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I.

INTRODUCTION

a) IMPORTANCE OF THE CASE STUDY

Knowing the different kinds of diseases in our community, it is


important for us to know how to prevent these kinds of diseases and
what is the management we are going to use if we encountered one of
these sicknesses. According to our source, disease management has
been defined as a system of coordinated care interventions in which
patient’s self care efforts are significant. For this case study, our
purpose in doing this is to provide an overview of Acute Renal Failure
and impart ways on how to prevent and manage this disease.

b) OBJECTIVES

• Introduce what Acute Renal Failure is.


• Differentiate between Acute Renal Failure and Chronic Renal
Failure.
• Discuss the Anatomy and Physiology of systems which can be
damaged by Acute Renal Failure.
• Explain the Pathophysiology of the disease.
• Discuss the predisposing and precipitating factors of the disease.
• Discuss the signs and symptoms of the disease.
• Discuss the possible complications of Acute Renal Failure.
• Present diagnostic and laboratory procedures in detecting Acute
Renal Failure.
• State management goals for a patient with Acute Renal Failure.
• List the types of oral and IV medications for Acute Renal Failure
and their mechanisms of action.
• Impart the role of Renal Failure self-management education in
assisting patients with Acute Renal Failure to make required
attitude changes to manage their disease.
Acute Renal Failure
Acute renal failure (ARF) is the rapid breakdown of renal (kidney)
function that occurs when high levels of uremic toxins (waste products
of the body’s metabolism) accumulate in the blood. ARF occurs when
the kidneys are unable to excrete (discharge) the daily load of toxins in
the urine.
Based on the amount of urine that is excreted over a 24-hour
period, patients with ARF are separated into two groups:

• Oliguric: patients who excrete less than 500 milliliters


per day (< 16 oz/day)
• Nonoliguric: patients who excrete more than 500
milliliters per day (> 16 oz/day)

In Nonoliguric patients, the urine is of poor quality (i.e.,


contains little waste) because the blood is not well filtered,
despite the fact that an adequate volume of urine is excreted.
Both kidneys are failing when ARF occurs. One normally
functioning kidney can maintain adequate blood filtering.

Chronic Renal Failure


Chronic, or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no
longer maintain the body’s internal environment. CRF can develop
insidiously over many years, or it may result from an episode of ARF
from which the client has not recovered.

Precipitating Factors of ARF:


• Diet (Eating salty and fatty foods)
• Lifestyle (Smoking And drinking)

Predisposing Factors:
• Age
• Heredity
Signs and Symptoms of ARF
The patient may manifest the following:
• Oliguria
• Tachycardia and hypotension
• Dry mucous membranes and flat neck veins
• Lethargy
• Cool, clammy skin
• Azotemia
• Electrolyte imbalances
• Nausea and vomiting
• Constipation
• Irritability and Fatigue

Complications of Acute Renal Failure


Ischemic acute tubular necrosis can lead to renal shutdown.
Electrolyte imbalance, metabolic acidosis, and other severe effects
follow as the patient becomes increasingly uremic, and renal
dysfunction disrupts other body systems. If left untreated, the elderly
patient is particularly susceptible to volume overload, precipitating
acute pulmonary edema, hypertensive crisis and infection.

Diagnostic and Laboratory Tests to Detect Acute Renal Failure


• Blood studies: BUN, serum creatinine, potassium,
bicarbonate, hematocrit, and hemoglobin, pH, serum
osmolality
• Urinalysis, protein, osmolality, sodium
• Creatinine clearance
• Electrocardiogram
• Ultrasonography
• X-ray of abdomen, kidney-ureter-bladder radiography
• Excretory urography, retrograde pyelography
• Renal scan, CT scan and nephrotomography
II. NURSING ASSESSMENT

A.PERSONAL HISTORY

Mr. R resides at Sta. Lucia Sasmuan Pampanga, and he is 57


years old. His wife is elementary teacher and he has a son who is in
college at present. Due to financial difficulties of the family of Mr. R in
his times, he is not able to finish his elementary course and finished
grade four. Their religion is Catholic.
Mr. R lives a sedentary lifestyle. He likes to eat salty and fatty
foods such as chicken, pork and instant noodles. He also states that
everyday, his day is not complete if he is not able to eat his favorite
food which is noodles. He smokes and drinks alcoholic beverages
whenever there is occasion but it’s neither a vice nor a habit. More
often, he sleeps around 7:30pm and wakes at 5:00am. He usually stays
at home and prepare their meal everyday, sometimes he play cards
with his neighbors. Mr. R does not exert effort on having exercise. His
wife supports them financially.

B.HISTORY OF PAST ILLNESS

Mr. R doesn’t remember if he had mumps or chickenpox before


nor completed his immunization. He had never been hospitalized
before. He has an allergic in penicillin. Their family doesn’t have
history of renal failure or any hereditary diseases. They believed on
traditional beliefs and seek for albularyo when their sick.

C.HISTORY OF PRESSENT ILLNESS

Mr. R condition started a week before he was admitted to the


hospital. He had fever and chills then took biogesic. On the second day
he had hypogastric pain and vomited that’s why they sought
consultation to a nearby hospital (Diosdado Macapagal Hospital).
He was admitted with the impression of Acute Renal Failure.
Because his condition becomes worst, they decided to transfer him to
JBLMRH last December 11, 2005 at 4:30 pm. He was brought to
Medicine Ward. His vital signs upon admission are as follows: BP:
120/80, CR: 89, RR: 22. His blood type is B. His doctor suggested
submitting himself for dialysis but he refused due to their financial
status. December 13, 2005, he was subjected for blood transfusion.
Because of his anxiety and fear of pain made by needle prick, he
refused to subject himself for CBC and withdraws for any kind of care
give to him; he even refuses to take his vital signs. Mr. R is suffering
from oliguria, uremia and anemia.
Usually the family argues about Mr. R diet. His wife stated that
Mr. R is hard headed but they can’t do anything because he is the one
who usually prepare their meal.

D.PHYSICAL ASSESSMENT

A. General Appearance
Mr. Romeo Velasco is 57 year old. He was brought to JBLMRH last
December 11, 2005 with a chief complaint of general body weakness.
Appears to be untidy (uncombed hair).Vital signs are as follows: BP:
120/80, CR: 90, RR: 22.

B. Review of Systems
SKIN: fair complexion, dry skin, no jaundice, cold to touch and
patient is pale
HEAD: head is proportional to the body, no tenderness observed,
and no inflammation
EYES: (+) Perrla, eyebrows are well-distributed, no cataract
observed, eyelids are able to blink
EARS: are symmetrical, no tinnitus, no discharges, no lesion
NOSE AND SINUSES: no epistaxis, no discharges, and no
tenderness observed
MOUTH AND THROAT: dry lips, hoarseness of voice, tongue can
be protruded, and no inflammation observed
NECK: able of full neck motion without pain, there is no
inflammation upon palpation, no lump and no swollen lymph node
RESPIRATORY: no sputum and no asthma
CARDIAC: hypertensive
GASTROINTESTINAL: low appetite, allergic to penicillin
URINARY: has oliguria (with average urine output of 10mL/hour)
GENITAL: not assessed
PERIPHERAL VASCULAR: nail beds are pale, with an impaired
capillary refill time
MUSKULOSKELETAL: with impaired mobility
NEUROLOGIC: general body weakness
HEMATOLOGIC: redness, pain in areas where transfusion was
done, has a decrease hgb count upon laboratory results
PSYCHIATRIC: patient is nervous and anxious
NO HISTORY OF FAMILIAL DISEASES

