I.
INTRODUCTION
Chronic kidney disease (CKD), also known as Chronic Renal Failure, is a progressive loss of renal function over a period of months or years. he symptoms of a worsening kidney function are unspecific, and might include feeling generally unwell and e!periencing a reduced appetite. "ften, chronic kidney disease is diagnosed as a result of screening of people known to #e at risk of kidney kidne y pro#lems, such as those with high #lood pressure or o r dia#etes and those with a #lood relative with chronic kidney disease. Chronic kidney disease may also #e identified when it cardiovascular disease, anemia or pericarditis. he kidneys fail in an organi$ed fashion. %rogression toward &'RD usually starts with a gradual decrease in renal function of * to +*. ere are the stages of CKD.
Stage 1: Diminished Renal Reserve Renal function is reduced, #ut no accumulation of meta#olic wastes occurs. he healthier kidney compensates for the diseased kidney. -#ility to concentrate urine is decreased, resulting in nocturia and polyuria. - / hour urine collection for creatinine clearance is necessary to detect that the renal reserve
is less than normal. Stage 2: Renal Insufficiency 0eta#olic wastes #egin to accumulate in the #lood #ecause the unaffected nephrons can no
longer compensate. Responsiveness to diuretics is deceased, resulting in oliguria and edema. he degree of insufficiency is determined #y the decreasing 1FR and is classified as mild, moderate and severe. reatment is medical. Stage : !nd Stage Renal Disease &!cessive amounts of meta#olic wastes such as urea and creatinine accumulate in the #lood.
he kidneys are una#le to maintain homeostasis. reatment is #y dialysis or other renal replacement therapy.
-ccording to research the prognosis of patients with CKD is guarded as epidemiological data has shown that all causes mortality increases as kidney function decreases. he Centers for Disease Control and %revention found that CKD affected an estimated 23.4* of adults aged years and older during + to 22. "ge: -ge of 5 3+ years old.
#ender: Chronic Kidney Disease is more common in men than in women.
#enetics: - family history of renal disease.
Race:
Chronicc Kidney Kidney Diseas Diseasee is a ma6or ma6or concern concern in 7ative 7ative -merica -merican, n, -fric -frican an -meri -merican can and Chroni ispanic mostly due to increased prevalence of hypertension. -mericans can #e attri#uted to high #lood pressure 8* of &'RD cases in -frican -mericans
C$mm$n Diseases:
eart Failure, ypertension, Dia#etes 0ellitus and 1lomerulonephritis.
%UR%OS! "ND O&'!CTI(!S 1. #eneral O)*ectives -ims to #roaden the knowledge, skills and attitude of the student nurses and the mem#ers of
the health team a#out the disease. o #e a#le to respond, intervene, and render accurate nursing care to clients with Chronic Kidney Disease
2. S+ecific O)*ectives 9nderstand the pathophysiology of Chronic Kidney Disease and determine the ma6or disease
manifestations, risk factors and etiology Formulate an effective nursing care plan and implement nursing interventions appropriately #ased on the prioriti$ed health needs of the client maintaining sound communication with the
patient and mem#ers of the health team. %rovide #etter nursing care and health teachings to their client through the utili$ation of the nursing process. SI#NI,IC"NC! "ND 'USTI,IC"TION
he group chose this case #ecause more clinical skills will #e developed #y e!periencing the clinical management of the disease condition and it will enhance one:s knowledge in implementing proper nursing intervention for the patient towards recovery. -nd it is the first time the group has encountered this type of case. SCO%! "ND -IIT"TIONS
he scope of the Chronic Kidney Disease encompasses the anatomy, physiology and pathophysiology. he actual interaction with the client was done last ;uly /, +, 3 and , 2/ on our hospital duty 3< am to 2< noon at "spital ng 0aynila 0edical Center, 0edicine =ard. he group interviewed client 1.> with her niece. he data was collected #y
reading the chart, interviewing the client as well as with the help of the staff nurses assigned to the client.
&"C/#ROUND O, T0! STUD
he site of the study was done at "spital ng 0aynila 0edical Center, 0edicine =ard. he different diagnostic procedures and operation were done in the same institution. he group chose this case study to know the disease, its clinical manifestations, risk factors, pathophysiology and diagnostic procedure for the disease, to identify different medical and nursing care management for patient with Chronic Kidney Disease.
II.
