Kidney Maybe Super No Www

KIDNEY MAYBE

ACKNOWLEDGEMENT

We, the students of Voces Illustres Pacis 2013 are blessed to have finally completed this arduous yet

inspiring task so that we could share the knowledge we have learnt through this case presentation and contribute to the body of

knowledge of each and every one of us who participated in this task. Without the contribution of each member of this group, this presentation

would not be made possible.

ACKNOWLEDGEMENT

To our beloved Sr. Carolina Agravante, SPC, President and the Dean of the College of

Nursing for her inspirational messages and prayers,

To our Associate Dean of the College of Nursing, Mrs. Marilyn Junsay, RN, MSN, for her constant support and care that she has presented to us,

ACKNOWLEDGEMENT

To our dear adviser, Mrs. Eden Shiz Parpa, RN, MAN, and for our supportive Team Leader, Ms. Chona Bacabac, RN, MAN, for

generously offering their time, effort, and knowledge for the betterment of this presentation,

To Mr. C.T and his family for the patience and trust to share to us their story,

ACKNOWLEDGEMENT

To our beloved parents, for their never-ending support and understand,

And above all, we thank our Almighty Father for blessing us always and rendering his

unconditional love to us. This is all for His glory.

SCOPE AND LIMITATIONS

For this case presentation, the BSN IV (Music Track) chose Hypertensive Urgency; Chronic Kidney

Disease secondary to Hypertensive Nephrosclerosis; Community Acquired

Pneumonia-Moderate Risk because this has a connection in our topics discussed in Medical-Surgical Nursing in the course of Nursing Care

Management 104.


This study was conducted by BSN IV (Music Track) of Voces Illustres Pacis 2012 of St. Paul

University Iloilo, Academic Year 2012-2013.

Data gathering and assessment were done on the following dates; August 15, 2012 to August 19,

2012, during our clinical exposure, every Monday to Wednesday from 7 am to 3pm,


at the Sacred Heart Annex of St. Paul Hospital Iloilo, Gen. Luna Street, Iloilo City and during our home

visit last September 19, 2012 at Oton, Iloilo.

A letter of permission to gather data was addressed to client. The case presenters started communicating

with the client last August 15, 2012.


Due to lack of time, we decided to return to our client on August 17-19, 2012. However, Mr. C.T. was not

around during August 17, 2012 due to an operation conducted to him, thus limiting our time with the client. Mr. C. T. sometimes appeared to be

inconsistent with some answers given to us but information was further validated from his wife.


Collecting the data, assessment and case discussions were done inside the school

premises at St. Paul University Iloilo and case presenters’ respective homes. Confidentiality of the patient’s data is crucial and was observed

at all times.


The data gathered included vital information, nursing history, physical assessment,

laboratories and medications written in the patient’s chart

Both primary and secondary data were gathered since the patient was inconsistent with his

information.

DEFINITION OF TERMS

Arteriovenous Fistula (AVF) - The connection of a vein to an artery, usually in the forearm, to allow access to the vascular system for hemodialysis, a procedure that performs the function of the kidney in people whose kidneys have failed. Connecting the vein and artery requires a surgical procedure. The fistula develops over a period of 1 to 2 months after the surgery.

Arteriovenous Fistula Creation – The procedure performed to provide a long-lasting site through which blood can be removed and returned during hemodialysis.

DEFINTION OF TERMS

Azotemia - A condition wherein the person’s blood contains uncommon levels of urea, creatinine, and other compounds rich in nitrogen. It is also one clinical characteristic of a wider condition known as Uremia, which includes other conditions such as Acidosis, Anemia, Hyperkalemia, Hypertension, and Hypocalcemia.

DEFINTION OF TERMS

Beriberi – Also known as Thiamine Deficiency, refers to the lack of thiamine pyrophosphate, the active form of the vitamin known as thiamine (also spelled thiamin), or vitamin B-1. Thiamine is a water-soluble vitamin that is absorbed in the jejunum. When the thiamine level in the small intestines is low, an active transport portal is responsible for absorption.

DEFINTION OF TERMSBlood Urea Nitrogen Test (BUN) – A test that measures

the amount of nitrogen in the blood that comes from the waste product. A normal range for BUN is generally 8 to 24 mg/dL for adult men (2.86 to 8.57 mmol/L) and 6 to 21 mg/dL (2.14 to 7.50 mmol/L) for adult women. Levels may also vary by age. Generally, a high blood urea nitrogen level means your kidneys aren't working well, particularly if the result is above 50 mg/dL (17.85 mmol/L). But, elevated urea nitrogen can also be due to urinary tract obstruction, congestive heart failure or gastrointestinal bleeding. Your blood urea nitrogen level may also increase as a result of dehydration, shock, burns or fever.

DEFINTION OF TERMS

Certain medications, such as corticosteroids, may increase urea nitrogen levels, too. In addition, a high protein diet can cause your BUN level to increase. Lower than normal blood urea nitrogen levels may be a sign of liver damage. But low levels can also be caused by malnutrition, a low-protein diet or a high-carbohydrate diet.

DEFINTION OF TERMS

Cardiomegaly - A condition wherein the heart enlarges in a cardiothoracic ratio of more than 0.50. It can be attributed to a lot of causes, but mostly it is because of low heart output, otherwise referred to as a cardiac failure. It occurs if the heart is more than 50 percent bigger than the inner diameter of one’s rib cage and is assumed to be the direct effect of the thickening of the heart muscles and that happens when the heart is given an increased workload.

DEFINTION OF TERMSThis increase workload on the other hand, may be

due to other health conditions present in the body. Viral illnesses and previous heart attacks can cause the heart to overwork. Drug abuse, inflammation of the heart, and uncontrolled hypertension are the known issues that may give rise to cardiomegaly. It is believed to not be the disease itself, but just a sign of a possibly more severe problem. Physicians diagnose this condition by conducting a chest x-ray. Usually, this disease is identified through an incidental test on the upper body, even if it is not directed to the disease in itself.

DEFINTION OF TERMS

Chronic Kidney Disease (CKD) – Occurs when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually, usually over months to years. It is divided into five stages of increasing severity.

DEFINTION OF TERMS

Stage Description GFR*mL/min/1.73 m2

1 Slight kidney damage with normal or increased filtration

More than 90

2 Mild decrease in kidney function

60 to 89

3 Moderate decrease in kidney function

30 to 59

4 Severe decrease in kidney function

15 to 29

5 Kidney failure Less than 15 (or dialysis)

DEFINITION OF TERMS

Cough Reflex - The events initiated by the sensitivity of the lining of the airways and mediated by the medulla as a consequence of impulses transmitted by the vagus nerve, resulting in coughing.

Dehydration – A condition in which the body does

not have as much water and fluids as it should. It is classified as mild, moderate, or severe based on how much of the body's fluid is lost or not replenished. When severe, dehydration is a life-threatening emergency.

DEFINITION OF TERMS

Edema - Swelling caused by the accumulation of abnormally large amounts of fluid in the spaces between the body's cells or in the circulatory system. It is most common in feet, ankles, and legs. It can also affect the face and hands.

End-Stage Renal Disease (ESRD) – Also known as Chronic Renal Disease; a progressive loss in renal function over a period of months or years. The symptoms of deteriorating kidney function are unspecific and might include feeling generally unwell and experiencing a reduced appetite.

DEFINITION OF TERMS

Erythropoietin – A hormone produced by the kidney that promotes the formation of red blood cells in the bone marrow.

Exudate - A fluid with a high content of protein and cellular debris which has escaped from blood vessels and has been deposited in tissues or on tissue surfaces, usually as a result of inflammation.

DEFINITION OF TERMS

Glomerular Filtration- It is the first step of urine formation; the renal process whereby fluid in the blood is filtered across the capillaries of the glomerulus and into the urinary space of Bowman's capsule.

Glomerular Filtration Rate - an expression of the quantity of glomerular filtrate formed each minute in the nephrons of both kidneys, usually measured by the rate of clearance of creatinine.

DEFINITION OF TERMS

Hemodialysis - A mechanical way to cleanse the blood and balance body fluids and chemicals when kidneys are not able to perform these essential functions. It is performed as critical life support when someone suffers from Acute or Chronic Kidney failure.

Hypertensive Cardiovascular Disease (HCVD) – A condition caused by high blood pressure (Hypertension) and manifests as Coronary Artery Disease (CAD), heart failure, and enlargement of the heart. It is the leading cause of hypertensive illness and death.

DEFINITION OF TERMS

Hypertensive Urgency – A condition wherein a person has very high blood pressure and have no symptoms. In these cases, the elevated blood pressure is discovered incidentally. This indicates that the blood pressure is high enough to cause serious risk of sudden, life threatening events, but that no such events are currently occurring. In other words, these patients have no organ failure or other immediately life threatening conditions, but could quickly develop them if their blood pressure isn’t quickly brought under control.

DEFINITION OF TERMS

Hypertrophy – Enlargement or overgrowth of an organ or part of the body due to the increase in size of the constituent cells.

Hypocalcemia – A low blood calcium level that occurs when the concentration of free calcium ions in the blood falls below 4.0 mg/dL (dL = one tenth of a liter). The normal concentration of free calcium ions in the blood serum is 4.0-6.0 mg/dL.

DEFINITION OF TERMS

Intrajugular Catheter – A central venous catheter inserted through the internal jugular vein to serve as a temporary vascular access for hemodialysis.

Nephrosclerosis – A progressive disease of the kidneys that results from sclerosis (hardening) of the small blood vessels in the kidneys. It is most commonly associated with hypertension or diabetes and can lead to kidney failure.

DEFINITION OF TERMS

Nitrogenous – Wastes that come during the breakdown of proteins. The main nitrogenous wastes are urea and uric acid. Urea is formed from gluconeogenesis of amino acids, while uric acid is from gluconeogenesis of nucleotides. These molecules are mainly removed from the body, keeping a low concentration of them in the blood. Urea is also used in the medulla to increase the amount of solute in the medullary interstitial fluid (making it more hypertonic). This helps in the reabsorption of water. Urea is a waste product and is also useful in the kidney for water reabsorption.

DEFINITION OF TERMS

Oliguria - A diminished capacity to form and pass urine less than 500 mL in every 24 hours so that the end products of metabolism cannot be excreted efficiently. It is usually caused by imbalances in body fluids and electrolytes, renal lesions, or urinary tract obstruction.

Pallor – Paleness of the skin or mucosa. Although it is commonly associated with anemia, many long-term cases show mucosa of normal color. It is also a common sign of shock

DEFINITION OF TERMS

Pneumonia – An inflammation of the lungs caused by infection. Bacteria, viruses, fungi or parasites can cause pneumonia. Pneumonia can range in seriousness from mild to life threatening.

Renin-Angiotensin Aldosterone System (RAAS) - A hormonal cascade that functions in the homeostatic control of arterial pressure, tissue perfusion, and extracellular volume. Dysregulation of the RAAS plays an important role in the pathogenesis of cardiovascular and renal disorders.

DEFINITION OF TERMSSerum Creatinine – A test performed to measure

the level of the waste product creatinine in a person's blood. This test also helps to assess the functioning of the kidneys. Creatine is formed during the metabolism of proteins. This creatine is further broken down into creatinine. The kidneys filter the blood and throw creatinine out of the body through urine.

DEFINITION OF TERMS

If the kidneys fail to do so effectively due to some kidney disease, the creatinine level in the urine decreases and that in the blood increases. This test is usually performed to check whether the kidneys are functioning normally. It is also useful in monitoring the progress of a kidney disease and to assess a patient's response to treatment. The test can also help to tell if a person is suffering from severe dehydration.