Rufina Aguilar Domingo Velasco Purificacion Sanchez Virgilio Roman

Antonio Velasco Virginia Velasco


Cecilia Roman Laura Roman

Romeo Velasco (allergic


in penicillin, has ARF) Julia Velasco
Narcisa Roman

Aries Velasco
III. ANATOMY AND PHYSIOLOGY

KIDNEYS

The kidneys are bean shaped organs, each about the size of a
tightly clenched fist. They lie on the posterior abdominal wall, behind
the peritoneum, with one kidney on either side of the vertebral column.
Structures that are behind the peritoneum are said to be
retroperitoneal. A connective tissue renal capsule surrounds each
kidney. Around a renal capsule is a thick layer of fat, which protects
the kidney from mechanical shock. On the medial side of each kidney
is the hilum, where the renal artery and nerves enter and where the
renal vein and ureter exit the kidney. The hilum opens into cavity
called the renal sinus, which contains blood vessels, part of the system
for collecting urine and fat
The kidney is divided into an outer cortex and an inner medulla,
which surround the renal sinus. The bases of several cone- shaped
renal pyramids are located at the boundary between the cortex and
the medulla, and the tips of the renal pyramids project towards the
center of the kidney. A funnel shaped structure called a calyx
surrounds the tip of each renal pyramid. The calyces from all the renal
pyramids join to form a larger funnel called the renal pelvis. The renal
pelvis then narrows to form a small tube, the ureter, which exits the
kidney and connects to the urinary bladder. Urine passes from the
kidney and connects to the urinary bladder. Urine passes from the tips
of the renal pyramids into the calyces. From the calyses urine collects
in the renal pelvis and exits the kidney through the ureter.
The functional unit of the kidney is the nephron and there are
approximately 1.3 million of them in each kidney. Each nephron
consists of a renal corpuscle, a proximal tubule, a loop of Henle, or
nephronic loop and a distal tubule. Fluid enters the renal corpuscles
and then flows into the proximal tubule. From there it flows into the
loop of Henle, each loop of Henle has a descending limb, which
extends towards the renal sinus and an ascending limb. Which extends
back toward the cortex. The fluid flows through the ascending limbs of
the loop of Henle to the distal tubule. Many distal tubules empty into a
collecting duct, which carries the fluid from the cortex, through the
medulla. Many collecting ducts empty intro a papillary duct and the
papillary ducts empty their contents into a calyx.
The renal corpuscles and both convoluted tubules are in the
renal cortex. The collecting duct and loop of Henle enter the medulla.
Approximately 15 % of the nephrons called juxtamedullary nephrons
have loop of Henle that extends deep into the medulla of the kidney.
The other nephrons called cortical nephrons have loop of Henle that do
not extend deep into the medulla.
The renal corpuscles of the nephrons consist of Bowman’s
capsule and the glomerulus. Bowman’s capsule consist of the enlarge
end of the nephron, which is extended to form a double walled
chamber. The indention is occupied by a tuft of capillaries called
glomerulus, which resembles a ball of yarn. The cavity of Bowman’s
capsule opens into the proximal tubule, which carries fluid away from
the capsule. The inner layer of Bowman’s capsule surrounds the
glomerulus and consists of specialized cells called podocytes. The
outer layer of the Bowman’s capsule consists of simple squamous
epithelial cells.
The glomerular capillaries have pores in their walls, and the
podocytes have cell processes with gaps between them. The
endothelium of the glomerular capillaries, the podocytes and the
basement membrane between them form a filtration membrane. In the
first step of urine formation, fluid called filtrate is filtered from the
glomerular capillaries into Bowman’s capsule through the filtration
membrane.
Most of the nephron and collecting duct are made up of simple
cuboidal epithelium. However, the thin segments of the descending
and ascending limbs of Henle’s loop have very thin walls up of simple
squamous epithelium. The cells of proximal, thick segment of the
ascending limb of Henle’s loop, distal tubules and collecting ducts have
microvilli and many mitochondria. The proximal tubule, thick segment
of the ascending limb of Henle’s loop and the collecting duct actively
transport molecules and ions across the wall of the nephron. The thin
segment of the descending limb of the Henle’s loop is very permeable
to water and solutes and the thin segment of the ascending limb is
permeable to solutes but not to water.

URETERS, URINARY BLADDER, and URETHRA

The ureters are small tubes that carry urine from the renal pelvis
of the kidney to the posterior inferior portion of the urinary bladder.
The urinary bladder is a hallow muscular container that lies in the
pelvic cavity just posterior to the symphysis. Its function to store urine
and its size depends on the quantity of urine present. The urinary
bladder can hold from a few millimeters to a maximum of about 1000
ml of urine. When the urinary bladder reaches a volume of a few
hundred ml, a reflex is activated, which causes the smooth muscle of
the urinary bladder to contract and most of the urine flows out of the
urinary bladder through the urethra
The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle shaped portion of the urinary bladder located
between the opening of the ureters and the opening of the urethra is
called tragone. The urethra carries from the urinary bladder to the
outside of the body.
The ureters and the urinary bladder are lined with transitional
epithelium, which is specialized to stretch. As the volume of the
urinary bladder increases the epithelial cells, and the number of
epithelial cell layers decreases. As the volume of the urinary bladder
decreases, transitional epithelial cells assume their columnar shape
and form a greater number of cell layers.
The walls of the ureter and urinary bladder are composed of
layer of smooth muscle and connective tissue. Regular waves of
smooth muscle contractions in the ureters produce the force that
causes urine to follow from the kidneys to the urinary bladder.
Contractions of smooth muscle in the urinary bladder force urine to
flow from the bladder through the urethra.
At the junction of the urinary bladder and urethra, the smooth
muscle of the bladder wall forms the internal urinary sphincter in
males. No well defined internal urinary is found in females. Elastic
fibers at the junction of the urinary bladder and urethra keep urine
from passing through the urethra until the urinary bladder pressure
increases. The internal urinary sphincter of males is under involuntary
control. Contraction of the internal urinary sphincter during ejaculation
prevents semen from entering the urinary bladder and keeps urine
from flowing through the urethra. The external urinary sphincter is
formed of skeletal muscle that surrounds the urethra as the urethra
extends through the pelvic floor. The external urinary sphincter is
under involuntary and voluntary control. It controls the flow of urine
through the urethra.
In male, the urethra extends to the end of the penis, where it
opens to the outside. The female urethra is much shorter
(approximately 4 cm) than the male urethra (approximately 20 cm)
and opens into the vestibule anterior to the vaginal opening.

IV. PATIENT AND HIS ILLNESS


A. PATHOPHYSIOLOGY (book based)

The driving force for glomerular filtration is the pressure gradient


from the glomerulus to the Bowman space. Glomerular pressure is
primarily dependent on renal blood flow (RBF) and is controlled by
combined resistances of renal afferent and efferent arterioles.
Regardless of the cause of ARF, reductions in RBF represent a common
pathologic pathway for decreasing GFR. The etiology of ARF comprises
3 main mechanisms.
Pre-renal failure is brought about by diminished blood flow to the
kidneys. GFR is depressed by compromised renal perfusion. Such
decreased flow may result fro hypovolemia, shock, embolism, blood
loss, sepsis, pooling of fluid in ascites or burns, and cardiovascular
disorders, such as congestive heart failure, arrhythmias and
tamponade.
Intrinsic renal failure results from damage to the kidneys
themselves, usually resulting from acute tubular necrosis. Such
damage may also result from acute poststreptococcal
glomerulonephritis, systemic lupus erythematosus, periarteris nodosa,
vasculitis, sickle-cell disease, bilateral renal vein thrombosis,
nephrotoxins, ischemia, renal myeloma and acute pyelonephritis.
Post obstructive renal failure initially causes an increase in
tubular pressure, decreasing the filtration driving force. This pressure
gradient soon equalizes, and maintenance of a depressed GFR is then
dependent upon renal afferent vasoconstriction. Post-renal failure is a
bilateral obstruction of urinary out-flow results. Its multiple causes
include kidney stones, blood clots, papillae from papillary necrosis,
tumors, benign prostatic hyperplasia, strictures and urethral edema
from catheterization.
Patients with chronic renal failure also may present with
superimposed ARF from any of the aforementioned etiologies.
Depressed RBF eventually leads to ischemia and cell death. This
initial ischemic insult triggers production of oxygen free radicals and
enzymes that continue to cause cell injury even after restoration of
RBF. Tubular cellular damage results in disruption of tight junctions
between cells, allowing back leak of glomerular filtrate and further
depressing effective GFR. In addition, dying cells slough off into the
tubules, forming obstructing casts, which further decrease GFR and
lead to oliguria.

