A Case of 45 year-old client with a diagnosis of CKD PRO sec to Chronic Glomerulonephritis Anemia sec to complicated

Urinary tract infection HCVD disease FC III sec to TYPE II Diabetes Mellitus

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN NCM-104B

Presented by:

BSN 3B GROUP 1

Arevalo, Cynthia C.

Baluyut, Rodelyn M.

Britanico, Sophia Patricia H.

Buenaventura, Clark Joseph C.

Bungao, Eiselle Mitch E.

Camalig, Kristine Aira N.

Castillo, Jessa Mae

Causon, Michael

Celiz, Emmanuel Jose M.

 Chiong, Michkaela G.

Manabat, Regina

Santos, Jeremia

Trinh, Tammy

Presented to:

Level III Clinical Instructors

Mrs. Abigail Ramos RN, MAN

Mrs. Maria Socorro Tolentino RN, MSN

Mrs. Racquel Espinosa RN, MAN

Mrs. Luzviminda Reyes RN, MAN

Introduction

This is a case of CPL JCM, 45 years old, male, Filipino, admitted in the institution on January 28, 2017. The patient is known hypertensive for 5 years with the
highest BP of 190/100 and usual BP of 130/80, poorly compliant to Nifedipine. Patient is also a known case of Diabetes for 7 years, maintained on Metformin
500mg, 1tab BID. Patient was admitted at the institution last January 2015 with an initial diagnosis of CKD stage V secondary to Chronic Glomerulonephritis,
Hypertensive Cardiovascular Disease FCII, Type 2 Diabetes Mellitus.

Statistics
CPL JCM is among the 1.2 million Filipinos who is suffering from renal diseases in the country today, requiring either dialysis for them to live.

According to the Department of Health, renal disease is now one of the top ten causes of death among Filipinos. In fact, seven thousand patients die annually due to
kidney malfunction in the country. It is alarming that the prevalence of renal diseases has been increasing especially at the end-stage.

The Philippines is one of the countries with a high risk population when it comes to renal disease because of numerous cases of diabetes, high blood pressure and
other hereditary diseases, all of which can lead to kidney malfunction and even heart attack. In fact, among the leading causes of kidney failure in the country are
diabetes (41%), inflammation of the kidney (24%) and high blood pressure (22%).

Worldwide, there is also an alarming level of renal disease with more than 500 million persons, about 10% of the adult population, suffering from some form of
damage to the kidneys. Over 1.5 million of them are kept alive either through dialysis or kidney transplant. Every year, over 12 million individuals die prematurely
of cardiovascular diseases linked to chronic renal disease. The numbers are rapidly increasing with the global epidemic of diabetes mellitus.

Chronic kidney disease (CKD) is a condition characterized by a gradual loss of kidney function over time. To read more about kidney function, see How Your
Kidneys Work. CKD is also known as chronic renal disease.

Chronic kidney disease includes conditions that damage your kidneys and decrease their ability to keep you healthy by doing the jobs listed. If kidney disease gets
worse, wastes can build to high levels in your blood and make you feel sick. You may develop complications like high blood pressure, anemia (low blood count),
weak bones, poor nutritional health and nerve damage. Also, kidney disease increases your risk of having heart and blood vessel disease. These problems may
happen slowly over a long period of time. Chronic kidney disease may be caused by diabetes, high blood pressure and other disorders. Early detection and treatment
can often keep chronic kidney disease from getting worse. When kidney disease progresses, it may eventually lead to kidney failure, which requires dialysis or a
kidney transplant to maintain life.
Since the 1950s, kidney disease has been clearly recognized as a common complication of diabetes mellitus (DM), with as many as 50% of patients with DM of
more than 20 years duration having this complication.
United States statistics
Diabetic nephropathy rarely develops before 10 years duration of type 1 DM (previously known as insulin-dependent diabetes mellitus [IDDM]). Approximately
3% of newly diagnosed patients with type 2 DM (previously known as noninsulin-dependent diabetes mellitus [NIDDM]) have overt nephropathy. The peak
incidence (3%/y) is usually found in persons who have had diabetes for 10-20 years, after which the rate progressively declines.
The risk for the development of diabetic nephropathy is low in a normoalbuminuric patient with diabetes duration of greater than 30 years. Patients who have no
proteinuria after 20-25 years have a risk of developing overt renal disease of only approximately 1% per year.
In terms of diabetic kidney disease in the United States, the prevalence increased from 1988-2008 in proportion to the prevalence of diabetes. [11] Among people with
diabetes, the prevalence of diabetic kidney disease remained stable.
International statistics
Striking epidemiologic differences exist even among European countries. In some European countries, particularly Germany, the proportion of patients admitted for
renal replacement therapy exceeds the figures reported from the United States. In Heidelberg (southwest Germany), 59% of patients admitted for renal replacement
therapy in 1995 had diabetes and 90% of those had type 2 DM. An increase in end-stage renal disease (ESRD) from type 2 DM has been noted even in countries
with notoriously low incidences of type 2 DM, such as Denmark and Australia. Exact incidence and prevalence from Asia are not readily available.
A study from the Netherlands suggested that diabetic nephropathy is underdiagnosed. Using renal tissue specimens from autopsies, Klessens et al found
histopathologic changes associated with diabetic nephropathy in 106 of 168 patients with type 1 or type 2 diabetes. However, 20 of the 106 patients did not during
their lifetime present with the clinical manifestations of diabetic nephropathy.

Background of the disease

Diabetic nephropathy -- kidney disease that results from diabetes -- is the number one cause of kidney failure. Almost a third of people with diabetes develop diabetic
nephropathy.
People with diabetes and kidney disease do worse overall than people with kidney disease alone. This is because people with diabetes tend to have other long-standing
medical conditions, like high blood pressure, high cholesterol, and blood vessel disease (atherosclerosis). People with diabetes also are more likely to have other kidney-
related problems, such as bladder infections and nerve damage to the bladder.
Kidney disease in type 1 diabetes is slightly different than in type 2 diabetes. In type 1 diabetes, kidney disease rarely begins in the first 10 years after diagnosis of
diabetes. In type 2 diabetes, some patients already have kidney disease by the time they are diagnosed with diabetes.

GENERAL OBJECTIVES
The foremost objective of this case study is to obtain a broad understanding and learning about Chronic kidney disease (CKD) through completing the
necessary action regarding the knowledge , skills and attitude and data for this case study.

SPECIFIC OBJECTIVES (KSA)

KNOWLEDGE

Increase knowledge about the disease.

Learn the probable cause, signs and symptoms of chronic kidney disease.
Have a further knowledge about this complication and how it can occur.

SKILLS

Learn and experience new clinical skills, as well as enhancing our current clinical skills.
Formulate and apply nursing care plan utilizing nursing process.
Develop our nursing responsibilities.

ATTITUDE

Observe and understand the behavior of client having Chronic Kidney disease.
Give proper care and build a genuine nurse-patient relationship conducive to good health.
Develop our unselfish love and empathy rendering nursing care to our patient so that we may able to serve future clients with higher level of holistic
understanding, as well as individualized care.

A. Biographic Data

Name: Mr. J.M

Age: 45
Sex: Male
Address: Hinabangan Western Samar
Birthdate: December 8 1971
 Marital Status: married
Occupation: Soldier
Religion: Roman Catholic
Educational Attainment: H.S.G
Health Care Financing: Wife: Vendor

B. Reason for Visit

Dito na talaga ako nagpapatingin pag may nararamdamn ako at dito ako nagpapa-dialysis. As verbalized by the client.
C. History of Present Illness/Condition

The patient is known hypertensive for 5 years with the highest BP of 190/100 and usual BP of 130/80, poorly compliant to Nifedipine. Patient is also a
known case of Diabetes for 7 years, maintained on Metformin 500mg, 1tab BID. 10 days prior to admission, patient complained of loose bowel movement,
watery, non-bilous, non-foul smelling associated with undocumented fever. Patient also complained of 1 week history of productive cough with whitish
phlegm with no associated night sweats, hemoptysis or weight loss.
LEGEND

