In Partial fulfilment of the requirements in Community Health Nursing RLE

Ateneo de Davao University

School of Nursing

Jacinto St, Davao City

CASE STUDY ON

COMMUNITY HEALTH NURSING

Submitted to: Mrs. Cynthia Jane Villanueva, RN MN

Submitted by:

Delos Santos, Marion

Estareja, Carmela Marie
Esmael, Zainah
Evangelista, Aubrey
Junasa, Trisha
Lacaneta, Katzoie
Lim, Stephen Josh
Modequillo, Quimberly Angela
Palabrica, Gregg Philip
Prado, Regie Marie Frances
Sumangil, Jason

Date: 10/08/2018
 ACKNOWLEDGMENTS

We would like to thank our most beloved clinical instructor, Mrs. Cynthia Villanueva,
RN MN. Without her motherly guidance, this CHN experience would not have been a success.
We would also like to thank the Barangay Captain of Crossing Bayabas, Hon. Terso Abrantes
and the Barangay Heath Worker of Purok II, Ms Tina Jumawan for their kind accommodation
and outstanding support in our endeavor to prevent illness and promote health through in Purok
II.

This Case Presentation would not have been possible without the full cooperation and
active participation of the community of Purok II. These individuals have given time out of their
busy schedule to welcome us to their homes and partake of what we had to offer. Their presence
and involvement in our interview process, health lecture, and culmination event was a blessing.
With what little time shared with these wonderful people, we have learned a lot from them in as
much as they have learned a lot from us.

We are also grateful and deeply indebted to the Sasuman and Rigoteo family who have
extended their homes to us during our 2 weeks community exposure. The Sasuman family has
provided us with more than we can ask for and their kindness and forbearance will forever be
remembered by the group. The Rigoteo family has rendered their home to be our area for our
culmination. They did not only allow us to use their location, but they also allowed us to use
their chairs, tables, and speakers to make our event successful. Spending time with these families
has taught us what it means to be an Atenean as they embody the ideals of Ateneo de Davao
Unversity as Being Men and Women for Others.

Nobody has been more important to us in the pursuit of this project than our own
families. We would like to thank our parents; whose love and guidance are with us in whatever
we pursue. They are the ultimate role models.

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 TABLE OF CONTENTS

CHAPTER I
INTRODUCTION 1

CHAPTER II
OBJECTIVES 3

CHAPTER III
THEORETICAL FRAMEWORK 6

CHAPTER IV
INITIAL DATA BASE 8
TYPOLOGY OF NURSING PROBLEMS 21
FAMILY COPING INDEX 23

CHAPTER V
PATIENT DATA 27

CHAPTER VI
PATIENT HISTORY 28
PAST HEALTH HISTORY 28
PRESENT HEALTH HISTORY 28

CHAPTER VII
GENOGRAM 29
NARRATIVE FAMILY HISTORY 31

CHAPTER VIII
DEVELOPMENTAL DATA 32

CHAPTER IX
REVIEW OF SYSTEMS 46
PHYSICAL ASSESSMENT 51

CHAPTER X
DEFINITION OF ILLNESS 60
ANATOMY AND PHYSIOLOGY 61
ETIOLOGY & SYMPTOMATOLOGY 84
PATHOPHYSIOLOGY 94
PROGNOSIS 100

CHAPTER XI
LABORATORY & DIAGNOSTICS 103

CHAPTER XII
PHARMACOLOGY 109

CHAPTER XIII
NURSING THEORIES 115

CHAPTER XIV

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 FNCP & NCP 122

CHAPTER XV
HEALTH TEACHINGS 139

CHAPTER XVI
CONCLUSION & RECOMMENDATION 141

CHAPTER XVII
SIGNIFICANCE OF THE STUDY 144
RELATED JOURNAL READ 145
REFERENCES 146

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 ABSTRACT

The group 2 of Third Year Bachelor of Science in Nursing had a community exposure in
Purok 2, Crossing Bayabas, Toril, Davao City to find a case that is related to fluid and
electrolytes imbalance. A 68 years old male resident of Purok 2 with the diagnosis of End-Stage
Renal Disease secondary to Urate Nephropathy was chosen as the basis for our case study. When
the group visited the family, all necessary data and information for our case study was gathered,
and the group was able to identify and categorized the health needs of the family based on the
first and second level of assessment through the typology of nursing problems, analyzing the
family's coping mechanism by using family coping index, and making an appropriate family
nursing care plan based on the identified and justified health, and family problems. Furthermore,
the signs and symptoms that the client manifested, the factors that cause the disease and, the
anatomy and physiology of the affected systems were identified by the group to have a basic
understanding of the disease process through pathophysiology. With the information gathered
and the care plans done, the group made a case presentation on the client’s condition of End
stage renal disease secondary to urate nephropathy. Some of the family & nursing care plan’s
goals were only partially met due to multiple factors which include but are not limited to time of
stay with the client, days of visit to family, materials used to convince the family & the client,
and the client’s participation, attitude, and cooperation on the health teachings & nursing
interventions. On the other hand, some goals were met because of its simplicity, measurability,
attainability, time-boundedness, and realistically formulated. At the end of the CHN exposure,
the group had their Culmination and Health teaching activity. Vitamin C was distributed to the
community, blood pressure was listed and monitored, Weight and age was also taken and listed,
and urine test for albumin and glucose was also done. The health teaching consists of topics
about asthma and hypertension, its definition, cause, and preventive factors. Overall the CHN
exposure was perceived by the group as a success however it still has rooms for improvement.

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 CHAPTER 1

INTRODUCTION

According to a famous historian, Thomas Fullers “Health is not valued until sickness
comes.” As old as history, individuals tend to overlook blessing in their lives. We do not
appreciate good occupation until we get fired, we do not appreciate the love others until they are
gone, and just in like health, we tend to disregard it until we are laying on our sickbeds.

Health is defined as the state of wellbeing that is free from any illness or injury. While
sickness, on the other hand, means that there is a presence of any diseases. (WHO). Usually, the
only time we feel the need to see a doctor is when symptoms cannot be further ignored.
Consequently, with such blatant disregard for heath, once one is ill, complication becomes a
common factor of illness continues. Indeed, ignorance is a bliss, up until it becomes too
complicated to ignore, such as that of the illness of the group’s patient. (World kidney day,2015)

The US National Kidney Foundation (NKF) says millions die each year due to
complications from this illness. The number of patients diagnosed with the chronic kidney
disease continues to increase at a rate of 5-7% per year. Taiwan, Japan, Mexico, the United
States, and Belgium currently have the highest prevalence of end-stage renal disease. Though
extensive data on global mortality rates is lacking, a 2007 report shows that U.S. mortality risk
was 15% higher than in Europe and 33% higher than in Japan on comparable treatment
modalities. (National Kidney Foundation, 2015)

In the Philippines, the increasing numbers of patients suffering from renal diseases are
just as disturbing. Five years ago, in 2013, there were approximately 10,000 Filipinos developing
kidney problems annually, but it has since jumped to 15,000 at present. The Department of
Health (2015) has estimated an increase in the number of kidney disease cases between 10% to
15% a year. Based on the Philippine Renal Disease Registry, as of 2015, there are over 28,000
Filipinos undergoing dialysis.

The Davao region has not been spared by the statistics of increasing numbers of kidney
related diseases. Davao region has ranked number four with the highest number of patients, who

1
undergo kidney dialysis as of 2016 up to present based on the report from the Renal Disease
Control Program of Department of Health. (Castillo, 2017)

Purok II Barangay Crossing-Baybas Toril Davao City is where the group 2 third year
nursing students of Ateneo de Davao University experienced their community health nursing
exposure. 2 weeks and approximately 5 days of service were rendered to the families of Purok II
Crossing-Bayabas, where the student nurses met different types of families. The practice of
community health nursing was applied and promoted to cater the health needs of the community,
focusing specially on caring for the families.

One of the families situated in Purok II Crossing-Bayabas Toril, Davao City has captured
the attention of the group. Through ocular survey and house-to-house interview, the group met
their key client whose condition has embodied the current topics in NCM 103 Lecture. Firstly,
the group established rapport with the family and identified the problems that would affect their
health. Secondly, to solve these problems, it was made realized to them through collaboration
and partnership. Finally, by providing health teachings and nursing interventions, the family will
be able to understand and learn about the present and potential health problems. With this type of
strategy, the family will be able to take appropriate actions and assume responsibility to solve
their perceived family health problems.

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 Chapter II

OBJECTIVES

General Objectives

For the community, the group's goal is to improve the level of health and well-being of the
families in Purok 2, Barangay Crossing-Bayabas in Toril, Davao City in the span of 3 weeks by
holding and facilitating activities such as health teachings, home visits, and culmination events
through providing quality nursing care with the effective use of available resources, and applying
the required knowledge, skills, attitudes and values the group have gained in the university to the
actual community situation.

For the family, the group’s objective is to make a detailed and comprehensive case study about
the health problems perceived by the group and identified by the chosen family. Moreover, the
group aims to gather specific data related to the NCM 103 Lecture Renal diseases and render
appropriate nursing management that fits the key client's condition and the family’s problem
through Nursing Care Plan and Family Nursing Care Plan.

Specific Objectives

Cognitive

• Analyze family background of the client through a genogram

• Explain the client’s family history in relation to possible genetic diseases

• Describe the developmental psychological theories related to the client

• Comprehensively assess demographic characteristics, health factors, and community

health resources of the family

• Identify the nursing problems observed in the community

• Organize according to prioritization the typology of nursing problems

• Evaluate the family’s coping ability by using the family coping index

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 • Evaluate the client’s overall health condition through a Physical Assessment

• Discuss the Anatomy and Physiology of systems and organs affected in the disease
process

• Identify the etiology & symptomatology of the client’s diagnosis

• Recognize the signs and symptoms present on the client

• Discuss the pathophysiology of End Stage Renal Disease secondary to Urate

Nephropathy

• Identify the drugs prescribed to the client and formulate a drug study

• Identify Nursing Theories appropriate for the case study

• Identify the potential and actual health problems of the family

• Design a family nursing care plan suited to the family’s needs

Affective

• Display a positive attitude towards the client’s family

• Acknowledge the time and effort given to us by the family during our assessment

• Establish rapport with the family to gain their trust and understanding

• Show genuine and willingness in serving and providing care to the family

• Respecting the client’s background, family, needs and his condition

• Attentively listen to the client and acknowledge his response

Psychomotor

• Record all relevant data related to the client’s disease and the family back ground using
the Initial Data Base form

• List the client’s personal and clinical data, relevant past medical history, and present
health history

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• Design a genogram of the client’s family background

• Organize all information gathered from our interview for the Initial Data Base

• Arrange the nursing problems observed in the community according to their

prioritization

• Perform a physical assessment to assess the client’s condition further

• Trace the pathophysiology of End Stage Renal Disease secondary to Urate Nephropathy

• Explain the indication and side effects of the drugs prescribed by the doctor to the client

• Perform the appropriate nursing care plans relevant to the client’s needs

• Provide health teachings to the client and the family in relation to the identified health
problems

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 Chapter III

THEORETICAL FRAMEWORK

Orem's approach to the nursing process provides a method to determine the self-care
deficits and the roles of client or nurse to meet the self-care demands. Through this, the group
made use of Orem’s theory as it was relevant to the chosen client and the case study.

Though some individuals face the adversity of chronic and complicated diseases, they are
still able to find hope and strength. This inner philosophy gives the person the drive to continue
living a functional and normal life despite facing deformity, pain, or suffering. This is not the case
of the groups client however. Since the client is suffering a complicated health status, he believes
that it is not anymore worthy to live a healthy life. The client’s mindset, coupled by his condition,
has immensely decreased the client’s ability for self-care.

This case presentation utilized Orem’s theory and the Nursing Process in determining
presence of self-care deficits present in the client. It is composed of three parts - first is the
assessment, which collects data to determine the problem or concern that needs to be addressed.
The group interviewed the client and assessed his health status. During the interview the group
found out that he has lived a rather unhealthy lifestyle. Because of such lifestyle he was diagnosed
with chronic kidney disease. As his disease worsened he was eventually recommended for an
operation, yet, the client did not push through. However, circumstances pushed the client to be
taken to the hospital when he was stabbed in the abdomen by a stranger. An immediate surgery
was performed, and this is also the time where one part of his kidney was removed. Through
assessment, the group found out that the client has had decreased value in his health even before
his current condition, and that the client needed nursing care.

The next step is the diagnosis and creation of a nursing care plan. Based on the client’s
medical information, aside from kidney disease, he has been suffering from severe gouty arthritis.
In conformance with this, the group made a nursing care plan which will provide that will help the
client be more independent and deal with his self-care requisites even without the presence of a
nurse. Moreover, through Orem’s framework, not only is the client being addressed to but the
entire family of the client. A Family nursing care plan is also used for health problems currently
existing or foreseeable that the family has identified.

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 The third and final step is the implementation and evaluation. To effectively implement
those nursing care plan and family nursing care plan, the group made sure that the client, as well
as his family, understood the importance of this plan. An evaluation was conducted after a week
to check if the client and family comply with the plan. Through this, it can be gauged whether
goals that have been set prior where achieved. Also, this is to further assess which areas did the
family achieved or failed to tweak the current nursing care plans to address specific needs of both
the client and his family.

Following Orem’s theory, there are basic conditioning factors that give different family
members unique self-care requisites. Because of the different levels of self-care agencies, the
family members can exact themselves, the group is able to determine at which areas they are
needed. The presence of self-care deficits is evidently seen by the group exciting in their chosen
family, from the children to the client. These nursing problems observed and noted by the group
range from physiological, psychological, risk, actual, and potential.

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 Chapter IV

FAMILY PROFILE

INITIAL DATABASE

A. Family Structure and Characteristics

1. Demographic Data of the Members of the Family

Family Age Sex Marital Relationship Educational Occupation

Members Status to Family Attainment
Head
Client 67 M Single Brother-in- 3rd year N/A
Heisendburg y/o law highschool
Feli 73 M Married Family College Councilor of Mati
y/o Head Graduate
Glory 59 F Married Wife College Businesswoman/Housewife
y/o Graduate
Az 32 F Single Daughter College Student
y/o Graduate
FJ 31 M Married Son College Office/Businessman
y/o Graduate
MA 23 M Single Nephew of 3rd year Student
y/o the wife college
C 30 F Married Daughter- College Housewife
y/o in-law Graduate
AB 1 F Single Grand- N/A N/A
6/12 daughter
y/o
EM 4 M Single Grandson N/A N/A
m/o

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Kay 14 F Single Grand- 3rd year Student
y/o daughter highschool
TA 10 F Single Grand- Grade 5 Student
y/o daughter
Th 40 M Single Niece College Nurse
y/o Graduate
Dondon 28 M Single Helper 2nd year All around helper
y/o highschool
Rits 58 F Sigle Helper Elementary All around helper
y/o Graduate

2. Type of Family

The type of family resembles an extended type. Feli is the head of his family, which is
comprised of him, his wife, his 2 children, daughter-in-law, his niece, his 4 grandchildren, 2
helpers, and client Heisenberg and his nephew. Moreover, both Feli and Glory are the
breadwinners of the family, they provide for the needs of roughly everyone in the family,
including their son FJ who already has work. Feli and Glory are the main decision makers of the
family when addressing family related concerns. However, if they are off to their work or out of
the city, FJ and AZ are the ones filling the role of decision making.

 General Family Relationship

The general family relationship is good, but it could use some improvement. There is an open
climate communication where the family is able to share with one another without feeling
resentment. Glory is able to open up concerns to her husband regarding private and personal
matters. She is also able to discuss personal things to her children. Though what Feli and Glory
does not discuss is monetary issues, especially how much one earns in their occupation. But, this
does not lead to animosity and secrecy, if and whenever it needs to be discussed the Feli and

9
Glory are open to talk about it. A good example is how Glory is able to converse with Feli on
how he handles his money.
This is open and communicative is however, only true for the nuclear family of Feli &
Glory, their 2 children AZ & FJ and their grandchildren. Beyond that, family relationship
becomes strained. It was observed by the group that Glory has no problems with her son and
daughter, but she treats her illegitimate grandchild Kay differently. Kay is the daughter of Feli’s
illegitimate child, and possibly through this Glory treats her differently. During interaction with
the family, Kay is heard addressing Glory as Ma’am, this connotes that Kay is subordinate to
Glory, and that her existence in their family is to serve the family as a housekeeper in payment
for her schooling.
Glory described FJs relationship to her as being a “mama’s boy”. FJ, though he has work, is
still financially reliant to his mother. Even as he is married and has two children, he still
dependent to his mother monetarily. This seem to bother Glory during the interview process, as
she believes that FJ should stop this behavior. It is not a problem to her when he and his family
stays in there home but his dependence borderline childishness. According to Glory, FJ should
start being more financially dependent and learn to prioritize, save, and budget his expenses and
money. Especially that he is now a father.
In the interview process Glory also described AZ’s relationship to her and her father. AZ
took after his own father, according to Glory. Her generosity in what he earns is the same of her
father Feli. However, AZ’s behavior distraught both her parents. According to Feli, generosity is
a good trait, but when it is put in the right place. AZ is a single mom who is raising a child with
special needs, for Glory and Feli, AZ should focus on her finances on her child and not give the
money away. Additionally, Glory and Femi shows empathy to AZ’s child, their granddaughter,
TA. Glory described TA as having a congenital birth defect that has rendered her somehow
immobile. Feli has searched for surgeons to reconstruct TA so she may live a normal life. Even
going as far as America & China to seek medical help, Feli’s love for his granddaughter holds no
bounds. Glory was also insistent that TA gets checked. Glory even believed that the reason why
TA became such was because AZ possibly took abortive medications when she was pregnant of
TA. Glory keeps this information to herself as she does not want to exacerbate the situation.
According to Glory, as long as she sees her daughter happy, and her granddaughter happy, then
she is happy.

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 Lastly, Heisenberg described his relationship of the M family, and his relationship to them.
Heisenberg said that he does not see any conflicts between the family members. Usually, the
family is able to talk things out without blowing things out of proportion. They are able to talk
and converse with one another without hiding their true intentions or emotions. If they felt hurt
or unhappy they are able to open it up to one another according to Heisenberg. However,
Heisenberg’s relationship to the family is somewhat different. He usually stays out of their way
when he can. It is also observed that the family members usually seem to ignore Heisenberg and
leave him alone. Heisenberg on the other also ignores the family members and only talk to them
when needed to. According to Glory, she has been bearing Heisenberg for the longest time.
When they were young Heisenberg was very hard headed according to Glory, and now that he is
sick he is still hardheaded. Glory said “tini-tiis ko na lng yan” meaning she is just enduring the
existence of his older brother Heisenberg. It was peculiar that, although the family is well-offed,
Heisenberg seeks help and monetary funding to the government. His Dialysis and medications
are because of government welfare. Glory said that she sometimes pays for it but only when
welfare is late.
Overall the family relationship is good. Communication is open between the parents and their
children. The family is able to share their emotions and thoughts with one another. However,
they do not discuss financial issues, only when it is needed to be discussed. Some of the
members also treat the extended family member differently. Though they are considered as
family, they are housed, clothed, and given food, they are still distant to the nuclear family.

