Rex Andrei H.

Fadrigalan April 2020

4NUR2 CA2 – MS
CASE 3
Care of Client with GI, PUD, Cancer, Liver Failure

PART I
Mr. MJ , 56 years old was brought to the Emergency Room because of weakness, loss
of appetite and decreasing level of consciousness. During the interview by the nurse, the wife
revealed that he was a smoker, alcoholic drinker , since he was 17 and fond of eating fatty, less
fiber food. He leads a stressful life because of his work in a multinational company. He had
undergone many diagnostic exams and procedures like colonoscopy with biopsy, esophago
gastrocopy, sclerotherapy, paracentesis for ascites , chemotherapy and radiotherapy. He had
been fatigued and anemic for the past year and had taken vitamin and iron supplements. The
wife narrated that he had undergone major abdominal surgery with colostomy, after which he
was placed on PCA morphine, post op monitors and were taught to take care of his colostomy
site.

Past medical history of MJ also revealed the following:

2017 – Hepatitis A
2018 – PUD ,managed by medications. BPH with dysuria. DRE revealed soft enlarged
prostate
2019 – Rectosigmoid cancer stage 3, underwent Abdominoperineal resection (APR) with
colostomy, underwent radiotherapy and chemotherapy
January 2020- Cirrhosis with portal hypertension.

A. What are the other possible risk factors that can contribute to his present condition?
Some of the possible risk factors that can contribute to his present condition are chronic
alcohol intake, fatty liver disease, Chronic Hepatitis A, Autoimmune diseases, genetics and
obesity.

B. When you assess Mr MJ having undergone APR, what kind of colostomy do you
expect?
Since Abdominoperineal Resection (APR) completely removes the distal colon, rectum and
anal sphincter the client will be expected to have a permanent colostomy.

C. What would you expect to drain from the colostomy? What are the different kinds of
colostomies?
For the first 24–48 hours after surgery, the colostomy will drain bloody mucus. Fluids and
electrolytes are infused intravenously until the patient's diet can gradually be resumed,
beginning with liquids. Usually within 72 hours, passage of gas and stool through the stoma
begins. Initially, the stool is liquid, gradually thickening as the patient begins to take solid
 foods. The patient is usually out of bed in eight to 24 hours after surgery and discharged in
two to four days. There are four types of colostomy namely:
1. Ascending colostomy — is made from the ascending part of the colon. The
ascending colostomy is usually located in the low to middle right side of the
abdomen. The output is often liquid to semiliquid, and gas is common.
2. Transverse colostomy — is made from the transverse part of the colon. The
transverse colostomy is usually located in the center of the abdomen above the navel.
The output often is liquid to pasty, and gas is common.
3. Descending colostomy — is made from the descending part of the colon. The
descending colostomy is typically located on the lower left-hand side of the abdomen.
The output may be pasty to a formed consistency, and gas is common.
4. Sigmoid colostomy — is made from the sigmoid colon. The sigmoid colostomy is
usually located in the lower left-hand side of the abdomen. The output is usually
pasty to a formed consistency, and gas is common.

D. How will he monitor his colostomy? Discuss colostomy care and colostomy irrigation.
Most of the monitoring will be done by inspection in which we will inspect the sire, spout,
consistency and number of lumens. We will also observe for potential complications of a
stoma like parastomal hernia, which is common in colostomies, prolapse, retraction or
infarction. Colostomy care is how to change, empty or clean the pouch system. To take care
of the colostomy pouch first you need to use the right size pouch and skin barrier opening.
Next is to change to pouching system regularly, clean the skin around the stoma with water
and watch out for sensitivities and allergies. Colostomy irrigation is a way to regulate bowel
movements by flushing and emptying the colon at a scheduled time. The process involves
instilling water into the colon through the colostomy, or stoma, which stimulates the colon to
empty. By repeating this process regularly. the colon can be trained to empty with minimal
spillage of stool in between irrigations. Colostomy irrigation also can help avoid
constipation.

E. Having undergone this surgery, discuss your nursing care for MJ after this abdominal
surgery.
The nursing care plan will be risk for infection related to post-operative APR with a goal of
the patient remaining free of infection. The interventions will be as follows:
1. Assess for the presence, existence of, and history of risk factors
2. Maintain or teach asepsis for dressing changes and wound care
3. Encourage deep breathing exercises
4. Encourage increase in fluid intake

F. Having undergone chemo/radiotherapy, the nurse knows that side effects can occur
with these therapy since these affect both abnormal and normal cells. What are these
 side effects that the nurse should focus on her health teachings whenever the nurse is
taking care of patient with cancer ?
Chemotherapy can cause fatigue, loss of appetite, nausea, bowel issues, trouble concentrating
or remembering things and increase in risk for infections. Some of the health teachings are as
follows:
1. Use soft bristle toothbrush when doing mouth care
2. Practice safe eating and drinking during cancer treatment
3. Wash hands with soap and water
4. Discuss to patient on how to prevent bleeding
5. Encourage to eat enough protein and calories to keep weight up
6. Do not smoke
7. Use sunscreen

G. What possible diagnostic exams and management were given to him when he was
suffering PUD?
Some of the diagnostic exams for PUD are:
1. Laboratory tests for H. pylori
2. Endoscopy
3. Upper Gastrointestinal series or barium swallow
One of the management of PUD is to eliminate the substances causing it, which in this case is
smoking and drinking alcohol. Some medications that can be given are Proton Pump
Inhibitor which reduce acid and allow ulcer to heal. Antibiotics are also given to treat H.
pylori

PART II
During your interview with the wife of MJ, he is also taking Aldactone, Lactulose. At
times he has been disoriented and had memory problems. You noticed ascites, some edema on
his lower extremities. Additional tests were done like serum enzyme tests, serum Bilirubin.,
total protein A/G ratio, PT.