B. PATHOPHYSIOLOGY (CLIENT CENTERED) WITH DIAGRAM

The patient’s condition that leads to acute renal failure is related

to nephrotoxins (diet, lifestyle). There is an increase in BUN and

creatinine that indicates impaired renal function .There is also an

increase in WBC, neutrophils, and lymphoctes that indicates of

infection /inflammation. The doctor’s order is to check the CBC, RBC,

BUN, CREATININE, Na, K Cl, and for Urinalysis. The patient was advice

to submit himself for dialysis because he is anemic and to take


Furosemide as diuretics. The doctor prescribed CaCo3 because of

hypocalcemia and Kalium Durule because of hypokalemia.

While there is decrease in renal blood flow the symphathetic

response is to increase the production of Renin and Angiotensin II that

cause hypertension, thus the doctor order manidipine for the patient.
PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE (Client Center)

Nephrotoxins

Increase WBC,
Neutrohils, Lymphocytes Circulatory Inadequacy

Symphatetic Response
Uremia /Severe Increase BUN and
Anemia Creatinine
Increase Renin and
Med’s given
Angiotensin II

Decrease K, Na Hypokalcemia
Hypertension
C. DIAGNOSTIC AND LABORATORY PROCEDURES

DATE ORDERED: DECEMBER 11, 2005

HEMATOLOGY

DIAGNOSTIC RESUL NORMAL INTERPRETATIO NURSING


PROCEDURE T VALUES N REPONSIBILITIES
MCH 32.4 27-33 pg Normal
MCV 90.1 82-92 fl Normal
MCHC 36 31-36g / dL Normal
reticulocyte 2.5 1- 5 % Normal
count
DATE ORDERED: DECEMBER 11, 2005
DIAGNOSTI RESUL NORMAL INTERPRETATIO NURSING
C T VALUES N REPONSIBILITIE
PROCEDURE S
Hgb 77 M:125-175g/L > Indication of >Notify the
F:115-155g /L severe anemia physician
>Continue
monitor the
laboratory results
>Advise the
patient to eat
foods rich and iron
>Encourage the
patient to take
iron supplements
Hct 0.23 M 0.40 – 0.52 > Indication of >Notify physician
F 0.38 – 0.48 anemia from >Monitor lab
dietary deficiency, results
malnutrition and
kidney diseases.
WBC 12.0 > Indication of > Notify physician
infection or
inflammation.
Neutrophils 0.90 0.20- 0.35 > Indication of > Notify physician
infection
Lymphocyte 0.08 0.02 – 0.05 > Indication of > Notify physician
s infection
Stab 0.02 0.02 – 0.05 Normal
Platelet 163 Normal

DATE ORDERED: DECEMBER 11, 2005


DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING
PROCEDURE VALUES N REPONSIBILITIES
FBS 6.64 3.85 – 9.0 Normal
mmol / L
BUN 13.1 1.7 – 8.3 > Indication of
mmol / L renal failure or
glomerulonephritis
.
Creatinine 1,939 M = 60 – > Indication of
120 mmol / L urinary tract
F = 58 – 100 failure or high
mmol / L protein diet
Sodium 137 136 – 145 Normal
mmol / L
Potassium 2.3 3.5 – 5.0 > Indication of >Notify Resident
mmol / L hypokalemia or on Duty
loss of potassium >Encourage to
in the body take potassium
because of severe supplements and
vomiting. foods rich in
potassium such as
banana etc.
Chloride 109 101 – 111 Normal
mmol / L
Calcium 1.71 2.05 – 2.60
mmol / L
Phosphorus 1.1 0.81 – 1.62 Normal
mmol / L

DATE ORDERED: DECEMBER 11, 2005


URINALYSIS
COLOR Light yellow
REACTION Acidic
SPECIFIC GRAVITY 1.020
COARSE GRANULAR 2.4 / LPF
PUS CELLS 8.10 / HPF
RC 3.5 / HPF
EPITHELIAL CELLS Few

DATE ORDERED: DECEMBER 12, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING


PROCEDURE VALUES N REPONSIBILITIES
FBS 95.9 70 – 105 Normal
mg / dL

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING


PROCEDURE VALUES N REPONSIBILITIES
Potassium 3.0 3.5 – 5.0 > Indication of >Notify resident on
mmol / L mild hypokalemia duty
or mild loss of >Encourage the
potassium in the patient to take
body because of potassium
vomiting. supplements and
foods rich in
potassium such as
banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING


PROCEDURE VALUES N REPONSIBILITIES
Sodium 135 136 – 145 > Indication of
mmol / L mild
hyponatremia,
renal insufficiency
and uremia.
Potassium 3.1 3.5 – 5.0 > Indication of >Notify resident on
mmol / L mild hypokalemia duty
or mild loss of >Encourage the
potassium in the patient to take
body because of potassium
vomiting. supplements and
foods rich in
potassium such as
banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING


PROCEDURE VALUES N REPONSIBILITIES
Hgb 73 M =125- > Indication of >Notify the
175g/L severe anemia physician
F = 115 – >Continue monitor
155g/L the laboratory
results
>Advise the
patient to eat
foods rich and iron
>Encourage the
patient to take
iron supplements
Hct .20 M =.40-.52 > Indication of >Notify physician
F = .38 anemia from >Monitor lab
-.48 dietary deficiency, results
malnutrition and
kidney diseases.

DATE ORDERED: DECEMBER 14, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATIO NURSING


PROCEDURE VALUES N REPONSIBILITIES
Hgb 83 M = 125 – > Indication of >Notify the
175 g / L severe anemia physician
>Continue monitor
the laboratory
results
>Advise the patient
to eat foods rich and
iron
>Encourage the
patient to take iron
supplements
Hct 0.25 M =.40-.52 > Indication of >Notify physician
F =.38-.48 anemia from >Monitor lab results
dietary deficiency,
malnutrition and
kidney diseases.
Potassium 3.0 3.5 – 5.0 > Indication of >Notify resident on
mmol / L mild hypokalemia duty
>Encourage the
patient to take
potassium
supplements and
foods rich in
potassium such as
banana, etc.
V. PATIENT AND HIS CARE

A. PLANNING (NURSING CARE PLAN)

NCP#1

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATIO


DIAGNOSIS EXPLANATIO N
N

Subjective: >Fatigue >A decrease >After 4 >Establish rapport >to facilitate >After 4
Objective: related to in Hgb count hours of client and hours of
>Patient is decreased Hgb would be a nursing student nurse nursing
conscious and count. factor in intervention, interaction intervention,
coherent having fatigue the patient goal was met
>with ongoing because RBC will as evidenced
IV of D5 0.3 plays an demonstrate >Discuss with the >education by:
NaCl 500cc X important role an improve patient the need may provide *clients
KVO in our cells ability to for activity. Plan motivation to verbalization
>Vital signs: and muscle to participate in schedule with the increase of feeling of
BP: 110/80 function desired patient and activity level less fatigue
PR: 79 normally. activities and identify the through and
RR: 20 Patient with he will activities that patient may weakness
Temp: 37.6 ARF may verbalize an leads to fatigue. feel too weak *patient
>Patient suffer to increase initially participates
manifest anemia energy level. in some
generalized because our activities as
body weakness kidney is one >Monitor vital >indicates much as he
>Patient is of the signs physiological could
pale producers of level of *patient is
>Patient is erythropoietin tolerance awake
dizzy that is one
>with poor component for
muscle tone RBC >Encourage the >to gain
>the patient production and patient to eat energy
has a decreased RBC are the
Hgb count of 83. one who >Administer >for the body
(Normal Value is carries oxygen medications such to have
123-175g/L for and nutrients as ferrous sulfate enough RBC
males) to other cells as prescribed to supply the
and muscles muscles and
for them to cells enough
function. A nutrients to
decrease in function
erythropoietin properly
production will
tend to >Encourage/advis >to increase
produce a e the patient to the patients
small amount perform ROM activity level
of RBC that exercise in a step-by-
would lead to step manner
a decreased
supply of >Encourage the >restoration
oxygen to patient to rest of energy
different cells
and muscles in >Promote overall >to correct
the body. health measures the need of
Therefore, such as proper supply of RBC
leading to poor nutrition, and to reduce
muscle tone adequate fluid fatigue by
and a problem intake and gaining
with muscle appropriate energy
contractility vitamin/iron
that could supplement.
make the
client feel that >Maintain >to improve
he is weak. strenuous activity activity
restrictions. tolerance,
avoid
activities that
requires too
much energy
NCP #2