FEMALE MALE CLIENT

D. History of Past Illness
According to Mr. JPM he did not have any past illness except for hypertension and diabetes.

DECEASED
D. FAMILY HEALTHHYPERTENSIVE
HISTORY (GENOGRAM-3RD GENERATION)
HPN
RM MM
HPN HPN

HCVD DM kidney
 JPM

HPN

45 y/o

JM JM JM JM

9 Y/O 13 Y/O 16 Y/O 18 Y/O

E. Growth and Development

PSYCHOSOCIAL PSYCHOSEXUAL COGNITIVE MORAL SPIRITUAL

STAGE
 MIDDLE-AGED ADULT
Generativity vs. Self absorption or
Stagnation Care
Career and work are the most
important things at this stage, along
with family. Middle adulthood is also
the time when people can take on
greater responsibilities and control.
For this stage, working to establish
stability and Eriksons idea of
generativity attempting to produce
something that makes a difference to
society. Inactivity and
Description meaninglessness are common fears
Genital
Puberty and after
Energy is directed toward full
sexual maturity and function and
development of skills needed to
cope with the environment.
Encourage separation from
parents, achievement of
independence, and decision-
making.
Sigmund Freud (1856-1939) the
personality develops in five
overlapping stages from birth to
adulthood. The libido changes its learn to think reason and
location of emphasis within the use language. It involves a
body from one stage to another.
Formal operation phase
Growth may be promoted
by major life events (such
as entry into a new career the family, group, nation, or
or the birth of a child) or
by brain growth (such as
the development of the
frontal lobe) or, perhaps,
by interaction of nature
and nurture
Piagets theory of
cognitive development is a
manner which people reasoning is a process that
persons intelligence,
Adolescence and Adulthood Individualizing -
reflexive
Conventional Person is
concerned with maintaining
expectations and rules of Constructing ones own
explicit system; high
society. The person values degree of self-
conformity, loyalty, and consciousness.
active maintenance of
social order and control.
Law and order orientation -
The person wants
established rules from
authorities and the reasons
for decisions are that social
and sexual rules and
traditions demand response.
Lawrence Kohlbergs James W. Fowler
theory holds that moral describes the
development of faith as a
is principally concerned force that gives meaning
with justice and that it to a persons life. He
continued throughout the believes that the
 during this stage. Therefore a particular body area perceptual ability and individuals lifetime. development of faith is
has special significance to a ability to process Learning what ought to be an interaction process
client at particular stage. information. and ought not to be done. between the person and
the environment.

Findings & Before getting sick he averages
Analysis about 3 intercourses a week with
his partner. Now that his sick his
do not having intercourse with
her wife. Hes not living with
her parents bacause he is the
hospital.
He understands all of our
questions and He answers
clearly and straight to the
point
Mr. J.M is married and He Our client is Roman
knows his responsibilities Catholic. he said that he
in their family. doesnt go to church
often but he prays daily.
Mr. J.M and her partner
is marriend

F. THEORETICAL APPLICATION
 THEORY THEORIST DESCRIPTION
The adult stage of generativity has broad application to family,
Stages of Erik Erickson relationships, work, and society. Generativity, then is primarily the
Psychosocial concern in establishing and guiding the next generation... the concept
Development is meant to include... productivity and creativity." During middle age
the primary developmental task is one of contributing to society and
helping to guide future generations. When a person makes a
contribution during this period, perhaps by raising a family or working
toward the betterment of society, a sense of generativity- a sense of
productivity and accomplishment- results. In contrast, a person who is
self-centered and unable or unwilling to help society move forward
develops a feeling of stagnation- a dissatisfaction with the relative
lack of productivity.
APPLICATION TO THE CLIENT
Mr. JCM has already established a sense of
generativity because he has a good
relationship with his family especially his
wife and children. He worked hard for his
family, to give them a good future and make
his children a responsible individual when
the time comes.

Though conservation of physical and emotional well-being is the most

Conservation Myra Levine vital part of attaining a successful outcome for patients, two additional
Theory Mr.JCM has established an acceptance on his
concepts, adaptation and wholeness, are also extremely important in a
patient's health; condition. At first, it was hard for him to
adapt with changes in his environment and
Adaptation- adaptation consists of how a patient adapts to the his body but as time passes by, he was able to
accept them. With this, responding to
realities of their new health situation- the better a patient can adapt
treatment and care has been easy for him as
to changes in health, the better they are able to respond to
well as his health care providers. Client
treatment and care.
conserves energy by sleeping and having
naps every day. With the energy he has, he
Wholeness - the concept of wholeness maintains that a nurse
can do simple exercises which are helpful for
must strive to address the client's external and internal
the functioning of his body.
environments. This allows the client to be viewed as a whole
person, and not just an illness.

Conservation -the product of adaptation; Conservation

describes the way complex systems are able to continue to
function even when severely challenged. Conservation allows
individuals to effectively respond to the changes their body faces,
while maintaining their uniqueness as a person.
Patients will be assessed for challenges to their external and internal
Gordons Approach
FUNCTIONAL HEALTH PATTERN (GORDON APPROACH)
A. Health Perception and Management:
B. Nutritional metabolic:
The client feels pain, he rates his pain 7/10.Mr. JM states that he feels pain on
his chest. He described the pain as needles piercing him. Client has anacquired
diabetes he said he got if from the food he is eating when he was younger. Client
drinks liquor and smoked for 10 years starting at the age 12 and ended at the age
of 22. The most recent cold of the client was last January 28, 2017. He got into
an accident when riding his motorcycle. He said that eating healthy foods is the
best way to preserve life. For JM, being healthy is important. It is his way of
showing his love to his family because being healthy prolongs life and having a
long life means you get to stay with your family longer.
72-Hour Diet Recall
Day 1- March 5
Day 2- March 6
Day 3- March 7
 Breakfast Lunch Dinner

Day 1 One cup of Rice One cup of Rice One cup of Rice
One piece of One small bowl One small bowl
Galungong of ginataang puso of ginisang sitaw
50 ml of water ng saging 40 ml of water
60 ml of water
Day 2 One cup of Rice One cup of Rice One cup of Rice
Once small bowl One leg part of One small bowl
of chapsuey chicken of ginisang
60 ml of water 40 ml of water ampalaya
50 ml of water
Day 3 One cup of Rice One cup of Rice One cup of Rice
One small bowl One piece of One leg part of
of Cornbeef galungong chicken
55 ml of water 60 ml of water 50 ml of water

C. Elimination Frequency Description

Urine Usually 3 times a day
Stool Usually 1 times a day
-Client voids in the
comfort room.
-States that his urine is
foamy, tea color,
aromatic, and no pain is
felt
- Client states that his
stool is brown and
sometimes its hard for
 him to eliminate waste
because of the solid
foods he is eating.
D. Activity and Exercise Mr. JM states that singing is his way of releasing stress.
Walking around the ward is his exercise and barely flexes and rotate his arm as
way of exercising.
E. Sleep Rest Client states that its hard for him to sleep at night.
He usually sleeps at 8:00 in the evening and usually wakes up between
4:00 to 5:00 in the morning.
Usually takes nap after lunch for 2-4 hours.

F. Cognitive Perceptual Client states that his vision is blurry especially when reading small letters.
Doesnt have hearing difficulties and hasnt noticed changes in his sense of
hearing. He experiences pain very often, rating is 7/10. States that he experiences
pain on his chest, hips area and below his axillary region. Triggering factors are
when breathing deeply and coughing.
G. Self-Perception Client states that despite his situation, he is still thankful that he is alive. Health
is very important for him because it is the act of showing his love to his family.
Though sometimes, it is hard for him to cope up because of weakness and pain,
he still is motivated to recover because he wants to be with his family.
H. Role-Relationship Mr. JM is married and has 4 children. His wife works 2 times a week to help him
with the finances at home. His family means so much to him thats why he wants
to recover soon. Both of his parents manifest hypertension. He states that he
easily get annoyed because of his hypertension.
 Anatomy of the Urinary System

The two kidneys lie to the sides of the upper part of the tummy (abdomen), behind the intestines and either side of the spine. Each kidney is about the size of a large
orange but bean-shaped.

A large artery - the renal artery - takes blood to each kidney. The artery divides into many tiny blood vessels (capillaries) throughout the kidney. In the outer part of
the kidneys, tiny blood vessels cluster together to form structures called glomeruli.
 Each

glomerulus is like a filter. The structure of the glomerulus allows waste

products and some water and salt to pass from the blood into a tiny channel
called a tubule whilst keeping blood cells and protein in the bloodstream.

Each glomerulus and tubule makes up a nephron. There are about one million nephrons in
each kidney.
 As the waste products and water pass along the tubule there is a complex adjustment of
the content. For example, some water and salts may be absorbed back into the
bloodstream, depending on the current level of water and salt in your blood. Tiny
blood vessels next to each tubule enable this 'fine tuning' of the transfer of water and
salts between the tubules and the blood.

The liquid that remains at the end of each tubule is called urine. This drains into larger channels (collecting ducts) which
drain into the inner part of the kidney (the renal pelvis). The urine then passes down a tube called a ureter which goes
from each kidney to the bladder. Urine is stored in the bladder until it is passed out when we go to the toilet.

The 'cleaned' (filtered) blood from each kidney collects into a large vein - the renal vein - which takes the blood back towards the heart.