H. What can cause MJ’s liver cirrhosis?

A wide range of disease and conditions can cause liver cirrhosis are chronic alcohol abuse,
fat accumulating in the liver, poorly formed bile ducts, destruction of the bile ducts and
chronic viral hepatitis.
I. Cite the complications of Liver cirrhosis that already exist with his presenting signs and
symptoms?

Some of the complications of liver cirrhosis that already exist with his presenting signs and
symptoms are Ascites, Hepatic encephalopathy, hepatorenal syndrome and liver cancer.

J. Give the rationale of the above management and diagnostic assessments for his
cirrhosis.

Management Rationale

Encourage to stop alcohol consumption Any amount of alcohol is toxic to the liver

Lose weight if cirrhosis is caused by fat People with cirrhosis caused by nonalcoholic
buildup in the liver fatty disease may become healthier if they
were able to lose weight

Medications to control hepatitis Medications may limit further damage to the

liver caused by hepatitis

Low sodium diet This may help in controlling the swelling

Diagnostic Test

Abdominal Computed (CT) scan This procedure combines special x-ray

equipment with sophisticated computers to
produce multiple, digital images or pictures
of the liver. It can help determine the severity
of cirrhosis as well as other liver diseases.

Abdominal Ultrasound Ultrasound is a type of imaging exam that

uses sound waves to create pictures of the
inside of the abdomen and/or pelvis,
including images of the liver. 

Elastography This exam assesses the stiffness of your liver

and can help diagnose how severe the
scarring is in the liver (known as liver
fibrosis).

Body Magnetic Resonance Imaging (MRI) This imaging exam uses a powerful magnetic
field, radio frequency pulses and a computer
to produce detailed pictures of the liver
allowing for assessment of damage caused by
 various liver diseases.

Magnetic Resonance MRCP is special type of MRI protocol that is

cholangiopancreatography (MRCP) designed to evaluate a part of the liver and
gallbladder.

During the 4th week of MJ’s confinement, the nurse observed the patient to be restless
and suddenly he vomited fresh blood.

K. What would be your immediate management at this time?

The initial treatment may require a drip into a vein to give you fluid or even a blood
transfusion if the bleeding is severe. This may not be necessary if the bleeding has been
minor and has stopped. However, if the bleeding is severe, full resuscitation and emergency
fluid/blood replacement may be required.

L. What could have caused the vomiting of fresh blood? What are your other parameters
of assessment with these advancing liver condition?

In the later stages of cirrhosis, the patient may vomit blood or have black tarry stools. This is
because blood can’t flow through the liver properly, which causes an increase in blood
pressure in the vein that carries blood from the gut to the liver. The increase in blood pressure
forces blood through smaller, fragile vessels that line your stomach and gullet (varices).
These can burst under high blood pressure, leading to internal bleeding, which is visible in
vomit and/or stools. Some parameters of assessment with advancing liver condition are
abdominal swelling, jaundice and GI bleeding. Findings on physical examination include a
contracted, nodular liver; splenomegaly; ascites; dilated abdominal wall veins; spider
angiomata; palmar erythema; peripheral edema; and asterixis.

For the succeeding days, MJ became comatose, ascites and edema worsening and was
hooked to dopamine for his dropping blood pressure and was confined in ICU with decreasing
GCS everyday.. The physician explained the irreversible effects of his advanced liver disease
and later on the family and relatives signed for DNR .

M. What ethical concepts are related to issues at end of life happening to MJ.

Some of the ethical concepts related are autonomy, beneficence, nonmaleficence and justice.
Since the patient is on DNR it means that the patient has elected for cardiopulmonary
resuscitation (CPR) to not be initiated or administered in the event of a cardiac arrest. CPR
could include the use of chest compressions, cardiac drugs, and the placement of a breathing
 tube.

N. With what members of the interdisciplinary team does the nurse collaborate when
caring for the dying patient and providing support for the family?

The nurse should collaborate with the hospice and palliative care teams provide
interdisciplinary care to seriously-ill and terminally-ill patients and their families. Care teams
are comprised of medical and non-medical disciplines and include volunteers and lay
workers in healthcare.

O. Give signs and symptoms related to the end of life.

Some of the signs and symptoms related to the end of life are:
1. Coolness
2. Confusion
3. Sleeping
4. Incontinence
5. Restlessness
6. Congestion
7. Urine decrease
8. Fluid and Food decrease
9. Change in breathing
10. Fever

P. Discuss the ethical and legal obligations of the nurse with regard to end of life care.

According the Code of Ethics for Nurses (ANA, 2015), the nurse may “not act deliberately

to terminate life”; however, the nurse has a moral obligation to provide interventions “to
relieve symptoms in dying patients even if the intervention might hasten death.”
Rex Andrei H. Fadrigalan April 2020
4NUR2 CA 2– MS
CASE 4
Neuro, Endocrine, Urinary

PART I
S.B. is a 62-year-old married woman with a past medical history of seizure disorder
controlled with Tegretol (last seizure was 5 years ago), underwent Total Thyroidectomy for
Toxic Nodular Goiter three years ago and presently receiving Synthyroid. She has a history of
HTN for the past 10 years and is receiving Enalapril for it. She has been diagnosed with DM
Type 2 since age 40 years old and being managed with Oral antidiabetic agents. She is obese
and the family admits to her being non-compliant to her diabetic control regimen. She sought
consult at the doctor’s clinic last September 2016 for her non-healing 2-cm wound with sero-
purulent drainage at her right foot. She reports that her latest blood tests two months ago reveal
an elevated glycosylated hemoglobin, BUN & creatinine levels. The daughter states that the
patient has been advised to undergo further tests for her kidneys to determine the extent of her
Diabetic Nephropathy. After the consult visit, the doctor advised admission for treatment of the
foot ulcer and further evaluation of her diabetic condition.

