in as many as 18%
of pregnant women and increases the risk for hypertensive disorders during pregnancy. The clinical
manifestations of diabetes include the “three P’s”: Polyuria, Polydipsia and Polyphagia. And other
symptoms are fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet,
dry skin, skin lesions or wounds that are slow to heal, and recurrent infections.

Diabetic nephropathy id pathologic changes in the kidney that reduces kidney function and
leads to renal failure. Diabetes is the leading cause of ESRD and renal failure in the United States.
Diabetic nephropathy affects 20%- 30% of those with type 1 diabetes 20 years onset. Although less
than 20% of clients with diabetes type 2 have nephropathy, about 60% of the clients with ESRD have
type 2 diabetes. Risk factors for diabetic nephropathy include 10-15 years of history of diabetes,
diabetic retinopathy, poor blood glucose control, uncontrolled hypertension, and genetic
predisposition.

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 Chronic kidney disease is an umbrella term that describes kidney damage or a decrease in
glomerular filtration rate (GFR) lasting 3 or more months. CKD is associated with decreased quality
of life, increased expenditures, and premature death. Untreated CKD can result in end-stage renal
disease (ESRD), which is the final stage of renal failure. ESRD results in retention in or uremic waste
products and the need for renal replacement therapies, dialysis, or kidney transplant. Diabetes is the
leading cause of renal failure in patients starting renal therapy and hypertension is the second leading
cause. The stages of CKD are Stage 1 were the GFR greater than 90 ml/min/1.73 square meter, which
the kidney damage with normal or increased GFR. Stage 2 GFR is 60- 89 ml/min/1.73 square meter,
or mild decrease in GFR. The stage 3 GFR is 30- 59 ml/min/ 1.73 square meter, or moderate decrease
in GFR. Stage 4 GFR is 15-29 ml/min/ 1.73 square meter, or severe decrease in GFR. And the last,
Stage 5 GFR is less than 15ml/min/ 1.73 square meter, or End-stage renal disease or chroming renal
failure. Elevated serum creatinine levels indicate underlying kidney disease; as the creatinine level
increases, symptoms of CKD begin. Anemia, due to decreased erythropoietin production by the
kidney, metabolic acidosis, and abnormalities in calcium and phosphorus herald the development of
CKD. Fluid retention, evidenced by both edema and congestive heart failure develops. As the disease
progresses, abnormalities in electrolytes occurs, heart failure worsens, and hypertension becomes
more difficult to control. When a patient has sustained enough kidney damage to require renal
replacement therapy on a permanent basis, the patient has moved into the fifth stage of CKD, also
referred to as ESRD or chronic renal failure.

Fournier gangrene is a type of necrotizing fasciitis or gangrene affecting the external genitalia
and/or perineum. Fournier’s gangrene involves an infection in the scrotum (which includes the
testicles), penis, or perineum. The perineum is the area between the scrotum and anus for a man; or
the area between the anus and vulva for a woman. The dead or dying tissue in people with this type
of gangrene is often found in the genitals and can stretch to the thighs, stomach, and chest.It
commonly occurs in older men, but it can also occur in women and children. It is more likely to occur
in diabetics, alcoholics, or those who are immunocompromised. About one per 62,500 males are
affected per year. Males are affected about 40 times more often than females. It was first described
by Baurienne in 1764 and is named after a French venereologist, Jean Alfred Fournier, following five
cases he presented in clinical lectures in 1883. Most cases of Fournier gangrene are infected by both
aerobic and anaerobic bacteria. Resulting mortality increases in individuals lacking access not only
to pragmatic resources such as sanitation and medical care, but to psychosocial resources, as well. A
2006 Turkish study reported 46% of those diagnosed with Fourniers had elevated blood sugar levels.
Some additional findings seemingly link Fourniers with immunosuppression and alcoholism. One
study reported about one-third of those diagnosed with Fournier had alcoholism with resulting
diabetes and malnutrition, while another 10% had been medical immunosuppressed via
chemotherapy, steroids, or malignancy. Initial symptoms of Fournier gangrene include swelling or

3
sudden pain in the scrotum, fever, pallor, and generalized weakness. More marked cases are
characterized by a foul odor and purulent discharge from the infected tissue. Crepitus has been
reported. It begins as a subcutaneous infection. However, necrotic patches soon appear in the
overlying skin, which later develop into necrosis.

The purpose of this case presentation is to have knowledge about Type 2 diabetes, chronic
kidney diseases secondary to diabetic nephropathy and fourners gangrene . This would help nursing
student to enhance assessment and management skills in caring of patients with this type of disease

4
 VITAL INFORMATION
Code Name: Elmo

Age: 60

Gender: Male

Civil status: Married

Date of birth: November 16, 1958

Place of birth: Tubod, Iligan City

Race: Filipino

Cultural or ethnic background: Cebuano

Primary language: Bisaya

Secondary language: English, Tagalog

Religion: Iglesia Ni Cristo

Highest educational attainment: College undergraduate

Occupation: Construction Manager

Usual health care provider: Attending Physician

Date of admission: January 06, 2019 @ 2:40 pm

Date of discharge:

Source of history: 10% Patient, 10% Nurse, 50% Chart, 30% SO

Reasons for seeking health care: Non- healing wound on scrotal area

Primary attending physician: Jenneate Abucayon- M.D

Initial impression/diagnosis: Sepsis secondary to fourners gangrene, chronic kidney disease secondary to

diabetic nephropathy status post hemodialysis, type 2 diabetes, insulin requiring hypertension.