DEFINITION OF TERMS

Serum Glutamic Oxaloacetic Transaminase (SGOT) - This enzyme is found in the liver, muscles (including the heart), and red blood cells. It is released into the blood when cells that contain it are damaged. Other names for this enzyme are aspartate aminotranskinase, aspartate transaminase, and AST.

DEFINITION OF TERMS

Serum Pyruvate Aminotransferase (SGPT) – Also known as Alanine Aminotransferase (ALT); done to see if the liver is diseased or damaged. This enzyme is found in cells of the heart, kidneys, muscles and pancreas in small amounts, but it is in much greater concentration in the liver. Although there is normally a low level of GPT in the bloodstream, it will greatly increase in the presence of certain diseases, such as cirrhosis and hepatitis. The use of certain medications, such as statins to lower cholesterol, can also irritate the liver causing GPT to be released.

DEFINITION OF TERMS

Severe Hypertension – A condition wherein the systolic blood pressure (SBP) is more than 180 mmHg or diastolic blood pressure (DBP) is more than 110 mmHg, with some variability from study to study.

Uremia - A toxic condition resulting from kidney disease in which there is retention in the bloodstream of waste products normally excreted in the urine. This is also known as azotemia.

NURSING HISTORY

Vital Information

Vital Information Client’s name: Mr. C.T.Age: 58 years oldSex: MaleCivil status: MarriedReligion: Roman CatholicNationality: FilipinoBirth date: March 20, 1954Birthplace: Oton, IloiloCurrent address: Barangay Cabanbanan, Oton,

Iloilo

Education attainment: Bachelor of Science in

Marine Transportation

(Iloilo Maritime

Academy -1980) Occupation: Assessor (John

B. Lacson

Maritime Academy,

Arevalo, Iloilo)

Chief complaints: Difficulty of breathing

Date and time of

admission to ER: August 8, 2012, 3:32

p.m.

Accompanied by: Mrs. R.T. (wife), Mr. A.T.

(son), Mrs. C. N.

(daughter), Mr. N. N.

(son-in-law)Mental/emotional status

upon admission: Awake, coherent, oriented

to person, place, time, and

eventAdmission vital signs: T: 36.8°C per axilla

RR: 22 breaths per minute

CR/PR: 80 beats per minute BP: 200/120 mmHg

Mode of transportation upon admission: AmbulatoryAccompanied by: Mrs. R.T. (wife),

Mr. A.T. (son), Mrs. C.

N. (daughter), Mr. N. N. (son-

in-law)

Mental/emotional status upon admission: Awake, coherent, oriented to person, place, time, and event

Medical diagnosis: Hypertensive Urgency;

Chronic Kidney Disease

secondary to Hypertensive

Nephrosclerosis; Community

Acquired Pneumonia-Moderate Risk

Attending physician/s: Dr. H.O. – Urologist Dr. J.A. – CardiologistDr. R.B. - DPBSNumber and dates of previous hospital admission: 1

August 1986 - St. Jude’s Hospital Makati - AppendectomyWard/unit, bed and room number: Sacred Heart Annex A., Room 206Food or drug allergy: NoneSources of Information: Primary - Mr. C.T.

Secondary – Patient’s chart; Mrs. R. T. (wife)

Height: 5 feet and 3 inches tallWeight: 50 kgHome access number: 09463397728Person to be contacted in case of emergency:

Mr. A.T. – son

Home access number: 09463397728Person to be contacted: in case of emergency:

Mr. A.T. - sonInsurance, health care financing, or usual source of medical care: Phil health

History of Present Illness

HISTORY OF PRESENT

ILLNESS Last 2007, at around noon time, after eating

lunch while watching Eat Bulaga at home, Mr. C. T. experienced dizziness described as “pagpalang dulom nga daw matumba”, aggravated by movement, blood pressure checked by neighbor, Mrs. W.T., which resulted to 200/110 mmHg, advised to rest and took 150 mcg Catapres to alleviate dizziness and elevated blood pressure as prescribed by Dr. J. A. upon initial consultation last 2006. Blood pressure was not rechecked. After a few hours of rest, dizziness was relieved.

3 days after, woke up at around 3 am, experienced feeling of fullness on both calves and felt no pain upon palpation. Assumed that enlargement of calves was “beri-beri”. No intervention was done and continued to observe lower extremities.

A month after, at around 11 am, experienced dizziness again and assumed that blood pressure was increased. Decided to seek consultation from Dr. J. A.’s clinic at St. Paul’s Hospital Iloilo regarding dizziness and enlargement of lower extremities; blood pressure was checked which resulted to 180/110 mmHg and prescribed to continue taking Catapres with the same dose of 150 mcg once a day and Atenolol 100 mg once a day and was immediately referred to Dr. H. O.

Seen and examined by Dr. H. O. and was requested with the following laboratories: Complete Blood Count, Urinalysis and Serum Creatinine to be monitored every week and prescribed Ketosteril 1 tab twice a day and Sodium Bicarbonate thrice a day. Results showed that CBC and Urinalysis were normal but initial Serum Creatinine results revealed 400mg/dL (normal range is 53-115 mg/dL).

After a week, Serum Creatinine result showed a decrease to 200mg/dL and Ketosteril was claimed to be effective. Diagnosed with Chronic Kidney Disease (Stage 2) and was encouraged to stop smoking and drinking alcoholic beverages and ordered Ketosteril as maintenance drug and no other interventions were given. Due to inconvenience of the distance from their place to the physician’s clinic, decided not to seek consultation but continued taking prescribed maintenance drug.

A week prior to admission, Mr. C.T. experienced difficulty of breathing, colds, productive cough and fever of 38°C via axilla taken by his daughter after a week of attending his brother’s wake, had adequate rest and sleep and took Biogesic 500mg to alleviate fever and colds and claimed not effective in decreasing fever and no further interventions were done.

The day prior to admission, experienced dizziness, difficulty of breathing and an increase in blood pressure of 200/110 mmHg, taken by Mrs. W.T., which reduced to 180/100 mmHg after taking 1 tab of Catapres 150 mcg; decided to have himself admitted if symptoms persist the following day.

On August 8, 2012, at around 12 p.m. while resting, still

experienced difficulty of breathing, dizziness, productive

cough to a yellowish, thick sputum approximately 15 cc.

Left home at about 2 p.m. via private car with no

interventions done upon travel and arrived at St. Paul’s

Hospital Iloilo Emergency Room, ambulating, alert and

conscious at around 3 p.m., accompanied by wife, eldest

daughter, eldest son and son-in-law. On August 14, 2012, at 9 a.m., student nurse receives the patient.

The following information was based from client’s chart: EMERGENCY NOTESInitial vital signs taken and recorded as follows: temperature 36.8 ° Celsius via axilla, skin is dry, warm to touch. RR 22 breaths per minute, spontaneous and non labored. CR 80 beats per minute, synchronous with cardiac unlabored. BP is 200/120 mmHg. Seen and examined by Dr. Mueño M.R.O.D, with orders made and carried out. IVF started with PNSS IL x 100 cc/hr, patent and infusing well at Left metacarpal vein. Catapres 75 mg SL now done. Stat medications done. Foley catheter inserted as ordered. Stat laboratories requested.

The following laboratories were requested and taken: Complete blood count, Serum Sodium, Potassium, Sodium, Creatinine, Fasting Blood Sugar, Lipid profile, Uric acid, Chest X-ray, Urinalysis. Watch out for untowards signs and symptoms required accordingly. Brought to room per wheel chair. Son arranged transfer to Sacred Heart Annex Room 206 on August 8, 2012 at 8 p.m. via stretcher. Transferred to bed and made comfortable, side rails pulled up to ensure safety. Endorsed to staff nurse in duty.

Course in the WardLast August 9, 2012 at 10:30 am, had

undergone ultrasound of liver and abdomen; foley catheter clamped. At around 12 noon, client experienced increase in respiratory rate of 25 breaths per minute. Was placed on high back rest; Furosemide 40 mg IV given as ordered; scheduled for stat hemodialysis. At 5:20 pm, hemodialysis was performed for 5 hours at the Kidney Service Unit; blood transfusion done of 1 unit packed RBC after proper cross matching; hemodialysis treatment tolerated and terminated. At 10 pm, client experienced increase in blood pressure of 170/100 mmHg; anti-hypertensive medication given and encouraged to rest.

Last August 10, 2012 at 12 noon, client experienced loss of appetite; encouraged to eat well-balanced diet, have adequate oral fluid intake and instructed to avoid strenuous activities. At 1 pm, had undergone hemodialysis, dressing done on right intrajugular catheter. At 6 pm, health teachings on diet and activity was given such as eating a well-balanced meal, drink fluids adequately, encouraged to do deep breathing exercises and to have adequate rest and sleep.

At 11 pm, same health teachings about diet and exercise was given.Last August 11, 2012 at 8 am, hemoglobin levels were decreased of 9.2 g/dL; encouraged to do deep breathing exercise, to have well balanced diet and adequate oral fluid intake, and to have enough rest and relaxation.Last August 15, 2012 at 12 noon, experienced non-productive cough; encouraged to do deep breathing and other relaxation techniques, placed on moderate back rest, monitored for persistence of cough and dyspnea.

Last August 16, 2012 at 8 pm, non-productive cough noted; same health teaching regarding non-productive cough was given, encouraged to have adequate rest and to avoid strenuous activities.Last August 17, 2012 at 7:30 am, had undergone hemodialysis at the Kidney Center.

Past Medical History

Mr. C. T. claimed that health was impaired prior to admission. Claimed to have received unrecalled immunizations during childhood and standard company protocol immunizations as part of requirements as part of the medical exam, name and date unrecalled. BCG scar noted on right shoulder. Experienced childhood illnesses such as measles, mumps, chicken pox and other common illnesses such as fever, cough and colds, age and dates unrecalled

Mother, Mrs. F.T., used herbal remedies such as “lamponaya” for cough and “oregano” for wounds, claimed that it was effective; cannot recall other treatments used. At the age of 31, experienced intermittent episodes of dizziness and headache and did not seek any consultation. Last August 1986, had undergone Appendectomy at St. Jude Hospital, Makati, Manila and did not experience any further complication. Client claims that he did not have any history of psychiatric illness, accidents, falls, injuries, trauma, disabilities or handicaps.

Lifestyle

Mr. C. T. claims to be independent with activities of daily living such as eating, bathing, toileting, transfer and locomotion and instrumental activities of daily living such as food preparation and managing medications without assistance and supervision. Considers walking every morning at least 30 minutes at the shoreline near their house as a form of exercise.

Claims that do not have any sleeping problem or changes in sleeping pattern and does not take any sleeping aides; sleeps in prone position most of the time with only one pillow supporting the head usually from 9 p.m., wakes up around 3 a.m. and remains in bed until 5 or 6 a.m.

Client verbalized that appetite is excellent and eats thrice a day to a full meal which consists of 1-2 cups of rice, fried fish and vegetables or vegetable soup such as “pakbet”, “laswa” or “sinabawan” and is able to consume approximately 6 glasses of water per day. Few weeks prior to admission, claims to have decreased appetite. Can no longer consume 1 cup of rice with small amount of viand. Water intake decreased to approximately 4-5 glasses per day with mineral water as source. Claimed weight loss from 50kg prior to admission to 48kg after admission.

Client verbalized that there was no difficulty in voiding and moving bowels prior to admission. Usually voids to yellow, aromatic urine 7-9 times a day, approximately 120cc- 150cc per urination and experience frequent urination at night. Moves bowel twice a day to a brown, soft stool.

Started smoking at the age of 20 and can consume 20-25 sticks of cigarettes per day and regularly drinks 3-4 bottles per day of San Miguel beer Pilsen; decided to gradually stop such vices last 2007 because of current condition.