3. Activities of Daily Living

 Eating Patterns

Most of the family members work at Mati, Davao Oriental, yet they are still able to eat together
as a family though incomplete. Rita wakes up first in the household at around 4:30am to cook
food for everybody. Feli and Glory usually wakes up earlier than the rest at around 6:30am and
eats breakfast together. Because both have diabetes, their meals are patterned to their health
needs. FJ their youngest son wakes up at around 7am and eats at around 8:00 on his own.
Sometimes when his wife and children are awake they also eat together as a family at around
8:30am. AZ their daughter stays in Davao City proper as she goes to school. The rest of the

11
household members eat after Feli, Glory, and FJ has eaten. Kay usually eats alone by herself
during breakfast at around 9am. Heisenberg does not eat together with the family. He usually
eats at the back by himself or with the company of house helpers by 9am. During lunch, the
original family eat together at 11:45 and the rest follows when they are done. By dinner the
original family eats first at 7pm and the rest follows by 7:30 – 8pm. The family is still following
a regular eating pattern of breakfast, lunch, and dinner with snacks in between meals. As a range
the entire family together with the extended members and the helpers they eat breakfast at
7:00am – 9:00am, lunch at 12:00pm – 1:00pm, and dinner at 6:00pm – 8:00pm. They tend to not
skip meals as skipping meals for Glory and Feli could be dangerous to their health. Client
Heisenberg wakes up early sometimes to cook rice. The family has their own cooking and food
storage devices, so they always cook rather than buying precooked foods. Their diet mostly
consists of fish, pork/beef meat, and vegetables.

o 24 Hours dietary recall

 Breakfast: Fried fish, scrambled egg, rice
 Cake
 Lunch: Law-uy, rice
 Crinkles with filling
 Dinner: Sweet and sour fish, rice

Sleeping Patterns

The family in general has good sleeping patterns. Glory and Feli usually sleeps earlier than the
rest at around 9pm. While others have varying time range of sleep. FJ usually put to bed his
children first before going to sleep together with his wife. FJ’s family is usually asleep at around
10pm. Other family members usually sleep at around 10pm in the evening, sometimes as late as
2am depending on the business of their schedule

Client Heisenberg has a poor sleeping pattern due to the discomfort of gout found almost
every joint in his body. At around 10pm most of the family members are already sleeping, except
for him. He sleeps for 2-3 hours only per day according to him. According to Heisenberg, it is

12
already a blessing to be asleep regardless of how long or short his sleep was. Sometimes he
drinks wine to inebriate himself to sleep. In other occasions, he does not sleep at all. He has been
awake for more than 24hrs, sometimes lapsing into doze and suddenly walking up due to pain
felt in his body.
 Leisure Time Activities
The family has different activities for leisure, but generally they usually go to the malls in
Davao City proper. Aside from that they also go to their rest house in Mati when they can. Above
all this however, the family likes to throw house parties. Glory shared how their garage area has
been renovated to accommodate guess for parties. Usually, the parties held are due to holidays,
birthdays, and special occasions. Sometimes FJ brings his friends to the place to party aswell.
Client Heisenberg usually has limited leisure activities, given that he has this worsening
condition. Usually one of his leisure activity is hitting the local lotto place in their area. Apart from
that, he also engages in parties when he can. The other helpers of the family does the whole work
in the house. Regularly, they, together with Heisenberg would be listening to music, listening to
local radio stations, watching TV, do short walks, and sometimes reading newspapers.

B. Socio-Economic and Cultural Factors

1. Income and Expenses
Client Heisenberg does not earn any money, he’s only dependent to his sister. The
head of the family is a municipal councilor at Mati, his sister has some money-making
business, and his nephew works with in the office with his father.

Name Occupation Place of Work Income

Fel City councilor Mati Php 70, 000

Glory Business Mati Php 245,000

FJ Office/Business Mati Php 40, 000 –

100, 000

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 Expenses Cost (per month)

Food Php 62, 000

Transportation Php 20, 000

House hold maintenance Php 20, 000

Electric Bill Php 13, 000

Water Bill Php 2, 500

Education Php 100, 000

Farming Php 50, 000

Other expenses (Wi-Fi, cable, etc.) Php 5, 000

Food

Monthly budget = Php 62, 000

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Rice = 10, 000

- Groceries

o Wet Market = Php 28, 000

o Dry Market = Php 24, 000

Transportation

SUV (gasoline) = Php 20, 000

4 (weeks in a month) x 5, 000+ (back and forth once a week) = Php 20, 000

Household maintenance

Monthly Budget = Php 20, 000

Electric Bill

Monthly Budget = Php 13, 000

Water Bill

Monthly Budget = Php 2, 500

Education

Tuition = Php 50, 000

Allowance = Php 50, 000

Farming

Monthly Budget = 50, 000

150, 000 (per harvest) / 3 (months in a harvest) = Php 50, 000

Other Expenses

Wi-Fi = Php 3, 000

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Cable = Php 2, 000

Total Amount = Php 256, 000

Total Income – Total Expenses = Total Family Revenue

Php 355, 000 – Php 272, 000 = Php 82, 500

2. Head of Money Decision-Making

Both Feli and Glory is the primary decision maker for their family.

C. Ethnic Background and Religious Affiliation

Feli, the head of the family, is originally from Mati, Davao Oriental. His wife,
which is client Heisenberg’s sister, is also from Mati, but decided to go to college in
Davao with no one to support her. They are both Roman Catholics as well. They
decided to settle in their present address 37 years ago, where their family was built.

Client Heisenberg is also from Mati. He transferred to Davao along with his sister
because he works as a driver to them. Client Heisenberg is not married. He’s been
into a relationship with different girls. Unfortunately, none of them ended up with
client Heisenberg since he cannot bear a child. One of the client’s long-term
relationship ended up badly. He was promised by the woman to come back after
finding work in America, however this did not happen as she left him for good.

D. Home and Environment

1. Adequacy of Living Space

The living space is adequate for a family of 10 adults and 3 children, and 1 baby.
The house lot is divided into two. One side contains the house of the original family with
3 rooms in it and a common bathroom, and adjacent to it is another 2-story structure
containing 2 rooms each with bathroom. It also contains a basement room. Situated on
the other side of the lot is a mixed concrete and wood type of structure that contains 3
rooms which provides sleeping quarters to their workers. All in all, the household is
consisting of 9 rooms, 3 bathrooms, and a living room with big sofas where they spent
their quality time when they are complete.

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 2. Sleeping Arrangement
The head of the family along with his wife sleeps in the master’s bedroom. FJ
sleeps together with his family 1 room with 2 beds. Az sleeps together with his daughter
in another room. K, the grand-daughter of the head of the family, sleeps in the room
alongside the room of Az. Rits sleeps in the room beside the master’s bedroom. Client
Heisenberg occupies one room on the other side of the household. M A, the nephew of
client Heisenberg and Glory, occupies the basement room. Dondon, their driver/helper,
sleeps at the room adjacent to client Heisenberg’s room.

Presence of Accident Hazards.

- The house is well modernized, and it is made up of concrete with fiber glasses. Accident
hazards in relation to the house is not so much of a concern. However, the house at the
back has experienced a leakage that has destroyed parts of the upper rooms flooring.
This has been condemned later on as it posed to be a threat if someone stays upstairs.
Even more if some stays below the sodden roofing as the roof can fall on them.

3. Food Storage and Cooking Facilities

- The family has a 2 big refrigerator for storage of both raw and cooked food. They
also own 2 stoves to cook their meals. They also own 2 rice cookers, water dispenser,
oven-toaster, and a microwave. They are also able to cook outside since they have a
griller. They also earn frying pans, pots, and sauce pans for cooking. The storage
materials used by the family are plastic, glass, and ceramic containers.

4. Adequacy of Furniture
- The family owns two Sala sets. One of the set is covered with cloth. The Sala that
they use is composed of a big couch and two chairs, both wooden that is covered with
foam. They also own two dining room set comprised of one table with a glass top and
made of steel with 6 accessory steel chairs that are of the same design. The other
dinning set is comprised of a big dining table made of hard wood that is good for 8-10
people. Furthermore, they also own beds that are adequate for the ones using it. The

17
 masters bed is made of hardwood and is good for two. Other beds are made of
aluminum steel and are easily bended under constant pressure. Each room also has
cabinets made of sturdy material for storage of clothing. Outside their house they also
have cabinets made of wood, electric fans, and another table and chair for receiving
guess. These chairs and tables are also made of hard wood. They also own cabinets in
their rooms that are also made of wood They also own a coffee table and a console
table that has aesthetic jars and pots that adds beatification to the house. Overall the
furniture owned by the family are either made of steel, wood, or a combination, that
are of high-quality, is well-made, and sturdy.

5. Presence of Insects and Rodents

- Presence of insects is evident. Empty cans, waiting to be sold, containing stagnant
water is also seen just at the back of the house. We have not seen one, but the client
verbalized that there is presence of rats in the area and it is mostly seen on the other
side of the household.

6. Water Supply
- The family’s water supply is owned from Davao City Water District. However, the
water that they drink is bought from water refilling stations in the area where it is
purified.

7. Toilet Facility
- The family has their own comfort room that is composed of ceramic flush type water
closet It is located inside their house. 1 near the master’s bedroom, one in each room
of the 2-story structure adjacent to the house. It is cleaned by the helper every day.

8. Garbage/Refuse Disposal
- The family practices segregation and they use the recycled sacks of rice as their garbage
bin. They frequently sell the plastics. Client Heisenbug said that that their garbage is

18
 not collected, instead their helper brings it to the area where the garbage collector
passes.

9. Drainage System
- Their drainage system is open, the water would flow straight and would not build up
underground. Outside, they have an open-canal where water collects during rain.

E. Kind of Neighborhood
The family lives in San Nicholas Manggahan, Purok 2, Brgy. Crossing Bayabas,
Toril, Davao City. The street where the family lives is quite with minimal houses.
Because of how expansive their lot is, the family tend to occupy one block of the
neighborhood. Their street is less congested, and most houses are gated and made up
of concrete. The road in the street where the family lives is not well repaired as it
contains several potholes.
However, some areas in the community are very congested, and houses are very
closely spaced. Sanitation has becoming an issue because some garbage from
neighbors are scattered on the street, some of which are seen piled near the creeks
bank. Breeding grounds for pests are evidently seen from the piles of garbage to
stagnant water, but it is blocks away from client Heisenberg’s house. Animal
droppings can also be seen multiple times in the area being spread by animals. Stray
dogs and cats are observed to be ever present in the community. Drinking and
smoking is increasing in the neighborhood as well. Sometimes, neighbors tend to
argue over small things and raising their voices causing a bit tension in the area.

F. Social and Health Facilities Available

Social facilities available are available within the community. Sari-sari stores can
be seen in every street selling variety of products ranging from canned goods, rice,
animal feeds, etc. because it is the main business of some people living in Purok 2.
An association for the blind is also available in the area. The Crossing Bayabas
satellite barangay and health center is one pedicab ride away, or even a minute walk
away from Purok 2. The Purok also has a small-town lottery sweepstake office and a

19
 small basketball court. Carinderya or small-eatery’s are also found in the purok.
Hollow block manufacturing stores can also be seen near the purok. Purok 2 also has
a bakery, a gasoline station, and a vulcanizing shop along the main highway. Pieded
school is also near the purok 2. A small billiard recreational place and a garage for
tricycles is also located near the small-town lottery office.

G. Communication and Transportation Facilities Available

Each of the family members owns a smart phone for communication purposes.
The family owns laptops as well as desktop computers. For transportation, the family
owns 2 pick-ups, 3 SUVs, and 3 motorcycles.
H. Awareness of Community Organization

The family is indirectly active in community organizations. They are aware of the
existing community organizations in the community and they have idea of its activities
and projects. The reason behind this is that most solicitations come across their
household. Glory admits of contributing financial help when there are solicitations
given to them. Glory exclaimed to be well known amongst the neighborhood. Usually
when neighbors have financial problems they usually go to the Family M household
according to Glory. Furthermore, when they have a problem regarding health, they go
directly to a hospital.

20
 TYPOLOGY OF NURSING PROBLEMS

DATE CUES FIRST LEVEL SECOND LEVEL

ASSESSMENT ASSESMENT
(Health Problem) (Family Nursing
Problem)
July 23, Subjective Health ThreatStress- Inability to provide
2018 provoking factors such adequate nursing care to
“Galisod ko usahay kay ako ra may as care-giving burden the sick, disabled,
gaatiman sa akong sarili sa balay. dependent or
Busy man gud sila sa ilang trabaho” vulnerable/at
risk member of the
as verbalized by the client family due to:
Objective Inadequate family
resources, specifically:
1.Family members are preoccupied
and busy with their own schedule  Member’s
preoccupation with
on
concerns/interests

July 23, Subjective: Health Threat Inability to recognize

2018 “Ga inom ko panagsa og wine aron Unhealthful lifestyle the presence of the
makatulog ko. Wala man pud ko na and personal condition or problem
unsa sa akong ginabuhat.” habits/practices – due to
specify: attitude/philosophy in
“Wala na may pulos ni akong tsinelas 1. Alcohol drinking life.
mao ra man giyapon kay wala man 2. Inadequate footwear
giyapon koy mabati.” 3. Eating restricted Inability to make
food decisions with respect
“Panagsa kung ako ra isa nagakaon ko to taking appropriate
gihapon ug mga bawal. Dili lng gud health action due to
daghan, wala na man pud mahitabo sa
negative attitude
akoa na mas lala pa sa karon”
towards the health
condition or problem.
Objective:
 Client drinks wine secretly to help
him sleep.
 Client has inadequate footwear
that is ripped and has holes in it.
 Client eats food that are restricted
to his current condition

July 24, Subjective: Foreseeable Crisis Negative attitude

2018 “Di naman sad kaayo ko mag Situation- Death of a towards the health
hunahuna, kay kabalo man ko na hapit family member condition or problem
nako mamatay.”
as verbalized by the client

21
 “Ngano wala man ka nag pa dialysis
karon?” asked by the nursing student

“Di ko gusto mu sakay ug jeep, kay

himantayon man gud kaayo ang mga
tao”
Replied by the client
July 24, Subjective: Presence of stress Feeling of alienation from
2018 “Di ko gusto mu sakay ug jeep, kay points – Social Stigma the community. Stigma
himantayon man gud kaayo ang mga due to physical deformity
tao” related to disease
condition.
“Di naman sad kaayo ko mag
hunahuna, kay kabalo man ko na hapit
nako mamatay.”

Objective:
Multiple gouts present in client’s body

22
FAMILY COPING INDEX
CRITERIA
Physical Independence
This category is concerned
with the ability to move about
to get out of bed, to take care
of daily grooming, walking
and other things which
involves the daily activities.
Therapeutic Competence
This category includes all the
procedures or treatment
prescribed for the care of ill,
such as giving medication,
dressings, exercise and
relaxation, special diets.
Knowledge of Health
Condition
This system is concerned
with the health condition that
is the occasion of care.
Applications of Principles
of Hygiene
This is concerned with the
family action in relation to
RATING JUSTIFICATION
6 Most of the member in the family can perform
their activities such as bathing, grooming,
walking, eating. They can also provide the care
and needs of the members in the family. Patient
Heisenberg has altered movement due to his
gout in both his upper and lower extremities,
though, he’s still physically independent and
doesn’t need help when doing activities.
However, their family has a baby, a toddler, and
a child with deformities which is highly
dependent to adults in terms of physical
independence.
9 The family maintains its competence in the
treatment such as taking their maintenance
medicine in efficiently with understanding of the
principals involved and with confidence and
willing attitude. They are also competent in the
management of its member.
9 The family has some general knowledge of their
disease and condition and understands the
rationale of care and they are both able to report
significant symptoms to their physician.
6 Household runs smoothly. They select meals
properly with the likes of fish and vegetables.
They have adequate rest and sleep. The only
problem is that, patient Heisenberg cannot sleep
23
maintaining family nutrition,
securing adequate rest and
relaxation for family
members, carrying out
accepted preventive
measures, such as
immunization.
Health Attitudes
This category is concerned
with the way the family feels
about health care in general,
including preventive services,
care of illness and public
health measures.
Emotional Competence
This category has to do with
the maturity and integrity
with which the members of
the family can meet the usual
stresses and problems of life,
and to plan for happy and
fruitful living.
Family Living
This category is concerned
largely with the interpersonal
or group aspects of family life
– how well the members of
the family get along with one
well due to the pain he experiences when lying
down. In addition, he is also not well groomed
because he movement has slightly been
compromised. Moreover, he does not eat the
right food as he secretly eats and drinks those
that is contraindicated of him
6 Patient Hinesburg and his family understand the
importance of having dialysis 2 times a week,
however, he sometimes skips his session due to
some personal reasons. They have stated that
they believe in the competence of the doctors to
treat their patients since they have the
knowledge on how to do it, so they go directly
to hospitals.
3 The family and patient Heisenberg are not that
open to each other regarding their problems in
life. Patient Heisenberg already accepted his fate
and he is not afraid of death anymore.
Furthermore, he verbalized “ah bahala na og
mamatay ko, tiguwang naman pud”.
Furthermore, Glory verbalizes how she just
endures her brother. She also added how her
brother has given them enough trouble even
before they were young.
6 The family members are in good terms with one
another. This is evident as patient Heisenberg
and other family member talks in a respective
manner. The family also provides the basic
needs of patient Heisenberg like food and home
since they live a luxurious life. However, patient
24
another, the ways in which
they take decisions affecting
the family.
Physical Environment
Heisenberg is a dialysis patient, yet they cannot
manage to accompany him, given that they have
so many cars, during his session at downtown,
so he will go there alone riding a jeep or
sometimes a metered cab. They engage mostly
in a serious conversation when there is a certain
matter that needs to be settled in their family.
But in terms of making decisions regarding
financial matter, they are moderately secretive
with one another. Feli felt distraught when he
found out that her daughter was giving her
earnings secretly behind her family to those
patients that can’t afford to pay the hospital bills,
because in the hospital where she works, they
have a practice to detain precious items of the
patient until they were able to pay the hospital
bills. He is distraught in a way that he is worried
that instead of spending her earnings to his
granddaughter with deformities, the daughter of
his daughter, she gives it all to the patients
leaving nothing for herself and her daughter.
Although it doesn’t affect their income as a
family, Feli’s concern is that not all the time they
are there for her, there will come a time that they
will pass away and if that time will come, Feli
wants her daughter to become an established
individual. And that is the time when Feli
convinced her daughter to take proper medicine.
9 The home environment is adequate for the
family member. The patient has a hut adjacent
25
 This is concerned with the
home, the community and the
work environment as it
affects family health.
Use of Community Facilities
Generally, keeps
appointments. Follows
through referrals. Tells others
about Health Departments
services
Total = 60 The family requires minimal on certain areas assistance however is capable of
independently dealing problems on their own
to the house with 1 bed in it. Stray dogs and cats
are also observed roaming around, however,
their house is enclosed with concrete walls and
gate and it is guarded by 4 dogs. Although the
community contains areas with congested &
dilapidated houses, the block where the family
lives is clean, quiet, and not clogged. The house
of the family itself is large, made of concrete &
steel, and has furniture and appliances to suit the
family’s needs
6 All the family members are aware of the
presence of health center in their area, but they
do not visit them when they have health
problems, instead they go directly to a hospital.
They do not also rely on the health center for
their health-related needs as they go to the
hospital for most of their concerns. The family
does keep appointments and follow ups however
the client, Heisenberg does not. Additionally,
they are participative in their barangay through
offering financial supports especially when
solicitations are given
26
 Chapter V

PATIENT’S DATA

Name: Heisenberg

Age: 67

Sex: Male

Religion: Roman Catholic

Nationality: Filipino

Ethnic Origin: Cebuano

Birthday: July 12, 1951

Birth Place: Mati City, Davao Oriental

Address: Durian St. Manggahan Toril, Davao City

Civil Status: Single

Occupation: None

Language: Tagalog, Bisaya, English

Vital signs taken during assessment:

BP: 130/90

HR: 80

RR: 16

Temp: 35.9C

Diagnosis: End Stage Renal Disease Secondary to Urate Nephropathy

Previous Occupation: Driver

Educational Background: 2nd Yr. High School

27
 Chapter VI

PAST AND PRESENT HEALTH HISTORY

PATIENTS HEALTH HISTORY

Client Heisenberg lives at Duran St., San Nicholas Manggahan, Purok 2, Crossing
Bayabas, Toril, Davao City. He works as a driver of the family before he was diagnosed with end
stage renal failure 4 years ago. He spent most of his youth and adulthood doing vices and habits
that significantly affected his life such as drinking too much alcohol and soda, smoking
cigarettes, eating too much innards, mung beans, and nuts. Because of these faulty lifestyles, by
his mid-30’s, he developed gout in some areas of his both lower and upper extremities. Left
untreated, his gout has caused him kidney problems and eventually developed kidney stones. 10
years have passed, he was diagnosed with nephrolithiasis and was scheduled to have his one
kidney removed because of its damage. One day while distributing goods to the voters, he was
stabbed in his lower abdomen and as a result, the operation took place immediately to repair the
cuts as well as to remove the kidney. He is not married due to the fact that he cannot bear a child.