Final diagnosis: End-stage renal disease secondary to diabetic nephropathy

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 HISTORY OF PRESENT ILLNESS

On December 20, 2018,prior to admission Mr. Elmo noticed that his scrotal area has a little
pimple and some rashes that surround. He scratched it until the pimple become lesion and four days
after he felt slight pain and slight burning sensation on the area. He went to AMCI out-patient
department for consultation but the Doctor on duty refer him to Dra. Abucayon and went to ER for
admission but that time there is no available room so Dra. Abucayon just gave him an antibiotic to
manage that lesion. Three days after, Mr. Elmo got on and off fever but he just ignore for 3 days until
he was rush at Mercy Community Hospital for emergency ICU because he had difficulty of breathing
with O2 saturation of 71% and creatinine of 900. He was confined in ICU for two days and transfer
to a private room. January 1, 2019, he undergone the first debridement of his lesion that worsen
already. After five days, he was transfer to another hospital which is AMCI for better management
and for the second debridement of his wound. January 08, 2019, Mr. Elmo had his first session of his
hemodialysis through central vein and it was scheduled twice a week or every Tuesday and Thursday.

HISTORY OF PAST ILLNESS

Mr. Elmo was delivered via normal spontaneous vaginal delivery at hospital. He forgot if he
had immunizations and vitamins. He experienced measles and chickenpox in his childhood years. He
stated he had frequent hospitalization because of fever, cold, and flu. He had hypertension with
previous consultation and maintenance. Year 2008, he was diagnosed diabetes and that year also he
know that his right kidney is small. After 8 years, he undergone nephrectomy for the right kidney at
CDO hospital. He said that he is Hypertensive since he was 31 years old and had his maintenance
medication.

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 PATERNAL GENORGRAM MATERNAL

PATIENT

LEGEND:

(FEMALE) HYPERTENSION (ALIVE) (UNKNOWN) DM

(MALE) colon cancer ( DECEASED) (cardio megaly)

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 PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS

AREAS ASSESSED SUBJETIVE OBJECTIVE DATA PROBLEM

DATA IDENTIFIED
General Health Have you been (+) cough (unproductive) Acute pain
Survey feeling well? (+) body weakness
(+) weight loss
“not really.” As (+) Headache Ineffective
verbalized by the (+) Dizziness breathing pattern
S.O (+) Abdominal Pain
(+) Chest pains
(+) Palpitations Imbalanced
(+) Vomiting nutrition: less than
Have you lost or (+) Dysuria body requirements
gained weight (+) Anuria
recently?  Conscious and coherent
 Afebrile Activity Intolerance
“oo nidako gyud  Not dyspneic
sya.” As verbalized  Pale and weak noted
by the S.O  Strong palpable pulse
 IVF PNSS 1L @ 20
gtts/min connected @ L
central vein catheter
 Central vein catheter in
place
 Urinary catheter is
attached
 Need assistance in
walking
-Fourners gangrene
-Chronic kidney disease
-post hemodialysis
-type II Dibetes
Mellitus, insulin
requiring hypertension

Vital signs:
BP 150/90
RR 19
PR 87
T 37.1
02sat 95%

Integumentary Do you have skin  Peripheral edema Anemia

System rashes or lesions?  Cyanotic all over the
body
“Wala raman sad.”  Warm to touch
Temp : 37.1’C
 Finger nails and
toenails were curvature
in angle and pale in
color


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HEENT Do you have any  Warm, clammy, Anemia
a. Head and visual problems? diaphoretic, and pale
Face appearance
b. Eyes “Yes! He wears  Pale conjunctiva
c. Ears reading glass”  Pupillary reflex: 4mm
d. Nose  Eyes open
e. Oral Cavity Do you have any spontaneously
hearing problem?  Anicteric sclerae
 Submandibular and
“Nope” submental
 Lymphadenopathy
nontender
 Lips were dry and
slightly pale
 Cyanotic nails

Neck Do you experience (-) lymp nodes Risk for infection

stiff neck?  Nontender
 Supple
“wala raman.”  Cervical Vein is
Attached @ L area of the
neck for emergency
dialysis
 Limited range of
motion
Respiratory System Do you have (+) Crackles on L lung field Ineffective
asthma?  Sternum is positioned breathing pattern
at midline and straight
“wala pod.”  Retractions not
observed
 No tenderness or pain
is palpated over the
lung area with
respirations
 Nasal flaring is not
observed
 Chest AP Portable
result: Homogeneous
opacity at the left
lower lung
 The right lung is clear
 The bony thorax is
normal
 Minimal left pleural
fluid
PR 87 bpm
RR 19 bpm

Cardiovascular Do you have chest  Chest AP Portable

system pain? result: the heart is
normal in size and
“kadtong naadmit orientation
sya sa mercy  Altered immobility

9
 maglisod na gyud HR 19 bpm
sya ug ginhawa ato PR 87 bpm
77% nalang iyang BP 150/90 mmHg
oxygen gud.” As O2sat 95%
verbalized by the
S.O
Breast and Axilla  No swelling, nodules
and ulceration detected

Gastrointestinal Do you have any (-) Murphy’s Risk for infection

System and the stomach problems?  Flat and soft
abdomen  Tender upon palpated
“gahi iyang tyan” of epigastric area soft
and mid-hypogastric
area
 Abdominal respiratory
movement is seen
RR 19 bpm
 Asymmetry is seen
 Diminished abdominal
respiration

Genitourinary / “okay man iyang  urinary catheter Risk for Infection

Reproductive System pagpangihi dili man attached
sya maglisod.” As  Noted to have Non
verbalized by the healing wound on
S.O scrotal area
 Wound Discharge Test:
Pseudomonas spp
 Positive Fourners
Gangrene
Musculoskeletal (+) Body weakness Activity intolerance
System (+) Edema related to
 Both lower and upper generalized body
extremities weakness

