I.

INTRODUCTION

“Wherever the art of Medicine is loved, there is also a love of Humanity.”

- Hippocrates

The best doctors were those who followed the advice of Hippocrates to pay
attention to the patient, not just the disease, and to render treatments that would first do
no harm. They formed healing relationships with patients, understood their needs and
psychology, and helped them mobilize natural resiliency to face and fight illness. But
what exactly is the art of medicine? We believe that quality of care is based on creating
the right structures, implementing the right processes and identifying the right
outcomes. Quality care is a blend of technical and interpersonal skills that together
create the art of medicine.

The relationship between medical art and science is changing rapidly, with the
science now overwhelming the art. Doctors more and more function like technicians, not
healers. As doctors gained in science they have lost in art; often they treat the lab tests,
not the patient. The precious and powerful doctor/patient relationship is lost in the
excessive application of unnecessary, even quite harmful, medical technology. It is the
ethical dimension of individuals that is essential to a system’s success. Ultimately, the
secret of quality is love and passion. If you have these qualities, you can then work
backward to monitor and improve your care that you implement on the patient.

Kidney failure occurs when the kidneys lose their ability to function. To treat kidney
failure effectively, it is important to know whether kidney disease has developed suddenly
(acute) or over the long term (chronic). Many conditions, diseases, and medicines can
create situations that lead to acute and chronic kidney disease. Acute kidney injury, also
called acute renal failure, is more commonly reversible than chronic kidney failure. Acute
kidney injury (AKI) is usually caused by an event that leads to kidney malfunction, such
as dehydration, blood loss from major surgery or injury, or the use of medicines while
Chronic kidney disease (CKD) is usually caused by a long-term disease, such as high
blood pressure or diabetes, that slowly damages the kidneys and reduces their function
over time. The presence or lack of symptoms may help the doctor determine whether acute
kidney injury or chronic kidney disease is present. (source: https://www.webmd.com)

Chronic kidney disease (CKD) is a slow progressive loss of kidney function over a
period of several years. Eventually, the patient has permanent kidney failure. It is not
unusual for people to realize they have chronic kidney failure only when their kidney
function is down to 25 percent of normal. As kidney failure advances and the organ's
function is severely impaired, dangerous levels of waste and fluid can rapidly build up in
the body. Treatment is aimed at stopping or slowing down the progression of the
disease - this is usually done by controlling its underlying cause. (source/:
http://www/whi.int/)

The two main causes of chronic kidney disease are diabetes and high blood
pressure, which are responsible for up to two-thirds of the cases. Diabetes happens
when blood sugar is too high, causing damage to many organs in body, including the
kidneys and heart, as well as blood vessels, nerves and eyes. High blood pressure, or
hypertension, occurs when the pressure of blood against the walls of blood vessels
increases. If uncontrolled, or poorly controlled, high blood pressure can be a leading
cause of heart attacks, strokes and chronic kidney disease. Also, chronic kidney
disease can cause high blood pressure.

Chronic kidney failure, as opposed to acute kidney failure, is a slow and gradually
progressive disease. Even if one kidney stops functioning, the other can carry out
normal functions. It is not usually until the disease is fairly well advanced and the
condition has become severe that signs and symptoms are noticeable; by which time
most of the damage is irreversible.

It is important that people who are at high risk of developing kidney disease have
their kidney functions regularly checked. Early detection can significantly help prevent
serious kidney damage. The most common signs and symptoms of chronic kidney
disease include anemia, decreased mental alertness, panting (shortness of breath),
sudden change in bodyweight, unexplained headaches, trouble sleeping, muscle
cramping at night, swollen feet and ankles, dry, itchy skin and need to urinate more
often, especially at night.

Glomerular Filtration Rate (GFR) is the best test to measure level of kidney
function and determine stage of kidney disease. Doctor can calculate it from the results
of blood creatinine test, age, race, gender and other factors. The earlier kidney disease
is detected, the better the chance of slowing or stopping its progression.

The world's disease profile is changing, and chronic diseases now account for the
majority of global morbidity and mortality, rather than infectious diseases. The causes of
chronic kidney diseases reflect this change and diabetes, together with hypertension, is
now the major cause of end-stage renal failure worldwide, not only within the developed
world, but also increasingly within the emerging world.

CKD is a major cause of cardiovascular morbidity and mortality and is considered

a significant public health problem that places a burden on global healthcare resources.
The prevalence of kidney/renal diseases has been in an increasing trend, especially the
end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry
(PRDR). The rate of death due to end-stage renal disease has been in the top ten list of
the mortality of the Department of Health (DOH). (source:http://www.net/kidney-disease)

This was disclosed by Estela Ilagan, nurse coordinator of the Department of

Health in region 12 who also said that one Filipino develops chronic renal failure every
hour or about 120 Filipinos per million populations per year. More than 5, 000 Filipino
patients are presently undergoing dialysis and approximately 1.1 million people
worldwide are on renal replacement therapy.

The DOH nurse coordinator said that in the past, chronic glomerulonephritis was
the most common cause of chronic renal failure. Today, diabetes mellitus and
hypertension have taken center stage in increasing the risk of ESRD which together
account for almost 60% of dialysis patients. The epidemic of diabetes and the related
diabetic nephropathy has largely contributed to the increase of ischemic heart disease
as well as overall cardiovascular mortality worldwide. (source:
http://www.manilatimes.net/kidney-disease)

Population-based studies estimate the prevalence of CKD at Females (15.93%)

had higher prevalence of CKD than males (13.52%), with adjustment for age. After age
adjustment, non-Hispanic blacks (17.01%) and Mexican-Americans (15.29%) had
higher crude prevalence than non-Hispanic whites (13.99%). Those with diabetes and
hypertension had far greater age-adjusted prevalence of CKD than those without these
conditions.

Ten percent of the population worldwide is affected by chronic kidney disease

(CKD), and millions die each year because they do not have access to affordable
treatment. Over 2 million people worldwide currently receive treatment with dialysis or a
kidney transplant to stay alive, yet this number may only represent 10% of people who
actually need treatment to live. Of the 2 million people who receive treatment for kidney
failure, the majority are treated in only five countries – the United States, Japan,
Germany, Brazil, and Italy. These five countries represent only 12% of the world
population. Only 20% are treated in about 100 developing countries that make up over
50% of the world population. (Source: http://www.who.int/)

Reasons for Choosing Case:

The primary reason why the group chose Chronic Kidney Disease (CKD)
secondary to DM Nephropathy as a case subject is because it is a highly prevalent
disorder that reduces patients' quality of life and imposes a significant economic burden
to the healthcare system. This condition could have underlying pathologic conditions,
which is often overlooked especially with the lack of knowledge regarding the disease
and limited access to healthcare. It would also be beneficial for the group to gain
knowledge and explore on it and as well to familiarize the underlying causes, clinical
manifestations, laboratory and diagnostic test, management both medical and nursing
management and also the disease process itself. The student nurses will also acquire
knowledge, which will be helpful in health teachings in future patients.
Objectives:

Nurse-centered Objectives:

After completion of the clinical case study, the student nurses will be able to:

STO:

 Establish therapeutic relationship with the client

 Gained information on the client’s reason for admission
 Defined to Chronic Kidney Disease secondary to DM Nephropathy
 Determined the possible risk factor that have contributed to the disease of the
patient
 Reviewed the anatomy and physiology of organs that can be affected by Chronic
Kidney Disease secondary DM Nephropathy
 Identified the clinical manifestations of the disease condition

 Learn new clinical skills as well as sharpen current clinical skills required in the
management of Chronic Kidney Disease secondary to DM Nephropathy
 Developed Nursing care plans for the manifestations of the disease condition

 Evaluate the effectiveness of nursing care

 Formulate conclusions based on findings

LTO:

 Identify current trends for the disease.

 Defined what is CKD and have background on the different types of kidney problem.
 Identify the factors through the patient history taking.
 Identify different clinical manifestations of the disease manifested by the patient and
explain it occurence.
 Identify the different modifiable and non modifiable factors that can lead to the
occurence of the disease and explain its effect.
  Identify the different laboratory and diagnostic test that was performed to the patient and
explain its indication and appropriate nursing interventions before, during and after the
procedure.
 Review the organ affected by the disease and its anatomy and physiology.
 Illustrate the pathophysiology of the disease both book base and patient centered.
 Identify the different medical management done to the patient in the coarse of
hospitalization; explain its indication and identify the different nursing intervention
before, during and after performing the said intervention.
 Identify and prioritized appropriate nursing diagnosis for the patient case.
 Enumerate the different independent, dependent and interdependent function of the
nurse in the care for the patient.

