Chronic Kidney Disease 2⁰ to Diabetes Mellitus II related to Hypertension, Anemia 2° to Nephropathy

Group 1

GROUP 1

Arceo, Mari Aguirre, Kim Leonard Bermudez, Joanna Marie Bongkingki, Janela Cassandra De Guzman, Fredaline Dayle De Guzman, Maria Cristina

Desvarro, Eric

Domingo, Jennifer Leyva, Allan Mario

Seminiano, Haidy

Socias, Christian Anthony

OUR LOVELY CLINICAL INSTRUCTOR

Mrs.Angelica Hernandez

Introduction

I. Background of the study

Presenting a case of Patient H.F., 51 year-old female admitted on the 24th of September , 2012 at 7:30 PM with baseline vital signs of T- 37.1 °C, PR-92bpm, RR-23 bpm, and a BP of 160/90mmHg. The patient was admitted to the Mandaluyong City Medical Center, and was given a final diagnosis of Chronic Kidney Disease 2⁰ to Diabetes Mellitus II related to Hypertension, Anemia 2° to Nephropathy Diabetes mellitus (DM) is a set of related diseases in which the body cannot regulate the amount of sugar (specifically, glucose) in the blood. The blood delivers glucose to provide the body with energy to perform all of a person's daily activities.

The liver converts the food a person eats into glucose. The glucose is then released into the bloodstream. In a healthy person, the blood glucose level is regulated by several hormones, primarily insulin. Insulin is produced by the pancreas, a small organ between the stomach and liver. The pancreas also makes other important enzymes released directly into the gut that helps digest food. Insulin allows glucose to move out of the blood into cells throughout the body where it is used for fuel. People with diabetes either do not produce enough insulin (type 1 diabetes) or cannot use insulin properly (type 2 diabetes), or both (which occurs with several forms of diabetes). In diabetes, glucose in the blood cannot move efficiently into cells, so blood glucose levels remain high. This not only starves all the cells that need the glucose for fuel, but also harms certain organs and tissues exposed to the high glucose levels.

Type 2 diabetes (T2D): Although the pancreas still secretes insulin, the body of someone with type 2 diabetes is partially or completely unable to use this insulin. This is sometimes referred to as insulin resistance. The pancreas tries to overcome this resistance by secreting more and more insulin. People with insulin resistance develop type 2 diabetes when they fail to secrete enough insulin to cope with their higher demands. At least 90% of adult individuals with diabetes have type 2 diabetes. Type 2 diabetes is typically diagnosed in adulthood, usually after age 45 years. It used to be called adult-onset diabetes mellitus, or non-insulindependent diabetes mellitus. These names are no longer used because type 2 diabetes does occur in younger people, and some people with type 2 diabetes require insulin therapy. Type 2 diabetes is usually controlled with diet, weight loss, exercise, and oral medications. However, more than half of all people with type 2 diabetes require insulin to control their blood sugar levels at some point in the course of their illness.

A. RATIONALE FOR CHOOSING THE CASE 1. To know the anatomy and physiology of the pancreas and the associated organs. 2. To know the pathophysiology of Diabetes Mellitus Type 2, its signs and symptoms and its further complications.

3. To know the appropriate nursing intervention in accordance with its scientific rationales.

4. To know the appropriate medical management in the treatment of the disease.

B. OBJECTIVES OF THE STUDY This case study aims to identify and determine general health problems and needs of the patient with a diagnosis Chronic Kidney Disease 2⁰ to Diabetes Mellitus II related to Hypertension, Anemia 2° to Nephropathy. This work also intends to promote health and medical understanding of such condition through the application of nursing process and skills. Specific Objectives: The students will be able to improve their skills in conducting appropriate assessment on the client’s health condition. The students will enhance their knowledge on the disease process and its effect to the human body. The students will be able to formulate a scientific-based pathophysiology based on the client’s health history and presenting signs and symptoms. The students will be able to formulate appropriate Nursing Care plan based on the client’s presented health problems and risks and effectively improve/alleviate client’s health condition.

The students will be able to utilize the nursing process and critical thinking skills in the management and care of the common problems of the patient. The students will be able to render quality care to patients guided with scientific based rationale. The students will be able to expand their knowledge on the drugs through identification of its indication, side effects, adverse reactions and mechanism of action on why it was prescribed to the patient and specific nursing considerations.

