end stage renal disease secondary to hydronephrosis secondary to diabetes mellitus type two

A Case Study

Presented to the Faculty of

The Ateneo de Davao University

College of Nursing

A Case Study on

End-Stage Renal Disease secondary to

Hydronephrosis secondary to Diabetes Milletus

Type 2

Submitted to:

Remedios Caubang, RN

Clinical Instructor – Panelist of the Case Study

Submitted by:

[Group 1B]

Beltran, Maribel S.

Bulosan, Von Rainer S.

Cabonita, Kristi Ann J.

Campaner,Marie Allexis I.

BSN-3H

1

November 7, 2009

TABLE OF CONTENTS

i. Acknowledgement....................................................................................................2

I. Introduction..............................................................................................................4

II. Objectives (General & Specific)..............................................................................6

III. Patient’s Data...........................................................................................................8

IV. Family Background and Health History...................................................................10

V. Developmental Data.................................................................................................14

VI. Definition of Complete Diagnosis............................................................................21

VII. Physical Assessment.................................................................................................24

VIII. Anatomy and Physiology.........................................................................................28

IX. Etiology and Symptomatology.................................................................................36

2

X. Pathophysiology.......................................................................................................42

XI. Doctor’s Order..........................................................................................................47

XII. Diagnostic Exam......................................................................................................55

XIII. Drug Study...............................................................................................................64

XIV. Surgical Procedure...................................................................................................74

XV. Nursing Theories......................................................................................................81

XVI. Nursing Care Plan....................................................................................................86

XVII. Discharge Plan (M. E. T. H. O. D.) & Prognosis.....................................................118

XVIII. Recommendation......................................................................................................128

XIX. References................................................................................................................131

ii.

3

ACKNOWLEDGEMENT

In accomplishing great things, we must not only think, but believe in the power of

our cognition; not only aim but make our visions tangible; and at the end of the day, not

only smile at the thought of accomplishment, but look back to where the strength to

achieve such success came from.

The proponents would like to extend their warmest gratitude to all the people who

helped make the success of this undertaking a reality.

First and foremost, to the Almighty Father, for His unceasing love and blessings;

for giving us enough power and fortitude to face all the hardships in the making of this

task. To Him be all glory and praise!

To our Clinical Instructor, Mrs. Willyn Adrias, RN, for her invaluable time and

effort rendered to us; for letting us have the chance to experience the joy and opportunity

of learning from you. For being a friend and companion in the area. You have made us

realize that not all CIs are intrinsically superfluous. To all other CIs that has been with us

in the whole rotation, Maam Baniel and Maam Llamido , for always being there to guide

us; for their unending help and understanding.

To our dear parents, for supporting us financially in all our endeavors. Thank you

for all your love and care.

Lastly, to each and every one who helped realize this job into completion, may it

be direct or indirect, no matter how minimal, the gratitude and pleasure for the

achievement of this task is ours to share.

4

INTRODUCTION

BSN-3H1 were given the opportunity to have a hospital exposure last November

12-14,2009 at Davao Medical Center – Med Ward; and on the said dates found a

commendable case reasonable to be presented for case study agreed by the whole

subgroup.

The patient, to be mentioned in this paper as Aling D, was one of the patients

admitted to Medicine Ward Nephro due to End Stage Renal Disease secondary to

Hydronephrosis stage II secondary to Diabetes Mellitus Type II.

End-Stage Renal Disease is the complete or almost complete failure of the

kidneys to function at a level needed for day-to-day life. The kidneys can no longer

remove wastes, concentrate urine, and regulate many other important body functions. It is

an irreversible decline in a person's own kidney function, which is severe enough to be

fatal in the absence of dialysis or transplantation. It usually occurs when chronic kidney

disease has worsened to the point at which kidney function is less than 10% of normal.

ESRD almost always follows chronic kidney disease. A person may have gradual

worsening of kidney function for 10 - 20 years or more before progressing to ESRD. The

most common causes of ESRD in the U.S. are diabetes and high blood pressure.

The incidence and prevalence of ESRD continue to grow worldwide. According

to data collected from 120 countries with dialysis programs, at the end of 2005 about

1,900,000 people were receiving renal replacement therapy (RRT). Among these

individuals, 1,297,000 (68%) received hemodialysis and 158,000 (8%) received

5

peritoneal dialysis; although an additional 445,000 (23%) were living with a kidney

transplant. Precise estimates of ESRD incidence and prevalence remain elusive, because

international databases of renal registries exclude individuals with ESRD who do not

receive RRT. (http://clinicalevidence.bmj.com/ceweb/)

Worldwide, the highest incidence and prevalence rates are reported from the

USA, Taiwan, and Japan. In America, 34% of cases of ESRD each year are caused by

diabetes, 25% by hypertension, 16% by glomerulonephritis, and 4% by kidney cysts.

(Renal Data Report, ANS, 1999)

End Stage Renal Disease is already the 7th leading cause of death among Fil-

ipinos. The population of ESRD patients requiring dialysis therapy in Asia is expanding

at a faster rate than in the rest of the world. In Philippines, the dialysis population is

growing at a rate of 10% or more annually. It is said that a Filipino is having the disease

hourly or 120 Filipinos per million populations per year. This shows that about 10, 000

Filipinos need to replace their kidney function. Unfortunately though only 73% or about

7, 267 patients received treatment. An estimate of about a quarter of the whole population

probably just died without receiving any treatment.

The group chose Aling D as their subject primarily because her case posed a very

intricate case requiring due understanding and knowledge. The group recognizes their

partial knowledge about End-Stage Renal Disease and the treatments involved in such

condition, thus making this case a good avenue to broaden the proponents’ knowledge

about the disease and the surgical procedures involved.

6

General Objective:

The main goal of the group is to be able to present the case study of our

chosen client that would provide a comprehensive discussion of the pathological

mechanism of the disease to yield significant information for the case study.

Specific Objectives:

In order to meet the general objective, the group aims to:

establish rapport to the patient and the patient’s significant others;

interpret the pertinent data gathered from the patient and her significant others;

state past and present health history of the patient;

trace the family genogram;

evaluate the present developmental stage of the patient according to the theories

of Erikson, Kohlberg, and Havighurst;

define the complete diagnosis of the patient;

present the cephalocaudal assessment obtained from the patient;

discuss the anatomy and physiology of the organ involved in the patient’s disease;

present the etiology and symptomatology of the patient’s disease;

trace the pathophysiology of the patient’s disease;

obtain and rationalize the doctor’s order;

interpret the laboratory test results of the patient;

discuss the nature of the drugs given to the patient;

discuss the surgical procedure performed to the patient;

7

relate the patient’s disease with the different nursing theories specifically those of

Nightingale, Orem and King;

present a specific, measurable, attainable, realistic and time-bounded nursing care

plans for the client;

justify the client’s prognosis according to the different criteria;

provide the patient and family with proper discharge planning (M.E.T.H.O.D);

and

outline recommendations based on the case study’s findings.

8

PATIENT’S DATA

Personal data:

Patients Name: Aling D

Age: 56 years old

Weight 130 lbs or 59kg

Height 4’10 ft

Gender: Female

Birth date: September 25, 1953

Address: Dumanlas, Buhangin, Davao City

Nationality: Filipino

Religion [Domination]: Christian [Roman Catholic]

Civil Status: Married

Educational Attainment: College graduate

Occupation: Teacher (retired)

Clinical/ Admitting Data:

Date of admission: November 9, 2009

Time of admission: 11:30 am

Hospital & Hospital Number: Davao Medical Center, Davao City [1604730]

Ward [Room & Bed Numbers]: Medicine Ward- Nephro Bed No. 12

9

Admitting Physician: Dr. Jovino C. Aquino

Attending Physician: Dr. Gil Florida

Chief complaint: Epigastric pain

Admitting Diagnosis: End Stage Renal Disease secondary to Hydronephrosis secondary

to Diabetes Mellitus Type II

Source of information: Patient and Patient’s Chart

10

FAMILY BACKGROUND AND HEALTH HISTORY

HEALTH BACKGROUND

A. Family Background

Aling D is 56 years old, female. She is the 3rd child of 5 siblings. Both her parents

are already dead, and she failed to mention the cause of their death. The patient

verbalized that her father was diagnosed with Diabetes Mellitus. She failed to mention if

her mother and siblings also have illnesses.

Aling D has been married for 32 years. She was a gradeschool teacher but she

already retired last 2005. Her husband is a government employee. They are blessed with

3 children, but one son is already dead due to cardiac arrest. The son died at the age of 23

who is the middle child. Her eldest son is 31 years old, and her youngest son is 28 years

old. Her eldest son is already married and doesn’t live with them anymore. Generally,

they have close family ties. Aling D told us that they share their daily experiences with

each other.

The family’s source of income is the patient and the husband. Her youngest son

also contributes to the family’s income, since he is also a government employee

particularly in the Department of Agriculture. Aling D’s pension per month is Php

15,000. Her husband’s income per month is Php 12,000, and her son’s income is Php

8,000. The family lives in Dumanlas, Buhangin, Davao City. Her family’s diet is

composed of meat, fish and vegetables, however, due to her hospitalization she has been

11

following a low salt low fat diet. She also avoids protein-rich foods and foods high in

sugar. She is a non-smoker and occasionally drinks alcohol.

B. History of Past Illness

The patient was born via normal spontaneous vaginal delivery. She did not have

any complications nor unusualities when she was delivered. The patient did not

experience any serious illness or accident during her childhood. But she did experience

having chicken pox when she was a child. Also, she only experienced common minor

illnesses such as colds, fever, stomach aches, headaches, and constipation. She drinks

over-the-counter drugs like paracetamol when she experiences fever. According to the

patient, she had been diagnosed with hypertension 20 years ago and diabetes mellitus 15

years ago. She takes insulin shots for her Diabetes. She verbalized that she did not have

strict compliance to her medications since her condition was not bad before.

C. Present Health History

On October 2009, the patient experienced chest pain. She also experienced

dyspnea occurring at night accompanied by bipedal edema. The patient also had cough

and abdominal pain. She took a supplement called Relieve for 23 days to alleviate the

symptoms she felt. She tolerated the symptoms until she had onset of epigastric pain. She

had her check-up on UM Multitest. Along with her laboratory results, she was diagnosed

with End Stage Renal Disease last October 15, 2009. However, she was not admitted by

then. She sought medical attention when she experienced severe epigastric pain, and thus

the admission.

12

D. Effects/ Expectations of Illness to Self/ Family

The patient verbalized that after the diagnosis was determined; she and her family

became bothered and worried. They did not expect that she will be diagnosed with a

disease which is already in end stage. The doctor who gave the diagnosis advised dialysis

to the patient, which added to the stress of the family and the patient. On the patient’s

part, she felt nervous because she used to know someone who underwent dialysis and

later died after 2 years of treatment. Nevertheless, she verbalized that she had already

accepted her treatment, its limitations, and consequences. According to her, she does not

want to be a burden to her family. On the family’s part, they worried about the finances

they will have to spend for the treatment. But, they are very positive in facing the disease.

Aling D stated that it must have really been God’s will and that they could do nothing

about it. Despite her health problem, they still have hope and they pray that their family

would be able to endure this and cope with all the inconvenience brought about by her

condition.

13

E. GENOGRAM

LEGEND:

* Deceased ** with Hypertension *** with Diabetes Mellitus

ALING D

MAMA PAPA***

LOLO LOLA**

UNCLE A *** UNCLE B

LOLA A *** LOLO A

14

DEVELOPMENTAL DATA

Human development: the science that studies how we learn and develop psychologically,

from birth to the end of life. This very young science not only enables us to understand how each

individual develops, it also gives us profound insights into who we are as adults. Each theory has

its own viewpoint on the development of man.

Erikson's Stages of Psychosocial Development

The Psychosocial Stages of Development developed by Erikson enumerates eight stages

though which healthily developing human should pass from infancy to late adulthood. Every

stage describes a task to be accomplished. These development stages can be seen as a series of

crisis and each stage forms on the successful accomplishment of the earlier stages. Successful

resolution of these crises supports a healthy self-development. Failure to resolve the crises

damages the ego and maybe expected to reappear as problems in the future.

Stage Description Result Justification

Middle

Adulthood

(25 to 65

years old)

According to Erik Erikson,

the developmental task in middle

adulthood is to form a sense of

generativity or the concern for

guiding the next generation. It is

the concentration on this task that

ACHIEVED

Our clent, Aling D has achieved generativity

as she is able to display behaviors that are

well acceptable for his age such as being

there for her children. She is able to expand

her interests at this time with her family’s

support and has assumed the responsibilities

15

GENERATI

VITY vs.

STAGNATI

ON

leads to typical adult behavior.

Middle adults must have

motivations for charitable and

altruistic actions, such as church

work, social work, political work,

community fund-raising drives and

cultural endeavors. They should

have time for companionship and

recreation, thus making marriage

more satisfying in the middle years

of life. Generative middle-aged

persons are able to feel a sense of

comfort in their lifestyle and

receive gratification from

charitable endeavors.

He knows well what his

responsibilities are and he

recognizes that he’s held

accountable of whatever actions he

take.

of middle –aged person. Our client usually

takes time to bond with her husband and

children. Even though her children are all

grown up and busy with their own life, but

still they make time for each other and share

to each other their daily experiences.

Furthermore, she manages to acknowledge

her aging body and sees whatever she has

now as part of her existence. According to

her as well as her family, her condition never

altered her role of being a wife to his better

half and a mother to her children. She is very

responsible in her duty to her family, as a

mother to her children, she has molded them

into a better person they are today, good and

responsible sons; and as a wife to her

husband, their expression of love is more

intimate and they cherished every minute

they are together. As a middle-aged adult, she

is also engaged in various activities in the

society in order to maintain a good societal

functioning like participating in the

16

development of their own community.