%R!S!NT"TION O, T0! C-I!NT
- case of 1.>. /? years old from medicine ward female. - Filipina came from the ethnicity of @isaya. - Roman Catholic, igh 'chool 1raduate, ousewife, from District AA ondo, 0anila. %atient was admitted for the second time at "spital ng 0aynila 0edical Center last ;uly , 2/ at e!actly 4am. 'he was conscious and coherent and am#ulatory accompanied #y her hus#and. 4 hours prior to admission the patient had an onset of difficulty of #reathing. %atient 1.> was admitted with a chief complaint of difficulty of #reathing. he patient is known Dia#etic for years. 'he had no accident or in6uries in the past and no food or drug allergies. >ast Fe#ruary 2, she was diagnosed with %@ at "spital ng
0aynila 0edical Center. er maintenance medications are 0etformin +mg "D per "rem and -mlodipine +mg "D per "rem. %atient has a family history of ypertension on paternal side and no known history on maternal side. er father died due to hypertension and her mother died due to la#or on her. er youngest #rother had ypertension and her younger sister died on dengue.
COURS! IN T0! "RD Date
D$ct$r3s Order
Interventi$ns
ward
;uly , 2/
%lease admit to %hilhealth Consent signed and secure
'ecure consent for admission and management
%R every hour and record
>ow salt low fat diet
Repeat the following<
"riented client and family to
ward policies Anitial E' taken &!plained diet to the client and
family 0aintained diet as ordered
B C@C, -@1, F@', @97, For Creatinine, >ipid %rofile, 7a, K,
referral
to
7ephrology
service
CR, and 2 > &C1.
Kept safe and comforta#le
0ed.
'een at times
2. 0etformin +mgta# @AD .Furosemide /mg AE 4 .-mlodipine +mgta# "D /. 7aC" 3+mgta# AD +. FeGF- "D Refer for -nesthesia 'urgery
for A; catheteri$ation Refer to 7ephro Refer accordingly
7%" from ?-0 after a light
meal
;uly /, 2/
For A; insertion scheduled at
%0 on ;uly +, 2/
( A; insertion scheduled at %0 0onitor vital signs hursday 2<+%0
on ;uly +, 2/) -naesthesia %lan< local
infiltration with possi#le sedation.
Consent signed, material on
#edside care of relative 'een #y the doctor with orders
made and carry out
0onitor vital signs every /
hours and record 0ake some of availa#ility of
all necessary materials for A; insertion. For %, -% with activity
"nce with access for D !
<%0
For
D once access
as
hours
ordered
9FH 2cc
@FRH 2+ccmin %lasil AE given as %R7 as
Dialysate FRH /ccmin.
ordered
0inimum heparini$ation. %lasil 2 amp AE every 3 hours
%R7
3
For #lood typing
%lease prepare and transfuse 2
For #lood transfusion 2 unit
pack R@C as ordered
pack R@C properly typed and For #lood typing as ordered cross matched to run for / hours
"mepra$ole
/mg AE now
was given
Ancreased Fe'"/GF- +g 'upportive care rendered 2ta# @AD
'een at times
"mepra$ole /mg AE now
'till for @ of 2I9I pack R@C 0onitor vital signs "f @ 2I 9I pack R@C
;uly +, 2/
Rescheduled A; insertion
Friday
on
0onday ;uly 4,2/ 3<pm
'upportive care rendered 'een at times
;uly 3, 2/
For hepatitis C screening
0onitor vital signs For hepatitis C screening
'aturday 22<am
<pm
'tart omepra$ole /mg AE "mepra$ole /mg AE
now then "D
given
Continue present management 'upportive care rendered
;uly 8, 2/ 'unday /<pm
Refer accordingly
'een at times
'till for A; insertion
0onitor vital signs 'till for A; insertion 'upportive care rendered 'een at times
was
-nesthesia 7otes ;uly 4, 2/
Referred
haemodialysis 0onitor vital signs
for
"n D on =ednesday ;uly
catheter insertion 0onday +<23pm
-septic
techniJue,
infiltration right
A;
done, and
cannulation
left
local
attempted 'upportive care rendered A;
vein 'een at times
B una#le to
thread guide wire on #oth sites Right femoral vein cannulated,
'eldinger techniJue done, a#le to aspirate #lood from #oth parts, secured to skin @oth parts locked if 2.c of
2 unitml of heparin %atient
tolerated
procedure
well with sta#le vital signs For chest ray
Chest
+<+pm
ray
reviewed
no
evidenced of pneumothora! on #oth sides
2<pm
, 2/
For #lood typing 'till for #lood typing units
pack R@C properly type and properly cross matched
'till for #lood transfusion Discontinue AE
;uly ?, 2/
"mepra$ole /mgta# "D
0onitor vital signs For @ units pack R@C 'upportive care rendered
uesday
'een at times
?<am
;uly , 2/
Continue management.