1. What relevant assessment data will you need related each of your patient’s medical
condition? Give the rationale for each assessment data.
Physical assessment Vitals signs, head to toe inspection, and
palpation of skin, hair and thyroid. Findings
should be compared with previous findings,
if available. Physical, psychological and
behavioral changes should be noted.
Health history A thorough health history and review of
systems are necessary for diagnosis and
management of these disorders.
Weight loss or gain Monitoring if the patient has lost weight
indicates Improvement of glycemic control
decreases glycosuria, which may impair
weight loss. The more excess weight you
have, the more resistant your muscle and
tissue cells become to your own insulin
hormone.
Color of urine Patches on the dipstick change color when
 albumin or blood is present in urine.

2. Identify predisposing factors to each of her medical problems that you need to check
out with S.B.
Some of the predisposing factors to her medical problems is her gender which is female and
her family history

3. Illustrate using a flow chart the pathophysiology of each of the medical problems of
S.B. and their possible complications.
Grave’s
Disease
Precipitating Factors Predisposing factors:
 Stress  Female
 History of seizures Lymph nodes cells “Antigen
 Family History
 Diabetes Presenting Cells” thyroid
stimulating hormone like antigen
activate “T-cells” in the lymph
node

Activated T cells activates “B

cells” to become a plasma cell

Plasma cells stimulates the

production of TSH receptor
antibody

Anti-bodies from the Auto antibodies target the TSH

immune system attacks receptors
thyroid gland

Results in excess Thyroxine Thyroid gland stimulated to

(T4) produce more thyroid hormones

Swelling of the Thyroid Increase of T3 and T4 cause a

Gland negative feedback to hypothalamus
 Goiter Hypothalamus will stop to produce
TRH and TSH to the Pituitary
gland as there is adequate T3 and
T4

Antibodies still exist and

production of hormones still
persists

Thyroid Gland will still produce T3

and T4

Lead to overproduction of Thyroid

Hormones

Hyperthyroidism

4. Using another flow chart, indicate the pathophysiologic relationship of the medical
problems of S.B. How do these conditions relate to each other, if they do?

Hyperthyroidism

Worsens blood
glucose control

Increased insulin
requirements

Increased insulin
requirements
 Excessive thyroid
hormone causes

 Increased glucose production in the

liver
 Rapid absorption of glucose through
the intestines
 Increased insulin resistance

It may unmask
latent diabetes

5. Prior to the thyroid surgery of your patient,

5.1. What manifestations would you have seen for a toxic nodular goiter
Patients may complain of fatigue, unintentional weight loss, heat intolerance,
diaphoresis, tremor, palpitations, hyperdefecation, anxiety, nervousness, irritability,
difficulty with mental concentration and hair loss. Toxic nodular goiter does not cause
the bulging eyes that can occur with Graves disease.

5.2. What medications were ordered to SB to help manage her condition? Give
their rationale.
Tegretol Carbamazepine is used to prevent and
control seizures. This medication is
known as an anticonvulsant or anti-
epileptic drug. It is also used to relieve
certain types of nerve pain (such as
trigeminal neuralgia). This medication
works by reducing the spread of seizure
activity in the brain and restoring the
normal balance of nerve activity.

Enalapril Enalapril is used alone or in combination

with other medications to treat high blood
pressure. It is also used in combination
with other medications to treat heart
failure. Enalapril is in a class of
medications called angiotensin-
converting enzyme (ACE) inhibitors. It
works by decreasing certain chemicals
 that tighten the blood vessels, so blood
flows more smoothly and the heart can
pump blood more efficiently.

6. Following total thyroidectomy,

6.1. What complications can possibly occur and why? Give their nursing and
collaborative preventive interventions.
Complications Reason Nursing and
Collaborative
preventive
interventions
Postoperative The incidence of  Avoid
bleeding bleeding after traumatizing the
thyroid surgery is thyroid tissue
low (0.3-1%), but during the
procedure
an unrecognized or
 Provide good
rapidly expanding intraoperative
hematoma can cause hemostasis
airway compromise  Avoid the use of
and asphyxiation. neck dressings, as
Patients present dressing that
with neck swelling, covers the wound
may mask
neck pain, and/or
hematoma
signs and symptoms formation
of airway
obstruction (eg,
dyspnea, stridor,
hypoxia)
Recurrent Recurrent laryngeal  In unilateral vocal
laryngeal nerve nerve (RLN) injury cord paralysis,
injury results in true vocal- corrective
fold paresis or procedures may be
delayed for at least
paralysis. Deliberate
6 months to allow
intraoperative time for
identification and improvement in a
preservation of the reversible injury,
RLN minimizes the unless the nerve
risk of injury. was definitely
transected during
surgery; surgical
treatment options
 are medialization
(most common)
and reinnervation
 In bilateral vocal
cord paralysis,
emergency
tracheotomy may
be required, but if
possible, first
perform
endotracheal
intubation;
cordotomy and
arytenoidectomy,
the most
commonly
performed surgical
procedures,
enlarge the airway
and may permit
decannulation of a
tracheostomy
 The patient must
be counseled that
his or her voice
will likely worsen
after surgery
Hypocalcemia Incidence is 3-5%.  Calcium
Surgery can lead to carbonate, which
trauma to the is the least
parathyroids, expensive and has
the most elemental
devascularization of
calcium
the glands with  Calcium citrate,
resultant ischemia, which is the most
or inadvertent easily absorbed
excision of these calcium phosphate,
small structures. which is also
Hypoparathyroidis easily absorbed
and doesn’t cause
m with subsequent
constipation
decreased
production of
parathyroid
hormone leads to
decreased serum
 calcium. Acute
hypocalcemia
generally presents at
24-48 hours as
laryngeal stridor and
airway obstruction.
First symptoms are
usually tingling in
the lips and
fingertips.
Airway Incidence of  Objects stuck in
obstruction hematoma is 1-2%, the airway may be
tracheomalacia removed with
incidence is <1%. special
instruments.
Acute airway
obstruction from  A tube may be
hematoma may inserted into the
occur immediately airway
postoperatively and (endotracheal
is the most frequent tube) to help with
cause of airway breathing.
obstruction in the
 Make an opening
first 24 hours. into the airway
Definitive therapy is (tracheostomy or
opening the surgical cricothyrotomy).
incision to evacuate
the hematoma. Re-
intubation may be
lifesaving for
persistent airway
obstruction.
Consider awake
fiberoptic
intubation.
Wound infection Currently,  Treat cellulitis
postoperative with antibiotics
infection occurs in that provide good
less than 1-2% of all coverage against
gram-positive
thyroid surgery
organisms (eg,
cases. Sterile staphylococci and
surgical technique is
 the key to streptococci)
prevention; routine
use of perioperative  Drain abscesses,
antibiotics has not and direct
antibiotic coverage
proven to be
according to
beneficial. culture findings