ASSESSMENT

Client’s Profile • Name • • • • • • • Age Gender Birth Date Civil status Occupation Nationality Religion : : : : : : : : Patient F.H. 51 years old Female December 22, 1960 Married Housewife Filipino Catholic

• Date of Admission • • Time of admission Admitting Diagnosis : :

:

September 24, 2012 N/A

Chronic Kidney Disease 2⁰ to Diabetes Mellitus II related to Hypertension, Anemia 2° to Nephropathy

B. Chief Complaint

:

Generalized body weakness

C. History of Present Illness

:

D. Past Medical History

:

Three days prior to admission, client experienced loss of Appetite, generalized body weakness and easy fatigability. Symptoms persisted which prompted consult. DM Type II for ten years Peripheral Vascular Disease

Accidents Hospitalization Medications taken

: : :

N/A Last hospitalization: July, 2012. Glucovance 2.5 mg Losartan 50mg

E. Family History

Legends

Grandfather Grandmother Father Mother Patient Brother 1 Sister Brother 2

Hypertension

Diabetes

Heart Disease Deceased

E. Family History

The following figure shows the family genogram of the patient. Fatherside

Grandfather Grandmother

Motherside

Grandfather

Grandmother

Father

Mother

LEGEND:

Deceased Diabetes Mellitus Colon Cancer Hypertension Husband Patient H.F Male Female

Nephropathy

F. Gordon’s Functional Health Pattern

•

Health Perception and Health Management

Before hospitalization, she knows that being healthy is important, but she is not fond of doing exercise. Her perception of a healthy person is anyone who can perform their daily task and one who doesn’t have a disease. She drinks alcoholic beverages occasionally and does not smoke. When the patient is hospitalized, she perceived herself as an unhealthy person.

Nutrition and Metabolism

Before hospitalization, the client states that she loves to eat. She loves to eat everything including those foods that are not advisable for her to eat. During hospitalization, the client is advised to be on a Low salt, low fat, DM Diet. She becomes more aware of her condition and states that she will try her best to follow the advised diet.

24 Hour Diet-Recall

Meal

Breakfast Food Rice Chicken Breast Coffee Lunch Lugaw with egg Orange juice Quantity Half cup Small serving 1 cup 1 bowl 1 glass (250 ml)

•

Elimination

Prior to hospitalization, the client defecates brownish, formed stool 6-7 times a week. She urinates clear-yellowish urine 6-7times a day. During hospitalization, client stated that she defecates once in every two days and she urinates 6-7 times per shift. She also stated that she perspires just right.

Activity – Exercise

Before hospitalization, client’s household chores serve as her way of exercising. Whenever she is doing something like cleaning the house or washing the chores, she gets tired easily. During hospitalization, walking is her only activity.

•

Sleep – Rest

Prior to hospitalization, client normally gets 6-7 hours of sleep. She does not have any difficulty sleeping. She claimed that hospitalization affects her sleeping pattern; she cannot sleep comfortably and wakes up easily.

Cognitive – Perceptual

The client can recall past memories when being asked. She has no hearing problems. The client is oriented with time, place, people and date. She is able to follow instructions. Client claimed that her memory hasn’t changed even during hospitalization.

Self Perception / Self Concept

Client claimed that she was already satisfied with her life. She states that prior to hospitalization, she perceives herself as a loving wife and mother. She perceives herself as a healthy person. Upon hospitalization, client sees herself as unhealthy.

•

Role Relationship Pattern

Prior to hospitalization, client lives with her husband and they have 7 children. Their child supports their financial needs. She and her husband take part in decision-making. They have open communication with each other. The client presently feels the support of her family and she is happy about it. Upon hospitalization, client’s husband takes responsibility in decision-making.

Sexuality – Reproductive

The client stated that they do not practice family planning ever since. Despite of their age, they’re still able to maintain a satisfying sexual relationship. The couple engages in sexual activity once or twice a month. During hospitalization, client doesn’t engage with sexual activity anymore.

•

Coping – Stress – Tolerance

Prior to hospitalization, Client’s usual cause of stress is misunderstanding with her husband and children. She easily gets irritated with arguments and cries whenever depressed. During hospitalization, she claims that she gets stressed whenever she experiences body weakness. Client would just vent out to her husband and try to sleep.

Value – Belief

The client states that she is a religious person and usually goes to church every Sunday. During hospitalization, client claimed that she becomes closer to God and that she never forgets to pray for her faster recovery.

G. Physical Examination

General Survey The patient’s body built is proportionate with coordinated posture and gait. Client is lethargic but coherent and oriented to time, place and person. Client appears to be physically weak upon assessment. Vital Signs Her temperature is 37.1 º C, axillary with a regular pulse rate of 75 bpm. The respiratory rate is 34 cpm, deep and her bp is 180/110 mmHg taken in a lying position. Anthropometric Measurements Her height is 5’2” and her weight is 136 lbs (upon admission), 129lbs (upon referral).