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION


DIAGNOSIS EXPLANATIO
N

Subjective: >Excess fluid >Kidneys are >After four >Establish >to facilitate >After four
Objective: volume responsible for hours of rapport client and hours, goal
>Patient is related to the elimination nursing student nurse met as
conscious and inability of the of waste interventions; interaction evidenced by:
coherent kidney to products in our *there would *an increase
>with excrete waste body. If there be a stabilized >Monitor vital >to be able to in urine
ongoing IV of products is an alteration fluid volume signs monitor the output from
D5 0.3 NaCl on the normal by increasing changes in 10mL to
500cc X KVO functioning of the urine the condition 30mL/hour
>Vital signs: the kidney, output of the of the client *the client
BP: 110/80 there would be patient verbalized
PR: 79 a problem in *the client >to monitor understandin
RR: 20 the excretion verbalize an >Monitor I and O the normality g of fluid
Temp: 37.2 of waste understanding of urine restriction in
>patient is products. of individual output his diet and
oliguric Making the dietary/fluid began to
average of waste to stay restriction >Assess appetite >to be able to implement it
10mL/hour in the and note for know other *patient is
>Hgb: 73 circulation and nausea or reason which awake
Hct: 0.20 excessive fluid vomiting contributes to *patient
(Normal may be the his condition always stay
Values: result because on bed
Hgb is 125- there are only >Restrict Na and >to avoid
175g/L and Hct intake but a fluid intake as further excess
I 0.40-0.52 for limited indicated fluid
male) amount of accumulation
>patient is output >Administer
restless because of the medications such >to promote
damaged of as diuretics as elimination of
malfunctioning ordered waste
kidney. products

>Evaluate >to reduce


edematous tissue
extremities, pressure and
change position risk of skin
frequently breakdown

>Discuss >for better


importance of understanding
fluid restriction on why the
and “hidden client needs t
sources” of restrict his
intake such as fluid
foods high in consumption
water content

>Identify >to ensure


“danger” signs timely
requiring evaluation
notification of
healthcare
provider.
NCP #3

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATIO


T DIAGNOSIS EXPLANATIO INTERVENTIO N
N N

Subjective: >Risks for >Risk for >After 5 >Establish > To gain the >Goal met
Objective: infection infection is the hours of rapport cooperation of because the
>Patient is related to state in which patient and the patient
patient as well
conscious and environmenta an individual is student nurse during the
as the SO
coherent l condition at risks for interaction interaction practicing the
>with being invaded the patient interventions
ongoing IV of by pathogenic will verbalize >Encourage the > To reduce or given
D5 0.3 NaCl organisms / understandin pt. and the S.O minimize the
500cc X KVO microorganisms g and identify to practice transfer of
>Vital signs: due to poor intervention proper hand microorganism
BP: 110/80 environmental to reduce risk washing s
PR: 79 sanitation to its for infection techniques
RR: 20 surroundings
Temp: 37.2 >Encourage the > To prevent
 = poor patient and the the spread of
sanitation SO to practice microorganism
 = unable to environmental s in the
meet sanitation surroundings
patients
demands >Encourage the > To avoid
for personal patient to throw insects and
care the garbage or other
 = poor trash properly microorganism
hygiene s that carries
 = presence viruses
of insects in
the >Instruct the > To increase
surroundin patient to eat body
gs foods rich in Vit. resistance
C like guava,
oranges,
calamansi etc…

>Encourage
compliance to > For
drug regimen protection
against
infection
NCP #4

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONAL EVALUATIO


DIAGNOSI EXPLANATIO INTERVENTIO E N
S N N

Subjective: >Ineffective >Ineffective >After 5 >Establish >To gain the >Goal was
Objective: therapeutic therapeutic hours of rapport cooperation partially met
>Patient is regimen regimen is the nursing of the as evidence
conscious and managemen state in which intervention patient by the patient
coherent t related to the patient was the patient during the cooperation in
>with ongoing financial unable to meet and the SO interaction some of the
IV of D5 0.3 NaCl status the demands in will >Provide intervention
500cc X KVO prevention and understand information >To know given.
>Vital signs: curing of illness the about the the
BP: 110/80 because of importance patients importance
PR: 79 financial in the condition of
RR: 20 problem compliance therapeutic
Temp: 37.2 of drugs and regimen and
 = refuse to other the value of
take the therapeutic treatment
medication regimen. >Encourage to program
given identify the
 = limited patients and >To identify
social significant others causative
interaction perception and factor
 = lack of expectation of
interest treatment
 =uncooperativ regimen
e

NCP #5

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONAL EVALUATIO


T DIAGNOSI EXPLANATIO INTERVENTIO E N
S N N

Subjective: >Knowledge >Knowledge >After 5 >Establish >To gain the >Goal met
“ Bisa deficit deficit is the hours of rapport cooperation because the
kung mangan related to state in which nursing of the patient
babi” disease the patient lack intervention patient participates in
condition of information the patient during the learning
Objective : about his verbalize interaction process.
>Patient is condition understandin
conscious and g about his >Assess for the >To evaluate
coherent condition patient’s if the patient
>with readiness to is ready to
ongoing IV of learn learn the
D5 0.3 NaCl concept of
500cc X KVO wound
>Vital signs: cleaning
BP: 110/80 >Determine
PR: 79 client’s ability to >To assess
RR: 20 learn. what level of
Temp: 37.2 teaching we
 =uncoopera are going to
-tive impose.
 = lack of >Determine
interest blocks to >To identify
 = the pt. learning. (Like possible
frequently language hindrances
ask about barriers, physical that would
his condition factors and affect in the
 = eating physical stability) teaching and
food which learning
are process
restricted on >Provide
his diet information >To
about the understand
patient condition the condition
of the
patient
>Encourage the
patient to follow
the right diet >To avoid
secondary
problem and
complication
NCP # 6

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATIO


T DIAGNOSI EXPLANATIO INTERVENTIO N
S N N

Subjective : Imbalanced Imbalanced After 4 hours >ascertain >to Goal was met
nutrition nutrition related of client and understanding of determine as evidenced
Objective : less than to therapeutic student nurse individual what by the clients
>Patient is body dietary interaction nutritional needs information to
verbalization
conscious and requirement restrictions; as the client will be provide
of
coherent s related to evidenced by be able to the client/SOunderstanding
>with disease lack of interest verbalize >discuss eating of the
ongoing IV of condition in food/eating understandin habits, including >to appeal to therapeutic
D5 0.3 NaCl g of the food preferences clients likes & dietary
500cc X KVO therapeutic desires restrictions
>Vital signs: dietary >assess drug
BP: 110/80 restriction interactions and >these
PR: 79 use of diuretics factors may
RR: 20 be affecting
Temp: 37.2 appetite, food
>body intake, or
weakness absorption
-numbness in >assist in
the lower developing >to correct
extremities individualized underlying
-dizziness diet regimen causative
-fatigue factors
-dry skin >explain to the
-pale client the >in order to
prescribed diet facilitate
understandin
g and gain
the clients
participation
to the diet
regimen
>provide oral
liquid >these will
preparation help in
providing
nutrients to
the client

