BSN III-F

presents...

A GRANDCASE PRESENTATION

Stealing Innocent Beans:

Wilms’ Tumor

Objectives

General Objective:

Within 4 hours of case presentation, participants will be able to gain knowledge, skills, and attitude regarding Wilms’ tumor.

Specific Objectives:

After 4 hours of case presentation, participants will be able to:

Knowledge:

1. Define Wilms’ tumor.2. Discuss the etiologic factors of the disease condition.3. Discuss thoroughly the Pediatric nursing health history of the client

with Wilms’ tumor.4. Compare the physical assessment manifested by the client in

correlation to the disease process.5. Enumerate the clinical manifestations of Wilms’ Tumor as compared to

the client.6. Correlate all the laboratory results and diagnostic studies based on the

client and the disease process.7. Discuss thoroughly the anatomy and physiology of urinary system.8. Discuss comprehensively the pathophysiology of Wilms’ Tumor.9. Formulate an effective nursing care plan for the client with Wilms’

Tumor.10. Explain the

action, indication, special precautions, contraindications, side effects, availability, and nursing responsibilities for the medication prescribed and taken by the client.

11. Identify the correct and appropriate medical-surgical and nursing intervention for clients with Wilms’ Tumor.

12. Formulate an appropriate discharge plan for clients with Wilms’ Tumor.

Skills:

1. Develop active listening skills during case presentation.2. Enhance effective skills through active participation during open forum.3. Design an appropriate nursing care plan for the identified nursing

problem.

4. Create constructive criticism regarding the case presentation.5. Apply the appropriate nursing interventions learned from the

presentation into their own related clinical experience.

Attitude:

1. Observe confidentiality pertaining to client’s data.2. Use appropriate and tactful words in critiquing and delivery of

questions.3. Exhibit active participation during the open forum.4. Observe punctuality on the day of grand case presentation.

PEDIA NURSING HISTORY

I. Personal Information:

• Informant: Mrs. GT Relation: Mother

• Name: GRT

• Age: 4 years old

• Sex: Male

• Chief Complaint: Abdominal pain

• Diagnosis: Wilm’s Tumor

• Attending Physician: Dr. I

II. PRE – NATAL HISTORY

The last menstrual period of Mrs. GT was last April 11, 2004. She discovered that she was pregnant when her menstrual period was delayed for three months and experienced some signs and symptoms such as nausea and vomiting, dizziness and breast tenderness. She visited her doctor at Iloilo Doctor’s Lying – in Clinic, she was suggested for serum pregnancy test and was confirmed to be positive. The physician prescribed Ferrous Sulfate 1 tablet once a day before breakfast and Folic acid 1 tab OD.

Mrs. GT completed her prenatal session at Iloilo Doctor’s lying – in clinic with an attending midwife. Her first visit was during her third month of pregnancy and does it monthly thereafter up to the seventh month only. She did not attend any mother’s class regarding pregnancy. However she obtained advises from her midwife and attending physician like appropriate food preferences and proper exercise. She felt discomforts when she experienced signs and symptoms of pregnancy specifically morning sickness like nausea and vomiting, headache, and constipation. She was advised to eat crackers when she felt nauseated and increase intake of high fiber fruits and vegetables. On her fourth month of pregnancy she received one dose of Tetanus Toxoid IM left deltoid and followed by the second dose after 2

weeks. She got only 2 doses of TT for whole period of pregnancy. When she reached her sixth month of pregnancy, she visited her attending midwife twice a month every Monday for her prenatal session.

She first experienced quickening during her fifth month of pregnancy. She had also undergone pelvic ultrasound at her 6 months of pregnancy and revealed no signs of any abnormalities to the growth of fetus. For healthy development of fetus inside her womb, Mrs. GT was eating nutritious foods like dark-green leafy vegetables and fresh fruits as well as milk (Anmum two glasses a day usually early in the morning and at bedtime). Also, she usually eats protein rich foods such as fish, chicken and meat. She doesn’t have cravings, food and fluid dislikes along her pregnancy. She usually sleeps at around 11:30pm and woke up 5:00 AM. And she’s taking a nap at noontime usually at around 2:00pm until 4:00pm and if unable to sleep she’s just watching television or chatting with her sister. She did not experience minor illness such as cough, colds and fever and she had not taken any over the counter drugs. GRT is their first child.

III. NATAL HISTORY

The Expected Date of Conception (EDC) of Mrs. GT was January 18, 2005.Mrs. GT verbalized that she started to have an abdominal pain radiating at her lower back and was aggravated by walking. starts at 12:00pm, at around 3:00pm she was brought at Iloilo lying-in clinic with cervix dilatation of 6 cm, her bag of water ruptured at around 5:00 pm. Episiotomy was made to Mrs. GT. GRT was delivered at 6:45 pm via normal spontaneous vaginal delivery (NSVD) in cephalic presentation at Iloilo Doctor’s Lying-in Clinic last January 15, 2005 and was attended by Dr. F.O.

IV. NEONATAL HISTORY

GRT cries loudly. The body appears pinkish in color. The anthropometric measurement of GRT was 2850 grams in weight and 47cm in height. His head circumference was 31 cm, chest circumference of 30 cm and abdominal circumference of 30 cm. GRT was injected with Vitamin K at Left vastus lateralis and Hepa B at R vastus lateralis. Baby GRT was discharge after 24 hours of observation.

V. POST NATAL HISTORY

According to Mrs. GT, GRT has a good sucking reflex during breastfeeding. 5 days after delivery, the umbilicus of GRT was totally healed

and dried. After 1 month Mrs. GT brought GRT to their Barangay Health Center for immunization of DPT and Hepa B.

VI. NUTRITION

GRT was purely breastfed from birth up to six months. Mrs. GT started to introduce mixed feeding the month thereafter with formula milk of Bona 3-4 scoops per 50ml water and he could consume 3-4 bottles of formula milk a day. Mrs. GT gave Tiki-tiki plus 1 ml and GRT started to eat supplementary foods like cereals when he was four months old. Mrs. GT started to offer solid foods when GRT was 6 months old such as biscuits and rice with maximum of 2 tablespoons, 2-3 times a day. Mrs. GT ensures that GRT get adequate nutrients from the food he consumed. She usually prepared nutritious foods such as vegetables, fruits and fish.At the age of 2 years old he started to choose own foods preferably junk foods, meat and fried chicken, he seldom eats vegetables. Oftentimes he drinks softdrinks and 2-3 glasses of water a day. GRT eats three times a day.