Compliant with maintenance medication of Ketosteril 650 mg 3x a day, Atenolol 100 mg once a day, Norvasc 10 mg once a day, and Calvit 400 mg 3x a day. Claimed that did not experience any side effects every after taking these medications but continued monitoring blood pressure twice a day every morning and before taking Atenolol; Last BP reading resulted to 140/90 mmHg.

Family History

Hypertension has been identified in the paternal side of the family. Father, Mr. P.T., died due to old age at the age of 90, and mother, Mrs. F.T. died at the age of 61 due to cardiac arrest.Has 5 siblings. Ms. F.T., the oldest sister and Ms. E.T., the second eldest sister died at the age of 65 and 63 respectively with no confirmed cause. Mrs. O.E., the third eldest sister is 62 years old, has history of cataract and impaired vision. 2 other siblings, Mr. A.T., 56 years old and Mr. P.T. 54 years old are in good state of health. Claims not to have any rare genetic conditions.

Personal and Social History

Graduated last 1980 with the Degree of Bachelor of Science in Marine Transportation and currently employed at John B. Lacson Maritime Academy, Arevalo, Iloilo as an assessor. Neighborhood is located in rural area and home is located in front of the beach; one-storey house made up of concrete materials, and claims that they do have environmental hazards present in the neighborhood such as the stagnant water in their backyards which is a breeding site for mosquitoes and the lack of wearing of footwear which may cause injury. Nuclear type of family and equalitarian in terms of decision-making regarding home, health, family and finances; has a stable and supportive relationship with family members. Current condition made their family bond stronger.

Client claimed that he has been absent at work for 13 days due to illness but verbalized that he is thankful for the support of his wife and for taking care of him; Mrs. R. T. is a housewife and children have their own families. With a monthly income of P15, 000 and claimed to be enough to meet the needs of their family.

Admits to have a monogamous sexual lifestyle and verbalized he is content with sexual activity with wife at least once every month; also claimed that due to current condition and age, sexual activity is not as active anymore.

Roman Catholic; goes to church every Sunday and participates in bible studies every Saturday near their place and does not participate in any other social activities and organizations; considered raising poultry and watching television as part of recreational activities. “Nagahinulsol guid ko kay

sang nabal an ko nga may ginabatyag ako kag

hindi man siya lala gin pabay an ko na lang ang

akun kundisyon,” as verbalized when asked about his outlook in life in relation to his condition.

Stressors

Mr. C.T. complains of feeling of numbness at intravenous site on right jugular vein and copes by the emotional support that the wife gives client and makes him feel assured regarding his condition; Also verbalized about the unfamiliar environment in the hospital which is difficult to adjust on the first few days of hospitalization and copes by the presence of family members who stay in the hospital to be with the client.

Client verbalized his anxiety about current condition and the further complications that it may lead into if proper interventions are not done and copes by expressing feelings towards his family and by the willingness of the family to comply with the treatments and other interventions that need to be done for the improvement of client’s condition; also expressed feelings about the workload missed at work due to absence because of hospitalization and copes by doing his best in complying with treatments and medications for fast recovery and to be able to go back to work as soon as possible.

PHYSICAL ASSESSMENT

Functional Area

August 15, 2012

(Pre Assessment)

August 19, 2012

(Post Assessment)

General Survey

58 years old, Filipino, Male; awake, conscious; in semi-fowler’s position using 1 pillow supporting the head and neck; skin brown in color; clean well groomed in hospital gown, no unpleasant body odor note; maintains eye contact; converses with wife at bedside; IVF of PNSS 1L x KVO with remaining of 600cc, infusing to at right intrajugular vein, dry intact dressing; personal items such as cellphone and tissue within easy reach.

58 years old, Filipino male;ectomorphic; in semi-fowler’s position using one pillow supporting the head; clean, well groomed in civilian clothing appropriate to current climate and setting; no unpleasant body odor noted; no IVF,intrajugular catheter located at right side of the neck, with dry intact dressing, left arteriovenous fistula located at left wrist; personal items within reach at bedside.

Respiratory Function

Respiratory rate of 23 breaths per minute; regular in rate and rhythm, non-labored breathing; use of accessory muscles not noted; intermittent productive cough, expectorating to whitish, frothy sputum, approximately 5cc per expectoration; nose is symmetrical and straight, color is uniform with the color of the face; nasal septum is at midline and non-deviated ; nasal mucosa is pink and moist; discharges not noted; trachea is located at the midline above suprasternal notch with equal distances on both sides; clavicles and scapula are equal in level during respiration; anterior and posterior chest is light brown in color; no sternal protrusion or depression noted; symmetrical and firm shaped thorax; no masses and tenderness noted in the frontal and maxillary sinuses upon palpation

Objective Cues:Respiratory rate of 21 breaths per minute, regular in rate and rhythm, non-labored breathing; intermittent productive cough, withuse of accessory muscles not noted; minimal crackles noted upon auscultation; no other changes noted

antero-posterior diameter to transverse diameter is 1:2; posterior thorax not assessed; symmetrical anterior chest expansion; tactile fremitus more pronounced on the upper part of the thorax, with diminishing vibration toward the lower part; equal, bilateral diaphragmatic excursion approximately 3 cm; dull sound heard on the 3rd and 4th intercostal spaces of the left anterior thorax upon percussion; lymph nodes on the neck are non-palpable and non-tender; tympanic sound heard on the 5th ICS; resonant sound heard until the 7th ICS; and dull sound on the 7th ICS; coarse crackles auscultated upon expiration on the anterior lung field

Circulatory Function

Objective Cues:

Slightly pale palpebral conjunctiva; soles of feet are pale, with capillary refill of 3 seconds on both nail beds of upper and lower extremities; with cardiac rate of 74 beats per minute synchronous with radial pulse rate,regular in rate and rhythm, not easily palpable, graded as 1;blood pressure of 130/90 mmHg taken at right arm on semi-fowler’s position; with IVF of PNSS1L x KVO, patent and infusing well at right intrajugular vein; no cyanosis noted; palpable carotid artery, regular in rate and rhythm, bruits not noted; lymph nodes not palpable; S1 and S2 heard at all sites, S1 loudest at apex of the heart and S2 loudest at the base; no murmurs, missed beats heard on landmarks.

Objective Cues:

Cardiac rate of 63 beats per minute synchronous with radial pulse rate, regular in rate and rhythm, not easily palpable, graded as 1; blood pressure of 130/80 mmHg taken at right arm in semi-fowler’s position;whooshing sensation felt upon palpation; arterio-venous fistula at left wrist, bruits noted upon auscultation; no other changes noted.

Mental, Cognition, Emotional Function

Objective Cues:

Inability to recall immediate memory; intact recent and remote memory; oriented to time, place and person; mood and affect appropriate to situation; answers questions with relevance and appropriateness, hints to questions are sometimes used; content, speech, and language skills intact; able to respond to questions appropriately when asked; able to verbalize feelings; clear and reality based perception.

Other changes not noted.

Nutrition Subjective Cues:“Hindi ko ka pa tama kaon kag inom tubig kay ginahapo ako.” Objectives Cues:Low salt, low fat as present diet; able to consume 50% of meal served composed of rice, fish, and vegetables; drinks approximately 3-4 glasses a day of water; lost 2 kilograms of body weight during hospitalization, from 50 kilograms to 48 kilograms at present;lips are soft, dry, pink in color; gums are dark brown in color, moist; has 32 yellowish teeth present with minimal dental caries noted at the two lower molars and two upper molars; no dentures noted; with casket


located at left upper incisor; uvula is at midline and rises upon saying “ah”; soft palate is pink and moist; lesions not noted upon inspection; tongue is at midline of the oral cavity, pink, moist and slightly rough on top surface; intact gag reflex; no feeding equipment attached to the client.

Neurologic Function

Objective Cues:With Glasgow Coma Scale of 15; spontaneous eye opening, obeys verbal command and answers questions appropriately; oriented to time, place, person and event with coordinated upper and lower extremities;negative pronator drift; grade 3 bilateral hand grasp strength; intact sensations to pain, light touch, kinesthesia, graphesthesia, and point location on both lower and upper extremities;smooth and coordinated finger-to-nose testing; abdominal reflex present.


Rest and Comfort

Subjective Cues:

“ Ga alay akon leog (points at right intrajugular catheter)”

Objective Cues:

Pain characterized as numbness located at right intrajugular catheter, rated as 2/10 using numeric pain rating scale(0 as no pain, 1-4 as moderate pain, 5 as tolerable pain, 10 as to excruciating pain); Muscle guarding and facial grimace not noted.

Other changes not noted

Thermoregulatory Function

Objective Cues:

Temperature of 36.3 degrees per axilla, afebrile; flushing, chills and diaphoresis not noted.

Temperature of 36.7 degrees Celsius per axilla, afebrile; other changes not noted.

Elimination Objective Cues:Bladder and bowel continent; voids 5-6 times a day to sometimes every hour to a yellowish, aromatic urine, approximately 120-150 cc per urination; defecates 2-3 times a week to a brown, hard stool, Type 1 based on Bristol stool chart (separate, hard nut-like lumps);last bowel movement on August 13,2012 as claimed by client; flat abdomen in supine position, with normoactive bowel sounds heard on four quadrants of the abdomen, with 8-12 gurgling sounds noted per minute; no abdominal and bladder distention noted upon palpation; masses and tenderness not noted upon palpation and percussion; no catheter or drains present

No other significant changes noted

Motor Function

Objective Cues:Shuffling gait noted; spine is straight, erect posture; independent with activities of daily living such as eating, using the bathroom, and bathing; needs supervision with bed mobility, transfer to and from bed, ambulating, and dressing; independent with instrumental activities of daily living such as managing money and taking medications; full range of movement against gravity and against full resistance; muscles are firm equal in size and shape; bilateral hand grasp graded as 3; muscle strength of both upper and lower extremities graded as 5.

Shuffling gait noted; no other significant changes noted

Social Function

Objective Cues:Interacts actively and appropriately to medical, nursing staff, student nurse on duty and his family; maintains eye contact and converses; cooperates well in procedures;


Integumentary Objective Cues:

Presence of palpable, minimal scars in both upper and lower extremities; skull is normocephalic, symmetrically round, smooth skull contour; still and upright; erect with no tremors; with coarse grayish hair; skin is brown in color, warm to touch, with good skin turgor; with fine body hair, evenly distributed on upper and lower extremities; clean fingernails and toenails; with light pink and smooth nail beds noted

Objective Cues:

Arterio-venous fistula present at left wrist; no other changes noted

Reproductive Function

Client refused to be assessed; claims to have no difficulty in voiding and moving bowels; pain, swelling, lesions, itching and any other discomfort in perineal area not noted as claimed by client

No other changes noted

SPECIAL SENSES

EYES

EARS

NOSE

MOUTH

Objective Cues:

Yellowish sclera; pale conjuctiva; CN2(optic) visual acuity/ field intact; CN3 (Occulomotor), CN4 (Trochlear), CN6(abducens) ocular movements, eye movement in conjugate function, Pupils equally react to light and accommodation; pupils are 4mm in natural light; eyebrow distributed evenly and symmetrically; eyelash are curled outward, symmetrically distributed, blinking reflex intact.

Objective Cues:

Cranial Nerve 8(Auditory) intact; ear is nearly upright, symmetrical in shape; color is same as of the face; smooth, mobile, firm, no piercing noted; auricles recoil when folded; minimal yellowish odorless cerumen noted in both ears

Objective Cues:

Altered sense of smell; shape of nose is symmetrical, color is the same as of the face; mucosa is pink in color, intact, moist; symmetrical nares; nasal septum is aligned and intact; lesions, masses, and swelling not noted.