PRESENT HEALTH HISTORY

After the removal of his right kidney 20 years ago, client Heisenberg is aware of the changes in
his lifestyle, but he disregarded it. By the year 2014 month of April, client Heisenberg had an
onset of anuria, a totally loss of urine. So, he was then brought to Southern Philippines Medical
Center, with a diagnosed case of nephrolithiasis S/P nephrectomy right, and he was diagnosed
with end stage renal disease secondary to urate nephropathy. The doctor told him that the only
way he can eliminate the excess fluid in his body is to have a dialysis. Having no other choice,
client Heisenberg agreed to have dialysis and his first session started on April 24, 2014 at
Nephrology Center of St. Alexius Inc. because it only cost him Php 488 per session. By the
month of May this year, he was referred to the office of the City Mayor for possible medical
assistance under Lingap Para Sa Mahirap Program.

28
 Chapter VII

FAMILY HISORY

GENOGRAM
The Family M household members

29
GENOGRAM
The Family of Heisenberg and Glory

Male Hypertension
& Diabetes
Female
Diabetes
Deceased

Alcoholism ESRD

Physical
Smoker Deformity

Asthma Illegitimate
child
Hypertension

30
NARRATIVE OF FAMILY HISTORY

Glory and Feli were born and raised in Mati City. They both graduated at Mati National
Comprehensive High School where they also first met. Glory is the second to the last youngest
sister of Heisenberg. She moved to Davao City when she was 20 years old to study college along
with Feli. They both studied in University of Mindanao. Glory finished Bachelor of Science in
Business Administration while Fely finished Bachelor of Science in Political Science. Glory and
Feli got married after they graduated from college. They had 2 children namely Az and Fj. Both
of their children graduated Bachelor of Science in Nursing at Davao Doctors College. However,
Az – the eldest daughter, got pregnant when she was in 3rd year college. Her child was born with
a deformity. According to Heisenberg, Az’s child cannot open her hand and maintain good
posture. Moreover, Az worked at the St. John of the Cross Hospital for 4 years. After working at
the hospital as a staff nurse, Az decided to pursue medicine. She studied at Davao Medical
School Foundation. Az pursue medicine to be able to have a stable income for her family in the
future. FJ, on other hand, didn’t practice his career as a nurse. He worked as a government
worker at his father’s office. Furthermore, FJ got married and had two children. All of them,
including our client Heisenberg, live together in one house. In addition, Heisenberg was a family
driver before he got sick. He is not fully supported by his sister, Glory. All his treatments,
dialysis and medications are handled by Lingap. The only thing that is only given to him is
shelter, food and clothes.

31
 Chapter VIII

DEVELOPMENTAL DATA

Sigmund Freud Psychosexual Stages Theory

Freud proposed that psychological development in

childhood takes place in a series of fixed
psychosexual stages: oral, anal, phallic, latency,
and genital (1905). These are known as
psychosexual stages, where each stage represents
the fixation of libido, or sexual drives/instincts on
the different area of the body. During the
development and growth of an individual, certain
areas around their body become important sources
of potential frustration, pleasure, or both. According to Freud, the first five years, or specifically
the oral, anal, and phallic stages of life is crucial to the formation of adult personality. Id, ego, and
superego develop within these stages to exercise this balance and control to the direct need for
gratification into socially acceptable channels. Gratification centers in different areas of the body
at different stages of growth, making the conflict at each stage psychosexual.

32
Psychosexual stage Age Achieved Justification
Genital stage Puberty to Failed Client Heisenberg belongs to the
Adulthood genital stage since he is already an
adult. During this stage its is a
significant event for adults to enter
long term relationships and raise a
family on their own. The client did
not experience such event in his life,
because of what he did before.
According to the client he never was
tied down to one woman. During his
younger years he had multiple
relationships with different women.
He lived a bachelors’ lifestyle.
However, at the onset of his disease,
it become increasingly difficult for
him find a partner. Eventually he fell
in love with someone. Time has
passed when the two decided to make
a family on their own. Around this
time, they found out he was impotent.
According to the client, his wife-to-be
left for America to find work. That
was more than 20 years ago, and he
has not heard from her since. Because
of previous events, the client has
failed this stage. During the genital
stage, the libido is re-awakened after
lying dormant in the genitals during
the progression of the latency stage.
Once awaken, the individual feels this

33
drive to satisfy this renewed sexual
desire. If the individual did not learn
from the phallic stage then his
superego would not be well
developed enough to aid him in the
genital stage. Because the client had
multiple partners during his teenage
and young adulthood this indicates
that he became a slave to his Id. The
Id demands gratification and only a
well-developed superego can halt this
lusting need to be fulfilled. The
patient did not develop a healthy and
mature superego for this. Thus, his
entire teenagerhood and young
adulthood was fulfilling the
hedonistic craving of the animalistic
Id.

34
Erik Erikson Psychosocial Development Theory

Erik Erikson postulated the Post-

Freudian theory of Psychosocial Development.
According to Erikson, much like an embryo, the
ego follows the epigenetic principle of
development. The epigenetic principle implies
that the ego develops at a step-by-step process,
that development undergoes a predetermined
rate and in a fixed sequence. The stages of
Psychosocial Development show that at each
stage of human life, infant to old age, there is an
interaction of syntonic and dystonic elements.
The antithesis between these elements produces
an ego quality or basic strength. Too little of
these basic strength results into a core pathology on that stage (Feist & Feist, 2009). Without going
into much detail, these are Erikson’s Eight stages of Development with their Basic strengths and
Psychosocial crises: Infancy (Trust vs. Mistrust), Toddler (Autonomy vs. Shame and doubt), Play
age (Initiative vs. Guilt), School age (Competence vs. Inferiority), Adolescence (Identity vs Role
confusion), Young adulthood (Intimacy vs. Isolation), Adulthood (Generativity vs. Stagnation),
and finally Old age (Integrity vs. Despair).

35
Psychosocial Crisis Age Achieved Justification
Ego Integrity vs. Maturity (65 to Failed Looking back, client Heisenberg
Despair death) only sees regret. He regrets he
smoked or drink, he regrets not
finishing school and going to
college, and he regrets not having
a wife of any children. Because of
these regrets, Heisenberg feels

36
resentment about his life. During
the interview, client Heisenberg no
longer cares on what will happen
to him or in the future. He is ready
to face death since he knows that it
is where he is going. He kept on
repeating that he does not mind if
he dies or not. Because of his
mindset, he no longer participates
in self-care activities to bolster his
health. He sometimes eat those
prohibited of him, he drinks more
than he should, and he even
intentionally misses his dialysis
schedule. The client has grown
apathetic and resentful of his life
and predicament. He further does
not care about the feelings of
others about him, as he sees
himself as “pabigat lng”.

37
Jean Piaget Stages of Cognitive Development

According to Jean Piaget (1936) cognitive

development goes under 4 stages, each
stage increases the sophistication of a how
an individual think. All children undergo
the four stages of development which is
largely determined by biological maturation
and interaction with the environment. The
first stage of Cognitive Development is the
Sensorimotor stage, this stage is from when
the child is born until he/she is 2 years of
age. Sensorimotor is characterized by the
achievement of object permanence or
knowing that objects still exists after it is
hidden. To achieve this a child must develop a schema or a mental representation of that object.
The next stage is Preoperational stage, this stage is from when the child is 2 years old until he/she
is 7 years old. In this stage children are now able to think things symbolically, meaning they can
make one thing, such as a word or an object, to stand for something other than itself. However, the
young child’s capacity to think is still very egocentric, that is they have difficulty seeing others
perspective aside from themselves. The third stage is the Concrete Operational stage, this stage is
from when a child is 7 to 11 years old. The Concrete operational stage is considered by Piaget as
the turning point in a child’s cognitive development as it marks the start of logical or operational
thought in a child. In this stage the child can internally work things in their head without requiring
trying physically these things out in the actual world. Finally, the last stage is classified to belong
in the Formal Operational stage. The concepts that underlie the Formal Operational stage, such as
Hypothetico Deductive reasoning, or to logically test hypothesis to formulate predictions and
answers, instead of approaching problem through a trial-and-error method. Abstract thought
formulates schemas without having to experience certain things.

38
 Stages of Age Achieved Justification
Development
Formal Age 11+ - Achieved Client Heisenburg can exhibit reasoning
Operational Stage Adolescence to think scientifically through producing
and adulthood hypothetical ideas to explain various
concepts. He is able to identify the cause
and effect of his actions whenever he
would skip dialysis and eat certain foods
that are not allowed especially that he
already is at the end-stage renal disease.
He is capable of deductive reasoning and
can make decisions for himself without
the help of others

39
Lawrence Kohlberg Stages of Moral Development

Kohlberg (1958) recognized three distinct level of moral reasoning with each level have
two sub stages. According to Kohlberg
individuals may only pass through the different
levels in order, with each level upgrades the
form of reasoning of the earlier stages. In this
theory, not everyone achieves all the stages.
The first level of moral development is Pre-
conventional morality, its two sub stages are
Stage 1. Obedience and Punishment
Orientation, where in morality of an individual
is limited to how individual does good to avoid
punishment, Stage 2. Individualism and
Exchange, where individuals see that there is
not just one right viewpoint handed by
authorities, but rather different individuals
have different viewpoints. The second level of moral development is Conventional morality, the
two sub stages under this level are Stage 3. Good Interpersonal Relationship, where the individual
only does good to be seen as good by other people, and Stage 4. Maintaining the Social Order,
where the individual becomes fully aware of the rules and laws of society that is needed to be
obeyed to uphold the law. Finally, the last level Post-Conventional morality level. In Level 3 the
individual’s moral judgments is largely based on self-chosen principles and the individual’s
perceived rights. Stage 5 Social Contract and Individual rights means that laws may exist for the
good of the greatest number but there is certain situation where rules and laws work against the
interest of an individual, and Stage 6. Universal Principle states that at these stage people make
their own set of moral guidelines which may or may not fit in with the laws.

40
41
 Kohlberg’s Stages of Moral Development
Level 3 – Post - Conventional Morality
Stage 5. Social Contract and Individual
Rights. The child/individual becomes
aware that while rules/laws might exist for
the good of the greatest number, there are
times when they will work against the
interest of particular individuals. The
issues are not always clear-cut. For
example, in Heinz’s dilemma, the
protection of life is more important than
breaking the law against stealing.
Stage 6. Universal Principles. People at
this stage have developed their own set of
moral guidelines which may or may not fit
the law. The principles apply to everyone.
Havighurst’s Developmental Milestones Theory
Achieved Justification
Failed Client Heisenberg belongs to Level 3
of Kohlberg’s Stages of Moral
Development specifically in Stage 6.
Only few individuals reach this stage
since it requires real-world
experience and actualization of
potentiality. Heisenberg belongs to
this stage because of his own moral
guidelines. However, he failed this
stage since he has a nihilistic mindset
and ultimately life has no purpose.
For him, it does not matter if he went
to dialysis, ate the right food, wear
clean clothes because he knows there
is only one way to go in his condition.
He lost all sense of self-care when his
condition complicated, and that no
matter what he will do, he will just
die. He is ready to face death since he
knows he is going there because of his
illness and of his late age.
42
 Robert Havighurst (1948) proposed a
biopsychosocial model of development in which the stages
of developmental tasks is influenced by the biological,
psychological, and sociological aspects of the individual.
Havighurst defined growth and development as having
eight to ten tasks. These tasks however are very cultural-
based with each task differing across cultures. An
individual who belongs to an agricultural community, for
instance, might make the preparations for an occupation
such as a becoming a farmer at an early. Conversely
members of an industrialized society require longer and
more specialized preparation for an occupation.
Nevertheless, Havighurst propose a list of common critical
developmental tasks which offers a rough picture of what
these specific developmental tasks are.
Havighurst’s Achieved Justification
Developmental
Milestones Theory
- Adjusting to Failed The client has the condition of
Later Maturity (over 60 deteriorating gout that led to the development
years) health and of end-stage renal failure. He
physical has been on dialysis for 4 years
strength now however he skips sessions
due to no one accompanying
him to the center and it is tiring
for him to go there alone. Since
he has ESRD, he is careful on
what he eats however when he
sees an opportunity to eat foods
that are not allowed on him, he

43
 eats it without no one knowing
it.

- Adjusting to Achieved Client Heisenburg in the age of

retirement 67 has long passed the age of
retirement. He is staying in the
house of his sister and most of
the time he just sits down
because of his condition. He is
able to do things for himself
such as cooking his own food.
He does not ask his family for
help since he knows that he can
still do things on his own in the
house however, he moves in a
very slow pace because of his
illness.

44
- Meeting social and Failed The client failed this
civil obligations developmental task since he
said to himself that his life has
no purpose already.

- Adjusting to death or Achieved The client never got married

loss of spouse and had a spouse to live with.
He is ready to die since he
knows that in his situation right
now wherein his health
condition is deteriorating he
knows that he is going there
someday.

45
 Chapter IX

PATIENT ASSESSMENT

REVIEW OF SYSTEMS

General Survey

Patient Heisenberg said that he has had his illness for 30 years now. He exclaimed that the cause
of his current condition is due to a combination of bad diet and unhealthy lifestyle. He did not
know which came first, it was either his gouty arthritis or his kidney disease. He also included
that he does not have any illnesses or disease prior to his condition now, however he has
experienced a stabbing scenario. He experienced stabbing 20 years ago, at that time he was
scheduled for a radical nephrectomy. Being stubborn as he his, he did not go through his
operation, until he was stabbed in the stomach while he was delivering rice. During the operation
of his wound, the doctor took it upon his medical judgment to remove the deceased kidney. The
patient continued how his diseases has made daily activity a painful experience. He cannot sleep,
move, sit, or lie down properly without feeling discomfort.

“Dugay na man ni akong sakit, mga 30 na ka tuig. Grabe man gud ko maka bisyo sa una. Inom,
sigarlyo, kana. Ganahan jud ko mukaon og laman-loob. Nagka bato akong kidney, didto na nag
sugod burot akong gout. Ambot, nakalimot ko kung unsay nauna ang bato ba o ang gout, dugay
naman pud to kaayo. Mao ra ni akong mahuna-hunaan nga sakit, pwera tong na dunggaban ko.

i- schedule na unta kog opera tung naanay bato akong kidney 20 ka tuig na nilabay. Unya kay
nadunggaban man ko, gi-isa na lng ug opera.

Lisod na kaayo mulihok, labaw na ug mulingkod ug muhigda. Dili gani ko katulog usahay. Basta
dong oi, lisod kaayo ilhok tanan parte sakung lawas sakit pajud kaayo.

Skin, Hair, and Nails

The patient said that his skin color is not uniform in color. His hands and feet are darker because
his gout has decreased tissue perfusion on the area. He also said that the clusters of hard
crystalized formation found on the dermis of his skin is still due to his gout, and that he
sometimes pops these tophi.

46
The patient also shared that he does not care about the length of his nails. He said that because of
his condition, he can no longer perform activities of daily living, including cutting his nails.

“Lahi-lahi na ug color dong, ingon sa doctor ni-itom dawn ang uban kay wa daw kaadtog
tarong ang dugo.

Gout pud na, kanang butoy-butoy nga gagmay? Gout pud na, gina pusa gani nako na panagsa.

Ginpasagdaan ko ra na akong kuko. Wa naman pud gihapon koy mabuhat, di man malihok
akong mga kamot. Ang uban dira nangamatay nag ani.

Dugay-dugay nana na upaw dong oi, tiguwang naman gud hehe

Head, Face, Neck, and Lymphatics

Patient Heisenberg said that he experiences headaches when he lacks sleep. He also expressed
how his face has become distorted because of the presence of gout. He denies pain when moving
his neck.

“Sakit akong ulo panagsa kay walay tulog.”

“Wa naman ni namao akong nawong tungod aning gout, daghan kaayo ug butoy-butoy. Makita
man siguro nimo sakong agtang.”

“Di man sakit lihukun akong liog”

Eyes

The Patient Heisenberg reported that he has cataracts and that he can no longer see very well, he
also said that he uses corrective lenses.

“Di na kaayo ko ka klaro naa man gud koy katarata”

“Nagagamit ko ug antipara”

47
Ears

Patient Heisenberg described having tophus located on the auricles of his ears. He denies of
having ear ache or any related pain in his ear.

“Naakoy gout sa akuang dalungan. Pero dili sa sulod oi, dira ra gawas. Gina buto gani nako
na”

“Wala man koy sakit-sakit sa akuang dalungan”

Nose

The patient stated he experienced episodes of nosebleed when he was still young. However, he
has no history of sinus problems, allergy or altered smell. But experienced colds sometimes.

“Ginasungo ko atung bata pa ko, karon wala naman, basig nay gout sa sulod haha.”

“Gina sip-on ko panagsa, labaw na kung kalinturahon ko. Wala koy mga allergies”

Mouth

The patient shared how he his toothless. He said that he loss his tooth while he was at his 40s. He
added that his tooth has discolored and has rotted due to his prolonged cigarette smoking.

“Pangagon ko, dili kompleto akoang mga ngipon, o! 40 anyos pa lng nag sugod na kalagas
akong ngipon. Wala man nagasakit akong ngipon”

“Grabe ko manigarilyo sa una, maong galagum ni akong lagos og nangadaot akong ngipon”

Thorax and Lungs

The patient denied of experiencing difficulty of breathing, but he shared how his doctor
described his breathing, that his lung expansion has decreased. This does not affect the patient’s
breathing pattern. The patient also shared how he does not experience pain during breathing.