Skin Her skin color is pale, with venoclysis on right metacarpal vein .She has no edema. She has dry skin, cool upon touch and show poor turgor.

Hair Her hair is evenly distributed, thick and silky. There is presence of sparse leg hair. There is no presence of infestations.

Nails Her nails are convex 160 º in curvature and angle. The texture is smooth with pale nail beds. The surrounding tissues are intact and capillary refills in 4 seconds. Skull and Face The skull is normocephalic, has smooth contour, has symmetrical facial features.

Eye Structures and Visual Acuity Her eyebrows are evenly distributed, eyelashes are equally distributed, intact skin, and eyes close symmetrically and have 15-20 involuntary blinks. She has pale conjunctiva and has transparent cornea, PERRLA. Her eye is coordinated in extraocular movement and she is able to read newspaper. There is a presence of peritorbital edema on both eyes. Ears and Hearing The pinna of her ears has a uniform skin color and symmetrical. The ear canal has presence of dry cerumen .The tympanic membrane is pearly gray and the hearing acuity is intact. Nose and Sinuses She has symmetrical nasolabial fold. Her septum is in midline, non-deviated and has no perforation. Its mucosa is dry but has no discharges. It is both patent. She has symmetrical gross smell. Sinuses are not tender.

Mouth and Oropharynx Her lips are dry, pale and with few lesions. She has 4 missing teeth; 1right, upper lateral incisor, 1st right, upper premolar, 2nd left, lower molar, 3rd left, lower molar. Tongue is in midline, pinkish, smooth and movable. Her palate is light pink and smooth with uvula is in midline. The oropharynx is also pink and smooth. Tonsils are not inflamed. The gag reflex is intact. Neck Her neck muscles are equal in size with a coordinated movement, full range of motion and equal muscle strength. The lymph nodes are not palpable. The trachea is in midline, the thyroid gland is not visible with a symmetrical carotid pulse. The jugular veins are not visible. Thorax and Lungs Her breathing pattern is rapid and deep. The shape and symmetry of the thorax and lungs is symmetrical, the spine is aligned with a smooth skin. The respiratory excursion is full and symmetric.

Breast and Axilla Her breast and axilla’s shape is rounded. The skin is smooth with round areola. The nipples are round. Abdomen The abdomen contour is rounded and the symmetry is symmetrical. The bowel sounds are normoactive with a tymphanic percussion and relaxed palpation. Upper and Lower Extremities The upper and lower extremities have an equal muscle size, firm muscle tone with equal muscle strength. Her range of motion is limited.

H. Laboratory and Diagnostic Study

PROBLEM IDENTIFICATION

A. Anatomy of Pancreas

The pancreas is an elongated, tapered organ located across the ba ck of theabdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small Intestine). The tapered left side extends slightly upward (called the body of the pancreas) and ends near the spleen (called the tail).The pancreas are made up of two types of tissue:

Exocrine tissue the exocrine tissue secretes digestive enzymes. These enzymes are secreted into network of ducts that join the main pancreatic duct, which runs the length of the pancreas. Endocrine tissue the endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones.

Anatomy of kidney The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells.

The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term “renal" is derived from the Latin name for kidney.)The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen (BUN) and creatinine (Cr).Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.

Diabetes Mellitus

Diabetes Mellitus type 2 is the most common form of Diabetes. Formerly known as adult onset diabetes, it usually affects people aged over 40 and progresses gradually. In this type the pancreas has not ceased to produce insulin, but the quantity is insufficient, or the hormone is not stimulating the glucose uptake in muscles and tissues required for energy. The result is a build-up of glucose in blood and urine. Although the cause of this malfunctioning is unclear, non-insulin dependent diabetes mellitus tends to run in families. Other risk factors, such as increasing age, obesity, and a sedentary lifestyle, probably contribute to its increased incidence in developed countries. Non-insulin dependent diabetes mellitus can often be controlled initially by diet alone, or in combination with tablets that reduce the amount of blood glucose. There are two main types of blood glucose-reducing drugs: sulphonylureas work mainly by stimulating the pancreas’s islet cells (known as the islets of Langerhans) to produce more insulin and iguanids increase the effectiveness of insulin on cells. Eventually, however, patients may need insulin injections.

Signs and Symptoms with Rationale Diabetes Mellitus HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL) May be due to lack of physiologically active insulin that transportsglucose from extracellular to intracellular leading to accumulation of glucose in the intravascular space. The glucose is not utilized by the body and it remains in the blood streams. POLYURIA

Increased frequency of urination. This may be due to the osmotic diuretic effect of the glucose, wherein it attracts water during urination.