Objective Cues:

Altered sense of taste; 5 (Trigeminal),CN 7 (Facial), CN 9(Glossopharyngeal), and CN12 (Hypoglossal) intact; Lips are pink in color, dry, and slightly asymmetrical; mucosa and gums are pink in color; intact, moist, no lesions, bleeding and masses noted; tongue is in midline of the oral cavity; tonsils are pink in color, graded as one; intact gag reflex.

Objective Cues:

Yellowish sclera; pale palpebral conjunctiva; no other changes noted

Objective Cues:

Pearly gray, shiny and translucent eardrum; no cerumen noted; no other changes noted

Objective Cues:

Altered sense of smell; No other changes noted

Objective Cues:

No other changes noted.

LABORATORIES

COMPLETE BLOOD COUNTThe complete blood count (CBC) with the differential is one of the most commonly performed test in health care. The test is used to determine the hematologic status of the patients. This laboratory test was taken as part of the hospital’s routine procedure which is done to the patient upon admission at the Emergency Room.

RESULT(8-8-12)

RESULT(8-10-12)

UNITS REFERENCE RANGE

SIGNIFICANCE

TOTAL WBC 6.6 10.5 X10^9/L 4.5-11.0 Normal. TOTAL RBC 1.94 3.19 10^12/L 4.1-5.4 Decreased. This shows

that there is a decrease production of red blood cells which results to anemia.Decreased due to hemolysis of red blood cells secondary to infection of the respiratory tract.

HEMOGLOBIN 5.7 9.2 g/dL 12.0-15.0 Decreased. This shows that there is a decreased amount of oxygen being supplied to different tissues. Since haemoglobin is a component of red blood cells, the level of haemoglobin decrease when levels of red blood cells decreases. Decrease haemoglobin compromises low oxygen transport from the lungs to the blood since client has pneumonia as seen in the chest x-ray.

HEMATOCRIT 18.3 28.8 g/dl 37.0-47.0 Decreased. This may show anemia and dietary insufficiency.Decreased in the number or size of red blood cells also decreases the amount of space they occupy, resulting in decrease haematocrit since it measures the percentage of blood that is comprised of red blood cell.

MCV 94 90 % 80-96 Normal.

MCH 29.6 28.9 cu.u 27-33 Normal

MCHC 31.4 31.9 uug 32-36 Decreased. This indicates a poor concentration of hemoglobin in a given volume of blood.Mean corpuscular haemoglobin concentration test is used to measure the average concentration of haemoglobin in the red blood cells

RDW-W 14.9 15.4 g/dL 11-16 Normal.

Stabs 1 % 0-7 Normal.

Segmenters 88 88 % 50-70 An increase in value of these cells generally indicates the presence of infection going on inside the body from pneumonia

Eosinophils 1 2 % 0-3 Normal.

Lymphocytes 10 10 % 20-45 Decreased. This indicates that the body's resistance to fight infection has been substantially lost and one may become more susceptible to certain types of infection.

BLOOD CHEMISTRYSerum creatinine was taken to evaluate the renal function of the patients. Normal levels mean normal excretion through the kidneys, Monitoring of the electrolytes was done to determine fluid and electrolyte imbalance.

Parameters Results Aug. 8, 2012

Result Aug.

9, 2012

Result Aug. 13,

2012

Units Ranges Significance

Creatinine 1274.34 664.63 H

(1277)

Umol/L 53 - 115 Creatinine level in the blood will rise due to poor clearance of the creatinine by the kidney. Abnormally high levels of creatinine thus warn possible malfunction or failure of the kidneys.

SGPT 40 U/L 30 – 65 Normal.Serum Sodium

136 L Mmol/L 136 - 145

Normal.

Serum . Potassium

5.8 4.5 Mmol/L 3.5-5.5 Increased. This may indicate hyperkalemia due to impaired glomerular filtration rate which may be combined with high dietary potassium intake relative to residual renal function

Serum Calcium

1.83 Mmol/L 2.12-2.52

Decreased. Hypokalemia due to decrease absorption of calcium

BUN

48.23

H

15.38 H

Mmol/L

2.50-

6.40

Increased. BUN concentrations may be elevated when there is excessive protein breakdown (catabolism). Due to loss of excretory renal function, there is decrease excretion of nitrogenous waste (blood, urea, nitrogen).

Fasting Blood Sugar

4.40 Mmol/L 4.10-5.90 Normal.

Uric Acid 0.41 H 0.16-0.43 Normal.

Total cholesterol

4.41 <5.2 Normal.

Triglycerides 0.98 <1.70 Normal.

HDL- Cholestero

l

1.41 0.90-1.55

Normal.

LDL-Cholestero

l

2.60 <3.90 Normal

PROTHROMBIN TIMEThis test is indicated to the patient to evaluate the patient’s coagulation process

Parameters Results

(8-8-12)

Units Ranges Significance

Patient Clotting time 13.1 Seconds 10-14 seconds Normal.

Prothrombin Act. 77 % 70-120 Normal

INR 1.18 0.8-1.2 Normal.

Control Clotting Time 13.2 Seconds 10-14 seconds Normal.

Prothrombin Act. 100 % 70-120 Normal.

CHEST X-RAY

August 8, 2012

Chest x-ray is used to diagnose pulmonary diseases and disorders of the mediastinum and bony thorax. It provides a record of the sequential progress or development of disease. This is also a hospital’s routine procedure.

Results:

There are hazy densities in the lower lungs confluent in the right.

The trachea is at the midline.

The cardiac silhouette is enlarged with cardio thoracic ratio of 0.59.

The distal ascending down to the proximal descending aorta is enlarged, measuring 6.5cm at its widest diameter.

There is a homogenous density in the left lower lung field obscuring the hemidiaphragm and costophenic sulcus.

The right hemidiaphragm is intact.

The rest of the structures are unremarkable.

Impression: PNA, Lower Lungs, with consolidation in the Right.

-Cardiomegaly

-Aortic Aneurismal dilatation considered. CT Scan correlation is suggested for further evaluation.

-Minimal Pleural effusion, Left.

Follow up is suggested.

Chest xray significance -A chest x-ray makes images of the heart,

lungs, airways, blood vessels and the bones of the spine and chest. An

x-ray (radiograph) is a noninvasive medical test that helps physicians

diagnose and treat medical conditions

URINALYSIS Urinalysis is one of the most commonly performed tests in health care. The test is used to diagnose and identify kidney disorders. This laboratory test was taken as part of the hospital’s routine procedure which was done to the patient upon admission to the Emergency Room.

PARAMETERS

RESULTS

(8-8-12)

UNITS

NORMAL VALUES

SIGNIFICANCE

MACROSCOPIC

Color PSTRAW Straw- dark yellow Normal

Transparency S Hazy Clear – hazy Normal

Specific gravity 1.020 1.003-1.029 Normal

Sugar Negative Negative Normal

PARAMETERS

RESULTS

(8-8-12)

UNITS

NORMAL VALUES

SIGNIFICANCE

MACROSCOPIC Color PSTRAW Straw- dark yellow Normal

Transparency S Hazy Clear – hazy NormalSpecific gravity 1.020 1.003-1.029 Normal

Sugar Negative Negative NormalProteins (ALB,

GLOB)Positive Negative Positive . Indicates

that there is a sign of kidney damage and problems in filtration of the urine.

MICROSCOPIC

Red blood cells 34-49 /hpf 0-5 The presence of red blood cell casts strongly suggest structural disruption in the integrity of glomerular basement membrane caused by inflammatory or immunologic processes.

Dysmorphic 30 % Dysmorphic RBC’s have odd shapes as a consequence of being distorted via passage through the abnormal glomerular structure.

Pus cells 26-30 /hpf 0-3 Illnesses of the respiratory tract may cause bacteria to proliferate in the kidneys or bladder.

CAST

Waxy None /hpf None Normal

Hyaline None /hpf None Normal

Fine None /hpf None Normal

Coarse None /hpf None Normal

ABNORMAL CRYSTALS

Monomial crystal None None Normal

NORMAL CRYSTALS

Amorphous wastes

None None Normal

ULTRASOUND REPORTDone to evaluate the urinary tract which includes the kidney, ureter and urinary bladder in the male patient the prostate gland and seminal vesicle are also scan.08/09/12

Lower Abdomen Ultrasound:The kidneys are small in size. The Right kidney measures 7.9 (L) x 4.1 (W) x 2.9

(AP) cm with cortical thickness of 0.7 cm, while the left kidney measures 7.6 (L) x 4.0 (W) x 3.5 (AP) cm with cortical thickness of 1.1 cm. The parenchyma of both kidneys appears hyperechogenic. The cortices are not thinned out. No lithiases.

The urinary bladder is partially filled. Foley catheter balloon is seen within the lumen.

The prostate gland measures 2.7 x 3.5 x 2.4 cm. (LWAP) with an approximate weight of 12.1 grams. There are concretions in the inner gland. The prostatic capsule is intact. REMARKS: RENAL PARENCHYMAL DISEASE, BILATERAL.

NORMAL PROSTATE ULTRASONICALLY. FOLEY CATHETER IN PLACE.

Significance: When renal parenchymal disease is seen on an ultrasound it means that the kidney has lost part or all of its function. The kidney can be scarred or damaged because of disease making it unable to function properly, therefore resulting in the kidney losing the ability to filter waste products properly.

Computed Tomography ReportThis is performed to confirm pneumonia. It is produces a more detailed image compared to chest xray

Results:

- Plain & contrast enhanced axial tomographic sections of the chart were obtained- There are fibrotic & nodular densities in the lung apices with minimal pleural thickening. There are hazy densities in the anterior

segment of the left upper & superior segment of the left lower and right middle lobes. There are fibrotic densities in the posterobasal segment of the left lower lobe.

- The bronchial walls are not thickened.- The trachea and medlastinal structures are undisplaced- There are subcentimeter nodular densities in the paratracheal and both axillary areas.- No pleural and pericaridial fluid evident- The heart is enlarged with cardio thoracic ratio of 0.62 cm. There calcific plaques in the aortic arch. There is focal dilatation in

the aortic arch and proximal descending thoracic aorta measuring approximately 7.3 cm in length and 4.6 cm at its widest portion. There is a crescent shapen hypodense collection along the walls of the proximal descending thoracic aorta. There is another focal dilatation measuring approximately 4.9 cm in length and 3.9 cm at its thickest portion in the visualized proximal abdominal aorta at T11-T12 level with note of a false lumen formed by an intimal lap.

- There is incidental finding of 1.2 x 1.2 cm (WAP) Cystic lesion in the segment 1 of the left liver lobe.- The rest of the soft tissue and the bony chest cage are unremarkable.

Impression:

-Atheramatous aorta with aneurysmal dilatations, aortic arch and proximal descending thoracic aorta and proximal abdominal aorta, with thrombus formations in the former and with dissection in the latter.

-Cardiomegaly

-Apical fibrosis, pleural thickening and granuloma formations.

- pneumonia, left upper and lower lobes and right middle lobe.

- incidental finding of hepatic cyst.