=ednesday < pm
present 0onitor vital signs
-cetylcysteine 3mgta# "n low salt low fat diet 2 ta# @AD.
'upportive care rendered 'een at times
-"&OR"TORI!S "ND DI"#NOSTICS T!ST
-a) !4am
@97
N$rmal values
.? L 8.+ mmol>
"ctual findings
/.2 mmol>
"nalysis 5 Inter+retati$n
&levated levels< Renal disease, reduced renal #lood flow (caused #y dehydration), urinary tract o#struction, and increased protein cata#olism (such as #urns)
Creatinine
.+2 mgdl
2+ mgdl
&levated levels generally indicate renal disease that has seriously damaged +* or more of the nephrons.
F@'
/.22 L +.? mmol>
+. mmol>
7ormal result
%otassium
.+ L +. mmol>
+. mmol>
7ormal result
riglyceride
./ L .+mmo>
./mmo>
- mild to moderate increase in serum triglyceride levels indicates #iliary o#struction, dia#etes mellitus, nephrotic syndrome or over consumption of alcohol.
'odium
2/ 2/+ mmol>
24mmol>
7ormal result
Chloride
224 mmol>
22 mmol>
-n increased in chloride levels may #e evident in
severe dehydration and complete renal shutdown.
"->
.4 L +.2 mmol>
/.34 mmol>
7ormal result
C">&'&R"> D>
.48 L 2.?/ mmol>
2.4 mmol>
7ormal result
>D>
2. L .+ mmol>
.+ mmol>
7ormal result
=@C 7eutrophils
/.3 2. 2e?> .3 L .8 2e?>
3.3 2e?> .+8 2e?>
7ormal result - small num#er of slightly immature neutrophils, known as #and cells, are
>ymphocytes 0onocytes 1@
. L ./ 2e?> .8 2e?> 2 24 2e?>
.8 2e?> ./ 2e?> 4.2e?>
C %latelet
.8 .+/gm> 2+ L /+ 2e?>
.gm> 4.2e?>
present in peripheral #lood. 7ormal result 7ormal result >ow hemoglo#in level may indicate anemia, recent hemorrhage, or fluid retention causing hemodilution. 7ormal result 7ormal result
#$rd$n3s ,uncti$nal 0ealth %attern %"TT!RNS O, 0!"-T0
%RIOR TO 0OS%IT"-I6"TION
DURIN# 0OS%IT"-I6"TION
"nalysis 5 Inter+retati$n
I. 0ealth +erce+ti$n and health management +attern
II. Nutriti$n and meta)$lism management
B%atient 1.> life:s #efore confinement consults medical doctor during her sickness and doesn:t use any illegal drugs and doesn:t maintain good health always eat whatever she likes especially salty and sweet foods.
B During hospitali$ation she maintains health #y avoiding salty, sweet and fatty foods.
B %atient 1.> life:s #efore confinement she eats whatever she likes. 'he loves to eat salty, sweet and fatty foods and ate times a day with snack, had a good appetite and drinks 4 glass of water.
BDuring hospitali$ation her diet has #een controlled and limit fluid intake ml per day as ordered.
•
ealth perception changes as the situation changes. Knowledge a#out health condition e!pands.
•
%atient perceives her health condition as a hindrance compared to the previous illness she e!perienced.
•
aving a nutritional diet is necessary for every individual to live. Food is the main source energy which contri#utes to meet physiologic function.
•
&at soft food. 0ust receive adeJuate nutrition while recovering.
III. !liminati$n +attern
B @efore #eing hospitali$ed, she voids 3 times a day and defecates twice a day.
B During hospitali$ation she does not void.
•
&limination pattern is necessary to flushed out the #acteria inside the #ody moreover it is a site of having system that functions well.
•
9na#le to defecate during hospitali$ation.