POLYDIPSIA Increased thirst and fluid intake. This may be due to the activation of thethirst center in the hypothalamus resulting form the intracellular dehydrat ion or volume depletion.

POLYPHAGIA Increased hunger and food intake. This may be due to the decrease glucose uptake by the cells leading the stimulation of the satiety center in the hypothalamus resulting to the ‘hunger sensation.” WEAKNESS/ FATIGUE This is due to the decreased glucose uptake by the cells leading to decreased energy production.

GLYCOSURIA

The kidney filters the blood, making it to its normal state. Glucose was filtered out and excreted in the urine. Due to the excess glucose ad compared to the kidney threshold, which results to the excretion of glucose in the urine. GASTROPARESIS (Stomach fullness)

CONSTIPATION and BLOATING This is due to changes in nerves and damages the blood vessels that carry oxygen and nutrients to the nerves. Over time, high blood glucose can damage the vagus nerve. The stomach fails to empty properly and is likely due to the generalized neuropathy. NAUSEA/ VOMITING Due to stomach fullness, there will be an involuntary emptying of stomach contents that are forcefully expelled by the mouth. A compensatory mechanism due to acidity of body because of decrease excretion of metabolic waste. PALE

Due to decreased production of erythropoietin.

B. Pathophysiology

C. Problem List

PLANNING

A. Problem Prioritization

NURSING PROBLEM

RANK 1 2

JUSTIFICATION

3

C. Discharge Planning

Medication

Instruct the patient the importance of regularly taking of prescribed home medications. Amlodipine 10mg 1 tab / OD Cefuroxime 500 mg 1 tab / BID NaHCO3 1 tab / TID CaCO3 1 tab / TID Ferrous sulfate + Folic acid 1 tab / OD Insulin Ensure safety by providing health teaching about the side effects and adverse effects of the drug. Instruct the patient to continue with follow up medical care. Advise the patient not to miss the intake of medication given by his physician.

Exercise and Environment

Encourage the patient mild exercise such as walking it is best to start slowly and more as the patient get stronger. Exercising can make the heart stronger, lower blood pressure and keep healthy. Exercise can benefit patient with CKD/DM Nephropathy. Resistance training in particular helps reduce the catabolic effects of a low-protein (0.6g/kg/day) diet, whereas aerobic exercise may help control blood pressure and lipid level. Treatment

Since the patient due to the loss of renal erythropoietin production and should be treated with supplement iron and synthetic erythropoietin to reach a target hemoglobin of 11-12g/ dL. Phosphate binders and dietary phosphorus restriction are indicated to keep phosphate, <4.5 mg/dL.

Instruct the patient to continue home medication. Instruct the patient to comply with the medication regimens prescribed by the physician and the life style adjustment on her diet and exercise. Explain renal dialysis and Transplantation.

Health Teaching

Encourage the patient also have adequate rest periods and to have an adequate sleep of at least of 8-10hrs. Encourage the patient to eat a low-protein diet. Instruct the patient to limit fluid intake. Instruct the patient regarding limiting the amount of salt (sodium), potassium, phosphorus and other electrolytes, getting enough calories, especially if patient is losing weight. Encourage the patient also have to Monitor of blood glucose levels. Help the patient/ Family learn self-observational skills (Temperature, Pulse, Respirations, Blood Pressure, intake and output and weight) and record keeping.

Explain the benefits of consuming simple, basic foods such as lean meat, fresh or frozen vegetables, and whole grained breads. Processed or prepared foods should be avoided.

Encourage the patient keep a food diary for several days. It should include food eaten, portion size, and time of consumption so that together you can modify the diet as needed. Explain avoidance of infection.

Out patient

Instruct the patient to come back for follow up check-up. Emphasize the need to be present in medical procedure schedule.

Diet

Low total and animal protein A prolonged high-protein intake is accompanied by an increase in GFR, 4 which in turn may cause intraglomerular hypertension and eventual loss of renal function. Sodium Restriction Patient with CKD are often salt-sensitive, responding to elevated intakes of sodium chloride with increase in glomerular filtration and proteinuria. Water-Soluble Vitamins Low-protein diets may increase the risk for deficiency of thiamine, riboflavin and especially pyridoxine, and vitamin C levels are also often low in DM.