Patient-centered Objectives:

At the end of the case study, the client will be able to:

 Established therapeutic relationship with the student nurse

 Gain better understanding of the treatment involved for Chronic Kidney Disease
secondary to DM Nephropathy
 Have a positive behavior change as evidence by having a healthy lifestyle in
avoidance to having Chronic Kidney Disease secondary to DM Nephropathy
 Showed willingness to participate in all necessary management for his condition
 Stated his concerns regarding to his disease condition.
II. NURSING PROCESS

A. ASSESSMENT

1.PERSONAL HISTORY

a. Demographic Data

Mr. CKD is a 57 years old Filipino male. He is married, has 2 children both are
girls, and resides with his family in Concepcion, Tarlac, Philippines. On September 2, he
was admitted at a tertiary hospital in Pampanga with a admitting and final diagnosis of
Chronic Kidney Disease Stage 5 secondary to Diabetes Mellitus Nephropathy.

b. Socio- Economic and Cultural Factors

B.1. Income and Expenses

Mr. CKD was a farmer but due to his condition he stopped working. One of his
children works in Singapore who provides the family’s expenses with 20,000php every
month. According to National Economic Development Authority, each family member
should have Php 2, 873.33 per month to meet the basic needs and they are considered
not poor since they are supported by their daughter. When asked to give an estimate of
their total income, the patient only said that it is slightly higher than their expenses.
Their expenses in a month are around 10,700php, which are usually spent on electricity
(P3000), food (P5000), water (P700), transportation (P2000).

B.2 Educational Attainment

Mr. CKD finished only 4th year high school and was not able to pursue a college
degree due to financial constraints. He has the ability to speak, read & write.

B.3. Religious Affiliation

The CKD family’s religion is Catholic. According to him, they attend the mass
regularly every Sunday.
B.4 Cultural factors affecting health of the family

The family immediately seek health services from hospitals or health centers if one
of them experiences sickness. They do not believe in other healing practices. “quack
doctors” or any herbolaryos. Since they have a friend who is a pharmacist they seek
medications that they can use instead of using herbal medication. Mr. CKD is a smoker
and he drinks alcohol beverages occasionally like birthdays, fiestas, Christmas, New
Year’s eve, etc. He is also fund of eating candies, salty foods, corn & fish with
seasonings/condiments.

C. Environmental Factors

According to Mr. CKD, they are exposed to the typical environmental factors of
pollution and heat in the Philippines, but try to maintain good health to their abilities. And
since Mr. CKD was a farmer he was exposed to pesticides & insecticides for their crops
in their farm.

They own a concrete house contains their bedroom, living room, kitchen and
comfort room. It has 4 windows located in each room and 3 doors. As he described
their house the ground is cemented and have adequate lighting and ventilation with 4
windows. In their kitchen they use a double burner gas stove for cooking. The family’s
source of water is from water district. This is utilized for laundry, cooking, and daily
hygiene. Their source of drinking water is from a water station where they buy mineral
water. The source of electricity is supplied by ANAW that supplied their fluorescent bulb
and electric fan. They use bottles, cups and pitcher for their drinking water. They have
two toilet facility with water carriage. They put their accumulated garbage in a 1 sack
and they put it on a one place (dumping) and burn it. Their means of transportation is by
using their private car and motorcycle. Mr. CKD usually eat fish and he said that every
time he eats, he always have seasonings with it.

Mr. CKD mainly buy their necessities from nearby grocery stores that have almost
everything they need. Generally speaking, they are contented from where they are
situated, according to the Mr. CKD commentary.
2. FAMILY HEALTH-ILLNESS HISTORY

GENOGRAM

Paternal Side Maternal Side

Grand Father Grand Grand Father Grand

Mother Mother
X X X X
OLD AGE OLD AGE
OLD AGE OLD AGE

Father
Mother
X
DIABETES HYPERTENSION
MELLITUS

Brother Mr. CKD Sister Sister

DIABETES CHRONIC
MELLITUS No Known
KIDNEY DISEASE No Known
Sickness
Stage 5 Sickness
Diabetes Mellitus
 LEGEND:

MALE

PATIENT CKD

FEMALE

X DECEASED

According to Mr. CKD knowledge about his family history, his grandparents from
both sides of his mother and father died because of old age. The father of Mr. CKD died
because of Diabetes Mellitus while his mother is still alive and has hypertension. Mr.
CKD’s father has DM that is why his brother possibly acquired it also. According to
Mr.CKD, there was no known sickness of his sisters.
HISTORY OF PAST ILLNESS

Mr. CKD was diagnosed of DM in 2010 and from that he already has 4
hospitalizations with unrecalled dates of confinement. According to the patient he was
operated below the knee amputation (left) last August 2013 due to a minor injury while
he was farming and no interventions done until it became severe. He was also
diagnosed of Hypertension in 2016 and is being maintain by his medications,
specifically clonidine, trimetazidine & amlodipine besylate. Then he was hospitalized
last June 2017 because of fecal stasis.

HISTORY OF PRESENT ILLNESS

Five days prior to admission, Mr CKD experienced sudden swelling of the

scrotum and he had localized epigastric pain rated as 8/10 (pain scale) which is relieved
by vomiting. There were no medication given and no consultation done. A day after,
signs & symptoms were persistent and epigastric pain became severe causing the
patient to consult a doctor and was prescribed with a Esomeprazole 40mg/tab. That is
to be taken twice a day, before meals only for temporary relief. And after 4 days, signs
and symptoms became worse and persistent Mr CKD decided to be admitted
September 02, 2017 at 6;41pm in a tertiary hospital in Pampanga with a chief complaint
of severe epigastric pain.

PHYSICAL EXAMINATION (IPPA - CEPHALOCAUDAL)

General Appearance

 Received patient on supine position, awake and weak with easy fatigability. Vital
signs are as follows: T= 36C RR= 17bpm PR= 86bpm
BP=160/100 Wt= 100kg Ht= 177cm

Integumentary

 (+) Dark brown discoloration on upper extremieties

  Good skin turgor
 Dry skin and cool to touch
 Absence of jaundice
 (+) Pallor
 With a capillary refill time of 4 seconds
 Absence of rashes and nodules
 Pink and square in shape nail beds noted

Head

 Hair is straight, gray in color, and equally distributed

 Absence of masses, swelling, and lesions upon palpation
 Skull is round in shape
 No abnormal movements noted
 No presence of infections or infestations are noted
 Slight hair loss observed

Face

 Facial features and movements are symmetrical

 Absence of swelling and masses upon palpation
 Able to perform different facial expressions

Eyes and Vision

 Brown iris
 White sclera
 Cornea is shiny and smooth
 Pupils equally round and reactive to light accommodation (PERRLA)
 (+) Pallor in the conjunctiva
 Eyebrows symmetrically aligned
 Eyebrow hair is evenly distributed and equal in movement
  Eyelashes are evenly distributed and curled outward

Ears and Hearing

 Auricle is smooth with no lesions, lumps, or nodules.