Neurologic System How would you Imbalanced

described your  Eyes move in a smooth nutrition: less than
mood? coordinated motion in body requirements
all directions
“moody gyud sya  Pupillary reflex: 4mm
usahay” (open spontaneously)
 Eyelids blink bilaterally
Do you feel any  Best verbal response: 5
numbness? (oriented and
converses)
“Wala raman pod”

Lymphatic/ Have you been tired?  Pale skin are noted Anemia
hematologic System  Stool color: brown
“bug-at kayo akong  No skin bruising,
lawas.” petechial rashes,

10
 ecchymosis and other
bleeding tenderness.
CBC results:
HGT: 286
Uric Acid: 462.04
Creatinine: 615
Hematocrit: 0.34
Hemoglobin: 112.0
WBC: 21
Lymphocytes: 0.10
Platelet count: 250
Potassium: 4.10
Sodium: 149.0

Endocrine System (-) Buffalo Lump Activity intolerance

(-) wound for signs of poor related to
healing generalized body
(-) abdominal pigmentation weakness
(-) eyes exophthalmia
(+) Body weakness

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 GORDONS ASSESSMENT

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

NUTRITIONAL/ METABOLIC PATTERN
 Mr. Elmo was fond of eating foods high in fat and  Daibetic diet,Lowin purine and Low salt
cholesterol like “ginataang manok”, lechon, and diet
meat products. He drinks soda 3x a day and coffee  He has a good appetite and always
once a day. He eats fast food most of the time, consumed all the foods served at him.
and desserts every after meals.  Drinks 500-800 mL of water noted on our
 He tried to modify his lifestyle after knowing his shift last January 16-17, 2019.
condition. He preferred eating fruits and  The patient has no dental problems, no foul
vegetable, he stopped drinking soda, coffee, and odor and excess perspiration.
he tried not to eat in fast food area. He drinks 4-5
glasses of water a day.
ELIMINATION PATTERN
 The client states he defecates once a day usually  Presently, the client has Foley catheter with
every morning with the characteristic of sem urine bag attached.
formed stool without difficulty and use of  No constipations noted
laxatives.
 The client urinate 3x a day or more varying in his
fluid, he verbalizes no difficulty in voiding.
EXERCISE AND ACTIVITY PATTERN
 He is fond walking and biking when he goes to  Confined to bed.
mountain climbing.

SLEEP/ REST PATTERN

 He usually sleeps early around 8-9 in the evening  Mr. Elmo had a slight insomnia and AP
and wakes 6 am in the morning. The client has 9 prescribed small dosage of sleeping pills.
hours of sleep every day without the any use
sleeping aids.
ALCOHOL AND STREET DRUGS
 Confine to bed
 Mr. X started to smoke at the age of 22. He can
consumes 5 sticks a day
 At the age of 30, he can already consumed 1 and
half packs of a day
 At the age of 37, he tried to stop gradually
consuming 3-4 sticks a day.
 He drinks alcoholic beverages occasionally
 He officially stopped his vices when he was
diagnosed with his current condition.

ENVIRONMENTAL HAZARDS
 They lives in subdivision, 1km away from the
highwayThe patient stated that their surroundings
are well sanitized and safe.
INTIMATE PARTNER VIOLENCE
 He never mistreated his wife or forced to do
something that does not satisfy them both. In fact
he takes good care of him so much.
 Confine to bed
 He is slightly irritated and anxious.
 His wife takes good care of him
 They are so sweet, with the endearment of
“dad”

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OCCUPATIONAL HEALTH
 He is a construction manager in a crashing and  Confine to bed
aggregates company.

COGNITIVE AND PERCEPTUAL PATTERN  Conscious

 Patient wears glasses.  Conversant
 He had his eye examined with a grade of 250  GCS of 15
and 300.
SELF- RELATIONSHIP PATTERN  Fears
 He sees himself able to do things according to  Anxiety
the manner he wants it but with extra careful of
his health condition.
COPING STRESS MANAGEMENT PATTERN
 The client states that he felt so down when his
mother died recently  Anxiety
 Whenever he encounters difficult situation, he
would think about it several times or ask his
wife’s opinion prior to decision making, as
verbalized by the patient.
VALUES AND BELIEF
 The patient is a iglesia ni cristo.  He always prays to God for his condition.
 He stated that he barely attends to church.
SPIRITUAL RESOURCES
Patient seek help and guidance to God for his condition.

13
 Diagnostic Tests

CBC RESULT RESULT RESULT NORMAL INTERPETATION/

(1/6/19) (1/9/19) (1/14/16) VALUE IMPLICATION
Red Blood Cells 4. 03 3.58 2.85 4-6 x 10 12/L DECREASED/
ANEMIA

Hematocrit 0.34 0.31 0.32 0.37-0.47 DECREASED

Hemoglobin 112.0 96.0 104.0 110-180 g/L DECREASED

21.9 14.51 7.23 INCREASED (presence

WBC 5-10 x 10 g/L of infection)
NORMAL

Segmenters 0.87 0.90 0.80 0.50-0.65 INCREASED

Lymphocytes 0.10 0.06 0.17 DECREASED

0.25-0.35
0 0 0
Stabs 0.05-0.10 DECREASED

Monocytes 0.03 0.02 0.03 0.03-0.07 NORMAL

Eosinophils 0 0.02 0 0.01-0.03 DECREASED

Basophils 0 0 0 0.01 DECREASED

Plaletet Count 250 140-450 x 10 NORMAL

g/L

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 BLOOD CHEMISTRY
TEST NORMAL RANGE RESULT IMPLICATION

Creatinine 7-12 917, 618, 389, INCREASED/

226.48 CKD
GFR 125ml/min/1.73 m2 21, 13 DECREASED/
STAGE 5 CKD OR
END STAGE
RENAL DISEASE.
SODIUM 135-148 mmol/L 150.5, 126.3 INCREASED/
FLUID
RETENTION
PHOSPORUS 0.87- 1.45 mmol/L 1.90, 3.11, 4.10 INCREASED/
DECREASED
FILTRATION OF
GLUMERULUS
OF THE KIDNEY