VII. GROWTH AND DEVELOPMENT

GRT’s birth weight was 2850 grams and 47 cm in height. During infancy GRT exhibits normal development of an infant just like the presence of primitive reflexes such as moro reflex, tonic neck reflex and sucking reflex on his first month. As well as his hands kept fisted and able to follow object to midline. On his second month, he could hold his head up when prone, he started to show his social smile, could made sounds and enjoyed bright colored objects. On the third month, he can hold his head and chest up when prone, could follow object past midline, could laugh out loud, and spent time looking at hands or uses them as toy. On the fourth month, his grasp, stepping, tonic neck reflexes were fading, he needed more space to turn. On the fifth month he could turn front to back and could handle rattles well. On his sixth month, he could turn both ways and moro reflex fading, he uses palmar grasp, could say “oh-oh”. First tooth erupted (central incisor), could sit unsteadily, could transfer objects hand to hand, and started to have fear on strangers on the seventh month. He could sit securely without support on the 8th month. On his ninth month he started to crawl and his first word was “mama”. He could pull self to standing, uses pincer grasp to pick up small objects, played games like peek-a-boo on the tenth month. He could walk with support on eleventh month. And on his first year he could stand alone and took his first step, could say ma-ma and da-da. According to Freud’s Psychoanalytic Theory infancy is termed to be on “oral phase” because

infants are so interested on oral stimulation or pleasure during this time, they suck for enjoyment or relief of tension, as well as for nourishment (Pillitteri, 2007).

On his toddler days he could hold a spoon well but may still turn it upside down on the way to the month, could walk alone, seat self in chair, could creep upstairs, able to say 4-6 words like “hindi”, and “mamam”. At year and a-half he could run and jump in place and walked up and down stairs holding into a person’s hand or railing. And on following years he could make lines or strokes for crosses with a pencil. A verbal language increases steadily. Spent time playing with his toys, either he’s alone or with friends. He’s afraid to be separated with her mama. In relation to Erikson’s Theory of Psychosocial Development in this stage of childhood the child is forming a sense of autonomy versus shame wherein a child learns to be independent and make decisions for self(Pillitteri, 2007). Also exhibits parallel play.

As a preschooler, based on Freud’s Psychoanalytic Theory little G.R.T. is in Phallic stage because he can identify his gender as a male. He could differentiate a boy from a girl. According to his mother, she could sometimes observe him fondling his genitals especially during bedtime. And according to Erikson’s Theory of Psychosocial development he is in Intuitive VS Guilt stage in which he imitates dance steps, and interprets songs played in televisions as well as he loves to follow the actions of his father just like for example painting the walls.

And in relation to Piaget’s Theory of Cognitive development he is on Intuitive thought wherein he can identify different colors, can count numbers from 1-10, able to memorized alphabet from A-J and able to answer simple questions just like “what is your name?” and “how old are you?” And lastly with regards to Kohlberg’s Theory of Moral Development he’s on Pre-conventional level 1 wherein he usually follow his mother but he is expecting a reward from her like getting something in their house as instructed to him in exchange of 5-peso coin. He usually does things for his own benefit. Currently he is 14 kilograms in weight. He is enrolled as a nursery pupil at Tilipunan Day Care Center.

VIII. IMMUNIZATION RECORD

VACCINE NUMBER/DOSE DATE REACTIONS

BCG 1 May 10, 2005 FEVER

DPT 3 June 14, 2005

July 26, 2005

September 6, 2005

NONE

OPV 3 June 14, 2005

July 26, 2005

September 6, 2005

NONE

HEPA B 3 July 6, 2005

September 6,2005

October 18,2005

NONE

MEASLES 1 February 7, 2006 NONE

VITAMIN A 1 February 7, 2006 NONE

IX. SOCIO – ECONOMIC HISTORY

They have an extended type of family. They use jeepney, tricycle and pedicab as their means of transportation. They used cellphones as means of communication. Mrs. GT was married to Mr. RT for nine years. Both of them are high school graduates. Mrs. GT is a plain housewife while Mr. RT is a pedicab driver. They also have a small sari-sari store as their other source of income. They have two children in which little GRT are their eldest child and his brother is a 3 years old. Presently they reside on Mr. RT’s mother. They were seven in their house which is made of concrete and light materials with two rooms wherein 4 of them occupying one room. Just along the road. They live in a congested area near in a factory (Gascon Company).

According to Mrs. GT their monthly income ranges from 4,000 – 5,000. They obtain their drinking water from a deep well which is 15 meters away from their toilet. According to Mrs. GT there were no conflicts among the family members because they understand and love each other. Both of them made decisions.

X. HISTORY OF PRESENT ILLNESS

5 months prior to admission, Mrs. GT noticed a non movable circular hard mass on GRT left lower quadrant of abdomen approximately 3x4 cm. in diameter Also, she noted that the left extremity of GRT appears larger than his right extremities approximately 2 cm in both upper and lower extremities. Mrs. GT decided to bring her son to a traditional “hilot” and was advised to apply “lana” three times a day on the affected areas; there were no changes on the said signs that were manifested by the client. Their neighbor recommended to apply altamisa leaves directly on little GRT ‘S abdomen but still no alleviation of signs and just ignored the signs manifested by client and did not seek medical help.

2 months prior to admission, there was a progression of the size of the mass approximately 12x15 cm. in diameter it is firm and non – movable. According to Mrs. GT, GRT claimed of occasional tolerable abdominal pain located at left lumbar area of abdomen and abdominal distention was noted .Mrs. GT again applied altamisa leaves but then there were no alleviation of pain. Still Mrs. GT did not seek any medical help because GRT is still active and playful.

1 month prior to admission, GRT experienced an on and off low grade fever which ranges from 37 – 37.5 C that last for 2 weeks. Mrs. GT gave Paracetamol (Calpol) 5ml q 6 hrs. and fever subsided. Mrs. GT verbalize “ gasuka sya kg wala sya gawa gana magkaon, duwa lang ka kutsara nga nilugaw iya makaon.” Also, Mrs. GT said that GRT claimed of tolerable pain on his left abdomen. Child appears weak.