 Able to hear watch tick from 1-2 inches
 Absence of tenderness, masses, and lesions upon palpation
 No pain is noted

Nose and sinuses

 Normal in shape and symmetrical

 No nasal obstruction
 No sneezing and epistaxis
 Absence of tenderness and lesions
 Absence of secretions

Mouth

 Lips were smooth and pinkish color

 Gums were pink in color with absence of swelling
 Color of buccal mucosa is dark pink, smooth and moist without lesions
 Tongue is in the central position, pink in color, and moist
 Teeth are aligned
 Tongue able to move freely and absence of lesions
 Uvula is positioned in the midline
 No hoarseness and sore throat noted

Neck
  Same color as facial skin
 Thyroid gland ascends when instructed to swallow and not visible
 Absence of tenderness and masses upon palpation
 Absence of difficulty movement when instructed to move in different directions
 No enlargement and tenderness on lymph nodes

Thorax and Lungs

 Symmetrical from posterior and lateral views

 Right and left shoulders and hips are symmetrical
 Scapula are symmetrical
 No adventitious breath sounds noted
 Chest expansion is symmetrical
 Sternum is position in the midline and symmetrical with size and shape
 Absence of tenderness upon palpation
 No shortness of breath , (-) Difficulty of breathing
 (-) Signs and symptoms of respiratory distress
 RR= 17bpm

Heart

 Normal heart rate with regular rhythm

 No murmurs auscultated
 No palpitations
 Regular rhythm
 PR= 86bpm

Abdomen

 No palpable masses
 No colic is noted
  Normoactive bowel sound
 Able to tolerate feeding
 (+) Vomiting
 (+) severe epigastric pain
 Rigid, Globular, Shifting dullness

Extremities

Upper Extremities

 Symmetrical in shape, firm, smooth

 Absence of tenderness, edema, lesions, and deformities

Lower Extremities

 Symmetrical in shape, firm, smooth

 Absence of tenderness, lesions, and deformities
 Amputated leg with prosthesis
 (+) Edema Grade 3, pitting on lower extremity right with blisters

Musculoskeletal

Muscle tone

 Equal size on both side of the body

 All reflexes are within the normal range

Neurological

Mental Status and Level of Consciousness

 Conscious and coherent with people, time, and place

 Able to answers the questions being asked by the group
 Sensory Function

 Normal sensory functions

 Able to identify "sharp" and "dull" sensations
 Able to hear ticking off the clock during the watch tick test

Motor Function

 Normal motor functions

 Motor movement controlled
 Absence of tremors or problems with coordination

Review of Systems

Integumentary
 (-) rashes, (-)lesions, (-) wounds

Eyes
 (-) visual changes, (-) headache, (-) eye pain, (-) double vision

Ears
 (-) stuffy ears, (-) ear pain, (-) ringing in ears (tinnitus)

Nose
 (-) Runny nose, (-) frequent nose bleeds (epistaxis), (-) sinus pain

Mouth and Throat

 (-) gingival bleeding, (-) toothache, (-) sore throat, (-) pain with swallowing
 (odynophagia)

Respiratory
 (-) cough, (-) sputum, (-) wheeze

Cardiovascular
 (-) chest pain, (-) palpitations
Gastrointestinal
 (-) indigestion
 (-) diarrhea & vomitting
 (+) bloatedness
 (+) easy satiety
Genitourinary
 (-) incontinence, (-) dysuria, (-) haematuria, (-) nocturia

Musculoskeletal
 (-) pain, (-) misalignment, (-) stiffness

Hematopoietic
 (-) anemia, (-) purpura, (-) petechia
 (+) pallor
DIAGNOSTIC AND LABORATORY PROCEDURES

Diagnostic/Laboratory Date Indication or Results Normal Analysis an

Procedure Ordered Purpose Values Interpretation
(Units used of Results
Date in the (Patient-
Result-In hospital) Centered)

Complete Blood Count CBC provides

(CBC) valuable
information about
the blood and
blood-forming
tissues (especially
the bone marrow),
as well as other
body systems.
Abnormal results
can indicate the
presence of a
variety of
conditions-including
infections.
Hemoglobin D.O.: It was done to the (1ST) (140-175 The
patient because the g/L) hemoglobin
9/2/2017 patient is pale upon 78 level is below
arrival at normal range
9/4/2017 (2nd)
Emergency Room. because the

D.R.: 100 kidney function

This is also ordered of producing
9/2/2017 to determine if the RBC is
patient responded impaired.
9/4/2017 well to the Because of this
treatment given the patient
which is blood ordered to have
transfusion. blood
transfusion.

The patient
RBC rised up
from 78 to 100.

Hematocrit D.O.: Hematocrit is used (1ST) (0.41-0.50) Hematocrit

to measure the level is below
9/2/2017 percentage of total 0.23 normal range,
blood volume meaning the
9/4/2017 (2nd)
composed RBC. It percentage of

D.R.: was tested because 0.28 RBC’s in a

anemia isa most sample of
9/2/2017 common whole blood is
manifestation in below lower
9/4/2017
patient’s who have limits. Low
CKD. hematocrit is
related to
anemia.
Red Blood Cell Count D.O.: Red blood cell (1ST) 4.50- The result is
count is a blood 5.00x10^12/ below normal
9/2/2017 test that doctor 2.60 L range and may
checked to find out indicate a
9/4/2017 (2nd)
how many vitamin B6, B12

D.R.: red blood cells 3.31 or folate

(RBCs) the patient deficiency. It
9/2/2017 have. It's also may also signify
known as an internal
9/4/2017
erythrocyte count. bleeding,
The test is kidney disease
important or malnutrition.
because RBC’s
contain
hemoglobin, which
carries oxygen to
body's tissues.

White Blood Cell Count D.O.: This is done to (1ST) 4.50-11.00 Result is within
determine infection x10^9/L normal range.
9/2/2017 or inflammation. It 7.03 The patient was
is used determine receiving
9/4/2017 (2nd)
the presence of antibiotic

D.R.: infection and to 8.26 therapy to

help monitor the combat the
9/2/2017 body’s response to severity of the
various treatment infection.
9/4/2017
and monitor bone
marrow function.
Lymphocytes D.O.: This test measures (1ST) 0.10-0.48 Lymphocytes is
the number of decreased, it is
9/2/2017 lymphocytes in 0.06 decreased by
peripheral blood. the condition of
9/4/2017
Lymphocytes is patient which is

D.R.: present in various (2nd) renal failure.

diseases and is
9/2/2017 especially 0.07
prominent in viral
9/4/2017
disorders.
Lymphocytes and
their derivatives the
plasma cells,
operate in the
immune defenses
of the body.

Neutrophils D.O.: Neutrohils is the (1ST) 0.18-0.70 An increase

most numerous percentage of
9/2/2017 and most important 0.88 neutrophil count
type of leukocytes as response to
9/4/2017
in the body’s an infection.,

D.R.: reaction to (2nd) since the

inflammation, patient has
9/2/2017 constitute a primary 0.82 metabolic
defense againts disorder
9/4/2017
microbial invasion (uremia).
process of
phagocytosis.

This test was

performed as a part
 of the WBC and
determine presence
of neutrophilia or
neutropenia,

Monocytes D.O.: The largest cells of (1ST) 0.00-0.04 The patient’s

normal blood, are monocytes is
9/2/2017 the body’s second 0.05 slightly
line of defense increased, this
9/4/2017 (2nd)
againt’s infection. can be the

D.R.: These phagocytes 0.07 effect of the

cells of varying size infection of the
9/2/2017 and mobility patient.
remove injured and Impairment of
9/4/2017
dead cells, the immune
microorganisms, system makes
and insoluble patient more
particles from susceptible to
circulating blood. infection.
This test counts
monocytes, which
circulate in certain
specific conditions.

Eosinophils D.O.: Eosinophils are a (1ST) 0.00-0.03 Result is within

component of the normal range
9/2/2017 innate immune 0.01 which indicates
system. They have there is no
9/4/2017 (2nd)
a variety of allergic

D.R.: functions but are 0.03 reaction,

especially important parasitic
9/2/2017 in defense against infections and
parasitic infections skin diseases.
 9/4/2017

Platelet count D.O.: The platelet count Platelet count is

is of value for below normal
9/2/2017 assessing bleeding (1ST) 150-400 range. This
disorders that occur x10^9/L means that the
9/4/2017 147
to patient’s with platelet of the

D.R.: CKD. (2nd) patient has

been damaged.
9/2/2017 132 This was done
to monitor the
9/4/2017
patient platelet
count because
thrombocytopen
ia in CKD is
common.
Sodium D.O.: This is ordered by (1ST) 135.00- The result is
the patient to 150.00 below normal
9/2/2017 determine whether 124.6 meq/L range. The
sodium kidneys also
9/4/2017
concentration is lose capacity

D.R.: within normal (2nd) to excrete

limits and to help excess fluids
9/2/2017 evaluate 130.5 and sodium.
electrolyte balance Apparent
9/4/2017
and kidney deceased in
function of the sodium may
patient; The be dilutional
results can help effect of water
the physician retention.
evaluate how
much decrease in
the regulatory
function of the
kidneys because
of the illness CKD.
It is also used to
monitor the
effectiveness of
hemodialysis.

Magnesium D.O.: Magnesium level (1ST) 0.73-1.06 Patient

may be ordered meq/L Magnesium
9/2/2017 periodically to 1.02 level is within
patient to help normal range.
9/4/2017
monitor kidney This reveals

D.R.: function and make (2nd) that the body

sure that the is trying to
9/2/2017 patient in not 1.05 compensate to
excreting or maintain a
 9/4/2017 retaining normal
excessive magnesium
amounts of level.
magnesium.