RBC 4-6X 10 12/L 4.03, 3.58, 2.85 DECREASED/

ANEMIA

HGT
NORMAL VALUE: 70- 110 mg%
DATE RESULT
1-6-19 228
1-7-19 249
1-8-19 219
1-9-19 302
1-10-19 181
1-11-19 483
1-12-19 159
1-13-19 200
1-14-19 398
1-15-19 117
1-16-19 103
1-17-19 146

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 NORMAL ANATOMY AND PHYSIOLOGY

Parts Functions

PANCREAS
 The pancreas is about 6 inches
 The pancreas is really two glands that
long and sits across the back of
are intimately mixed together into
the abdomen, behind the
one organ. The bulk of the pancreas
stomach. The head of the
is composed of “exocrine” cells that
pancreas is on the right side of
produce enzymes to help with the
the abdomen and is connected
digestion of food. These exocrine
to the duodenum (the first
cells release their enzymes into a
section of the small intestine)
series of progressively larger tubes
through a small tube called the
(called ducts) that eventually join
pancreatic duct. The narrow
together to form the main pancreatic
end of the pancreas, called the
duct. The main pancreatic duct runs
tail, extends to the left side of
the length of the pancreas and drains
the body.
the fluid produced by the exocrine
 Parts of the pancreas:
cells into the duodenum, the first part
 Head: The head is the widest
of the small bowel.
part of the pancreas. The head
 The second functional component of
of the pancreas is found in the
the pancreas is the "endocrine"
right side of abdomen, nestled
pancreas. The endocrine pancreas is
in the curve of the duodenum.
composed of small islands of cells,
Using the hand analogy from
called the islets of Langerhans. These
earlier, the head of the pancreas
endocrine cells don’t release their
corresponds to the palm of your
secretions into the pancreatic ducts,
hand.
instead they release hormones, such
 Uncinate Process: The
as insulin and glucagon, into the
uncinate is the part of the head
blood stream, and these hormones in
of the pancreas that hooks
turn help control blood sugar
towards the back of the
(glucose) levels.
abdomen. The uncinate hooks
around two very important
 The islets of Langerhans are the
blood vessels, the superior
endocrine (endo= within) cells of
mesenteric artery and the
the pancreas that produce and

16
 superior mesenteric vein. secrete hormones such as insulin
Again, using the hand and glucagon into the bloodstream.
anaology, the uncinate would The pancreatic hormones, insulin
correspond to your pinkie and and glucagon, work together to
thumb. maintain the proper level of sugar
 Neck: The neck is the thin (glucose) in the blood. Blood sugar
section of the gland between is used by the body for energy.
the head and the body of the
pancreas. Using the hand
analogy, the neck corresponds
to your first knuckles.
 Body: The body is the middle
part of the pancreas between
the neck and the tail. The
superior mesenteric artery and
vein run behind this part of the
pancreas. Using the hand
analogy, the body corresponds
to the middle of your fingers.
 Tail: The tail is the thin tip of
the pancreas in the left side of
the abdomen, in close
proximity with the spleen.
Using the hand analogy, the tail
corresponds to the tips of your
2nd, 3rd and 4th fingers.

 The liver and these organs work

 The liver is a large, meaty
LIVER together to digest, absorb, and
organ that sits on the right side
process food.
of the belly. Weighing about 3
 The liver's main job is to filter the
pounds, the liver is reddish-
blood coming from the digestive
brown in color and feels
tract, before passing it to the rest of
rubbery to the touch. Normally
the body. The liver also detoxifies

17
 you can't feel the liver, because chemicals and metabolizes drugs.
it's protected by the rib cage. As it does so, the liver secretes bile
 The liver has two large that ends up back in the intestines.
sections, called the right and The liver also makes proteins
the left lobes. The gallbladder important for blood clotting and
sits under the liver, along with other functions.
parts of the pancreas and
intestines.

PARTS & FUNCTIONS:

KIDNEY
 Two kidneys. This pair of
purplish-brown organs is located
below the ribs toward the middle
of the back. Their function is to
remove liquid waste from the
blood in the form of urine; keep a
stable balance of salts and other
substances in the blood; and
produce erythropoietin, a hormone
that aids the formation of red
blood cells. The kidneys remove
urea from the blood through tiny
filtering units called nephrons.
Each nephron consists of a ball
formed of small blood capillaries,
called a glomerulus, and a small
tube called a renal tubule. Urea,
together with water and other
waste substances, forms the urine
as it passes through the nephrons
and down the renal tubules of the
kidney.
 Two ureters. These narrow
tubes carry urine from the kidneys

18
 to the bladder. Muscles in the
ureter walls continually tighten
and relax forcing urine downward,
away from the kidneys. If urine
backs up, or is allowed to stand
still, a kidney infection can
develop. About every 10 to 15
seconds, small amounts of urine
are emptied into the bladder from
the ureters.
 Bladder. This triangle-shaped,
hollow organ is located in the
lower abdomen. It is held in place
by ligaments that are attached to
other organs and the pelvic bones.
The bladder's walls relax and
expand to store urine, and contract
and flatten to empty urine through
the urethra. The typical healthy
adult bladder can store up to two
cups of urine for two to five hours.
 Two sphincter muscles. These
circular muscles help keep urine
from leaking by closing tightly
like a rubber band around the
opening of the bladder.
 Nerves in the bladder. The
nerves alert a person when it is
time to urinate, or empty the
bladder.
 Urethra. This tube allows urine to
pass outside the body. The brain
signals the bladder muscles to
tighten, which squeezes urine out
of the bladder. At the same time,
the brain signals the sphincter

19
muscles to relax to let urine exit
the bladder through the urethra.
When all the signals occur in the
correct order, normal urination
occurs.