2 weeks prior to admission, Mrs. GT was worried and decided to brought GRT to their Barangay health Center and he was given medication for deworming (Mebendazole) because she thought that the cause of GRT’s pain and distended abdomen was intestinal parasites. Abdominal girth of 56 cm.

8 days prior to admission, GRT experienced again persistent highgrade fever. Mrs. GT checked her son’s temperature using their own thermometer at home and revealed 38.8 ˚C. She immediately gave Paracetamol 5ml q6h and monitored his temperature every after 30 mins. She performed TSB to help alleviate GRT temperature. Fever lowered down to 37. 6C. Also, he lost his appetite and just consumed at least 2 tablespoons of his meal.

4 days prior to admission, Mrs. GT decided to bring GRT to City health Office at Plaza Libertad to seek consultation. GRT was examined by Dr. J, no medication was prescribed but requested to undergo an ultrasound.

1 day prior to admission, Mrs. GT brought GRT at WVMC for an ultrasound and result was evaluated at Western Visayas Medical Center and revealed a mass on left abdomen 16x12x12 cm in size and probably renal in origin. Then, Mrs. GT was encouraged to admit GRT to further assess his condition.

January 20 at around 7:00 pm GRT experiencing on and off tolerable pain on the lumbar area of the abdomen graded as 5 according to facial scale of pain. The previous signs and symptoms became persistent and severe Mrs. GT decided to bring GRT at WVMC thus was admitted. He was diagnosed with Wilm’s tumor.

XI. PAST MEDICAL HISTORY

4 years prior to admission, GRT fell off from the table in which his head was injured and develop a scar approximately 3 cm in length. Mrs. GT applied Betadine for 1week.

3 years prior to admission, GRT was hospitalized due to inflammation of the right eye because his playmate punctured it with a stick. He was admitted at Western Visayas Medical Center and stayed for 3 days. He was prescribed with ofloxacin (Inoflox) 1 drop OD for 2 weeks.

GRT usually have fever and cough. Mrs. GT usually gave Paracetamol preparation of a suspension 5 ml q 6 hrs. Also, Lagundi 5ml three times a day of taking the medication.

According to Mrs. GT, GRT doesn’t have any allergies to food and drugs. Also, GRT was fully immunized. GRT didn’t experience any childhood illnesses such as chickenpox and measles.

XII. FAMILY MEDICAL HISTORY

GRT’s mother has asthma while his father has a hypertension. Also, his aunt and grandmother on his mother side were diagnosed with breast cancer. His grandfather on his father side died because of prostate cancer.

Physical Assessment

Name: GRT Chief Complain: Abdominal PainAge: 4 y/o Diagnosis: Wilm’s Tumor Sex: Male Attending Physician: Dr. I

Date and time P.A done: Jan. 21, 2010; 9 AM Height : 99 cm Weight: 13 kg

General Survey: On sitting position, awake, moaning, oriented to person, time, and place, ambulatory, appropriately dressed and neat in appearance. Appears to be skinny. Complained of pain, facial grimace noted graded with a score of 8/10 with 10 being the most painful and 0 as no pain. With IVF of D5IMB 500 cc x 24 cc/hr attached at right cephalic vein, patent and infusing

well. Vital signs revealed: Temp: 36.3 degree Celsius PR: 112 bpm RR: 24 bpm BP: 110 / 90 mmHg.

Skin: Skin is dark brown in color, uniform to all parts of the body except for the palms of the hand and the soles of the feet. Excessive sweating noted. Scar noted at 5cm in length on the right anterior forearm, and 7cm on the left brachial area. Intact, cold and clammy to touch. Has good skin turgor of two seconds when pinched .

Nails: Nail beds are pinkish. No yellowish discoloration noted. With dirty and untrimmed free edges. Absence of clubbing. Smooth in texture with intact surrounding tissues. Convex in curvature with an approximate angle of 160 degrees. With good capillary refill of 2 seconds upon blanched test.

Hair: Terminal hairs are evenly distributed on the scalp, with short and slightly curved endings, black in color, absence of infestations noted. Shiny, oily and smooth in texture.

Scalp: Color is lighter than facial skin, absence of dandruff, lesions, scars and any infestations noted. Intact and smooth in texture. Absence of masses or lumps noted.

Head: Normocephalic, size is proportionate with the body. Presence of scar on both eyebrows about 3 cm in diameter. With head circumference of 49 cm, with absence of lumps and masses. With palpable temporal pulse, frontal and occipital prominences.

Neck: In midline position of the body, in full range of motion with no limitations of movement, no pain and rigidity while moving. No deviation upon inspection, lymph

nodes not palpable, trachea is in midline position of the neck, thyroid glands are not enlarge or swollen and moves upward when swallowing upon palpation, carotid pulse palpable.

Eyes: Eyebrows are symmetrically aligned as well as the eyelashes, they are black in color and evenly distributed. The inner and outer canthus of the eyes are both properly aligned to the pinna of the ears. Eyelid surfaces have no discharges, intact, no presence of lesions, edema and scars. Eyelids completely cover the cornea when closed and color is same with facial skin. Upper eyelids are symmetrical, lesion and scar free and does not sag or droop when the client opens his eyes. Eyeballs are not protruding and round in shape. Conjunctivas are shiny and smooth, pinkish in color with visible

small blood vessels. Both scleras are anicteric with transparent, smooth and shiny cornea. Pupils are black in color, equally round reactive to light and accommodation and in equal size approximately 2mm in diameter. Iris are round and flat with grayish discoloration around it, blinking reflex counts at 3x /minute, upon palpation eyelids show no evidence of swelling and tenderness. Eyeballs felt equally firm and not overly hard or spongy, both eyes move in unison.

Ear: Auricles has same color with facial skin, no inflammation, lesions, scars, and nodules are apparent. No crackling, thickening, scaling or lesions detectable behind the ears. Presence of light yellow cerumen noted on both ear canals, no other discharges seen. No redness or swelling apparent, the pinna is properly aligned with the inner and outer canthus of the eyes, pinna recoils within 2 seconds after folding, both auricles are non tender, firm, nonsymmetrical in size(the left auricle appears larger than the right) no masses or tenderness on auricles upon palpation. Lymph nodes are non palpable. Mastoid process has well defined bony edges with no signs of tenderness. Has good hearing acuity, can repeat whispered voice from 1 foot away.