Vitamin D Supplementation Deficiency of vitamin D is present early in the course of DM, and correction may prevent activation of key pathogenic mechanism in cardiovascular disease. (e.g. Inflammation, Myocardial cell hypertrophy and Proliferation and the renin-angiotensin system). A Diet in Fiber and Low in saturated Fat and cholesterol Most patients with Chronic Kidney Disease die from cardiovascular causes before developing DM Nephropathy. Dietary and supplemental source of fiber may be helpful for reducing the build up of nitrogenous waste products in the blood that cause many symptoms of uremia. Maintain on low salt and low fat. Limit sodium, potassium, phosphorus and other electrolytes. Limit fluid intake.

The following table is a proposed 1 week diet of the patient: Sunday Monday Tuesday Wednesd Thursday ay Oatmeal Orange juice Brown Rice 1/2cup 1 serving of tinolang manok Grape juice 1 glass 1 ¼ cup fiber one Original cereal 1 ¼ cup Skim milk slice of melon and strawberrie Friday Saturday

Breakfast Cereals Apple slices Fresh Bread w/ milk tuna spread Pineapple juice.

1 cup Prepared Oatmeal ¼ cup Skim milk 2 tbsp. Seedless raisins 1 servings of oranges

2 oz cheddar cheese, low fat 2 slices of wheat bread Watermelon 2 servings A glass of Orange juice

Sunday

LUNCH

Toast, hardboiled eggs & Orange. Slices (340 calories) 1 slice whole wheat toast

Monday Tuesday Wednesd ay Brown Steam 2 slices Rice rice 1 whole 1/2cup cup wheat Chicken Ampalay bread

(280 calories)

2 servings of Papaya slice

Thursday

Friday

Saturday

2 tsp. Jam

2 large Hardboiled eggs 1 medium Orange, cut into segments 100g Non-fat fruit yogurt Glass of Water

1 serving of sinigang Steam rice na bangus a with 90g tuna, 1 cup scramble canned Brown 1 glass of s egg 2 in water Rice 2 servings 1/2cup servings 1 tbsp. of ripe Glass of Mayonn 1 glass of Kiwifruit water aise Orange Glass of juice 2 leaves water lettuce 2 servings of apple slices

2 serving of pinakbet

2 servings of tortang talong

Steam rice 1 cup Pineapple juice 2 servings of slices melon

Sunday

Monday

100 g DINNER chicken breast, 1 servings boneless, skinless Vegetabl cooked es salad with tuna 1 cup medium Orange grain juice brown rice (cooked) 2 cups Green beans, steamed

Tuesday Wednesd ay 1 1 servings serving Pesang s of chopsue dalag y with miso Brown Rice ½ cup Brown Rice ½ cup

Thursday 1 servings Shrimp sinigang With vegetables Brown Rice ½ cup Pineapple

Friday

Saturday

1 servings 100 g Paksiw chicken na isda breast, boneless, Brown skinless Rice ½ cooked cup 2 servings Brown Rice ½ cup of Papaya

2 servings of ripe mangoe s

juice

slice

Glass of water

Spiritual Counseling

Encourage the patient not to lose hope and have faith in GOD. Encourage the patient to seek the LORD’s guidance and pray in times of hopeless.

IMPLEMENTATION

A. Drug Study

GENERIC NAME BRANDNAME CLASSIFICATION : : : Amlodipine Norvasc Cardiovascular agent ; Calcium channel

blocker; antihypertensive agent. DOSAGE : 10 mg 1 tab//OD DRUG ACTION : These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. INDICATION : Chest pain or heart pain (angina) occurs because of insufficient oxygen delivered to the heart muscles. Insufficient oxygen may be a result of coronary artery blockage or spasm, or because of physical exertion which increases heart oxygen demand in a patient with coronary artery narrowing. Amlodipine is used for the treatment and prevention of angina resulting from coronary spasm as well as from exertion. Amlodipine is also used in the treatment of high blood pressure.

ADVERSE REACTION: The two most common side effects are headache and edema (swelling) of the lower extremities. Less common side effects include dizziness, flushing, fatigue, nausea, and palpitations NURSING RESPONSIBILITY: Monitor BP for therapeutic effectiveness. BP reduction is greatest after peak levels of amlodipine are achieved 6–9 h following oral doses. Monitor for S&S of dose-related peripheral or facial edema. Monitor BP with postural changes. Report postural hypotension. Monitor more frequently when additional anti hypertensives or diuretics are added.