“Wala ko naga lisod og ginhawa. Ingon sa doctor dili na kaayo katarong og palabad akong
baga , pero wala man ko gi lisdan”

“Di sakit mg-ginhawa, dili pud ko hubakon”

48
Cardiovasclar

He denies history of diseases related to cardiovascular system. However, the patient experiences
high blood pressure but it is due to his kidney disease.

“Wala man koy sakit sa kasingkasing. Wala pud sa among pamilya ang highbloodon. Diabetes
lng. Highbloodon man ko tungod sa sakit sakong kidney”

“Sukad-sukad wala koy gibati na problema sa akong kasing-kasing

Abdomen

The patient has undergone an operation due to a stabbing incident. He was stabbed using a large
knife 20 years ago while delivering sacks of rice. He shared his experience and how he felt a
numbing pain after the surgery. He also shared his daily nutritional intake and how he can eat
and drink only those that is required of him, but he still eats those that are prohibited. He passes
bowels regularly and has not experienced any diarrhea or constipation.

“Kaning tahi? Mao na tong na dunggaban ko ug gi tangal akong kidney.”

“Sa-una ngol-ngol ni katong bagong tahi pa, karon wala naman”

“Makakaon kog tarong, kanang pwede lng sa ingon ni doc pero gakaon ko ug bawal patago”

“Katarong kog libang, wala ko ginakalibanga ug git obol. Wala nagasakit akong tiyan pud ko
naga suka”

Musculoskeletal System

Patient explained how his gout has affected roughly all joints of his body. He experiences pain
during movement, however he is still able to walk properly. He shared how he does not like to
ride the jeep, fearing the comments and judgments he might get from the passengers. He
described of how limited his movements are with his hands, arms, legs, and feet.

“Ang gout nikalat na sa tibuok nakong lawas. Naa sa akuang abaga, sa tibuok kamot, sa lubot,
sa tibuok tiil.”

“Makabaklay-baklay pa ko dira mupatad ug lotto, pero lisod na jud siya ilihok.”

49
“Di ko ganahan mag jeep kay hinawayun ang mga tao, lisod pud ug kapoy. Labi na kung batsi”

“Maka kaon paman ko pero akong malihok ra akong too na kamot”

“Ma-shock man gani ang mga doctor kay dako na kaayo ning gout sa akuang tuhod, pero maka
baklay-baklay pa ko”

“Di ko katulog tarong kay sakit akong gout labaw na sa akong lubot, duha ka buok dako”

Neurologic System

The patient described decreased sensation on his peripheries, and that he can no longer feel
sensation his hands and moreover his feet. He described that he is still able to talk but not
properly due to missing teeth. Furthermore, the patient denied experiencing seizure or any
neurologic illness.

“Naminhod nana akong tiil pati akong kamot. Di na kaayo ko ka bati dirang dapita”

“Maka storya pa man kog tarong, yungit ra usahay kay pangag ko”

“Wa man ko gina patol, Wala man ko naka sinati og lipong o sakit sa ulo pwera na kung di ko
katulog”

50
 PHYSICAL ASSESSMENT

Date: July 24, 2018

Patient: Heisenberg Age: 67

Sex: Male Occupation: Driver (before)

Religion: Roman Catholic

Address: Purok 2 Crossing Bayabas, Toril, Davao City

I. General Assessment
Patient Heisenberg is 67 years from Purok 2 Crossing Bayabas Toril, Davao City. During
initial observation, he does not exhibit complete and proper range of motion in both his upper
extremities and lower extremities. His body does not appear symmetrical because of the presence
of multiple swollen and inflamed gouty arthritis. The patient’s arms appeared warped with uric
crystals collecting over both his shoulders, his elbows, and his fingers. The AV fistula is found
on the left anterior forearm and is noted to be protruding and enlarged. The patient’s legs are of
irregular shape, size, and height due to the enormous inflamed joints of the hip, the knees, and
the feet. The patient walked with a staggered gait with clear observable physical distress during
movement. His skin appears bronze brown, it is also dry and rough. He appears his stated age
and wears inappropriate clothing for his location. Also, the patient appeared to be not well-
groomed and unkept. His clothes are derelict with patches of dirt seen on different parts of the
clothing. His foot wear is appears worn, with parts of his feet exposed by holes and torn rubber.
Patient Heisenberg’s baseline vital signs were T = 35.9 * C, Pulse Rate = 80 beats per minute left
radial, Respiratory Rate = 16 breaths per minute, Blood Pressure = 130/90 mmHg left arm,
sitting.

51
 II. Mental Status Assessment
During the interview, patient Heisenberg was seated with a slouch with both arms resting on
his lap. He did not sit comfortably since he remarked pain on his hip and buttocks. However, this
did not hinder the interview process and the physical assessment. Throughout the assessment, the
patient was oriented to the time, the place, and the people. He was also alert, cooperative and
responded to the questions promptly and appropriately. The patient did not maintain good eye
contact because his vision is partially blurred from his cataracts. The patient appeared calm sharing
his story to the interviewers, there was no resistance or intransigence observed during the process.
His facial expressions are parallel to what he is saying and what he is feeling. His voice is rough
and speaks sometimes inaudibly with a slow pace since he has multiple teeth absent. The interview
process with the patient was generally difficult but free-flowing. Necessary and significant
information was acquired during the interview process and the physical assessment. Towards the
end, the patient agreed to have his picture taken. There were clear signs of physical discomfort
during the entire course of the interview.

III. Skin, Hair, and Nails

Skin

INSPECTION: Patient Heisenberg’s has a bronze-brown skin complexion that emits a

yellowish hue. His skin is not uniform in color. Evidently, the hands and the feet of the
patient have a darker tone with some areas around the feet that are black in color. The uric
crystals are easily observable and emanates a whitish yellow color under the skin. The
articular joints of the shoulders, the elbow, the wrist, the fingers, the knees, the feet, and
the toes are inflamed due to gout. Tophi is found developing on the left side of the patient’s
forehead, the left side of the temple, the auricles of both ears, where the left ear having a
cluster of tophi (1cm2), the middle finger of the left hand, and the dorsum of both feet. A
20 cm Midline incision scar observed running down the patient’s abdomen, 2cm below the
epigastric area to the hypogastric area 3cm below the umbilicus. There is also a Transverse
scar running across the umbilicus measuring approximately 7cm.

52
 PALPATION: The patient’s skin is dry and rough. The temperature of the skin varies, the
hands and the feet are cold to the touch, while the arms and the thighs are warm. The skin
of the patient is wrinkled with skin turgor that of an elderly. Palpation of the tophi revealed
a hard, crystalized, palpable nodule. Palpation of the joints showed a large, solid, palpable
mass that is fixed over the articular joints. A thrill is palpable over the AV fistula.
Hair

INSPECTION: The patient’s is balding with white sparse hair that is thicker on the sides
of the head. The patient has facial hair that is also white
PALPATION: Upon palpation, his hair is rough to touch and oily
Nails

INSPECTION: The nails of the patient of both the fingers and the toes are long with dirt
seen accumulating under the nails. The color of the nails of the fingers are pale, while the
nails of the toes are brownish in color.
PALPATION: Nails are rough, long, and distorted with a capillary refill of < 3 seconds

IV. Head, Face, Neck, and Regional Lymph Nodes

Head

INSPECTION: Patient Heisenberg scalp is brownish in color. There is an observable

lesion on the middle of his head. Tophi is seen on his forehead and the temple of his head.
His head is symmetrical and normocephalic. There were wrinkles seen on the patient’s
forehead
PALPATION: Upon palpation, there is dry lesion located at the middle of the patient’s
head. It was not painful upon palpation. The tophi are crystalized nodules that can be
palpated over the dermis of the patient. Generally, the skin of the patient’s scalp is wrinkly,
rough, and oily.

53
Face

INSPECTION: Patient’s face is asymmetric and appeared wrinkled ang sagging. The
facial bones of the patient are prominent especially the cheek bones. The nasolabial folds
are prominent specially on the left side of the face. The marionette line jowl is also present
but more present over the right area. This gives the patient a permanent smirk on his face.
The brow droop is present on both sides. The Frown line are also present. Tear troughs are
present but thicker on the left side. The lip border on the left side is also more prominent
as compared to the left. The mental crease is also observable. The patient’s jaw line curves
towards the right side.

PALPATION: Patient’s face was rough, oily, and wrinkly. The facial bones are
prominently and very palpable. There is presence of a red nodule on the right side of the
cheek. The tophi can be palpable over the dermis of the skin. There was no pain on the
frontal and maxillary sinus upon palpation. Temporomandibular joint moves smoothly
without crepitation or pain. Temporal pulse is palpable (2+)
Neck

INSPECTION: The patient’s neck is symmetric and has full range-of-motion. He was also
able to move her neck without any pain and was also able to swallow without pain. His
neck veins were not distended, and no irregular pulsating was observed. The skin of the
neck is saggy with distinct presence of the sternocleidomastoid muscle.
PALPATION: No masses and enlargement of the facial lymph nodes were noted, and his
trachea is in the midline on his neck. The carotid pulse are easily palpated (3+)

Eyes, Eyebrows, and Eyelashes

INSPECTION: The patient’s eyebrows are thick, black in color, and evenly distributed.
They are symmetrically aligned and showed equal movement. Eyelashes are present,
curved out ward and distributed evenly. Eyelids close symmetrically with involuntary
blinks. No ptosis, ectropion and entropion were observed. Patient’s bulbar and palpebral
conjunctiva are pale. The sclera is yellowish white with vascularity noted. The cornea of
the patient’s eye is smooth the iris however is visible. The lens of eye is appearing cloudy

54
 due to cataracts. The pupils are not completely round and have less brisk response to light
due to the opacity of the lens. There is decrease in the peripheral visual filed of the patient.
Patient uses corrective lenses.

Ears

INSPECTION: Patient Timmy’s ears are of not equal in size bilaterally. Auricles are
symmetrical and aligned with the outer canthus of the eyes. However, the helix of the left
auricle has clusters of tophi making it look pointed. The Antihelix of the left auricle also
contain clusters of tophi. The ears have the same color as his skin and the skin is intact and
firm with noted swelling and masses found on both the auricles of the ear. Patient was able
to hear spoken words bilaterally with ease. During the whisper test, patient was able to hear
whispered words easily and during the watch tick test, the patient was able to hear the
ticking of the watch on both ears.
PALPATION: The pinna of the ears recoils when folded, but there is pain when folding
the pinna. The auricles are firm, and the tophi are palpable. The skin is intact with presence
of uric crystal nodules that are not painful upon palpation.

V. Nose and Sinuses, Mouth and Throat

Nose and Sinuses

INSPECTION: Patient Timmy’s nose is symmetric, and in the midline of the face.
There were no deformities, bleeding, masses and discharges noted upon inspection.
The patient has patent nares and can distinguish between pleasant and foul odors.
PALPATION: Upon palpation, no tenderness, swelling, lesions, or discharges were
noted. No pain and tenderness were felt on the frontal and maxillary sinuses when
pressure was applied on the sinuses.
Mouth

INSPECTION: During the inspection, patient’s lips were slightly pale and dark in
color and dry in texture. The tongue is pink in color and is in the center of the mouth
with no abnormal movements. The uvula rises in the midline when patient was asked
to say “ah”. Upper teeth and lower teeth are incomplete. There is 4 teeth on the upper

55
 part comprised of the incisors and canine, while the lower teeth has only the molars on
each end. The teeth also are not straight. Discoloration of the teeth was also noted.
Other than that, there was no report of unusual bleeding in gums and no ulcers, lesions,
and swelling were present in the lips, gums and tongue.

VI. Breast (Male)

INSPECTION: Upon inspection, the breasts had no discharges from the nipples and areola

VII. Thorax and Lungs

INSPECTION: Patient Timmy’s respiration is shallow & slow with 16 breaths per minute.
His respiration is quiet without the use of his accessory muscles such as that of his
sternocleidomastoid muscle and trapezius muscle. His breathing is rhythmic, quiet, and
effortless when the patient is relaxed or not talking. His chest diameter is smaller than the
transverse diameter with a ratio of 1:2, with decreased but symmetric expansions of the
chest. Respiratory distress is not observed. The thumbs separate <2cm during the
assessment of respiratory excursion.
PALPATION: The chest wall is intact with no tenderness and masses when palpated. The
skin of the patient is saggy with decreased elastic properties of the skin.
PERCUSSION: The lung fields are resonant during percussion in the anterior left and
right midclavicular line and midaxillary line.
AUSCULATATION: There is adventitious breath sounds heard soft light crackles are
heard over the lower lung fields upon auscultation. The spine is vertically aligned, the right
and left shoulders and the hips are of the same height.

VIII. Heart and Neck Veins

56
 INSPECTION: Upon inspection, the patient’s heart and neck veins show negative visible
pulsation on the aortic and pulmonic areas. Also, the neck has no noticeable jugular vein
distention.
PALPATION: The pulse rate is 80 beats per minute right radial (2+). The radial, brachial,
and carotid pulse is consistent, regular and was easily palpable. The patient’s blood
pressure 130/90 right arm. Apical pulse is felt in the left 5th ICS, midclavicular area.
PERCUSSION: Percussion of heart border reveals heart is still normal in size
AUSCULTATION: Apical pulse shows a heart rate of 80 beat per minute. Normal sound
of lub and dub can be heard on S1 and S2.

IX. Abdomen
INSPECTION: The patient’s abdomen is flat to rounded. The abdomen is wrinkly and
symmetrically bilateral. There is no localized bulging, visible mass, or asymmetric shape.
There is the presence of a Midline incision scar 20cm and a transverse scar 8cm on the
umbilicus area. The umbilicus is midline and inverted with no sign of discoloration,
inflammation, or hernia. Pigmented nevi are observed to be present on the abdomen.
AUSCULTATION: There was presence of bowel sounds on all four quadrants with 30
bowel sound /minute with no bruits present.

PALPATION: Umbilicus in the midline but was noted to be protruding. The abdomen
saggy and wrinkly with noted decrease of elastic skin property.

X. Musculoskeletal system
INSPECTION: The patients joints, and muscles are asymmetric with decreased range-
of-motion over the articular joints of the upper extremities however there was no
crepitation observed. The joints of the shoulders, the elbow, the wrist, and the fingers are
evidently inflamed and swollen. The fingers of the right hand are curved inwardly and
adducted, with movement only present on the thumb and the pointing finger. The patient
is able to only pinch with the right hand. The fingers of the left hand conversely are curved
outwardly but adducted towards the midline. There is very limited motion of the left hand.

57
 The joints of lower extremities were observed to be inflamed, enormous, and firm
especially on both knees of the patient. The legs of the extremities can flex and extend
but there is decreased range of motion. The toes of the feet are everted due to the presence
of gout. The skin of the feet is black with presence of dry lesions on the plantar surface.
Movement is noticeably decreased on both the extremities. Muscle weakness was also
observed on both upper and lower extremities but more evident on the lower extremities.
During the grip test, patient failed to grip the fingers of the interviewer.

PALPATION: The gouty arthritis is easily palpable, it is a large, crystalized formation

over the articular joints of the elbows and the knees. There is also presence of it in the
fingers and toes. The gout and severely deformed the patient’s bone and joint structure.
There is pain when moving the joints in its natural ROM, however there were no
crepitations when moving the joints. His muscles are not palpable, and the muscle tone is
not firm when asked to be contracted. The temperature of the feet are cold to the touch,
as well as the hands. Sensation of the feet is loss when assessing the patient. Overall
muscle and joint status is Grade 1 with slight contraction.

XI. Neurologic system

Mental status: Appearance, behavior and speech is appropriate. She is alert and oriented to
person, place and time.

Cranial Nerves

I. Identifies smell of rubbing alcohol

II. Both eyes do not require corrective lenses
III. Pupils does not react to light briskly due to opaque lens
IV. Pupils does not react to light briskly due to opaque lens
V. Sensation intact and equal bilaterally. Patient’s jaw strength is present and maintained
during contraction
VI. Pupils does not react to light briskly due to opaque lens
VII. Facial muscles intact and symmetric
VIII. Tick of the watch heard on both ears, whispered words heard bilaterally.
IX. Swallowing intact and gag reflex present, uvula rises in midline on phonation.
X. Swallowing intact and gag reflex present, uvula rises in midline on phonation.

58
 XI. Capable of shoulder shrug but with pain noted, head movement intact and equal
bilaterally with 3/5 muscle strength score.
XII. Tongue protrudes midline with no tremors
Motor: Presence muscle atrophy and weakness. Gait uncoordinated and staggered

Sensory: Able to identify texture of cotton only in particular areas.

XII. Male Genitalia Assessment

INSPECTION: Patient’s genitals was not inspected.

59
 Chapter X

PATHOPHYSIOLOGY

DEFINITION OF ILLNESS

Final Diagnosis

End-Stage Renal Disease secondary to Urate Nephropathy

End-Stage Renal Disease

- The final stage of kidney failure that is marked by the complete or nearly complete
irreversible loss of renal function. Defined as either the presence of kidney damage or
a glomerular filtration rate of less than 60 ml/min for 3 months or longer. (Brunner &
Suddarth, 2010).

- The last final stage of CKD where there is progressive accumulation of toxins, fluid,
and electrolytes due to a radical decrease of GFR <15ml/min for more than 3 months.
Normally excreted by the kidneys, these metabolic waste and excess fluid &
electrolytes results in the uremic syndrome that can cause death if left unmanaged.
(Jameson & Loscalzo, 2013)

- A progression of chronic kidney disease to a GFR less than 10–15 cc/min, which
requires renal replacement therapy. (Lerma, Bern & Nissenson, 2012)

Urate Nephropathy

- Acute renal failure due to tubular obstruction from urate and uric acid deposits in
the tubular system. (Brunner & Suddarth, 2010)

- Urate nephropathy is a rapidly deteriorating renal failure that is caused by high

levels of uric acid in the urine (LeMone et.al, 2015)

- Urate nephropathy is defined as the development of acute oligoanuric renal failure

caused by obstructions of the renal tubule by urate and uric acid crystals. (Black
& Hawks, 2009)

60
 ANATOMY AND PHYSIOLOGY

URINARY SYSTEM

The urinary system consists of two kidneys, two ureters, the urinary bladder, and the urethra. The
most well-known function of the kidney is that it filters blood. Blood flows through the kidneys,
which remove substances such as nitrogenous waste from the blood to form urine. Urine
comprises of different substances such as water and ions, metabolic wastes, and toxic substances.
Once blood has been filtered out by the kidney the urine it produces flows through the ureters to
the urinary bladder, where it is stored until it is eliminated through the urethra (VanPutte et.al,
2013).

VanPutte et.al (2013) described the major function of the urinary system is to control the
composition and volume of body fluids and it does this through multiple processes:

1. Excretion. The kidneys are the major excretory organs of the body. They remove waste
products from the blood. Many waste products are toxic, but most are metabolic by-products of
cells and substances absorbed from the intestine.

2. Regulation of blood volume and pressure. The kidneys play a major role in controlling the
extracellular fluid volume in the body. They can produce either a large volume of dilute urine or
a small volume of concentrated urine. Thereby, the kidneys regulate blood volume and blood
pressure.