Nose: Nose is in midline position of the face, color is same with facial skin, absence of lesions and scars. Septum is intact with no deviation. Nasal mucosa is pinkish with no obstructions. Both nostrils are patent and air can freely move upon ventilation. External structure of nose is free from structural deviations, tenderness and swelling. Frontal and maxillary sinuses are free from tenderness and edema has good smelling acuity, able to identify the smell of coffee and scent of orange.

Mouth: Lips are symmetrical, pinkish, absence of crust and cracks on the upper and lower lips, with minimal dryness, smooth in texture, gums are pinkish, smooth and firm with no presence of ulcers and lesions. Tongue is centrally located inside the mouth, with whitish rough surface on top, can move freely without rigidity and pain, prominent veins noted on base of the tongue. Hard palate has ridges and soft palate is smooth, no presence of lesions and swelling noted. Uvula is intact and in midline, moves upward when told to say “ah”. Tonsils are pinkish, lesion free with no swelling or enlargement noted. With yellowish pigmentation on tooth enamel, with dental carries noted on both upper and lower molars. Central incisors, lateral incisors and cuspid teeth are intact. No retractions noted. With good gag and swallowing reflex.

Thorax: (Anterior) Skin color is the same with the rest of the body, no lesions and rashes noted. Chest configuration is symmetrical from side to side. Thorax expansion is symmetrical to the back and chest. Chest shape is normal with no deformities noted. Chest wall expands symmetrically during respiration. No tender spot, masses, lumps or bulges upon palpation. Lymph nodes are non palpable. Resonant sound heard at both lung fields noted upon percussion. Bronchovesicular sounds heard upon auscultation.

Thorax:(Posterior) Skin color is same with the body, intact with no presence of lesions and scars noted. Upon palpation, no lumps and masses noted. Scapula are symmetrically aligned. Spine is in midline position of the body, with normal respiratory excursion. Thumbs separate at a distance of 3cm. No tenderness noted upon palpation. Tactile fremitus are bilaterally heard. Upon auscultation, bronchovesicular sounds are heard all over the lung fields.

Heart: Cardiac rate is regular in rhythm and rate. With cardiac rate of 112 bpm. Apical pulse palpable.

Abdomen: Color is same with the rest of the body, free from vascular lesions, surgical scars and rashes. Umbilicus is clean and positioned midway between the xiphoid process and the symphisis pubis. There is movement caused by respiration. Guarding behavior and protective gestures noted. Distention noted with abdominal girth of 57 cm. Left lumbar region of the abdomen has circular in shape. Upon percussion tympany is the predominant sound over hollow organs including the stomach, intestine, bladder, abdominal aorta and gallbladder, normoactive bowel sounds heard on each quadrant at 7 cycles/ min.

Genitals: Skin color of the penis is light brown, Urinates 3-4 times a day at approximately 20 cc per void, and moves his bowel 3 times a week or once every other day as claimed by the mother. Uncircumcised. No lesions, masses or discharges noted.

Extremities

Upper: Same color with the rest of the body, left arm appears bigger than the right arm, right arm circumference measures 12 cm while the left circumference measures 14cm. Has full range of motion with no weakness, deviations or pain noted. No lesions, masses, lumps or swelling noted. Brachial and radial pulse palpable.

Lower: Same color with the rest of the body, left leg is bigger than the right leg, left thigh circumference measures 23cm while the right thigh circumference measures 21cm. No lesions, masses, scars and lacerations noted.Has full ROM with no deviations, weakness and pain noted. Absence of varicosities. Femoral, tibial, dorsal and popliteal pulse palpable.

Blood Chemistry:

Done to determine the serum electrolyte level of the client.

Serum alkaline Phosphatase: measures amount of alkaline phosphate in serum, aid in diagnosing bone disorders.

Creatinine is a breakdown product of creatine, which is an important part of muscle..Creatinine can also be measured with a urine test.

BLOOD CHEMISTRY 01/22/10

TEST RESULTS NORMAL RANGE

SIGNIFICANCE

Creatinine Substc. 88.4mmol/L 88-146mmol/L NormalUric 242 240-510 Normal

Alk.Phos. 279 70-306 Normal

Sodium (ISE) 130.30mmol/L138-144mmol/L

Decreased; May indicate renal failure and decreased tubular function (which helps regulate sodium and other electrolytes to reabsorb).

Potassium 4.78mmol/L 3.4-4.7mmol/L Increased, may indicate

hypertension

LDH ( male=4-6 y.o.)1642.50U/L 155-280U/L

Increased, may indicate cellular

death

Hematology:

Do to deremine the clients hemodynamic status, to assess for anemia or bleeding problems, assess clients hemoglobin, RBC, WBC and microscopic contents of the blood.

A complete blood count (CBC) test measures the following:

The number of red blood cells (RBCs) The number of white blood cells (WBCs) The total amount of hemoglobin in the blood The fraction of the blood composed of red blood cells (hematocrit) The size of the red blood cells (mean corpuscular volume, or MCV)

The CBC test also provides specific information the size and hemoglobin content of individual red blood cells. This is determined from the additional following measurements:

Mean corpuscular hemoglobin (MCH) Mean corpuscular hemoglobin concentration (MCHC)

The platelet count is also usually included in the CBC.

HEMATOLOGY 01/23/10Test Result Normal Range Significant

Hemoglobin 12.9 g/dl 11-16g/dl Normal

WBC count 9.0x109/L 4.6-6.9x10⁹/L Increased; may be due to infection.

Differential count

0.40 0.54-0.68 Decreased may indicate viral infection or bone marrow depression

Neutrophils

Segmenters 0.81 0.32-0.62 Increased; due to infection.

Stabs 0.03 0.00-0.06 Normal

Eosinophils 0.11 0.00-0.04 Increased; May indicate presence of parasitic infestations or parasitic infection

Lymphocytes 0.49 0.25-0.33 Increase may be

due to infectionHematocrit 0.38 vol% 0.31-0.41 vol% Normal

Platelet count 296x109/L 150-450x10⁹/L Normal

Peripheral Blood Smear:

is obtained to determine variation and abnormalities in erythrocytes, leukocytes and platelets.