Kohlberg's Stages of Moral Development

This theory specifically addresses moral development in children and adults. The

morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the

reasons an individual makes a decision.

Kohlberg's Stages of Moral Development

This theory specifically addresses moral development in children and adults. The

morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the

reasons an individual makes a decision.

Stage Description Result Justification

Conventional

Stage (Law

and Order

Orientation)

The conventional level of moral

reasoning is typical

of adolescent and adults. Those

who reason in a conventional

way judge the morality of

actions by comparing them to

society's views and

ACHIEVED In this stage of Kohlberg's Moral

Development theory, the client must

go after the laws in order to

maintain a good functioning in the

society as a morally upright citizen.

Aling D is a good citizen.

According to her, she is a registered

17

expectations. In this stage, it is

important to obey

laws, dictums and social

conventions because of their

importance in maintaining a

functioning society. Moral

reasoning in stage four is thus

beyond the need for individual

approval exhibited in stage

three which is interpersonal

accord and conformity driven.

Meaning the self enters society

by filling social roles; therefore

society must learn to transcend

individual needs. A central

ideal or ideals often prescribe

what is right and wrong, such

as in the case of

fundamentalism. If one person

violates a law, perhaps

everyone would—thus there is

an obligation and a duty to

voter in order to exercise her right

to vote for a leader suited to our

country, she offered her services

during election periods when she

was still working as a teacher. She's

also an active GKK or Gagmayng

Kristohanong Katilingban member

in their barangay and actively

participates for the development of

their community. For her, it is really

important to observe the rules

inculcated by the society in order to

maintain peace and order. She also

stated that as a constituent of the

society, she should be a good

example for the future generations

to come.

Aling D said that the simplest way

to become a good citizen is that you

must not disobey any simple rules

and regulations which the society

dictates you to follow and abide,

18

uphold laws and rules. When

someone does violate a law, it

is morally wrong; culpability is

thus a significant factor in this

stage as it separates the bad

domains from the good ones.

Most active members of society

remain at stage four, where

morality is still predominantly

dictated by an outside force.

because if one does not follow rules

it is already considered in this stage

to be morally wrong. So, one must

maintain a good reputation without

any stain of misdemeanor done.

In the stage four of Conventional

level, it is said that following the

laws and dictums of the society is

important to maintain a good

functioning in the society, so we

have concluded that Aling D has

done her part in the society as a

good citizen. She follows and obeys

the rules and she had become a

good example to everybody,

especially to her children.

Havighurst’s Developmental Task

19

Havighurst (1972) defines a developmental tasks as one that arises at a certain period in

our lives, the successful achievement of which leads to happiness and success with later tasks;

while leads to unhappiness, social disapproval, and difficulty with later tasks He identifies three

sources of developmental tasks (Havighurst, 1972).

Tasks that arise from physical maturation

Tasks that arise from personal values

Tasks that have their source in the pressures of society

Havighurst also identified Six Major Stages in human life covering birth to old age which are the

following:

1. Infancy & early childhood (Birth till 6 years old)

2. Middle childhood (6-12 years old)

3. Adolescence (13-18 years old)

4. Early Adulthood (19-30 years old)

5. Middle Age (30-60years old)

6. Later maturity (60 years old and over)

Our client belongs to the fifth stage which is the middle age, wherein men and women in

this stage reach the peak of their influence upon society, and at the same time the society makes

its maximum demands upon them for social and civic responsibility. It is the time of life to

which they have looked forward during their adolescence and early adulthood.

20

The following are the developmental task that a middle age adult must fulfill or achieve:

DEVELOPMENTAL TASK ACHIEVED OR NOT

ACHIEVED

JUSTIFICATION

Helping teenage children to

become happy and

responsible adults

Achieved The client's children are all old

enough to understand what their

mother taught them; especially

the moral values that would

make them become better

persons and become good

example to others.

Achieving adult social and

civic responsibility

Achieved According to her, she

participates in barangay activities

for the development of their

community and she is an active

member of their GKK. She is

also registered voter in order to

do her duty as a good citizen of

the country.

Reaching and maintaining

satisfactory performance in

Achieved Since the client has already met

her expectations in her job in the

21

one’s occupational career past and have already fulfilled

her dream of becoming a teacher.

Now, she is already retired from

her work.

Developing adult leisure time

activities

Achieved The client as an adult develops

leisure time activities together

with her family like having

meaningful conversations with

her children or sharing their daily

experiences and watching

television shows to strengthen

their bonding as a family.

Relating oneself to one’s

spouse as a person

Achieved The client and her husband have

been there for each and never

leave each other’s side. They

have been married for a long

time already. Whenever they

have problems, they’ve talked

about it and together they decide

on how to solve their

predicament. Now that the client

has been hospitalized, her

22

husband has been there to

support her emotionally through

sending her text messages or

calling her sometime.

To accept and adjust to the

physiological changes of

middle age.

Achieved The client has adjusted to the

changes on her body. She already

have wrinkled skin and easily

gets tired but she has learned to

accept this reality.

Adjusting to aging parents. Achieved The client has already adjusted to

her aging parents in the past

when her parents were still alive.

23

DEFINITION OF COMPLETE DIAGNOSIS

END -STAGE RENAL DISEASE

End-stage renal disease occurs when 90% of the nephrons are lost. Patients at this stage

experience chronic and persistent abnormal kidney function.

Hopper P.D., Williams, L.S.; Understanding Medical Surgical Nursing 3rd edition

Kidney or renal end-stage disease is defined as a point at which kidney is so badly

damaged or scarred that dialysis or transplantation is required for patient survival.

Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition

During this stage, renal function is less than 10% to 15% of normal; all renal functions

are severely decreased; and homeostasis is significantly altered.

Ray A. Hargrove-Huttel; Medical Surgical Nursing

HYDRONEPHROSIS

Hypdronephrosis is the abnormal dilation of kidneys caused by obstruction of urine flow.

24

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

Hydronephrosis develops when urinary obstructions block the outflow of the kidneys.

Hydronephrosis may be gradual, partial or intermittent.

Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

Enlargement of kidney resulting from urine accumulation in the upper urinary tract caused by a

blockage of the urinary tract.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or

action result in high blood sugar level.

Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia

resulting from defects in insulin secretion, insulin action, or both (The American Diabetes

Association, 1997). Type II DM is formerly known as Non-insulin Dependent Diabetes Mellitus.

25

Type 2 diabetes usually occurs at any age but most cases occur after age 30. More than 80% of

the clients are overweight and do always experience classic symptoms.

Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

Diabetes mellitus occurs when beta cells are unable to produce insulin (Type I DM) or

produce an insufficient amount of insulin (Type II DM). As a result, glucose does not enter cells

but remains in the blood.

Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

26

PHYSICAL ASSESSMENT

I. Personal data:

Date of Assessment: November 13, 2009

Time of Assessment: 11:30 pm

Location of Assessment: Bed No. 12, Medicine Ward Nephro, Davao Medical Center

II. General Survey:

During assessment, the patient was lying supine on bed with ongoing Intravenous Fluid

infusion of Plain Normal Saline Solution, 1 liter to run at KVO rate at the level of 750 cc,

infusing well on her left metacarpal vein. Patient was awake, conscious, coherent, and oriented to

time, place, person and reason for admission. She was calm, cooperative and responsive. The

quality and organization of speech is understandable and in moderate pace and it exhibits thought

association. The relevance and organization of thought is also logical and has a sense of reality.

General physical appearance is good; however, poor personal hygiene is evident.

III. Vital Signs:

Temperature: 36.9°C

Pulse rate: 88 beats per minute

Respiratory rate: 22 cycles per minute

Blood pressure: 150/100 mm Hg

27

IV. The Integument

a. Skin

The patient’s skin color was brown and sallow, and generally uniform in

distribution except for areas that are not usually exposed to the sun. Pallor is

noted on her palms, soles and nail beds. The palms and the soles are cal-

loused. The capillary refill took 3 seconds. Age spots are also highly visible

on the face and the body. Poor skin turgor was noted when the skin was

pinched. No other lesions or deformities were noted.

b. Hair

Hair is evenly distributed over the scalp. Most hair on the scalp is gray as

a result of advanced age. Dandruff is not present. Fine hairs are evenly

distributed on both extremities.

c. Nails

The patient’s nails were untrimmed with pail nail beds, with normal angle

curvature. Surrounding tissues were intact; neither lesions nor lacerations

were observed.

V. The Head

a. Skull and Face

The patient’s head is normocephalic and proportional to body size. The

skull is also noted to be smooth in contour. Presence of nodules or masses is

28

not noted. Facial features and movements are symmetrical. The patient is able

to raise her eyebrows, close her eyes, frown, and smile. Her face manifests a

feeling of slight tiredness.

b. Eyes

The hairs of the eyebrows are evenly distributed which are also symmetri-

cally aligned. Eyelashes are equally distributed and slightly curled outward.

The skin of the eyelids is intact, no visible discharge, and discoloration is

noted. The eyelids close symmetrically. The sclera is white in color. The con-

junctiva is shiny and pink in color. The color of her iris is dark brown. The

details of the iris are also visible. The eyes do not appear sunken. The client’s

pupils are round, black and are 3mm in diameter each pupil. When a pupil is

illuminated, both pupils constrict. Both eyes have coordinated movements;

move in unison and with parallel alignment. According to her, when looking

straight ahead, she can see objects in periphery. There was no edema or ten-

derness noted over her lacrimal glands. The patient was not wearing any

glasses or contact lenses.

c. Nose and Sinuses

The external nose is symmetrical, straight and uniform in color. Nasal

flaring was not noted. Color is the same with the entire face. No tenderness

was noted during palpation. Both nares were patent. Air could move freely

when breathing in and out. The nasal septum is intact and is to be found in the

midline. The frontal and maxillary sinuses were not tender. Sense of smell is

29

present and good since the patient was able to differentiate alcohol from

coffee by means of scent.

d. Ears

The auricles are smooth. The patient’s ears have the same color with her

facial skin. The ears are symmetrical in terms of size and position. The ears

are normoset since both ears are located in line with the outer canthus of his

eyes. The auricles are firm and not tender. The pinna recoils after it is folded.

The patient has no difficulty hearing normal and whispered voice tone. No

discharge was noted.

e. Mouth and Oropharynx

The lips are pink in color and glistening. The lips are also moist. The pa-

tient is able to purse her lips. The teeth are white and shiny. Some teeth are

also missing. The gums are moist and pink in color, with no signs of bleeding.

The tongue is positioned in the center. It is pink in color. No lesions observed.

The papillae of the tongue are raised. The tongue is able to move freely and

the base has prominent veins. No swelling or ulcerations noted. The uvula is

positioned in midline of the soft palate. Tonsils are pink and not inflamed.

The patient is able to swallow with no difficulty.

VI. Neck

The muscles in the neck are symmetrical and the head movement is coordinated.

There was no limited range of motion noted as the patient turns her head from left to

30

right; up and down; and circular motion. Trachea was located centrally in the midline

of the neck. No lymph nodes noted on any of the areas of the neck. Moreover, no

neck blood vessels were distended around the neck area.

VII. Chest and Lungs

The patient has a regular and normal breathing pattern. She has quiet, rhythmic,

and effortless respirations with a respiratory rate of 22 cycles per minute. There was a

full and symmetric chest expansion. Chest pain was not reported. Crackles were

heard on both lung fields upon auscultation.

VIII. Heart and Blood vessels

The point of maximal impulse was located at the fifth left intercostal space. The

patient has a cardiac rate of 85 beats per minute. Abnormal heart sounds or murmurs

were not noted upon auscultation. The patient’s pulse is regular in rhythm and has a

thrusting characteristic.

IX. Abdomen

As observed, the patient’s abdomen has uniform skin color. Also, the abdominal

contour is rounded or convex. The umbilicus is medially located and shows no signs

of inflammation. It also has a symmetric contour. When breathing, there is symmetric

movement which is caused by respiration. Bowel sounds are present upon ausculta-

tion.

31

X. Genito-urinary

The patient reported that there were no lesions, tenderness and masses in her per-

ineum and anus. Patient has dark yellow colored urine. She also has oliguria. Upon

palpation distended bladder was noted.

XI. Musculoskeletal

a. Upper Extremities

Patient’s peripheral pulses were symmetrical and regular, however, they

are weak. The patient’s nails took 3 seconds for the capillary refill. The pa-

tient was able to exhibit strong hand grip on both arms. She was able to ex-

tend and flex her both arms. Hand tremors were not noted.

b. Lower Extremities

Bipedal pitting edema grade 2+ was noted. She has difficulty ambulating

because of the muscle removed from her right foot.

32

ANATOMY AND PHYSIOLOGY

The Urinary System is the system of organs that produces and excretes urine from the

body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess water, salts,

and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-

shaped organs that continuously filter substances from the blood and produce urine. Urine flows

from the kidneys through two long, thin tubes called ureters. With the aid of gravity and

wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The

normal adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the

tubelike urethra.

An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a min-

imum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products.

The kidneys lie embedded in fat tissue on either side of the backbone at about waist level. Each

fist-sized kidney is reddish-brown, weighs 140 to 160 g (5 to 6 oz), and is similar in shape to the

kidney beans sold at the supermarket.

33

On the inner border of each kidney is a depression called the hilum, where the renal

artery, the renal vein, and the ureter connect with the kidney (the adjective renal is from the

Latin term renalis, meaning of or near the kidneys). The renal artery delivers over 1700 liters

(450 gal) of blood to the kidneys each day, which these organs filter and return to the heart via

the renal vein. Each kidney contains about 1 million microscopic coiled channels, called

nephrons, which perform this critical blood-filtering function and produce urine in the process.

The bulblike upper portion of the kidney’s nephrons filters water; urea, the nitrogen-

containing breakdown product of protein; salts; glucose; amino acids, the building blocks of

34

proteins; yellow bile compounds from the liver; and other trace substances from the blood. As

this material moves through a long, looped tubule, many of these filtered materials are

reabsorbed into the blood to be reused by the body to maintain normal body functions. Less than

1 percent of the water and other materials remain behind to be excreted as waste products in the

urine.