3. Regulation of the concentration of solutes in the blood. The kidneys help regulates the
concentration of the major molecules and ions, such as glucose, Na+, Cl−, K+, Ca2+, HCO3 −,
and HPO4 2−.

4. Regulation of extracellular fluid pH. The kidneys excrete variable amounts of H+ to help
regulate extracellular fluid pH.

5. Regulation of red blood cell synthesis. The kidneys secretes hormone, erythropoietin, which
regulates the synthesis of red blood cells in bone marrow.

6. Regulation of vitamin D synthesis. The kidneys play an important role in controlling blood
levels of Ca2+ by regulating the synthesis of vitamin D

61
 Anatomy of the Kidney

The kidneys are bean-shaped organs,

that lie on the posterior abdominal wall,
behind the peritoneum. A layer of
connective tissue called the renal
capsule surrounds each kidney. Middle
of the kidney is a structure called hilum.
The hilum is where the renal artery and
nerves enter and where the renal vein,
ureter, and lymphatic vessels exit. The
hilum opens into a cavity called the
renal sinus, which contains blood
vessels, part of the system for collecting
urine, and adipose tissue (VanPutte
et.al, 2013).

The kidney is divided into an

outer cortex and an inner
medulla. The bases of several
renal pyramids are located at
the boundary between the
cortex and the medulla, and the
tips of the renal pyramids
project toward the center of the
kidney. A funnel-shaped
structure called a calyx
surrounds the tip of each renal
pyramid. The calyces from all
the renal pyramids join to form a larger funnel called the renal pelvis. The renal pelvis then
narrows to become the ureter, which exits the kidney and connects to the urinary bladder. Urine

62
passes from the tips of the renal pyramids into the calyces. From the calyces, urine collects in the
renal pelvis and exits the kidney through the ureter (ibid.)

Nephrons

Each nephron consists of a renal corpuscle, a proximal convoluted tubule, a loop of Henle, and a
distal convoluted tubule. Fluid
moves from the renal corpuscle
and into the proximal convoluted
tubule, then it continues towards
the loop of Henle going down the
descending limb and up the
ascending limb. Finally, the fluid
from the ascending limb of the
loop of Henle goes towards the
distal convoluted tubule where
several distal convoluted tubules
empty into a collecting duct.
Eventually, the collecting duct
caries the fluid from the cortex,
through the medulla and empties
into a single papillary duct, that
empties their contents into a calyx.

The renal corpuscle is composed

of the Bowman capsule and the
glomerulus. The Bowman capsule
consists of the enlarged end of the nephron, which is indented to form a double-walled chamber.
The glomerulus is a clump of capillaries and lies within the dents of the Bowman capsule. The
cavity of the Bowman capsule opens into the proximal convoluted tubule, which carries fluid
away from the capsule. The inner layer of the Bowman capsule consists of specialized cells
called podocytes which wrap around the glomerular capillaries. The outer layer of the Bowman
capsule consists of simple squamous epithelial cells.

63
The glomerular capillaries have pores in their walls, and the podocytes have numerous cell
processes with gaps between them. The filtration membrane is formed by the endothelium of the
glomerular capillaries, , the podocytes, and the basement membrane. During the first step of
urine formation, fluid consisting of water and solutes passes in the glomerular capillaries through
the filtration membrane towards the Bowman capsule. Once fluid has passed across the filtration
membrane it becomes a filtrate.

The proximal convoluted tubules, the thick segments of the loops of Henle, the distal convoluted
tubules, and the collecting ducts are portions of the nephron where active transport of molecules
and ions occur. (ibid.)

URINE PRODUCTION

The primary function of the kidney is regulation of body fluid composition. The kidney is the
organ that sorts blood substances for either removal in the urine or return to circulation. The

64
nephron is the functional until of the Kidney. Urine formation is categorized into three major
processes: filtration, tubular reabsorption, and tubular secretion (Tortora & Derrickson, 2008).

Filtration

Filtration occurs when blood pressure forces water and other small molecules out of glomerular
capillaries and into the Bowman capsule, forming a fluid called filtrate. The pressure that forces
water and other substance from the glomerular capillary across the filtration membrane is called
the filtration pressure. The glomerular capillary pressure is the major force causing fluid to move
from the glomerular capillary across the filtration membrane into the Bowman capsule (Tortora
& Derrickson, 2008).

Two major forces oppose movement of fluid into the Bowman capsule, the capsular pressure and
the colloid osmotic pressure. The capsular pressure is caused by the pressure of filtrate present
inside the Bowman capsule, while the colloid osmotic pressure is the amount of protein solutes
within the glomerular capillary exerting osmotic pressure. Thus, filtration pressure is influenced
by the blood pressure in the glomerular capillaries, the blood protein concentration, and the
pressure in the Bowman capsule (ibid.)

Reabsorption

Tubular reabsorption is the movement of substances from the filtrate across the wall of the
nephron back into the blood of the capillaries. Certain solute molecules and ions are reabsorbed

65
by processes such as active transport and cotransport. Reabsorption of water occurs by osmosis
across the nephron wall (VanPutte et.al, 2013).

Secretion

Is the active transport of solutes across the nephron walls into the filtrate. In totality urine,
consists of substances that are filtered across the filtration membrane and those that are secreted
from the peritubular capillaries into the nephron, minus the substances that are reabsorbed
(VanPutte et.al, 2013).

Hydrogen ions are actively transported into the proximal convoluted tubule. The epithelial cells
actively transport large quantities of H+ across the nephron wall into the filtrate. The secretion of
H+ plays an important role in regulating the body fluid pH. In the proximal convoluted tubule,
K+ is reabsorbed. However, in the distal convoluted tubule and collecting duct, K+ is secreted,
resulting in a net loss of K+ in the urine (ibid.)

HORMONAL MECHANISMS OF URINE REGULATION

According to VanPutte et.al (2013) there are three major hormonal mechanisms involved in
regulating urine concentration and volume: the renin-angiotensin-aldosterone mechanism
(RAAS), the antidiuretic hormone (ADH) mechanism, and the atrial natriuretic hormone (ANH)
mechanism.

RAAS Mechanism

66
Renin is secreted by cells of the juxtaglomerular apparatuses in the kidneys. Renin acts on
angiotensinogen, a plasma
protein produced by the
liver, and converts it to
angiotensin I. Angiotensin I
is rapidly converted to a
smaller peptide called
angiotensin II by
angiotensin-converting
enzyme (ACE). Angiotensin
II acts on the adrenal cortex,
causing it to secrete
aldosterone. Aldosterone
increases the rate of active
transport of Na+ in the distal
convoluted tubules and
collecting ducts (ibid).

Antidiuretic Hormone Mechanism

67
ADH is a hormone secreted by the posterior pituitary gland that has direct influence to the
kidneys. ADH regulates the amount of water reabsorbed by the distal convoluted tubules and
collecting ducts. When ADH levels increase, the permeability of the distal convoluted tubules
and collecting ducts to water increases, hence more water is reabsorbed, and a more concentrated
urine is produced. On the other hand, when ADH levels decrease, the distal convoluted tubules
and collecting ducts become less permeable to water. As a result, less water is reabsorbed, and a
large volume of dilute urine is produced. The release of ADH from the posterior pituitary is
regulated by the hypothalamus. Certain cells of the hypothalamus are sensitive to changes in
solute concentration. A reduced solute concentration in the blood causes inhibition of ADH
release (Tortora & Derrickson, 2008).

Baroreceptors that monitor blood pressure also influence ADH secretion. A large decrease in
blood pressure causes an increase in ADH secretion, and a large increase in blood pressure
decreases ADH secretion (ibid).

Atrial Natriuretic Hormone

Atrial natriuretic hormone (ANH) is secreted from the cardiac muscle cells in the right atrium of
the heart when blood pressure in the right atrium increases above normal. ANH acts on the
kidney to decrease Na+ reabsorption. Therefore, Na+ and water remain in the nephron to become
urine. The increased loss of Na+ and water as urine reduces the blood volume and the blood
pressure.

68
69
BODY FLUID COMPARMENTS

Intracellular fluid

The intracellular fluid compartment includes the fluid inside all the cells of the body.
Approximately two-thirds of all the water in the body is in the intracellular fluid compartment.
Intracellular fluid has a similar composition from cell to cell. It contains a relatively high
concentration of ions, such as K+, magnesium (Mg2+), phosphate (PO43−), and sulfate
(SO42−). It has a lower concentration of Na+, Ca2+, Cl−, and HCO3− than does the
extracellular fluid. The concentration of protein in the intracellular fluid is also greater than that
in the extracellular fluid (Rizzo, 2015).

Extracellular fluid

The extracellular fluid compartment includes all the fluid outside the cells. It constitutes
approximately one-third of the total body water. The extracellular fluid compartment includes
the interstitial fluid, the plasma within blood vessels, and the fluid in the lymphatic vessels. Like
intracellular fluid, the extracellular fluid has a fairly consistent composition from one area of the
body to another (ibid).

Exchange in Fluid Compartments

The cell membranes that separate the body fluid compartments are selectively permeable. Water
continually passes through them, but ions dissolved in the water do not readily pass through the
cell membrane. Water movement is regulated mainly by hydrostatic pressure differences and
osmotic differences between the compartments. The major influence controlling the movement
of water between the intracellular and extracellular spaces is osmosis. When a person becomes
dehydrated, the concentration of ions in the extracellular fluid increases. Therefore, water moves
from the intracellular fluid to the extracellular fluid, thus maintaining the extracellular fluid
volume (Rizzo, 2015).

70
Regulation of Extracellular Fluid Composition

Thirst Regulation

Thirst is controlled by a cluster neuron in the hypothalamus called the thirst center. When blood
becomes more concentrated, the thirst center responds by initiating the sensation of thirst. When
water or another dilute solution is consumed, the blood becomes less concentrated and the
sensation of thirst decreases (VanPutte et.al, 2013).

Ion Concentration Regulation

If the water content or concentration of ions in the extracellular fluid deviates from its normal
range, cells cannot control the movement of substances across their cell membranes or the
composition of their intracellular fluid. Regulating the concentrations of positively charged ions,
such as Na+, K+, and Ca2+, in the body fluids is particularly important. Action potentials,
muscle contraction, and normal cell membrane permeability depend on the maintenance of a
narrow range of concentrations for these ions (ibid).

Sodium Ions

Sodium ions (Na+) are the dominant ions in the extracellular fluid. About 90–95% of the
osmotic pressure of the extracellular fluid results from sodium ions. The kidneys provide the
major route by which the excess Na+ is excreted. Stimuli that control aldosterone secretion
influence the reabsorption of Na+ from nephrons of the kidneys and the total amount of Na+ in
the body fluids. Reabsorption of Na+ from the distal convoluted tubules and collecting ducts is
very efficient, and little Na+ is lost in the urine when aldosterone is present.

Because Na+ has such a large effect on the osmotic pressure of the extracellular fluid,
mechanisms that influence Na+ concentrations in the extracellular fluid also influence the
extracellular fluid volume. The mechanisms that play important roles in controlling these levels
are the renin-angiotensin-aldosterone mechanism, the atrial natriuretic (ANH) mechanism, and
antidiuretic hormone (ADH) (ibid.)

Potassium Ions

71
Aldosterone plays a major role in regulating the concentration of K+ in the extracellular fluid.
Increase in aldosterone secretion from the adrenal cortex causes K+ secretion to increase. If the
K+ concentration in the extracellular fluid decreases, aldosterone secretion from the adrenal
cortex decreases. In response, the rate of K+ secretion by the kidneys is reduced (ibid.)

Calcium Ions

Increases and decreases in the extracellular concentration of Ca2+ have dramatic effects on the
electrical properties of excitable tissues. Decreased extracellular concentrations of Ca2+ cause
spontaneous action potentials in nerve and muscle cells, resulting in hyper excitability and
muscle tetany. Increased extracellular concentrations of Ca2+ inhibit action potentials in nerve
and muscle cells, resulting in reduced excitability and either muscle weakness or paralysis.

Parathyroid hormone (PTH), secreted by the parathyroid glands, increases extracellular Ca2+
concentrations. The rate of PTH secretion is regulated by the extracellular Ca2+ concentration.
Vitamin D increases Ca2+ concentration in the blood by increasing the rate of Ca2+ absorption
by the intestine. PTH affects the intestinal uptake of Ca2+ because PTH increases the rate of
vitamin D production in the body.

Calcitonin secreted by the thyroid gland reduces the blood Ca2+ .An elevated blood Ca2+
concentration causes the thyroid gland to secrete calcitonin, and a low blood Ca2+ concentration
inhibits calcitonin secretion (ibid.)

Phosphate and Sulfate Ions

Some ions, such as phosphate ions (PO43−) and sulfate ions (SO42−), are reabsorbed by active
transport in the kidneys. The rate of reabsorption is slow, so that if the concentration of these
ions in the filtrate exceeds the nephron’s ability to reabsorb them, the excess is excreted into the
urine. If the concentration of these ions is low, nearly all of them are reabsorbed by active
transport (ibid.)

72
73
ACID-BASE BALANCE

Chemical Buffers

Buffers are chemicals that resist a change in the pH of a solution. Buffers in the body fluids
contain salts of either weak acids or weak bases that combine with H+ when H+ increases in
those fluids, or release H+ when H+ decreases in those fluids. The major buffers in the body
fluids are HCO3 − buffer system and H2CO3 – buffer system (Rizzo, 2015).

HCO3 − buffer system is critical because it can be regulated by the respiratory and urinary
systems. Carbon dioxide (CO2) combines with water (H2O) to form carbonic acid (H2CO3),
which in turn forms H+ and HCO3.Reaction between CO2 and H2O is catalyzed by an enzyme,
called carbonic anhydrase, which is found in red blood cells and on the surface of capillary
epithelial cells (ibid).

The higher the concentration of CO2, the greater the amount of H2CO3 formed, and the greater
the amount of H+ and HCO3 − formed. This results in a decreased pH. However, the reaction is
reversible. If CO2 levels decline, the equilibrium shifts in the opposite direction. That is, H+ and
HCO3 − combine to form H2CO3, which then forms CO2 and H2O, and the pH increases (ibid).

Respiratory System

Increasing CO2 levels stimulate neurons in the respiratory center of the brain and cause elevated
rate and depth of ventilation. When CO2 combines with H2O, Carbonic Acid is the result. An
increasing CO2 causes the pH to decrease. CO2 is eliminated from the body through the lungs at
a greater rate. As CO2 levels decline, the concentration of H+ also declines. The pH therefore
rises back toward its normal range (Ibid.)

Kidneys

The nephrons of the kidneys secrete H+ into the urine and therefore can directly regulate the pH
of the body fluids. As the pH of the body fluids drops below normal, the rate at which the distal
convoluted tubules secrete H+ increases. The increased rate of H+ secretion and the increased
rate of HCO3 − reabsorption both cause the blood pH to rise toward its normal value. If body

74
fluid pH elevates above normal, the rate of H+ secretion by the distal convoluted tubules
declines, and the amount of HCO3 − lost in the urine increases (Ibid).

ACIDOSIS AND ALKALOSIS

Acidosis

Acidosis occurs when the blood pH falls below 7.35. Acidosis is separated into two categories:
Respiratory acidosis and Metabolic acidosis. Respiratory acidosis is when the respiratory system
is unable to eliminate adequate amounts of CO2 causing the pH to decrease. Metabolic acidosis
results from excess production of acidic substances, such as lactic acid and ketone bodies,
because of increased metabolism or decreased ability of the kidneys to eliminate H+ in the urine
(VanPutte et.al, 2013).

Alkalosis

Alkalosis occurs when the blood pH increases above 7.45. The major effect of alkalosis is
hyperexcitability of the nervous system. Respiratory alkalosis results from hyperventilation, as
can occur in response to stress. Metabolic alkalosis usually results from the rapid elimination of
H+ from the body, as occurs during severe vomiting (VanPutte et.al, 2013).

75
76
 SKELETAL SYSTEM

This system consists of bones and their associated connective tissues which include
cartilage, tendons and ligaments. Skeleton is derived from the Greek word meaning dried.
However, skeleton is far from being dried, Rather, Skeletal System consist of living tissues that
can grow, adapt to stress, detect pain stimuli and can undergo repair after injury. (Van Putte,
Regan & Russo, 2013)

The five major functions of the Skeletal system are as follows: (1) Support in bearing weight, (2)
Protection for organs it surrounds, (3) Movement, (4) Storage of some minerals such as
Phosphorus and Calcium and, (5) Blood Cell Production. (ibid)

GENERAL FEATURES OF BONE

77
The four categories of bones are based on their shape: long, short, flat, and irregular. The Long
bones are longer than they are wide. Upper and lower limbs are mostly comprising of long
bones. Short bones on the other hand, are wider than they are long. Example of short bones are
the wrist and ankles. Flat bones are flattened shape and relatively thin like the scapula and
sternum. Irregular bones are bones which have shape that do not fit into the three category. (ibid)

APPENDICULAR SKELETON
It consists of bones in the upper and lower limbs, and also the girdles which attach the limbs to
the axial skeleton. Pectoral girdle also called shoulder girdle consist of two scapulae and two
clavicles. The scapula (shoulder blade) is a flat and triangular bone with three large fossae where
muscles in the arm are attached. Clavicle or collarbone articulates with the scapula at the
acromion process. (ibid)

78
The forearm has two bones: the ulna o the medial side of the forearm and the radius on the lateral
side. Upper limbs consist of the arm the region between the shoulder and the elbow, the wrist
which is relatively short region between the forearm and hand which is composed of eight carpal
bones: Scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate and hamate. Hands
are also part of the upper limbs which consist of five metacarpal bines that are attached to the
carpal bone. (ibid)

The lower limb consists of the bones in thigh which is the region between the hip and the knee
which is also contains a single bone called femur, the leg which is the region between the knee
and the ankle. It contains two bones which is the tibia, the major weight-bearing bone of the leg

79
and the fibula. The ankle is also part of the lower limb which consist of the seven tarsal bones
which are the talus, calcaneus, cuboid and navicular and the medial, intermediate and lateral
cuneiforms. Foot is consisting of metatarsal bones and phalanges which are arranged in the same
mannered with the metacarpal bones and phalanges. (ibid)

JOINTS
A joint or also called an articulation, is a place where two bones come together. It is usually
considered movable. However, most joint exhibit limited movements. There are three
classification of joints: (1) fibrous joints, (2) Cartilaginous Joints and (3) synovial joints. The
fibrous joints consist of two bones that are connected or compressed by fibrous tissue and it
exhibits little or no movement. The joints in this group are subdivided on the basis of structure as
sutures, syndesmoses and gomphoses. Sutures are fibrous joints between the bones of the skull.
The second one is the syndesmoses which are fibrous joints in which the bones are separated by
some distance and held together by ligaments. Lastly, the gomphoses is held in place by the
ligaments. Example of this is the joint between a tooth and its socket. (ibid)

Cartilaginous joints unite two bones by means of cartilage. Slight movement can occur at these
joints. Example of this joints are the epiphyseal plates of growing long bones and the cartilages
between the ribs and the sternum. The last classification is the synovial joints which are joints
that can freely move and contains fluid in a cavity surrounding ends of articulating bones. Most
joints that unite the bones in the appendicular skeleton are synovial joints.