PATHOPHYSIOLOGYChronic Kidney Disease Stage 5

Increased Serum CreatinineOf400mg/dL taken on

2007

Predisposing factors:

I. Modifiable:

a. Lifestyle

b. Stress

II. Non modifiable:

a. Age

b. Gender

c. Family history

Precipitating factors:

Hypertension Narrowing of glomerular arteries

Hardening of walls of glomerular arteries

Decreased blood flow in the kidney

Decrease renal blood flow

Decrease glomerular filtration

Decreased libido based on Personal and Social

History taken on August 15, 2012

Diluted urine Dehydration

Hypertrophy of nephrons

Inability to concentrate urine

Loss of nephron functions Loss of excretory renal functions

Loss of nonexcretory renal function

Disturbance in reproductive system

Deterioration of hormone

testosterone

Hypocalcemia based on Laboratory Results of 1.83 Mmol/L on August 10, 2012

Anemia based on Total RBC of 3.19 10^12/L andHct of 18.3 g/dl taken on August 10,

2012; Pallor and Pale Conjunctiva based on Physical Assesment on Circulatory Function

on August 19, 2012

Failure to produce erythropoietin

Immune disturbanceMicroorganism

enters the respiratory tract

Prone to infection

Failure to convert inactive forms of calcium

Decrease calcium absorption

Calvit 1tab OD

Chills and chest pain

Decreased Potassium excretion Hyperkalemia based on

Laboratory Results of 5.8 Mmol/ L

Microorganisms multiplies and releases

damaging toxins

Microorganisms enters the lungs

“Cough reflex”

Lung inflammation

Pneumonia

Accumulation of fluid and exudates.

Colds, Productive cough and fever of

38°C via axillary route experienced a

week prior to admission,

shortness of breath experienced on the

day prior to admission

Altered smell and taste after performing Cranial nerve 1

(Olfactory) and 7 (Facial) based on Physical assessment performed on

August 15 and 19, 2012

Fluid in the lungs as seen in Chest xray performed on

August 8, 2012and Infectionwith presence of

increased segmenters of 88% and decreased lymphocytes with result of 10% as seen in the Urinalysis performed last

August 10, 2012

CNS changes UremiaDecrease excretion of nitrogenous wastesAzotemia

Altered mental state (inability to recall

immediate memory) based on Physical

assessment performed on August 15 and 19,

2012

Increased BUN level of 48.23 mmolbased on August 8, 2012 and

15.38 Mmol on August 13, 2012 laboratory results; IncreasedSerum Creatinine level of 1274.34 Umol/L

based on August 8, 2012 and 664.63Umol/L based on August 13,

2012;Proteinuriaas seen in Urinalysis performed on August 8, 2012

Decrease Sodium reabsorption

RAAS malfunction

Water retention

Fluid restriction of 1,500 liters per

day

Furosemide 40 mg/tab 1 tab

Q12H, Atenolol 100mg/tab 1 tab

OD

Edema experienced on 2007 based on

History of Present illness

Increased BP of 200/120 mmHg prior to admission

Oliguria

Amlodopine (Norvasc) 10 mg/tab 1 tab

OD

Loss of appetite, Nausea and

vomiting, abdominal pain

HEMODIALYSIS

DRUG STUDY

DOCTOR’S ORDER/ TIMING: Calvit 1 tab TIDBRAND NAME:CalvitGENERIC NAME: Calcium CarbonateDRUG CLASSIFICATION: SupplementINDICATION:

It is given to the patient because the patient’s kidneys are unable to filter calcium; as a result, calcium is freely eliminated by the kidney which resulted to the patient having a decrease serum calcium level (refer to laboratory results). Calvit is given to the patient to maintain the patient’s calcium level to a normal level to prevent future bone resorption and muscle wasting.

ACTION:

Calvit contains vitamin D that helps in calcium absorption and regeneration in the bones and muscles.

SIDE EFFECTS:

Drowsiness, Nausea, DizzinessADVERSE EFFECTS:

HypersensitivityNURSING RESPONSIBILITIES: Drug should be taken with food. Drug should be swallowed whole, do not crush or chew. Watch out for signs of Hypercalcemia such as muscle

weakness, vomiting, anorexia, dehydration, constipation, depression, polyuria, lethargy and fatigue .

Monitor the serum calcium levels thru laboratory results. Instruct patient to refer any signs and symptoms of

hypercalcemia that are manifested.

BRAND NAME/ DOCTOR’S ORDER/ TIMING:NAC (Fluimucil) 600mg/tab 1 tab in one half glass H2O OD

GENERIC NAME: AcetylcysteineDRUG CLASSIFICATION: MucolyticINDICATION:

To treat pneumonia with abundant mucus secretions.CONTRAINDICATIONS:

Known hypersensitivity to acetylcesteine. As Acetylcysteine (Fluimucil) granules and tablets contain aspartame, it is contraindicated in patients suffering from phenylketonuria.

ACTION:

SIDE EIt reduces the viscosity of bronchial secretions. The free sulphydryl group in Fluimucil breaks the disulphide bridges present in the mucus and thereby causes mucolysis. Further, in the mucus producing cells.Fluimucil prevents the formation of disulphide bonds and thereby regulates the viscosity of the mucus. Also, as a precursor of glutathione, an endogenous antioxidant.Fluimucil ensures a protective acion on the respiratory system. Thus, it not only protects the respiratory function, but also improves it.

EFFECTS:

Increased productive cough

Nausea

GI upset

ADVERSE EFFECTS:

Bronchospasm

Angioedema

Rashes

Pruritus

nausea and vomiting

fever

Syncope

sweating

arthralgia

blurred vision

disturbances of liver function.

NURSING RESPONSIBILITIES: Teach patient about proper coughing and deep

breathing techniques Monitor rate, depth, rhythm, and type of

respiration Monitor for bronchospasm Drug should be taken with full stomach Watch for any adverse effects such as rashes,

nausea and vomiting, fever, and blurred vision.

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Furosemide 40 mg/tab 1 tab Q12H

GENERIC NAME: FurosemideDRUG CLASSIFICATION: Loop diuretic ACTION: Inhibits reabsorption of sodium and chloride from the

proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis.

INDICATION: Treatment of hypertension

CONTRAINDICATIONS: Contraindicated with allergy to furosemide,

sulphonamides; allergy to tartazine (in oral solution); anuria, severe renal failure; hepatic coma

Use cautiously with systemic lupus erythematosus, gout, diabetes mellitus

SIDE EFFECTS: Common side effects of furosemide include low blood

pressure, dehydration and electrolyte depletion (for example, sodium, potassium). Less common side effects include jaundice, ringing in the ears (tinnitus), sensitivity to light (photophobia), rash, pancreatitis, nausea, diarrhea, abdominal pain, and dizziness. Increased blood sugar and uric acid levels also may occur.

ADVERSE EFFECTS: CNS: Dizziness, vertigo, paresthesias, weakness, headache, drowsiness, fatigue,

blurred vision, tinnitus, irreversible hearing loss CV: orthostatic hypotension, volume depletion, cardiac arrhythmias,

thrombophlebitis GI: nausea, anorexia, vomiting, oral and gastric irritation, diarrhea GU: polyuria, nocturia, glycosuria, urinary bladder spasm. Hematologic: leukopenia, anemia, fluid and electrolyte imbalances Other: muscle cramps and muscle spasms

NURSING RESPONSIBILITIES: Assess fluid status throughout the therapy. Monitor daily weight,

intake and output ratios, amount and location of edema, lung sounds, skin turgor, and mucous membrane. Report thirst, dry mouth, lethargy, weakness, hypotension, or oliguria.

Monitor blood pressure and pulse before and during administration. Monitor frequency of prescription refills to determine compliance in patients treated for hypertension.

Monitor electrolytes, renal and hepatic function, serum glucose, and uric acid levels prior to and periodically throughout therapy.

Caution patient to change positions slowly to minimize orthostatic hypotension.

Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occurs.

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Atenolol 100mg/tab 1 tab OD

GENERIC NAME:AtenololDRUG CLASSIFICATION: Antianginal,

Antihypertensive, Beta1-selective adrenergic blockerACTION: Blocks beta-adrenergic receptors of the sympathetic

nervous system in the heart and juxtaglomerular apparatus (kidney), thus decreasing the excitability of the heart, decreasing cardiac output and oxygen consumption, decreasing the release of renin from the kidney, and lowering blood pressure

INDICATION : Treatment of hypertensionCONTRAINDICATION: Contraindicated with sinus bradycardia, second- or third-degree heart block,

cardiogenic shock, heart failure, hypersensitivity to any component of the drug; Use cautiously with renal failure, diabetes or thyrotoxicosis, respiration disease

SIDE EFFECTS: Unexplained swelling or sudden weight gain Chest pain Dizziness, lightheadedness, or fainting spells Cold, tingling, or numbness in the hands or feet Confusion An irregular heartbeat (arrhythmia) Signs of an allergic reaction, including unexplained rash, hives, itching,

unexplained swelling, wheezing, or difficulty breathing or swallowing.

ADVERSE EFFECTS: Allergic reactions: Pharyngitis, erythematous rash, fever, sore throat, laryngospasm,

respiratory distress CNS: Dizziness, vertigo, tinnitus, fatigue, emotional depression, paresthesias, sleep

disturbances, hallucinations, disorientation, memory loss, slurred speech CV: Bradycardia, heart failure, cardiac arrhythmias, sinoatrial or AV nodal block, tachycardia,

peripheral vascular insufficiency, claudication, CVA, pulmonary edema, hypotension Dermatologic: Rash, pruritus, sweating, dry skin EENT: Eye irritation, dry eyes, conjunctivitis, blurred vision GI: Gastric pain, flatulence, constipation, diarrhea, nausea, vomiting, anorexia, ischemic

colitis, renal and mesenteric arterial thrombosis, retroperitoneal fibrosis, hepatomegaly, acute pancreatitis

GU: Impotence, decreased libido, Peyronie’s disease, dysuria, nocturia, frequent urination Musculoskeletal: Joint pain, arthralgia, muscle cramps Respiratory: Bronchospasm, dyspnea, cough, bronchial obstruction, nasal stuffiness, rhinitis,

pharyngitis Other: Decreased exercise tolerance, development of antinuclear antibodies, hyperglycemia

or hypoglycemia, elevated serum transaminase, alkaline phosphatase, and LDH

NURSING RESPONSIBILITIES Take drug with meals if GI upset occurs. Do not stop taking this drug unless told to do so by

a health care provider. Avoid driving or dangerous activities if dizziness or

weakness occurs Side effects: Dizziness, light headedness, loss of

appetite, nightmares, depression, sexual impotence. Report difficulty breathing, night cough, swelling of

extremities, slow pulse, confusion, depression, rash, fever, sore throat.

BRAND NAME/ DOCTOR’S ORDER/ TIMING:Catapres 150 mg/tab 1 tab OD

GENERIC NAME:Clonidine hydrochlorideDRUG CLASSIFICATION: Antihypertensive, Central analgesic,

Sympatholytic (centrally acting)ACTION: Clonidine stimulates alpha-adrenoreceptors in the brain

stem. This action results in reduced sympathetic outflow from the central nervous system and it decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure.

INDICATION: Treatment of hypertension

CONTRAINDICATION: Contraindicated with hypersensitivity to clonidine or

any adhesive layer components of transdermal system. Use cautiously with severe coronary insufficiency,

recent MI, cerebrovascular disease; chronic renal failureSIDE EFFECTS: Dizziness Lightheadedness Drowsiness Dry mouth Constipation

ADVERSE EFFECTS: CNS: drowsiness, sedation, dizziness, headache, fatigue that tend to

diminish within 4-6 weeks, nightmares, insomnia, hallucinations, delirium, nervousness, restlessness, anxiety, depression, retinal degeneration.

CV: Heart failure, orthostatic hypotension, palpitations, tachycardia, bradycardia, Raynaud’s phenomenon, ECG abnormalities manifested as Wenckebach period or ventricular trigeminy.

Dermatologic: Rash, angioneurotic edema, hives, urticaria, hair thinning and alopecia, pruritis, dryness, itching or burning of the eyes, pallor

GI: dry mouth, constipation, anorexia, malaise, nausea, vomiting, parotid pain, parotitis, mild transient abnormalities in LFTs.

GU: Impotence, sexual dysfunction, nocturia, difficulty in micturition, urinary retention

Other: Weight gain, transient hyperglycemia or elevated serum creatine phosphokinase level, gynecomastia, weakness, muscle or joint pain, cramps of the lower limbs, dryness of the nasal mucosa, fever.