Functions of the kidneys:

remove waste products from the body

remove drugs from the body

balance the body's fluids

 release hormones that regulate blood pressure

produce an active form of vitamin D that promotes strong, healthy bones

control the production of red blood cells

Review of the Patients SGPT/ALT 20.93 U/L 45

I. Diagnosis: CKD Pro Sec. to Chronic Glomerulonephritis, Anemia Sodium 139 mmol/L 135-148
Sec. Complicated UTI, HCVD Disease FCIII, Type 2 DM Potassium 4.1 mmol/L 3.5-5.3
Magnesium 1.03 mmol/L 0.73-1.06
II. Urine and Creatinine Test
Test Name Result Unit Flag Ref. Range
Blood Urea 36.32 mmol/L H 2.5-7.2
Nitrogen
Creatinine 1481.50 umol/L H 71.115
Blood Uric 710.62 umol/L H 208.0-428
Acid
Albumin 33.00 g/L L 35-52
 (+)HPN,5years, maintained (+) PTB, paternal Smoker, 14 pack years
on Nefedipine (+)Kidney (stopped 2003)
Ionized AVL 1.12-1.32 (+)DM, 7years, maintained disease,Paternal
Calcium 1.14 mmol/L
on Metformin (-)HPN Occasional alcoholic
GFR = 3.8 BP = 140/90 mmHg
(-)Thyroid disease (-)DM beverage 2-3x/week
III. History of Present Illness (-)BA (-)malignancy (stopped 2003)
(-)Allergy
Past Medical History Family History Personal and Social (-)PTB Denies any illicit drug use
History

IV. Complete Blood Count Result related to Anemia

RESULTS REF. RANGE UNIT

Hemoglobin 92.20 130-180 g/L
Hematocrit 0.305 0.40-0.50 g/L
 PATHOPHYSIOLOGY OF THE FACTORS CONTRIBUTING TO CKD

Diabetes Mellitus Type 2

"Diabetes mellitus," more commonly referred to as "diabetes," is a condition that causes blood sugar to rise to dangerous levels: fasting blood glucose of 126
milligrams per deciliter (mg/dL) or more.

After eating a meal, the food is broken down by the digestive system and blood sugar (or glucose) rises. The pancreas is an organ that produces a hormone called
insulin. With the help of insulin, the body's cells take up the glucose and use it for energy. When your body does not produce enough insulin and/or does not
efficiently use the insulin it produces, sugar levels rise in the bloodstream. When this happens, it can cause two problems:

1. Right away, the body's cells may be starved for energy.

2. Over time, high blood glucose levels damage the eyes, kidneys, nerves or heart.

Type 2 Diabetesis the most common form of diabetes. diagnosed primarily in adults.The body develops "insulin resistance" and can't make efficient
use of the insulin it makes, and the pancreas gradually loses its capacity to produce insulin.
Diabetes link to Kidneys disease:
 Chronic hyperglycemiais thought to be the primary cause of diabetic
nephropathy

Glomerular hyperfiltration:
o Glomerular hyperfiltration is mediated mainly via dilatation the
afferent arteriole leading to a rise in the GFR and the renal blood flow.
Hyperglycemia and high insulin-like growth factor-1
(IGF-1) concentrations (observed in diabetic patients) both are
hypothesized to cause a rise in the GFR increasing renal flow
Hyperfiltration of glucose leads to augmented sodium-
glucose transport in the proximal convoluted tubule causing
enhanced sodium transport
Cause expansion of blood volume which leads
to a rise in GFR
The rise in proximal reabsorption also leads to a
reduced distal fluid delivery which activates the
tubuloglomerular feedback with the renin-angiotensin system
which works to raise the GFR as well.
Hyperglycemia and AGE:
o Hyperglycemia and AGE directly induce mesangial matrix
production, cellular expansion and apoptosis.
o The two have also been shown to increase basement membrane
permeability to albumin.
Cytokines:
o Elevations in vascular endothelial growth factor (VEGF),
transforming growth factor beta (TFG-), and profibrotic proteins
increase damage to the nephrons at different levels.
 Hypertension Cardiovascular Disease FCIII

Hypertension link to Kidney disease:

Glomerular and vascular changes:

1. Elevated systemic blood pressures cause a hypertrophic response leading
to intimal thickening of the large and the small vasculature.
2. The mechanisms are compensatory at first, but later lead to glomerular
damage
Global sclerosis ischemic injury to the nephrons causes death
Focal segmental sclerosis glomerular enlargement for
compensation of the loss of nephrons in other areas of the kidney.

Interstitial nephritis:
1. The vascular and glomerular disease lead to tubular atrophy and an
intense chronic interstitial nephritis
The intense chronic interstitial nephritis is thought be secondary to
immunologic processes against ischemia-mediated antigen
changes on the tubular epithelial cell surface.

Chronically these changes lead to tubular and glomerular loss
causing nephrons loss.
1. With the death of some nephrons, less are available to maintain the GFR.
2. Gradual decline in the GFR is noticed as the nephrons continue to die.

Urinary Tract Infection

 A urinary tract infection is a bacterial infection that
grows within the urinary tract - anywhere from
the kidneys, the ureters, the bladder and through to the
urethra.
Common Complicated UTI in Diabetic Patient:
Causative agent (E.coli)

Emphysematous pyelonephritis a severe,

necrotizing form of multifocal bacterial nephritis
with gas formation within the renal parenchyma
Emphysematous pyelitis the presence of gas
localized to the renal collecting system.
Emphysematous cystitis occurs rarely,
characterized by pockets of gas in and around the
bladder wall produced by bacterial or fungal
fermentation

Kidney disease link to UTI:

This is due to the presence of glycosuria, neutrophil

dysfunction, increase bacterial growth to the uroepthelial
cells, metabolic control, nephropathy, bladder not fully
emptying, resistance of pathogen.

 Anemia

Anemia is a condition in which your blood has a lower than normal number
of red blood cells. Anemia also can occur if your red blood cells don't
contain enough hemoglobin Hemoglobin is an iron-rich protein that gives
blood its red color. This protein helps red blood cells carry oxygen from the
lungs to the rest of the body.

Kidney disease link to Anemia:

The interstitial fibroblast cells in the kidneys make an important hormone
called erythropoietin (EPO). The kidney cells that make erythropoietin are
sensitive to low oxygen levels in the blood that travels through the kidney.
These cells make and release erythropoietin when the oxygen level is too
low. A low oxygen level may indicate a diminished number of red blood
cells in the body. EPO will signal your bone marrow to make red blood
cells. When you have kidney disease, your kidneys cannot make enough
EPO due to the damaged tissues and cells. Low EPO levels cause your red
blood cell count to drop and anemia to develop.

Chronic Glomerulonephritis (CGN)

 Chronic glomerulonephritis is caused by slow, cumulative damage and
scarring of the tiny blood filters (glomeruli) in the kidneys. These filters,
known as glomeruli, other terms used are nephritis and nephrotic
syndrome. When the kidney is injured, it cannot get rid of wastes and extra
fluid in the body. If the illness continues, the kidneys may stop working
completely, resulting in kidney failure.
Secondary Cause of CGN isdiabetic nephropathy

CGN link to CKD

-Altered basement membrane composition with loss of heparin sulfate that
forms the negatively charged filtration barrier.
-Mesangial matrix expansion due to accumulation of the extracellular
matrix (ECM).
-Vascular changes with hyaline and hypertensive arteriosclerosis.

Chronic Kidney Disease (Stage 5)

 Progressive loss of renal functions over time; based on a gradual decline
in the GFR and creatinine clearance. The diagnosis of CKD requires the
following:
1. Decline of kidney function for 3 months or more AND
2. Evidence of kidney damage (e.g. albuminuria or abnormal biopsy) OR
GFR <60 mL/min/1.73 m2

Two main categories of Kidney damage:

Microalbuminuria: in this condition, the amount of albumin that leaks

into the urine is between 30 and 300 mg per day. It is also called
incipient nephropathy.

Proteinuria: in this condition the amount of albumin that leaks into the
urine is more than 300 mg per day. It is also called macroalbuminuria or
overt nephropathy.

Each patient is classified into one of the following 5 stages

of CKD because management and prognosis varies according to the
progression of damage.
Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73
m2)
Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m2)
Stage 3: Moderate reduction in GFR (30-59 mL/min/1.73 m2)
Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m2)
Stage 5: Kidney failure (GFR <15 mL/min/1.73 m2 or dialysis)




DIAGNOSTIC TESTS FOR CKD

Early detection and treatment of chronic kidney disease are the keys to keeping kidney disease from
progressing to kidney failure.

1. A test for protein in the urine. Albumin to Creatinine Ratio (ACR), estimates the amount of a albumin that is
in your urine. An excess amount of protein in your urine may mean your kidney's
filtering units have been damaged by disease. One positive result could be due to
fever or heavy exercise, so your doctor will want to confirm your test over several
weeks.
2. A test for blood creatinine. Your results, along with your age, race, gender and
other factors, to calculate your glomerular filtration rate (GFR).