 For deep neck

abscesses, begin
with broad-
spectrum
antibiotics (eg,
cefuroxime,
clindamycin,
ampicillin-
sulbactam) until
definitive culture
results are
available

6.2. Why is the patient being given Synthyroid? What specifc health teachings
need to be given regarding this drug.
Synthroid is used if the thyroid production is low due to surgery, radiation, certain
drugs or disease of the pituitary gland or hypothalamus in the brain. The patient
should be made aware that the drug is used as a replacement for a hormone that is
normally produced by the thyroid gland to regulate the body’s energy and
metabolism. The patient should also be instructed that it is to be taken once a day
preferably before breakfast to prevent insomnia.

7. What criteria is used for the establishment of a definite diagnosis of DM?

Diabetes can be classified into the following general categories:

1. Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin

deficiency)
2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of
insulin resistance)
3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third
trimester of pregnancy that is not clearly overt diabetes)

1. Diabetes may be diagnosed based on A1C criteria or plasma glucose criteria, either
the fasting plasma glucose (FPG) or the 2-h plasma glucose (2-h PG) value after a 75-g oral
 glucose tolerance test (OGTT)

8. What health teachings can be given to the family members of S.B. to keep them from
developing DM?
Some health teaching that should be given are
 Maintaining a healthy weight
 Exercise regularly
 Choose lean and low fat food
 Eat healthy, moderate amounts

9. What 2 acute complications of DM2 should be watched out for in S.B.? Give their
manifestations, preventive and therapeutic interventions.
Hyperosmolar hyperglycemic nonketotic coma and hypoglycemia. Possible signs and
symptoms of Hyperosmolar hyperglycemic nonketotic coma include: Blood sugar level of
600 milligrams per deciliter (mg/dL) or 33.3 millimoles per liter (mmol/L) or higher,
excessive thirst and dry mouth. To prevent HHNS, know the symptoms of high blood sugar,
monitor blood sugar level, increase fluid intake, follow diabetes management plan and stay
current on vaccinations. Treatment typically includes: Intravenous fluids to counter
dehydration, intravenous insulin to lower your blood sugar levels, intravenous potassium, and
occasionally sodium phosphate replacement to help your cells function correctly. The
manifestations of hypoglycemia are shakiness, dizziness, sweating, hunger, irritability or
moodiness, anxiety or nervousness and headache. To prevent hypoglycemia, monitor blood
sugar, don’t skip or delay meals or snack, measure medication carefully and take it on time
and eat additional snack. The treatments are insulin glargine, diabetes management,
sulfonylurea and diazoxide

10. Can the patient develop a DKA? Support your answer.

Diabetic ketoacidosis can happen in type 2 diabetes but it is very rare since there’s somewhat
a sufficient level of insulin that may prevent the occurrence of DKA by suppressing lipolysis.
If there is a lack of insulin in a type 2 diabetic patients then the process of lipolysis can occur
and undergo DKA. Such causes of DKA can stem from the decreased or missed doses of
insulin, illness, or infection and undiagnosed and untreated diabetes.

11. How do you recognize the difference between a Somogyi effect & the Dawn
phenomenon?
The somogyi effect is a rebound effect in which an overdose of insulin induces
hypoglycemia. Usually occurring during hours of sleep, the somogyi effect produces a
decline in blood glucose level, in response to too much insulin. Counter regulatory hormones
are released, stimulating lipolysis, gluconeogenesis and glycogenolysis, which in turn
 produce rebound hyperglycemia and ketosis. The danger of this effect is that when blood
glucose is measure in the morning, hyperglycemia is apparent and the patient may increase
the insulin dose. The effect is associated with the occurrence of undetected hypoglycemia
during sleep, though it can happen anytime. The dawn phenomenon sometimes called the
dawn effect is an early morning increase in blood sugar which occurs to some extent in all
humans, more relevant to people with diabetes. Dawn phenomenon is not associated with
nocturnal hypoglycemia.