These waste materials then pass from the nephrons into a funnel-shaped area called the

renal pelvis. From the renal pelvis, waste trickles out of the kidney into the ureter, which is about

25 to 30 cm (10 to 12 in) long and about 0.5 cm (0.2 in) in diameter. The ureter empties into a

hollow, muscular sac called the urinary bladder. A valvelike flap of tissue at the point of entry

into the bladder prevents urine from flowing backward into the ureter. The urinary bladder is

able to expand and contract according to how much urine it contains. As it fills with urine, the

walls of the bladder stretch and become thinner, with the bladder itself lengthening to 12.5 cm (5

in) or more and holding up to about 0.5 liter (1 pt) of urine. A ringlike sphincter muscle

surrounds the bladder’s outlet and prevents spontaneous emptying.

As the bladder becomes full, stretch-sensitive receptors in its walls are stimulated, and

the person becomes aware of the fullness. When the person is ready to urinate, or expel urine, the

sphincter relaxes and urine flows from the bladder to the outside through the urethra. In females,

the urethra is about 3.8 cm (1.5 in) long and is strictly a urinary passage. In males, the urethra is

about 20 cm (8 in) long; it passes through the penis and also serves to convey semen during

sexual intercourse.

35

Production of Urine. Blood enters the kidney through the renal artery. The artery di-

vides into smaller and smaller blood vessels, called arterioles, eventually ending in the tiny capil-

laries of the glomerulus. The capillary walls here are quite thin, and the blood pressure within the

capillaries is high. The result is that water, along with any substances that may be dissolved in it

—typically salts, glucose or sugar, amino acids, and the waste products urea and uric acid—are

pushed out through the thin capillary walls, where they are collected in Bowman's capsule.

Larger particles in the blood, such as red blood cells and protein molecules, are too bulky to pass

through the capillary walls and they remain in the bloodstream. The blood, which is now filtered,

leaves the glomerulus through another arteriole, which branches into the meshlike network of

blood vessels around the renal tubule. The blood then exits the kidney through the renal vein.

Approximately 180 liters (about 50 gallons) of blood moves through the two kidneys every day.

Urine production begins with the substances that the blood leaves behind during its passage

through the kidney—the water, salts, and other substances collected from the glomerulus in

Bowman’s capsule. This liquid, called glomerular filtrate, moves from Bowman’s capsule

through the renal tubule. As the filtrate flows through the renal tubule, the network of blood ves-

sels surrounding the tubule reabsorbs much of the water, salt, and virtually all of the nutrients,

especially glucose and amino acids, that were removed in the glomerulus. This important

process, called tubular reabsorption, enables the body to selectively keep the substances it needs

while ridding itself of wastes. Eventually, about 99 percent of the water, salt, and other nutrients

is reabsorbed.

36

At the same time that the kidney reabsorbs valuable nutrients from the glomerular filtrate,

it carries out an opposing task, called tubular secretion. In this process, unwanted substances

from the capillaries surrounding the nephron are added to the glomerular filtrate. These sub-

stances include various charged particles called ions, including ammonium, hydrogen, and potas-

sium ions.

Together, glomerular filtration, tubular reabsorption, and tubular secretion produce urine,

which flows into collecting ducts, which guide it into the microtubules of the pyramids. The

urine is then stored in the renal cavity and eventually drained into the ureters, which are long,

narrow tubes leading to the bladder. From the roughly 180 liters (about 50 gallons) of blood that

the kidneys filter each day, about 1.5 liters (1.3 qt) of urine are produced.

Other functions. In addition to cleaning the blood, the kidneys perform several other

essential functions. One such activity is regulation of the amount of water contained in the blood.

This process is influenced by antidiuretic hormone (ADH), also called vasopressin, which is

produced in the hypothalamus (a part of the brain that regulates many internal functions) and

stored in the nearby pituitary gland. Receptors in the brain monitor the blood’s water

concentration. When the amount of salt and other substances in the blood becomes too high, the

pituitary gland releases ADH into the bloodstream. When it enters the kidney, ADH makes the

walls of the renal tubules and collecting ducts more permeable to water, so that more water is

reabsorbed into the bloodstream.

The hormone aldosterone, produced by the adrenal glands, interacts with the kidneys to

regulate the blood’s sodium and potassium content. High amounts of aldosterone cause the

37

nephrons to reabsorb more sodium ions, more water, and fewer potassium ions; low levels of al-

dosterone have the reverse effect. The kidney’s responses to aldosterone help keep the blood’s

salt levels within the narrow range that is best for crucial physiological activities.

Aldosterone also helps regulate blood pressure. When blood pressure starts to fall, the

kidney releases an enzyme (a specialized protein) called renin, which converts a blood protein

into the hormone angiotensin. This hormone causes blood vessels to constrict, resulting in a rise

in blood pressure. Angiotensin then induces the adrenal glands to release aldosterone, which pro-

motes sodium and water to be reabsorbed, further increasing blood volume and blood pressure.

The kidney also adjusts the body's acid-base balance to prevent such blood disorders as

acidosis and alkalosis, both of which impair the functioning of the central nervous system. If the

blood is too acidic, meaning that there is an excess of hydrogen ions, the kidney moves these

ions to the urine through the process of tubular secretion. An additional function of the kidney is

the processing of vitamin D; the kidney converts this vitamin to an active form that stimulates

bone development.

Several hormones are produced in the kidney. One of these, erythropoietin, influences the

production of red blood cells in the bone marrow. When the kidney detects that the number of

red blood cells in the body is declining, it secretes erythropoietin. This hormone travels in the

bloodstream to the bone marrow, stimulating the production and release of more red cells.

38

ETIOLOGY AND SYMPTOMATOLOGY

A. ETIOLOGY

Predisposing

FactorsPresent/ Absent Rationale Justification

Age Present In ESRD, the patient is

predisposed to the disease

by her age because with

increased age, there is

already wear and tear of the

organs and diminished

ability of the kidneys to

perform as they should.

Also, major candidates for

Diabetes Mellitus type 2

are seen to be of the adult

population; this

predisposed the patient to

the disease which lead to

The patient is aged 56

years old.

39

ESRD.

Family History Present The risk of ESRD

secondary to

hydronephrosis secondary

to diabetes mellitus is

substantially increased if

either of a patient’s parents

had diabetes. Diabetes is

often inherited (passed

from the parent to the

child).

Although family

history of ESRD is

not present, it is

important to note that

ESRD in this

particular patient

rooted from the

existent disease

diabetes mellitus

which runs in the

paternal side of the

patient’s family. The

father of the patient

and some of the

family members in

the father’s side of

the patient has

diabetes mellitus.

Precipitating

FactorsPresent/ Absent Rationale Justification

40

Obesity Absent Researchers attribute most cases of Type 2 diabetes to obesity. Studies show that the risk for developing Type 2 diabetes increases by 4 percent for every pound of excess weight a person carries. Researchers are investigating the exact role that extra weight plays in preventing the proper utilization of insulin and why some overweight peo-ple develop the disease while others do not.

Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved.

The patient is not

obese. Her weight

which is 59kg or 130

lbs and height of 4’10

is suggestive of a BMI

of 27 which may be

overweight but is still

not considered as

obese.

Sedentary lifestyle absent A sedentary lifestyle may

contribute to obesity which

is said to be a factor which

can cause diabetes mellitus

type two.

The patient is not

having a sedentary

lifestyle as reported.

The patient claims that

she has been living a

fairly active lifestyle.

Although she does not

exert any effort to jog

or stretch habitually;

she reports to do

chores at home such as

41

doing the laundry,

watering her plants and

others.

Increased dietary fat

intake

present The accumulation of too much fat in the body is associated with a variety of health problems. Studies show that individuals who are overweight or obese run a greater risk of developing diabetes mellitus, hypertension, coronary heart disease, stroke, arthritis, and some forms of cancer.

Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved.

The patient does not

deny the fact that she

used to have high

intake of fats prior to

her hospitalization

B. SYMPTOMATOLOGY

Symptoms Present/Absent Rationale Justification

Peripheral edema present Edema is apparent,

resulting from fluid

retention due to the

impairment of the

ability of the kidneys

to excrete fluids.

Bipedal edema with the score

of 2+ is noted.

42

Increased

creatinine levels

present Increased creatinine

levels suggest renal

insufficiency.

The creatinine level of the

patient is 697.90mmOl/L

Flank pain absent Flank pain is one of

the classic symptoms

of kidney damage.

The patient did not report any

experience of flank pain.

Massive

proteinuria

absent Protein is a macro

molecule which is not

supposed to cross the

urine, however, in

cases of renal

impairment, proper

glomerular filtration

is damaged that the

kidneys could not

efficiently filter

macromolecules

causing them to cross

the urine.

Electrolyte

imbalances

present One of the major

functions of the

kidney is to regulate

Sodium levels are relatively

high.

43

electrolyte levels in

the body.

Anemia present The kidneys produce

the hormone

erythropoietin in

adults. This stimulates

the production of red

blood cells which

carry oxygen in the

body. Diminished

RBCs is termed

anemia.

The Blood test of the patient

shows abnormally low levels of

RBCs, hemoglobin and

hematocrit.

Hemoglobin= 77

Hematocrit= 0.22

RBCs=2.60

44

PATHOPHYSIOLOGY

HeredityAge

DietLifestyle

Glucose in the blood

Cells do not respond to the effects of insulin in type 2 diabetes

Excessive thirst, generalized weakness, excessive urination, blurred vision, delayed wound healingDiet and lifestyle modification

Administration of medications Increased blood viscosity

HypertensionStretching of intravascular spaces

Stretching of capillaries

Renal capillary collapse

Loss/ impaired of nephron function

Diminished renal reserve Loss of excretory renal function

Inefficient urine flow/Urine flow interruption

40-50% renal function

Renal Insufficiency 20-40% renal function

HYDRONEPHROSIS

Chronic Renal Disease

Cardiovascular

HypertensionEdema

Neurologic

LOC changesWeaknessFatigue

Hematologic

Anemia

Musculoskeletal

Loss of muscle strengthMalaise

ESRD

45

Due to Diabetes Mellitus type 2 resulting from etiologies, blood glucose levels start con-

centrating in blood because of the inability of the cells to respond to the effects of insulin. As

blood glucose levels increase, blood viscosity also increases, thereby stretching intravascular

spaces systemically leading to extensive dilation of capillaries. This overstretching also results to

hypertension; however, the worst scenario that it can bring is the collapse of end capillaries espe-

cially in vital organs such as the kidneys. In this case, the extensive dilation of kidney capillaries

result in renal capillary collapse which causes impairment in the renal function.

ESRD Excessive ac-

cumulation of metabolic wastes

Kidneys un-able to main-tain home-ostasis

Psychological changes

10-15% renal function

If not treated

DEATH

TreatmentA. Medications

NaHCO3 Diuretics Antihypertensive drugs Antacids Aluminum Hydroxide Multivitamins

B. Dialysis Peritoneal Hemodialysis

C. Renal TransplantD. Lifestyle and Diet Modifications

GOOD PROGNOSIS

46

The kidneys function as filtering devices in our body, it also excretes urine as wastes and

secrete hormones essential to the body. With the destruction of proper renal functioning, several

problems arise. On one hand, excreting function is impaired thus causing urinary retention lead-

ing to hydronephrosis. On the other end, impaired renal functioning will start progressing into

chronic kidney disease in which leads to several discomforts and changes in the body such as

edema, anemia, LOC changes, uremia and many others. These conditions, if still not properly

managed and detected early will all lead to the dreadful end stage renal disease.

47

DOCTOR’S Orders

48

Date Order Rationale Remarks

Novemb

er 9,

2009

Pls admit to IMCU The patient is admitted to IMCU

because her condition fits in this

department basing on disease

categorization.

Done

Low Fat Low Salt The patient has hypertension, high

intake of dietary sodium and fat

may worsen the condition of the

patient.

Done

VSq4 This is done in order to constantly

monitor any changes in the vital

signs of the patient which may

indicate new advances or

worsening of the condition of the

patient in order to be addressed

immediately.

Done

Venoclysis:

PNSS@KVO

PNSS is given to the patient in

order to serve as a line for her

IVTT medications. Also, PNSS is

an isotonic solution, it will not

cause any changes in the

osmolarity of the fluids in the

patient’s body given that the

patient’s renal function is already

impaired.

Done

Serum electrolytes This test is being ordered in order

to know the specific values of

electrolytes in the blood. It also

suggests progress in the treatment

Done

55

DIAGNOSTIC EXAM

A. Actual Laboratory Tests and Diagnostic Examinations

Urinalysis

Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions

that produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.

Date Laboratory TestNormal Value /

ResultsResult Clinical Significance

Nursing

Interventions

O

C

T

O

B

E

R

Color Yellow, straw, amber Dark Yellow

(normal)

Colorless: overhydration, diuretic therapy,

diabetes insipidus and mellitus

Dark red or pink: porphyria, hematuria, ingestion

of red food coloring, beets, berries, fava beans,

rhubarb

Dark yellow: bile

Green: pseudomonas bacteriuria, urinary bile

pigments

Pretest:

>Provide

patient with

urine

container with

lid.

>Instruct the

patient to

56

1

9

2

0

0

9

Appearance

Reaction

Specific gravity

Clear to faintly hazy

4.0-8.0

1.003- 1.030

Clear

(normal)

6.0

(normal)

1.042

(high)

Cloudy, smoky or hazy: pyuria, bacteriuria,

phosphates in urine

If >8.0, finding may be the result of UTI If <4.0,

may indicate respiratory or metabolic acidosis

increased in:dehydration, fever, profuse sweating,

vomiting, diarrhea, glycosuria, proteinuria, CHF,

adrenal insufficiency, SIADH

Decreased in: overhydration, diuresis,

hypotension, pyelonephritis, glomerulonephritis,

renal tubular dysfunction, severe renal damage,

diabetes insipidus

Positive in: nephrotic syndrome, renal

collect a

sample of

urine,

preferably on

arising in the

morning;

must not be

contaminated

by toilet

paper, toilet

water, feces

or secretions.