 TERMINOLOGIES

1. An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel. The embolus may be a blood clot (thrombus), a fat
globule, a bubble of air or other gas (gas embolism), or foreign material. An embolismcan cause partial or total blockage of blood flow in the affected
vessel.

2. Lipiduria or lipuria is the presence of lipids in the urine. Lipiduria is most frequently observed in nephrotic syndrome where it is passed as lipoproteins
along with other proteins. It has also been reported as a sign following fat embolism.
3. The reninangiotensin system (RAS) or the reninangiotensinaldosterone system (RAAS) is a hormone system that is involved in the regulation of the
plasma sodium concentration and arterial blood pressure.

4. The Renin-Angiotensin-Aldosterone System (RAAS)

Your body has a huge system involved in the sensation and control of blood pressure, not only within the kidneys, but all over the body - especially in times
of great need. This is in contrast to a smaller system called tubuloglomerular feedback, which you can think of as the system that senses and controls blood
pressure and glomerular filtration rate within the kidneys on a moment-by-moment basis. When called upon, this smaller system can also rev up the really
big system I'm about to get into. So, what is this really big system?
Could I get a drumroll? The most important system involved in the regulation of systemic blood pressure, renal blood flow and glomerular filtration rate is
called the renin-angiotensin-aldosterone system, or (RAAS) for short.
 The Release of Renin

When systemic hypotension, or low blood pressure throughout the body, occurs, receptors in your blood vessels called baroreceptors sense this change. Cells
of the kidney's juxtaglomerular apparatus get involved as well. Detection by one or both of these mechanisms leads juxtaglomerular cells in the kidneys to
release an enzyme called renin. Renin is an enzyme released by the juxtaglomerular cells of the kidneys in response to low blood pressure, causing the
transformation of angiotensinogen to angiotensin I.

Angiotensinogen & Angiotensin I

Angiotensinogen is a precursor protein made in the liver for a hormone called angiotensin I. Essentially, renin catalyzes a reaction that converts the
angiotensinogen protein into angiotensin I, which is a precursor hormone that is converted to an active hormone called angiotensin II by an enzyme known
as angiotensin-converting enzyme in the lungs. Wow, that was a mouthful! Let's break this down.
Here's how to remember what becomes what. Angiotensinogen's purpose is to serve as a precursor to angiotensin I. Angiotensinogen is cleaved, or broken
apart, by renin. Since it's broken apart, it gets smaller and becomes shorter in name as well. Therefore, it's now called plain old angiotensin I. Angiotensin I
decides to have a little kid and name it after itself. Therefore, when angiotensin I is converted in the lungs by an enzyme called ACE, it becomes angiotensin
junior - or more technically, angiotensin II.

Angiotensin I is converted into angiotensin II

in the lungs by the enzyme ACE
5. Angiotensin-Converting Enzyme (ACE) & Angiotensin II

It bears repeating that the angiotensin-converting enzyme, or ACE for short, is an enzyme located mainly in the lungs that converts angiotensin I into
angiotensin II. Once angiotensin II is made, it can have a big effect on the body. Namely, angiotensin II is a vasoconstrictive hormone that increases
systemic blood pressure, renal perfusion pressure and the glomerular filtration rate.
Angiotensin II not only constricts blood vessels all over the body in order to increase systemic blood pressure, it also works in the kidneys in order to
maintain blood pressure in the glomerulus so that the glomerular filtration rate stays normal even in the face of low blood pressure.

6. Control of the Glomerular Filtration Rate (GFR) by the RAAS

Let's see how this works with a familiar example. If you connect a hose to a faucet and turn the faucet on, a certain pressure will be exerted by the water on
the walls of the hose. Likewise, blood running through the glomerulus (our hose) does the same thing. If the faucet is turned down a bit due to hypotension,
there is less water running through the hose and therefore less pressure being exerted on the hose. If this were to happen in our glomerulus due to
hypotension, this would be very bad. We need to maintain pressure in the glomerulus at a certain level if we want to filter our blood enough to stay alive.
To maintain pressure in the glomerulus and therefore keep the glomerular filtration rate steady, angiotensin II constricts both the efferent and afferent
arteriole, but with a much greater effect on the efferent arteriole. Remember, the effect of angiotensin II is greater on the efferent arteriole. This means that
the blood entering the glomerulus has a much harder time leaving it because the exit is far smaller than the entrance. This causes a backup of blood in the
glomerulus, increases the pressure within it and, therefore, keeps the GFR at an appropriate rate.

Angiotensin II constricts the afferent and

efferent arterioles.

In addition, angiotensin II increases the absorption of sodium in the renal tubule. Since water follows sodium, it increases the amount of fluid in the blood
vessels, further causing an increase in blood pressure in addition to the vasoconstriction that already occurred.
7. Aldosterone

Angiotensin does some other important things that you must remember. It causes the release of a hormone called aldosterone from the adrenal glands.
Aldosterone is a hormone that increases the absorption of water from the distal convoluted tubule and collecting duct of the kidney's nephrons.
Aldosterone has many other functions, including the secretion of potassium into urine. However, for this lesson, you should understand that aldosterone
causes the absorption of sodium out of the renal tubule's filtrate and into the blood. Since water follows sodium, more water is reabsorbed back into the
blood in order to increase the blood pressure.

8. Definition of SCLEROSIS

- pathological hardening of tissue especially from overgrowth of fibrous tissue or increase in interstitial tissue; also : a disease characterized
by sclerosis
-an inability or reluctance to adapt or compromise

9. Medical Definition of ONCOTIC PRESSURE

the pressure exerted by plasma proteins on the capillary wall

10. Definition of ATHEROMA

-an abnormal fatty deposit in an artery

-fatty degeneration of the inner coat of the arteries

11. Medical Definition of ATHEROSCLEROSIS

- an arteriosclerosis characterized by atheromatous deposits in and fibrosis of the inner layer of the arteries
 12. Cytokines

Your body is made up of trillions of cells. These cells are basic units of life; they carry out all the vital functions that keep you alive. But did you know that
your cells lead very active social lives? Take the cells of your immune system, for instance. These cells are constantly sending out signals to let other cells
know what's going on. To communicate, your immune cells use cytokines, which are a group of proteins secreted by cells of the immune system that act as
chemical messengers.
Cytokines released from one cell affect the actions of other cells by binding to receptors on their surface. You can think of these receptors as mailboxes. They
receive the cytokine's chemical message, and then the receiving cell performs activities based on that message.
There are different types of cytokines, including chemokines, interferons, interleukins, lymphokines and tumor necrosis factor. They can act alone, work
together or work against each other, but ultimately the role of cytokines is to help regulate the immune response. Cytokines are involved in many aspects of
inflammation and immunity. In fact, you can blame the different cytokines for triggering some familiar symptoms that arise when your body fights an
infection, such as fever, inflammation and pain.

13. Chemokines

Chemokines are a type of cytokines that call in cells to the site of infection. You might recall that the ability to call in other cells using a chemical message is
a process referred to as chemotaxis. This fact shows us how this type of cytokine gets its name; chemokines induce chemotaxis. Chemokines are the
coordinators of the battle. For example, when a foreign substance is detected, chemical orders are sent out to immune cells, including various white blood
cells. These cells then travel toward the area to eliminate the threat.

14. Interferons

Interferons are proteins that inhibit viruses from replicating. If a cell gets invaded by a virus, it releases interferons. This signals other cells to put up their
shields so the virus does not spread. So, interferons interfere with the spread of a virus. Interferons also activate natural killer T-cells. These cells further the
fight against the virus by destroying infected cells.

 PHYSICAL ASSESSMENT

Name: JM

Age: 45 years old

Date: March 6, 2017

Vital signs:

NORMAL FINDINGS ACTUAL FINDINGS REMARKS

Blood Pressure 120/90 mmHg 140/90mmHg Deviation from Normal;

Hypertension may occur due
to interference with renin-
angiotensin-aldosterone
system
Pulse rate 60-100 bpm 102bpm Deviation from normal;
Arrhythmia due to increased
cardiac workload
Respiratory rate 12-20 19 cpm Normal

Temperature 36.5-37.5 C 36.5 C Normal

 BODY PART
TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS REMARKS
ASSESSED

A.GENERAL
APPERANCE

Body built
Height: 155 cm Deviation from

Inspection Proportionate Weight: 62 kg Normal; Overweight
Bmi: 25.8
Height and

weight

Inspection Relaxed, erect posture Relaxed, erect posture Normal
Posture

Coordinated Normal
Gait Inspection Coordinated movements

Dress, grooming
Inspection Clean, neat Well groomed Normal
and hygiene

Obvious physical The client looks healthy

Inspection Healthy in appearance Normal
deformities and does not have any
signs of illness


B. MENTAL
STATUS

Level of Responsive; responds to Responds correctly and

Inspection Normal
consciousness questions clearly and clearly in regards to the
questions being asked.
Appropriate
Orientation Inspection Cooperative Normal
Cooperative\

No signs of distress noted

Emotional status Inspection Appropriate to situation Normal
upon assessment, well-
oriented
Language and Understandable; exhibits Relevant, good in
Inspection Normal
communication thought association communication when
talked to


C. SKIN

Varies from light to dark Skin is brown in color,

Skin color Inspection Normal
brown rough dry and warm.