PERIPHERAL BLOOD SMEAR REPORT 02/21/10

TEST RESULT NORMAL RANGE

SIGNIFICANT

Hemoglobin 11.2g/dl 11-16g/dl Normal

Hematocrit 0.33L/L 0.31-41/L Normal

Platelet count 540x10⁹/L 140-440x10⁹/LIncreased; may indicate rebound thrombocytosis and medication intake such as aminogylocoside

WBC count 11.7x109/L 4.6-6.9x10⁹/L Increased, may indicate infection

RBC count: 3.5x10¹²/L 4.5-5.7x10¹²/LDecreased; may be due to decrease production of erythropoietin.

DIFFERENTIAL COUNT Neutrophils 0.76 0.5-0.7 Increased; may be due to infections

and inflammatory response.

Segmenters: 0.75 0.5-0.7 Increased; may indicate infection

stabs: 0.01 0.03-0.05Decreased; may be due to effect of increase neutrophils in white blood cells.

Lymphocytes: 0.21 1.2-3.3x10⁹/L

Decreased; may indicate bacterial agents, malnutrition, severe stress, intense or prolonged physical exercise (due to cortisol release), and iatrogenic (caused by other medical treatments) conditions.

Eosinophils: 0.02 0.01-0.04 Normal

Monocytes: 0.01 0.00-0.07 Normal

Reticulocyte count: 1.4%

Children:2.5-6.5%

Decreased; count may mean fewer red blood cells are being made by the bone marrow. This can be caused by aplastic anemia or other types of anemia, such as iron deficiency anemia.

REMARKS: Normocytic normochromic RBC by morphology within Normal limit and WBC for age with relative and absolute neutrophilia and

relative lymphocytopenia Moderate thrombocytosis with occasional large platelet seen No other abnormal cells noted in the peripheral blood smears examined

Urinalysis:

Urinalysis is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine, done:

As part of a routine medical exam to screen for early signs of disease If you have signs of diabetes or kidney disease, or to monitor you if you are being

treated for these conditions To check for blood in the urine To diagnose a urinary tract infection

Microscopic appearance:o The urine sample is examined under a microscope. This is done to look at

cells, urine crystals, mucus, and other substances, and to identify any bacteria or other microorganisms that might be present.

Chemical appearance:o A special stick ("dipstick") tests for various substances in the urine. The

stick contains little pads of chemicals that change color when they come in contact with the substances of interest.

Urine specific gravity:

o is a laboratory test that measures the concentration of all chemical

particles in the urine, helps evaluate your body's water balance and urine concentration.

URINALYSIS 1/23/10

Physical Properties:

Color: pale straw

Normal

Straw-amber

Significance

Normal Transparency: slightly hazy Reaction: alkaline

Clear-Hazy

acidic

Normal

May indicate alkalosis, or when the acidifying mechanism of the kidney fails or is poisoned.

Specific Gravity: 1.005 1.010-1.030

Decreased; May be due to renal failure, because the remaining functional nephrons undergo compensatory structural and hypertrophic

changes. These compensatory changes result in urine that is almost isotonic with plasma. .

Clinical test:

Negative Normal Sugar: negative Protein: negative Negative Normal

Microscopic Exams:

0-2 hpf Increased, may due to damage of the glomerular membrane or tumor cells.

RBC: 1-3 ( occasional)/hpf

Pus Cells: 6-8 (+) /hpf 0-2hpf Increased; may indicate infection.

Casts: none None Normal

Normal Crystal Amorphous Phospahates: few /hpf Few-occasional NormalSquamous Epithelial Cells: few Few-occasional NormalRound epitelial cells: none None Normal Bacteria: few 0-few Normal Mucus threads: few 0-few Normal

URINALYSIS 02/06/10

Physical Properties:

Color: pale straw

Normal

Straw-amber

Significance

Normal Transparency: slightly hazy Reaction: acidic

Clear-Hazy

acidic

Normal

normal

Specific Gravity: 1.015 1.010-1.030 normal

Clinical test: Negative Normal Sugar: negative Protein: negative Negative Normal

Microscopic Exams:

0-2 hpf NormalRBC: 0-2 ( occasional)/hpfPus Cells: 0-1 (+) /hpf 0-2hpf Normal

Casts: none None Normal

Normal Crystal Amorphous Urates: few /lpf Few-occasional NormalSquamous Epithelial Cells: few Few-occasional NormalRound epitelial cells: none None Normal Bacteria: few 0-few Normal Mucus threads: few 0-few Normal

Fecalysis:

Done to determine the presence of parasites that could affect his nutritional status.

FECALYSIS 01/23/10

Method Used: Direct Fecal SmearPhysical Properties: Normal Range: Significance

Color: dark brown Brown-dark brown Normal

Consistency: soft Normal

Microscopic Exam:

None Increased; may indicate infection.

Increased; may indicate intestinal parasites, intestinal disorders

Bacteria: Many

Blastocystic Hominis: 3-5 cysts/ smear

FECALYSIS 02/06/10

Method Used: Direct Fecal SmearPhysical Properties: Normal Range: Significance

Color: dark brown Brown-dark brown Normal

Consistency: formed Normal

Microscopic Exam:

None

None

Increased may indicate intestinal parasite because of contaminated food and water ingested.

Increased may indicate intestinal parasite because of contaminated food and water ingested.

Ascaris ( lumbrixoides): more than 12 ova/smear (many)

Trichuris trichiura: 4 ova/smear (few)

CT (computed tomography) scan:

This scan uses x-rays to take many pictures of the body. The pictures are then combined by a computer to give a detailed cross-sectional image. A CT scan is one of the most useful methods of finding a mass inside the kidney. It is also used to see whether the cancer has spread beyond the kidney.

COMPUTED TOMOGRAPHY REPORT

Examination: WHOLE ABDOMEN CT SCAN PLAIN AND CONTRAST Plain and contrast enhanced axial tomographic sections of the whole abdomen were obtainedNo untoward reaction were observedThe liver is normal in size and tissue density, no focal masses are seenThe intrahepatic and extrahepatic ducts are not dilatedThe gallbladder is normal in size and tissue density, No evident lithiasisThe pancreas and spleen are normal in size and tissue densityNo focal masses are seenThe left kidney is transformed into a huge, solid, inhomogenous well-defined enhancing mass measuring 11x12x13cm almost occupying the entire left hemiabdomenThere is lymphnode enlargement in the right renal hilar areaThe right kidney is normal in size and tissue density and exhibit good excretory functionNo focal masses are seenThe urinary bladder has smooth walls. There are neither lithiasis nor masses. The visualized stomach and the rest of the bowel loops don not appear unusualNo ascites notedRemarks:

Wilm’s Tumor Lymphadenopathy as described

ANATOMY AND PHYSIOLOGYOF THE

URINARY SYSTEM

Group of organs in the body concerned with filtering out excess fluid and other substances from the bloodstream.