12. Discuss briefly the management strategies for DM and their rationale.
Management Rationale
1. Balancing food intake with medication and 1. Keep the blood glucose levels as near to
activity. normal as possible
2. Monitor blood sugar 2. To be aware of the lever of blood sugar
3. Control blood pressure 3. For the blood pressure not to go over
140/90

13. Make a nutritional health teaching plan for S.B.

The patient will be encourage to have a healthy diabetic eating which includes:
 Limiting foods that are high in sugar
 Eating smaller portions, spread out over the day
 Being careful about when and how many carbohydrates you eat
 Eating a variety of whole-grain foods, fruits and vegetables every day
 Eating less fat
 Limiting your use of alcohol
 Using less salt

14. What are the different types of oral antihyperglycemic agents that can be given? Make
a table to include: Type of drug; examples; therapeutic action; onset, peak & duration
of action; side effects
Drug Exampl Therapeutic Onset, peak & duration Side effects
e action
Sulfonylur Glipizid Stimulate CNS:dizziness,drowsiness,
eas e beta cells of Onset:P.O. 15-30 min headache, weakness
the pancreas Peak:1-2 hr CV:increased CV mortality
risk
to secrete Duration: Up to 24 hr
insulin, may EENT:blurred vision
imprve
landing GI:nausea,vomiting,diarrhe
between a,constipation,cramps,heart
 insulin and burn,epigastric
insulin distress,anorexia
receptors or
Hematologic:aplastic
increase the
anemia,agranulocytosis,leu
number of kopenia,pancytopenia,
insulin thrombocytopenia
receptors
Hepatic: cholestatic
jaundice,hepatitis
Metabolic:
hyponatremia,hypoglycemi
a
Skin:rash,pruritus,erythema
,urticaria,eczema,angioede
ma,photosensitivity
Other:increased appetite
Sulfonylur Glyburi Used in type Onset: P.O. 45-60 min weakness CV:increased CV
eas de 2 diabetes to Peak:1.5-3 hr mortality risk EENT:visual
control Duration:24 hr accommodation changes,
blurred vision
532 glyburide
!Canada UK Hazardous
drug High alert drug
GI:nausea,vomiting,diarrhe
a,constipation,cramps,heart
burn,epigastric
distress,anorexia
Hematologic:aplastic
anemia,leukopenia,thrombo
cytopenia,agranulocytosis,p
ancytopenia Hepatic:
cholestatic
jaundice,hepatitis
Metabolic:
hyponatremia,hypoglycemi
a
Skin:rash,pruritus,urticaria,
eczema,
erythema,photosensitivity,a
ngioedema Other:increased
appetite
Biguanides Glimepi Lowers Route Onset Peak Adverse reactions
ride blood Duration CNS:dizziness,drowsiness,
glucose Route: P.O. headache, weakness
 level by Onset: 1 hr CV:increased CV
stimulating Peak: 2-3 hr mortality risk
insulin Duration: >24 hr EENT:blurred vision
GI:nausea,vomiting,diarrhe
release from
a,
pancreas,inc constipation,cramps,heartb
reasing urn,epigastric
insulin distress,anorexia
sensitivity at Hematologic: aplastic
receptor anemia,leukopenia,pancyto
sites,and penia,thrombocytopenia,ag
ranulocytosis
decreasing
Hepatic: cholestatic
hepatic jaundice,hepatitis
glucose Metabolic:
production . hyponatremia,hypoglycemi
Also a
increases Skin:rash,erythema,maculo
peripheral papular
eruptions,urticaria,eczema,
tissue
angioedema,photosensitivit
sensitivity to y Other:increased appetite
insulin and
causes mild
diuresis.
Biguanides Metfor Increases ONSET GI:diarrhea,nausea,vomitin
min insulin PEAK g,abdominal bloating
sensitivity DURATION ACTION Metabolic:lactic acidosis
Other:unpleasant metallic
by
P.O. Unknown 2-4 hr taste,decreased vitamin
decreasing 12 hr P.O. Unknown 4- B12 level
glucose 8 hr 24 hr
production
and
absorption
in liver and
intestines
and
enhancing
glucose
uptake and
utilization
Alpha- Acarbo Improves ONSET GI:diarrhea,abdominal
Glucosidas se blood PEAK pain,flatulence
e inhibitors glucose DURATION ACTION Metabolic:hypoglycemia
 control by (when used with insulin or
slowing P.O. sulfonylureas)
carbohydrate Rapid Other:edema,hypersensitivi
1 hr ty reaction (rash)
digestion in
Unknown
intestine and
prolonging
conversion
of
carbohydrate
s to glucose
Alpha- Miglitol Inhibits Onset: P.O.Unknown GI:abdominal
Glucosidas alpha- Peak:2-3 hr pain,diarrhea,flatulence
e inhibitors glucosidases Duration: Unknown Skin:rash
,which
convert
oligosacchar
ides and
disaccharide
s to
glucose.This
inhibition
causes blood
glucose
reduction
(especially
in
postprandial
hyperglycem
ia).
Non- Repagli Inhibits Onset: P.O. Within 30 CNS:headache,paresthesia
Sulfonylur nide alpha- min CV:angina,chest pain
eas glucosidases Peak: 60-90 min EENT:sinusitis,rhinitis
Duration: <4 hr GI:nausea,vomiting,diarrhe
,enzymes
a,constipation,dyspepsia
that convert GU:urinary tract infection
oligosacchar Metabolic:
ides and hyperglycemia,hypoglycem
disaccharide ia Musculoskeletal: joint
s to pain,back pain Respiratory:
glucose.This upper respiratory
infection,bronchitis
inhibition
Other:tooth
lowers blood
 glucose disorder,hypersensitivity
level,especia reaction
lly in
postprandial
hyperglycem
ia.
Non- Nategli Decreases Onset: P.O. Rapid CNS:dizziness GI:diarrhea
Sulfonylur nide blood Peak: Within 1 hr Metabolic:hypoglycemia
eas glucose Duration 4 hr Musculoskeletal: back
pain,joint pain Respiratory:
level by
upper respiratory tract
stimulating infection,bronchitis,coughi
insulin ng Other:flulike
secretion symptoms,trauma
from
pancreatic
beta
cells;interact
s with
calcium and
potassium
channels in
pancreas
Thiazolidi Ploglita Used along Onset: within 30 min Edema, weight
nediones zone with a Peak: within 2hrs gain, macular
proper diet Duration: 3 – 7 hr edema and heart failure.
Moreover, they may cause
and exercise 
hypoglycemia when
program to combined with other
control high antidiabetic drugs as well
blood sugar i as decrease hematocrit
n patients and hemoglobin levels.
with type 2 Increased bone fracture
diabetes. It risk is another TZD-related
side effect.
works by
helping to
restore your
body's
proper
response to
insulin,
thereby
lowering
 your
blood sugar.
Thiazolidi Rosiglit Inhibits Onset: P.O. Unknown CNS:fatigue,headache
nediones azone alpha- Peak: Unknown EENT:sinusitis GI:diarrhea
glucosidases Duration: 12-24 hr Hematologic: anemia
Metabolic:
,enzymes
hyperglycemia,hypoglycem
that convert ia Musculoskeletal: back
oligosacchar pain Respiratory: upper
ides and respiratory infection
disaccharide Other:edema,injury,weight
s to gain
glucose.This
inhibition
lowers blood
glucose
level,especia
lly in
postprandial
hyperglycem
ia.
Dipeptidyl Vildagli Inhibits the Onset: 90 min Gastrointestinal problems –
peptidase- ptin inactivation Peak: 30 min including nausea, diarrhoea 
4 of GLP-1 Duration: >10 hrs and stomach pain.
and GIP by Flu-like symptoms
DPP-4, – headache, runny nose, sor
e throat.
allowing
Skin
GLP-1 and
reactions – painful skin
GIP to followed by a red or
potentiate purple rash.
the secretion
of insulin in
the beta cells
and suppress
glucagon
release by
the alpha
cells of the
islets of
Langerhans
in the
pancreas. Vi
 ldagliptin ha
s been
shown to
reduce
hyperglycem
ia in type 2
diabetes
mellitus.
Glucagon- Liraglut An analog of Onset: Unknown Nausea
like ide human GLP- Peak: 8hrs Other common adverse
peptide-1 1 and acts as Duration: 13hrs effects include injection
site reactions, headache,
agonist a GLP-1
and nasopharyngitis, but
receptor these effects do not
agonist. Lira usually result in
glutide incre discontinuation of the
ases drug.
intracellular
cyclic AMP
(cAMP)
leading to
insulin
release in
the presence
of elevated
glucose
concentratio
ns.
Sodium- Dapagfl A class of Onset: within 4 weeks Genital yeast infections
glucose iflozin drug called Peak: 12 weeks in men and women.
co- SGLT2 Duration: Unknown Urinary tract infections
(UTIs) Increased
transporter inhibitors
urination.
2 These
drugs work 
by targeting
and helping
to stop
sodium-
glucose
transport
proteins
from
 allowing
glucose that
has been
filtered out
of the blood
by the
kidneys to
be
reabsorbed
back into the
blood.