20
 PATHOPHYSIOLOGY
MODIFIABLE FACTORS: MODIFIABLE FACTORS:
PANCREAS
- Hypertension - Age (increasing age)
- High fat, high salt, high - Gender
sugary food intake, and - Family history (paternal
drinking soda ISLETS OF LANGERHAMS side)
- Serendentary lifestyle
- Alcohol consumption
- Smoking
BETA CELLS ALPHA CELLS

INSULIN GLUCAGON

BLOOD MAINTAIN THE BLOOD

CONSTANT GLUCOSE IN
THE BLOOD
INSULIN LIVER
RECEPTORS GLYCONEOGENESIS
STIMULATE TO
GLUCOSE RELEASE THE GLYCOGENOLYSIS
STORED GLUCOSE

CELL

TYPE 2 DIABETES
ENERGY

21
 HYPERPLASIA INCREASE BLOOD GLUCOSE
HYPERTROPHY

INSULIN
AMYLIN

HYPO INSULIN RECEPTORS

INSULIN RESISTANCE

CELLS
DAMAGE BETA CELLS

GLUCOSE IN THE BLOOD

DECREASE INSULIN PRODUCTION

INCREASE GLUCOSE IN THE BLOOD BETA CELLS

HYPERGLYCEMIA INSCREASE INSULIN

22
 NURSING CARE PLANS

ASSESSMENTS NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Acute pain related to STO: Independent:
Subjective: post debridement as Goals are met.
evidenced by facial After 3 hours  Assess the patient status ,  Assist in determining the
“usahay I feel pain dri akong grimace and surgical of nursing description of pain cause and effect of chest STO:
bugan dapit” incision in scrotal interventions:  Obtain ECG discomfort
As the patient verbalized. area. 1. the client will state 3  Vital signs assessed frequently  Can diagnose the ongoing After 3 hours of nursing
Pain scale of 6 out of 10. ways of relieving pain  Physical rest in bed with the head ischemia interventions:
such as imagery of the bed elevated  Baseline data 1. The client stated 3
,application of hot and  Instruct the patient to avoid ways of relieving pain
Objective: cold compress and straining  Helps decrease chest such as imagery
 Facial grimace therapeutic touch.  Provide a restful environment discomfort and dyspnea ,application of hot and
 Patients complain of 2.the client’s pain scale  Prevent increase oxygen cold compress and
pain will decrease from 6/10  Position the patient in semi- demand therapeutic touch.
 Guarding behaviour to 3/10 fowler’s position  This allows for rest and 2.the client’s pain scale
 Weakness Dependent: adequate chest exurcion, will decreased from 6/10
 Administer oxygen as prescribed to increase available to 3/10
Vital signs: LTO: (flow rate of 1-2 L/ min) via oxygen
BP 150/90 nasal cannula LTO:
RR 19 After 1 month of nursing  Administer medications as - Analgesic
PR 87 interventions, the client - Pregabalin 75 mg cap OD HS After 1 month of nursing
T 37.1 will be free from - Tramadol 50mg IV q 8 hours interventions, the client
02sat 95% experiencing pain in the (PRN; pain) are free from experiencing
genital area pain in the genital area
Collaborative:
Nutrition diet ( Low purine, low salt)

23
 ASSESSMENTS NURSING DIAGNOSIS PLANNING INTVERVENTIONS RATIONALE EVALUATION
Imbalanced nutrition: less STO: INDEPENDENT  Goals are met.
Subjective: than body requirements 1. Weigh daily or as ordered. 1. Weighing serves as an
related to decrease oral After 12 hours of assessment tool to STO:
“pa kunti kunti lng yung kinakain intake secondary to nursing intervention determine the adequacy of
nya” as the SO verbalized. anorexia. the client will ingest 2. Ascertain patient’s dietary nutritional intake. After 12 hours of nursing
appropriate amounts of program and usual pattern then 2. Identifies deficits and intervention the client
calories/nutrients. compare with recent intake. deviations from therapeutic ingested appropriate
Objective: needs. amounts of
LTO: 3. Discuss eating habits and calories/nutrients.
 Recent weight loss encourage diabetic diet 3. To achieve health needs of
 Body weakness After 2 days of nursing (balanced diet) as prescribed the patient with the proper
 Pallor interventions, the by the doctor. food diet for his condition. LTO:
client will demonstrate
Vital signs: stabilized weight or DEPENDENT:
BP 150/90 gain toward After 2 days of nursing
RR 19 usual/desired range. 4. Consult dietician and/or interventions, the client
PR 87 physician for further 4. To reveal changes that demonstrated stabilized
T 37.1 assessment and should be made in the weight or gain toward
02sat 95% recommendation regarding client’s dietary intake. For usual/desired range.
food preferences and greater understanding and
nutritional support. further assessment of
specific foods.