I(. "ctivities and e4ercise +attern
B -ccording to her, she B During hospitali$ation always does the activities of daily living household chores, and #ecome more limited. had some minutes: 'ome activities reJuire walk around their assistance or community. as selfcare supervision. hygiene and grooming, sitting #y her own, getting up from #ed and changing clothes.
•
•
he a#ility to move provides mental wellness and the effectiveness of #ody functioning depend largely on their mo#ility status which could influences the self esteem and #ody image. er condition affects mo#ility and gait wherein there are already limitations in performing activities.
(. C$gnitive +erce+tual +attern
Bhere are no changes in Bhere are no changes her sensory a#ilityM she is in her sensory a#ilityM ver#ally and physically she is ver#ally and responsive. physically responsive.
•
•
umor is increasingly valued as #oth an interpersonal skill for nurse and a healing strategy for patients. here are no changes in her sensory a#ilityM she is ver#ally responsive to physical stimuli. 'he has a competent learning pattern.
(I. Slee+ and rest +attern
B %atient 1.> life:s #efore confinement she sleeps 4 hours a day and has no difficulty in sleeping, does not wake up in the middle of the night.
B During hospitali$ation she is always at her #ed and taking a nap whenever possi#le.
•
Rest and sleep are essential for health. Rest implies calmness, rela!ation without emotional stress, and freedom from an!iety. At
restores the energy that has #een used, which allows the person to resume optimal functioning. •
9pon hospitali$ation the num#er of her sleep was lessen due to the environmental factors arising in the hospital.
(II. Self7+erce+ti$n and self7c$nce+t +attern
B'he descri#ed herself as cheerful, talkative and not easily gets angry.
B 9pon hospitali$ation she:s still cheerful and gets worried a#out simple things.
•
'elfconcept is how
•
a person feels a#out himself and perceives the physical health and handle situations. 'uch attitude can affect health practices, responses to stress and illness and the time when treatment is sought. %atient shows self confident.
(III. R$le and relati$nshi+ +attern
B'he has 2 daughter and si#lings. Family worries on her hospitali$ation.
B'he has 2 daughter and si#lings. Family worries on her hospitali$ation.
•
Relationship with other family mem#ers #oosts her selfesteem and self confidence allowing her to cope with her pro#lem. 0oreover, a person having health pro#lems
needs selfesteem and selfconfidence in order for her to handle the situation of the pro#lem.
I8. Se4uality and re+r$ductive +attern
B0enarche started at 2 years old. as gravida 2, para 2, preterm , a#ortion , children living 2.
•
'e!uality is a crucial
•
part of personNs identity. 'e! determines who we are to our emotional well#eing and to the Juality of our lives. 7o se!ual intercourse had #een noted #ecause she was a widowed.
8. C$+ing stress and t$lerance +attern
B'he was a#le to cope with her stress #y taking care of her grandchild and she also manages her stress #y doing household chores.
BDuring hospitali$ation she was playing cards, and listening to radio and chatting to her niece.
8I. (alues and )elief +attern
B'he has a strong faith in 1od and prays often.
BDuring hospitali$ation her faith in 1od #ecomes stronger. 'he always prays for her fast recovery.
•
Coping strategies vary from individuals and are often related to individuals perception of a stressful events strategy use #y the client was emotion focus and a very typical coping strategies used #y the patient.
•
Ealues are learn through o#servation and e!perience as a result they are heavily influence #y a person, socio cultural environment
that is #y societal tradition, ethnic, and religious group.
III.
"N"-SIS "ND INT!R%R!T"TION
An our study the client was diagnosed with chronic kidney disease, secondary to dia#etes mellitus nephropathy. 7ephropathy is pathologic change in the kidney that reduces kidney function and leads to renal failure. Chronic high #lood glucose levels causes hypertension in kidney #lood vessels and e!cess kidney perfusion. he increased pressure damages the kidney in many ways. he #lood vessels #ecome leakier, especially in the glomerulus. his leakiness allows the filtration of larger particles (including al#umin O other proteins) which then form deposits in the kidney tissue O #lood vessels. Deposits narrow the vessels, decreasing kidney o!ygenation O leading to kidney cell hypo!ia O cell death. hese processes worsen over time. @lood vessels in the glomerulus #ecome scarred O una#le to filter urine from the #lood, leading to renal failure.
