RENAL PARENCHYMAL DISEASE T/C ACID PEPTIC DISEASE

MARY JHOY CELARIO ELISSA CORPUZ KARISSA ESTRELLA ROXEAN JEAN MADAYAG ELSA MANZANO LAWRENCE NEMIR ERLINDA VIRAY

INTRODUCTION:

For the purpose of confidentiality, the real name of the patient in this case is withheld and he will referred to us, as MR.V throughout the entire document. He is a 28 years old male, single but ha a live-in partner with two daughters, a Roman Catholic from Moncada. Tarlac. He was admitted because of a chief complaint of Abdominal Pain. I chose MR. V to present this case because his case is related to our concept in Medical Surgical in Nursing. Renal Parenchymal Disease includes maladies that damage the outermost internal region of the kidney, where infiltration and urine formation occur. Autoimmune disorders, Medical conditions or obstructions may all contribute to Renal Parenchymal Disease.It is the most common cause of secondary hypertension. Acid Peptic Disease, otherwise simply known as a peptic ulcer condition or peptic disease is a condition whose the patient will begin to experience abdominal pain. The pain is generated by ulcers that can develop in either the stomach or the tube the tube that connects to the stomachs called the esophagus. The most common symptom experienced by a majority of the patients is pain varying intensities, bloating, nausea and vomiting and weight loss.

OBJECTIVES:
To establish rapport to the client and significant other(s) to be able to acquire correct data needed. To assess the patient cephalo-caudal that will serve as baseline for nursing intervention To identify nursing problems based on data gathered. To impart health teachings to the client and significant other(s). To plan appropriate interventions to the client. To prioritize the problems observed in the assessment phase.

NURSING PROCESS
Data Base

A. Nursing Health History

Demographic Data Age: 28 years old Weight: 52kg Sex: male Height: 54

Birthdate: April 6, 1984

Birthplace: Moncada, Tarlac Address: Aringin, Moncada, Tarlac

Nationality: Filipino
Chief Complaint: Abdominal pain

History of Present Illness:

Patient is known to have renal problem, whom more than one week prior to admission, had episodes of flank pain bilateral extending to the epigastric area, consult done, medication taken and referred to gastro. Childhood Illness: Mumps Measles Chicken Pox TB Immunizations: He stated that he completed his immunizations. Pneumonia Rheumatic Rubella HPN Hepatitis Others:

Hospitalizations: Mr. V has been hospitalized 6 months ago at Ramos Hospital with a diagnosis of kidney problem.

Review of System:
General Description:

Weight Loss: x Night Sweats:

Skin:

Fatigue: x Weakness:

Anorexia: x

Itch: x Rash: x Lesions: x

Eyes: Pain: x Diplopia: x

Bruising: x Bleeding: x Color Change: x

Itch: x Blurring: x

Vision Loss: x Excessive Tearing: x

Glasses/Contact Lenses: x

Ears: Earaches: x Hearing Loss: x Nose: Obstruction: x Epistaxis: x Discharges: x Discharge: x Tinnitus x

Throat and Mouth:

Sore Throats: x Tooth Decay: x Neck: Bleeding gums: x Tooth aches: x

Swelling: x
Chest:

Dysphagia: x

Horseness : x

Cough: x Sputum: x Hemoptysis: x Wheeze: x Pain on respiration Dyspnea: Rest/Exertion x

Breast: lumps Bleeding: x

CVS:

x Discharge: x

Pain: x

Chest pain: x Edema: x PND: x

GIT:

Palpitation: x Orthopnea: x

Dyspnea on exertion: x Others:

Food intolerance: x Heartburn: x Nausea: x Jaundice x Vomiting: x Pain: x Bloating: x Excessive gas: x Constipation: x Change in BM: Melena: x GU:

Dysuria: Polyuria: x Others:

Nocturia x Retention: x Dribbling: x Hematuria; x

Flank pain:

Extremities: Joint pains: x Edema: x Neuro: Headaches: Fainting: x Numbness: x Paresis: x Seizures: x Mental Health Status: Anxiety: Depression: x Insomnia: Dizziness: Tingling: x Others: x Memory Loss: Paralysis: x Varicose veins: x Claudication: x Stiffness: x Deformities: x

Sexual Problems: x

Fear: x

B. Nursing Health History a. General Description of the client: Approximately 5 feet and 4 inches in height with a body built of mesomorph b. Health Perception- Health Management

Mr. V is aware to his condition and usually visits his doctor at Ramos Hospital whenever he feels unusual.
c. Nutritional Metabolic Pattern

Mr. V eats three times a day. He usually eats vegetables like eggplant and also meat.
d. Elimination Pattern

She has a difficulty in urination.

e. Activity- Exercise Pattern

Mr. V wake-up at 4-5:00 in the morning. He is a tricycle driver thats why he used to wake-up earlier.
f. Sleep-Rest Pattern