Several features of synovial joints are important to their function. A thin layer of articular
cartilage provides smooth surface on the synovial joints where the bones meet. The joint cavity is
filled with fluid and it is enclosed by a joint capsule which helps hold the bones together and
allows for movement. The synovial membrane lines the joint cavity except the articular cartilage.
This membrane produces synovial fluid which is a complex mixture of polysaccharides, proteins,
lipids and cells. (ibid)

80
In certain synovial joints, the synovial membrane may extend as a pocket called a bursa. It is
located between structures that rub together such as where a tendon crosses a bone. It reduces
friction which could damage the structures involved.

TYPES OF SYNOVIAL JOINTS

The types of synovial joints are classified are according to shape of the adjoining articular
surfaces. Plane joints (gliding joints) consist of two opposed flat surfaces that glide over each
other. Articular facets between vertebrae are example of these joints. Saddle joints consist of two
saddle-shape articulating surfaces oriented at right angles to each other. Movement in these joints
can occur in two planes. The joint between the metacarpal bone and the carpal bone of the thumb
is a saddle joint. Hinge joints permit movement in one plane only. It consists of a convex
cylinder of one bone applied to a corresponding cavity of the other bone. Example of this are
elbow and knee joints. Pivot joints restrict movement to rotation around a single axis. Each pivot
joint consists of a cylindrical bony process that rotates within a ring composed partly of
ligament.

81
The ball-and-socket joints consist of a head at the end of one bone and a socket in an adjacent
bone into which a portion of the ball fits. It allows wide range of movement in almost any
direction. Shoulder and hip joints are example of this joints. The Ellipsoid joints (Condyloid
joints) are elongated ball-and-socket joints. The shape of the joint limit its range of movement
nearly to that of a hinge motion but in two planes. One of the examples of this joint is the joint
between the occipital condyles of the skull.

82
83
 ETIOLOGY & SYMPTOMATOLOGY

Etiology

Predisposing Factors

Factors Presence Rationale Justification

Sex Present The prevalence of gout in men is higher since women are The client
protected against gout in the premenopausal period due to is male.

uricosurics effect of female sex hormones. Estrogen in

women helps the kidneys eliminate more uric acid as it
induces the expression of transporters called Uric Acid
Transporter1, Organic Anion Transporter 1 and Organic
Anion Transporter 3. Men have more muscle mass which
entails more lactic acid production. Lactic acid competes with
uric acid for excretion in the kidney. (Arromdee et. al, 2002)

Age Present In the concept of wear and tear, as the kidney’s function The client
diminishes over time, absorption of uric acid is affected, is 67 and is
an elderly.
leading to hyperuricemia. (Wallace, Riedel, Joseph-Ridge,
Wortmann, 2004)

84
Precipitating Factor

Factors Presence Rationale Justification

Lifestyle: Present Purine intake is associated with hyperuricaemia and an The client
increased risk of incident gout formation. Uric acid, the stated that
Poor he still
Nutrition and final product of purine metabolism, is a weak acid that
consumes
Excessive circulates as the deprotonated urate anion under food high in
Alcohol purine such
physiologic conditions and combines with sodium ions
Consumption as meat,
to form monosodium urate. MSU crystals are known to
organ meats
have a triclinic structure, in which stacked sheets of and
purine rings form the needle-shaped crystals that are shellfish.
The client
observed microscopically. Charged crystal surfaces are
also used to
thought to allow for interaction with phospholipid drink
membranes and serum factors, playing a role in the alcohol
crystal-mediated inflammatory response (Choi et. al, frequently
before.
2004). However,
presently,
Alcoholic drinks promote the production of uric acid
he only
and have a diuretic effect. Alcohol also inhibits the consumes
kidneys elimination of uric acid. It is known that the one glass of
wine every
oxidation of alcohol to acetaldehyde is coupled in part
night
with the reduction of pyruvate to lactate,ll NADHz .
This results in increased hepatic lactate production,
increased blood levels of lactate, decreased urinary uric
acid excretion, leading to cause hyperuricemia, namely,
alcoholic hyperuricemia, secondary to renal retention of
uric acid. (Choi et. al, 2004)

85
Weight Present Carrying extra weight slows down the removal of uric The client
acid by the kidneys. Obesity is a strong risk factor for used to be
overweight
the development of gout. Obese adipose tissue is
30 years
hypoxic, and that hypoxia induces dysfunction of ago. As
adipose tissue, such as dysregulation of adipocytokines verbalized
by the
and chronic low-grade inflammation. Hypoxic-induced
client,
increase in xanthine oxidoreductase activity has been ”Mga 110 –
reported in various cultured cells. Local tissue hypoxia 120 kilos
ciguro ko
up-regulated intracellular XOR activity and increased
ato”
uric acid production by 3T3-L1 mature adipocytes.
(Cigolni et. al, 1995)

86
 Symptomatology

Factors Presence Rationale Justification

Weakness/ Present A severe decrease in kidney function The client had low activity
can lead to a buildup of toxins and tolerance due to weakness he
Fatigue
impurities in the blood. This can feels every day. The client
cause people to feel tired, weak and spends the entire day lying,
can make it hard to concentrate. sitting, or doing activities
Another complication of kidney that require minimal energy
disease is anemia. Anemia is a such as reading or watching
condition in which you don't have tv.
enough healthy red blood cells to
carry adequate oxygen to the body's
tissues and can cause weakness and
fatigue (Kimmel et. al, 2003)

Pallor/ Present Changes related to color include The client’s skin, lips and
Yellowing of pallor, attributed to the anemia of gums are pale and client
the skin chronic disease and erythropoietin manifested a bronze to
deficiency, yellowing of the skin due yellow skin.
to the presence of urea deposits on
the dermis. (Brown et. al, 2015)

Increased Present Creatinine comes from proteins
creatinine present in skeletal muscles. The rate
Level of creatinine excretion depends on
muscle mass, physical activity and
diet.
Without major changes in diet or
physical activity, the serum
creatinine is constant. Creatinine is
partially excreted by the kidney
The client’s creatinine level
based on laboratory result is:
668.0 umol/L. Client is also
on the last stage of Chronic
Kidney Disease which
equates diminished function
of the kidneys.

87
 tubules, and a decrease in kidney
function leads to a build-up of serum
creatinine.

As the kidneys become impaired for

any reason, the creatinine level in
the blood will rise due to poor
clearance of creatinine by the
kidneys. Abnormally high levels of
creatinine thus warn of possible
malfunction or failure of the
kidneys. It is for this reason that
standard blood tests routinely check
the amount of creatinine in the
blood.

A more precise measure of the

kidney function can be estimated by
calculating how much creatinine is
cleared from the body by the
kidneys. This is referred to as
creatinine clearance and it estimates
the rate of filtration by kidneys
(glomerular filtration rate, or GFR).

(Carmona & Liponis, 2017)

High BUN Present Urea excretion is disrupted by CKD;
it is made from protein metabolism
and is excreted by kidneys. The
BUN level normally varies directly
with protein intake. As kidney
function continues to decline, the
The client has an increased
BUN laboratory test result
which is 22.1 mmol/L value
that exceeds the normal
value of 2.9-7.1 mmol/L.

88
 BUN increases and urine output
decreases. (Brown et. al, 2015)

Anemia Present Chronic kidney failure can The client’s laboratory

cause anemia. This is due to a results:
•Low RBC
decreased secretion of the hormone RBC: 3.14 (low)
count
erythropoietin. Hemoglobin: 88 q/L (low)
•Low hbg Hematocrit: 0.27 (low)
The causes of anemia include a
•Low hct decreased erythropoietin level that The results indicate that the
decreases RBC production, client has low RBC, HBG
decreased RBC survival time results and HCT.
from uremia, iron, folic acid
deficiencies, and increased bleeding
because of impaired platelet
function.

In the bone marrow, the first

morphologically recognizable
erythroid precursor is the

pronormoblast. This cell can

undergo four to five cell divisions,
which result in the production

of 16–32 mature red cells. With

increased EPO production, or the
administration of EPO as a

drug, early progenitor cell numbers

are amplified and, in turn, give rise
to increased numbers

of erythrocytes. The regulation of

EPO production itself is linked to

89
 tissue oxygenation. (Harrisons)

Generally, anemia is recognized in

the laboratory when a client's

hemoglobin level or hematocrit is

reduced below an expected value
(the normal range). (Babitt & Lin,
2012)

Hyperuricemia Present Uric acid is the poorly soluble
circulating end product of the purine
nucleotide metabolism in human
beings. A decrease in the glomerular
filtration rate (GFR) contributes to
hyperuricemia (HUA), which is
frequently observed in clients with
chronic kidney disease (CKD)
Based on the laboratory
results, the uric acid level
was high at 500mmol/L and
the normal ranging from
200-420 mmol/L.

(Clive, 2000)

Hyperphosphat Present Hyperphosphatemia is an electrolyte Laboratory test for

emia disturbance in which there is an phosphate level showed 2.08
abnormally elevated level of mg/dL which deviates from
phosphate in the blood. Often, the normal level of 0.81-
calcium levels are lowered 1.45mg/dL
(hypocalclemia) due to precipitation
of phosphate with the calcium in
tissues. The kidney is damaged, as
such, it is unable to release
phosphorus (Kimmel et. al, 2003).

Podagra Present The striking predilection of gout for Uric acid crystals present at
the first metatarsophalangeal joint the metatarsophalangeal

90
 appears to be multi-factorial in joint.
origin and arises from the unique
combination of the susceptibility of
the joint to osteoarthritis and local
anatomical considerations of
temperature, minor physical trauma
and biomechanical stress, leading to
ideal conditions for monosodium
urate crystal formation and
deposition in predisposed
hyperuricemia individuals,
manifesting as clinical gout (Kufo
et. al, 2015)

Oliguria Present In urinary tract obstruction, there is
a blockage that inhibits the flow of
urine through its normal path,
decreasing the level of urine being
excreted.
The client verbalized that he
has decreased amount of
urine during urination.

In the presence of decreased kidney

function, there is low levels of blood
being filtered by the kidneys,
thereby decreasing the amount of
urine output (Kufo et. al, 2015)

Flank pain Present Flank pain originating in the urinary The client described pain in
system is caused by distention of the the costovertebral area
ureter or renal pelvis or distention of during onset of his kidney
the renal capsule. The severity of the disease 30 years ago.
pain is directly related to the rapidity
of the distention and not to the
degree of distention (Dewolf &

91
 Fraley, 1975).

Hypertension Present Renal disease interferes with salt The client’s BP is 130/90.
excretion, leading to volume
overload and consequent
hypertension. The excess salt and
water retention increase the blood
flow to the tissues, which sets in
motion the phenomenon of
autoregulation. The tissue arterioles
vasoconstrict to decrease the
excessive blood flow. The resulting
vasoconstriction raises the
peripheral vascular resistance, which
is the cardinal most consistent
findings in hypertension (Lewis et.
al, 2000)

Proteinuria Present Increased glomerular capillary 4+ proteinuria level on

hydraulic pressure lead to more client’s urine
filtrate formed per nephron. These
changes, initially helpful to
minimize the functional
consequences of nephron loss, are
ultimately detrimental, causing
relentless injury of remaining intact
nephrons. Enhancing
intraglomerular capillary pressure
and perfusion pressure results in
stretching of the glomerular
capillaries, leading to impaired filter
function and loss of larger

92
 molecules, such as proteins, in the
urine (Remuzzi et. al, 2006).
Hyperkalemia Present Increased potassium intake in the
vascular space is caused by reduced
renal excretion, excessive intake or
leakage of potassium from the
intracellular space (Klevay et. al,
2007).
Hyperkalemia is the most
common electrolyte
imbalance in kidney disease.
Our client has end-stage
renal failure.
93
PATHOPHYSIOLOGY

94
PATHOPHYSIOLOGY

95
PATHOPHYSIOLOGY

96
PATHOPHYSIOLOGY

97
PATHOPHYSIOLOGY

98
PATHOPHYSIOLOGY

99
 PROGNOSIS

Good Fair Poor Justification

Onset of Illness is poor because it

happened at an early age. The
Onset of Illness X
client’s condition started when he
was 37 years old.
Duration of illness is poor because
the client was diagnosed of his
condition 30 years ago. The
severity of client's current
condition had gotten worse since
he did not do any measures to
Duration of Illness X
improve his health. ESRD is the
last stage of renal impairment and
is treated only with renal
replacement therapy such as
dialysis and renal transplant which
means that the client's condition is
irreversible.
Client Heisenberg reported that
before he was diagnosed with
ESRD he was constantly eating
organ meats and he drank alcohol
Precipitating X often. The client also stated that
Factors
since he was a driver, he did not
urinate frequently. After he was
diagnosed, he noted that there
were only little changes in his
lifestyle; he still consumed organ
meats however he tried to limit his

100
 alcohol consumption to only one
glass of wine per night.

Client Heisenberg’s family are

cooperative and willing to comply
with all the medications and
treatments such as weekly
Willingness to take
medications X hemodialysis because they are
aware of its effects and how it can
help his condition. However, the
patient is noncompliant with his
dialysis treatment, only attending
to his schedule ever so often.
The client’s home environment is
conducive to health maintenance,
Environmental it is suitable for rest and comfort
Factors X
since there are adequate resources
such as comfortable bed and
adequate food supply.
Patient Heisenberg stated that his
brother has been financially
Family Support supportive of his dialysis
X
treatment and of letting him stay
in his home. However, Patient
Heisenberg feels as though he has
been a burden in the family.
Total 2 4.6 6.4 Poor: 3X1.6 = 4.8

Fair: 2X2.3 = 4.6

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 Good: 2X2.4 = 4.8

Total: 14.2/6 = 2.4

Range of Value:

1.0-1.6 = Poor

1.7-2.3 = Fair

2.4-3.0 = Good

The results showed a sign of good prognosis for the client. Client Heisenberg was
diagnosed of a chronic illness at a young age due to his lifestyle. Although, he was diagnosed at
an early age, still he was able to preserve his life and maintain his condition for 30 years.
Moreover, having a family that fully supports him physically, financially and emotionally,
Patient Heisenberg has an access life-sustaining treatment such as dialysis and medications.

102
 Chapter XI

LABORATORY & DIAGNOSTICS

LABORATORY TESTS

Hematology

Date Received: July 26, 2016

Results Reference Justification Nursing

Range Responsibilities
Complete Blood Prior:
Count  Explain the
test
WBC Count 4.21 x 5-10 x10 The patient’s kidney
procedure.
9^3/L is not properly  Encourage to
(L) working anymore avoid stress if
possible
thus results to low
because
WBC count. altered
Hemoglobin 88 g/L 140-170 Kidney produces physiological
(L) erythropoietin, which status
influences
is a hormone that and changes
Hematocrit 0.27 0.40-0.51 forms RBCs. Since normal
(L) the patient’s kidney hematologic
values.
is not functioning
RBC Count 3.14^12/L 5.5-6.5 x properly anymore, During:

(L) 12/L this results to a low  Assist the

hemoglobin count, patient going
to the
low hematocrit and
laboratory.
low RBC count. Comfort the
Differential Count patient by
relieving her
anxieties and
Neutrophil fears.
Segmenters: 0.60 0.55-0.65 Normal

103
 Lymphocytes 0.38 0.25-0.40 Normal After:
Monocytes 0.02 0.01-0.05 Normal  Monitor the
patient’s
Platelet Count 228 140-440 x Normal puncture site
x109/L 109/L for the
discharge
hematoma.

Blood Chemistry

Date Performed: July 26, 2016

Results Reference Justification Nursing

Range Responsibilities
Phosphorus 2.08 mmol/L 0.81-1.45 When kidneys Prior:
(H) mmol/L do not function  During:
well, there will Explain the
be problems in procedure to
the patient
filtration thus
resulting to  Instruct the
excess patient not to
contaminate the
phosphorus.
urine specimen
with toilet
paper
During:

 Instruct the
patient to
collect an early
morning
specimen of at
least 50 ml of
uncontaminated
urine in a
container.
After:

104
  Immediately
transport the
specimen to the
laboratory.
Blood Urea BUN is done to
Nitrogen see how well
your kidneys are
working, if they
Pre-BUN 22.1 mmol/L 2.8-7.2 are not able to
(H) mmol/L remove urea
from the blood
normally, BUN
Post-BUN 8.43 mmol/L rises.
(H) 2.8-7.2
mmol/L
Serum 668 80.0-115 Creatinine is the
Creatinine (H) umol/L end product of
creatine
metabolism.
High creatinine
level signifies
impaired kidney
function or
kidney disease
because
creatinine is
only excreted
through urine.
Calcium 1.25 1.13-1.32 Normal
mmol/L
Uric Acid 500 umol/L 400-420 Uric acid is the
(H) umol/L end product of
purine
metabolism.
High uric acid
level happens
when there is
increase
production of

105
 uric acid,
decrease
excretion of uric
acid or both.
Increase
production of
uric acid is
caused by diet,
while excretion
of uric acid is
caused
commonly by
kidney disease.
Both the patient
has a diet and
lifestyle that
increases
production of
uric acid and an
existing kidney
disease.

Urinalysis

Date: June 14, 2015

Test Result Reference Range Justification

Physical

Color Yellow *** Normal

Transparency Turbid *** Patient’s cloudy urine

is caused by crystals,
red blood cells and
pus present.

Chemical

Reaction 6.0 4.60-6.50 Normal

106
 SP-Gravity 1.010 1.01-1.03 Normal

Albumin + *** The presence of

albumin in the urine
is indicative of
kidney is damage.
This means
macromolecule such
as albumin is able to
leak out of the
damaged glomerulus.

Glucose Negative Normal

***

Microscopic

Epithelial cells Few *** Normal

2.00-5.00 When there is an

Pus Cells TNTC/hpf
obstruction in the
0.00-2.00 renal system, urine in
Red Blood Cells 6-9/hpf
the bladder becomes
more alkalitic.
Bacteria +
Decrease in urine pH,
increases production
of crystals and
bacteria.

A presence of
crystals can cause
wound in the lumen
of the urinary system
such as the bladder
and the urethra,
which results
presence of RBC in

107
the urine. RBCs are
macromolecules that
are able to leak out of
the glomerulus when
there is profound
kidney damage.

When urine is more

alkalotic, bacteria is
able to thrive and
grow.

108
 Chapter XII

PHARMACOLOGY

Generic Name
COLCHICINE
COLCHICINE

Brand Name Novocolchine

Classification ANTIGOUT AGENT

General Action Alkaloid of the plant Colchicum autumnale with antimitotic and indirect
anti-inflammatory properties.
Dose and Route Acute Gouty Attack
Adult: PO 0.5–1.2 mg followed by 0.5–0.6 mg q1–2h until pain relief or
intolerable GI symptoms (max: 4 mg/attack) IV 2 mg followed by 0.5 mg
q6h until relief or intolerable GI symptoms (max: 4 mg/attack)
Prophylaxis
Adult: PO 0.5 or 0.6 mg every night or every other night as needed (up to
1.8 mg/d may be needed for severe cases) IV 0.5–1 mg 1–2 times/d
Surgical Patients
Adult: PO 0.5 or 0.6 mg t.i.d. starting 3 d before surgery and continuing for

109
 3 d after surgery
Renal Impairment
Clcr 10–50 mL/min: prolonged use is not recommended. Clcr <10 mL/min:
reduce recommended dose by 50%

Indications or Prophylactically for recurrent gouty arthritis and for acute gout, either as
Purposes
single agent or in combination with a uricosuric such as probenecid,
allopurinol, or sulfinpyrazone.