Calcium D.O.: The serum (1ST) 4.5-5.5 The calcium

Calcium test is meq/L level of the
9/2/2017 used to monitor 1.02 patient is
patients with renal decrease due
9/4/2017
failure since CKD to impaired

D.R.: there is impaired (2nd) Vitamin D

Vitamin D synthesis
9/2/2017 synthesis, which 1.18 because of
necessary for poor calcium
9/4/2017
Calcium absorption
absorption in the brought about
gastrointestinal by altered
tract and Vitamin D
increasing metabolism.
reabsorption from
bone.

Potassium D.O.: It is ordered to the (1ST) 3.50-5.50 Result is within

patient because meq/L normal range
9/2/2017 when kidneys fail 3.74 meaning the
they can no longer kidneys can
9/4/2017
remove remove

D.R.: excess potassium, (2nd) excess

so the level builds potassium
9/2/2017 up in the body and 3.9 level builds up
high potassium in in the body.
9/4/2017
the blood is called
hyperkalemia,
which may occur
 in people with
advanced stages
of chronic kidney
disease (CKD) .

BUN (Blood Urea . D.O.: This fast, simple (1ST) 2.78- High BUN
Nitrogen) blood test is most 8.07mmol/L levels of the
9/2/2017 commonly used to 97.03 client is due to
evaluate kidney accumulation
9/4/2017
and liver function of waste

D.R.: or the ability of the (2nd) products,

patient to excrete such as BUN
9/2/2017 by-products. 97.05 as response to
decrease
9/4/2017
glomerular
filtration of the
body thus
excretion of
wastes that
may occur
results into
increase level.
 D.O.: A serum creatinine (1ST) 63.00- Result is within
test — which 108.00 normal range
Creatinine 9/2/2017 measures the level 78.12 umol/L reflecting
of creatinine in glomerulus
9/4/2017
your blood — can ability to

D.R.: indicate whether (2nd) excrete waste

your kidneys are product from
9/2/2017 working properly in 76.77 muscle
elimination waste metabolism.
9/4/2017
products of muscle
metabolism.

Serum Amylase D.O.: The patient chief (1ST) 0-100 U/L Result is within
complain is severe normal range
9/2/2017 abdominal pain 41.97 meas the
serum amylase is cause of pain
9/4/2017
checked to r/o is not

D.R.: problems in (2nd) pancreatitis in

pancreas. nature.
9/2/2017 46.96

9/4/2017

SGOT/AST D.O.: To check if the (1ST) 0.00-35.00 Result is within

liver was damage U/L normal range
9/2/2017 which can cause 28.07 meaning the
pain in the liver is
9/4/2017
abdominal area. functioning

D.R.: (2nd) well and pain

exhibit by the
9/2/2017 23.19 patient is not
related to liver
9/4/2017
damage.
SGPT/ALT D.O.: The alanine (1st) 0.00-45.00 Result is within
aminotransferase U/L normal range
9/2/2017 (ALT) blood test is 1.33 meaning the
typocally used to patient has no
9/4/2017 (2nd)
detect liver injury. liver disease

D.R.: It is often ordered 9.12 or any

in conjunction damage.
9/2/2017 which aspartate
aminotransferase
9/4/201
(AST) or as a part
of a liver panel to
screen for
diagnosing liver
disease.

It was checked to
the patient
because he have
some medications
which are
hepatotoxic and
check for any liver
complications
Urinalysis Urinalysis was Color: Straw The patient has
ordered to normal color
D.O.: Light
determine yellow urine.

9/3/2017 whether the

urine contains
D.R.: substances
indicate or
9/3/2017
normally absent
from urine and
detected by The patient
Trans: urine is turbid in
urinalysis are
Clear
proteins, Turbid color because
acetone, blood, of the presence
pus and casts. of pus , albumin
and RBC in the
It is ordered to urine.
patient to check
presence of
albumin in the
Rxn: Patient has
urine which can
Slightly acidic acidic urine.
also be a cause
Acidic
This is caused
of patient’s
by
edema.
compromised
kidney function
of minting acid-
base
homeostasis.
Albumin None The result
shows the there
++++
is the presence
of albumin in
patients urine
caused by
failure of the
kidneys to filter
macromolecule
s secondary
from the
increased
permeability of
the glomerular
membrane
because of this
patient
experience
edema.

Specific (1.010-1030)
gravity: The result
shows is within
1.020
normal range.
A microscopic Microsco RESULTS Pus cells,
examination pic epithelial cells,
may or may not Examinat
ion mucus threads,
be performed as
part of a routine bacteria, and
urinalysis. It will crystals are all
typically be
Pus Cells 1-2/HPF normal findings.
done when
there are Red blood cells
abnormal in the urine are
findings on the
found as
physical or
chemical abnormal and
examination Epithelial Rare
as seen in the
and the results Cells
results, the
from all will be
taken into patient’s RBC’s
account for in the urine are
interpretation way below
normal levels.
RBC’s in the
urine may also
Mucus N/A coincide with
Threads
proteinuria/albu
minuria, which
is expected
from a patient
with Diabetes.

Few
Bacteria
 Crystals N/A

SURGICAL MANAGEMENT

Internal Jugular Central Venous Line

Central venous access is essential in providing quality medical care to many patients for
whom intensive therapy is required. In many situations, a semipermanent tunneled
central line is preferred (see Indications). An anterior approach to the internal jugular
vein (IJV) is the best option in this situation because it offers the easiest route with a low
risk of complications.

In this procedure, a tunneled catheter is surgically inserted into a vein in the neck
or chest and passed under the skin. Only the end of the catheter is brought through the
skin. Medicines and intravenous (IV) fluid can be administered through this catheter;
other tasks, such as blood sampling, can also be performed. Passing the catheter under
the skin helps secure the catheter, reduces the rate of infection, and permits free
movement of the catheter port. Placement of a tunneled catheter should be carried out
by practitioners with specific experience in the procedure.

Compared with femoral site access, IJV or subclavian vein access has been
associated with a lower risk of catheter-related bloodstream infections (CRBSIs) in
some studies; however, subsequent studies have found no significant differences in
CRBSI rates between these three sites. Overall, the IJV is a more suitable site,
especially in children, though other factors (eg, interindividual vein size variation) must
be kept in mind.
INDICATIONS

1. Central venous access for infusion of vasoactive drugs, TPN, high dose KCl, etc.
2. Hemorrhagic disorder where large volumes blood/blood products needed
3. Measurement of central venous pressure
4. Need for frequent blood draws where peripheral access limited.
5. Lack of peripheral venous access

CONTRAINDICATIONS
1. Severe coagulopathy; INR > 1.5-1.6; platelets < 50 K (relative contraindication).
The femoral or IJ site is preferred with a coagulopathy or anticoagulation due to the
ability to compress the vein in the event of serious hemorrhage.
2. Infected skin site
3. In patients with higher risks for pneumothorax or inability to tolerate pneumothorax,
the IJ or femoral sites may also be preferred.
4. Thrombosis of target vein

RISKS
The risk of complications of central line placement varies with the experience of
the operator and the conditions (emergency vs. elective) under which the line is placed.
Nonetheless, some general statements can be made and used when obtaining consent
from a patient. Risks associated with central venous catheterization include infectious,
mechanical, and thrombotic complications. A chest radiograph should be obtained to
confirmplacement and to assess for complications.
Infectious Complications

Catheter infections occur by means of one of three mechanisms: local insertion

siteinfection, which travels down the catheter externally; or hub colonization followed by
infection via the intralumenal route or via hematogenous seeding of the catheter.

The Institute for Healthcare Improvement recommends five steps to reduce

central-line infections: hand hygiene, adherence to maximal barrier precautions,
chlorhexidine skin antisepsis, selection of an optimal catheter site, and daily review of
the necessity of the catheter, with prompt removal when the catheter is no longer
needed. Implementation of these steps has been conclusively shown to decrease the
rate of catheter-related bloodstream infection. Scheduled changing of a catheter over a
guide wire or moving a catheter to a new site can increase mechanical and infectious
complications, and neither is recommended. Antiseptic containing hubs and
antimicrobial-impregnated catheters have been shown to decrease the rate of catheter-
related bloodstream infections. Topical antibiotic ointments are ineffective, promote
antibiotic-resistant bacteria, and increase fungal colonization.