Mr. V has approximately 6-7 hours of sleeps a day. She usually sleeps at 11pm and usually wake-up in between hours.
g. Cognitive- Perceptual Pattern There is a time that he feels down because of his condition but he believed that God is with him and above will protect him.

h. Self Perception- Self Concept Pattern His self-esteem is in moderate state and nervous to undergo a surgery. I. Role Relationship Pattern |He is a father of 2 children. Sometimes he plays and communicates to his family as a form of their bonding. j. Sexually- Reproductive Pattern The patient is sexually active.

k. Coping- Stress Pattern

Whenever he has a problem, Mr. V is not hesitated to consult his feelings to his wife and aunt.

l. Value- Belief Pattern

Mr. V goes to church or attend a mass every Sunday.

Physical Assessment: General Survey: Body Position/ Alignment Supine Fowlers Others: Alignment Appropriate Mental Acuity: Oriented Coherent Appropriate responsive Others: Disoriented: x Incoherent: x Inappropriate responsive: x Sensory/Motor Restrictions: Amputation: x Paralysis: x Fracture: x Speech: x Deformity: x Gait: x Others: Paresis: x Hearing Disorder: x

Semi-Fowlers Inappropriate

Emotional Status: Euphoric: x Apprehensive: x Angry/Hostile: x Medically Imposed Restrictions: Depressed: x Others:

CBR w/out BRP OOB-Chair

BR w/ BRP Restricted Ambulation

Other Health Related Patterns: Fatigue : x Restlessness: x Weakness: x Insomnia: x Coughing: x Dyspnea: x Dizziness: x Others: Pain (pelvic area)

Environment: Room Temperature: Inadequate Lighting: Inadequate Safety: Violations of Medical Asepsis: Violations of Safety Measure: Activities of Daily Living: Can/Cannot perform Feeding Brushing Teeth Bathing: Transferring Dressing Combing Others: Adequate Adequate

Vital Sign: HR

83 beats/min

Temperature: 36.6 C

BP

Supine R/L arm 120/70 mmHg Capillary Refill: 2sec. Sitting R/L arm 120/80 mmHg Standing R/L arm 120/80 mmHg Others: x

Physical Assessment

Body Part Head/Skull

Method Used Inspection Palpation

Eyes/Vision

inspection

Normal Findings Normo-cephalic >Smooth skull contour >Proportion to the size of the neck and body >Absence of nodules and masses >Sclera is white >Pupil is round and reactive to light accommodation

Ears/Hearing Inspection Palpation Interview/test

Actual Findings Normo-cephalic >Smooth skull contour >Proportion to the size of the neck and body >Absence of nodules and masses Sclera is white >Pupils are equally round and reactive to light accommodation >Iris is dark brown in color >Placement is normal (top air conduction of pinna level with eye) is>Placement is normal >Both ears are at equal (top of pinna level with level eye) >External auditory >Both ears are at equal meatus is present level Pinna, tragus, and >External auditory mastoid non tender on meatus is present manipulation Pinna, tragus, and Tuning fork; air mastoid non tender on conduction is longer than manipulation bone conduction Tuning fork; longer than bone conduction

Nose/Mouth/Throat

Inspection \

Symmetrical >Air is felt when exhaled Oral mucosa is wet due to presence of saliva.

Symmetrical >Air is felt when exhaled Oral mucosa is wet due to presence of saliva.

Heart/Cardiovascular

auscultation

Abdomen

Inspection Auscultation palpation

>Normal heart rate >Normal rhythm >No murmur >No abdominal enlargement without discoloration No abdominal vowel sounds No masses, lesions, or tenderness

>Normal heart rate >Normal rhythm >No murmur >No abdominal enlargement without discoloration No abdominal vowel sounds No masses, lesions, or tenderness

Neurological/Musculoskeletal

Patient is coherent and conscious. She is appropriate responsive. No deformities and no joint pains

Patient is coherent and conscious. She is appropriate responsive. No deformities and no joint pains Patient refuses to be assessed

Genetalia Extremities Symmetrical to the body >No lesion

Symmetrical to the body >There is a presence of lesion on the lower extremeties

Laboratory Findings Ultrasound: (Whole Abdomen) The liver is normal in size with normal parenchymal echogenicity. The intrahepatic ducts and common bile duct are not dilated. No parenchymal mass is noted. Gallbladder is demonstrated with no calculus seen within. Gallbladder wall is normal in thickness. The visualized pancreas and spleen are normal in size and echogenecity. Kidneys are normal in size, contour and echotexture. No renal mass, calyceal calculus or hydronephrosis seen. The urinary bladder is normal. There is no ascites or peritoneal mass lesion. Impression: Unremarkable liver, gallbladder, visualized pancreas, spleen, kidneys and urinary bladder.