>provide >to prevent


frequent mouth stomatitis,
care remove bad
taste,
increase
patients
comfort

>provide atleast >to minimize


30-35 kcal/kg metabolism of
body weight/day body protein
and maintain
body weight

>restrict protein >to improve


and maintain taste and
body weight increase
carbohydrate/
calorie intake

>restrict protein >to decrease


and phosphate at the metabolic
prescribed end products
amount of urea,
potassium,
phosphate
and hydrogen
NCP # 7

ASSESSMEN NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATIO


T DIAGNOSI EXPLANATIO INTERVENTIO N
S N N

Subjective Impaired Usually occurs After 4 hours >assess clients >to be able Goal was met
urinary with urinary of client and understanding of to provide as evidenced
Objective: - elimination tract student nurse condition appropriate by the clients
>Patient is related to obstruction that interaction information verbalization
conscious and disease affects the the client will that are of
coherent condition kidneys be able able needed by understanding
>with bilaterally such to verbalize the client
ongoing IV of as prostatic understandin of condition
D5 0.3 NaCl hyperplasia g of condition >provide time >provide
500cc X KVO for the client to hard candy or
>Vital signs: have question gum
BP: 110/80 and answer them >in order to
PR: 79 in the simplest facilitate
RR: 20 understandable understandin
Temp: 37.2 form g
>oliguria
>irritability > Determine
>decreased clients previous
urine output elimination >in order to
pattern of assess
elimination and deviation
compare with
current situation

>palpate bladder

>to assess
>Emphasize retention
importance of
keeping the area >to reduce
clean and dry risk of
infection
and/or skin
breakdown
NCP # 8

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATIO


DIAGNOSI EXPLANATIO INTERVENTIO N
S N N

Subjective: Social Aloneness After 4o of >Established >To improve Goal met.


Isolation experienced nursing rapport client’s After 4 o
of
Objective: related to by the intervention perception nursing
>Patient is traumatic individual and the patient of self as a intervention
conscious and incidents perceived as will be able worthwhile the patient
coherent causing imposed by to person was able to
>with ongoing physical others as a demonstrate demonstrate
IV of D5 0.3 pain. negative or willingness >Encouraged >to enhance willingness or
NaCl 500cc X threatening or desire to the patient to client’s desire to
KVO state. socialize with express his feelings of socialize with
>Vital signs: other. feelings self worth other.
BP: 110/80
PR: 79 >Identify >to maintain
RR: 20 support system involvement
Temp: 37.2 available to the with others
>the patient patient
manifest >to
restlessness, >Provide encourage
incommunicable positive continuation
, reinforcement of efforts
projects hostility when client
in behavior, make moves
poor eye toward others
contact.

>Be honest and >honesty


keep all and
promises dependabilit
y promote a
trusting
relationship

>Be cautious >a


with touch until suspicious
trust has client may
established. perceive
touch as a
threatening
gesture.

>Introduce >provide
client to those role models,
with similar / encourage
shared interest problem
and other solving.
supportive
people

NCP #9

Cues Nursing Scientific Desired Interventions Rationale Expected


Diagnosi Explanation Outcome Outcomes
s

Subjective Anxiety Anxiety often After 30 Create an > Trust is an After 30


: related to accompanies minutes of atmosphere essential first minutes of
Ø pain. pain. The threat nursing that facilitates step in the nursing
of the unknown intervention, trust. therapeutic intervention,
Objective: and the the patient relationship the patient
>Patient is inability to will appear appears
conscious
control the pain relaxed and Seek to > To facilitate relaxed and
and
coherent or the events report understand planning for reported
>with
surrounding it anxiety is client’s the best anxiety is
ongoing IV
of D5 0.3 often augment reduced to a perspective of a approach to reduced to a
NaCl 500cc
the pain manageable stressful anxiety manageable
X KVO
>Vital perception. A level. situation. reduction. level.
signs:
perception of > To identify
BP: 110/80
PR: 79 lacking control Encourage specific
RR: 20
or a sense of verbalization of emotions
Temp: 37.2
helplessness feelings, such as anger
> poor eye tends to perceptions, or
contact increase pain and fears. helplessness,
>restless- perception. distorted
ness perceptions
>irritable and
> increase unrealistic
tension fears.
> facial Identify > These will
tension situations that enable the
> facial precipitate client to
grimace anxiety prevent or
(describe what recognize his
the person anxiety in
experienced order to
immediately initiate
prior to feeling problem
anxious and solving.
identify
associated
events).
B. IMPLEMENTATION
1. MEDICAL / SURGICAL MANAGEMENT

INTRAVENOUS FLUID

Date Ordered: Date IVF (type of Fluid Description Nursing


Started/discontinued fluid and Responsibility
regulation)
Date Started: December > D5 0.3 > It is a solution of sodium > Watch out for
11, 2005 and December NaCl 500 cc chloride in sterile water but in emptying of the
15, 2005 X KVO much higher concentration. solution. Replace
Discontinue: December solution whenever
16, 2005 necessary.
>Check for the
Date Started: December >PNSS >In medicine saline is a patency of IV lines.
12, 2005 and December 500cc X KVO solution of sodium chloride in
14, 2005 sterile water, used commonly
Discontinue: Discontinue for intravenous infusion,
after BT, replace cleaning contact lenses, and
previous IVF nasal irrigation or jala neti.
Sodium chloride (NaCl) is
ordinary salt.
MEDICATION AND DRUG STUDY

DRUG DATE ACTION INDICATIO DOSAGE: ROUTE SIDE NURSING


ORDERE N OF EFFECTS RESPONSIBILITIES
D ADMINISTRATION
, FREQUENCY

Generic December Antipyreti Analgesic- 300 mg IV 30 min CNS: Monitor


Name: 11, 2005 c Antipyretic prior to BT Headach Temperature
Paracetamol in patients e
Analgesic with aspirin GI: Assess for history of
allergy, Hepatic allergy to
haemostatic toxicity Paracetamol,
disturbances and impaired hepatic
and failure, function, chronic
bleeding. jaundice alcoholism.
CV: Chest
pain, Physical
dyspnea assessment, skin
color, lesions, liver
evaluation; CBC,
liver and renal
function test.

Give drug with food


if upset is noted.

Discontinue drug if
hypersensitivity
reactions occur.
Report skin rash,
unusual bleeding or
bruising, following
of skin or eyes,
changes, in voiding
patterns.
DRUG DATE ACTION INDICATIO DOSAGE SIDE NURSING
ORDERED N EFFECTS RESPONSIBILITIE
S

Generic Name: December Competitivel Relief of 1 amp IV - Dizziness Assess history of


Diphenhydramin 11, 2005 y blocks the symptoms 30 min -Sedation allergy to
e effects of associated prior to - antihistamines.
Hydrochloride histamine at with allergic BT Drowsiness
H1 receptor reactions to -Dry mouth Physical
Brand Name: sites, has blood or assessment, skin
Benadryl atropine- like plasma. color, lesions,
an texture, reflexes,
antipruritic, PR, RR, BP,
and sedative adventitious
effects. sounds; bowel
sounds; prostate
palpation; CBC with
differential.

Inform patient
about the following
side effects that
may occur.

Monitor for
difficulty breathing,
hallucinations,
tremors, loss of
coordination,
unusual
disturbances, and
irregular heartbeat.
DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIE
S

Generic December Essential Dietary 1 tab TID - Assess history o


Name: 11, 2005 element of supplement constipation allergy to calcium;
Calcium the body; when -nausea renal calculi;
Carbonate helps calcium -GI upset hypercalcemia
maintain the intake is -loss of ventricular
Brand functional inadequate. appetite fibrillation; digitalis
Name: integrity of toxicity.
Caltrate the nervous
and Physical
muscular assessment, BP,
systems, peripheral
helps perfusion, ECG;
maintain abdominal exam,
blood bowel sounds,
coagulation. mucous
membranes; serum
electrolytes,
urinalysis.