S.B’s non-healing wound is debrided and treated further with oral antibiotics.

15. The patient asks, “When will this wound heal? Why is it taking so long? What other
bad thing can I have because of this?” What would be your response to these
queries?
Diabetes slow healing wounds. High levels of blood glucose caused by diabetes can, over
time, affect the nerves (neuropathy) and lead to poor blood circulation, making it hard for
blood - needed for skin repair - to reach areas of the body affected by sores or wounds.

16. What relevant teaching can you provide at this time?

The patient should dry the area well after washing; apply antibiotic ointment to keep the sore
germfree. Tell the patient that she will feel better and heal faster if she keep pressure off the
wound.

17. Should the patient’s foot condition further deteriorate, when would amputation be
indicated? What major concerns related to care would you have?
Diabetes causes foot ulcers and wounds that do not heal or become infected. The
deterioration of the foot is depended on how worse is the DM of the patient. Amputation is
indicted if the circulation of the blood is poor because it damages, or it narrows the arteries
called the peripheral arterial disease which results the cells cannot get oxygen and nutrients
from the bloodstream.

The doctor evaluates for other possible effects of her poorly managed DM.

18. What tests would you expect to be ordered? What would their findings be to indicate
the presence of complications?
Fasting blood sugar test Indication Blood sugar level of 200 mg/dL,
 especially when coupled with any of the s/sx
of diabetes such as urination and thirst. (N =
70-120 mg/dL)
Oral glucose tolerance test (OGTT) Indication: 200 mg/dL or higher. (N = less
than 140 mg/dL)
Indication: 200 mg/dL or higher. (N = less Indication: 126 mg/dL or higher. (N = 99
than 140 mg/dL) mg/dL and below)
BUN above 20 mg/dL. (N = 7-20 mg/dL)
Creatinine above 1.4 mg/dL. (N = 0.6-1.2 mg/dL)
Creatinine based GFR above 150 mL/min. (N = 100-150 mL/min.)
(N = 100-150 mL/min.) Indication for females 129 mL/min. (N = 88-
128 mL/min.)

The lab test results return confirming previous results with elevated BUN & creatinine.
S.B. appears worried & states, “My mother had DM and had dialysis for several years before
she died because of chronic Renal failure. I don’t want to have the same thing happen to me.”

19. How will you address this concern?

The nurse’s responsibility will be to have a calm approach and educate the patient how to
prevent such complications.