The substances are filtered out from the body in the form of urine. Urine is a liquid produced by the kidneys, collected in the bladder and

excreted through the urethra. It is used to extract excess minerals or vitamins as well as blood corpuscles from the body.

The Urinary organs include the kidneys, ureters, bladder, and urethra. The Urinary system works with the other systems of the body to help

maintain homeostasis. KIDNEYS: are the main organs of homeostasis because they maintain

the acid base balance and the water salt balance of the blood

Urethra

Is a muscular tube that connects the bladder with the outside of the body.

Its function is to remove urine from the body.

It measures about 1.5 inches (3.8 cm) in a woman but up to 8 inches (20 cm) in a man.

Men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis) and the urinary tract.

Male urethra

In the human male, the urethra is about 8 inches long and opens at the end of the head of the penis.

The length of a male's urethra, and the fact it contains a number of bends, makes catheterisation more difficult.

Urinary Bladder

Is a hollow, muscular and distendible or elastic organ that sits on the pelvic floor (superior to the prostate in males).

Can hold approximately 17 to 18 ounces (500 to 530 ml) of urine, however the desire to micturate is usually experienced when it contains about 150 to 200 ml.

Ureters

These are two tubes that drain urine from the kidneys to the bladder.

Each ureters is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters send the urine in small spurts into the bladder, (a collapsible sac found on the forward part of the cavity of the bony pelvis that allows temporary storage of urine). After the urine enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing backward flow of the urine.

The outlet of the bladder is controlled by a sphincter muscle.

are two tubes that drain urine from the kidneys to the bladder.

Each ureter is a muscular tube about 10 inches (25 cm) long.

Kidney

Are a pair of bean shaped, reddish brown organs about the size of your fist. It measures 10-12 cm long, 2.5 cm in thickness, 5-7 cm wide, 120 – 170 g. They are covered by the renal capsule, which is a tough capsule of fibrous connective tissue.

Supply 20% – 25% of cardiac output

Located peritoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic vertebra to the 3th lumbar vertebra in the adult.

They are considered retroperitoneal, which means they lie behind the peritoneum.

There are three major regions of the kidney, renal cortex, renal medulla and the renal pelvis.

STRUCTURE OF KIDNEY

Renal Cortex- contains the glumeruli, proximal and distal tubules and cortical collecting ducts and their adjacent peritubullar capillaries. It Contains 85% of nephrons.

Renal Medulla- It resembles conical pyramids. The pyramids are situated with the base facing the concave surfface of the kidney and the apex facing the hilum, or pelvis. Each kidney contains approximately 8-18 pyramids. Contains 15-20% of nephrons

Renal Pelvis or Hilum- It is the concave portion of the kidney through which the renal artery enters and the renal vein exits.

Renal Vein

are veins that drain the kidney.

They connect the kidney to the inferior vena cava.

Renal arteries 

normally arise off the abdominal aorta and supply the kidneys with blood.

Afferent/Efferent Arterioles

afferent arteriole supplies blood to the glomerulus. A group of specialized cells known as juxtaglomerular cells are

located around the afferent arteriole where it enters the renal corpuscle

The efferent arteriole drains the glomerulus. Between the two arterioles lies specialized cells called the macula

densa.

Nephrons

is the basic structural and functional unit of the kidney. its chief function is to regulate water and soluble substances by

filtering the blood, reabsorbing what is needed and excreting the rest as urine.

eliminate wastes from the body, regulate blood volume and pressure, control levels of electrolytes and metabolites, and regulate blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.

NEPHRONE STRUCTURE

Glomerulus

is a capillary tuft that receives its blood supply from an afferent arteriole of the renal circulation.

The glomerular blood pressure provides the driving force for fluid and solutes to be filtered out of the blood and into the space made by Bowman's capsule.

Glomerular Capsule or Bowman's Capsule

surrounds the glomerulus and is composed of visceral (simple squamous epithelial cells) (inner) and parietal (simple squamous epithelial cells) (outer) layers.

The process of filtration of the blood in the Bowman's capsule is ultrafiltration (or glomerular filtration), and the normal rate of filtration is 125 ml/min, equivalent to ten times the blood volume daily.

Proximal Convoluted Tubule (PCT)

The proximal tubule can be anatomically divided into two segments: the proximal convoluted tubule and the proximal straight tubule.

The proximal convoluted tubule can be divided further into S1 and S2 segments based on the histological appearance of it's cells.

Can hold 10ml urine.

The Nephron Loop or Loop of Henle.

is a U-shaped tube that consists of a descending limb and ascending limb.

It begins in the cortex, receiving filtrate from the proximal convoluted tubule, extends into the medulla, and then returns to the cortex to empty into the distal convoluted tubule.

Its primary role is to concentrate the salt in the interstitium, the tissue surrounding the loop.

Descending limb

Its descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium.

Ascending limb

is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop.

The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange.s

Distal Convoluted Tubule (DCT)

The distal convoluted tubule is similar to the proximal convoluted tubule in structure and function.

Kidney Functions

1. Erythropoietin production – when the kidneys sense a decrease in the oxygen tension in renal blood flow, they release erythropoietin. Erythropoietin stimulates bone marrow to produce red blood cells (RBCs), thereby increasing the amount of hemoglobin available to carry oxygen.

2. Vitamin D synthesis – the kidneys are also responsible for the final conversion of inactive vitamin D to its active form, 1, 25 – dihydroxycholycalciferol. Vitamin D is necessary for maintaining normal calcium balance in the body.

3. Regulate pH level – the kidney partner up with the lungs and together control the pH. The kidneys have a major role because they control the

amount of bicarbonate excreted or held onto. The kidneys help maintain tha blood pH mainly by excreting hydrogen ions and reabsorbing bicarbonate ions as needed.