Generally uniform in color

Skin uniformity Inspection except in areas exposed to Brownish in color Normal
the sunlight

Presence of Inspection No edema Edema are present on left Deviation from

and right foot Normal; due to extra
 edema fluid and sodium in
circulation
Inspection and Brownish in color
Skin lesions No abrasions or other lesions Normal
palpation discolorations that
resembles freckles
Inspection and Moisture in skin folds and
Skin moisture Moisture in skin folds and
palpation axillae Normal
axillae
Uniform within normal range
Skin temperature Palpation Uniform within normal
of 36.5 - 37.5 C Normal
range of 36.5 - 37.5 C
When pinched, skin springs It goes backs in 3seconds,
Skin turgor Inspection Normal
back to previous state when we pinched his
skin.
D. NAILS

Fingernail plate Convex curvature, about 160

Inspection Convex curvature, about
shape degree Normal
160 degree
Color Inspection Pinkish in color
Deviation from Normal
Pale ( Anemia )
Fingernail and
Inspection Smooth texture
Deviation from Normal
toenail texture Rough texture
Tissue
Inspection Intact epidermis Intact epidermis Normal
surrounding nails

Capillary refill Inspection Prompt return of usual color Prompt return of usual
Normal
color


E. HEAD AND
FACE

Normal cephalic and Normal cephalic and

Size and shape of symmetrical; smooth
Inspection symmetrical; smooth skull Normal
skull skull contour
contour

Smooth; uniform Smooth; uniform
consistency; absence of consistency; absence of Normal
Masses and
Palpation nodules or masses nodules or masses
nodules

Hair is dry in texture; its

color black with minimal
Hair growth and Inspection and
Few hair grow; smooth streaks of gray. Scalp is
texture palpation Normal
clear from dandruff and
lice.

Symmetrical facial
Face ( symmetry Symmetrical facial features features and movements;
Inspection Normal
and movement) and movements; coordinated coordinated



F. EYES

Hair evenly distributed;

Eyebrows Inspection skin intact; eyebrows No distress noted

Normal
symmetrically aligned; equal
movement

Hair evenly distributed;

Eyelashes Inspection
Normal
curled slightly outward curled slightly outward
Skin intact; no discharge; no Skin intact; no discharge;
Eyelids Inspection discoloration; lids closed no discoloration; lids Normal
symmetrically closed symmetrically

Less than 2 involuntary
Blink response Inspection blinks per minute; bilateral 18 involuntary blinks per
Normal
blinking minute

Deviation from
Conjunctiva Inspection and Bulbar: pinkish or reddish;
Pale bulbar conjunctiva normal; pale
( bulbar) palpation capillaries sometimes evident conjunctiva may be
caused by CRF anemia
Deviation from
Conjunctiva Inspection and Palpebral; shiny; smooth; Pale palpebral conjuctiva normal; pale
( palpebral) palpation pink or red conjunctiva may be
caused by CRF anemia
Sclera Inspection Transparent, clear
Normal
Transparent, clear
Cornea and iris Inspection Cornea: transparent; shiny Cornea: transparent; shiny Normal

Iris: visible, varies in color
Black in color; equal in size;
round; briskly reactive to
light and accommodation
Pupils Inspection reaction to light; illuminated
pupils constricts( direct
response); no illuminated
pupil constricts ( consensual
response)
Iris: visible, varies in
color
Black in color; equal in
size; round; briskly
reactive to light and
accommodation reaction
to light; illuminated
Normal
pupils constricts( direct
response); no illuminated
pupil constricts
( consensual response)

Lacrimal Inspection and No edema or tearing

No edema or tearing Normal
apparatus palpation

Both eyes coordinate, move

Alignment and Both eyes coordinate,
Inspection in unison and with parallel Normal
coordination move in unison and with
alignment
parallel alignment

Extraocular Both eyes coordinated in Both eyes coordinated in
Inspection Normal
muscle union with parallel alignment union with parallel
alignment
When looking straight ahead,
Peripheral visual When looking straight
Inspection the client can see object in Normal
fields ahead, the client can see
the periphery. object in the periphery.
 Near vision Inspection Able to read newsprint Able to read newsprint Normal
Distant vision Inspection 20/20 vision on snellen chart Not Done Not Done
G. EAR

Color same as facial skin;

Color same as facial skin;
symmetrical; aligned with
symmetrical; aligned with the the outer cantus of the
Inspection and outer cantus of the eye;
Auricles eye; recoils back when its Normal
palpation recoils back when its folded; folded;
mobile and firm mobile and firm

Pearly gray in color; distal
part has hair follicle;
External canal Inspection presence of small amount of Pearly gray in color
Normal
waxes but no redness or
discharge

Hearing acuity Inspection Normal voice tones audible Normal voice tones
Not Done
audible
Webers test Inspection Hear in both ears Not Done Not Done
Air conduction is heard
Rinnes test Inspection Not Done Not Done
loudly than bone conduction

H. NOSE
 Symmetric and straight; no Symmetric and straight;
External Inspection discharge or flaring; uniform no discharge or flaring; Normal
in color uniform in color

Nasal septum Inspection Intact and in midline Intact
Normal

Mucous Pinkish; clear watery
Inspection clear watery discharge; no Normal
membrane discharge; no lesion
lesion
Air moves freely in and out Air moves freely in and
Patency Palpation out of the nasal cavities Normal
of the nasal cavities

Nasal cavity Inspection No obstruction No obstruction
Normal

Sinuses Palpation No tenderness
Normal
No tenderness

I. MOUTH AND
OROPHARYNX

Lips Inspection and Uniform in color; soft; moist; Uniform in color; soft;
palpation smooth texture; symmetry; moist; smooth texture;
Normal
moist smooth soft and elastic symmetry; moist smooth
texture soft and elastic texture



Deviation from

normal; skin and
Pink in color; moist smooth Purplish in color mucous membrane
Buccal mucosa Inspection and soft and elastic texture color changes due to
palpation anemia

Central position of tongue Central position of tongue

tongue and frenulum, purplish in Deviation from
and frenulum, pink color;
Inspection and color; moves freely; no normal; skin and
moves freely; no tenderness; tenderness; prominent mucous membrane
palpation
prominent veins at the base veins at the base and no color changes due to

and no nodules nodules anemia

4 dentures at the upper
Teeth Inspection 32 permanent teeth and 3 dentures on lower, Deviation from Normal
the permanent teeth are
12

Inspection and Pink gums; moist firm
Gums There is a part of the gum
palpation texture Deviation from Normal
that is inflamed due to the
tooth cavity
Lighter pink hard palate,
Palates Inspection Lighter pink hard palate, Normal
smooth and soft palate
smooth and soft palate
Uvula Inspection Midline of soft palate Midline of soft palate
Normal

Mucosa Inspection Pinkish mucosa Purplish in color Deviation from
 normal; skin and
mucous membrane

color changes due to
anemia
Pink and smooth; no
Tonsils Inspection No discharge Normal
discharge

Gag reflex Inspection Present Present Normal

J. NECK

Coordinated, smooth
Head movements Inspection movement with no Coordinated
Normal
discomfort

Equal strength; muscles Equal strength; muscles

Muscle strength Inspection equal in size and head equal in size and head Normal
centered centered

Inspection and Central placement in midline Central placement in
Trachea midline of the neck Normal
palpation of the neck

Not visible and glands Not visible and glands
Thyroid gland Inspection Normal
ascends during swallowing ascends during
swallowing
Lymph nodes Palpation Not seen and palpated
Normal



K. BREAST
AND AXILLA

Breast symmetry Inspection Breast are round and
and contour generally symmetric; no
tenderness, masses and
lesions
Breast are round and
generally symmetric; no
tenderness, masses and
Normal
lesions

Inspection and skin uniform in color; skin

palpation smooth and intact skin uniform in color;
Skin skin smooth and intact Normal
characteristics

Nipple condition Inspection Bilaterally round and pinkish

and presence of in color; no presence of
Bilaterally round and
discharge discharge Normal
pinkish in color; no
presence of discharge

Areola Inspection Round in shape, pinkish Round in shape,

color Normal

 Axillary, Palpation No tenderness, masses or No tenderness, masses or
subclavicular and nodules nodules
supraclavicular Normal
lymph nodes