Diagn$sis
"ltered &reathing %attern
9pon admission patient reported onset of difficulty of #reathing. -s per emergency room record, respiratory rate is 3 #reaths per minute. %atient had flaring nostrils and could not tolerate flat lying position. he condition is pro#a#ly due to lung congestion which resulted from altered glomerular filtration that cause sodium retention that further holds fluid and congest the lungs so the lungs cannot e!pand as usual. %atient e!perienced feeling of heaviness.
•
Ris9 f$r infecti$n and "cute +ain
%atient is schedule for A; insertion. -t /<pm, right 6ugular vein inserted failed. -t /
N$n7c$m+liance
%atient does not follow dietary advice of avoiding salty and fatty foods. 'he also doesn:t e!ercise regularly. here are times when patient forget to take her maintenance medication.
!4cess fluid v$lume
%atient was ordered Furosemide /mg AE J4 for edema. %atient had increase #lood pressure 232mmg and dyspnea. Complete #lood count reveals decrease hemoglo#in 43
e?>, and decrease hematocrit .gm>. @lood chemistry reveals elevated @97 /.2mmol> and elevated serum creatinine level 2+.2mggl. he condition is pro#a#ly due to increased fluid retention which resulted from the malfunction of reninangiotensinaldosteronesystem. he damaged kidney does not recogni$e the increase in #lood pressure and fluid and continue to produce renin which stimulates the production of aldosterone which stimulates kidney tu#ules to rea#sor# sodium and water
I(.
SU"R O, T0! ,INDIN#S CONC-USIONS "ND R!CO!ND"TIONS
O)*ective 1< 9nderstand the pathophysiology of Chronic Kidney Disease and determine the
ma6or disease manifestations, risk factors and etiology.
%ath$+hysi$l$gy:
Chronic Kidney Disease starts with a gradual decrease in renal function of +*. -t first there is a diminished renal reserve. An this stage reduced renal function occurs without accumulation of meta#olic waste in the #lood #ecause of the unaffected nephrons overwork to compensate for the diseased nephrons. Renal damage increases systemic #lood pressure, which also increases glomerular pressure and the pressure in the remaining unaffected nephrons. &ventually, the unaffected nephrons may #e damaged #y this long term increased pressure, causing the progressive renal damage of CRF. An the ne!t stage renal insufficiency, meta#olic wastes #egin to collect in the #lood #ecause of not enough healthy nephrons remain to
compensate completely for the nonfunctioning nephron. >evel of @97, serum creatinine, uric acid, and phosphorus are elevated in proportion to the amount of nephrons lost. "ver time, most clients progress to &'RD. &!cessive amount of urea and creatinine #uild up in the #lood, and the kidneys cannot maintain homeostasis. 'evere fluid, electrolyte, and acid#ase #alances occurs. =ithout renal replacement therapy, fatal complications a re likely. anifestati$ns:
Chronic kidney disease initially without specific symptoms and is generally only detected as increase in serum creatinine or protein in the urine. he client may also e!perience nausea, vomiting, loss of appetite, fatigue and weakness, sleep pro#lems, changes in urine output, swelling of feet and ankles, chest pain, shortness of #reath and high #lood pressure. -lso patient with chronic kidney disease suffer from accelerated atherosclerosis and are more likely to develop cardiovascular disease than the general population. !ti$l$gy:
hree main causes of CKD are Dia#etes 0ellitus, ypertension and 1lomerulonephritis. Ris9 fact$rs:
Race< 7ative -merican, -frican -merican, ispanic. -ge< 5 3+ years old. 1enetics< Family history of renal disease. Certain diseases like eart Failure, ypertension, D0 and 1lumerulonephritis. O)*ective 2: -naly$e, assist and interpret the different diagnostic and la#oratory procedures, its
purpose and relationship to client:s disease condition.
•
&UN
&levated levels< renal disease, reduced renal #lood flow (caused #y dehydration), urinary tract o#struction, and increased protein cata#olism (such as #urns)
•
TRI#-C!RID! .
P0arkedly increased levels without an identifia#le cause reflect congenital hyperlipoproteinemia and necessitate lipoprotein phenotyping to confirm the diag nosis.
•
C0-ORID!.
Decreased levels may result from e!cessive diaphoresis, heart failure, hypochloremic meta#olic alkalosis, or prolonged vomiting gastric suctioning.