4. Maintaining Water-Salt Balance- It is the job of the kidneys to maintain the water-salt balance of the blood. It also maintain blood volume as well as blood pressure.

5. Removal of metabolic waste products and foreign substances from the plasma- kidneys excrete nitrogenous waste. As the liver breaks down amino acids it also releases ammonia. The liver then quikly combines that ammonia with carbon dioxide, creating urea which is the primary nitrogenous end product of metabolism in human. We can also excrete some ammonia, creatinine and uric acid. The creatinine comes from the metabolic breakdown of creatinine phosphate. Uric acid in the blood will build up and form crystals that can collect in the joints and cause gout.

6. Renin-angiotensin aldosterone system- Renin is an enzyme that converts angiotensinogen, an inactive substance fromed by the liver, into angiotensin 1. renin is release by the juxtaglumerular cells of the kidneys in response to decrease renal perfusion. Angiotensin-converting enzyme converts angiotensin 1 to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulate thirst. As the symphathetic nervous system is stimulated, aldosterone is release in response to an increase release of renin. Aldosterone is a volume regulator and is also release as serum potassium increases, serum sodium decreases or adrenocorticotropic hormone increases.

FORMATION OF URINE

Urine is formed in three steps: Filtration, Reabsorption, and Secretion.

Filtration

Blood enters the afferent arteriole and flows into the glomerulus.

Reabsorption

Within the peritubular capillary network, molecules and ions are reabsorbed back into the blood.

Secretion

Some substances are removed from blood through the peritubular capillary network into the distal convoluted tubule or collecting duct.

PATHOPHYSIOLOGY

Wilms’ tumor, also called nephroblastoma, is the most common type of kidney cancer that affects children. It usually affects only one kidney, but in few cases (5 percent) tumors occur in both kidneys. Unfortunately, Wilm’s tumor is diagnosed only when the tumor is already big, but before the cancer metastasize. Kidneys start to develop before the baby is born, when the kidney’s cells are not yet differentiated into various mature kidney cells. The maturation process of the kidney cells ends around the age of three or four. However, this maturation process can be impaired, and some of these undifferentiated cells grow and divide uncontrollably and exaggerated causing tumors to form.

Clinical Manifestations:

Abdominal massAbdominal pain (minimal and moderate)Loss of appetiteFever(low grade and high-grade) ConstipationHemihypertrophyCryptorchidism

PATHOPHYSIOLOGY of WILM’S TUMOR

Predisposing Factors

1.Age: Wilm’s Tumor diagnosed at the age of 3-5 y.o.Our client is 4 y.o.2.Congenital anomalies3.Heredo-familial Predisposition to cancer

Precipitating Factors

1.Second Hand Smoking: The father or our client is smoking 6-8 cigarette stick/day in their house2. Exposure to asbestos, heavy metal

HemihypertrophyCryptorchidism

Decrease in the number of WTI

Destruction of the structure of chromosome 11

Cellular mutation in the kidney

Unregulated and unsuppressed growth of cells and tissues

Affects the renal cortex

Tumor production

Cortical and medullary infiltration and proliferation

Suppression of function of nephrons

Wilm's tumor

Cancer is confined only in the kidney (Stage I)

With medical-surgical intervention:Good prognosisPrevent metastasis

Without medical-surgical intervention:Tumor progression

Spread beyond the kidney into a nearby fat or tissue (Stage II)

With medical-surgical intervention:Good prognosisPrevention of metastasis

Without medical-surgical intervention:Tumor progression

Spread to lymph nodes from the abdominal cavity and adjacent vital

structures (Stage III)

With medical-surgical intervention:Good prognosisPrevention of metastasis

Without medical-surgical intervention:Tumor progression

Abdominal massConstipation

Abdominal pain (minimal)Loss of appetiteFever(low grade)

Cancer enters blood stream and affects other organs (Stage IV)

Decrease production of

Vit. D

Altered RAA mechanism

Decreased erythropoietin production

Altered waste

production

Decreased absorption of calcium in the

intestines

Hypertension

Decreased number of

RBC

Hypocalcemia

Anemia

Cancer is present on both sides of the kidney

Decreased urine

formation

Urinary retention

Without medical-surgical intervention:Tumor progression

With medical-surgical intervention:Good prognosisPrevention of metastasis

Abdominal massConstipation

Abdominal pain(moderate)Loss of appetiteFever(high grade)

Urinary Retention

Edema

Altered Acid Excretion

Decreased catabolism of proteins

Acidity

Discharge PlanGeneral Objective

To provide continuity of care and appropriate needs and teachings at home in the absence of a professional healthcare provider after discharge from the hospital.

Specific objectives• Client’s folks will be oriented about the client’s disease process in

order for them to be fully aware about the client’s health status.• Client’s folks will observe proper aseptic technique in rendering home

care to eliminate the spread of pathogens and microbes that can possibly infect primary and secondary infection to the client as well as to the whole members of the family.

• Client’s folks will employ certain measures that will include promotion, prevention, cure and rehabilitation of the client’s health status.

• Provide education on client and folks about proper nutrition.• Instruct the mother to strictly follow the therapeutic regimen of her

child indicated by the physician on the discharge instructions to prevent complications.

• Inform the folks of the schedule for the follow-up visit in order to assess health status.

Health Teaching

A. Knowledge

Wilms’ tumor also called nephroblastoma is a rare type of kidney cancer that affects mostly children. It causes a tumor on one or both kidneys. Having certain genetic conditions or birth defects can increase the risk of developing Wilms’ tumor. The peak time of Wilms’ tumor occurrence is around ages 3 to 4, and it occurs only rarely after age 6.

Signs and Symptoms

Abdominal swelling An abdominal mass you can feel

FeverBlood in the urine (hematuria) Reduced Appetite High blood pressure Constipation Stomach Pain Nausea

Risk factor

• Sex – girls are slightly more likely to develop Wilms’ tumor than boys• Race – black children have a slightly higher risk than Asian – American• Family history – if someone had Wilms’ tumor in the family or presence

of any type of cancer increase the risk• Aniridia – iris of the eye forms particularly or not at all• Hemihypertrophy – one side of the body is noticeably larger than other

side • Undescended testicles – one or both testicles fail to descend into the

scrotum• Hypospadias – urinary (urethral) opening is not at the tip of the penis

but on the other sideSexRace Family History AniridiaHemihypertrophy Undescended testiclesHypospadias

Stages

• Stage I – cancer is only found in the kidney• Stage II – cancer has spread deeper into other parts of the kidney and

to nearby blood vessels, but was completely removed by surgery. No cancer cells are found at the edges of the area where the tumor was removed.