Breast Palpation No areas of tenderness No areas of tenderness

Normal

L. THORAX
AND LUNGS

Anteroposterior to transverse Anteroposterior to

Shape and
Inspection diameter in ratio of 1:2; transverse diameter in Normal
symmetry ratio of 1:2; symmetric
symmetric chest
chest

Spine is vertically aligned,
spinal column is straight, Spine is vertically
Inspection and aligned, spinal column is
Spine alignment right and left shoulders are Normal
palpation
straight and hips are in the straight, right and left
same shoulders are straight and
hips are in the same

Skin intact, uniform
Chest Palpation temperature, no tenderness
and no masses; full and
symmetric chest expansion
Spine is vertically
aligned, spinal column is
straight, right and left
Normal
shoulders are straight and
hips are in the same
 Percussion notes resonate,
except over scapula; lower
Posterior thorax Percussion
point of resonance is at
diaphragm
Bronchiovesicular and
Posterior chest Auscultation
vesicular breath sounds
Percussion notes resonate,
except over scapula; Normal
lower point of resonance
is at diaphragm
Bronchiovesicular and
Normal
vesicular breath sounds

Breathing pattern Inspection Quiet, rhythmic, effortless Quiet, rhythmic, effortless
Normal
Costal angle is less than 90,
Costal angle Inspection and the ribs insert into the Not Done Not Done
spine at approximately at 45

Full symmetric excursion; Deviation from

Respiratory Unsuccessful symmetric
palpation thumbs normally separate to normal; due to
excursion excursion
5cm complaints of mid-

axilliary pain
Same as posterior vocal Same as posterior vocal
fremitus is normally fremitus is normally
Tactile fremitus Palpation decreased over heart and Normal
decreased over heart and
breast tissue breast tissue

Bronchial and tubular breath Bronchial and tubular
Trachea Auscultation Normal
sounds breath sounds

Anterior chest Auscultation Bronchiovesicular and Bronchiovesicular and Normal

 vesicular breath sounds vesicular breath sounds

Percussion notes resonate

down to the 6th rib at the level
of diaphragm but are flat
over areas of heavy muscle
Anterior thorax Percussion Not Done Not Done
and bone, dull on areas over
the heart and the liver, and
tympanic over the underlying
stomach

M. ABDOMEN

Unblemished skin; uniform

Skin integrity Inspection Unblemished skin; Normal
color
uniform color
Flat, rounded or scaphoid; no Globular abdomen and
Contour and evidence of enlargement of dullness was noted upon
Inspection Normal
symmetry spleen or liver; symmetric percussion.
contour

Symmetric movements caused Symmetric movements

by respiration; visible
Movements Inspection peristalsis on very lean people
aortic pulsations in the thin
persons at epigastric area
Vascular pattern Inspection No visible vascular pattern
caused by respiration;
visible peristalsis on very
lean people aortic Normal
pulsations in the thin
persons at epigastric area
No visible vascular Normal
 pattern

Audible bowel sounds; Audible bowel sounds;

Bowel sounds auscultation absence of arterial bruits; absence of arterial bruits; Normal
absence of friction rub absence of friction rub

Presence of
Percussion Tympany over the
tympany Tympany over the stomach and
stomach and gas filled
gas filled bowels; dullness,
bowels; dullness,
especially over the liver and

especially over the liver
spleen, or a full bladder
and spleen, or a full Normal
No tenderness; relaxed bladder

abdomen with smooth No tenderness; relaxed
Palpation
Abdomen ( four consistent tension
( light) abdomen with smooth
quadrants) consistent tension
Tenderness maybe present
Tenderness maybe present near
Abdomen ( four Palpation near xiphoid process over
xiphoid process over cecum, cecum, and over sigmoid Normal
quadrants) (deep)
and over sigmoid colon colon

Liver Palpation May not be palpable
Normal
Not palpable

Bladder Palpation Not palpable Normal
Not palpable

UPPER
EXTREMITIES
INSPECTION Equal strength on both sides of Equal strength on both Normal
Motor strength & PALPATION the limb sides of the limb

Muscle tone PALPATION Normally Firm Normally Firm Normal

Presence of INSPECTION No lesions; no deformities; no There is a fistula on his Normal

lesions, right arm
Tenderness
deformities and
varicosities

 LOWER Equal strength on both Equal strength on Normal
EXTREMITIES INSPECTION & sides of the limb both sides of the limb
PALPATION
Motor strength

Normally Firm Normally Firm Normal

Muscle tone PALPATION

Presence of lesions, No lesions; no Edema are present on Deviation from

deformities and INSPECTION deformities; no both feet Normal; due to
varicosities Tenderness extra fluid and
sodium in
circulation

Drug Study

Generic Name/ Route of Indication/Acti Contraindicatio Adverse effect Nursing

Brand Name/ administration/ on n intervention
Classification Dosage/Frequency
Calcium Reduces total Contraindicated CNS: Headache, Take as directed.
carbonate Route: PO acid in GI tract, in patients with irritability, Increase fluid
elevates gastric pH ventricular weakness. intake and bulk
Dosage: 500mg to reduce pepsin fibrillation or in diet to prevent
Classification: activity, strengthens hypercalcemia GI: nausea, constipation
Calcium salt gastric mucosal constipation,
Frequency: TID
barrier, and flatulence, rebound When used as a
increases hyperacidity supplement take
esophageal 1-1 hr after
sphincter tone. meals as an
antacid take 1hr
after meals and
bedtime
Human Albumin During HD Acute Contraindicated CV: Hypotension, Give to all blood
Nephrosis: Albumin with allergy to heart failure, groups or types
Classification: 20% or 25% and albumin severe pulmonary edema
blood product loop diuretic may anemia, cardiac after rapid infusion Monitor BP;
Plasma protein help to control failure, normal or discontinue
edema daily for 7- increased Hypersensitivity: infusion if
10 days intravascular Fever, chills, hypotension
volume, current changes in blood occurs.
Renal dialysis: use of pressure, flushing,
Albumin 20% or cardiopulmonary nausea, vomiting, Report headache,
25% may be useful bypass. changes in nausea, vomiting,
in treatment of respiration, rashes difficulty
shock and Use cautiously breathing, back
hypotension. 5% with hepatic or pain
solution may be renal failure.
used as adjunct in Continue using
hemodialysis whole blood;
infusion provides
 Albumin only
(human) is a symptomatic
concentrate of relief of
plasma proteins hypoproteinemia
from human blood.
It works by
increasing plasma
volume or serum
albumin levels.
Folic acid Folic acid Use in aplastic, Allergic: skin rash.
Route:P.O (which is normocytic, or Itching, erythema, Dietary sources
Classification: converted to pernicious general malaise, of folic acid include
Folic acid Dosage:500mg/1 tetrahydrofolic anemias (is respiratory difficulty dark green leafy
Vitamin tab acid) is ineffective). due to vegetables, beans,
supplement necessary for bromchospasm. fortified breads, and
normal Folic acid should cereals. Prolonged
Frequency:OD
production of not be used in GI: Nausea, cooking destroys
RBCs and for undiagnosed anorexia, abdominal folate in vegetables
synthesis of megaloblastic distention,
nucleoproteins. anaemia unless flatulence, bitter or Drug may
vitamin B12 is bad taste (in those discolor urine a deep
administered taking 15mg/day for yellow
concurrently, 1 month)
otherwise . A varied diet that
neuropathy may CNS: altered contains fresh fruit
be precipitated. sleeping patterns, and vegetables
irritability, usually provides
excitement, sufficient folic acid.
difficulty in
concentration,
 overactivity,
depression,
impaired judgement,
confusion.

Erythropoietin Route: SC Treatment of Signs of acidosis Instruct patients
anemia due to should be assessed Cardiovascular: to read the
Class: Dosage: 4000u concomitant such as Hypertension Medication Guide
Recombinant human myelosuppressiv disorientation, (28%); vascular before starting
erythropoietin e chemotherapy headache, weakness, therapy and at
Frequency: 2x/ access thrombosis
in patients with dyspnea and regular intervals
week with BP (8%); DVT (6%);
nonmyeloid hyperventilation. during treatment.
precautions thrombosis (5%);
malignancies;

anemia due to MI, pulmonary Inform patients
chronic kidney embolism (1%). of the risks and
disease in CNS: Headache benefits of epoetin
dialysis and (18%); dizziness alfa prior to
nondialysis (10%); insomnia treatment.
patients to (6%); depression
decrease the (5%); seizures
need for RBC (postmarketing).
transfusion; Dermatologic:
anemia due to Pruritus (21%); rash
zidovudine (19%); urticaria
administered at (3%); erythema
4,200 mg or less (1%).
per week in HIV GI: Nausea (56%);
patients with vomiting (28%);
endogenous stomatitis (10%);
serum
erythropoietin
 levels of 500
milliunits/mL or dysphagia (5%).
less; to reduce HematologicLeuko
the need for penia (8%);
allogeneic RBC porphyria, PRCA
transfusions
(postmarketing).
among patients
Hypersensitivity:
with
perioperative Serious allergic
Hgb greater than reactions
10 to 13 or less (postmarketing).
g/dL who are Local: Injection-site
high risk for pain (13%);
perioperative injection-site
blood loss from irritation (7%).
elective, Metabolic:Weight
noncardiac, decrease (9%);
nonvascular hyperglycemia
surgery. (6%); hypokalemia
(5%); edema (3%).
Musculoskeletal:Ar
thralgia (16%);
myalgia (10%);
bone pain, muscle
spasm (7%).