NURSING RESPONSIBILITIES Instruct patient to take drug exactly as prescribed. Do not miss doses.

Do not discontinue the drug abruptly unless instructed by your health care provider.

Attempt lifestyle changes that will reduce blood pressure. Restrict intake of salt.

Inform patient that he may experience side effects such as: Drowsiness, dizziness, light-headedness, headache, weakness (get up slowly when rising from a sitting or lying position; observe caution when driving or performing other tasks that require alertness or physical dexterity); dry mouth (sucking on sugarless lozenges or ice chips may help); GI upset (eat frequent small meals); dreams, nightmares (reversible); impotence, other sexual dysfunction, decreased libido (discuss with your health care provider).

Report urinary retention, changes in vision, blanching of fingers, rash. Check blood pressure before and after drug administration.

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Ketosteril 1 tab TID

GENERIC NAME: Essential amino acidsDRUG CLASSIFICATION:Ketoanalogues; Essential amino

acidsACTION: Normalizes metabolic process, promotes recycling product

exchange. Reduces ion concentration of potassium, magnesium, and phosphate.

INDICATION: To decrease BUN level based on chemistry laboratory result

last August 8, 2012 which revealed 48.23 Mmol/L (Normal Range: 2.50 – 6.40 Mmol/L)

CONTRAINDICATIONS: Allergy and hypersensitivity to any content of

this drug Distributed amino acid metabolism Use cautiously for patients with phenylketonuriaSIDE EFFECTS: Hypercalcemia

NURSING RESPONSIBILITIES: Evaluate for any contraindications Take drug as prescribed Warn patient about possible side effects and how

to recognize them Give with food if GI upset occurs Frequently assess for hypercalcemia

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Avelox 400 mg/tab 1 tab OD

GENERIC NAME: MoxifloxacinDRUG CLASSIFICATION: anti-

infective; antibiotic; quinoloneACTION: Interferes with action of enzymes needed for bacterial

replication.Inhibits topoisomerases I (DNA gyrase) and IV, impairing bacterial DNA replication, transcription, repair and recombination.

INDICATION: Treatment for upper and lower respiratory tract

infections.

SIDE EFFECTS:

Dizziness

Nausea and vomiting

Headache

Hypertension

Abdominal pain

Constipation

Allergic reactions

NURSING RESPONSIBILITIES:

Drug may be given without regard to meals.

Monitor patient for hypersensitivity reactions.

Monitor blood pressure.

Inform patient that he may experience side effects such as: Drowsiness, dizziness, light-headedness, headache, weakness (get up slowly when rising from a sitting or lying position; observe caution when driving or performing other tasks that require alertness or physical dexterity); dry mouth (sucking on sugarless lozenges or ice chips may help); GI upset (eat frequent small meals); dreams, nightmares (reversible); impotence, other sexual dysfunction, decreased libido (discuss with your health care provider).

Report urinary retention, changes in vision, blanching of fingers, rash.

Check blood pressure before and after drug administration.

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Ketosteril 1 tab TID

GENERIC NAME: Essential amino acidsDRUG CLASSIFICATION: Ketoanalogues; Essential amino

acidsACTION: Normalizes metabolic process, promotes recycling

product exchange. Reduces ion concentration of potassium, magnesium, and phosphate.

INDICATION: To decrease BUN level based on chemistry laboratory

result last August 8, 2012 which revealed 48.23 Mmol/L (Normal Range: 2.50 – 6.40 Mmol/L)

CONTRAINDICATIONS: Allergy and hypersensitivity to any content of

this drug Distributed amino acid metabolism Use cautiously for patients with phenylketonuriaSIDE EFFECTS: Hypercalcemia

NURSING RESPONSIBILITIES: Evaluate for any contraindications Take drug as prescribed Warn patient about possible side effects and how

to recognize them Give with food if GI upset occurs Frequently assess for hypercalcemia

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Moxifloxacin (Avelox) 400 mg/tab 1 tab OD

GENERIC NAME: MoxifloxacinDRUG CLASSIFICATION: anti-infective; antibiotic; quinoloneACTION: Interferes with action of enzymes needed for bacterial

replication.Inhibits topoisomerases I (DNA gyrase) and IV, impairing bacterial DNA replication, transcription, repair and recombination.

INDICATION: Treatment for upper and lower respiratory tract infections.

SIDE EFFECTS:

Dizziness

Nausea and vomiting

Headache

Hypertension

Abdominal pain

Constipation

Allergic reactions


Drug may be given without regard to meals.

Monitor patient for hypersensitivity reactions.

Monitor blood pressure.

Tell patient to finish entire course of therapy, even if symptoms are relieved.

Warn patient that drug can cause dizziness and light headedness.

Store drug at controlled room temperature.

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Azithromycin 500mg/tab 1 tab OD

GENERIC NAME: Azithromycin

DRUG CLASSIFICATION: Macrolide AntibioticACTION: Bacteriostatic or bactericidal in susceptible

bacteriaINDICATION:Treatment of lower respiratory infections. CONTRAINDICATION: Contraindicated with hypersensitivity to azithromycin,

erythromycin, or any macrolide antibiotic. Use cautiously with gonorrhea or syphilis,

pseudomembranous colitis, hepatic or renal impairment

SIDE EFFECTS: Nausea Loose stools or diarrhea Vomiting Abdominal pain Headache Unexplained rash

ADVERSE EFFECTS CNS: Dizziness, headache, vertigo, somnolence, fatigue GI: Diarrhea, abdominal pain, nausea, dyspepsia, flatulence,

vomiting, melena, pseudomembranous colitis Other: Superinfections, angioedema, rash, photosensitivity

NURSING RESPONSIBILITIES: Administer on an empty stomach 1 hour before or 2-3

hours after meals. Food affects the absorption of this drug.

Counsel patients being treated for STDs about appropriate precautions and additional therapy.

Take the full course prescribed. Do not take with antacids. Tablets and oral suspension can be taken with or without food.

Inform client that he may experience side effects such as: Stomach cramping, discomfort, diarrhea; fatigue, headache (medication may help); additional infections in the mouth or vagina (consult your health care provider for treatment).

BRAND NAME/DOCTOR’S ORDER/TIMING:Omeprazole 40mg/tab 1 tab OD

GENERIC NAME: Omeprazole Magnesium

DRUG CLASSIFICATION: Proton Pump Inhibitor

INDICATION

Reduce gastric acid production

CONTRAINDICATION

Contraindicated with hypersensitivity to omeprazole or its components.

ACTION

Gastric acid-pump inhibitor. Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium adenosine triphosphatase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

SIDE EFFECTS Dizziness, headache, nausea, vomiting, diarrhea, symptoms of upper

respiratory tract infection such as cough, nasal congestion, runny nose, nasal breathing, sneezing, sore or scratchy throat, painful swallowing, malaise and fever.

ADVERSE REACTIONS Insomnia Anxiety Rash Pruritus Abdominal pain Back pain Fever

NURSING RESPONSIBILITIES: Take the drug before meals. Swallow the tablet whole; do not chew or crush. Eat small frequent meals. Maintain proper nutrition. Have medical follow-up visits. Report severe headache, worsening of symptoms,

fever, chills.

BRAND NAME/DOCTOR’S ORDER/TIMING: Piperacillin-Tazobactam / Piperacillin-Tazobactam 2.25 gms IV Q12H

GENERIC NAME: Piperacillin SodiumDRUG CLASSIFICATION: AntibioticINDICATION To treat pneumonia. CONTRAINDICATION Hypersensitivity to penicillins, history of gastrointestinal disease, particularly

colitis, renal impairment. ACTION By binding to specific penicillin – binding proteins located inside the bacterial

cell wall, piperacillin inhibits the third and last stage of bacterial cell wall synthesis. Cell lysis is then mediated by bacterial cell wall autolytic enzymes such as autolysins; it is possible that piperacillin interferes with autolysin inhibitor.

SIDE EFFECTS Nausea, vomiting, stomach pain, constipation,

mild diarrhea; headache, dizziness; runny nose; skin rash or itching;pain, swelling, or other irritation where the injection was given.

ADVERSE REACTIONS Pale or yellowed skin, dark colored urine, fever,

confusion; white patches or sores inside your mouth or on your lips; easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin.

NURSING RESPONSIBILITIES: Advise patient to use this medication for the full prescribed length

of time. Skipping doses may also increase your risk of further infection that is resistant to antibiotics.

Instruct patient to use exactly as prescribed by doctor. Do not use in larger or smaller amounts or for longer than recommended.

Properly dispose of used needles, IV tubing, and other items used to inject the medicine.

Must be given slowly, and the IV infusion can take at least 30 minutes to complete.

Piperacillin and tazobactam must be mixed with a liquid (diluent) before using it.

Do not use the medication if it has changed colors or has particles in it. Inform doctor for a new prescription.

Store unmixed medicine and the liquid diluent at cool room temperature.

BRAND NAME/DOCTOR’S ORDER/TIMING: Norvasc / Amlodipine (Norvasc) 10 mg/tab 1 tab OD

GENERIC NAME: AmlodipineDRUG CLASSIFICATION: Calcium Channel BlockersINDICATION Indicated for the treatment of high blood pressure.CONTRAINDICATION Amlodipine is contraindicated if you have any unusual or

allergic reaction to amlodipine, heart problems like heart failure or aortic stenosis, liver disease

ACTION Relaxes (widens) blood vessels and improves blood flow.

SIDE EFFECTS Headache, dizziness, drowsiness, tired feeling,

stomach pain or flushing (warmth, redness, or tingling sensation)

ADVERSE REACTIONS Feeling like you might pass out, swelling in your

hands, ankles, or feet, pounding heartbeats or palpitations; chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating.

NURSING RESPONSIBILITIES: Take amlodipine exactly as prescribed by your doctor. Do not take in

larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Take this medication by mouth with or without food as directed by your doctor.

Inform patient that chest pain may become worse when you first start taking amlodipine or when the dose is increased. Call your doctor if the chest pain is severe or ongoing.

Amlodipine is only part of a complete program of treatment that may also include diet, exercise, weight control, and other medications. Follow your diet, medication, and exercise routines very closely.

Tell patient to call the doctor if the condition does not improve or if it worsens (for example, your blood pressure readings remain high or increase)

BRAND NAME/ DOCTOR’S ORDER/ TIMING: Movelax 30cc OD if w/o BM for the day

GENERIC NAME: LactuloseDRUG CLASSIFICATION: Laxative INDICATION: Treatment of constipation

ACTION: The drug passes unchanged into the colon where bacteria

break it down to organic acids that increase the osmotic pressure in the colon and slightly acidify the colonic contents, resulting in an increase stool water content, stool softening.

SIDE EFFECTS: Abdominal fullness, flatulence, belching

ADVERSE EFFECTS: Diarrhea, nausea and vomiting, distention,

NURSING RESPONSIBILITIES: Assess condition before therapy and reassess regularly thereafter to

monitor drug’s effectiveness Monitor patient for any adverse GI reactions, nausea, vomiting, diarrhea. For patient with hepatic encelopathy, regularly assess mental condition monitor I & O Ask patient to report diarrhea, sever belching, and abdominal fullness.

BRAND NAME/DOCTOR’S ORDER/TIMING: NaHCO3 1 tab TID

DRUG CLASSIFICATION: Antiulcer agents, Alkalinizing agent

INDICATION: Metabolic acidosis, neutralize acidity in the gastric acid because patient is taking antibiotics

CONTRAINDICATION:

• Metabolic or respiratory alkalosis

• Excessive chloride loss

• Patients on sodium restricted diet

• Renal failure

• Severe abdominal pain of unknown cause especially if associated with fever

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.