Monitor serum
phosphorus levels
periodically during
long-term oral
therapy.

Advice client to
take drug between
meals and at
bedtime. Chew
tablets thoroughly
before swallowing,
and follow with a
glass of water or
milk.

Advice client about


following side
effects that may
occur.

Advice client to
report loss of
appetite; nausea,
vomiting,
abdominal pain,
constipation, dry
mouth, thirst,
increased voiding.
DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIE
S

Generic December Inhibits the -Edema 80 mg IV -Increased Assess history:


Name: 11, 2005 reabsorption associated post BT volume and Allergy to
Furosemide of sodium with renal frequency of furesemide,
and chloride disease. urination; sulfonamides;
Brand from the - drowsiness tartazine;
name: proximal -dizziness electrolyte
Lasix and distal -feeling faint depletion anuria,
renal tubule on arising severe renal failure.
and the loop -sensitivity
of henle, to sunlight Physical
leading to -loss of body assessment: skin
sodium, rich potassium color, lesions,
diuretics. edema, orientation,
reflexes, hearing,
pulses, baseline
ECG, BP, orthostatic
BP, perfusion; RR,
liver evaluation,
bowel sounds;
urinary output
patterns; CBC,
serum electrolytes,
blood sugar, liver
and renal function
tests, uric acid,
urinalysis.

Administer with
food or milk to
prevent GI upset.

Inform client about


the side effects that
may occur.

Report loss or gain


of more than 3 lbs.
in one day, swelling
in ankles or fingers,
unusual bleeding or
bruising, dizziness,
trembling,
numbness, fatigue,
muscle weakness
or cramps.
DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIE
S

Generic December Competively -Hypertension, 50 mg 1 -Dizziness Assess history of


Name: 15, 2005 blocks beta- alone or with tab BID -Drowsiness sinus bradycardia
Metoprolol adrenergic other drugs, -Light (HR < 45
Brand receptors in especially headedness beats/min)
Name: the heart and diuretics. -blurred Second or third-
Toprol XL juxtaglomerula -prevention of vision degree heart block
r apparatus, reinfarction in -nightmares (PR interval > 0.24
decreasing the the MI pts who -depression sec), cardiogenic
influence of are -sexual shock CHF, systolic
the hemodymacall impotence BP < 100 mg Hg;
sympathetic y stable or diabetes or
nervous within 3-lod of thyroxicosis;
system on acute MI asthma or COPD.
these tissues -treatment of
and the angina Physical
excitability of pectoris. Assessment:
the heart, weight, skin
decreasing condition,
cardiac output neurologic status,
and the PR, BP, ECG,
release of respiratory status,
rennin, and kidney and thyroid
lowering BP; function, blood and
acts in the CNS urine glucose.
to reduce
sympathetic Inform clients
outflow and regarding side
vasoconstrictor effects that may
tone. occur.

Monitor difficulty
breathing, night
cough, swelling of
extremities, slow
pulse, confusion,
depression, rash,
fever and sore
throat.
Name of Mechanis Indication Dosage, Contraindicatio Side Nursing
Drug m of Route of n Effects/Advers Implicatio
Action administratio e Effects n
n and
Frequency
(Date
Oredered)

Generic Long-acting For patients Manidipine It should not be Cardiovascular: Blood


Name: calcium with 20mg/tab OD taken by the Facial hot Pressure
Manidipine antagonist, hypertensio patient who is flushes, feeling should
dilating n pregnant or of warmth, always be
Brand blood > December suspected of conjunctival monitored.
Name: vessels, 14, 2005 being pregnant. congestion,
Caldine mainly by palpitation or Watch out
calcium tachycardia. for
channel GI: Nausea, excessive
blockade vomiting, drop of
stomach blood
discomfort, pressure so
enlarged feeling that
of abdomen, appropriate
constipation or measures
oral dryness. such as
Psychoneurologic dosage
: Dizziness, restriction
dizziness on and
standing up, cessation
headache, dull should be
headache, done.
sleepiness or
numbness. Caution the
Blood: patient that
Leukopenia. such
Liver: Elevation symptoms
of GOT, GPT, g- like
GPT, LDH and dizziness
alkaline may occur.
phosphatase.
Kidney: Elevation Advise the
of BUN and patient to
serum creatinine. avoid
Hypersensitivity: hazardous
Rash or pruritus. activities
Others: General requiring
malaise, the
weakness, alertness of
edema, the patient.
pollakiuria and
elevation of total Watch out
serum for adverse
Cholesterol, uric reactions.
acid and
triglycerides.
Name of Mechanism of Indication Dosage, Contraindication Side
Drug Action Route of Effects/Adverse
administratio Effects
n and
Frequency
(Date
Orederd)

Generic Recombinant Symptomatic 5000 iu / SC / -uncontrolled Increased blood


Name: human or transfusion once a week hypertension pressure and
Erythropoieti erythropoietin requiring -known hypertensive
n (r-HuEPO) is a anaemia hypersensitivity to encephalopathy
Brand purified associated >December 16, mammalian-cell -Flu-like
Name: glycoprotein with chronic 2005 derived products symptoms, bone
Eprex which renal failure. -known pain and chills
stimulates hypersensitivity to following
erythropoiesis. any of the injections
components of -Seizures
this product -Headache
-Pain in the
subcutaneous
area
Name of Mechanis Indication Dosage, Contraindicatio Side Nursing
Drug m of Route of n Effects/Advers Implication
Action administratio e Effects
n and
Frequency
(Date
Ordered)

Generic Replaces For patients Kalium Durule 1 Contraindicated Hyperkalemia, Frequently


Name: potassium with tab TID for patients with arrhythmias, monitor the
KCl and hypokalemi hyperkalemia weakness, potassium
Brand maintain a >December 13, and renal confusion and levels of the
Name: potassium 2005 insufficiency hypotension. patient
Kalium levels
Durule Use the drug
with caution
for patients
with cardiac
disease.

The drug is
commonly
used orally
with
potassium
wasting
diuretics to
maintain
potassium
levels.

Watch out
for adverse
reactions.
SPECIAL PROCEDURES

DATE
ORDERED / PROCEDURE RESULT PROCEDURE NURSING
DATE DESCRIPTION RESPONSIBILITIE
PERFORMED S
December 11, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusion reactions transfusion is reactions
(1 “u”) performed to > Watch for signs
supply any of shock
blood loss or
any deficiency
in RBC.

December 12, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusin reactions transfusion is reactions
> Watch for signs
(1 “u”) performed to of shock
supply any
blood loss or
any deficiency
in RBC

> Watch for allergic


December 14, > Blood > No allergic > Blood reactions
2005 Transfusion reactions transfusion is > Watch for signs
(1 “u”) performed to of shock
supply any
blood loss or
any deficiency
in RBC
VI. PATIENTS DAILY PROGRESS

Doctor’s Order
Name: Romeo Velasco Age: 57 Male Civil
Status: M
Address: Sasmuan, Pampanga Ward: Med
Hospital #: 130290

Date: December 11, 2005


 Please admit to as under ORANGE
 Secure consent for admission and NGT
 TPR on shift
 NPO temporarily except meds
 # uremia
CBC 12 LEKG
RBC CXR PAV
BUN / Creatinine Renal UTZ
Na K CL Urinalysis
.Uremia / anemia 2° to ESRD prob. To CBN
BP = 130/80mmHg CR = 76 bpm Cra. = 3.1
 IVF D5 0.3 NaCl 500cc x KVO, start KCL drip 10meqs + 90cc
PNSS x 1° x 4 doses then for serum K 1 hour after the last
dose.
 CaCO3 500mg/tab 1 tab TID
 Advise dialysis
# Anemia
Place MCV MCH MCHC PBC Retic G
 prepare 3 “u” PRBC properly typed and matched
 PNSS 500cc while on BT, replace previous IVF after each unit
 Transfuse 1st unit once available

Paracetamol 300mg / IV and Diphenhydramine 50g /IV 30


minutes prior to BT
Furosemide 80mg/ IV / post BT
 Insert Folley Catheter and do I & O q 1° and record pls.
 Monitor vital signs q 1°.
# Glucoserum
FBS in AM
HBAC
 CBC q 12° and record pls.
 Inform service residence.
 Complete Hx / pls.
 Refer accordingly.