Ciprofloxacin Route: P.O. Inhibits Contraindicated CNS: seizures, Tell patient to
bacterial DNA in patients headache, take as
Dosage : synthesis, sensitive to restlessness. prescribed, even
mainly by fluoroquinolones. feeling better.
 Classification: 500mg/tab blocking DNA
antibiotics gyrase; bacterial Use cautiously in GI: Advise patient to
Frequency: BID patients with pseudomembranous drink plenty of
CNS disorders, colitis, diarrhea, fluids to reduce
and in those at risk of urine
nausea, vomiting.
risk for seizures. crystals

Drug may cause
CNS stimulation GU: crystalluria, Advise patient
interstitial nephritis. not to crush,
split, or chew the
Skin: rash, steven extended- release
johnson syndrome, tablets.
toxic epidermal
necrolysis. Tell patient to
Other:hypersensitiv avoid excessive
ity reactions. sunlight or
artificial
ultraviolet light
during therapy.








Celecoxib 1tab BID with Analgesic and Contraindicated CNS: Headache, Administer drug
(Celebrex) meals (prn) anti- with allergies to dizziness, with food or
 inflammatory sulfonamides, somnolence, other meals if GI
Drug Classes: activities related celecoxib, insomnia, fatigue, upset occurs
Analgesic(nonop to inhibition of NSAIDs, or tiredness Take only the
iod) the COX-2 aspirin, prescribed dosage,

NSAID enzyme, which significant renal do not increase
CV: MI, stroke
is activated in impairment, dosage
Specific COX-2
inflammation to perioperative pain You may
enzyme inhibitor Derma: Rash,
cause the signs post CABG experience these
and symptoms surgery, pruritus, sweating,
dry mucous side effects:
associated with pregnancy(third
inflammation, trimester); membranes, Dizziness,
does not affect lactation stomatitis drowsiness
the COX-1
enzyme, which GI: Nausea, Report sore
protects the abdominal pain, throat, fever,
lining of the GI dyspepsia, rash, itching,
tract, and has flatulence, GI bleed weight gain,
blood clotting swelling in
and renal Hema: ankles or fingers;
functions. changes in
Agranulocytosis
vision; chest
pain, shortness of

Other: breath, slurred

anaphylactoid speech.
reactions to
anaphylactic shock

Allopurinol 1 tab OD P.O Inhibits the Contraindicated CNS: Headache, Administer drug
(Aloprim, Apo- enzyme with allergy to drowsiness, following meals.
Allopurinol (CAN), responsible for allopurinol, blood peripheral Encourage
Zyloprim) the conversion dyscrasias. neuropathy, neuritis, patient to drink
of purines to Use cautiously paresthesias 2.5-3L/day to
Drug Class: uric acid, thus with liver disease, Derma: Rashes, decrease the risk
Antigout Drug reducing the renal failure, maculopapular, of renal stone
Purine analogue production of lactation and scaly or exfoliative development
uric acid with a pregnancy. sometimes fatal Check urine
decrease in GI: Nausea, alkalinity-urates
serum and vomiting, diarrhea, crystallize in acid
sometimes in
abdominal pain, urine, sodium
urinary uric acid
levels, relieving gastritis, bicarbonate or
the signs and hepatomegaly, potassium citrate
symptoms of hyperbilirubinemia, may be ordered
gout. cholestatic jaundice to alkalinize the
Hema: Anemia, urine.
leukopenia, Report rash;
agranulocytosis, unusual bleeding
thrombocytopenia or bruising; fever
chills; gout
attack; numbness
or tingling; flank
pain,rash.
Ferrous sulfate 1 tab OD P.O Elevates the Contraindicated CNS: CNS toxicity, Confirm the
(Apo- Ferrous serum iron with allergy to acidosis, coma and patient does not
Sulfate (CAN) concentration, any ingredient; death with overdose have iron
Enfamil, Fer-in- and is then GI: GI upset,
sulfate allergy; deficiency
Sol, Feosol, Ferosul) converted to anorexia, nausea
Hgb or trapped hemochromatosis, anemia before
and vomiting,
in the hemosiderosis, constipation, treatment
Drug Class:
reticuloendothel hemolytic diarrhea, dark
Iron preparation
ial cells for anemias Give drug with
storage and meals (avoiding
eventual Use cautiously stools. milk, eggs,
conversion to a with normal iron coffee and tea) if
usable form of balance; peptic GI discomfort is
iron. ulcer, regional
severe, slowly
enteritis,
ulcerative colitis increase to build-
up tolerance

Warn patient that
stool may be
dark or green

Treatment may
not be necessary
if cause of
anemia can be
corrected. It may
be needed for
several months to
reverse anemia

Report severe GI
upset, lethargy,
rapid
respirations,const
ipation


CNS: Dizziness, Advise patient to
Nifedipine Thought to Contraindicated light headedness, avoid taking drug
Route: P.O inhibit calcium ion in patients giddiness, headache, with grapejuice.
Classification: influx across hypertensives to drug
weakness,
antihypertensives Dosage:30mg/ta cardiac and smooth , in those taking
muscle cells, strong CYP450 nervousness, mood Advise patient
b
decreasing inducers (rifamipin), changes, shakiness, that adalat CC

contractility and and in patients with sleep disturbances, tablets contain
Frequency:TID
oxygen demand. cardiogenic shock. fever. lactose and
Drug may also BP must be shouldnt be used
dilate coronary lowered at a rate CV: flushing, heat by patients with
arteries and appropriate for
sensation, peripheral galactose
arterioles. patientss clinical
condition to avoid edema, palpitations, intolerance,
symptomatic transient lapplactase
hypotension with or hypotension. deficiency, or
without syncope glucose-
Avoid use in EENT:nasal galactose
patients with heart congestion sore malabsorption
failure; drug may throat, blurred
worsen symptoms vision Tell patient to
Rare reversible GI: Nausea, heart
protect capsules
elevations in BUN burn , diarrhea, from direct and
and serum creatinine constipation light and
levels have been
moisture.
reported in patients
with preexisting
chronic renal failure
insufficiency.


Contraindicated
Tramadol 1 tab q8h prn for Binds to mu- CNS: Sedation, Do not cut,
with allergy to
hydrochloride pain P.O opiod receptors and dizziness or vertigo, crush, or chew
tramadol or
(ConZip, Rybix inhibits the reuptake headache, ER tablets;
ODT, Ryzolt, of norepinephrine opiods or acute confusion, anxiety swallow them
Ultram) and serotonin; intoxication with whole.
causes many effects alcohol, opiods, CV: Hypotension,
Drug classes: similar to the or psychoactive tachycardia, Dissolve orally
Analgesic (centrally opiods-dizziness,n drugs. bradycardia, disintegrating
acting) somnolence, tablets in your
vasodilation
Opiod analgesic nausea, mouth and

conmstipation- but swallow without
does not have the Derma: Sweating, water.
respiratory Use cautiously pruritus, rash,
depressant effects. with pregnancy, pallor, urticarial You may
lactation;
experience these
seizures; GI: Nausea, side effects:
concomitantuse vomiting, dry dizziness,
of CNS mouth, constipation, sedation,
depressants, flatulence drowsiness,
MAOIs, SSRIs, impaired visual
TCAs; renal Other: acuity; nausea,
impairment; anaphylactoid loss of appetite
history of reactions ( lie quietly, eat
seizures; hepatic frequent small
impairment meals)
.
Report severe
 nausea,
dizziness, severe
constipation,
thoughts of
suicide.

Chlorhexidine TID Post meals Chlorhexidine is You should not Staining of the teeth Follow all
gluconate oral rinse an antiseptic and use this and other oral areas, directions on your
(Peridex, antimicrobial oral medication if you dental tartar (dental prescription label.
Periogard, rinse. It provides are allergic to calculus), Do not use this
Periochip) protection against a chlorhexidine altered sense of medicine in larger or
wide range of gluconate. taste, smaller amounts or
Drug Classes: bacteria. It kills toothache, and for longer than
Antiseptic, Anti- bacteria by binding oral mucosal recommended.
to bacteria cell irritation.
microbial
walls. Rinse your
Is commonly mouth with
prescribed orally for chlorhexidine
treating gingivitis gluconate twice daily
which causes after brushing your
redness, swelling, teeth.
and bleeding of the
gums. Do not add water
to the oral rinse. Do
not rinse your mouth
with water or other
mouthwashes right
after using

Chlorhexidine
 gluconate may leave
an unpleasant taste in
your mouth. Do not
rinse your mouth to
remove this taste
after using the
medication. You may
rinse the medicine
away and reduce its
effectiveness.