SIDE EFFECTS

• Edema, flatulence, gastric distention, metabolic alkalosis, hypernatremia, sodium and water retention


• Assess the client’s fluid balance throughout the therapy. This assessment includes intake and output, daily weight, edema and lung sounds.

• 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, 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.

IV sites should be observed closely. Extravasation should be avoided as tissue irritation or cellulitis may occur when taking sodium bicarbonate.

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.

PROBLEM LIST

PROBLEM DATE IDENTIFIED SIGNATURE DATE RESOLVED SIGNATURE Ineffective Airway Clearance maybe

related thick secretion as manifested by:

a) Episodes of productive cough with

whitish phlegm approximately 5cc each expectoration and minimal crackles noted

b) Verbalized difficulty of breathing

Imbalance nutrition risk for less than body requirements maybe related to increased metabolic needs as evidenced by:

a) Inadequate food intakeb) Poor appetite

Activity intolerance maybe related to

imbalance between oxygen supply and demand as manifested by:

a) Verbal report of fatigue and weaknessb) Presence of arterioventricular fistula

Disturbed thought process as manifested by:

a) Impaired ability to recall immediate

memory Risk for decreased cardiac output may

be related to cardiomegaly

August 15, 2012

August 15, 2012

August 15, 2012

August 15, 2012

August 15, 2012

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NURSING CARE PLAN

NURSING CARE PLANNursing Diagnosis:

Ineffective Airway Clearance maybe related to thick secretion as manifested by:a) Episodes of productive cough with whitish phlegm approximately 5cc each expectoration, minimal crackles notedb) Verbalized difficulty of breathingGOALS OF CARE NURSING

INTERVENTIONS RATIONALE EVALUATION CLIENT’S RESPONSE

Within 4 days of medical and nursing intervention, client will be able to: 1. Maintain airway

patency.2. Expectorate /

clear secretions readily.

INDEPENDENT Position patient in

semi- or high-Fowler’s position

Proper

positioning helps mobilization of secretion through gravity drain.

DONE

After 4 days of medical and nursing intervention: Client maintains

semi-fowlers position and client claims to be comfortable.

1. Demonstrate behaviors to improve or maintain clear airway.

2. Identify

potential complications and how to initiate appropriate preventive or corrective actions.

Increase oral

fluid intake. Offer warm, rather than cold, fluids

Auscultate

breath sounds and assess air movement. Monitor vital signs, noting blood pressure and pulse changes. Observe signs of respiratory distress (increased rate, restlessness/ anxiety, use of accessory muscles for breathing)

COLLABORATIVE: Give

expectorants/ bronchodilators, mucolytics, analgesics.

Fluids (especially warm liquids) aid in mobilization and expectoration of secretions

Decreased

airflow and bronchial breath sounds occur in areas consolidated with fluid areas. Crackles, rhonchi, and wheezes are heard on inspiration and/ or expiration in response t fluid accumulation, thick secretions, and airway spasm/obstruction

Aids in reduction of bronchospasm and mobilization of secretions.

DONE

DONE

DONE

A whitish sputum was expectorated effectively with less effort.

Breathing is Non- labored, with minimal crackles on the left lower lung field noted upon auscultation. (Refer to X-ray result.)

Client was able to

understand health teachings and intervention done by the student nurse and expectorates whitish sputum effectively.

General Evaluation:After 4 days of medical and nursing intervention, client was able to:

a) Maintain airway patency.b) Expectorate / clear secretions readily.c) Demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within patient norms)d) Verbalize understanding of cause(s) and therapeutic management regimen.e) Demonstrate behaviors to improve or maintain clear airway.f) Identify potential complications

Nursing Diagnosis: Nutrition imbalanced less than body requirements maybe related to increases metabolic needs as manifested by:a) Inadequate food intakeb) Poor appetiteGOALS OF CARE NURSING

INTERVENTION RATIONALE EVALUATION CLIENT’S RESPONSE

Within 4 days of medical and Nursing intervention, client will be able to: a. Demonstrate

stable weight gain toward goal with normalization of laboratory values and no signs of malnutrition.

INDEPENDENT: Assess and

document dietary intake.

Provide small

frequent feedings. Schedule meals according to dialysis needs.

Aids in identifying

deficiencies and dietary needs.

Minimized anorexia and nausea associated with uremic state/diminished peristalsis.

DONE

DONE

After 4 days of nursing and medical intervention: Client’s diet is

composed of fish and vegetables and consume ½ cup of rice, 500ml of water per day and has difficulty consuming large amounts of food.

Client reports

improvement in eating and reports decrease in episodes of vomiting.

a. Encourage

patient’s involvement in menu choices.

Encourage frequent mouth care/rinse with dilute

COLLABORATIVE: Monitor

laboratory studies, e.g., BUN, Pre-albumin/albumin,

sodium and potassium.

May enhance oral

intake and promote sense of control/responsibility

Mucus membranes may become dry and cracked. Mouth care soothes, lubricates and helps freshens mouth tastes.

Indicators of

nutritional needs, restrictions, and necessity for effectiveness of therapy.

DONE

DONE

DONE

Client has a better appetite in eating foods which are chosen personally, and an increase in appetite while eating other foods is also noted.

Client verbalized

comfort, freshness in the mouth and has intact oral mucosa upon observation. Client claims a much better appetite to eat with the mouth feels clean and fresh.

BUN is 15.38 H Mmol

last August 13, 2012, sodium is 136mg/dl. (Refer to laboratory tests results).

nutritional support team.

Provide high calorie,

low/moderate protein diet. Include complex carbohydrates and fat sources to meet caloric need and also essential amino acids.

Restrict potassium, sodium,

and phosphorus intake as indicated.

Administer medication as

indicated:

a. Iron preparation b. Calcium Vitamin D c. Antiemetic

Determines individual calorie and nutrient needs within the restrictions, and identifies most effective route and product.

Carbohydrates meet energy needs

and limit tissue catabolism. Essential amino acids improve nitrogen balance and nutritional status stimulate repair of tubular epithelial cells and enhance patients ability to fight systemic complications.

Restriction of this electrolytes may be needed to prevent further renal damage, especially if dialysis is not part of treatment, and or during recovery phase of ARF.

Supplements iron deficiency

Restores normal serum level to

improve cardiac and neuromuscular function, blood clotting and bone metabolism.

Necessary to facilitate absorption of

calcium from the GI tract.

Relieve nausea and vomiting and may enhance oral intake

DONE

NOT DONE

DONE

DONE

DONE

DONE

NOT DONE

nutrients.

Client feels less weak. BUN, Creatinine

levels are decreasing. (refer to laboratory test results.) Contraindicate to client

Client manifests no evidence of edema.

Sodium 136 umol/L (136-145 umol/l) Potassium 4.5 (2.5-5.1 umol/l. (refer to laboratory results)

Client’s RBC count and Hematocrit are

elevated. (Refer to laboratory tests results).

Calcium is within normal range. (Refer to laboratory tests results)

Calcium level was 1.83 mmol/l last August 13, 2012.

General Evaluation:After 4 days of nursing and medical intervention, client

was not able to:a) Demonstrate stable weight gain toward goal with normalization of laboratory values and no signs of malnutrition.

Nursing diagnosis: Activity intolerance maybe related to imbalance between oxygen supply and demand as manifested by:a) Verbal report of fatigue and weaknessb) Presence of arterioventricular fistula

GOALS OF CARE INTERVENTION RATIONALE EVALUATION CLIENT’S RESPONSE Within 4 days of nursing and medical intervention, client will be able to: a) Participate in

necessary or desired activities

b) Report measurable

increase inactivity intolerance

c) Demonstrate a decrease in physiological signs of intolerance

INDEPENDENT: Asses the patient’s

response to activity, noting pulse rate more than 20 beats per minute faster than resting rate; marked increase in blood pressure during/after activity; dyspnea or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope

Instruct patient energy-

conserving techniques, e.g., using chair when showering, seating to brush teeth or combed hair, carrying out activities at a slower pace.

The stated parameters are

helpful in assessing physiological responses to the stress of activity and, if present, are indicators of overexertion.

Energy-saving techniques

reduce the energy expenditure, thereby assisting in equalization of oxygen supply and demand

DONE

DONE

After 4 days of clinical and medical intervention: Clients pulse rate was

74 beats per minute, blood pressure 130/90 mmHg, no dyspnea or chest pain, excessive fatigue and weakness noted.

Client minimizes activities that requires more energy.

Encourage

progressive activity-self care when tolerated. Provide assistance as needed.

Gradual

activity progression prevents a sudden disease in cardiac workload. Providing assistance only as needed. Encourages independence in performing activities.

DONE

Client was

able to tolerate performing self care related activities.

General Evaluation:After 4 days of medical and nursing intervention, client was able to:•Participate in necessary or desired activities•Report measurable increase activity intolerance•Demonstrate a decrease in physiological signs of intolerance

Nursing diagnosis: Disturbed thought processes may be related to accumulation

of toxins as evidenced by:

a) Impaired ability to recall immediate memory

GOALS OF CARE INTERVENTION RATIONALE EVALUATION PATIENTS’S RESPONSE

Within 4 days of medical and nursing intervention, the client will be able:

1. Identify ways

to compensate to cognitive impairment/ memory deficit

INDEPENDENT Assess extent of impairment

in thinking ability, memory and orientation. Note attention span

Provide quiet/ calm

environment and judicious use of television, radio, and visitation

Uremic syndromic’s effect

can begin with minor confusion/ irritability and progress to altered personality or inability to assimilate information and participate in care. Awareness of changes provides opportunity for evaluation and intervention

Provides comparison to

evaluate progression/resolution of impairment

DONE

DONE

After 4 days of medical and nursing intervention:

Client has short attention span

and was not able to recall the 3 objects given by the student nurse.

Client agrees by putting the

lights off and maintaining silence in the room while resting.

1. Present reality concisely, briefly, and do not challenge illogical thinking

Communicate information/ instruction in simple, short sentences. Ask direct, yes/no questions. Repeat explanations as necessary

Establish a regular

schedule for expected activities such as

Promote adequate rest and

undisturbed periods or sleep

COLLABORATIVE Monitored laboratory

studies, e.g, BUN/Cr, serum electrolytes,

• Minimizes environmental stimuli to reduce sensory overload/ confusion while preventing sensory deprivation.

Provides clues to aid in

recognition of reality Confrontation potentiates

defensive reactions and mat lead to patient mistrust and heightened denial activity

May aid in reducing confusion, increases possibility that communications will be understood/ remembered

Correction of elevations/ imbalances can have profound

DONE

DONE

DONE

DONE

DONE

Client was able to respond

appropriately to the situation given by the student nurse.

Client was able to understand

and re-state to the student nurse the instructions and information given.

Client agreed to the student

nurse’ health teaching regarding limitation of activities and scheduled activities must be implemented.

Client verbalizes being more alert and can easily remember things when after rest or sleep.

BUN 15.38 H last August 13,

2012, Creatinine1032.5 umol/l last August 16,

glucose level, and ABGs

Provide supplemental

oxygen as indicated Prepare for dialysis

effects on cognition/ mentation

Correction of hypoxia alone can improve cognition

Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis

NOT DONE

DONE

2012 (Refer to laboratory tests results)

Client vomited a frothy sour

taste vomitus and experienced upper epigastric pain after the procedure

General evaluation: After 4 days of medical and nursing intervention, the client was not able to:• Identify ways to compensate to cognitive impairment or memory deficit

GOALS OF CARE NURSING INTERVENTION RATIONALE EVALUATION CLIENT’S RESPONSE

Within 4 days medical and nursing intervention, client will be able to:a. Participate in activities

that reduce BP/ cardiac workload

b. Maintain BP within individually acceptable range

c. Demonstrate stable cardiac rhythm and rate within patient’s normal range.