>Women

should not

collect urine

during

57

Albumin

Sugar

Epithelial Cells-

Squamous

Pus cells

Red Blood Cells

Negative

Negative

+++

≤ 4 cells/HPF

≤ 2 rbc hpf

positive

negative

5-8

0-2 hpf

disorders, associated with hypertension,

diabetes mellitus, SLE, amyloidosis

Positive in: hyperglycemia, diabetes mellitus

Positive in: urinary tract infection (UTI)

Positive in indicates bleeding at some location

in the urinary tract, from the glomeruli to

urethra, or leakage of rbc through the

glomerular membrane.

menstruation.

>Instruct

patient to

collect a

midstream

voided

specimen.

Posttest:

>The lid must

be sealed

completely

and the

container

must be

labeled

58

Mucous threads ++ properly.

>Specimen

must be

delivered to

the laboratory

immediately.

COMPLETE BLOOD COUNT AND PLATELET COUNT

The CBC is a series of different tests used to evaluate the blood and the cellular components of RBC’s, WBC’s and

platelets. The CBC is used to assess the patient for anemia, infection, inflammation, polycythemia, hemolytic disease, and the effects

of ABO incompatibility, leukemia and dehydration status

59

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical

SignificanceNursing Responsibilities

Novemb

er 10,

2009

Hemoglobin 115 – 175

g/L

The test that

measures the

amount of

hemoglobin per

liter of blood

96 Low Increased in:

polycythemia,

dehydration,

acute thermal

injury, COPD

Decreased in:

hemorrhage,

bleeding,

anemia,

hemolytic

anemia, fluid

overload, fluid

retention,

pregnancy,

1. Discuss and explain the

procedure and purpose of

the test.

2. Inform the patient that no

fasting is needed.

3. Assess the patient for any

factor that will probably

affect the results of the

test.

4. Make sure patient is well

60

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


cirrhosis of the

liver,

hyperthyroidis

m

A low

hemoglobin is

referred to as

anemia.

hydrated. Dehydration

elevates the test results.

5. If patient is connected to

IVF, make sure that the

blood is not taken from

the arm connected to the

IVF. Hemodilution

causes false decrease of

the test results.

6. After the puncture, assess

the site for bleeding or

bruising.

Hematocrit 0.36 – 0.48

The test measures

the percentage of

RBC in the total

blood volume

0.27 Low

A low

hematocrit is

referred to as

anemia.

RBC count 4.20 – 6.10 The test measures

the circulating

3.58 Low Low RBC may

indicate blood

61

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


RBCs in 1 cubic

millimeter of

blood.

loss, anemia,

hemorrhage,

bone marrow

failure,

leukemia, and

malnutrition

7. If patient is under

treatment from an

infection, inform the

patient that the test will

be repeated to monitor

progress.

8. Any abnormality noted

will be reported to the

physician.

WBC count 5.0 – 10.0

The test measures

all leukocytes

present in 1 cubic

millimeter of

blood.

6.01 Normal Normal

Neutrophil 55 – 75 Neutrophils serve

as the body's

primary defense

62 Low Normal

.

62

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


against infection

through the

process of

phagocytosis.

Usually used to

diagnose specific

type of illnesses.

Lymphocyte 20 – 35 Lymphocytes

initiate

immunologic

cresponses. The

test determines

lymphocyte blood

count.

37 High Abnormally high

levels of

lymphocytes can

be due to flu,

chicken pox, and

some viral and

bacterial

63

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


infection.

Monocyte 2 – 10

Monocytes have

phagocytic action.

It removes dead

or injured cells,

cell fragments,

and

microorganism.

This test is done

to diagnose an

illness such as

inflammatory

diseases.

9 Normal Normal

Eosinophils 1 – 8 Eosinophils 7 Normal Normal

64

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


initiate allergic

responses and act

against parasitic

infestation. The

test is use to

diagnose worm

infestation.

Basophil 0 – 1

Basophils initiate

type 1 allergic

responses

1 Normal Normal

Platelet count 150 – 400 The test measures

all platelets

present in 1 cubic

millimeter of

214 Normal Normal

65

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


blood.

Chemistry

Potassium 3.5 – 5.5

The test measures

potassium levels

of the blood.

4.0 Normal Normal

Sodium 136 – 155 The test measures

the sodium levels

in the blood.

168 High High Serum

sodium indicates

retention of

sodium in the

body and a

diminished

filtration

function of the

66

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


kidneys.

Creatinine 53 - 115

The test usually

indicates renal

function.

697.90 High

This measures

renal

sufficiency.. The

lower the level

of creatinine in

the body, the

healthier the

kidneys are.

Activated Partial Thromboplastin Time (APTT)

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


Novemb APTT 29.4 – 38.4 The test measures 34.0 Normal Normal

67

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


er 13,

2009

the time in

seconds for a

specific clotting

process to occur.

APTT Control 26.0 – 31.0

If the test sample

takes longer than

the control

sample, it

indicates

decreased clotting

function in the

intrinsic pathway.

28.5 Normal Normal

Prothrombin Time (PT)

Date Exam Normal Rationale Result of Remearks Clinical Nursing Responsibilities

68

Date ExamNormal

ValueRationale

Result of

PatientRemearks

Clinical


Value Patient Significance

PT Patient 11.8 – 15.1 PT may be

ordered when a

patient is to

undergo an

invasive medical

procedure, such

as surgery, to

ensure normal

clotting ability.

14.6 Normal Normal

June 21,

2009PT Control 12.0 – 15.0 13.5 Normal Normal

64

Drug Study

Generic Name Furosemide

Brand Name Apo-Furosemide, Furosemide Special IV, Furoemide, Lasix, Novo-semide,

Uritol

Classification Loop diuretic

Suggested Dose Acute pulmonary edema (adult): 40 mg I.V. injection slowly over 1 to 2

minutes; then 80 mg I.V. in 60 to 90 minutes if needed

Edema (adult): 20 to 80 mg P.O. daily in the morning.

(infants and children): 2 mg/kg P.O. daily, increased by 1 to 2 mg/kg in 6

to 8 hours if needed

Hypertension (adult): 40 mg P.O. b.i.d.

65

(children): 0.5 to 2 mg/kg P.O. once or twice daily.

Mechanism of

Action

Inhibits sodium and chloride reabsorption at proximal and distal tubule and

the ascending loop of Henle

Indication Pulmonary edema, edema in CHF, nephrotic syndrome, hypertension

Contraindication Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation and

electrolyte depletion

Drug Interaction Amioglycosides antibiotics, cisplatin: may increase risl of hypokalemia.

Antidiabetis: may decrease hypoglycemic effects

Antihypertensives: may increase risk of hypertension

Cardiac glycosides, neuromuscular blockers: may increase toxicity of these

drugs from furosemide-induced hypokalemia

Chlorothiazide, chloothalidone, hydrochlorothiazide, indapamide,

metolazone: may cause excessive diuretic response, causing serious

electrolyte abnormalities and dehydration.

Ethacrynic acid: may increase risk of ototoxicity

Lithium: may decrease lithium excretion, resulting in lithium toxicity

NSAIDs: may inhibit diuretic response

Side/Adverse Effects CNS: vertigo, headache, dizziness, paesthesia, weakness, restlessness, fever.

CV: orthostatic hypotension, thrombophlebitis with I.V. admnistration.

EENT: transcient deafness, blurred or yellowed vision, tinnitus.

ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic

66

alkalosis

GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting,

constipation, pancreatitis

GU: nocturia, polyuria, frequent urination, oliguria

Hematologic: agranulocytosis, aplastic anemia, leucopenia,

thrombocytopenia, azotemia, anemia

Hepatic: hepatic dysfunction, jaundice

Metabolic: volume depletion and dehydration and dehydration asymptomatic

hyperuricemia, impaired glucose tolerance, hypokalemia, hypochloremic

alkalosis, hyperglycemia, dilutional hyponatremia, hypocalemia,

hypomagnesemia

Musculoskeletal: muscle spasm

Skin: dermatitis, purpura, photosensitivity reactions, transcient pain at I.M.

injection site

Other: gout

Nursing

Responsibilities

1. Monitor potassium level closely, glucose level in diabetics patient and

lithium level.

2. Monitor patient closely for signs and symptoms of excessive diuretic

response.

3. Advise patient to avoid excessive sunlight exposure.

4. To prevent nocturia, give P.O. and I.M. preparations in the morning. Give

second dose earlier afternoon.

67

5. Monitor weight, blood pressure, and pulse rate routinely with long-term

use and during rapid dieresis. Use can lead to profound water and

electrolyte depletion.

6. If oliguria or azotemia develops or increases, drug may need to be

stopped.

7. Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide

levels frequently.

8. Watch for signs of hypokalemia, such as muscle weakness and cramps.

9. Consult prescriber and dietitian about a high-potassium diet or potassium

supplements. Foods rich in potassium include citrus fruits, tomatoes,

bananas, dates, and apricots.

10. Drug may not be well absorbed orally in patient with severe heart failure.

Drug may be given I.V. even if patient is taking other oral drugs.

11. Monitor uric acid level, especially in patients with a history of gout.

12. Advise patient to take drug with food to prevent GI upset, and to take in

morning to prevent eed to urinate at night.

13. Inform patient of possible need for potassium or magnesium supplements.

14. Instruct patient to stand slowly to prevent dizziness and to limit alcohol

intake and strenuous dizziness upon standing quickly.

68

Generic Name Amlodipine

Brand Name Norvasc

Classification Calcium channel blocker

Suggested Dose Chronic stable angina vasospastic angina (Prinzmetal or variant)

(adult): initially, 5 to 10 mg P.O. daily.

(elderly): initially, 5 mg P.O. daily

Hypertension (adult): initially, 2.5 to 5 mg P.O. daily.

(elderly): initially, 2.5 mg P.O. daily

Mechanism of Action Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates

coronary arteries and arterioles, and decreases blood pressure and

myocardial oxygen demand.

Indication Chronic stable angina pectoris, vasospastic angina, hypertension

Contraindication Hypersensitive to drug , Sick sinus syndrome, 2nd-3rd degree heart block,

hypotension less than 90mmHg systole

Drug Interaction Increased hypotension with alcohol, fentanyl, quinidine,

antihypertensives, nitrates

Neurotoxicity with lithium

69

Decreased hypertensive effects with NSAIDs

Side/Adverse Effects CNS: headache, somnolence, fatigue, dizziness, light-headedness,

paresthesia

CV: edema, flushing, palpitations

GI: nausea, abdominal pain

GU: sexual difficulties

Musculoskeletal: muscle pain

Respiratory: dyspnea

Skin: rash, puritus

Nursing

Responsibilities

1. Monitor patient carefully. Some patients, especially those with severe

obstructive coronary artery disease, have developed increased

frequency, duration, or severity of angina or acute MI after initiation of

calcium channel blocker therapy or at time of dosage increase.

2. Monitor blood pressure frequently during initiation of therapy. Because

drug induced vasodilation has a gradual onset, acute hypotension is rare.

3. Notify prescriber if signs of heart failure occur, such as swelling of

hands and feet or shortness of breath.

4. Abrupt withdrawal of drug may increase frequency and duration of

chest pain. Taper dose gradually under medical supervision.

5. Don’t confuse amlodipine with amiloride.

6. Caution patient to continue taking drug, even when feeling better.

70

7. Tell patient S.L. nitroglycerin may be taken as needed when angina

symptoms are acute. If patient continues nitrate therapy during

adjustment of amlodipine dosage, urge continued compliance.

8. Administer once a day without regard to meals.

9. Instruct the patient to take the drug as prescribed, do not double or skip

dose.

10. Evaluate for therapeutic response; decreased anginal pain, decreased BP,

increased exercise tolerance.

Generic Name Ferrous Sulfate

Brand Name Apo-Ferrous Sulfate, ED-IN-SOL, Feosol, Fer-gen-sol, Fer-In-Sol, Fer-iron

Classification Hematinic

Suggested Dose Iron deficiency (adult): 150 to 300 mg P.O. elemental iro daily in three

divided doses.

(children): 3 to 6 mg/kg P.O. daily in three divided doses.

As a supplement during pregnancy (adult): 15 to 30 elemental iron P.O.

daily during last two trimesters.

71

Mechanism of Action Provides elemental iron, an essential component in the formation of

hemoglobin.

Indication Prevention and treatment of iron deficiency anemias; dietary supplement for

iron; unlabeled use: supplemental use during epoetin therapy to ensure

proper hematologic response to epoetin

Contraindication Patients with hemosiderosis, primary hemochromatosis, hemolytic anemia

(unless patient also has iron deficiency anemia), peptic ulceration, ulcerative

colitis, or regional enteritis and in those receiving repeated blood

transfusions.

Drug Interaction Antacids and H2 blockers (cimetidine): Concurrent administration may

decrease iron absorption.

Chloramphenicol: Response to iron therapy may be delayed.

Levodopa, methyldopa, penicillamine: Iron may decrease absorption

when given at the same time.

Quinolones: Absorption may be decreased due to formation of a ferric

ion-quinolone complex

Tetracyclines: Absorption of oral preparation of iron and tetracyclines

are decreased when both of these drugs are given together

Vitamin C: Concurrent administration of 200 mg vitamin C per 30 mg

elemental iron increases absorption of oral iron.

GI: nausea, epigastric pain, vomiting, constipation, black stools, diarrhea,

72

Side/Adverse Effects anorexia

Other: temporarily strained teeth from liquid forms.