GENERIC NAME : Cefuroxime BRANDNAME : Zinacef CLASSIFICATION : Cephalosporin DOSAGE : 500mg 1 tab//BID DRUG ACTION : Decreases or control the infection. INDICATION : For the treatment of many different types of bacterial infections such as bronchitis, sinusitis, tonsillitis, ear infections, skin infections, gonorrhea, and urinary tract infections. CONTRAINDICATION : Contraindicated in patients hypersensitive to drug or other cephalosporin. CV: phlebitis, thrombophlebitis. GI: diarrhea, anorexia, vomiting. Hematologic: hemolytic anemia, thrombocytopenia, transient neutropenia, eosinophilia

NURSING RESPONSIBILITY: Determine history of hypersensitivity reactions to cephalosporins, penicillins, and history ofallergies, particularly to drugs, before therapy is initiated.

Report onset of loose stools or diarrhea

Monitor for manifestations of hypersensitivity. Discontinue drug and report their appearance promptly. Monitor I&O rates and pattern: Especially important in severely ill patients receiving high doses. Report any significant changes.

NaHCO3 bakinSoda, Bell-Ans, Citrocarbonate, Neut, Soda Mint CLASSIFICATION : antiulcer agents, alkalinizing agent DOSAGE : 1 tab//TID DRUG ACTION : Sodium Bicarbonate acts as an alkalinizing agent by releasing bicarbonate ions. Following oral administration of this medication, it releases bicarbonate which is capable of neutralizing gastric acid. INDICATION : > Management of metabolic acidosis >Used to alkalinize urine and promote excretion of certain drugs in over dosage situations. >Used as an antacid CONTRAINDICATION : Metabolic or respiratory alkalosis Hypocalcemia, Excessive chloride loss. It is not recommended as an antidote following ingestion of strong mineral acids. Patients on sodium restricted diet. Renal failure, Severe abdominal pain of unknown cause especially if associated with fever, Edema, Flatulence, Gastric distention, Metabolic alkalosis, Hypernatremia, Hypocalcemia, Hypokalemia, Sodium and water retention, Irritation at IV site, Tetany

DRUG BRANDNAME

: :

NURSING RESPONSIBILITY: • Assess the client’s fluid balance throughout the therapy. • Symptoms of fluid overload should be reported such as hypertension, edema, difficulty breathing or dyspnea, rales or crackles and frothy sputum. • Signs of acidosis should be assessed such as disorientation, headache, weakness, dyspnea and hyperventilation. • Assess for alkalosis by monitoring the client for confusion, irritability, paresthesia, tetany and altered breathing pattern. • Hypernatremia clinical manifestations should be assessed and monitored which includes: edema, weight gain, hypertension, tachycardia, fever, flushed skin and mental irritability.

• Hypokalemia should also be assessed by monitoring signs and symptoms such as: weakness, fatigue, U wave on ECG, arrhythmias, polyuria and polydipsia.

• Monitor the client’s serum calcium, sodium, potassium, bicarbonate concentrations, serum osmolarity, acid-base balance and renal function before and throughout the therapy.

• Tablets must be taken with a full glass of water.

• For clients taking the medication as a treatment for peptic ulcers it may be administered 1 and 3 hours after meals and at bedtime.

DRUG CLASSIFICATION

: CaCO3 Calcium Carbonate : Class of calcium-containing preparations. Used as dietary supplements. DOSAGE : 500mg 1tab//TID DRUG ACTION : Decreases total acid load of GI tract. Increase esophageal sphincter tone. INDICATION : Antacid, calcium supplement, osteoporosis. CONTRAINDICATION : Patients with Ca renal calculi or history of renal calculi; hypercalcaemia; hypophosphataemia. Patients with suspected digoxin toxicity. Constipation, flatulence; hypercalcaemia; metabolic alkalosis; milk-alkali syndrome, tissue-calcification. Gastric hypersecretion and acid rebound (with prolonged use).

NURSING RESPONSIBILITY: Administer as antacid 1 hour after meal and at bed time Administer as supplement 1½ hrs after meal and at bed time Advice patient to increase fluids to 2L unless contraindicated

DRUG : FeSO4 + Folic CLASSIFICATION : Iron preparation DOSAGE : 1tab//OD DRUG ACTION : Elevates the serum iron concentration on which then helps to form high or trapped in the reticulo endothelial cells for storage and eventual conversion to a usable form of iron. INDICATION : Prevention and treatment of iron deficiency anemia. Dietary supplement for iron. CONTRAINDICATION : Hypersensitivity, Severe Hypotension, Dizziness, N & V, Nasal Congestion, Dyspnea, Hypotension, CHF, MI, Muscle cramps, Flushing NURSING RESPONSIBILITY : Advice patient to take medicine as prescribed. Caution patient to make position changes slowly to minimize orthostatic hypotension. Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician. Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs.

Inform patient that angina attacks may occur 30 min. after administration due reflex tachycardia. Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, and lifestyle changes and stress management.