O)*ective : %rovide #etter nursing care and health teachings to their client through the
utili$ation of the nursing process. %r$)lem: -ltered #reathing pattern related to decreased lung e!pansion as evidenced #y
difficulty of #reathing. Anterventions< • • • •
%osition with proper #ody alignment for optimal #reathing pattern. %rovide rela!ation training as appropriate -dminister o!ygen at lowest concentration. &ncourage adeJuate rest period #etween activities.
%r$)lem< -ltered comfort related to pain as evidenced #y previous A; insertion Anterventions< • • • • •
%rovide rest period to facilitate comfort, sleep O rela!ation. -pply warm compress &ncourage diversional activities %rovide calm O Juiet environment Anstruct use of rela!ation e!ercise such as focused # reathing.
%r$)lem: &!cess fluid volume related to end stage renal failure Anterventions < • •
• • •
0easure AO" every / hours, and notify physician if im#alances are significant 0aintain patient:s dietary restrictions, including fluid restrictions. %ost signs and remove water pitcher from room. 0onitor vital signs every hours and %R7. 7otify physician for significant changes. "#serve patient and assess for degree of ede ma to e!tremities and periphery 0onitor la# work for @97, Creatinine, and electrolyte levels
%r$)lem< Risk for infection related to insufficient knowledge to avoid e!posure to pathogen Anterventions < •
"#serve for locali$ed sign of infection at insertion sites of invasive line, sutures, and
•
surgical wounds. -ssess and document skin conditions around insertions of pins, wires and tongs noting
•
inflammation and drainage. 7oting signs and symptoms of sepsis< fever, chills, diaphoresis, altered level of
•
consciousness, positive #lood culture. Anstruct client in techniJues to protect the integrity of skin, care for lesions and prevention of spread of infection
%r$)lem: 7oncompliance to difficulty changing #ehaviour. Anterventions< • • •
Develop therapeutic nurseclient relationship. &ncourage client to maintain selfcare, providing for assistance when n ecessary. %rovide for continuity of care in and out of the hospital care setting, including long range plans.
• •
%rovide information and help client to know where and how to find it on her own. 1ive information in managea#le amounts using ver#al, written, and auto visual modes at level of client:s a#ility.
C$nclusi$n
'ince the patient suffered from Chronic kidney disease, the related factors that promoted meeting of needs is to prevent or slow further damage to the kidneys, and monitor conditions such as dia#etes or high #lood pressure that usually causes kidney disease, so it is important to identify and manage the condition that is causing the kidney disease. At is also important to prevent diseases and avoid situations that can cause kidney damage or make it worst.
Competencies of nurses that promoted the meeting of needs include ensuring safety and privacy, alleviating discomfort, monitoring vital signs on time and instructing the client to follow the diet that is recommended #y the physician. 'trict #lood pressure control is a high priority in the care of the patient with chronic kidney disease. For the reasons mentioned a#ove, -C& inhi#itors are commonly used as the initial medications to achieve #lood pressure controlM however, often a multidrug regimen is needed. Commonly, diuretics are needed for patients with chronic kidney disease #ecause of the hypertensive effect of volume overload. Regardless of the cause of CKD, tight glycemic control should #e achieved for all dia#etic patients. -dministering insulin is recommended to control further complications and increase in #lood glucose level.
•
-ltered #reathing pattern related to decreased lung e!pansion his pro#lem is solved as evidenced #y respiratory rate of 2? #reaths per -
minute.
•
&!cess fluid volume related to end stage renal failure his pro#lem is still unresolved as evidenced #y #iped al edema. -
•
-ltered comfort related to pain his pro#lem is partially resolved as evidenced #y reduced pain as ver#ali$ed -
#y the patient. %'< 2
•
Risk for Anfection related to insufficient knowledge to avoid e!posure to pathogens his pro#lem is resolved. %atient ver#ali$ed understanding of ways to prevent -
infection. •
7onCompliance related to difficulty changing lifestyle particularly diet and medication regimen. his pro#lem is resolved. %atient ver#ali$ed understanding of disease -
condition and importance of following treatment regimen.
Rec$mmendati$n
-fter conducting the case study and finding the client:s response to interventions, we recommend the following< 'tudent nurses should properly assess the client:s level of understanding of her disease
condition, and provide appropriate nursing interventions and other health care follow ups. 'tudent nurses should provide appropriate management #ase on the physical assessment, 1ordon:s functional pattern and la#oratory and diagnostics findings.