5. Auscultate bowel sounds. Note 5. Hyperglycemia and fluid

reports of abdominal pain,
bloating, nausea, vomiting of
undigested food. Maintain
NPO status as indicated.
and electrolyte disturbances
can decrease gastric motility
and/or function (due to
distention or ileus) affecting
choice of interventions.
Note: Chronic difficulties

24
 with decreased gastric
emptying time and poor
intestinal motility may
suggest autonomic
neuropathies affecting the
GI tract and
Collaborative: requiring symptomatic
treatment.
6. Administered medications as
prescribed: 6. Multivitamins
- Multivitamins TF plus 2
caps OD P.C BF

25
 ASSESSMENTS
Subjective:
“sige lng na xa gusto matulog man”
as the SO verbalized.
Objective:
 Overwhelming lack of
energy
 inability to maintain usual
routines
 decreased performance,
 accident-prone
 Impaired ability to
concentrate,
 Listlessness
 disinterest in surroundings
NURSING PLANNING INTVERVENTIONS EVALUATION
DIAGNOSIS
Fatigue related to STO: INDEPENDENT Goals are met.
Increased energy
demands: hyper After 2 hours of nursing 1. Discuss with patient the need STO:
metabolic intervention the client for activity. Plan schedule
state/infection will verbalize increase in with patient and identify
energy level. activities that lead to fatigue After 2 hours of nursing
intervention the client
LTO: 2. Alternate activity with periods verbalized increase in energy
of rest and uninterrupted sleep. level.
After or within 2 days
of nursing interventions 3. Discuss ways of conserving
the client will display energy while bathing, LTO:
improved ability to transferring, and so on.
participate in desired After or within 2 days of
activities. nursing interventions the
client displayed improved
4. Assess muscle strength of ability to participate in desired
patient and functional level of activities.
activity.

DEPENDENT:
Vital signs:
BP 150/90 5. Administer oxygen as
RR 19 ordered.
PR 87
T 37.1
02sat 95%

26
 ASSESSMENTS NURSING PLANNING INTVERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Risk for skin integrity STO: INDEPENDENT Goals are met.
Subjective: related to decreased 1. Assess integrity of the skin. 1. These are
circulation and After 2 hours of nursing Assess knee and deep assessments for STO:
“last Monday pana nag start ang sensation caused by intervention the client tendon reflexes and neuropathy. Skin on
iyang hupong sa iyang duh aka ttil peripheral neuropathy will patient will proprioception. lower extremity
og kamot” as the SO verbalized. and arterial demonstrate proper skin pressure points is at After 2 hours of nursing
obstruction. care. great risk for intervention the client
Objective: ulceration. verbalized increase in energy
LTO: 2. Use gentle moisturizers on 2. Moisturizers soften level.
- Positive peripheral edama the oedematous and lubricate dry skin,
After or within 2 days extremities.. preventing skin
of nursing interventions cracking. LTO:
the client will patient’s
skin on legs and feet 3. Wash extremitiest daily 2. Decreased sensation After or within 2 days of
remains intact while the with mild soap and warm increases the risk for nursing interventions the
patient is hospitalized water. Check water burns. client displayed improved
Vital signs: temperature before 3. These are signs that ability to participate in
BP 150/90 immersing feet in the water. the skin needs desired activities.
RR 19 4. Inspect feet daily for preventive care.
PR 87 erythema or trauma
T 37.1 DEPENDENT:
02sat 95% Diuretics
6. Administered medication as
prescribed:
- Furosemide

27
28
 NURSING PLANNING INT5ERVENTIONS RATIONALE EVALUATION
ASSESSMENTS DIAGNOSIS
Risk for infection STO: INDEPENDENT Goals are met.
Subjective: related to high glucose 1. Observe for the signs of infection 1. Patients with DM may be STO:
“ming kalit rana iyang samad sa levels, decreased After 3-4 hours of nursing and inflammation: fever, flushed admitted with infection,
iyang scrotal area man” leukocyte function and intervention the client will appearance, wound drainage, which could have After 3-4 hours of
As the SO verbalized. existing scrotal wound. Identify interventions to purulent sputum, cloudy urine. precipitated the nursing intervention
prevent/reduce risk of ketoacidotic state. They the client Identified
Objective: infection. may also develop interventions to
2. Teach and promote good hand nosocomial infection. prevent/reduce risk of
 Pallor LTO: hygiene. 2. Reduces risk of cross- infection.
 Appears weak contamination.
 After or within 12 hours of 3. Provide meticulous skin care: gently 3. Peripheral circulation may LTO:
nursing interventions the massage bony areas, keep skin dry. be ineffective or impaired,
Vital signs: client will demonstrate Keep linens dry and wrinkle-free. placing the patient at After or within 12
BP 150/90 techniques, lifestyle changes increased risk for skin hours of nursing
RR 19 to prevent development of breakdown and infection. interventions the
PR 87 infection. 4. Reposition and encourage coughing 4. Aids in ventilating all lung client demonstrated
T 37.1 or deep breathing if patient is alert areas and mobilizing techniques, lifestyle
02sat 95% and cooperative. Otherwise, suction secretions. Prevents stasis changes to prevent
airway using sterile technique as of secretions with increased development of
needed. risk of infection. infection.