20. When does the nephrologist generally decide to perform dialysis on a patient? What is
the purpose of this procedure?
Dialysis should be instituted whenever the glomerular filtration rate (GFR) is <15 mL/min and there
is one or more of the following: symptoms or signs of uremia, inability to control hydration status or
blood pressure or a progressive deterioration in nutritional status. In any case, dialysis should be
started before the GFR has fallen to 6 mL/min/1.73m 2, even if optimal pre-dialysis care has been
provided and there are no symptoms. High-risk patients e.g. diabetics may benefit from an earlier
start. To ensure that dialysis is started before the GFR is 6 mL/min, clinics should aim to start at 8–10
mL/min. The main purpose of dialysis is to help impaired renal function. When your kidneys are
damaged, they are no longer able to remove wastes and excess fluid from your bloodstream
efficiently. Wastes such as nitrogen and creatinine build up in the bloodstream.

S.B. is eventually sent home after a week’s stay in the hospital with take home regimen
for her medical problems.

PART II
Last December 26, 2016 during an outing this Christmas season in Tagaytay Highlands
with her family, she slipped while walking around the zoo park and landed on the back of her
head. She experienced loss of consciousness at the scene. She was taken to a nearby medical
center where a CT scan revealed a Left subdural hematoma. The family wanting more
experienced management transferred the patient to USTH 2 days later. At USTH, she was given
the diagnosis of Acute subdural hematoma.

1. What assessment parameters are important upon admission? Why is each of them
important?
The patient’s LOC, medications and most current VS should be monitored. Any change is
LOC, confusion, dizziness, vertigo, slurred speech or drowsiness indicates a possible
increase in ICP. VS should also a good indication if the patient is experiencing hemorrhage.

2. What diagnostics do you expect to be ordered? Give the rationale for each and expected
findings.
Diagnostics Rationale
CT Scan A CT scan uses X-rays and a computer to
create detailed images of the inside of your
body. It can show whether any blood has
collected between your skull and brain.
an acute subdural hematoma appears as a
hyperdense (white), crescent-shaped mass
between the inner table of the skull and the
surface of the cerebral hemisphere
MRI An MRI is helpful in imaging
chronic subdural hematoma when CT scans
are difficult to interpret

3. What major concerns/problems exist upon admission related to her diagnosis?

Some problems may include change of mood, seizure, speech problems and weakness of the
limbs

a. What immediate interventions do you expect to be done for each major concern.
Give the rationale for these interventions.
Concern Intervention Rationale
Change of mood Primarily treated Even with medications
through medications though, most mental health
and psychotherapy providers recommend them
in combination with
psychotherapy.
Psychotherapy, or talk
therapy, is focused on
changing thought patterns
 and behaviors
Seizure  Place a pillow, During a seizure, the most
blanket or other important event is the
soft object under safety of the patient.
the person’s
head if
available.
 Be sure that the
patient is not
face down to
prevent
suffocation
 Do not stop the
patient’s
movement or
hold them down
Speech Problems  Provide an  An alternative
alternative means of
means of communication
communication (e.g., flash cards,
for times when symbol boards,
interpreters are electronic
not available messaging) can help
the patient express
 Clarify your ideas and
understanding of communicate needs.
the patient’s
communication  Feedback promotes
with the patient effective
communication.
Weakness of the limbs  Physical Therapies can help in
Therapy improving physical
 Occupational wellbeing. Exercise can
Therapy help in improving the body

4. Using a flow chart, illustrate the pathophysiologic responses resulting from acute
subdural hematoma.

Accident: Head
trauma
 High speed impact
to the skull

Torn bridging vein

Clotted blood liquefies in

subacute phase

Hematoma

Midline Shift Increased Intracranial Reduced cerebral

Pressure blood flow (CBF)

Emergency
Brain Herniation Craniotomy

Pressure on CNS 2
Subfacial hernation Transtentorial
(Compression of the herniation
anterior cerebral artery)

Decreased
Cerebral Infarct Tearing of blood
reactivity
vessels supplying
brain stem

Dilation of
Duret hemorrhage
Ipsilateral pupil
and death
5. Can S.B’s have any effect or influence on her medical diagnosis? Support your answer
and briefly discuss how.
Complications of subdural hematomas may occur soon after the injury or sometime after the
injury has been treated. The extent of complications depends on the severity of the brain
injury. Other health issues may affect either chronic or acute subdurals. People who take
anticoagulants (blood thinners) are at higher risk. People over the age of 65 also have a
higher risk, especially for the chronic type.

6. What parameters would you use to monitor for any neurological change? Give the
pathophysiologic basis of significant findings that could be encountered.
Some of the parameters used are Level of Consciousness (LOC) using the Glasgow Coma
Scale (GCS), pupillary response, Limb movement/strength and Vital Signs.

GCS
Provides a standardized measure of the patient’s LOC by observing the patient’s behavior in
response to a gradually increasing stimulus. This stimulus ranges from a less invasive
stimulus, to the application of a painful stimulus in order to obtain a behavioral response. The
scale contains three subscales: best eye opening response, best verbal response and best
motor response. It has a collective maximum score of 15 indicating a fully alert and oriented
person, and a minimum score of 3 indicating a comatose person.

Pupillary response
Tests the function of Cranial nerves II & III. Changes in the pupil size, equality and/or
reaction may be an indicator of a change in intracranial conditions. This could be caused by a
number of conditions, such as increased intracranial pressure, brainstem damage, anoxia,
ischemia or oculomotor nerve compression

Limb movement/ Strength

Limb Muscle strength is tested to observe for any sign of asymmetry between limbs, and may
provide information about the possible anatomical location of any intracranial pathological
process or dysfunction

Vital Signs
Changes in vital signs related to neurological deterioration are often a late sign of
deterioration. Changes to pupils, LOC, and motor strength/symmetry are typically observed
first.

7. What is the best position for the client and why?

 The patient should have the Head of Bed elevated by 45 degrees to help decrease ICP and
help facilitate reabsorption of blood

S.B. is also placed on seizure precautions.