Side effects GI: Nausea, vomiting, diarrhea, abdominal pain, anorexia, hemorrhagic
gastroenteritis, steatorrhea, hepatotoxicity, pancreatitis. Hematologic:
Neutropenia, bone marrow depression, thrombocytopenia, agranulocytosis,
aplastic anemia. CNS: Mental confusion, peripheral neuritis, syndrome of
muscle weakness (accompanied by elevated serum creatine kinase). Skin:
Severe irritation and tissue damage if IV administration leaks around
injection site. Urogenital: Azotemia, proteinuria, hematuria, oliguria.
Contraindications Blood dyscrasias; severe GI, renal, hepatic, or cardiac disease; use of IV
colchicine in patients with both renal and hepatic dysfunction. Severe local
irritation can result from SC or IM use; pregnancy (category C). Safe use in
children not established.
Nursing Assessment & Drug Effects
Responsibilities
 Lab tests: Baseline and periodic determinations of serum uric acid
and creatinine are advised, as well as CBC, including Hgb, platelet
count, serum electrolytes, and urinalysis.
 Monitor for dose-related adverse effects; they are most likely to
occur during the initial course of treatment.
 Monitor for early signs of colchicine toxicity including weakness,
abdominal discomfort, anorexia, nausea, vomiting, and diarrhea,
regardless of administration route. Report to physician. To avoid
more serious toxicity, drug should be discontinued promptly until
symptoms subside.

110
  Monitor I&O ratio and pattern (during acute gouty attack): High
fluid intake promotes excretion and reduces danger of crystal
formation in kidneys and ureters.
 Keep physician informed of patient's progress. Drug should be
stopped when pain of acute gout is relieved. Therapeutic response:
articular pain and swelling generally subside within 8–12 h and
usually disappear in 24–72 h after PO therapy, and 6–12 h after IV
administration.

Patient & Family Education

 If taking colchicine at home, withhold drug and report to the

physician the onset of GI symptoms or signs of bone marrow
depression (nausea, sore throat, bleeding gums, sore mouth, fever,
fatigue, malaise, unusual bleeding or bruising).
 always Keep colchicine on hand to start therapy or increase dosage,
as prescribed by physician, at the first suggestion of an acute attack.
 Physician may prescribe sodium bicarbonate, or sodium or
potassium citrate, to maintain alkaline urine and thus prevent
formation of urate stones.
 Avoid fermented beverages such as beer, ale, and wine as they may
precipitate gouty attack. The physician may allow distilled alcoholic
beverages in moderation.

111
Generic Name
EPOETIN ALFA
EPOETIN ALFA (HUMAN RECOMBINANT ERYTHROPOIETIN)

Brand Name Epogen, Eprex ,

Procrit

Classification BLOOD FORMERS, COAGULATORS, AND ANTICOAGULANTS;

HEMATOPOIETIC GROWTH FACTOR
General Action Glycoprotein that stimulates RBC production. Hypoxia and anemia
generally increase the production of erythropoietin.
Dose and Route Anemia
Adult: SC/IV 3–500 U/kg/dose 3 times/wk, usually start with 50–100
U/kg/dose until target Hct range of 30–33% (max: 36%) is reached, Hct
should not increase by more than 4 points in any 2-wk period, rapid
increase in Hct increases the risk of serious adverse reactions (hypertension,
seizures), may increase dose if Hct has not increased 5–6 points after 8 wk
of therapy, reduce dose after target range is reached or the Hct increases by
>4 points in any 2-wk period, dose usually increased or decreased by 25
U/kg increments
Child: SC 150 U/kg/dose 3 times/wk initially, when Hct increased to 35%,
decrease dose by 25 U/kg/dose until Hct reaches 40%

Indications or Elevates the hematocrit of patients with anemia secondary to chronic

Purposes
kidney failure (CRF); patients may or may not be on dialysis; other anemias
related to malignancies and AIDS. Autologous blood donations for

112
 anticipated transfusions. Reduces need for blood in anemic surgical
patients.

Side effects CNS: Seizures, headache. CV: Hypertension. GI: Nausea, diarrhea.
Hematologic: Iron deficiency, thrombocytosis, clotting of AV fistula. Other:
Sweating, bone pain, arthralgias.
Contraindications Uncontrolled hypertension and known hypersensitivity to mammalian cell–
derived products and albumin (human).
Nursing Assessment & Drug Effects
Responsibilities
 Control BP adequately prior to initiation of therapy and closely
monitor and control during therapy. Hypertension is an adverse
effect that must be controlled.
 Be aware that BP may rise during early therapy as the Hct increases.
Notify physician of a rapid rise in Hct (>4 points in 2 wk). Dosage
will need to be reduced because of risk of serious hypertension.
 Monitor for hypertensive encephalopathy in patients with CRF
during period of increasing Hct.
 Monitor for premonitory neurological symptoms (i.e., aura, and
report their appearance promptly). The potential for seizures exists
during periods of rapid Hct increase (>4 points in 2 wk).
 Monitor closely for thrombotic events (e.g., MI, CVA, TIA),
especially for patients with CRF.
 Lab tests: Baseline transferrin and serum ferritin. Monitor aPTT &
INR closely. Patients may require additional heparin during dialysis
to prevent clotting of the vascular access or artificial kidney.
Determine Hct twice weekly until it is stabilized in the target range
(30–33%) and the maintenance dose of epoetin alfa has been
determined; then monitor at regular intervals. Perform CBC with
differential and platelet count regularly. Monitor BUN, creatinine,
phosphorus, and potassium regularly.

113
Patient & Family Education

 Important to comply with antihypertensive medication and dietary

restrictions.
 Do not drive or engage in other potentially hazardous activity during
the first 90 d of therapy because of possible seizure activity.
 Note: As Hct increases, there is an improved sense of well-being
and quality of life. It is important to continue compliance with
dietary and dialysis prescriptions.
 Understand that headache is a common adverse effect. Report if
severe or persistent, may indicate developing hypertension.
 Keep all follow-up appointments.

114
 Chapter XIII

NURSING THEORIES

Dororthea E. Orem: Self – Care Deficit Theory of Nursing

Dororthea E. Orem, MSNEd, DSc, RN was born in 1914 in

Baltimore, Maryland. She began her nursing education at
Providence Hospital School of Nursing in Washington, DC.
After receiving her diploma in early 1930s, she earned her BS
Nursing education in 1939 and her Master of Science in
nursing education in 1945 from the Catholic University of
America.

The focus on the general theory of Orem is the absence of the

ability to care for one’s self or self-care deficit and how this
condition validates the existence of nursing. The Self-Care
Deficit Theory of Nursing is composed of 3 interrelated theories which are the Theory of Self-
Care, The Self-Care Deficit Theory, and the Theory of Nursing System. Incorporated within and
supportive of these theories are six central concepts of self-care, self-care agency, therapeutic
self-care demand, self-care deficit, nursing agency, and nursing system, as well as the peripheral
concept of basic conditioning factors.

As stated by Orem, nursing is needed when self-care demands exceed that of self-care abilities.
Nursing systems are designed by the nurse when it has been determined that nursing care is
needed. The systems of wholly compensatory, partly compensatory, and supportive-educative
specify the role of the nurse and the patient (Orem & Taylor, 1986)

115
Person: Individuals are an integrated whole composed of an internal physical, psychological and
social nature with varying degrees of self-care ability.

Health: Health and healthy are terms to describe living things according to Orem, they are
structurally and functionally whole or sound, includes that which make a person human, she
defines health as "a state of physical, mental and social sell-being, and not merely the absence of
disease or infirmity”.

Nursing: According to Orem Nursing is an art through which the practitioner of nursing gives
specialized assistance to persons with disabilities that needed greater than ordinary assistance to
meet the daily needs for self-care. It consists of actions deliberately selected and performed by
nurses to help patients under their care to maintain or change conditions in themselves or their
environment.

Environment: Environment according to Orem, is the surrounding of the patients may affect their
ability to perform their selfcare activity. Includes two dimensions a. physical, chemical, biologic
features and socioeconomic features.

Application:

Because of the client’s condition, the theory of Self-Care deficit can be applied religiously. The
client is unable to perform certain self-care needs because his state has rendered him immobile.

116
Activities such as cleaning oneself and one’s surrounding is impaired on the client. Furthermore,
his self-care agency is also affected by the basic conditioning factor of health. Because of these
aspects the client has an increased therapeutic self-care demand and the requirement of a nurse is
greatly needed. The self -care requisites greatly affected because of the clientt’s condition are:
Universal Self-Care – Air, water, food, elimination, activity/rest, & prevention of hazard. Health
Deviation Self-Care – Adherence to medical regiment, Awareness of potential problem
associated w/ regimen, Modification of self-image to incorporate changes in health status, and
Adjustment of lifestyle to accommodate changes in health status.

Hildegard E. Peplau: Interpersonal Relations Theory

Hildegard E. Peplau was born in Reading, Pennsylvania, and

started her career by graduating from a diploma nursing program
in Pottstown, Pennsylvania, in 1931. She also graduated from
Bennington College with a BA in Interpersonal Psychology in
1943, and an MA in Psychiatric nursing in 1947 at Columbia
University, New York. She also obtained an EdD in Curriculum
Development in 1953.

The core of Interpersonal Relations theory is the interpersonal

process which is an integral part of nursing. The process consists
of the phases of Orientation, Identification, Exploitation, and Resolution. These phases vary in
duration and also overlap and interrelate with one another.

Phase Focus
Orientation Problem-defining phase
Identification Selection of appropriate professional assistance
Exploitation Use of professional assistance for problem-solving alternative
Resolution Termination of the professional relationship
PHASES OF THE NURSE-PATIENT RELATIONSHIP

117
The nurse and the patient initially clarify the patient’s problems, and mutual expectations. As the
process continues, mutual expectations and goals are explored while deciding on appropriate
plans for improving health status. The entire process is influenced by both the nurse’s and
patient’s perceptions and preconceived ideas emerging from their uniqueness.

During the therapeutic interaction both the patient and nurse mature, because when two persons
meet in a creative relationship, there is a continuing sense of mutuality and togetherness
throughout the experience. Both individuals are involved in a process of self-fulfilling which
becomes an avenue of growth and experience (Peplau, 1952)

Person: Peplau defines man as an organism that continuously “strive in its own way to reduce
tension generated by needs.” The client is an individual with felt needs

Health: According to Peplau, health is “a word symbol that implies forward movement of
personality other ongoing human processes in the direction of creative, constructive, productive,
personal, and community living.”

Nursing: Peplau considers nursing to be a “significant, therapeutic, interpersonal process.” She

defines it as a “human relationship between an individual who is sick, or in need of health
services, and a nurse specially educated to recognize and to respond to the need for help.”

118
Environment: Although Peplau does not directly address society/environment, she does
encourage the nurse to consider the patient’s culture and mores when the patient adjusts to
hospital routine.

Application:

During the interview and physical assessment of the client, it was observed by the group that the
client showed apathy towards family members and indifference towards his life. Therefore, with
the use of Peplau’s theory, the group can focus on the interpersonal processes that occur between
the student nurse and the client. The four phases of nurse-patient relationship were pertinent to
determine the phase where the interaction belong and was used to improve the process for a
smooth and easy transition to other phases. With this theory the student nurses found out that the
problem was during the Orientation phase since during this phase the client did not have a felt
need for professional assistance and moreover did not respond the need for significant others.

Lydia E. Hall: Care, Core, Cure

Lydia E. Hall received her basic nursing education at York

Hospital School of Nursing in Pennsylvania. Both her BS in Public
Health Nursing and MA in teaching Natural Sciences are from
Teachers College, Columbia University, New York. Lydia Hall
was the first director of the Loeb Center for Nursing and
Rehabilitation and continued in that position until her death in
1969.

Lydia Hall’s theory involves three interlocking circles that

represents one aspect of nursing. The first circle is the care aspect.
The care aspect represents intimate bodily care of the patient. The second circle is the core
aspect. This aspect illustrates the innermost feelings and motivations of the patient. Finally, the
last circle is the cure aspect. This aspect deals with how the nurse aid the patient and family

119
through medical facets of care. The main tool the nurse uses to help the patient realize his or her
motivations and grow self-awareness is that of reflection.

Hall’s theory defines Nursing as the “participation in care, core and cure aspects of patient care,
where CARE is the sole function of nurses, whereas the CORE and CURE are shared with other
members of the health team.” The major purpose of care is to achieve an interpersonal
relationship with the individual that will facilitate the development of the core (Hall, 1964).

Person: The individual human who is 16 years of age or older and past the acute stage of a long-
term illness is the focus of nursing care in Hall’s work. The source of energy and motivation for
healing is the individual care recipient, not the health care provider. Hall emphasizes the
importance of the individual as unique, capable of growth and learning, and requiring a total
person approach.

Health: Health can be inferred to be a state of self-awareness with conscious selection of

behaviors that are optimal for that individual. Hall stresses the need to help the person explore
the meaning of his or her behavior to identify and overcome problems through developing self-
identity and maturity.

Nursing: Nursing is defined as the function necessary to carry out care, core, cure. The aspect of
Care is the sole function of nurses. Core and Cure are shared with other medical members of the

120
health care team. Nursing is identified as consisting of participation in the care, core, and cure
aspects of patient care.

Environment: The concept of society or environment is dealt with in relation to the individual.
Hall is credited with developing the concept of Loeb Center because she assumed that the
hospital environment during treatment of acute illness creates a difficult psychological
experience for the ill individual. Loeb Center focuses on providing an environment that is
conducive to self-development. The focus of the action of the nurses is the individual, so that any
actions taken in relation to society or environment are for assisting the individual in attaining a
personal goal.

Application

The application of this theory lies heavily on the Care aspect of nursing. The cleint’s condition
has rendered him to be weak and in certain ways immobile. The Care used by the group focused
on providing comfort, care, and health education to the client. The group help the client complete
basic daily biological tasks such as dressing and cleaning. Moreover, the group also included
educating the patient regarding diet, lifestyle, and dialysis adherence in the importance of his
maintenance of well-being. Using the Core factor of the theory, the group together with the
patient aided him in setting a goal for himself regarding the improvement of his condition.
Though this proved to be difficult because the client showed certain resistance, the group
focused on the social, emotional, and intellectual needs of the client in relation to his condition to
understand and empathize where his resistance is coming from. Finally, the application of this
theory also used the Cure aspect of the Care, Core, Cure. The student nurse assigned to the
patient is the one who administered medical teachings. The aspect however is shared with other
health professionals so the focus on the Cure aspect was less compared to the Cure.

121
 Chapter XIV

NURSING CARE PLAN & FAMILY NURSING CARE PLAN

122
 INTERVENTION PLAN

FAMILY NURSING METHOD OF

NURSING INTERVENTIONS NURSE-FAMILY
CUES HEALTH PROBLEMS GOAL OF OBJECTIVES CONTACT RESOURCES EVALUATION
PROBLEM CARE OF CARE REQUIRED

Subjective Health Inability to After 3 After nursing 1.Establish short- Home Visit Human Goal Partially
threat provide hours of intervention, term & realistic Resources: Met.
“Galisod ko adequate nursing the client and goals with the
usahay kay Stress- nursing care to intervention the family client and the Time and
ako ra may provoking effort of
the sick, , the family will be able: family After nursing
gaatiman sa factors such both the
akong sarili disabled, will realize intervention,
as care- dependent or and bestow 1.To 2. Encourage the nurse and
sa balay. the client was
giving vulnerable/at on giving verbalize family to the clients.
Busy man able to
gud sila sa burden risk member of attention understandin accompany the
g to take client in going to verbalize his
ilang the family due and care to understanding
trabaho” to: the client control in dialysis center
caring for the regarding the
as when 3.Implement health
Inadequate necessary client
verbalized measures to teaching and
family
by the client 2. To promote was able to
resources, The client
specifically: will show demonstrate independence but openly speak
Objective
openness good intervene when up his
1.Family  Member’s and relationship the patient cannot concerns.
members preoccupati willingness with each perform properly.
other Reevaluation
are on with on to 4. Encourage the and follow up
preoccupied concerns/int communicat 3. To family to make a visitation are
and busy erests e to his willingly help schedule in needed to
with their needs to the the client in assisting the assess the
own significant doing ADL client progress of
schedule others and provide the client and
5. Allow the the family’s
family members
123
his necessary to openly discuss relationship
needs their schedule to with one
find available another.
4.To time in taking
wholehearted care of the client
ly accept the
support of the 6. Encourage
significant family members
others to include the
client in family
5. To manage outing or
time between gatherings
their work
and the 7. Educate the
providing family members
care to the about the
client importance of
adhering to the
client’s dialysis
schedule

8. Encourage the
client to
participate and
help in household
chores

9. Encourage
client to verbalize
feelings towards
family members

10. Encourage
family members
124
to involve client
during decision-
making activities

125
126
 INTERVENTION PLAN
HEALTH FAMILY GOAL OF CARE OBJECTIVE METHOD OF RESOURCES EVALUATION
CUES PROBLEM NURSING OF CARE NURSING NURSE- REQUIRED
PROBLEM INTERVENTION FAMILY
CONTACT
Subjective: Health Inability to Within the two Within the Help the family to Home Visit -Time and effort Goal Partially
Threat: recognize the weeks of two weeks understand the of the student Met
“Ga inom ko Unhealthful presence of the exposure, the of implications of nurse and family
panagsa og lifestyle and condition or nurse together exposure, alcohol drinking After two
wine aron personal problem due to with the family, the family: and eating -Transportation weeks of
makatulog ko. habits/practi attitude/philoso will help the unhealthily in expenses of the exposure, the
Wala man pud ces phy in life. client change his 1. Will be relation to the student nurse family was
ko na unsa sa specifically attitude or able to client’s condition. able to
akong alcohol Inability to philosophy recognize -Cooperation of demonstrate
ginabuhat.” drinking, make decisions towards life & the effect of Together with the the family support to the
inadequate with respect to make him alcohol in family, identify client by
“Wala na may footwear, taking recognize his relation to the reasons of the helping and
pulos ni akong and eating appropriate current the client’s client’s guiding him in
tsinelas mao ra food health action condition and condition. consumption of changing his
man giyapon restricted in due to negative how his alcohol despite attitude
kay wala man relation to attitude unhealthy 2. Will be client’s condition towards a
giyapon koy his towards the lifestyle affects able to healthier
mabati.” condition. health his current support him Together with the lifestyle
condition or condition. to change family, explore through
“Panagsa kung problem. his with the client discipling his
ako ra isa attitude/phil how to lessen or diet and
nagakaon ko osophy in stop the alcohol intake
gihapon ug life and consumption of
mga bawal. stop his alcohol.
Dili lng gud unhealthful
daghan, wala habits for Provide a health
na man pud his own teaching to the
mahitabo sa good. family about the
akoa na mas client’s condition
lala pa sa 3. Will be and how to
karon” able to

127
 recognize prevent further
Objective: and complications.
understand
 Client the reason Teach the family
drinks why the to monitor the
wine client client’s fluid
secretly to drinks intake and output.
help him alcohol As well as proper
sleep. despite his diet
 Client has condition.
inadequate Empathize
footwear 4. Will be together with the
that is able to family, the
ripped and recognize condition of the
has holes the client.
in it. importance
 Client eats of wearing Inform the family
food that proper of the client’s
are footwear. access to alcohol
restricted and restricted
to his 5. Will be food
current able to
condition understand Encourage the
the family to have an
significance open
of staying communication
away from between the
food that client.
are
restricted Involve the
family in
planning in
changing the
lifestyle of the
client.