Tranexamic 1 tab TID Allergic reaction Severe allergic The medication
acid 500mg prn for Is a synthetic to the drug or reactions such as can be taken with
(Hemostan, active bleeding derivative of the hypersensitivity rash, hives, itching, or without meals.
Fibrinon, amino acid dyspnea, tightness
Cyklokapron, lysine. It exerts Presence of blood in the chest, Swallow
Lysteda, Transamin) its clots (eg, in the swelling of the Tranexamic Acid
antifibrinolytic leg, lung, eye, mouth, face, lips or whole with
Drug Classes: effect through brain), have a tongue plenty of liquids.
Anti-fibrinolytic, the reversible history of blood Do not break,
antihemorrhagic blockade of clots, or are at Calf pain, swelling crush, or chew
lysine-binding risk for blood or tenderness before
sites on clots swallowing.
plasminogen Chest pain
molecules. Anti- Current If you miss a
fibrinolytic drug administration of dose of
 inhibits factor IX Decreased urination Tranexamic
endometrial complex Acid, take it
plasminogen concentrates or Severe or persistent when you
activator and anti-inhibitor headache remember, then
thus prevents coagulant take your next
fibrinolysis and concentrates Severe or persistent dose at least 6
the breakdown body malaise hours later. Do
of blood clots. not take 2 doses
Shortness of breath at once.


Unusual change

in bleeding
pattern should be
immediately
reported to the
physician.

Prioritization

March 6, 2017 Decreased cardiac output
related to increase cardiac load
as manifested by arrhythmia,
skin and mucous membrane
changes, variation in blood
pressure changes, decrease
peripheral pulses and/ or
prolonged capillary refill
March 6, 2017 Excess fluid volume related to
decrease glomerular filtration
rate as manifested by edema
Arrhythmia(PR=102 bpm) This is our 1st priority because
Skin and mucous membrane decreased cardiac output can
color changes cause decrease perfusion to
BP = 140/90 organs moreover, we need to
Decrease peripheral pulses manage hypertension caused by
Prolonged capillary refill the interference with the system
of the renin-angiotensin-
aldosterone system caused by
renal dysfunction
Dry skin This is our 2nd priority because
Skin lesions on arm the patient has edema on both
Edema on right feet feet. As a nursing student, we

March 6, 2017 Activity intolerance related to
decreased tissue oxygenation as
manifested by fatigue
Prioritization
GFR = 3 want to improve our patients
condition by giving an
independent intervention.
RBC = 3.17 Our 3rd problem is activity
Pale skin intolerance because based on
Fatigue our interview, the patient is
anemic, he get tired easily on a
task or daily activites. He has a
low RBC result so we assumed
that it may cause fatigue
because of decrease tissue
oxygen carried by the rbc.

1. Excess fluid volume

Assessment Diagnosis Planning Intervention Rationale Evaluation

 Subjective: Di ko Excess fluid Short term: After Independent Short term: After
nga alam kung bat volume related to 1 hour of nursing Monitor and record 1 hour of nursing
may ganyan yung decrease intervention, the Vital signs Obtain baseline data intervention, the
balat ko eh, tapos glomerular patient will be able patient is now
minamanas yung filtration rate as to verbalize Accurate I & O is verbalizing the
Record Input and necessary for
paa ko As manifested by understanding of measures to
output of patient determining renal
verbalized by the edema the measures to function and fluid prevent and lessen

client. prevent and lessen replacement needs in fluid volume

fluid volume reducing risk of fluid excess.
excess. Note presence of overload.

edema May indicate increase

Objective:

Long term: After in fluid retention
Dry skin Evaluate Mental

May indicate cerebral Long term: After
Skin lesions on arm 24-48 hours of status edema
Edema on both feet nursing Auscultate breath nursing
These signs are
GFR = 3 intervention, the sounds (crackles in caused by intervention, the
VS : patient will the lungs, changes in accumulation of fluid patient is now
BP : 140/90mmHg manifest stabilize respiratory pattern, to lungs. stabilized fluid
T : 36.5 fluid volume and shortness of breath, volume and free
will be free from and orthopnea.)
P: 89 from signs of
Elevate edematous
R:22 signs of edema. Elevation increases edema. Goal was
extremities, and
venous return to the met.
handle with care.
heart and, in turn,

decreases edema.
Edematous skin is
more susceptible to
injury.
Educate patient and

 family members
regarding fluid Information is key to
volume excess and its managing problems
causes.


Dependent Fluid and sodium
Restrict fluid and management is
sodium intake usually calculated to
prevent further fluid
retention
Administer
medications such as To treat hypertension
antihypertensive as by counteracting
prescribed by the effects of decrease
physician blood flow.
2. Decreased Cardiac Output

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Decreased cardiac Short Term: Goal met: after 30
Minsan output related to After 30 mins of Independent: minutes of
pakiramdam ko increased cardiac nursing Determine vital Provides baseline independent and
pagod na pagod at load as manifested intervention, the signs/hemodynamic data for collaborative
ako at parang by arrhythmia, skin client will parameters comparison to nursing
hinihingal ako as and mucous verbalize follow trends and intervention, the
stated by the client. membrane color knowledge of the evaluate response client is now
changes, variation in disease process or to interventions verbalizing the
Objective: blood pressure treatment plan and knowledge of
(+) Arrhythmia (PR: changes and/or will display To note the disease process,
 102 decreased peripheral hemodynamic Auscultate the heart presence of and displays
bpm) pulses stability (blood sound tachycardia and hemodynamic
(+) Skin and mucous pressure and irregular heart rate stability (PR: 88;
membrane color cardiac output) BP: 130/80)
changes
(+) Variation in Long Term: Hypertension
blood pressure After weeks of occurs due to
readings (BP: 140/90 nursing interference with
mmHg) management the Assess for the system of the
(+) Decreased client will hypertension renin-angiotensin-
peripheral pulses maintain cardiac aldosterone system
output and blood caused by renal
pressure with dysfunction
evidence of
cardiac frequency Fatigue can also
in the normal accompany CRF

range, strong anemia

peripheral pulses,

same with Decreases oxygen
capillary refill Assess activity level
consumption and
time and will
risk of
participate in
Keep client on bed or decompensation
activities that
chair rest in position To detect change
reduce the
workload of the of comfort and allow for
heart, timely intervention

Provide for diet To lower blood
restrictions, as pressure
indicated


Teach self-
monitoring of pulse
and blood pressure

Collaborative:
Administer
analgesics
Administer anti-
hypertensive drug
(Nifedipine)

3. Activity Intolerance

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity intolerance Short Independent : Short
Minsan related to decreased term: Assess patients ability to Influences choice of interventions or term:
madalas ako tissue oxygenation as After 8 perform normal task or needed assistance After the
mapagod agad manifested by fatigue hours of activities of daily living nursing
sa ginagawa nursing
intervention
ko as interventi Plan activity progression with Promotes gradual return to
the patient
patient views essential, normal activity level and
verbalized by on, the is now
increase level of activities as improved muscle tone or
the patient patient tolerated stamina without undue seeing signs
Report an fatigue. of
 Objective: increase Recommend quiet increasing
RBC = 3.17 inactivity atmosphere,bed rest if Enhances rest tolower bodys activity
Pale skin tolerance indicated oxygenrequirements, tolerance
Fatigue including andreduces strain onthe heart for daily
activities and lungs. living and is

of daily now
Elevate the head of the bead
living and Enhances lung expansion to showing an

will maximize oxygenation for acceptable

display cellular uptake range of
Note changes inbalance/
laboratory laboratory
gaitdisturbance, muscle
values weakness. May indicate neurological values. Also
within changes associated with the patient
acceptable
vitamin B12 deficiency, is now free
range. affecting patient safety or from signs
Identify or implement energy riskof injury.
savingtechnique like sitting while of

Long doing a task weakness.

term:

Goal was
After met.
Encourages patient to do as
months of Dependent: much aspossible, while
nursing .Consult dietitian to request a conserving limited energy and
interventi proper meal for the patient. preventing fatigue.
on, the
patient

will be

free from Administer medicines such as

weakness erythropoetin, folic acid +
Dietitian is the one who
and risk ferrous sulfate as prescribed
 for by the physician provides nutritional care for
complicati patient. They are responsible
ons has for the intakes and diet that
will help the patient
been

prevented

To help the patient to maintain
normal RBC count and to treat
anemia.