Nursing

Responsibilities

1. GI upset may be related to dose.

2. Between-meal doses are preferable. Drug can be given with some foods,

although absorption may be decreased.

3. Enteric-coated products reduce GI upset but also reduce amount of iron

absorbed.

4. Oral iron may turn stools black. Tell patient that although this

unabsorbed iron is harmless, it could be mask melema.

5. Monitor hemoglobin level, hematocrit, and reticulocyte count during

therapy.

6. Don’t confuse different iron salts; elemental content may vary.

7. Tell patient to take tablets with juice (preferably orange juice) or water,

but not with milk or antacids.

8. Instruct patient not to crush or chew extended-release forms.

9. Caution patient not to substitute one iron salt for another because

amounts of elemental iron vary.

10. Advise patient to report constipation and change in stool color

consistency.

11. In administering liquid form, let patient take it with straw to avoid

straining of teeth.

73

Generic Name Tramadol hydrochloride

Brand Name Dolcet, Dolotral, Milador, Siverol, Tramal

Classification Pharmacologic class: opioid agonist

Therapeutic class: analgesic

Suggested Dose Adults:

Patients who require rapid analgesic effect: 50–100 mg PO q 4–6 hr; do

not exceed 400 mg/day.

Patients with moderate to moderately severe chronic pain: Initiate at 25

mg/day in the morning and titrate in 25-mg increments q 3 days to

reach 100 mg/day. Then, increase in 50 mg-increments q 3 days to

reach 200 mg/day. After titration, 50–100 mg q 4–6 hr; do not exceed

400 mg/day.

Patients with cirrhosis: 50 mg q 12 hr.

Patients with creatinine clearance < 30 ml/min: 50–100 mg PO q 12 hr.

Maximum 200 mg/day.

Pediatric Patients:

74

Safety and efficacy not established.

Geriatric patients or patients with renal or hepatic impairment> 75 yr: Do

not exceed 300 mg/day.

Mechanism of

Action

Binds to mu-opioid receptors and inhibits the reuptake of norepinephrine and

serotonin; causes many effects similar to the opioids—dizziness, somnolence,

nausea, constipation—but does not have the respiratory depressant effects.

Indication Relief of moderate to moderately severe pain when non-opioid anal-

gesics are not active enough

Renal impairment

Hepatic impairment

Contraindication Contraindicated with allergy to tramadol or opioids or acute intoxica-

tion with alcohol, opioids, or psychoactive drugs.

Opioid-dependent patients.

Severe hepatic impairment.

Patients on obstetric preoperative medication.

Abrupt discontinuation.

Children <16 years old.

Use cautiously with pregnancy, lactation, seizures, concomitant use of

CNS depressants or MAOIs, renal dysfunction, or hepatic impairment.

Drug Interaction Drug – Drug

Carbamazepine. Significantly decreases tramadol levels (may need

75

up to twice usual dose).

MAO Inhibitors. Tramadol may increase adverse effects.

Tricyclic Antidepressants, Cyclobenzaprine, Phenothiazines, Selec-

tive Serotonin Reuptake Inhibitors (SSRI), MAO Inhibitors. May

enhance seizure risk with tramadol.

Other CNS Depressants. May increase CNS adverse effects of tra-

madol.

Herbal: St. John's Wort. May increase sedation.

Side/Adverse Effects CNS: sedation, dizziness or vertigo, headache, confusion, dreaming, sweating,

anxiety,

CV: hypotension, tachycardia, bradycardia

Skin: sweating, pruritus, rash, pallor, urticaria

GI: nausea, vomiting, dry mouth, constipation, flatulence

GU: urinary retention / frequency, menopausal symptoms, dysuria, menstrual

disorder

Other: potential for abuse

Nursing

Responsibilities

1. Assess for level of pain relief and administer prn dose as needed but not to

exceed the recommended total daily dose.

2. Monitor vital signs and assess for orthostatic hypotension or signs of CNS

depression.

3. Explain the drug action, purpose of drug and side effects.

76

4. Advise the patient to avoid activities that require mental alertness.

5. Assess for history of drug addiction, allergy to opiates or codeine or

seizures.

6. Assess the patient’s skin color, texture, lesions; orientation, reflexes,

bilateral grip strength, affect; P, auscultation, BP; bowel sounds, normal

output; LFTs, renal function tests.

7. Instruct the patient to lye down for a while after taking the drug.

8. Report severe nausea, dizziness, severe constipation.

9. Monitor input and output ratio. Check for decreasing output.

10. Instruct the patient to make position changes slowly.

11. Tell the patient and watcher to report symptoms of CNS changes, allergic

reactions.

12. Provide safety measures: side rails, night light, call bell within easy reach.

Generic Name Metoclopramide

77

Brand Name Apo-Metoclop. Clopra, Maxeran, Maolon, Octamide PFS, Pramin, Reglan

Classification Dopamine antagonist

Indication and

Suggested Dose

To prevent or reduce nausea and vomiting from emetogenic cancer

chemotherapy: Adult: 1 to 2 mg/kg I.V. 30 minutes before chemotherapy;

repeat q 2 hours for two doses, then q 3 hours for three doses.

To prevent or reduce postoperative nausea and vomiting: Adult: 10 to

20 mg I.M. near end of surgical procedure, repeat q 4 to 6 hours, p.r.n.

To facilitate small-bowel intubation, to aid in radiologic examinations:

Adults and children older than age 14: 10 mg or 20 ml I.V. as a single dose

over 1 to 2 minutes.

Children ages 6 to 14: 2.5 to 5 mg or 0.5 to 1 ml I.V.

Children younger than age 6: 0.1 mg/kg I.V.

Delayed gastric emptying secondary to diabetic gastroparesis: Adult:

10 mg P.O. 30 minutes before each meal and at bedtime for mild symp-

toms. Give slow I.V. infusion over 1 to 2 minutes 30 minutes before each

78

meal and at bedtime for up to 10 days for severe symptoms; then P.O. dose

may be started and continued for 2 to 8 weeks.

Gastroesophageal reflux disease: Adult: 10 to 15 mg P.O. q.i.d., p.r.n., 30

minutes before meals and at bedtime.

Emesis during pregnancy: Adults: 5 to 10 mg P.O. or 5 to 20 mg I.V. or

I.M. t.i.d.

Mechanism of

Action

Stimulates motility of upper GI tract, increases lower esophageal sphincter

tone, and blocks dopamine receptors at the chemoreceptor trigger zone.

Contraindication Hypersensitivity to drug and in those with oheochromocytoma r seizure

disorders.

Stimulation of GI motility might be dangerous

History f depression, Parkinson disease, or hypertension

Drug Interaction Substrate (minor) of CYP1A2, 2D6; Inhibits CYP2D6 (weak)

Anticholinergic agents antagonize metoclopramide's actions

Antipsychotic agents: Metoclopramide may increase extrapyramidal symp-

toms (EPS) or risk when used concurrently.

Opiate analgesics may increase CNS depression

Side/Adverse Effects CNS: anxiety, drowsiness, dystonic reaction, fatigue, lassitude, restlessness,

neuroleptic, malignant syndrome, seizures, suicide ideation, akathisia,

confusion, depression, dizziness, extrapyramidal ymptoms, fever, hallucinatins.

Headache. Insomnia, tardive dyskinesia.

CV: bradychardia, superventricular tachycardia, hypotension, transient

79

hypertension.

GI: bowel disorders, diarrhea, nausea

GU: incontinence, urinary frequency

Hematologic: aggranulocytosis, neuropenia

Skin: rash, uricaria

Other: loss of libido, prolactin secretion.

Nursing

Responsibilities

1. Assess for mental status; depression, anxiety and irritability.

2. Monitor bowel sounds.

3. Safety and effectiveness of drug haven’t been established for therapy

lasting longer than 12 weeks.

4. Tell patient to avoid activities that require alertness for 2 hours after doses.

5. Urge patient to report persistent or serious adverse reactions promptly.

6. Advise patient not to drink alcohol during therapy.

7. Administer 1 ½ hour before meals for better absorption

8. Monitor vital signs, especially cardiac rate to monitor tachycardia.

9. Evaluate for therapeutic effects: absence of nausea, vomiting, anorexia and

fullness.

Generic Name Sodium Bicarbonate

80

Brand Name Arm & Hammer Baking Soda, Bell/ans, Neut, Soda Mint

Classification Alkanizer

Suggested Dose Metabolic acidosis: Adults and children: dosage depends on blood carbon

dioxide content, pH, and patient’s condition; usually, 2 to 5 mEq/kg I.V. in-

fused over 4- to 8- hour period.

Systemic or urinary alkalanization: Adults: initially, 4 P.O.; then 1 to 2 g q

6 hours. Children: 84 to 840 mg/kg P.O. daily.

Antacid: adults: 300 mg to 2 g P.O. up to q.i.d. taken with glass of water.

Cardiac Arrest: Adults: 1 mEq/kg I.V. of 7.5% or 8.4% solution; then 0.5

mEq/kg I.V. q 10 minutes depending on arterial blood gas (ABG) level. Base

further dosages on results of ABG analysis. If ABG level is unavailable, use

0.5 mEq/kg I.V. q 10 minutes until spontaneous circulation returns. Infants

81

and children: 1 mEq/kg (1 ml/kg of 8.4% solution) I.V. slowly followed by 1

mEq/kg q 10 minutes of arrest. Don’t give more than 8 mEq/kg I.V. total; a

4.2% solution may be preferred.

Mechanism of

Action

Dissociates to provide bicarbonate ion which neutralizes hydrogen ion

concentration and raises blood and urinary pH

Indication Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac

Arrest

Contraindication Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown

abdominal pain

Drug Interaction Decreased effect/levels of lithium, chlorpropamide, methotrexate, tetracy-

clines, and salicylates due to urinary alkalinization

Increased toxicity/levels of amphetamines, anorexiants, mecamylamine,

ephedrine, pseudoephedrine, flecainide, quinidine, quinine due to urinary

alkalinization

Side/Adverse Effects CNS: tetany

CV: edema

Metabolic: hypokalemia, metabolic alkalosis, hypernatremia,

hyperosmolarity with overdose

Skin: pain and irritation a injection site

82

Nursing

Responsibilities

1. To avoid risk of alkalosis, obtain blood pH, partial pressue of arterial

oxygen, partial pressure of arterial carbon dioxide, and electrolyte levels.

Tell prescriber laboratory results.

2. Oral products may contain 27% sodium.

3. Tell patient not to take drug with milk because doing so may cause high

levels of calcium in the blood, abnormally high alkalinity in tissues and

fluids, or kidney stones.

4. Advise patient of milk-alkali syndrome if use is long-term; observe for

extravasations when giving I.V.

Generic Name Ketosteril

Brand Name Ketosteril

Classification Keto Analog of Essential Amino Acids

Suggested Dose Adult 70 kg 4-8 tab tid given if GFR is 5-15 mL/min.

83

Mechanism of

Action

This drug is combination of amino acids which promotes splitting of urea. It

reduces ion concentration of K, Mg and Phosphate. This promotes recycling

products exchanging and anabolism of protein while reducing urea

concentration in serum.

Indication Pre-ESRD in CKD & DN patients stage 3, 4, 5 together w/ a very low protein

(0.3-0.6 g/kg body wt/day), high caloric diet in compensated &

decompensated retention to reduce uremic symptoms, slow or arrest of the

progression of renal failure, prevent the degradation of body protein, reduce

the daily urinary protein loss, normalisation of the carbohydrate metabolism,

correct the disturbances in Ca & phosphate metabolism, secondary

hyperparathyroidism & renal osteodystrophy, improve the disturbed serum

lipid profile & delay the need for dialysis. Dialysis CKD patients together

with high protein (1.2-1.3 g/kg body wt/day) to reduce uremic symptoms &

improve malnutrition status.

Contraindication Hypercalcemia, disturbed amino acid metabolism. In case of hereditary

phenylketonurie it has to be taken into account that this product contains

phenylalanine.

Drug Interaction Tetracycline affects Ca absorption

Side/Adverse Effects Headache, dizziness, dry mouth, nervousness, flushing, or irritability

Trouble sleeping, stomach cramps, hot flashes and leg cramps

84

Chest pain, slow/fast/irregular heartbeat, swelling of the feet or ankles,

difficulty urinating, swelling of the breasts or discharge from the nipple in

men or women, menstrual changes, sexual difficulties.

Nursing

Responsibilities

1. Tell patient to inform prescriber of all prescriptions, OTC medications, or

herbal products he is taking, and any allergies he have.

2. Advice patient not to take any new medication during therapy unless

approved by prescriber.

3. Tell patient that he may take without regard to food. Maintain adequate

hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake.

4. Inform the patient that the drug is available in many forms and dosages.

The patient must take the drug in a dosage ordered by the prescriber.

5. Tell patient to report episodes of hypersensitivity reaction immediately.

6. Tell the patient not to abruptly stop the medication unless ordered by the

physician.

7. Ensure that the patient does npt manifest any condition contraindicated in

taking this drug.

8. Warn patient to avoid alcohol..

9. Tell woman to stop drug and notify prescriber immediately if she is or

may be pregnant or if she’s breastfeeding.

10. Assess the efficacy of the drug by monitoring VS and laboratory results.

Refer accordingly.

85

Generic Name Atorvastatin Calcium

Brand Name Lipitor, Atacor

Classification HMG-CoA reductase inhibitor

Suggested Dose Oral:

Children 10-17 years (females >1 year postmenarche): HeFH: 10 mg once

daily (maximum: 20 mg/day)

Adults: Hyperlipidemias: Initial: 10-20 mg once daily; patients requiring

>45% reduction in LDL-C may be started at 40 mg once daily; range: 10-80

mg once daily

Primary prevention of CVD: 10 mg once daily

Dosing adjustment in renal impairment: No dosage adjustment is

necessary.

Dosing adjustment in hepatic impairment: Do not use in active liver

86

disease.