Mechanical Complications

Mechanical complications include arterial puncture, hematoma, pneumothorax,

hemothorax,arrhythmia, and improper location of the catheter, whether in an accessory
vein or in the other vessels of the upper vascular system. Insertion of a catheter into the
femoral vein, not shown in this video, has the highest risk of mechanical complications,
but the rates of serious mechanical complications for femoral and subclavian insertion
are similar. If an artery is punctured, further attempts at that site should be abandoned,
and access to an alternative site should be attempted. Internal jugular and subclavian
cannulation sites are preferred because of their lower overall rate of mechanical
complications. However, these sites carry a small risk of hemothorax and
pneumothorax. Ultrasound guidance for internal jugular cannulation significantly
reduces the number of attempts required and the risk of complications.
Thrombotic Complications

Central venous cannulation increases the risk of central venous thrombosis, with
the concomitant potential risk of venous thromboembolism. Thrombosis may occur as
early as the first day after cannulation. The site with the lowest risk for thrombotic
complications is the subclavian vein. Prompt removal of the catheter when it is no
longer needed decreases the risk of catheter-related thrombosis.

INDWELLING CENTRAL VENOUS CATHETER REMOVAL

GUIDELINES

1. No specific time interval for changing or removal. Catheter site and need should be
reassessed daily. If site becomes infected, removal and if needed, replace at a
different site.
2. If line is to be removed because of suspicion of a catheter-related infection, and the
skin site is not infected-looking, guide wire exchange with blood cultures through
the line and culture of the tip should be performed
3. Catheter removal may not be required with coagulase-negative Staph line infection
without infected skin site, but most other catheter related infections require removal
and antibiotics.

PREP & ANESTHESIA

1. Cleanse a 15-20 cm area over the side of the mid- to lower neck with povidone-
iodine solution; the right side is preferred due to more direct line to the atrium and
avoids injuring the thoracic duct. If you are using ultrasound guidance, do a quick
look prior to preparing your sterile field to localize the IJ and its relationship to the
carotid artery.
2. The site of entry should be at the top of the triangle formed by the two heads of the
sternocleidomastoid muscle and clavicle.
3. Drape the patient with the provided paper/plastic drape with center cutout.
4. Estimate the length of catheter to be placed to end up with tip above right atrium
5. Using the 25 ga needle, make a wheal under the skin at the desired spot, and
anesthetize the subcutaneous tissue
6. Using the 20 ga needle, anesthetize deeper.
7. Always pull back before injecting to avoid intravascular injection of lidocaine.

TECHNIQUE

1. Place the guide wire, dilator, catheter, and scalpel on the sterile drape for easy
reach when needed.
2. Have the patient turn head in the opposite direction
3. Using the 18 ga finder needle (largest needle in the kit) and a small syringe, enter
the skin at the top of the jugular triangle. In obese patients where the landmarks are
not discernable, a reasonable rule of thumb is to go three finger breadths lateral
from the tracheal midline, and three finger breadths up from the clavicle.
4. Alternatively use ultrasound guidance with the portable ultrasound in a sterile
sleeve to localize the vein and follow your needle into its lumen.
5. Ultrasound Guidance: In numerous studies, ultrasound guidance has been shown
to increase the success of first-time catheter placement and to decrease the risk of
complications. When using ultrasound guidance, enlist an assistant either to handle
the probe or to remove it when it is no longer needed. The vein and artery appear
 circular and black on the ultrasound image; the vein is much more compressible
when gentle pressure is applied to the skin via the probe. The needle appears
echogenic and can be followed into the image of the vein
6. Palpate for the carotid impulse an make sure you are lateral to this.
7. Insert the needle at 30 degrees and aim for the ipsilateral nipple.
8. Gradually advance the needle, always gently pulling back on the plunger as you
progress; a flash and easy withdrawal of dark blood, this indicates entrance into the
vein.
9. If you bury the needle without blood, gradually withdraw; you may still get into the
vein as you may have collapsed it on the way in.
10. Once in the vessel, steady the needle and remove the syringe, holding a thumb
over it to prevent air embolism.
11. Insert j-tipped guide wire into needle; if resistance is felt do not force it.
12. Watch monitor as guide wire is advanced. Ventricular ectopy indicates placement in
RV, and guide wire should be pulled back a few cm.
13. Holding guide wire, remove needle from skin.
14. Make a small nick with the number 11 blade where wire enters skin.
15. Advance dilator over guide wire with a twisting motion; there will be resistance.
16. Remove dilator, holding guide wire and having some gauze 4x4 in your hand to
apply pressure to a site that will now bleed after dilation.
17. Place catheter over guide wire; it should advance easily. Hold guide wire at skin
entrance and feed it back through distal port of central line (brown cap). When wire
comes out, grab it at the end and finish advancing catheter.
18. Remove guide wire and flush line through all 3 ports.
19. Suture catheter in place via flange with holes. If more than a cm or 2 of catheter is
exposed due to length, either suture the catheter down or use the snap-on flange
provided in the kit.
20. Order a stat CXR to evaluate for line placement and complication. The tip of the
catheter should be at the junction of the SVC and right atrium on chest xray. New
data would suggest that this is 2cm below the superior right cardiac sillhouette
which is made up by the right atrial appendage.
MEDICAL MANAGEMENT

INTRAVENOUS FLUID

Medical Classification General Indication(s) Client's

Management/ Action or Response
Treatment Purpose(s)

PNSS (0.9 Isotonic solution NSS is a To treat Patient's

solution of
NaCl 1 L x 30 hyponatremia sodium level
common salt
gtts/min) with Plasma volume in distilled and decrease increased
expander water, of
nicardipine blood pressure from 124 to
strength of
drip KVO 0.9%. It is 130 for the 1st
Anti-hypertensive called
treatment and
normal
saline also
because the decreased
percentage
of salt blood
resembles pressure from
that of the
160/100mmHg
crystalloids
in the blood to 140/100
plasma. It is mmHg
an isotonic
solution. It is
less irritating
for the body
cells. the
medication
nicardipine
regulates
your blood
pressure.
Nursing Responsibilities

Intravenous Fluid

Before:

1. Check the Doctor’s order

2. Check the expiration date of IVF.
3. Inform patient about the IVF to be given.
4. Explain the procedures to the patient or the patient’s significant orders.

During:

1. Clean the site of administration and observe aseptic technique.

2. Choose vein on the distal arm first.
3. Support patient hand and maintain aseptic technique.
4. Instruct the significant others to support the body of the patient especially the
while inserting the needle.
5. Once in the place regulate the IVF as ordered.
6. Label the IVF bottle properly.

After:

1. Document the IVF properly on the chart.

2. Check for any sign of infection.
3. Monitor the rate flow every hour.
 4. Monitor the patency of the tube and the IV site.

Medical Classification General Indication(s) Client's

Management/ Action or Response
Treatment Purpose(s)

Blood Partial Red Blood To To treat anemia Patient's

Transfusion immediately
Cell restore and increase hemoglobin
2 units blood hematocrit and level
volume to
treat severe hemoglobin increased
anemia, to from 78 to 100
be able to
and
maintain
oxygen hematocirt
transport to from 0.23 to
the different
parts of the 0.28 for the
body. 1st treatment

Nursing Management

Before

1. Assess client for history of previous BT and any adverse reactions

2. Ensure that the client has an 18 to 19 gauge IV catheter in place
3. Use 0.9% sodium chloride IVF
4. Verify the ABO group, Rh type, client and blood numbers and expiration date.
5. Take baseline vital signs before initiating BT
6. Identify the patient prior to transfusion
7. Explain the purpose of the transfusion

During

1. Start transfusion slowly

2. Maintain prescribed transfusion rate
3. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post
transfusion

After

1. Monitor for adverse reactions

Medical Classification General Indication(s) Client's

Management/ Action or Response
Treatment Purpose(s)

Dialysis Hemodialysis Chronic kidney to remove Patient's

disease cause wastes, such
the kidneys to as urea, from electrolyte
lose their ability the blood, restore level is within
to filter and the proper
remove waste balance normal. He
and extra fluid of electrolytes in experienced
from the body the blood,
difficulty of
.Hemodialysis is eliminate extra
a process that fluid from the breathing
uses a man- body. during the
 made treatment
membrane
dialyzer