DEPENDENT:
 Administer meds as prescribed
- Anti biotic
- Levofloxacin 500 mg OD
- Piperacillin + tazabactan 2.5 mg
BID IV

29
 DISCHARGE PLAN
A. OBJECTIVE
1. Summarize a simple and productive health education plan;
2. Adhere prescribed medications for health maintenance and resistance;
3. Promote a health lifestyle, maximize the level of health ;
4. Gains knowledge in managing the condition; and
5. Maintain and ensure adequate intake for nourishment

B. METHOD
Medications
DRUG STUDY

Generic Classification Indication Mechanism of Action Route/ Adverse Reaction Contraindication Patient teaching
Name Freque
ncy/Do
sage
Amlodipine Antihypertensiv  Amlodipine is These medications block 10 mg  Side effects of PREGNANCY/ Monitor BP for therapeutic effectiveness.
e also the (1/2 amlodipine are NURSING BP reduction is greatest after peak levels
Calcium- used in the transport of calcium into tab) bid generally mild of amlodipine are achieved 6 9 h
MOTHERS:
channel blockers treatment of the p.c and reversible. following oral doses.
high blood smooth muscle cells lining The two most Monitor for S&S of dose-related
pressure the common side Generally, peripheral or facial edema that may not
coronary arteries and other effects are amlodipine is be accompanied by weight gain; rarely,
arteries of the body. Since headache and avoided in severe edema may cause discontinuation
calcium is important in edema pregnancy, and of drug.

30
 muscle (swelling) of the by nursing Monitor BP with postural changes.
contraction, blocking lower mothers since it Report postural hypotension. Monitor
calcium extremities. more frequently when additional
transport relaxes artery Less may cross the antihypertensives or diuretics are added.
muscles and dilates common side blood brain barrier
coronary effects include and cause Monitor heart rate; dose-related
arteries and other arteries dizziness, palpitations (more common in women)
of flushing, may occur.
the body. By relaxing fatigue,
coronary nausea, and
arteries, amlodipine is palpitations
useful in
preventing chest pain
(angina)
resulting from coronary
artery
spasm. Relaxing the
muscles
lining the arteries of the
rest of
the body lowers the blood
pressure, which reduces the
burden on the heart as it
pumps blood to the body.
Clonidine Antihypertensiv Hypertension, Clonidine stimulates alpha- 75 gm  Dry mouth, Hypersensitivity. Monitor BP for therapeutic effectiveness.
hydrochlori e, Sympatholytic used alone or as 2receptors in brainstem (1/2 drowsiness, Disorders of cardiac BP reduction is greatest after peak levels
de (centrally part which results in reduced tab) tid dizziness, pacemaker activity of amlodipine are achieved 6 9 h
acting), Central of combination sympathetic outflow from headache, and conduction. following oral doses.
analgesic therapy the CNS and a decrease in constipation, pregnancy and Monitor for S&S of dose-related
peripheral resistance Impotence, vivid lactation peripheral or facial edema that may not
leading to reduced BP and dreams, urinary be accompanied by weight gain; rarely,

31
 pulse rate. It does not alter
normal hemodynamic
response to exercise at
recommended dosages
Carvidilol Antihyperlipide Hypertension, Carvedilol causes
mic Alpha- and alone or with vasodilation by blocking
beta-adrenergic other oral drugs, the activity of α-blockers,
blocker especially mainly at alpha-1receptors.
Antihypertensiv diuretics It exerts antihypertensive
e . effect partly by reducing
total peripheral resistance
and vasodilation. It is used
in patients with renal
impairment, NIDDM or
IDDM.
retention; dry, severe edema may cause discontinuation
itching, burning of drug.
sensation in the Monitor BP with postural changes.
eye; fluid or Report postural hypotension. Monitor
electrolyte more frequently when additional
imbalance, GI antihypertensives or diuretics are added.
upset, paralytic
ileus, orthostatic Monitor heart rate; dose-related
hypotension, palpitations (more common in women)
weakness, may occur.
sedation ,pruritus,
myalgia, urticaria,
nausea, insomnia,
arrhythmias,
agitation. Reduced
GI motility at times
may cause
paralytic ileus
25 mg Bradycardia, AV Hypersensitivity; Monitor BP for therapeutic effectiveness.
OD block, angina severe chronic BP reduction is greatest after peak levels
pectoris, heart failure, of amlodipine are achieved 6 9 h
hypervolemia, bronchial asthma or following oral doses.
leucopenia, related broncho Monitor for S&S of dose-related
hypotension, spastic conditions; peripheral or facial edema that may not
peripheral edema, severe hepatic be accompanied by weight gain; rarely,
allergy, malaise, impairment severe edema may cause discontinuation
fluid overload, of drug.
melena, Monitor BP with postural changes.
periodontitis, Report postural hypotension. Monitor
hyperuricemia, more frequently when additional
hyponatremia antihypertensives or diuretics are added.
32
 Monitor heart rate; dose-related
palpitations (more common in women)
may occur.

Levofloxaci Fluoroquinolone Complicated skin inhibits the enzyme DNA 500mg CNS: seizures GI: Hypersensitivity to Avoid rapid or bolus I.V. administration,
n and skin-structure gyrase insusceptible gram- OD pseudo membranous drug, its components, because this may cause severe hypotension.
infections. negative and gram-positive colitis Hematologic: or other quinolones Check v/s, specially BP. Too-rapid
aerobic and anaerobic lymphocytepenia infusion can cause hypotension.
Uncomplicated skin bacteria, interfering with Metabolic: Closely monitor patients with renal
and skin-structure bacterial DNA synthesis. hypoglycemia insufficiency.4.Assess for severe diarrhea,
infections. Other: Steven- which may indicate pseudo membranous colitis.
Johnson syndrome
Complicated UTI
Pantoprazol Anti-Ulcerant For the treatment Reduces gastric acid 40/30m  CNS: dizziness,  Ampicillin,  Assess for symptomatic improvement.
e+Domperi of gastro secretion and increases g 1 tab headache cyanocobalamin,  Monitor blood glucose level in
dine esophageal reflux gastric mucus and once a  CV: chest pain digoxin, iron diabetic patient.
disease; non-ulcer bicarbonate production, day  EENT: rhinitis salts,  Tell patient to swallow delayed
dyspepsia, gastric creating protective coating  GI: vomiting, ketoconazole: release tablets whole without
or duodenal ulcer, on gastric mucosa diarrhea, delayed crushing, chewing, or splitting.
dyspepsia, abdominal pain, absorption of
bloating, fullness, dyspepsia these drugs
belching, NSAID Metabolic:  Atazanavir,
induced hyperglycemia nelfinavir:
dyspepsia.  Musculoskeletal substantially
: hip, wrist, decreased
spine fractures atazanavir or
(with long-term nelfinavir plasma
daily use) concentration
with loss of
therapeutic effect

