UNIVERSITY OF SANTO TOMAS

COLLEGE OF NURSING
COMPETENCY APPRAISAL 2

MS CASE #4
(Neuro, Endocrine, Urinary)

FOCUS OF STUDY:
A. ENDOCRINE DISORDERS: THYROID & DM
B. URINARY: RENAL FAILURE
C. NEUROLOGICAL: BRAIN INJURY, INCREASED ICP, SEIZURE DISORDER, CRANIOTOMY

PRE-REQUISITE LEARNINGS:

1. Review of anatomy and physiology of organs involved

2. Pathophysiology of DM, HYPERTHROIDISM, RENAL FAILURE
3. Pathophysiology of BRAIN INJURY
4. Review of modifiable and non-modifiable risk factors
5. Pre-operative Nursing Management
6. Intra-operative Nursing Management
7. Post-operative Nursing Management
8. Bioethical Principles involved
9. Rehabilitation principles

INSTRUCTIONS:

1. All Class secretaries will provide the facilitator the CLASS LIST for grading
purposes.
2. The facilitator will provide the class with Case Scenario/ Case Study a week
before the discussion with corresponding focus of study and guidelines.
3. Each RLE group will submit their written output before the case presentation in
class. This will be graded and counted as part of their presentation grade
4. Each student must be ready for learning issues and discussion during the class.
This will be graded and counted as part of their participation grade.
5. There will be a post test after the class discussion.
Learning outcomes:

After studying the case scenario, the student should be able to:

1. Identify learning issues

2. Utilize the Nursing Process in the plan of care for this client

3. Integrate bioethical concepts in the care of your client

4. Integrate psychosocial aspects of care

CASE SCENARIO:
PART I

S.B. is a 72-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 2012 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.
2. Identify predisposing factors to each of her medical problems that you need to check out with
S.B.
3. Illustrate using a flow chart the pathophysiology of each of the medical problems of S.B. and
their possible complications .
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?
5. Prior to the thyroid surgery of your patient,
5.1. What manifestations would you have seen for a toxic nodular goiter ?
5.2. What medications were ordered to SB to help manage her condition? Give their
rationale?
6. Following total thyroidectomy,
6.1 What complications can possibly occur and why? Give their nursing and collaborative
preventive interventions.
6.2. Why is the patient being given Synthyroid? What specifIc health teachings need to be
given regarding this drug.
7. What criteria is used for the establishment of a definite diagnosis of DM?
8. What health teachings can be given to the family members of S.B. to keep them from
developing DM?
 9. What 2 acute complications of DM2 should be watched out for in S.B.? Give their
manifestations, preventive and therapeutic interventions.
10. Can the patient develop a DKA? Support your answer.
11. How do you recognize the difference between a Somogyi effect & the Dawn phenomenon?
12. Discuss briefly the management strategies for DM and their rationale.
13. Make a nutritional health teaching plan for S.B.
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 effects1

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?
16. What relevant teaching can you provide at this time?
17. Should the patient’s foot condition further deteriorate, when would amputation be
indicated? What major concerns related to care would you have?

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?3

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 chonic Renal failure. I don’t want to have the same thing happen to me.”
19. How will you address this concern?
20. When does the nephrologist generally decide to perform dialysis on a patient? What is the
purpose of this procedure?
21. Do you believe the patient would be a good candidate for renal transplant? Defend your
answer.

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

Last December 26, 2018 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?
2. What diagnostics do you expect to be ordered? Give the rationale for each and expected
findings.
3. What major concerns/problems exist upon admission related to her diagnosis?
a. What immediate interventions do you expect to be done for each major concern.
Give the rationale for these interventions.
4. Using a flow chart, illustrate the pathophysiologic responses resulting from acute subdural
hematoma.
 5. Can S.B’s other medical conditions have any effect or influence on her medical diagnosis?
Support your answer and briefly discuss how.
6. What assessment parameters would you use to monitor for any neurological change? Give
the pathophysiologic basis of significant findings that could be encountered.
7. What is the best position for the client and why?
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?
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.?
10. You are the primary nurse of S.B. What would be your priority concerns in your pre-operative
care?
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.
12. If S.B’s LOC started to decrease, what information would you give the neurosurgeon when
you call?
13. How would you provide support to S.B’s family?
14. What positive parameters will you observe to say that the patient’s condition is improving?

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.

STUDENTS, PLS NOTE:

1. The following R LE groups will make a pathophysiologic flowchart of the ff:
RLE 1 – HYPERTHYROIDISM AND COMPLICATIONS
RLE 2 – DM
RLE 3 - DM COMPLICATIONS
RLE 4 - ACUTE SUBDURAL HEMATOMA  INC. ICP & SEIZURES
. Focus only on the critical points.
2. Each student is to read and answer each question of the case.
3. The facilitated discussion will dwell on the questions stated. Students who give
answers to the questions will be given the participation grade.
4. All Class secretaries, kindly provide the facilitator the CLASS LIST for grading
purposes
CA2/2019