• Stage III – cancer has spread beyond the kidney area to nearby lymph nodes or other structures within the abdomen

• Stage IV – cancer has spread to distant structures such as the lungs, liver or brain

• Stage V – cancer cells affect both kidneys

SOURCE: New England Journal of Medicine

RATIONALE:To give folks an idea regarding the disease process, signs and

symptoms, risk factors and treatment.

B. Personal Hygiene

Instruct client/folks to practice strict hand washing before and after eating or before and after using the toilet to prevent the spread of infection among the family members and to reduce the risk of wound infection. Intruct client’s mother to keep client’s fingernails clean and short to prevent from scratching that results in skin injury. Instruct client/folks to clean thoroughly fresh fruits before eating to avoid from ingestion of pathogens and any microorganisms. Instruct client/folks to change clothing everyday or frequently as much as possible to promote comfort and to grooming. Instruct folks to provide a smoke free and dust free environment for the client to avoid nasal irritation that might aggravate client’s condition. Instruct folks to change bed linens thrice a week to prevent to prevent dwelling of microbes, dust and viruses in the linens. Instruct client to avoid touching the surgical site to reduce the risk of infection and injury. Clean skin surface with running water and mild soap after change of dressing to reduce skin contaminants. If client cannot take a bath, offer him regular sponge bathing when client verbalized feeling of discomfort to promote comfort and well-being. Instruct folks to observe proper aseptic in dressing and cleaning of surgical site to reduce the risk of contamination and infection. Encourage good oral hygiene such as mouth rinse that can be helpful for sores or areas that are bleeding and use of lip balm or petroleum jelly to soothe cracked lips.

RATIONALE:Proper personal hygiene prevents contamination and spread of

microorganisms which can lead to further complications and infections.

C. Activities of daily living

Encourage client to turn reposition, transfer and ambulate to promote blood circulation, increase peristalsis and pain tolerance; promote maximum

lung expansion during respiration. Tell the mother to make sure that her child avoid vigorous exercise or activities and exhaustion and always have rest periods. Encourage client to take adequate rest and sleep to avoid stress. Instruct client to continue deep breathing 10x per hour to improve lung ventilation and produces endorphins that promotes feeling of comfort. Encourage/instruct the client or address the mother to avoid second hand smoking and any other strong chemicals to be inhaled because these could enter the blood stream and could affect his health condition. Encourage folks to boil or sterilize their drinking water to prevent ingestion of pathogens such as Entamoeba Hystolitica. Avoid doing hard activities, such as heavy lifting, pulling, and pushing. Instruct client to limit body movements, especially bending his back. Encourage walking soon after surgery for early return bowel function, promotes effective breathing, mobilizes secretions, improves circulation, prevents stiffness of joints and relieves pressure. Inform the mother to inspect surgical site/size, noting characteristics and integrity to recognize early or delayed healing/developing complication may prevent a more serious situation such as infection. Monitor surgical dressing, placement, and bleeding to make appropriate referrals if there are significant findings such as hypovolemic shock.

RATIONALE:To give on folks what activities of daily living must be practice at home

to aid prevention and recovery for the client.

C. Nutrition

Encourage to continue to eat vitamin C rich foods such as citrus fruits and protein such as meat products, for faster wound healing and prevents infection by enhancing immune system/response. Instruct mother to include fruits and vegetable in client’s diet to replace dead cells and tissue in the body. A well balanced diet is encouraged to promote healing and good bowel function. Encourage client’s folks to have an adequate hydration by drinking at least 6 - 8 glasses of sterilized water to promote blood circulation and maintain fluid balance in the body. Instruct mother to provide foods to the client that is rich in iron and vitamin C to boost the immune system. Instruct the mother to avoid foods that are oily in order not to aggravate client’s health condition. Prepare favorite foods to gain weight for upcoming chemotherapy because his appetite may decrease. Instruct mother to increase fluid intake of the child to counter the decrease in solid food intake. Avoid legumes because it is high in purines which produce uric acid that can deposit in the kidneys in the form of urate stones.

RATIONALE:To take foods that promotes and aid recovery and avoidance of

restricted foods.

D. Medication

Instruct the mother to follow the medication program carefully. The drugs prescribed to client are designed to prevent various complications and to treat the condition.

MEDICATION DOSAGE and TIMING INDICATION

Paracetamol 240 mg/5ml, 5ml every 4 hours for 7 days

For mild pain and fever

Cefuroxime 125 mg/8ml, 8ml every 8 hours for 10 days

For the treatment of many different types of bacterial infections such as urinary tract infections.

Strictly instruct the mother not to give any medicines, over-the-counter drugs, vitamins, herbs, or food supplements to her child without first talking to physician. Tell the mother to call the physician if she thinks the medicines are not helping or if the child is having side effects. Instruct the mother not quit the home medications until she discuss it with the physician. Teach the folks on how to administer the medication, its correct route, dosage, and timing.

RATIONALE:To subject folks for medications and special procedures to enhance

health.

E. Follow up check up

Tell the mother to return to the physician for physical exams and imaging tests such as ultrasound and CT scans to look for the growth or return of the tumor. Remind the mother that blood and urine tests will be done to check how well the remaining kidney is working. Physician may schedule follow-up check up. But if any unusual symptoms occur before the date of check up, client should visit the physician’s clinic immediately.

February 23, 2010 first visit.March 1, 2010 (releasing of biopsy result) biopsy result should be taken at the dept of pathology to know the type of the cancer cell of tumor.

SEEK CARE IMMEDIATELY IF: There is trouble breathing or chest pain all of a sudden and trouble having a bowel movement or passing urine, if bandage becomes soaked with blood, if incisions are swollen, red, have pus coming from them, or they have come apart and there are chills or fever of 101 F or more. Severe pain that is not relieved by pain medication.

RATIONALE:Follow-up visit to help evaluate effective of the treatment and

interventions. It would provide support to client with regards to the achievement of goals.