128
Discuss to the
family the
importance of the
client having a
proper footwear
especially for his
current condition.

129
 INTERVENTION PLAN
HEALTH FAMILY NURSING GOAL OF OBJECTIVE OF METHOD RESOURCES EVALUATION
CUES PROBLEM PROBLEM CARE CARE NURSING OF NURSE- REQUIRED
INTERVENTION FAMILY
CONTACT
Subjective: Foreseeable Negative attitude After two Within the two 1. Encourage Home Visit -Time and GOAL MET
““Di naman Crisis towards the days of weeks of client to effort of the
sad kaayo ko Situation- health condition nursing exposure, the verbalize student nurse After two
mag Death of a or problem intervention, family will be feelings about and family days of
hunahuna, kay able to:
family the family his condition nursing
kabalo man ko 1. Understand -
member will be able and its relation intervention,
their role as a Transportation
na hapit nako to help the to his life the family
expenses of
mamatay.” client support system 2. Observe client the student was able to
as verbalized realize the to the client behavior and nurse comfort the
by the client importance determine client
of following 2. Recognize reason & -Cooperation through
“Ngano wala dialysis client’s meaning behind of the family verbalization
man ka nag pa schedule, negative the behavior & of feelings,
dialysis know the behavior as a words and provide
karon?” asked consequence 3. Establish the the client
call for
by the nursing of not family as a emotional
attention
student following support system support and
treatment, 3. Understand for the client plan a proper
“Di ko gusto and realize the importance through open diet.
mu sakay ug the worth & and communication
jeep, kay importance consequence of between the “bawasan na
himantayon of his life the treatment client and the nako ang
man gud and to others. protocol set to family pagkaon sa
kaayo ang the client 4. Educate the mga bawal sa
mga tao” need of ako og
Replied by the 4. Together following magpa
client with the client, treatment dialysis na
understand the protocol and its jud ko” as
inevitability of consequences verbalized by
death of failing to the client.

130
 meet dialysis
schedule
5. Advice the
family on the
importance of
constant
communication
to the client
6. With the client,
list important
factors that
makes life
worth living for
7. Help client
understand and
verbalize his
purpose in life.
8. Inform the
family the
inevitability of
death to the
client if
treatment is
ignored
9. Encourage the
family to be
proactive in the
caring &
treatment of the
client such as
reminding
client of
schedule
10. Determine
client’s
perception
towards life and
131
 empathize with
client’s
understanding

INTERVENTION PLAN
FAMILY EVALUATION
HEALTH GOAL OF OBJECTIVES METOD OF
CUES NURSING NURSING RESOURSES
PROBLEM CARE OF CARE NURSE FAMILY
PROBLEMS INTERVENTION REQUIRED
CONTACT

132
Subjective: Home visit Time and effort Goal Met
“Di ko Presence of Feeling of After two After 2 weeks 1. Encourage of the nurse,
gusto mu stress points alienation days of of nursing client to client, and After 2 weeks of
sakay ug – Social from the nursing intervention, verbalized family. nursing
jeep, kay Stigma community. intervention the family feelings intervention the
himantayon , the client will be able 2. Educate client was able to
man gud Stigma due to will be able the family about Cooperation of verbalize his
to comfort the
kaayo ang physical to the importance of client and family understanding,
client through
mga tao” deformity understand making the client members acceptance of his
related to current verbalization feel accepted by condition, and
“Di naman disease condition of feelings. providing the how others sees
sad kaayo condition. and accept Also, the client with him to be. Some
ko mag that family emotional family members
hunahuna, physical members will support. were able to
kay kabalo deformities be able to 3. Help the comfort the client.
man ko na is normal in provide the client develop
hapit nako his client wit skills on how to “Itry najud nako
mamatay.” condition. emotional deal with na magtuman sa
support. discrimination. akong schedule sa
Such as dialysis. Kanang
acceptance of his bahala kung
condition and unsay ingnon sa
understanding mga pasahero sa
that other people jeep dira sa akoa.
are judgmental Di man pud sila
due to their kabalo” as
ignorance. verbalized by the
4. Advice client
family and friends
on the importance
to visit and show
their concerns.
5. Educate
the client that it is
normal in his
condition and that

133
 it is important
accept himself.
6. Help
client understand
and verbalize his
purpose in life.
7. Determine
client’s reason for
skipping schedule
for dialysis
8. Help
them in their
feeling of
loneliness by
engaging on
different activities
daily.
9. Maintains a
desired level of
role function
and problem-
solving.
10. Determine
client’s
perception
regarding sense
of social
isolation.

DATE/ NURSING
TIME/ ASSESSMENT NEED DIAGNOSIS OBJECTIVES INTERVENTION EVALUATION
SHIFT
134
 GOAL
July 23, Subjective: “Dili C Chronic pain r/t After 4 hours of 1. Provide a comfortable position, joint PARTIALY MET
2018 kayo ko makatulog O chronic physical nursing pain (leg) rested and given bearing.
og tarong tungod G disability secondary intervention, the R: Rest can reduce local metabolism and After 4 hours of
10:30 sakit akoang lawas, N to chronic gouty client will be able reduce joint movement occurs. nursing
AM mga 2-3 hours ra I arthritis to: interventions, the
jud akoang tulog” T 2. Administer alternating cold compress client was able to
7-3 PM As verbalized by I R: Gout is a disease for 3 mins and warm compress for 30 demonstrate
the client. V in which defective - Describes seconds on affected area to reduce pain different
E metabolism of uric satisfactory pain R: Cold compress immediately reduces relaxation skills
Objectives: - acid causes arthritis, control at a level swelling and inflammation; hot compress such as
- Presence of P especially in the less than 4 to 5 on relaxes and soothe the joints and increase positioning and
tophi on the E smaller bones of the a rating scale of 0 range of motion deep breathing
patient’s hip R feet, deposition of to 10. exercises and
joints C chalkstones, and 3. Administer prescribed medication to diversional
- Hip joints are E episodes of acute - Demonstrates use decrease swelling activities as
inflamed, P pain because it of different R: Colchicine may be prescribed for indicated for
swollen, and T triggers relaxation skills acute attack and used in small doses for client’s situation
painful during U inflammation and and diversional prevention. Preventing the pain is one
movement and A pain in the joints and activities as thing that a patient needs to consider.
when applied L surrounding tissue indicated for
pressure and elevated levels individual 4. Encourage verbalization of feelings
- Pain scale: 8/10 P of uric acid in the situation.
A blood. about the pain
- Grimace face
T R: Only the client can judge the level and
- Displays distress of pain; pain management should
T (Cheever, K. 12th improved well-
E edition medical be a team approach that includes the
being such as client.
R surgical nursing) relaxed muscle
N tone or body 5. Encourage and assist client to do deep
posture. breathing exercises.
R: Deep breathing for relaxation is easy
- Uses to learn and contributes to pain relief
pharmacological and/or reduction by reducing muscle
and tension and anxiety
nonpharmacologi
cal pain-relief

135
strategies. Such as 6. Provide rest periods to promote relief,
prescribed pain sleep, and relaxation.
medications not R: Pain may result in fatigue, which may
contraindicated result in exaggerated pain. A peaceful
for renal patients and quiet environment may facilitate rest.
and the use of
alternating cold & 7. Discuss with the client and relatives
warm compress the importance of early detection and
and positioning reporting of changes or any unusual
for non- physical discomforts/changes
pharmacologic R: It promotes early detection developing
pain relief complications especially on the client’s
strategies. condition where further deposition and
growth of gout increases uric acid levels
on the client’s system.

8. Validate the patient’s feelings and

emotions regarding current health status
R: Validation lets the patient know the
nurse has heard and understands what
was said, and it promotes the nurse-client
relationship.
9. Encourage adequate rest balanced with
moderate activity. Promote adequate
nutritional intake.
R: Facilitates healing process and
enhances natural resistance. Aiding the
client in performing ROM exercise that
he can perform on his own, increases
activity during the day.

10. Perform diversional activities such as

talking to the client, watching videos,
listening to music, or reading newspaper

136
 to decrease awareness and sensation of
pain
R: Diversional activities distracts the
client from the sensation pain through
diversion of perception to a different
thing

DATE,
SHIFT & ASSESSMENT NEED NURSING OBJECTIVES INTERVENTION EVALUATION
TIME DIAGNOSIS
July 24, Subjective: H Ineffective Health After 3 hours of Independent GOAL MET.
2018 “Hilig kaayo ko E Maintenance nursing intervention 1.Determine the client’s daily After 3 hours of
mukaon ug mga A related to the client will be health care regimen. nursing intervention
7-3 pm laman loob, L negative attitude able to: R: This will serve as a guide and it the client was able to
monggos ug mani. T regarding health -Identify necessary will serve as a basis for everyday identify necessary
11 AM Akong tubig dapat H condition health maintenance care and treatment. health maintenance
1L sa isa ka adlaw activities in relation activities such as
lang pero usahay P R: Since the client to his condition. 2.Identify support groups related to healthy eating and
muabot kog 2L. E is diagnosed wit -Verbalize the illness or disease process of the social supports,
Pero karon, naga R ESRD secondary understanding to client. verbalize
kaon nako gamay C to urate current situation. R: This will let the client be more understanding to
ug gulay ug isda” E nephropathy, -Assumes motivated in the compliance of his current situation by
As verbalized by P there are certain responsibility for treatment. Support from significant stating “Iwasan na
the client. T things he can and own healthcare others will help the client to be nako mag sige kaon
I can’t do. For needs. more motivated to follow dialysis ug mga bawal na
O instance, his diet schedule and diet plan. makalala sa aking
N has been severely sakit.” And assumed
Objective: - restricted since 3.Encourage the client to choose a responsibility for own
-Showed little H his kidney can no healthy lifestyle that is suited to his healthcare needs.
interest in E longer excrete condition.
A waste or excess

137
improving his L fluid. The client is R: It will prevent further
lifestyle T restricted by the complications and even death that
-Admitted to have H doctor to only may arise. The client must
poor diet drink 1 L of understand what defines a healthy
M fluids. This lifestyle.
A includes coffee,
N water, and etc. 4.Educate the client about the
A The client also treatment regimen that he is
G has urate undergoing. This includes the
E nephropathy, benefits of compliance to the
M meaning his treatment and possible effects if not
E kidney has been completed.
N damaged by uric R: Giving the client information
T crystals. Another regarding his condition would
food the client is make the client more aware of his
P restricted to is condition. And that, through his
A food rich in awareness will he able to follow
T purine. These through his treatment regimen.
T include but are
E not limited to 5.Develop plan with the client’s
R nuts, beans, red significant other for self-care.
N meat, organ meat, R: Involving the client’s family can
and small fishes. help the client see and feel that he
The client is also is not alone in his illness. And that
not allowed to support from the family is pertinent
drink any to the client’s healing process.
alcoholic
beverages as 6.Identify ways to adapt exercise
alcohol can program.
increase uric acid R: Sedentary lifestyle increases
production and deposition of uric acid crystals in
can further the joints. Uric acid crystals are
138
damage the metabolizing during physical
kidney. activity.

7.Encourage client to socialize.

R: Socializing with other people
can increase client’s well-being.
Socializing over-all contributes to
the client’s health as it also
contributes to his general mental

139
 Chapter XV

SUMMARY OF HEALTH TEACHINGS

Community Health Nursing is the synthesis of nursing and public health practice applied
to promote and protect the health of the population. Also, for the improvement of the conditions
in the social and physical environment, rehabilitation of illness and disability according to the
World Health Organization (WHO,2010). Community Health Nurses can make a significant
difference in the lives of the people in the community. One of our major tasks is to conduct
studies that focus on the residents who are at at-risk for any fluid and electrolyte imbalance and
use the findings to implement nursing actions, to provide and promote knowledge to help
improve the public’s health.

In this case, the group gathered information in the community and coordinated with the
barangay health worker to look for a client who is experiencing fluid and electrolyte imbalances.
The group had developed plans and activities for the two weeks of community exposure in Purok
2, Crossing Bayabas, Toril, Davao City. The group has provided them health education, and
interventions to help the individuals, families, and their community to maximize and strengthen
their health status. Interviews and health teachings were done during our house-to-house
visitations and obtained the initial database.

The group was able to choose a client who has End-Stage Renal Disease. During the
assessment, the group was able to recognize the client’s understanding about his condition and
the client’s overall indifference towards his treatment. The group was able to utilize and access
the information to know the priority needs of the client and provided health teaching. The
following health teachings are:

 The importance of complying with his dialysis treatment schedule; as dialysis treatment
prolong his life and preserve well-being through removal of nitrogenous waste from the
blood, remove excess fluid from the blood, help control blood pressure, and maintain
balance of electrolytes.

 The significance of maintaining proper electrolyte balance (Sodium, Potassium, Calcium,

Phosphate) his condition prevents him from removing excess fluids and electrolytes in his
body. Proper electrolyte balance promotes health and decreases risks or complications to
the client

140
  Maintaining proper renal diet and minimize his eating food rich in purine (Asparagus,
Dried beans, Lentils, Meat, fish and poultry, Mushrooms, Dried peas, Shellfish) this will
help in minimizing formation of gout.

 The consequence of using inadequate foot wear in relation to his condition. This can
increase the risk of infection.

 Behavioral modification towards accepting and understanding his condition. His negative
philosophy decreases self-care behavior, adherence to treatment schedule and medication,
and overall outlook in life.

The last day of our community exposure was our Culmination Day. It is not just gesture
that serves as our thanksgiving for the community for accommodating and cooperating with the
group, but the main purpose is to impart something that cannot be easily acquired, knowledge.
The content of the health teaching was hypertension and asthma because most of the cases the
group encountered are the said disease.

During the Culminating activity, the group also weighed the clients, computed their body
mass index, took their blood pressure, and conducted albumin and benedicts' urine tests to assess
the presence of albumin and glucose in the urine, and gave away free vitamin C for adults and
children. These procedures are made to determine the residents’ health status for them to be
aware and to seek medical help if necessary.

141
 Chapter XVI

CONCLUSION AND RECOMMENDATION

Community health Nursing is the blend of nursing and public health practice applied to
promote and protect the health in families, community, and population. Nurses have access to not
only a patient’s chart, but their heart, soul, and family as well. They see the emotional side and
learn about the patient’s life on a personal basis. With that knowledge in hand, community health
nurses can use this knowledge during the implementation phase.

The group incorporated the Community Health Nursing concept and the Fluids and
Electrolytes Imbalances concept in their two weeks of exposure in Purok 2 Toril Crossing Bayabas.
The group was blessed with an accommodating, cooperative, and participative community. The
group was able to apply the concepts learned in Community health nursing and the topics in NCM
103 to formulate health lectures, health services, and culminative activity to the community. The
community participated to the health teachings of the group. Furthermore, during the event,
vitamins c where handed out to the cooperative participants, blood pressure was also monitored
together with age and weight, and urine was tested for sugar and albumin. The culmination event
was deemed a success however it still has rooms for improvement. The group shows promise
however communication and teamwork are recognize by the group to be lacking.

In relation the groups client, the nursing process provided the group and the family
opportunities to validate assessment data and modify family nursing care plans based on the
family’s perception and responses. The group, together with the family developed a nurse-family
effort at exploring the best choices in the family’s situated possibilities. Through immersion into
the client’s reality, the group got the chance to fully understand the depth of the meaning of the
client’s experiences as both enhanced each other’s opportunities to facilitate the journey from
apathy to courage, vacillation of decisiveness, hopelessness to empowerment.

142
 RECOMMENDATIONS

Methods of data collection are important such as interviewing, observing, and conducting
physical assessment. Moreover, conducting ocular survey and home visiting in the client’s
community is necessary. As student nurses, our goal is health promotion and disease prevention.
It is our duty to provide care, comfort, and confidentiality for the client and his/her family to
meet and respond to their needs.

The goal of Community Health Nursing is to help the individual, family, and community
in obtaining their optimum level of holistic health, promotion and maintenance of health lifestyle
and disease prevention through appropriate health teachings. To fulfil our purposes, the support
and cooperation of the family and the barangay health workers of Purok 2, Crossing Bayabas is
needed. Thus, the group would like to recommend:

To the client and family,

The group recommends the family to show more affection and support to the client’s
condition especially that client Heisenberg is an end-renal stage disease patient. The client is also
a dialysis patient which means she needs to go to a dialysis center regularly. Furthermore, the
family, as a whole, must be responsible for taking care of their health and do their best to follow
the health teachings and interventions designed for them by the group. In order to acquire more
knowledge regarding the health maintenance and disease prevention, the family should engage in
a certain program and activity, such as community health class, made by the barangay officials,
together with the barangay health workers that can serve as a basis in handling health matters at
home, and in certain situations which require appropriate health actions.

To the members of the group,

Exposure in the community unlocks a lot of opportunities for a student nurse to handle
real situations outside the four corners of the room in school and hospital settings. It allows them
to deal and interact with different types of families, different cultures and societies in which they
can apply nursing knowledge and skills. During the Community Health Nursing exposure, the
group encountered hardships and obstacles, such as finding clients appropriate to our concept in

143
NCM 103 and fulfilling the standards set by the Clinical Instructor We encourage the members
of the group to maintain full dedication in their work. Teamwork and being open to suggestions
are two of the things a student nurse should possess in order to become effective and efficient
nurses in the future.

To the clinical instructor,

This exposure was not possible without the group’s clinical instructor who was there with
the group despite the heat under the sun and the stressful circumstances along the way. Without
her presence and motherly guidance, the experiences that the group had in the community would
not have been a success. Thus, the clinical instructor may continue to be the model of excellence
as how a community health nurse should embody.

144
 Chapter XVII

SIGNIFICANCE OF THE CASE STUDY

NURSING PRACTICE

The significance of this case to Nursing Practice is its goal to ensure the overall health of
the families in the community. It also gives opportunity to the community health nurses to
improve their skills on caring for the family through a daily monitoring through house visits to
follow up each family’s health condition. Also, to provide health teachings to the community
such as proper hygiene and sanitation, communicable diseases, fluid and electrolyte imbalances
and health and nutrition since these are the some of the problems observed in the community.
The nurses should also inform the residents about the programs being offered by the health
center since some families are not aware of the health center programs. The families in the
community can benefit from this since they are being well taken care of by the community health
nurses and they are being provided with the knowledge they needed in the different problems
that was observed.

NURSING EDUCATION

This study is significant to Nursing Education in Ateneo de Davao University as it serves

as a guide to the clinical instructors, student nurses and other health care providers in dealing
with environmental issues in the community. Also, it gives information about the community’s
culture and norms. This is vital for nursing education because it would provide the background
about the community and it will enable the future nursing students who will be exposed on the
community the things that is needed to be reassess and if it was maintained or improved.

NURSING RESEARCH

This study can be a basis for conducting future nursing research whose topic is like our
case study. The data and findings presented in this case study can be used by future researchers
as a baseline information and would inspire them to further study and explore about this case to
come up with their own research output.

145
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