8. Why is there a need for seizure precautions? Why is it especially important to make
sure that her Tegretol is given and that she has a therapeutic serum level?
The patient is a case of acute subdural hematoma which may cause seizures. Tegretol is an
antiepileptic medication that should be kept at a constant serum level to help control seizure
activity by increasing the threshold of excitation at neuronal synaptic clefts through alteration
of Na+ channels in neurons.  Seizure activity can lead to potentially lethal effects in this
patient as tonic-clonic associated movements can result in further tearing of the vascular
network and cause increased hemorrhage, increased ICP, and death.

A repeat CT scan is done and the doctor writes the order for craniotomy in the morning.

9. What is the primary indication for a craniotomy to be done on S.B.?

The patient is a case of acute subdural hematoma. Craniotomy is the main treatment for
subdural hematomas that may develop soon after a severe head injury.

10. You are the primary nurse of S.B. What would be your priority concerns in your pre-
operative care?
Some of the preoperative care are as follows:
 Obtain informed consent of the patient and educate the patient on regarding what is
expected to happen during the procedure.
 Remind the patient not to take anti-inflammatory medicines or blood thinners for at
least one week before the procedure
 Keep patient on NPO
 Shave the patient’s head

S.B. undergoes craniotomy.

11. What 4 priority objectives do you have for your post-op care for her. For each
objective, give the relevant nursing and collaborative interventions and their rationale.
Objective Interventions Rationale
Reduce risk for infection  Keep the incision  Craniotomy incisions
clean are usually closed
 Watch the incision with sutures or
for signs of infections surgical staples.
 or complications Follow the
physician’s
instructions regarding
incision care.
 An incision that
becomes red and
warm to the touch
may be infected.
Leaking or oozing
fluid (after the
bandage has been
removed) can indicate
a possible
complication, such as
increased brain
pressure or a
cerebrospinal fluid
leak. Any
abnormalities should
be reported
immediately.
Promote Cerebral Tissue  Assess mental status  To check for affected
Perfusion and changes in LOC CN functions in the
 Position patient in brain
low fowler’s position  Help venous drainage
 Avoid extreme from the brain and
rotation of the neck promote brain
expansion
 This will compress
the jugular veins
leading to an
increased ICP
Relieve Acute pain  Determine pain  Establishes baseline
characteristics for assessing
through patient’s improvement/change
gestures and response  The patient’s
to intervention experiences of pain
 Provide rest periods may become
to facilitate comfort, exaggerated as a
sleep and relaxation result of fatigue
  Administer specific  Appropriate pain
pain management killers to provide
drugs as prescribed relief of discomfort
by the physician
Promote Skin Integrity  Reinforce initial  Protects wound from
dressing and change mechanical injury and
as indicated. Use contamination.
strict aseptic Prevents
techniques. accumulation of
 Gently remove tape fluids that may cause
(in direction of hair excoriation.
growth) and dressings  Reduces risk of skin
when changing. trauma and disruption
 Check tension of of wound.
dressings. Apply tape  Can impair or
at center of incision occlude circulation to
to outer margin of wound and to distal
dressing. Avoid portion of extremity.
wrapping tape around  Decreasing drainage
extremity suggests evolution of
 Assess amounts and healing process,
characteristics of whereas continued
drainage. drainage or presence
of bloody or
odoriferous exudate
suggests
complications

12. If S.B’s LOC started to decrease, what information would you give the neurosurgeon
when you call?
First is to explain the current clinical picture to the neurosurgeon. Notify the changes in
LOC, changes in VS and exact ICP.

13. How would you provide support to S.B’s family?

Provide education to the family and explain the course of treatment because expectations of
the patient and family are an important supportive intervention for both the patient and
family.

14. What positive parameters will you observe to say that the patient’s condition is
improving?
 Some of the positive parameters that will say that the patient’s condition is improving are as
follows:
 Does not lose consciousness for a short period of time
 Have no or few neurological symptoms when evaluated by a doctor
 Does not have other associated brain injuries
 Are awake and alert

S.B’s condition improves and the doctor tells you to prepare the patient for a possible discharge
in 2 days.
15. Outline your comprehensive discharge teaching plan for your patient.
Medications
The doctor will provide the patient with prescriptions for the medication that she is going to
take at home.
Environment
Provide easy to do homemaking skills
Provide adequate emotional support from the family
Investigate of sources for economic support
Treatment
Some of the treatment are as follows:
Provide relaxation or medications whenever pain occurs
Increase activity slowly
Take medicine exactly as directed
Get plenty of rest and sleep
Avoid drinking alcohol
Educate patient and relative the purpose of any treatment to be continued at home
Health Teaching
If the patient notes clear leakage from the craniotomy incision, which could indicate CSF
egress, an immediate call to the neurosurgeon is made. Bleeding from the incision site for the
first few days following surgery is common and not concerning. If the wound itself is noted
to be tender, red, or not healing well or the patient develops fevers and chills, the patient
should contact the neurosurgeon. If the patient feels nauseous, vomits, notices visual changes
(blurriness, field cuts), experiences increasing headaches, has word-finding difficulties,
experiences cognitive slowing, has newly onset weakness and/or numbness, or is noted to be
lethargic, confused, or difficult to arouse by family, an urgent call should be placed to the
neurosurgeon. In terms of wound care, the patient is allowed to shower on the third
postoperative day but typically discouraged from a bath until 1–2 weeks later. Hair products
other than baby shampoo are also discouraged for at least 2 weeks. Also, the patient is
cautioned against picking and manipulating the incision. Most patients who undergo
craniotomy are considered fit to return to most occupations 2–6 weeks following the
operation.
Outpatient
The discharge paperwork will include information on who, when, and how to contact the
physician after discharge.
Diet
The patient may resume the type of diet she had before surgery. Eating a well-balanced diet
is important for proper wound healing.