Nursing Management

Before

1. Explain the purpose of the transfusion

2. Have client void
3. Chart client’s weight
4. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension
(unless ordered otherwise)

During

1. Obtain and record vital signs before and every 30 mins. during the procedure
2. Ensure bedrest with frequent position changes for comfort
3. Proper heparinization must be done to prevent coagulation during the therapy
4. Inform client that headache and nausea may occur
5. Monitor closely for bleeding since blood has been heparinized for procedure

After

1. Weight the patient after the therapy and record

2. Monitor vital signs especially hypotension.
 3. Assess for complications (hypovolemic shock, dialysis disequilibrium
syndrome)

MEDICATION

Date
ordered
Route of
admin. Client’s
Date Indication (s)
Name of Dosage General response
Taken
Drug and freq. action to
Purpose(s)
Of medication
Date
admin.
changed
or D/C
Generic DO:
Name: 09/03/17 40g/IV Anti It is a treatment for Patient didnt
secretory GERD with patients experience
Omeprazole drug who is experiencing vomiting
Proton epigastric pain and
pump decreases
inhibitor verbalization
of pain
Brand
Name:

Losec
Nursing responsibiltites:

BEFORE :

1. Assess for any history of allergy and lactation

2. Assess the color of the skin and lesions affect and orientation.
3. Orient the patient about the drug to be given
4. Perform any abdominal and respiratory examinations.

DURING :

1. Administer drug before meals.

2. Provide appropriate safety and comfort measures if CNS effector occurs to
prevent injury
3. Make sure the patient swallow the tablets or capsules whole, not to open, chew
or crush.
4. Offer support and encouragement to help patient cope with the disease and the
drug regimen.
5. Provide thorough patient
6. teaching about the drug to enhance patient’s knowledge about drug therapy and
promote compliance.
AFTER :

1. Caution patient to avoid hazardous activities if he gets dizzy to avoid injury

2. Monitor for adverse effect of the drugs.
3. Monitor effectiveness to comfort and safety measures and compliance with
regimen.
4. Evaluate effectiveness of teaching plan.

Date
ordered
Route of
admin.
Date Indication (s) Client’s
Name of Dosage General
Taken response to
Drug and action
Purpose(s) medication
freq. Of
Date
admin.
changed
or D/C
DO:
09/03/17 To decrease Patient's blood
blood pressure pressure
Generic 35mg Blocks and heart rate decreased
Name: OD, oral stimulation from
of beta1 160/100mmHg
(myocardial)- to 140/100
Trimetazidine adrenergic mmHg
receptors. It
does not
usually affect
Brand beta2
Name: (pulmonary,
vascular,
uterine)-
adrenergic
Trimet receptor
 sites. It also
decreases
blood
pressure and
heart rate.

Nursing Responsibilites:

1. Monitor blood pressure, and pulse frequently.

2. Monitor intake and output ratios and daily weight.

3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight
gain, peripheral edema, jugular venous distention)

4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold

medication and notify health care professional.

5. Administer metoprolol with meals or directly after eating.

6. Caution patient minimize activities that require alertness because metoprolol can
cause dizziness.

7. Caution patient that this medication can increase sensitivity to cold.

8. Instruct to avoid caffeinated drinks like teas and colas.

9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue

occurs.
10. Reinforce the need to continue additional therapies for hypertension such as sodium
restriction, stress reduction, regular exercise)

11. Emphasize compliance to the medication.

Date
ordered
Route of
Client’s
Date admin. Indication (s)
Name of General response
Taken Dosage
Drug action to
and freq. Purpose(s)
medication
Date Of admin.
changed
or D/C
DO:
09/03/17 used to lower uric Patient
acid levels in people didnt
80g OD, Anti-uric with gout. manifest
oral acid increase in
Generic uric acid as
Name: well as
kidney
stones

Febuxostat

Brand
Name:

Uloric
Nursing Responsibilities:

1. Assess patient’s history, gout may be secondary to disease such as acute or

chronic leukemia, polycythemia vera, multiple myeloma or psoriasis.
2. Assess for pain including location, characteristics, onset/duration, frequency,
quality, intensity or severity of pain, precipitating factors.
3. Monitor uric acid levels every 2 weeks. Monitor renal function; check intake-
output ratio, increase fluids to 2 L/day to prevent stone formation, toxicity, BUN,
creatinine.
4. Monitor CBC and hepatic function at the start of therapy and periodically
thereafter.
5. Be alert for adverse reaction and drug interaction, anemia, hepatitis.
6. Advaic patient to avoid hazardous activities requiring mental alertness until CNS
effect are known.
7. Advice patient to avoid taking large dose of vitamin C, it may cause kidney stone
formation. Maintain a diet enhancing urine alkalinity, and if taking drug for
calcium oxalate stones, reduce dairy products, refined sugar,

Date
ordere
d
Route of
Client’s
admin.
Date Indication (s) response
Name of Dosage General
Taken to
Drug and freq. action
Purpose(s) medicati
Of
Date on
admin.
change
d or
D/C
 DO: Failing kidney
09/03/1 health often
Metabolic acidosis is a
7 causes more
Generic 650mg condition where there Patient
Name: TID, oral acid than did not
is an acid-alkali
normal in the show any
imbalance in the side
blood
blood, that results in effects
Sodium (acidosis),
high blood acidity (low
Bicarbona which in itself
te pH) and low
is thought to
plasma bicarbonate le
cause harm. It
vels
has been
Brand
Name: suggested that
a treatment
strategy
Zegerid for patients wit
h acidosis is
to give alkaline
solutions to
counteract or
neutralize
effects of the
acid

Nursing Responsibilities:

1. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea,

hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered breathing
pattern), hypernatremia (edema, weight gain, hypertension, tachycardia, fever, flushed
skin, mental irritability), or hypokalemia (weakness, fatigue, arrhythmias, polyuria,
polydypsia)
2. Assess fluid balance (intake and output, daily weight, edema, lung sounds)

3. Take med with full glass of water.

4. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance, and

renal function prior to and periodically through out the therapy.

Date
ordered
Route of
admin. Client’s
Date Indication (s)
Name of Dosage General response
Taken
Drug and action to
Purpose(s)
freq. Of medication
Date
admin.
changed
or D/C
DO:
09/03/17

Generic 1 tab TID Anti-ulcer Patient was

Name: relief from
Gastric pain which
protector Gastroprotective is originated
drug for efficacy from the
Mucosta to heal peritoneal
experimental cavity and
gastric ulcers due to fluid
retention
and epigastric
Brand
pain
Name:

Rebamipide
Nursing Responsibilities:

1. May be taken with or without food

2. Assess for signs of acidosis (disorientation, headache, weakness, dyspnea,

hyperventilation), alkalosis (confusion, irritability, paresthesia, tetany, altered
breathing pattern), hypernatremia (edema, weight gain, hypertension,
tachycardia, fever, flushed skin, mental irritability), or hypokalemia (weakness,
fatigue, arrhythmias, polyuria, polydypsia)
3. Assess fluid balance (intake and output, daily weight, edema, lung sounds)
4. Take med with full glass of water.
5. Monitor serum electrolyte concentrations, serum osmolarity, acid-base balance,
and renal function prior to and periodically through out the therapy.

Date
ordered
Route of
admin. Client’s
Date Indication (s)
Name of Dosage General response
Taken
Drug and action to
Purpose(s)
freq. Of medication
Date
admin.
changed
or D/C
DO:
09/03/17 Patient's
Prevention and electrolyte
Generic 2 tab 40g Essential treatment of levels
Name: TID amino acids conditions increases
caused by as to 1st
Protein modified or treatment
supplement insufficient
Ketoanalogue protein
metabolism
in chronic renal
Brand failure
Name:

Ketobest
Nursing Responsibilities:

1. Evaluate for any contraindications

2. Take drug as prescribed

3. Warn the patient about possible side effects and how to recognize them

4. Give with food if GI upset occurs

5. Frequently assess for hypercalcemia

Date
ordered Route
of
Date admin. Indication (s) Client’s
Name of
Taken Dosage General action response to
Drug
and Purpose(s) medication
Date freq. Of
changed admin.
or D/C
 DO:
09/03/17 Patient's blood
pressure
Generic 40 mg Calcium decreased
Name: 1 tab antagonist, from
BID antihypertensive 160/100mmHg

Amlodipine is also used to

Amlodipine to treat high blood 140/90mmHg
besylate pressure(hypertension).
Lowering blood
pressure may lower
your risk of a stroke or
Brand heart attack.
Name:

Norvasc

Nursing Responsibilities:

1. Monitor blood pressure, and pulse frequently.

2. Monitor intake and output ratios and daily weight.

3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight
gain, peripheral edema, jugular venous distention)

4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold

medication and notify health care professional.