Mechanism of

Action

Inhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol

biosynthesis.

Indication Adjunct to diet to reduce LDL, total cholesterol, apolopoproteim B, and

triglyceride levels in patients with primary hypercholesterolemia

(heterozygous familial ad nonfamilial) and mixed dyslipideia (Fredrickson

types IIa and IIb); adjunct to diet to reduce triglyceride level (Fredrickson

type IV); primary dysbetalipoproteinemia (Fredrickson type III) in

patients who don’t respond adequately to diet.

Alone or as adjunct to lipid-lowering treatments, such as LDL apheresis,

to reduce total and LDL cholesterol in patients with homozygous familial

hypercholesterolemia

Heterozygous familial hypercholesterolemia

To reduce the risk of MI, stroke, angina, or revascularization procedures in

patients with multiple risk factors for CAD but who don’t yet have the

disease.

Contraindication Hypersensitivity to atorvastatin or any component of the formulation; active

liver disease; unexplained persistent elevations of serum transaminases;

pregnancy; breast-feeding

Drug Interaction Substrate of CYP3A4 (major); Inhibits CYP3A4 (weak)

Antacids: Plasma concentrations may be decreased when given with mag-

nesium-aluminum hydroxide containing antacids (reported with atorvas-

87

tatin and pravastatin). Clinical efficacy is not altered, no dosage adjust-

ment is necessary

Cholestyramine and colestipol (bile acid sequestrants): Reduce absorp-

tion of several HMG-CoA reductase inhibitors; separate administration

times by at least 4 hours. Cholesterol-lowering effects are additive.

Clofibrate and fenofibrate may increase the risk of myopathy and rhab-

domyolysis.

CYP3A4 inhibitors: May increase the levels/effects of atorvastatin. Ex-

ample inhibitors include azole antifungals, ciprofloxacin, clarithromycin,

diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone,

nicardipine, propofol, protease inhibitors, quinidine, and verapamil.

Digoxin: Plasma concentrations of digoxin may be increased by ~20%;

monitor.

Grapefruit juice: May inhibit metabolism of atorvastatin via CYP3A4;

more likely to occur with lovastatin or simvastatin; avoid high dietary in-

take of grapefruit juice

Niacin may increase the risk of myopathy and rhabdomyolysis.

Side/Adverse Effects CNS: headache, asthenia, insomnia

CV: peripheral edema

EENT: pharyngitis, rhinitis, sinusitis

GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea.

88

GU: UTI

Musculoskeletal: rhbdomyolysis, arthritis, arthralgia, myalgia

Skin: rash

Other: allergic reactions, flulike syndrome, infection

Nursing

Responsibilities

11. Tell patient to inform prescriber of all prescriptions, OTC medications, or

herbal products he is taking, and any allergies he have.

12. Advice patient not to take any new medication during therapy unless

approved by prescriber.

13. Tell patient that he may take without regard to food. Maintain adequate

hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake.

14. Inform patient drug can cause headache (consult prescriber for approved

analgesic); diarrhea (buttermilk, boiled milk, or yogurt may help);

euphoria, giddiness, or confusion (use caution when driving or engaging

in tasks that require alertness until response to medication is known).

15. Tell patient to report unresolved diarrhea, unusual muscle cramping or

weakness, changes in mood or memory, yellowing of skin or eyes, easy

bruising or bleeding, or unusual fatigue.

16. Remind patient not to donate blood while taking this medication and for

same period of time after discontinuing.

17. Teach patient about proper dietary management, weight control, and

exercise. Explain their importance in controlling high fat levels.

18. Warn patient to avoid alcohol..

89

19. Advise patient that drug can be taken at any time of day, without regard to

meals.

20. Tell woman to stop drug and notify prescriber immediately if she is or

may be pregnant or if she’s breastfeeding.

Generic Name Domperidone

Brand Name Alti-Domperidone; Apo-Domperidone®; Dom-Domperidone; FTP-

Domperidone Maleate; Motilium®; Novo-Domperidone; Nu-Domperidone;

ratio-Domperidone

Classification Antiemetic

Suggested Dose Oral: Adults:

90

GI motility disorders: 10 mg 3-4 times/day, 15-30 minutes before meals;

severe/resistant cases: 20 mg 3-4 times/day, 15-30 minutes before meals

Nausea/vomiting associated with dopamine-agonist anti-Parkinson agents: 20

mg 3-4 times/day

Dosage adjustment in renal impairment: Decrease dose to 10-20 mg 1-2

times/day

Mechanism of

Action

Domperidone has peripheral dopamine receptor blocking properties. It

increases esophageal peristalsis and increases lower esophageal sphincter

pressure, increases gastric motility and peristalsis, and enhance

gastroduodenal coordination, therefore, facilitating gastric emptying and

decreasing small bowel transit time.

Indication Symptomatic management of upper GI motility disorders associated with

chronic and subacute gastritis and diabetic gastroparesis; prevention of GI

symptoms associated with use of dopamine-agonist anti-Parkinson agents

Contraindication Hypersensitivity to domperidone or any component of the formulation;

patients with GI hemorrhage, mechanical obstruction, or perforation; patients

with prolactin-releasing pituitary tumor

Drug Interaction Substrate of CYP3A4 (minor)

Anticholinergics: May decrease effects of domperidone.

91

Domperidone may increase the rate of absorption of drugs from small bowel,

while slowing absorption of drugs from the stomach. Absorption of sustained-

release or enteric-coated tablets may be altered.

QTc-prolonging drugs: Use with caution in combination with domperidone;

includes type Ia and type III antiarrhythmics, some fluoroquinolones, and

selected antipsychotics (thioridazine, mesoridazine).

Side/Adverse Effects 1% to 10%:

Central nervous system: Headache/migraine (1%); does not cross blood-brain

barrier; fewer CNS effects compared to metoclopramide

Gastrointestinal: Xerostomia (2%)

<1%: Abdominal cramps, constipation, diarrhea, dizziness, dysuria, edema,

extrapyramidal symptoms (EPS) rarely, galactorrhea, gynecomastia, heart-

burn, hot flashes, increased prolactin, insomnia, irritability, nervousness,

thirst, lethargy, leg cramps, mastalgia, menstrual irregularities, nausea, palpi-

tation, pruritus, rash, regurgitation, stomatitis, urinary frequency, urticaria,

weakness

Nursing

Responsibilities

1. Watch patient for agitation, irritability, confusion, and rarely EPS

2. In GI motility disorders, it should be taken 15-30 minutes prior to meals.

92

3. Inform patient to take drug as directed, 15-30 minutes prior to meals.

4. Advise patient not to increase dosage without consulting prescriber

(adverse effects may occur with overuse).

5. Tell patient that drug may cause dizziness, headache, insomnia and

irritability.

6. Tell patient to contact prescriber if experience abnormal, uncontrolled

movements or confusion occur.

7. Advise patient to report breast pain or enlargement, milk production,

menstrual irregularities, or impotence.

Generic Name Sodium Chloride

Brand Name Altamist [OTC]; Ayr® Baby Saline [OTC]; Ayr® Saline [OTC]; Ayr® Saline

Mist [OTC]; Breathe Right® Saline [OTC]; Broncho Saline® [OTC];

Entsol® [OTC]; Muro 128® [OTC]; NaSal™ [OTC]; Nasal Moist® [OTC];

93

Na-Zone® [OTC]; Ocean® [OTC]; Pediamist® [OTC]; Pretz® Irrigation

[OTC]; SalineX® [OTC]; SeaMist® [OTC]; Simply Saline™ [OTC]; Wound

Wash Saline™ [OTC]

Classification Sodium salt

Suggested Dose Fluid and electrolyte replacement in hyponatremia caused by electrolyte

loss or in severe salt depletion: Adults: dosage is individualized. Use 3% or

5 % solution only with frequent electrolyte level determination and only slow

I.V. For 0.45% solution, 3% to 8% of body weight, according to deficiencies,

over 18 t o 24 hours. For 0.9% solution, 2% t 6% of body weight, according to

deficiencies, over 18 to 24 hours. For 0.9% solution, 2% to 6% of body

weight, according to deficiencies, over 18 to 24 hours.

Heat cramp caused by excessive perspiration: Adults: 1 g P.O. with each

glass of water.

Mechanism of

Action

Principal extracellular cation; functions in fluid and electrolyte balance,

osmotic pressure control, and water distribution

Indication Parenteral: Restores sodium ion in patients with restricted oral intake (es-

pecially hyponatremia states or low salt syndrome). In general, parenteral

saline uses:

Bacteriostatic sodium chloride: Dilution or dissolving drugs for I.M., I.V.,

or SubQ injections

Concentrated sodium chloride: Additive for parenteral fluid therapy

94

Hypertonic sodium chloride: For severe hyponatremia and hypochloremia

Hypotonic sodium chloride: Hydrating solution

Normal saline: Restores water/sodium losses

Pharmaceutical aid/diluent for infusion of compatible drug additives

Ophthalmic: Reduces corneal edema

Oral: Restores sodium losses

Inhalation: Restores moisture to pulmonary system; loosens and thins con-

gestion caused by colds or allergies; diluent for bronchodilator solutions

that require dilution before inhalation

Intranasal: Restores moisture to nasal membranes

Irrigation: Wound cleansing, irrigation, and flushing

Contraindication Hypersensitivity to sodium chloride or any component of the formulation;

hypertonic uterus, hypernatremia, fluid retention

Drug Interaction Decreased levels of lithium

Side/Adverse Effects CV: aggravation of heart failure, thrombophlebitis, edema when given too

rapidly or in excess.

Metabolic: hypernatremia, aggravation of existing metabolic acidosis with

excessive infusion.

Respiratory: pulmonary edema.

95

Skin: local tenderness, tissue necrosis at injection site

Other: abscess

Nursing

Responsibilities

1. Use with caution in patients with CHF, renal insufficiency, liver cirrhosis,

hypertension, edema; sodium toxicity is almost exclusively related to how

fast a sodium deficit is corrected; both rate and magnitude are extremely

important; do not use bacteriostatic sodium chloride in newborns since

benzyl alcohol preservatives have been associated with toxicity.

2. Monitor serum sodium, potassium, chloride, and bicarbonate levels; I &

O, weight.

3. Explain use and administration of drug to patient and family

4. Tell patient to report adverse reactions promptly.

5. Tell patient that wax matrix may appear in stool.

Generic Name Omeprazole

96

Brand Name Prilosec®; Prilosec OTC™ [OTC]; Zegerid™

Classification Proton pump inhibitor

Suggested Dose Oral:

Children 2 years: GERD or other acid-related disorders:

<20 kg: 10 mg once daily

20 kg: 20 mg once daily

Adults:

Active duodenal ulcer: 20 mg/day for 4-8 weeks

97

Gastric ulcers: 40 mg/day for 4-8 weeks

Symptomatic GERD: 20 mg/day for up to 4 weeks

Erosive esophagitis: 20 mg/day for 4-8 weeks

Mechanism of

Action

Suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP

pump

Indication Symptomatic gastroesohageal reflux disease (GERD) without esophageal

lesions.

Erosive esophagitis and accompanying symptoms caused by GERD

Maintenance of healing erosive esophagitis

Pathologic hypersecretory conditions (such as Zollinger-Ellison

syndrome)

Duodenal ulcer (short-term treatment)

Helicobacter pylori infection and duodenal ulcer disease, to eradicate H.

pylori with clarithromycin and amoxicillin (triple therapy)

Short-term treatment of active benign gastric ulcer

Frequent heartburn (2 or more days a week)

Contraindication Hypersensitivity to omeprazole, substituted benzimidazoles (ie, esomepra-

zole, lansoprazole, pantoprazole, rabeprazole), or any component of the

formulation

Zegerid™: Also contraindicated with metabolic alkalosis and hypocal-

98

cemia (due to sodium bicarbonate content)

Drug Interaction Benzodiazepines metabolized by oxidation (eg, diazepam, midazolam,

triazolam): Esomeprazole and omeprazole may increase levels of benzo-

diazepines metabolized by oxidation.

Carbamazepine: Esomeprazole and omeprazole may increase carba-

mazepine levels.

CYP2C8/9 substrates: Omeprazole may increase the levels/effects of

CYP2C8/9 substrates. Example substrates include amiodarone, fluoxetine,

glimepiride, glipizide, nateglinide, phenytoin, pioglitazone, rosiglitazone,

sertraline, and warfarin.

CYP2C19 inducers: May decrease the levels/effects of omeprazole. Ex-

ample inducers include aminoglutethimide, carbamazepine, phenytoin,

and rifampin.

CYP2C19 substrates: Omeprazole may increase the levels/effects of

CYP2C19 substrates. Example substrates include citalopram, diazepam,

methsuximide, phenytoin, propranolol, and sertraline.

Itraconazole and ketoconazole: Proton pump inhibitors may decrease the

absorption of itraconazole and ketoconazole.

Phenytoin: Elimination of phenytoin may be prolonged; monitor. Pheny-

toin may decrease omeprazole levels/effects.

Protease inhibitors: Proton pump inhibitors may decrease absorption of

99

some protease inhibitors (atazanavir and indinavir).

Warfarin: Elimination of warfarin may be prolonged; monitor.

Side/Adverse Effects CNS: asthenia, dizziness, headache

GI: abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting

Musculoskeletal: back pain

Respiratory: cough, upper respiratory tract infection

Skin: rash

Nursing

Responsibilities

1. Inform patient that capsule should be swallowed whole; do not chew,

crush, or open. Best if taken before breakfast. May be opened and contents

added to applesauce.

2. Administer drug via NG tube should be in an acidic juice.

3. Administer powder for oral suspension 1 hour before a meal.

4. Inform that drug Should be taken on an empty stomach; best if taken be-

fore breakfast.