December 12, 2005


BP = 110/ 70mmHg (+) body weakness (-) N / V
 Repeat serum K after 4th dose KC

 Low salt, low protein diet.


 Transfuse 1 unit PRBC properly typed and matched to run for 4
hours.
 Furosemide 80mg / post BT.
 For renal UTZ
 Repeat with in 6 hours post BT.
 Continue meds.

December 13, 2005 7:30am


(-) pallor
 For repeat H & H.

Romeo Velasco – refused dialysis.


8:00am
BP = 120/80mmHg; T = 35.8 °C; RR = 21; PR = 79bpm
(+) nausea (+) vomiting of coffee
 Transfuse 1 “u” PRBC properly typed and matched to run for 6
hours.
 Furosemide 80mg / IV.
 Insert NGT.
 Fecalysis with occult blood
 Still for dialysis.
 Monitor VS, I & O q 1°
 Continue meds.
 Consent for blood transfusion.
 Meds:
1. Furosemide 80mg TID
2. CaCO3 TID

4:20pm
 Start Kalium Durules 1 tab. TID
December 14, 2005
BP = 180/ 100mmHg: CR = 94bpm; (+) anorexia
 Manidipine 200mg / tab OD
 For H/H.
 For removal of NGT.
 Start tube feeding at 1600 kcal in 6 divided doses.
 Continue meds.
 VS q 4°

12.14.5 6:50pm
BP = 140/90 mmHg CR = 82bpm T = 37.2 °C
(+) upper arm twitching (-) DOB (-) chest pain
 May remove NGT.
 For K and Albumin

 Prepare and transfuse 1 “u” of PRBC properly typed and


matched.
 H/H 6° prior to BT
 Furosemide 80mg / post BT, watch for transfusion reaction.
 VS q 1°

December 15, 2005 4:00pm
BP = 170/90mmHg
 start metoprolol 50mg / tab BID
 H/H prior to BT
 Continue meds.
 VS q 1°
Refused medications, VS q 1° and BT.

December 16, 2005


BP = 110/80mmHg
MGH
 home meds
1. Erythropoietin 5,000 u/ sc once a week
2. CaCO3 / tab TID.
3. Manidipine 20mg /tab OD

Follow up check up:: January 11, 2006

Discharged @ 4:30pm 12/16/05


Daily Progress Table

12-11-2005 12-12-2005 12-13- 12-14-2005 12-15- 12-16-2005


2005 2005
Vital Signs T: 37 T: 36.7 T: 35.8 T: 37.2 T: 37 T: 37.2
at 12PM PR: 90 PR: 76 PR: 79 PR: 82 PR: 83 PR: 79
RR: 22 RR: 20 RR: 21 RR: 22 RR: 20 RR: 21
BP: 120/80 BP: 110/70 BP: 120/80 BP: 140/90 BP: 170/90 BP: 110/80
Lab *Blood *Blood *Blood *Blood REFUSED REFUSED
Procedure Chemistry* Chemistry* Chemistry Chemistry*
>MCH – 32.4 >FBS – 95.9 * >Hgb – 83
>MCV – 90.1 >K – 3.0 >K – 3.0 >Hct – 0.25
>MCHC – 36 >Hgb – 73 >Hgb – 73 >K – 3.0
>Reticulocyte >Hct – 0.20 >Hct –
count– 2.5% 0.20
>Hgb – 77
>Hct – 0.23
>WBC – 12.0
>Neutrophils –
0.90
>Lymphocytes –
0.08
>Stab – 0.02
>Platelet – 163
>RBS – 6.64
>BUN – 13.1
>Crea – 1939
>Na – 137
>K – 2.3
>Chloride – 109
>Ca – 1.71
>Phosphorus – 1.1

*Urinalysis*
>Color: Light
Yellow
>Reaction – Acidic
>Specific Gravity
– 1.020
>Coarse Granular
– 2.4/LPF
>Puss Cells –
8.1/HPF
>RC – 3.5/HPF
>Epithelial cells –
few
Medication >CaCO3 Continue meds: New Meds: New Meds: New Meds: MGH
s 500mg/tab TID >CaCO3 >Kalium >Manidipine >Metoprolo Home meds:
>Paracetamol 300 500mg/tab TID Durule 200mg/tab OD l 50mg/tab >Erythropoietin
mg IV BT meds: 1tab TID Continue meds: TID 5,000 u/ sc
>Diphenhydramid >Diphenhydramid Continue >CaCO3 Continue once a week
e 50mg IV 30 e 50mg IV 30 meds: 500mg/tab TID meds: >CaCO3 / tab
mins prior to BT mins prior to BT >CaCO3 >Kalium Durule >Manidipin TID.
>Furosemide >Furosemide 500mg/ tab 1tab TID e >Manidipine
80mg IV Post BT 80mg IV Post BT TID BT meds: 200mg/tab
20mg /tab OD
>Diphenhydramid OD
e 50mg IV 30 >CaCO3
mins prior to BT 500mg/tab
>Furosemide TID
80mg IV Post BT >Kalium
Durule 1tab
TID

IVF >D5 0.3 NaCl >PNSS 500cc X >PNSS 500cc X >D5 0.3
500cc X KVO KVO KVO NaCl X KVO
>PNSS 500cc X
KVO
Special >1st unit BT >2nd unit BT >3rd unit BT
Procedure 9:40PM 11:30AM 9:00PM
s
NORMAL VALUES:

* Normal Values
M: 125 – 175g/L
Hgb
F: 115 – 155g/L
M: 0.40 – 0.52
Hct
F: 0.38 – 0.48
WBC
Neutrophils 0.45 – 0.65
Lymphocyte 0.20 – 0.35
Stab 0.02 – 0.05
Platelet
RBS 3.85-9.0mmol/L
BUN 1.7-8.3
M: 60 – 120
Creatinine
F: 58 – 100
Sodium 135 – 145
Potassium 3.5 – 5.0
Calcium 2.02 – 2.60
Phosphorus 0.81 – 1.62
Chloride 101 – 111
FBS 4.1 – 6.1 mmol/L
MCH 27 – 33 pg
MCV 82 – 92 fl
MCHC 31 – 36 g/dL
Reticulocyte count 1 – 5%
PATIENTS DAILY PROGRESS

12-11-05

The patient was transferred from Diosdado Macapagal Hospital at Lubao,


Pampanga, and was admitted to JBLMRH under orange service.
The vital signs taken were BP 130/80, PR 76. The ongoing diagnosis is
Uremia/Anemia 2° to ESRD prob. 2° to CBN.

He was hooked with an IVF of D5 0.3 NaCl 500cc x KVO, started KCl drip 10
meqs + 90 cc PNSS x 1°x 4 doses then for serum K 1° after the last dose.

CaCO3 500 mg 1 tad TID was ordered as meds

Patient is refusing dialysis, that’s why dialysis was advised

# Anemia
1st unit of 3 U pack RBC was transfused. Pre BT meds are given and they are as
follows: Paracetamol 300 mg IV, Diphenhydramine 50 g IV 30 mins prior to BT
and furosimide 80 g IV was given post BT.

Foley catheter was inserted

# Glucoserum

FBS in AM was taken


HBAC

CBG was ordered to be done q 12°.

12-12-05

The patient BP was 110/70. There was (+) body weakness and (-) N/V. Serum K
after 4th dose KCl was repeated. Low salt, low protein diet was prescribed.

1 unit of packed RBC was transfused, consumed within 4 hours, furosemide 80


mg was given post BT.

For renal UTZ, H/H was repeated within 6 hours post BT.