5. Administer metoprolol with meals or directly after eating.

6. Caution patient minimize activities that require alertness because metoprolol can
cause dizziness.

7. Caution patient that this medication can increase sensitivity to cold.

8. Instruct to avoid caffeinated drinks like teas and colas.

9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue

occurs.

10. Reinforce the need to continue additional therapies for hypertension such as sodium
restriction, stress reduction, regular exercise)

11. Emphasize compliance to the medication.

Date
ordered Route
of
Date admin. Indication (s) Client’s
Name of
Taken Dosage General action response to
Drug
and Purpose(s) medication
Date freq. Of
changed admin.
or D/C
DO: Clonidine lowers
09/03/17 blood pressure Patient's blood
by decreasing pressure
Generic 75mg 1 decreased
tab BID the levels of from
Name: certain 160/100mmHg
lonidine is used to treat
chemicals in hypertension (high
Clondine to
your blood. This blood pressure).
140/90mmHg
allows your
blood vessels to
Brand relax and your
Name: heart to beat
more slowly and
 Catapres easily.

Nursing Responsibilities:

1. Monitor blood pressure, and pulse frequently.

2. Monitor intake and output ratios and daily weight.

3. Assess routinely for signs and symptoms of CHF (dyspnea, rales, crackles, weight
gain, peripheral edema, jugular venous distention)

4. Take apical pulse before administering. If <50bpm or if arrhythmia occurs, withhold

medication and notify health care professional.

5. Administer metoprolol with meals or directly after eating.

6. Caution patient minimize activities that require alertness because metoprolol can
cause dizziness.

7. Caution patient that this medication can increase sensitivity to cold.

8. Instruct to avoid caffeinated drinks like teas and colas.

9. Monitor blood glucose levels especially if weakness, malaise, irritability, or fatigue

occurs.
10. Reinforce the need to continue additional therapies for hypertension such as sodium
restriction, stress reduction, regular exercise)

DIET

Date ordered
Indication (s) Client’s
General
Type of diet Date started response to
description
Purpose (s) the diet
Date changed

Low salt, low DO: 09/03/17 Foods that has To decrease Patient strictly
protein low salt and further complied with
protein value. production of the prescribed
purine which diet
Animal can contribute
products (fish, in increasing
poultry, eggs, level of
meat and dairy
creatinine in the
products) are blood
considered
"high quality
protein."
Vegetable
products
(breads,
cereals, rice,
pasta, dried
beans) are
considered "low
quality protein.

Diet for diabetic monotherapy

Diabetic diet Patient's
patients must as an adjunct to
glucose level
 be accurately diet maintaned in a
weighed or and exercise to normal range
gauged. Too lower blood
many glucose in
carbohydrates patients with
mean too much type 2 diabetes
glucose; too whose
much protein hyperglycemia
and fats may cannot be
overwork the controlled by
liver and diet
kidney. and exercise al
one.
Fruits and
vegetables.
Meat and
seafood.
Choose fatty
fish for heart
health and
brain
protection.
Legumes.
Dairy. Shoot for
two to three
low-fat servings
per day
Frozen foods. .
Breakfast
cereals and
snacks
Grains

Nursing Responsibilities

Prior:

1. Check and determine the prescribed diet

 2. Inform the SO about the prescribed diet
3. Explain the procedure and purpose of the prescribed diet
4. Cite foods that are restricted.

During:

1. Check vital signs to obtain baseline data

2. Observe for initial response.

After:

1. Inform SO if it would be changed

2. Observe and monitor for changes

EXERCISE

Date ordered
Indication (s) Client’s
Type of General
Date started response to
activity description
Purpose (s) the activity
Date changed

An activity To decrease
wherein the consumption of
Bed rest with DO: 09/03/17 patient is oxygen and to Patient strictly
bathroom advised to be able to complied with
privelege stays at bed conserve the prescribed
and allowed to energy activity
do activities like
doing bathroom
priveleges
Nursing Responsibilities

1. Explain the procedure to patient.

2. Explain importance of activity.
3. Assist patient in doing the activity.

ACTUAL SOAPIE

September 07, 2017

S>Ø

O> Received patient on sitting position, awake and appears wake with easy fatigability

> VS taken and recorded as follows: T-36, PR-86, RR-17, BP-160/100

A > Decreased cardiac output r/t vascular resistance secondary to hypertension

P > After 6 hrs of nursing interventions, patient will improve cardiac output as evidence
by normal vital signs and decreased in fatigability

I > Monitored VS and recorded

> Established rapport

 > Instructed to avoid strenuous activity

> Provided calm environment

> Encourage to ambulate early

> Assisted in changing position

> Instructed SO to avoid introducing stress to the patient

> Monitored I&O strictly

E > Goal met as evidence by decreased blood pressure from 160/100mmHg to

140/90mmHg
 D. Evaluation

1. Clients Daily Progress Chart (From Admission to 6th day)

1st Day 2nd Day 3rd Day 4th Day 5ft Day

(09/2/17) (09/3/17) (09/4/17) (09/5/16) (9/6/17) SNPI

1. Nursing Problems
1.Ineffective Tissue Perfusion *
2. Fluid Volume Excess (Interstitial *
spaces)
3. Decreased Cardiac Output *
4. Acute pain *
5.Activity Intolerance *
6.Deficient knowledge *
7. Impaired Urinary Elimination *
Vital Signs
Temperature 36.6’C 36’C
Pulse Rate 88 86
Respiratory Rate 19 17
Blood Pressure 150/100 160/100
2. Complete Blood Count
Hemoglobin (140-175 g/L) 78 100
Hematocrit (0.41-0.50 g/L) 0.23 0.28
Platelet Count (150-400x 109/L) 147 132
White Blood Cell (4.50-11.0x 109/L) 7.03 8.26
Neutrophils (0.18.0-0.70%) 0.88 0.82
Lymphocytes (0.10-0.48%) 0.06 0.07
Monocytes (0.00-0.04%) 0.05 0.07
Eosinophils(0.003-0.003) 0.01 0.03
Electrolytes
Sodium (135-150meq/L) 124.6 130.5
Potassium (3.50-5.50 meql/L) 3.74 3.9

Magnesium (1.5-2.5meq/L) 1.02 1.05

Calcium (4.5-5.5meql/L) 1.02 1.18

Creatinine (63-108umol/L) 78.12 76.77

BUN (2.78-8.07mmol/L) 97.03 97.05
SGOT/AST (0.00-35.00) 28.07 23.19
SGPT/ALT (0.00-45.00) 1.33 9.12
3. Urinalysis
Color (Straw) Light
Yellow
Trans (Clear) Turbid
Rxn (Slightly acidic) Acidic
Specific Gravity (1.010-1.030) 1.020
Albumin(none) ++++
MICROSCOPIC EXAMINATION
Pus (None) 1-2
Epithelial Cells rare
Mucus Threads N/A
Bacteria Few
Crystals N/A
Medical Management
IVF
a. PNSS 1L * * * * * *
BLOOD TRANSFUSION
a. PRBC 2 Units * *
DRUGS
1. FeSO4 + Fa * * * * * *
2. Omeprazole * * * * *
3. Trimetazidine * * * * *
4. Febuxostat * * * * * *
5. Sodium Bicarbonate * * * * * *
6. Mucosta * * * * * *
7. Ketoanalogue * * * * * *
8. Amlodipine besylate * * * * * *
9. Clonidine * * * * * *
DIET
1. LOW SALT * * * * *
2. LOW PROTEIN * * * * *
3. DM DIET * * * * *
III.SUMMARY OF FINDINGS:

 Chronic kidney disease (CKD) is a slow progressive loss of kidney function over
a period of several years.
 CKD develops primarily as a result of decreased renal synthesis of
erythropoietin, manifests as fatigue, reduced exercise capacity, impaired
cognitive and immune function, and reduced quality of life.
 Testing in patients with chronic kidney disease (CKD) typically includes a
complete blood count (CBC), basic metabolic panel, and urinalysis, with
calculation of renal function. Blood urea nitrogen (BUN) and serum creatinine .
Serum albumin levels may also be measured.
 Kidney failure is generally a multi-organ health issue, with a variety of cross
effects on different body systems.
 The appropriate nursing diagnosis fotr the patient are Ineffective tissue
Perfusion, Fluid Volume Excess, Decrease Cardiac Output, Acute pain, Activity
Intolerance, Deficient knowlede and Impaired Urinary Elimination.
 The two main causes of chronic kidney disease are diabetes and high blood
pressure
 Primary non-modifiable risk factors for the progression of CKD have been
identified, including age, ethnicity, gender and family history modifiable risk
factors, which are associated with both impaired renal and cardiac function,
include diabetes, hypertension, smoking, inflammation and anemia.
 Early detection can significantly help prevent serious kidney damage.
 Glomerular filtration rate (GFR) is the best estimate of kidney function.
 Treatment for chronic kidney disease focuses on slowing the progression of the
kidney damage, usually by controlling the underlying cause.
 It is not unusual for people to realize they have chronic kidney failure only when
their kidney function is down to 25 percent of normal.
 The final stage of CKD is called end-stage renal disease (ESRD).
 Chronic kidney disease can cause high blood pressure.
  Chronic kidney disease can progress to end-stage kidney failure, which is fatal
without artificial filtering (dialysis)
 There are no symptoms in the early stages of diabetic nephropathy. If you have
kidney damage, you may have small amounts of protein leaking into your urine
(albuminuria).
 Important treatments for kidney disease are tight control of blood glucose and
blood pressure. Blood pressure has a dramatic effect on the rate at which the
disease progresses. Even a mild rise in blood pressure can quickly make kidney
disease worsen.

IV. CONCLUSION:

In conclusion, Chronic kidney failure, as opposed to acute kidney failure, is a slow

and gradually progressive disease. CKD is a major cause of cardiovascular morbidity
and mortality and is considered a significant public health problem that places a burden
on global healthcare resources. Mr. CKD develops primarily as a result of decreased
renal synthesis of erythropoietin, manifests as fatigue, reduced exercise capacity,
impaired cognitive and immune function, and reduced quality of life.Primary non-
modifiable risk factors for the progression of CKD have been identified, including age,
ethnicity, gender and family history modifiable risk factors, which are associated with
both impaired renal and cardiac function, include diabetes, hypertension, smoking,
inflammation and anemia.

Testing in patients with chronic kidney disease (CKD) typically includes a

complete blood count (CBC), basic metabolic panel, and urinalysis, with calculation of
renal function. Blood urea nitrogen (BUN) and serum creatinine . Serum albumin levels
may also be measured. Kidney failure is generally a multi-organ health issue, with a
variety of cross effects on different body systems.Important treatments for kidney
disease are tight control of blood glucose and blood pressure. Blood pressure has a
dramatic effect on the rate at which the disease progresses. Even a mild rise in blood
pressure can quickly make kidney disease worsen. The appropriate nursing diagnosis
fotr the patient are Ineffective tissue Perfusion, Fluid Volume Excess, Decrease Cardiac
Output, Acute pain, Activity Intolerance, Deficient knowlede and Impaired Urinary
Elimination.

The best that we can do at present is to concentrate our efforts on the prevention
of the progression of renal diseases. We should redouble our efforts to remind the
public on the need to pay attention to maintain their blood sugar and blood pressure at
the normal level. Prevention through a healthy lifestyle plays a major role to reduce if
not totally control the epidemic of renal failure and this could be achieved through
proper education. With that, we will be able to help decrease or at least slow down the
increase in statistics of patients suffering from kidney problems.

The student nurses have learned in this case study the characteristics of three
interrelated disease conditions, their risk factors that predisposed the client to such
condition, and the management for such condition. They were able to understand
different mechanisms, physiology, as well as the pathophysiology of the disease.

The student-nurse patient interaction plays a very crucial role because it serves as
a way to know more about the disease condition & its manifestation through thorough
assessment of the patient’s history.

V. RECOMMENDATIONS

To all health care providers, that they may have more knowledge and updated
information about the disease condition and aid in its early detection so that nursing
care may be rendered to be of quality to the patient.

To the nursing administration, that they may conduct seminars on the topic so
that clients may be more aware of the disorder process and thereby, prevent its
occurrence.

To the public, that they may become more knowledgeable of the disease
condition risk factors and signs and symptoms. Also, the management involved in its
course.
 For the patients who are undergoing this kind of condition for them to be more
familiar of their diagnosis and to know certain alternatives to avoid the progress of the
disease and improve their health status.

This will help the patients and their significant others to have their activities and
lifestyle modified to prevent further complications. Proper maintenance and care for the
patient is essential. Stress the significance of regular check-up so that secondary
complications may be prevented. Advise the family to maintain healthy and harmonious
relationships and provide holistic support to the patient.

VI. LEARNING DERIVED

Learning is a continuous process which we gain not only through books and
lectures but also with the situations we encounter around us in our everyday life. Seeing
a person experience difficulty because of a disease condition is an eye opener. Life is
always at stake in this profession. Thus, making a mistake or assumption must never be
an option. One of the most important things we learned is to change our view about
doing a case study. We usually see this requirement as a burden since it requires too
much time and effort. However, we realized that this case study is not conducted for us
to complete our requirements but for us to learn a little about our profession compare to
the vast knowledge that lies ahead of us. It is a method of widening the horizon of
learning as it is an essential part of students especially nursing students who are
aspiring to handle life of their patients.

Through the case study, I was able to recall the concepts of anatomy and
physiology specifically how the kidneys work that we should not abused them for they
are important organs of our body to maintain homeostatis. If our kidneys were
damaged, it looses its function and it will not filtrate waste products and this might
accumulate in our body which can lead to other health problems, including heart
disease, anemia and bone disease. After conducting the study, our group may have
struggled we were able to finish and apply everything that we learned from NCM and i
appreciated it more since we were able to handle a patient that has Chronic Kidney
Disease. This case study made me realize that i have to be aware of the risks that can
make me prone to having kidney problems.

-Garcia, Ayanalynn

Through this case study, I was able to understand the patient’s condition. It made
me realized that through a thorough assessment, I was able to provide appropriate
nursing interventions. This case study really helped me in constructing nursing
diagnosis that would be appropriate to the patient’s condition. I am very lucky and
blessed to have a chance to meet a patient with this kind of condition. After doing this
case study, I think I am challenge to handle different cases.

-Ohashi, Jiromi Jerico

As a student nurses I was able to hear from the different patients in the ward that
they admitted that they are the cause why they’re hospitalized. They told us that they’re
not taking good care of their health. One of our responsibility as a nurses is to educate
the people for them to become an independent individuals and to prevent different
diseases and to prevent different complications that may arise if the disease is not
treated immediately. We were able to emphasized to our patients the health teachings
and they were able to verbalized and understand it.

-Pangilinan, Raidis

Case study is one of our requirements. It was made for us student nurses to be
able to gain knowledge and information regarding our patient’s condition. In this case
study,I able to learn more about CKD secondary to DM Nephropathy. We were able to
connect and rationalize the manifestations of our patient with the disease condition. This
case study really helped me to understand the definition, risk factors, pathophysiology,
diagnostic tests, interventions and was able to formulate nursing diagnosis in relation to
our patient’s condition. Through this case study, I was able to understand the patient’s
condition. I hope to have a chance to see more new cases to increase my knowledge
and capabilities.

-Tapnio, Crizzel Ann

VII. BIBLIOGRAPHY

 Fundamentals of Anatomy and Physiology Workbook (Ian Peate)

 Susan C. deWit, Candice K. Kumagai’s Medical-Surgical Nursing: Concepts & Practice,
2nd Edition
 Black and Hawk’s Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 8th edition
 Lemone’s Medical-Surgical Nursing: Critical Thinking in Patient Care, 5th edition
 Karch, Amy. Lippincott Nursing Drug Guide, 2015
 http://www.who.int/
 https://www.niddk.nih.gov/health-information/health-topics/kidney-disease/anemia-in-
kidney-disease-and-dialysis/Pages/facts.aspx
 http://www.karger.com/Article/Abstract/418267
 http://patient.info/doctor/chronic-kidney-disease-pro