GENERIC NAME : Glipizide BRANDNAME : Glucotrol CLASSIFICATION : It belongs to the sulfonylurea class of drugs which also includes glimepiride (Amaryl), glyburide (Micronase, Diabeta), tolbutamide (Orinase) and tolazamide (Tolinase). DOSAGE : 2.5mg 1tab//OD DRUG ACTION : Patients with type 2 diabetes have high glucose (sugar) levels in their blood because the cells in their bodies are resistant to the glucose-removing effect of the insulin, and the liver produces too much glucose. In addition, in type 2 diabetes the pancreas is unable to produce the increased amounts of insulin that are necessary to overcome the resistance. Glipizide reduces blood glucose by stimulating the pancreas to produce more insulin INDICATION : Glipizide is used together with diet and exercise to reduce blood glucose in patients with type 2 diabetes.

CONTRAINDICATION : Contraindicated with allergy to sulfonylureas; diabetes with ketoacidosis, sole therapy of type 1 diabetes or diabetes complicated by pregnancy, diabetes complicated by fever, severe infections, severe trauma, major surgery, ketosis, acidosis, coma (insulin is indicated); type 1 diabetes, serious hepatic impairment, serious renal impairment. Side effects of glipizide are possible, such as dizziness, diarrhea, and nervousness. In many cases, these side effects are minor and easily treated by you or your healthcare provider. However, some glipizide side effects should be reported to your doctor, including chest pain, shortness of breath, or signs of an allergic reaction. NURSING RESPONSIBILITY: Give drug 30 min before breakfast; if severe GI upset occurs or more than 15 mg/day is required, dose may be divided and given before meals. Monitor urine or serum glucose levels frequently to determine drug effectiveness and dosage.

C. Course in the ward

September 24, 2012 (7:45pm)

Diagnostic Procedure: CBC, Na, K, Crea , BUN, RBS, U/A, CXR Diet: Diabetic diet/ low fat, low salt

Exercise/Activity: Ambulatory

Treatment: (not yet handled) A Patient 51 yr. old female admitted to FMW under charity. Received by a wheel chair; Endorsed by ER nurse and transferred to bed safely with (+) generalized body weakness and (+) dyspnea. With on going IVF PNSS 1L x 6° regulated as ordered. Treatment given D50-50 1 vial TIV NaHCO3 or CaCO3 500 mg / tab TID. FeSO4 + FA 1 tab TID, Clonidine 75 mg/tab PRN for BP ≥ 140 / 90mmHg it is administered by NOD.

September 25 2012 (12: 45pm)

Diagnostic Procedure: CBG, BT s/p Diet: Low Salt, Low Fat diet, Diabetic diet

Exercise/Activity: Ambulatory Treatment: (not yet handled) CBG monitored And done cross matched for BT. V/ S q4° monitored and recorded. Informed in ROD and referred accordingly.

September 25 2012 (12: 45pm)

Diagnostic Procedure: Diet: CBG

Low Salt, Low Fat diet, Diabetic diet Ambulatory

Exercise/Activity:

Treatment: (not yet handled) With venoclysis PNSS 1l x 12° regulated as ordered.

September 27, 2012 (6:00pm)

Diagnostic Procedure: Diet: Repeat U/A ,CBC TID , BT,

Low Salt, Low Fat diet, Diabetic diet Ambulatory

Exercise/Activity:

Treatment: (not yet handled) Hooked and regulated IVF PNSS 1L x KVO. For BT 1“U” and 2 “U” PRBC properly typed and crossed matched. Repeated CBC for 2nd “U” of BT. Each unit to run for 4 hours with 4 hours intervals. Pre-BT meds given prior to first unit of PRBC. paracetamol 500 mg/tab 1 tab PO and Diphenhydramine 25 mg/IV given by the NOD. Cefuroxime 500 mg/ 1 tab BID.

September 28, 2012

Diagnostic Procedure: Diet: Hgb & Hct,

Low Salt, Low Fat diet, Diabetic diet Ambulatory

Exercise/Activity:

Treatment: (not yet handled) With the same venoclysis regulated @ desired amount. Administered plasil 10 mg TIV q 8° PRN for vomiting. Given furosemide 80 mg TIV for BT. Done repeated UTZ.

September 29, 2012 (2:00pm)

Diagnostic Procedure: Diet: Repeat CBC, Hct & Hgb

Low Salt, Low Fat diet, Diabetic diet

Exercise/Activity:

Ambulatory

Treatment: (not yet handled) Transfused 3 “U” PRBC with IVF PNSS 1l x KVO. After the last PRBC has been transfused, CBC and Hgb & Hct repeated. Treatment of NaHCO3 1 tab TID Amlodipine 10 g/ 1 tab OD, Cefuroxime 500 mg/ 1 tab BID x 5 days , Glipizide 2.5 mg/ 1 tab OD CaCO3 500 mg/ 1 tab TID , FeSO4 + Folic 1 tab TID , given by the NOD.