33

Novolin R Regular Insulin Treatment of type Insulin is a hormone
2 (non– insulin- secreted by the beta cells of
dependent) the pancreas that, by
diabetes that receptor-mediated
cannot be effects, promotes the
controlled by diet storage of the body's fuels,
or oral agents. facilitating the transport
of metabolites and ions
(potassium)through cell
membranes and stimulating
the synthesis of glycogen
from glucose, of fats from
lipids, and proteins from
amino acids.
 Skin: rash, and development
pruritus of drug resistance
 Other: injection
site reaction
10 units Contraindicated Allergy—local 
with allergy to pork reaction at the
products (varies injection sites.
with preparations; -redness, swelling,
human insulin not tenderness.
contraindicated
with pork allergy)

34
 2. EXERCISE/ACTIVITY and HOME ENIVRONMENT
1. Depending on the status, the patient is encouraged to return to usual activities gradually.
a) Encourage the patient and instructed the significant others to control activities for daily living
b) Encourage the patient and instructed the significant others to participate in passive active range of motion as tolerated
c) Instructed the significant others to provide safety precautions to the patient, especially when ambulating or using a bathroom
d) Instructed the significant others to include 30 minutes of walking as tolerated
a) Encourage patient to include at least 30 minutes of walking
e) or jogging or perform tolerated and preferred activities as a means of exercise

RESTRICTIONS:
1. Strenuous activities
2. Heavy lifting greater than 5kg
3. Prolonged exposure to sunlight

HOME ENVIRONMENTAL HAZARDS:

a) Restrict smoker
b) Crowded area

3. TREATMENTS/THERAPIES
a) Attending the follow up check up :
 Educate client by adhering maintenance therapy, appropriate diet and having exercise will reduce likelihood

of occurrence and aggravation of disease.

35
 4. HEALTH TEACHING/EDUCATION
PREVENTION/PROMOTION
Health teaching about the disease, exercise and diet
 Instructs the patient about home-made interventions in reducing blood pressure such as:
a.) Pineapple or calamansi juice to reduce blood pressure
b) chewing of raw or fried garlic after meals
c.) refrain from consumption of caffeinated beverages, such as coffee and chocolate

5. OPD Visit
Instruct that they need to have a health check up
 Emphasize the importance of adhering to medications and attending follow-up check.
 Encourage patient to adhere to weakly blood pressure monitoring and daily hgt monitoring.

6. DIET
 Low calories- calorie restriction in individuals with hypertension
 Low fat- Advisable to reduce the fat consumption since hypertension has greater risk of atherosclerotic. Foods rich in cholesterol are liver, meat organ, egg
yolk,lobster, crabs, and prawns. Recommended: vegetable oil like sunflower and olive oil
 High protein: Most high protein foods are extremely low in carbs and extremely low in saturated fat. Therefore, by eating a high protein diet loaded with high
protein foods, at the same time you’d end up eating low carbs and low saturated foods
 Low sodium and High in potassium: Help to lower blood pressure
Foods rich in potassium: tomato, watermelon, banana, apple, raw carrots, leafy vegetables and potato
 Diabetic diet- low in sugar and carbohydrate, low in purine food.

36
7. SPIRITUAL CARE AND PSYCHOLOGICAL OR SEXUAL NEEDS
(/) Spiritual counseling
(/) Grief work
(/) Anger Management
(/) Confession
(/) Family therapy
(/) Reconciliation of conflicted Relationships
(/) Supportive Counseling
(/) Join church Organizations/Activities
(/) Prayer
(/) Meditation, Reflection, and Spiritual Devotion
(/) Religious rituals
(/) Religious/ Spiritual Materials

SEXUAL NEEDS
(/) Marriage counseling
(/) Sex Therapy
(/) Sexual Therapy
(/s) Referral to appropriate Agencies

37
References:

1. Taylor (2008) Nursing Diagnosis Pocket Guide (2th ed.).Philadelphia: Wolters

Kluwer Health/Lippincott Williams & Wilkins.

2. Lewis, Heitkemper ,Dirksen ,O'Brien,Bucher (2007): Assessment and

Management of Clinical Problems, liver, Pancreas and Biliary Tract problems,
Medical Surgical Nursing, MOSBY.1st Edition, 1101:15.

3. Ignatavicius & Workman (2006) Medical Surgical Nursing: Critical Thinking for
Collaborative Care. USA. Elsevier.

4. Smeltzer & Bare (2004). Medical- Surgical Nursing. Philadelphia. Lippincott

Williams & Wilkins.

5. Tortora (2011). Principles of Anatomy and Physiology , 14th Edition John Wiley
& Sons, 2008.

6. Weber & Kelley (2014). Health Assessment In Nursing. Philadelphia. Lippincott

Williams & Wilkins.

7. Goldman and Schafer (2016).Goldman-Cecil Medicine. 25th ed. Philadelphia,

PA: Elsevier Saunders.

8. Cecil, Goldman,Bennett (2000).Cecil Textbook of Medicine . 21st ed.

Philadelphia, PA: WB Saunders Company.

38
39