5. Notify to take as directed, before eating. Do not crush or chew capsules.

6. Inform patient to avoid alcohol.

7. Report changes in urination or pain on urination, unresolved severe diar-

rhea, testicular pain, or changes in respiratory status.

8. Inform patient that breastfeeding is not recommended.

100

9. Patient may experience anorexia. Advice to take frequent meals may help

to maintain adequate nutrition.

Generic Name Lactulose

Brand Name Constulose®; Enulose®; Generlac; Kristalose™

Classification Disaccharide

Suggested Dose Prevention of portal systemic encephalopathy (PSE):

Oral: Infants: 2.5-10 mL/day divided 3-4 times/day; adjust dosage to produce

2-3 stools/day. Older Children: Daily dose of 40-90 mL divided 3-4

times/day; if initial dose causes diarrhea, then reduce it immediately; adjust

dosage to produce 2-3 stools/day

Constipation: Oral: Children: 5 g/day (7.5 mL) after breakfast. Adults: 15-30

mL/day increased to 60 mL/day in 1-2 divided doses if necessary

Acute PSE: Adults: Oral: 20-30 g (30-45 mL) every 1-2 hours to induce

101

rapid laxation; adjust dosage daily to produce 2-3 soft stools; doses of 30-45

mL may be given hourly to cause rapid laxation, then reduce to recommended

dose; usual daily dose: 60-100 g (90-150 mL) daily

Rectal administration: 200 g (300 mL) diluted with 700 mL of H20 or NS;

administer rectally via rectal balloon catheter and retain 30-60 minutes every

4-6 hours

Mechanism of

Action

The bacterial degradation of lactulose resulting in an acidic pH inhibits the

diffusion of NH3 into the blood by causing the conversion of NH3 to NH4+;

also enhances the diffusion of NH3 from the blood into the gut where

conversion to NH4+ occurs; produces an osmotic effect in the colon with

resultant distention promoting peristalsis

Indication Constipation, to prevent and treat hepatic encephalopathy, including hepatic

precoma and coma in patients with severe hepatic disease.

Contraindication Hypersensitivity to lactulose or any component of the formulation;

galactosemia (or patients requiring a low galactose diet) Contraindicated in

patients on galactose-restricted diet

Drug Interaction Decreased effect: Oral neomycin, laxatives, antacids

Side/Adverse Effects Frequency not defined: Gastrointestinal: Flatulence, diarrhea (excessive dose),

abdominal discomfort, nausea, vomiting, cramping

Nursing

Responsibilities

1. Dilute lactulose in water, usually 60-120 mL, prior to administering

through a gastric or feeding tube. Syrup formulation has been used in

102

preparation of rectal solution.

2. Monitor blood pressure, standing/supine; serum potassium, bowel move-

ment patterns, fluid status, serum ammonia.

3. Contraindicated in patients on galacatose-restricted diet; may be mixed

with fruit juice, milk, water, or citrus-flavored carbonated beverages.

4. Inform patient drug is not for long-term use.

5. Tell patient to take as directed, alone, or diluted with water, juice or milk,

or take with food.

6. Inform patient that laxative results may not occur for 24-48 hours; do not

take more often than recommended or for a longer time than recom-

mended. Do not use any other laxatives while taking lactulose.

7. Advice to increased fiber, fluids, and exercise may also help reduce con-

stipation.

8. Tell patient not to use if experiencing abdominal pain, nausea, or vomit-

ing. Diarrhea may indicate overdose.

9. Inform drug may cause flatulence, belching, or abdominal cramping. Re-

port persistent or severe diarrhea or abdominal cramping.

10. Tell patient to consult prescriber if breast-feeding.

103

104

NURSING THEORIES

Nightingale’s Environmental theory

Florence Nightingale, commonly known as the “Lady with the Lamp”, created the

Environmental Theory which is still widely used nowadays. She affirmed in her nursing notes

that nursing "is an act of utilizing the environment of the patient to assist him in his recovery"

(Nightingale 1860/1969) and that it involves the nurse's initiative to configure environmental

settings appropriate for the gradual restoration of the patient's health, and that external factors

associated with the patient's surroundings affect life or biologic and physiologic processes, and

his development.

Environmental factors affecting health

Defined in her environmental theory are the following factors present in the patient's

environment:

Pure or fresh air

Pure water

Sufficient food supplies

Efficient drainage

Cleanliness

Light (especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life

processes or diminished health status. Emphasized in her environmental theory is the provision

105

of a quiet or noise-free and warm attending to patient's dietary needs by assessment,

documentation of time of food intake, and evaluating its effects on the patient.

In the case of our client, she was situated in the Medicine ward, she really needs a clean

and quiet environment conducive for her condition, since Medicine ward is quiet noisy and not

well sanitized. The patient and significant others should have sufficient knowledge about

sanitation so that they can provide her a more clean environment which is helpful for her

recovery. She should be provided with a more comfortable milieu and also she should eat more

nutritious foods that would help boost her immune system and must avoid foods that could

worsen her health condition.

The client also needed to breathe fresh air and feel the heat of the sun outside the

Medicine Ward, since every man needs it to meet personal needs and to attain a good health

status.

Orem's Model of Nursing

The theory Orem is based upon the philosophy that all "patients wish to care for

themselves". Orem’s theory emphasizes on client’s self-care needs. Client can recover faster and

holistically if they are allowed to carry out their own self cares to the best of their ability. When

self-care is not maintained, illness, disease and death will occur.

She has self care deficit. She unable to take care of herself and was unable to perform

activities of daily living without assistance, since she is an aging person and cannot tolerate

doing some of the activities because of her illness.

Although it is our job to provide care for our client, it is important to promote

independence and self-reliance to the patient since it promotes holistic well-being. We, as nurses

106

should persuade the patient to become self-reliant and independent through giving health

teachings on how to do such things but since the client needed assistance in doing some of her

activities, we must also instruct the significant others to offer themselves to the client.

King’s Goal Attainment Theory

This theory wants to integrate the concept of the nurse and the patient jointly

communicating information, establishing goals, and taking action to attain goals. It describes a

situation in which two people, usually strangers, come together in a health care organization to

help or be helped to sustain a state of health. The focus of the nurse is to help the individual

maintain health and function in an appropriate role. The Goal Attainment Theory addresses

interaction, perception, time, space, communication, transaction, role, stress and growth and

development.

Our client had great interaction with the group and was able to set up goals and attain

them. Since it’s the nurse’s role to assess the patient and discuss the problems with them, it is

also the role of the patient to collaborate with the nurse not only with the assessment but most

especially in the interventions, so that they will be able to achieve their desired goal. It is

essential that not only the nurse will discover the problem but the client should also take part in

acknowledging it so that there will be cooperation between them. So in this case, the patient was

able to identify and cooperate with the group very well.

86

NURSING CARE PLAN

Name: Aling D Medical Diagnosis: ESRD 2° HN 2° DM type II

Age: 56 years old Attending Physician: Dr. Gil Florida

Sex: Female

Date Cues Needs Nursing

Diagnosis

Plan of Care Nursing Interventions Evaluation

November

13, 2009

@

12:00 AM

11-7

SUBJECTIVE:

“Malipong pud

ko usahay

karon tapos

medyo luya

akong lawas”

OBJECTIVE:

Hemoglo-

A

C

T

I

V

I

T

Y

Ineffective

peripheral

tissue

perfusion

related to low

hemoglobin

concentration

in blood

secondary to

At the end of 2 hours

of nursing care, the

patient will be able

to:

Verbalize un-

derstanding of

the condition;

and

1. Determine factors re-

lated to individual sit-

uation.

® To assess causative

factor of the condition

2. Note customary base-

line data.

® To provide compar-

ison with current find-

GOAL MET

November 13,

2009 @ 2:00pm

At the end of 2

hours of nursing

care, the patient

87

bin (115-

175 g/Dl)=

77

RBC (4.20-

6.10)= 2.60

Hematocrit

(0.36-

0.52)= 0.22

Weak pe-

ripheral

pulses

Weakness

Pallor

CRT=3sec

Skin cold

to touch

-

E

X

E

R

C

I

S

E

P

A

T

T

E

R

anemia

R: A decrease

in oxygen

resulting in the

failure to

nourish the

tissues at the

capillary level.

Nurses’ Pocket

guide by

Doenges et.al.

Determine

ways to im-

prove circula-

tion

ings

3. Review laboratory

studies.

® To serve as a scien-

tific basis for the

problem.

4. Encourage for a quiet

and restful atmos-

phere.

® To conserve energy

and lowers tissue oxy-

gen demands

5. Perform assistive

range of motion exer-

cise.

® To promote circula-

was able to:

Verbalize un-

derstanding of

the condition

“Mao diay

malipong ko,

dala dala pod

diay ni sa

akong sakit.”

88

N tion.

6. Encourage early am-

bulation as much as

possible.

® To enhance venous

return.

7. Promote position

changes and discour-

age staying at the

same position for a

long period of time.

® To maximize tissue

perfusion.

8. Elevate head of bed or

add pillow when pa-

tient is lying on bed.

89

especially at night.

® To increase gravita-

tional blood flow.

9. Discuss ways to im-

prove circulation such

as eating iron rich

foods.

® To help patient

10. Administer medica-

tions with precautions.

® Drug response,

half-life and toxicity

levels may be affected

by altered tissue per-

fusion.

11. Demonstrate and en-

courage the use of re-

90

laxation techniques

such as deep breathing

exercise.

® To decrease tension

levels.

91

DATE CUES NEED NURSING

DIAGNOSIS

OBJECTIVE OF

CARE

NURSING

INTERVENTIONS

EVALUATION

November

13, 2009

S:

“Nanghupong akong

tiil day,” verbalized

by the client.

O:

high serum

sodium=168

pitting

edema=2 +

oliguria

high blood

pressure=150/

100 mmHg

N

U

T

R

I

T

I

O

N

A

L

–

M

E

T

A

B

O

Fluid volume excess:

extracellular secondary

to fluid shift secondary

to altered GFR

secondary to ESRD as

manifested by pitting

edema

R: There is an increased

isotonic retention as

manifested by pitting

edema.

After 4 hours of

nursing

intervention, the

client will be able

to:

Verbalize

understand-

ing of con-

dition and

commit co-

operation to

the proce-

dures and

therapy to

be done to

her with re-

1. Monitor vital signs

q 4˚.

® In order to have a

baseline data in comparing

regularity of the patient’s

vital signs and determine

significant changes.

2. Monitor I & O.

® In order to monitor

hydration and elimination

status.

3. Monitor serum

electrolyte levels.

® Serum electrolytes

contribute largely to

retention of fluids in the

body.

GOAL MET.

After 4 hours

of nursing in-

tervention,

the patient

was able to

verbalize un-

derstanding

of her condi-

tion and com-

mitted coop-

eration.

92

L

I

C

P

A

T

T

E

R

N

gards to her

condition

4. Establish safety

precautions.

® LOC changes may be

apparent due to electrolyte

imbalances.

5. Limit fluid intake

as ordered.

® To reduce fluid

acculmulation.

6. Instruct patient to

strictly adhere to

the advised diet.

® The advised diet helps

modify the intake of foods

which may affect fluid

retention.

7. Discuss importance

of fluid restrictions.

93

® In order to let the patient

know the importance of

fluid restrictions imposed

on her.

8. Administer medi-

cations as ordered.

® In order to give relief.

9. Elevate edematous

extremities.

® In order to provide

venous backflow of

retained fluid.

10. Provide adequate

rest periods.

® To relax the patient.

94

DATE CUES NEED NURSING DIAGNOSIS OBJECTIVE OF

CARE

NURSING

INTERVENTIONS

EVALUATION

November

14, 2009

Subjective:

“Dali lang ko

kapuyon.”

Objective:

-exertional

discomfort noted

-palmar pallor

noted

-hemoglobin level:

77

-hematocrit level:

0. 22

-red blood cell:

2.60

-CRT= 3 secs

A

C

T

I

V

I

T

Y

-

E

X

E

R

C

I

S

E

Activity Intolerance

related to imbalance

between oxygen supply

and demand secondary

to anemia

R: There is an

insufficient

physiological or

psychological energy to

endure or complete

required daily activity.

Nurses’ Pocket Guide by

Doenges et. al.

Within the span of

3 hours, the client

will:

a) Verbalize

techniques to

enhance ac-

tivity toler-

ance;

b) Participate

willingly in

necessary/de-

sired activi-

ties.

1. Determine patient's

perception of causes

of fatigue or activity

intolerance.

R: Assessment guides

treatment.

2. Monitor vital signs.

R: To watch for

changes in blood

pressure, pulse and

respiratory rate after

activities

3. Assist with ADLs as

indicated.

R: Assisting the pa-

tient with ADLs al-

lows for conservation

Goal met

After 3 hours of

nursing care, the

client was able to:

a) verbalize tech-

niques to en-

hance activity

tolerance, say-

ing “Kina-

hanglan jud

nako mag-

pahuwayhuman

ko mulakaw-

lakaw.”

b) Participate will-

ingly in neces-

95

P

A

T

T

E

R

N

of energy.

4. Encourage rest and

sleep.

R: In order to help re-

lax the patient.

5. Provide a calm envi-

ronment.

R: To promote a res-

ful atmosphere.

6. Place necessary ma-

terials near the bed-

side.

R: To avoid overex-

ertion

7. Encourage active

ROM exercises.

R: Exercises maintain

muscle strength and

sary/desired ac-

tivities.

96

joint

ROM.

8. Teach patient/care-

givers to recognize

signs of physical

overactivity.

R: So not to tire the

patient.

9. Teach energy conser-

vation techniques,

like:

Sitting to do tasks,

Changing positions

often

R: In order not to ex-

haust the patient.

10. Administer iron sup-

plement as ordered.

97

R: To have supple-

mental iron which

could help alleviate

anemia.