INDEPENDENT

Monitor BP. Measure in both arms/thighs three times, 3-5min apart while patient is at rest, and when sitting for initial evaluation. Use correct cuff size and accurate technique.

Note presence, quality of central and peripheral pulses

Comparison of pressure provides a more complete picture of vascular involvement/ scope of problem. Severe hypertension is classified in the adult as a diastolic reading above 110 mmHg; progressive diastolic reading above 120 mmHg are considered first accelerated, then malignant

Bounding carotid, jugular, radial, and femoral pulses may be observed/palpated. Pulses in the legs/ feet may be diminished, reflecting effects of vasoconstriction and venous congestion

DONE

DONE

Client’s initial blood pressure result is 130/90 mmHg taken at right upper arm and upon final assessment, BP 130/90 mmHg

Client’s apical pulse described as normal, easily palpable, and not obliterated graded as 2; bilateral peripheral pulses described as weak, diminished, and barely palpable graded as 1.

NURSING CARE PLAN

Nursing diagnosis: Risk for decreased cardiac output maybe related to cardiomegaly

GOALS OF CARE NURSING INTERVENTION RATIONALE EVALUATI

ON CLIENT’S RESPONSE Auscultate heart

tones and breath sounds

Observe skin color, moisture, temperature and capillary refill time

Note dependent/general edema.

Provide calm, restful surrounding, minimize environmental activity/ noise. Limit the number of visitors and length of stay

Maintain activity restriction, e.g,. bedrest/chair rest; schedule periods of uninterrupted rest; assist patient with selfcare activities as needed

S4 heart sounds is common in severely hypertensive patients because of presences of atrial hypertrophy. Development of S3 indicates ventricular hypertrophy and impaired functioning. Presence of crackles, wheeze may indicate pulmonary congestion secondary to developing or chronic heart failure

Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/ decreased out.

May indicate heart failure, renal or vascular impairment

Helps reduce sympathetic stimulation; promotes relaxation

Reduce physical stress and tension that affect blood pressure and the course of hypertension

DONE

DONE

DONE

DONE

DONE

S1 and S2 heard at all sites, S1 loudest at apex of the heart and S2 loudest at the base; no murmurs, missed beats heard on landmarks

Client’s skin is brown in color, soles of feet are slightly yellowish in color, no cyanosis noted, skin is warm to touch, with capillary refill of 3 seconds on both nail beds of both upper and lower extremities.

Edema not noted

Client is positioned in a moderate high back rest.

Approached folks when asking questions about the patient instead of interrupting the patient’s sleep. Patient had adequate rest

GOALS OF CARE NURSING INTERVENTION RATIONALE EVALUATION CLIENT’S RESPONSE

Monitor response to medication to control blood pressure

COLLABORATIVE: Administer medications as

indicated:o Diuretics

o Alpha, beta, or centrally acting antagonist

o Calcium channel antagonist

o Angiotensin-converting enzyme inhibitor

Response to drug therapy is dependent on both the individual as well as the synergistic effect of the drugs. Because of side effects, drug interactions, and patient’s motivation to use the smallest number and lowed dosage of medication

These drugs produce marked diureses by inhibiting resorption of sodium and chloride and are effective antihypertensives

Specifications of these drugs vary, but they generally reduce BP through the combined effect of decreased total peripheral resistance, reduce cardiac output, inhibit sympathetic activity and suppression of renin release

Maybe necessary to treat severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP

The use of an additional sympathetic inhibitor may be required for its cumulative effect when other measures have failed to control BP or when congestive heart failure or diabetes is present

DONE

DONE

DONE

DONE

DONE

Client did not manifest any untoward signs and symptoms after taking prescribed medications

Clients urine was approximately 200 as the highest output and 5 cc as the least output in an hour. Foley catheter was pulled last August 13, 2012

Client heart rate was 63 beats per minute. Blood pressure was 130/90 mmHg



GOALS OF CARE NURSING INTERVENTION RATIONALE EVALUATION CLIENT’S

RESPONSE

Implement dietary sodium, fat, and cholesterol restriction, as indicated

These restrictions can help manage fluid retention and with associated hypertensive response, decrease myocardial workload

NOT DONE Client is in low salt low fat diet

After 4 days of clinical and medical intervention, client was able to:Participate in activities that reduce BP/ cardiac workloadMaintain BP within individually acceptable rangeDemonstrate stable cardiac rhythm and rate within patient’s normal range.

DISCHARGE PLAN

Discharging this patient Mr. C.T., 58 years of age, male, married, Roman Catholic, in semi-fowlers position, conscious and coherent, and willing to cooperate; accompanied by Mrs. R.T. (wife) and Mr. A.T.(son), under the service of Dr. H.O and Dr. J.A. with chief complaints of difficulty of breathing and a medical diagnosis of Hypertensive Urgency; Chronic Kidney Disease Secondary to Hypertensive Nephrosclerosis; Community Acquired Pneumonia-Moderate Risk; in an improved condition, with laboratories attached to chart. Upon discharge the patient received and understood health instruction.

MEDICATIONS:1. Instruct client of strict compliance to medication regimen

ordered by physician:

a. Amlodipine (Norvasc) 10mg/tab 1 tablet once a day

Calcium Channel Blockers• Instruct client to take Amlodipine as prescribed by the

doctor;• Instruct not to take in larger or smaller amounts or for

longer than recommended• Instruct to take medication with or without food as

directed by the doctor• Instruct client to notify physician if condition does not

improve or if it worsens

b. Atenolol (Velorin) 100 mg/tab 1 tablet once a day

Antianginal, Antihypertensive, Beta1-selective adrenergic blocker

• Instruct to take drug with meals if GI upset occurs• Instruct not to abruptly stop intake of medication

unless ordered by health care provider• Instruct to avoid driving or dangerous activities if

dizziness or weakness occurs• Educate client about the side effects that are

commonly felt such as dizziness, light headedness, loss of appetite, nightmares, depression, and sexual impotence.

• Instruct to immediately report adverse effects such as difficulty of breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash, fever and sore throat.

c. Clonidine (Catapres) 150 mg/tab 1 tablet every 6 hours; 10 AM, 4 PM, 10 PM, 4 AM

Antihypertensive, Central analgesic, Sympatholytic (centrally acting)

• Instruct client to take drug exactly as prescribed; Do not miss doses; Do not discontinue the drug unless instructed by health care provider

• Instruct client to attempt lifestyle changes that will reduce blood pressure; restrict intake of salt; exercise regularly.

• Educate client about the side effects that are commonly felt such as drowsiness, dizziness, light-headedness, headache, weakness (often transient; observe caution driving or performing other tasks that require alertness or physical dexterity); dry mouth (sucking on sugarless lozenges or ice chips may help)

GI upset (eat frequent small meals); dreams, nightmares (reversible); dizziness, light-headedness when you change position (get up slowly; use caution climbing stairs); impotence, other sexual dysfunction, decreased libido (discuss with your health care provider); breast enlargement, sore breasts; palpitations.

• Instruct client to immediately report adverse effects such as urinary retention, changes in vision, blanching of fingers and rash

d. Moxifloxacin (Avelox) 400 mg/tab 1 tablet once a day; 8 AM

anti-infective; antibiotic; quinolone• Instruct client to take full course of therapy as prescribed• Educate client about the side effect that commonly felt such as

dizziness and light headedness

e. Ketosteril 1 tablet three times a day; 8 AM, 1 PM, 6 PM

Ketoanalogues; Essential amino acids• Instruct client to take drug with meals if GI upset occurs• Instruct client to take drug as prescribed

f. NaHCO3 1 tablet three times a day; 8 AM, 1 PM, 6 PMAntiulcer agents, Alkalinizing agent

• Instruct client to take drug with a full glass of water• Instruct client to report signs of possible hypernatremia such as

edema, weight gain, tachycardia, fever, flushed skin and mental irritability.

g. Calcium Carbonate (Calvit) 1 tablet three times a day; 8 AM, 1 PM, 6 PM

Supplement• Instruct client to take drug with food to avoid GI upset• Instruct not to crush or chew drug; swallow whole

h. Furosemide (Lasix) 40 mg/tab one tablet every 12 hours; 6 AM, 6 PM

Loop diuretic• Instruct client to change positions slowly to minimize

orthostatic hypotension. • Instruct patient to contact health care provider

immediately if muscle weakness, cramps, nausea, dizziness, numbness, or tingling of extremities occur

i. Omeprazole Magnesium (Omeprazole) 40 mg/tab 1 tablet once a day; 6 AM Proton Pump Inhibitor• Instruct client to take drug before meals• Instruct client to immediately report adverse effects such as

severe headache, fever and chills

j. Acetylcysteine (Fluimucil) 600 mg/tab 1 tablet once a day; 10 PM

Mucolytic• Instruct client to do proper coughing and deep breathing

exercises• Instruct client to take drug on a full stomach• Instruct client to dissolve tablet in 1 glass of water k. Lactulose 30cc once a day

Laxative• Instruct client to report diarrhea, sever belching, and abdominal

fullness

EXERCISE:• Advise patient to do cardiovascular exercises such as

walking, or any other activities that patient can tolerate in which large muscle groups are continuously used which can improve blood pressure control, lipid profiles and mental health.

• Advise that intensity should be at comfortable level• Exercise for at least 30 minutes or as tolerated for at

least 3 times a week, non consecutively• Ensure adequate periods of rest between exercises.• Advise that morning and evening are best time for

exercise• Instruct to wait one hour after meals• Instruct to stop exercise when experiencing shortness of

breath, chest pain, tachycardia, leg cramps, nausea or fatigue.

TREATMENTS:• Discuss drug therapy to both patient and significant

others.• Strict medication regimen.• Instruct patient and significant others to comply with

any follow-up examinations, therapies, check-ups after discharge.

• Instruct patient and significant others to maintain a sanitary environment with non harmful effects and conducive to rest and relaxation such as a well ventilated area, with adequate lighting.

HEALTH TEACHINGS:• Encourage promotion of adequate bed rest.• Explain to the patient and significant others the importance of

medication compliance.• Advise patient to go to the health clinic for check-up or if patient

or significant others have certain questions regarding present illness which need to be clarified.

OUTPATIENT:• Instruct patient and significant others to regular schedule of

follow-up check up appointments and laboratory examinations.• Encourage patient to take medication exactly as directed. Don’t

skip doses. Continue taking antibiotics as directed until course of therapy is finished- even if they start to feel better.

• Stress out to patient or significant others to seek immediate consultation if adverse reaction of drugs occurs.

DIET:• Instruct patient to eat food with low salt and low fat

contents.• Advise to avoid food rich in potassium for it becomes

difficult to remove the potassium from the body as kidney losses its functions altogether

• Encourage to consume enough protein but not in excess • Instruct to maintain normal phosphorus level for poor

maintenance may cause bone disease and heart problems.

• Encourage to eat plenty of green leafy vegetables which avoids accumulation of toxic levels of phosphorous in the body.

SPIRITUAL:• Encourage patient and significant others to attend

mass on Sundays or special obligatory masses.• Encourage frequent prayers to client in order for him

to express thoughts and feelings towards his current health condition.

• Advise client to engage into spiritual counselling, family therapies, religious groups and church activities.

• Encourage patient to read spiritual and inspirational books.

CULTURAL AWARENESS:• Instruct significant others that the patient needs the

care of people around him.• Instruct patient to develop and establish a good

relationship with other people• Instruct significant others that they must accompany

patient during exercise or any activity that may cause stress to the patient.

• Instruct significant others to help patient understand his current condition and the physical changes that he might undergo.

Kidney Maybe Super No Www

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