September 30, 2012 (2:00pm)

Diagnostic Procedure: Diet: ABG

Low Salt, Low Fat diet, Diabetic diet

Exercise/Activity:

Ambulatory

Treatment: (not yet handled) With the same venoclysis and regulated at the same ordered. Treatment given is Amlodipine 10 g/ 1 tab OD, Cefuroxime 500 mg/ 1 tab BID x 5 days , NaHCO3 1 tab TID, Glipizide 2.5 mg/ 1 tab OD CaCO3 500 mg/ 1 tab TID , FeSO4 + Folic 1 tab OD , given by the NOD.

October 1, 2012 (2:00pm)

Diagnostic Procedure: Diet: Repeat CBC , Na , K , CBG, Urinalysis

Low Salt, Low Fat diet, Diabetic diet

Exercise/Activity:

Ambulatory

Treatment: (not yet handled) Client is conscious and coherent, on DM diet, low salt, low fat. V/S taken and recorded. Due meds. given. I & O measured and recorded.

EVALUATION

A. Summary

This study is about 51 year old women, who was admitted at the Mandaluyong City Medical Center and was diagnosed with Chronic Kidney Disease 2⁰ to Diabetes Mellitus II related to Hypertension, Anemia 2° to Nephropathy, her suspicious and concern about her condition led her to seek for medical assistance together with her relatives. Her chief complaint generalized body weakness. The patient examined by her attending physician.

Her diagnosis is worthy to study to find out how she end up on having that kind of condition with her permission and blessing, We as a student nurse of BSN level 4 (Old curriculum) Group 1A and 1B have decided to make a study regarding her condition. Patients having this kind of condition serve as a challenge not just in the health care system but also in the field of nursing. More than caring, caring is the essential component of nursing the best way to help patient is to render a service that is honesty and full of compassion.

This study also aims to widen the knowledge about the problem known in the pathophysiology of the study, the appropriate interventions and management for patient who are under this condition.

B. Conclusion

This data was studied and gathered by the BSN 4 (Old Curriculum) Group 1A and 1B to present a simple but yet concise information based on case study presentation. Nursing students were able to apply the proper nursing action to the patient during assessment. Students were able to identify causes of patient condition with the use of different taught of the group base on the knowledge gain. Students were able to formulate a scientific based pathophysiology that is parallel with the patient condition from the risk factors to the disease process manifesting signs and symptoms based on the physical assessment, medical procedure and Laboratory results. Actual and probable health problems to determine based from the highest to the least priority in order to prevent further complications caused by conditions. Nursing care plans to classified using SMART, specific, measurable, attainable, realistic, and time bounded. Nursing interventions was rendered to give the proper care that client needed. As the Student nurses tried their best in rendering the ideal and not just the ordinary care that can be seen in the hospital now days.

We, the nursing students determined the actions, classifications, indications, contraindications, side effects and adverse reaction and most importantly the appropriate nursing considerations. We future nurse need to know that in giving medications prioritizing the 10R’s is needed to avoid medication error. We need to assure that obligation to our patient is not just giving the medication and preparing it but to know the essential classification of the drugs and its effectiveness that soon will help to the patient for their fast recovery.

REFERENCES

MOSBY’S Clinical Nursing (4th edition) Saunders manual of Nursing Care http://www.Creativehealthinstitute.com Kozier, B.,et al. (2007) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process & Practice. (8th Edition, Vol. 1). Philippines.Pearson Education South Asia PTE. LTD. Marieb, E. (2006). Essentials of Human Anatomy and Physiology. (8th Edition) Philippines. Pearson Education Inc., Prentice Hall Smeltzer, Suzanne C., et.al (2010). Medical-Surgical Nursing.(12th Edition). Philadelphia. Wolters Kluwer Health & Lippincott Williams &Wilkins Doenges, Marilynn, Moorhouse, M.F, & Alice Murr. (2008) Nurse’s Pocket Guide:Diagnoses, Prioritized Interventions and Rationales. (11th Edition). Taiwan.F.A.Davis Company Brunner and Suddharts, et al. (2008) Textbook of Medical-Surgical Nursing (11th Edition) PhiladelpiaWolters Kluwer, Lippin Colt Williams and Wilkins. MIMS.com (2010) Philippines Index of Medical Specialties (123rd Edition 2010)