September 24, 2012 CBC: Hgb: 16.5 Hct: 48.2 WBC: 8.56 4.5-11 RBC: 5.63 4.3-5.7 PLT: 218 400 CREA: 143

13.2-17.3 39-49

10e3/UL %
10c6/UL 10e3/UL 5.3-106 mmol/L 150-

September 26, 2012 Creatinine (male):131 umol/l 71133umol/l BUN:3.0 mmol/l 3.2-7.1 mmol/l Sodium (Easylyte):143.4 mmol/l 135-147mmol/l Potassium (Easylyte) :3.49 mmol/l 505.30 mmol/l

Urinalysis:
Transparency: Slightly Turbid Color: Dark Yellow Occult Blood: NEGATIVE Bilirubin: 1+ Reaction: 5.5 SpGravity: 1.020

Leukocytes: NEGAT Pus Cells: 0-2/HPF

Urobilinogen: 0.2 E. U/dl

Ketone: NEGATIVE Protein: 1+ Nitrite: NEGATIVE Glucose: NEGATIVE Method: Urometer 600 Computerized Other Findings: Fine Granular Cast: 0-1/LPF

RBC: 0-2/HPF

Routine Stool Exam

Macro Color: GREEN Occult: NEGATIVE Competency: WATERY Micro: NEGATIFOR INTESTINAL PARASITE (AMOEBA/OVA) PROTHROMBIN TEST (SYSEX) Result: controls value: 12.1 seconds Patients value: 10.5 seconds % activity: 109.0 % INR: 0.91 Remarks: patient N V: 10-14 seconds Control NV: 11.0-15.0 seconds % Activity: 73.1-99.1 % Remarks: SYSEX CA-530

LOWER ENDOSCOPY REPORT:

Procedure: COLONOSCOPY Indication: RECURRENT DIARRHEA Pre-operative Diagnosis: R/O IBD Endoscopic Findings: RECTUMDILATED VESSELS ABOVE DENTATE LINE SIGMOIDNO MASS, NO POLYP NOTED. DES. COLONNO MASS, NO POLYP NOTED TRANS. COLONNO MASS, NO POLYP, NOTED ASC. COLONNO MASS, NO POLYP NOTED CECUMNO MASS, NO POLYP NOTED Anatomic Extent of Examination: CECUM Endoscopic Diagnosis: INTERNAL HEMORRHOIDS

UPPER ENDOSCOPIC REPORT: Procedure: EGD Indication: EPIGASTRIC PAIN, RECURRENT Pre-operative Diagnosis: T/C ACID-PEPTIC DISEASE ENDOSCOPIC FINDINGS: ESOPHAGUSNORMAL CARDIANORMAL FUNDUSNORMAL BODYNO MASS, NO ULCER NOTED ANTRUMERYTHEMATOUS MUCOSA PYLORUSROUND DUODENUM- NORMAL UP TO THE SECOND PORTION OF DUODENUM Anatomical Extent of Examination: SECOND PORTION OF DUODENUM Endoscopic Diagnosis: ANTRAL GASTRITIS

ANATOMY OF THE URINARY SYSTEM

URINARY SYSTEM includes pair organ - kidney (organ producing urine) and organs, which store up and bring out urine (ureters, urinary bladder and urethra). Two Kidneys are pair parenchymatic organs, which positioned in abdominal cavity behind peritoneum (retroperitoneal position) in right and left lumbar regions. Kidney is projected on front abdominal wall in epigastric, lateral and umbilical regions. Right kidney extends from Th 12 vertebra till L 3 lumbar vertebra, left one - from Th 11 vertebra till L 2 lumbar vertebra.

Posterior abdominal wall, after removal of the peritoneum, showing kidneys, suprarenal capsules, and great vessels.

Posterior surface of each kidney in superior part adjoins to diaphragm, and in middle and inferior - to muscular bed, which is formed by muscle: psoas major, quadratus lumborum and transverse abdominis. To anterior surface of left kidney adrenal gland adjoins above, to superolateral part - spleen, to middle portion - stomach and pancreas, inferiorly - medially is loops of small intestine, and superolaterally - colon. To anterior surface of right kidney suprarenal gland adjoins above, to middle part - liver, to medial margin - duodenum, to inferiomedial - loops of small intestine and to inferiolateral - large intestine

Vertical section of kidney.

Each kidney has superior extremity and inferior extremity, anterior surface and posterior surface, medial margin (concave) andlateral margin (convex). On medial margin are situated the renal hilus, where artery, nerves enter, and vein, lymphatic and renalpelvis exit. The renal hilus gets into kidneys, forming a renal sinus, filled by adipose tissue, also major renal calices and minor renal calices and initial part of renal pelvis are present there.