12-13-05

7:30 am
There was (-) pallor. The patient was for H/H

The patient refused dialysis


8:00 am
The patients vital signs were as follows: BP: 120/80, T: 35.8°C, RR: 21, PR: 79.
The patient has (+) nausea and vomiting.

He was transfused with 1 U PRBC consumed for 6 hours; furosemide 80 mg IV


was given. He was inserted with NGT. For fecalysis with occult blood.
The patient was for dialysis but still he is still refusing.

4:20 pm

Kalium Durule TID was started.

12-14-05

The patients vital signs are as follows; BP: 180/100, CR: 94. Manidipine 200 mg
1 tab OD was started. For H/H. Tube feeding was 1600 kcal in 6 divided doses.
The NGT was removed due to the anxiety of the patient.

12-14-05

6:50 pm

The patients vital signs were as follows BP: 140/90, CR: 82, T: 37.2°C. There
was positive arm twitching, negative DOB, negative chest pain. He was
for K, Ca, and Albumin count.

12-15-05

The patient BP was 170/90. Metropolol 50 mg 1 tab BID was started. For H/H
post BT.

The patient was lying on bed and not talking and would not open his eyes. He
refused H/H, and all his oral meds.

12-16-05

The patient BP was 110/80. The he was sitting on bed, and verbalizes that he
does not remember that he had refused all to take all his medications. There
was (+) dizziness and loss of appetite due to therapeutic diet prescribed. He is
still refusing dialysis.
May go home. Home meds were as follows: Erythropoietin 5,000 IU SC once a
week, CaCO3 1 tab TID, and Manidipine 20 mg 1 tab OD.

He was scheduled to have his checked up on Jan.11, 2006. The patient was
discharged at 4:30 pm.
VII. DISCHARGE PLANNING

Medications:
• Erythropoietin 5000 IU, SC once a week
• CaCO3 1 tab TID
• Manidipine 20mg 1 tab OD

Exercise:
• Encouraged to perform ROM exercise
• Limit activities that requires too much movement
• May perform ADL in a limited range

Treatment:
• Medication as prescribed by ROD
• Low salt – low fat diet and Uremic diet

Health Teaching:
• Advised patient to eat nutritious food like fruits, fish and
vegetables.
• Advised to limit salt and fat intake
• Advised patient to monitor intake and output.
• Advised patient to perform light exercises

Out-Patient Visit
• Instructed patient to be back on January 11, 2006 for
follow up check-up.

Diet:
• Low fat – low salt diet, Uremic diet
VIII: Conclusion and Recommendation

Acute Renal Failure is a kind of disease that is suddenly


manifested by people who are not aware of what they are eating.
People who manifest ARF have same manifestations and these are
high in creatinine, hyperkalemia, oliguria, anemia and the worst is
uremia. Uremia is a toxic manifestation of this disease in which a
person has urine in its blood because of inability of the kidney to
excrete the waste from the body because of its damage. Having
uremia in a person with ARF can lead to its worst condition and if
cannot be prevented, it can lead to death of the person. However,
there is still hope in treating Acute Renal Failure in compare with
Chronic Renal Failure. There are different prevention strategies,
diagnostic screening methods and treatments that can be applied in
patients with Acute Renal Failure.
Renal Failure can be acute or chronic. Chronic Renal Failure
affects patients for a long period of time and can only be treated by
kidney transplant. Unlike Acute Renal Failure, the normal functioning of
the kidney can be achieved by spontaneous treatment and
hemodialysis if advised by the doctor. Though, hemodialysis can be
performed for persons with CRF, however, the normal functioning of
the kidney could not be achieved. To manage the patient with this kind
of condition (ARF), it should be done with complete cooperation of the
patient and its family. The client with ARF must be endowed to accept
self-management and learn how to control himself in times of
temptation of doing wrong things that could affect his condition.
Clients with ARF should have a consistent check-up, updating and
monitoring his own condition.
Proper education should be imparted in clients with ARF. They
should be educated on what are the things that they should be aware
of. This includes his diet, his activities of daily living and his
medications. Proper monitoring of his urine output should also be
included in educating them. In addition to the diet of the client, we
should also present substitutes for foods that the patient wants that
could not affect his condition. A uremic and a low-salt low-fat diet
should be imposed on patients with ARF. We should also include that
they should abide the orders of the physician in order for him to be
treated in his condition. As nurses, we should also take in consideration
the financial stability and the degree of knowledge our client has so
that we can come out with nursing interventions that is appropriate to
his level of understanding.
Health care providers should be aware of the risk and
complications of acute renal failure to patients. We should always
monitor their fluid and electrolyte balance and other laboratory results
for us to be updated of the patient’s progress in the hospital.
Acute Renal Failure is a major disease condition. We should be
careful of what we are eating and doing. We can avoid having this
disease by following a healthy diet and regular exercise. As a famous
saying from the medical field, “Prevention is better than cure”.

Current Trends on Acute Renal Failure

Taken from: RenaMed Biologics and Genzyme Announce Worldwide


Collaboration to Advance Investigational Treatment for Acute Renal
Failure
-- Data from Phase II study, completed by RenaMed, to be presented at
ASN in November –

Sep 28, 2005

LINCOLN, R.I., and CAMBRIDGE, Mass., Sept. 28 – RenaMed Biologics,


Inc. (RenaMed™), formerly Nephros Therapeutics, Inc., and Genzyme
Corporation
(NASDAQ = GENZ ) announced today that they have entered into a
strategic collaboration to jointly develop and commercialize RenaMed’s
Bio-Replacement Therapy™ for the treatment of acute renal failure.
The product utilizes physiologically active renal epithelial cells,
administered ex vivo in a hollow-fiber cartridge, intended to treat a
sudden loss of kidney function with the ultimate goal of improving
survival rate. Genzyme and RenaMed will undertake a collaborative
effort to advance the product through clinical development,
manufacturing, and commercialization on a worldwide basis.

The joint development and commercialization agreement calls for a


50/50 sharing of costs and profits. Genzyme will contribute funding of
approximately $23 million through the third quarter of 2006 to support
the next stage of clinical development, and may make additional
payments to RenaMed upon completion of certain developmental
milestones. These additional payments could total $20 million.
Thereafter, the agreement calls for shared program funding, and for
potential additional milestone payments by Genzyme at approval.
Genzyme also made an equity investment in a recent private financing
completed by RenaMed in June 2005.

Reaction:

It is a fact that acute renal failure is one of the major diseases


that occur in this world. There are lots of treatments that are being
presented today to treat acute renal failure. These include
hemodialysis, medications and many more. But recently, corporations
which are the RenaMed and the Genzyme joined forces to develop and
commercialize a new product to treat Acute Renal Failure; the Bio-
Replacement therapy which utilizes epithelial cells and so on to treat
the sudden loss of function of our kidney and improve the survival rate
of the patient who possess this kind of disease.
This latest trend in medicine will contribute a lot in treating this
kind of disease. As individuals here in this society, we should support
this kind of breakthroughs because this will not just benefit the elite
people in our society but also to indigent people who cannot afford the
expensive therapies that should be done in treating acute renal failure.
Even though this kind of treatment was discovered and developed, we
should always be careful on what we are doing so that the probability
of having the disease will decrease. But the most important is, early
prevention and detection of the disease is one of the main goal to
avoid renal failure such as limit intake of salty and fatty foods.

IX. BIBLIOGRAPHY / REFERENCES

 Laboratory Procedures and Results/ Reference unit HAU Library


 www.yahoo.com
 Medical-surgical book by Black
 Angeles City Library (Nursing Books specifically Pathophysiology
Book)
 Anatomy and Physiology (Official book of CON-HAU)
 JBLMRH (Patient’s Records)

Holy Angel University


College of Nursing

In Partial Fulfillment of the requirement in


Related Learning Experience

A case study about

Presented by :
Group - 1

Acoba, Anna Mary Golda G.


Angeles, Leonardo Jr. M.
Antido, Arleen
Bognot, Mariel
Castilllo, Christine C

Presented to:
Mr. John Paul Cuengco, R.N

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