98

DATE CUES NEED NURSING DIAGNOSIS WITH ®

OBJECTIVE OF CARE

NURSING INTERVENTIONS WITH

®

EVALUATION

November 14, 2009

S: “Naka-ihi

nako pero ka-ihion gihapon ko,” as ver-balized by the client.

O: Residual

urine Dark-yellow

urine Distended

urinary blad-der

Oliguria Concentrated

urine Urine specific

gravity= 1.042 (1.010-1030)

ELI

MINATION

PATTERN

Urinary infrequency related to altered Glomerular Filtration Rate secondary to ESRD.

® The patient has an ncomplete emptying of the bladder due to use of medications, psychological/ neurological factors or an underlying health condition.Nurses’ Pocket Guide by Doenges et. al.

After 4 hours of nursing inter-vention, the pa-tient will be able to: Verbalize re-

lief from uri-nary infre-quency; and

Verbalize understand-ing of her condition

1. Monitor I & O.R: In order to fol-low up hydration and elimination status/

2. Insert urinary catheter as or-dered.R: To ensure uri-nary elimination.

3. Assess the pres-ence pathological conditions which may underlie uri-nary infrequency.R: To properly ad-dress urinary infre-quency, the under-lying cause must be determined.

4. Administer diuret-ics as ordered.R: To help in uri-nary elimination.

5. Institute fluid re-striction as or-dered.R: To prevent fur-ther accumulation of fluids.

6. Explain to the pa-

Goal met.The client was able to verbalize understanding of condition and verbalize relief from urinary infrequency.

99

tient importance of fluid restriction.R: To include the patient in the plan of care.

7. Establish infection precautions.R: Catheterizations may increase the risk for UTIs.

8. Encourage compli-ance with medica-tions.R: To ensure con-tinuity of therapy ordered.

9. Discuss with the patient the compli-cations of incom-pliance to medica-tions.R: To promote compliance.

10. Encourage patient to report any dis-comfort in urina-tion including the frequency, consis-tency and color of urination.R: To help medical personnel address immediately to

100

any discomforts experienced by the patient.

DATE CUES NEED NURSING DIAGNOSIS OBJECTIVE OF CARE

NURSING INTERVENTIONS

EVALUATION

November 12, 2009

11:00pm

11 - 7shift

S:

“Makatamad maligo, ana man pod ang ubang pasyente diari. Lisod jud maligo sa hospital.”

O:

-not well groomed-presence of body odor

ACTIVITY-EXERCISE

PATTERN

Self care deficit: bathing / hygiene related to lack of motivation

R: The patient has an impaired ability to provide self care requisites due to environmental and psychological factors.

After 2 hours of nursing intervention, the client will be able to recognize self care need and enumerate the importance of personal hygiene.

1. Assess client’s self care need.R: This will serve as a mark as to where the nurse will an-chor her inter-ventions.

2. Assess client’s physical condi-tion relating to hygiene.R: This will point our any factors present in the patient physically that may hinder her capacity to meet the need.

Goal met. After 2 hours of nursing intervention, the patient was able to verbalize understanding of the problem and the need to meet it. The patient was also able to point out several courses of action that she must undertake to promote hygiene aside from bathing,such as brushing the teeth and combing the hair.

101

3. Educate the pa-tient on the im-portance of personal hy-giene.R: Makes the patient realize that hygiene is related to health.

4. Let the patient enumerate her ideas on the importance of hygiene.R: Encourages the patient to understand the need.

5. Discuss ways to attain good personal hy-giene such as bed bath.R: provides the patient options in performing bathing.

6. Provide and maintain pri-vacy.

102

R: Makes the patient secure that she can perform bathing without risking her pri-vacy.

7. Let the patient enumerate her own ideas as to the ways and other tech-niques that she can undertake in order to at-tain good per-sonal hygiene thru bathing.R: Involves the patient in the plan of care.

8. Discuss the possible nega-tive implica-tions of not taking a bath such as infec-tions and odor.R: Broadens the patient’s idea about the

103

problem and encourages her to meet the need.

9. Encourage pa-tient to ask questions re-garding hy-giene.R: Clears up any ambigui-ties in the pa-tient’s mind and improves understanding.

10. Appreciate the patient’s under-standing of the things dis-cussed.R: Lets the pa-tient feel that her idea is well con-sidered by the nurse and that her wellness and un-derstanding of the importance of the need is the best in-terest of the nurse.

12

PROGNOSIS

GOOD FAIR POOR JUSTIFICATION

Onset of the

illness

☻ It was during June 1994 that the patient was

diagnosed of Diabetes Mellitus type II. Her DM II

that is 15 years ago eventually lead to

Hydronephrosis and ESRD.

Duration of illness ☻ After experiencing the signs and symptoms of

Diabetes Milletus type 2, the patient immediately

went to the hospital for medical help. Yet it was 15

years ago when she was diagnosed with Diabetes

Milletus type 2. Sad to say her diabetes lead her to

hydronehprosis and eventually to end-stage renal

disease.

Precipitating

factors

☻ Even after being diagnosed of Diabetes Milletus

and Hydronephrosis, the patient still doesn’t

strictly adhere to medical advices regarding her

nutrition.

Willingness to

take medications

and treatment

☻ The patient submits herself to the treatment

regimen which is required for her to take but she is

not complying with the treatment properly. She

has the knowledge of the purpose of the treatment

13

he undergoes. Yet the patient is able to buy all the

medicines being ordered.

Age ☻ Aling D is already 56. As the age increases, it puts

the patient into higher risk of having ESRD

especially she also has diabetes and

hydronephrosis.

Environmental

factors

☻ The client’s home as reported is conducive for rest

and sleep. The patient lives in a therapeutic

environment. There are smaller chances of

pollution and noise. It can be said that the

environment as well was generally peaceful and

calm is very favorable for rest and promotes better

health.

Family Support ☻ The family has been very supportive throughout

the whole process. Her sons visited the patient

constantly. Throughout our duty the group only

sees her sons and never saw her husband. The

support, most especially from her husband could

help the patient accept her situation.

Total 3 2 2 Computation:

Poor: (4*1)/7 = 4/7

Fair: (2*2)/7 = 4/7

Good: (1*3)/7 = 3/7

14

Total: 1.57

General Prognosis:

1-1.6 = POOR

1.7-2.3 = FAIR

2.4-3.0 = GOOD

Rationale for a Good Prognosis

As shown by the calculated prognosis in relation to the different factors involved,

the patient has a poor chance of survival. The factors presented in relation to prognosis shows

that patient can poorly cope up after being discharged. The condition was diagnosed 15 years ago

and eventually her diagnosed Diabetes Milletus lead to End-Stage Renal Disease. The patient

submits herself to treatment yet not complying to it properly. In addition, support has been given

by the family members to make the patient feel that she is not alone in what she’s going through.

Finally, it is seen that the patient has lesser chance of coping up wither illness. Yet she could

help herself, with the help of her family to accept any possibilities that might result from her

illness.

15

DISCHARGE PLAN (M.E.T.H.O.D.)

Medication

Instruct client to continue take her prescribed medications

Orient the client about the name of drugs, their actions, the exact dosage, the frequency

and the route of administration.

Instruct client to follow the instruction when administering medication.

Encourage the significant others not to leave the client during medication

Explain to the client the side effects and adverse effects of the drugs she takes by pre-

scribing its manifestations.

Encourage the client not to stop intake of prescribed medications, unless approved by the

physician.

Encourage the client to report to the physician immediately if any adverse effects or side

effects had occurred.

Exercise

Instruct client to balance activities with adequate rest periods.

Educate client on proper body mechanics to prevent muscle strain and enable client to re-

lax.

Encourage early ambulation, assist the client if needed.

Treatment

Educate client the importance of drug compliance.

16

Discuss to the client the complication of the condition because knowledge about the con-

dition supports learning that will decrease deficit and anxiety.

Hygiene

Encourage client to do daily hygiene.

Discuss to the client the importance of proper hygiene to promote enhancement of

knowledge regarding its importance.

Encourage client to ask assistance if needed.

Outpatient orders

Call the doctor if any of the following occur:

You cannot make it to your follow-up or dialysis visit.

Have itchy skin and develop skin rashes.

You are passing little to no urine.

Experience nausea and vomiting.

You heart is beating fast or you are breathing fast.

You have a seizure (convulsion).

You have chest pain or trouble breathing all of a sudden.

You have questions or concerns about your care, medicine, or treatment.

Diet

To promote wellness, eat a balanced diet rich in fresh fruits and vegetables.

Instruct the client to eat foods low in sodium, low in Potassium and low in sugar content.

17

Encourage protein intake to be high biologic value like non-fat or low-fat milk, egg white

and meat.

18

RECOMMENDATION

This case study has provided the proponents with important information about the

patient’s disease. In order to ensure that optimal health is restored and maintained, the group

would like to recommend the following:

To the patient

Whenever there is, the onset of a certain disease it implies one to contribute her

cooperation and willingness to be responsible for her own health. The patient must submit

herself to palliative care for her to reducing the severity of her disease. The goal is to prevent and

relieve suffering and to improve quality of life for people facing serious, complex illness. The

patient must be sensitive of her own needs and be able to expect liability for her actions. She is

also encouraged to verbalize her own thoughts and feelings concerning how she perceives her

condition affect her life and her acceptance of her disease. She is advised to take part in

complying with the treatment designed for her. She should realize the importance of complying

with her medication and the benefits this practice would bring to her and her family’s well-being.

Moreover, she must not hesitate on seeking medical assistance whenever she feels any

unusualities in her body.

To the patient’s family

The patient’s family plays an important role in the patient’s illness and palliative care.

The family should make themselves physically present so that the patient would somehow feel

19

their support and concern. They are encouraged to be the patient’s source of strength and

inspiration as she undergoes painful, traumatic and harrowing situation. In addition, it is of prime

importance that they are oriented and educated basic facts regarding the patient’s condition so

that they will understand her even better and assist her in her daily activities.

To the student nurses:

This case study would help them better understand the patient’s condition. What is

entrusted to student nurses is the life of their patient. Even with the clinical instructor’s presence,

they can still make mistakes and errors, which can harm the patient. Hence, they are encouraged

to equip themselves with necessary knowledge that will enable them to render quality and

holistic nursing care and intervention to patients in need.

It is known that nurses play a major role in helping the client and family implement

healthy behaviors and help them monitor the client’s health. Thus, anticipatory guidance and

knowledge about health should be supplied to help clients attain, maintain, or regain an optimal

level of health. Student nurses should prioritize interaction with family members and significant

others to provide support, information, and comfort in addition to caring for the patient. Thus,

they should prepare themselves with the reality that they are soon to become health

professionals.

Genuineness, empathy, and respect are key elements for the nurse to possess. Student

nurses must develop patience, love for our work, and empathy to our patients. They must assist

in facilitating a remarkable experience as well as share our knowledge regarding the case. They

must also continue to study different cases and be able to impart this to other student nurses,

patients and their significant others.

20

To the Ateneo de Davao University- College of Nursing

The AdDU- College of Nursing is the source that provides student nurses with exposures

that enable them to apply the knowledge they have gained and practice the skills they honed

necessary for their profession. The faculty and staff are encouraged to continue improving the

standards of the Ateneo Nursing Curriculum by providing quality education to students. Also

they, themselves, must be well-trained to delegate learning to student nurses. It is important that

they continue to inspire generations of today to perceive nursing as a gift and act of charity rather

than a mere means to success.

To the Professional Medical World

End Stage Renal Disease is a class of disease that can affect every person. Therefore, it is

recommended that there should be facilities or institutions that are made for the research of how

to prevent end-stage renal disease . Also, the proponents recommend that medical practitioners

work hand in hand in order to improve the welfare of the society, promote optimum health, and

prevent the spread of diseases. They should have proper information dissemination in order for

the community to be aware and be well informed about the different diseases, their

manifestations, and how they can be prevented and cured. They should teach the public proper

hygienic practices, proper sanitation and handling of foods, and healthy lifestyle. They must also

do further research, inventions, and discoveries in the field of medicine in order to save more

lives. In partnership with other health sectors, attaining the goal in establishing optimum health

to the whole population is possible.

21

REFERENCES

Kozier and Erb’s Fundmentals of Nursing 8th Edition

Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al.

Textbook of Medical Surgical Nursing 11th Edition

Lippincot and Willers

Adrogué HJ, Madias NE (September 1981). "Changes in plasma potassium concentration

during acute acid-base disturbances". Am. J. Med. 71 (3): 456–67.

National Institute for Health and Clinical Excellence. Clinical guideline 73: Chronic kidney

disease. London, 2008.

Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G (October 1998). "Renal

function and requirement for dialysis in chronic nephropathy patients on long-term ramipril:

REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN).

Ramipril Efficacy in Nephropathy". Lancet 352 (9136): 1252–6.

Lewis EJ, Hunsicker LG, Clarke WR, et al. (2001). "Renoprotective effect of the an-

giotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes".

N Engl J Med 345: 851-60.

Brenner BM, Cooper ME, de ZD, et al. (2001). "Effects of losartan on renal and cardiovascu-

lar outcomes in patients with type 2 diabetes and nephropathy". N Engl J Med 345: 861-9.

Perazella MA, Khan S (March 2006). "Increased mortality in chronic kidney disease: a call

to action". Am. J. Med. Sci. 331 (3): 150–3.

22

WEBSITES

National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney

disease". http://www.kidney.org/professionals/KDOQI/guidelines_ckd.

http://www.medscape.com/viewarticle/590644

http://www.medicalnewstoday.com/articles/139028.php

http://www.medpac.gov/publications/other_reports/

Sept06_MedPAC_Payment_Basics_dialysis.pdf MedPAC ESRD program overview

http://www.empiremedicare.com/pdf/combined/mmr2008-1.pdf Medicare Monthly Review

http://www.cahabagba.com/part_b/msp/providers_general_info.htm Cahaba GBA

Documents

end stage renal disease secondary to hydronephrosis secondary to diabetes mellitus type two