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CHAPTER I

INTRODUCTION

Pneumonia (say: new-moan-ya) is an inflammation of one or both lungs. In


people with pneumonia, air sacs in the lungs fill with fluid, preventing oxygen from
reaching blood cells and nourishing the other cells of the body. When you breathe
in, you pull oxygen into your lungs. That oxygen travels through breathing tubes
and eventually gets into your blood through the alveoli (say: al-vee-oh-lie).
( Encarta 2006)

Pneumonia can be divided into three groups: community acquired,

hospital or nursing home acquired (nosocomial), and


pneumonia in an immunocompromised person.

Community-acquired Pneumonia is a disease in which individuals who have


not recently been hospitalized develop an infection of the lungs. It is an acute
inflammatory condition that’s result from aspiration of oropharyngeal secretions or
stomach contents in the lungs. CAP occurs because the areas of the lung which
absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot
work effectively. Streptococcus pneumoniae remains the most commonly identified
pathogen in community-acquired pneumonia. Other pathogens have been reported
to cause pneumonia in the community, are Staphylococcus,
Haemophilusinfluenzae, Klebsiella, Legionella. ( Johnson:2008)

Accrording to DOH,in the Philippines, there are more than 40,000 cases of
CAP annually. More than 50% are admitted in the hospital. Pneumonia is considered
the 3rd leading cause of death and the 4th leading cause of morbidity as of 2005.
The morbidity trend decreased slightly from 1997 to 2000 but the number of cases
remained high at 829 cases per 100,000 population in 2000. On the other hand,
there is a decreasing trend of mortality from pneumonia in the general population
from 1990 to 2000 despite the high number of cases per year. The mortality rate
from pneumonia decreased from 64.7 deaths per 100,000 population in 1990 to

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42.7 deaths per 100,000 in 2000 (PHS). This reflects improvement in the diagnosis
and treatment of cases.

Chronic kidney disease (CKD), also known as chronic renal disease, is a


progressive loss of renal function over a period of months or years. The symptoms
of worsening kidney function are unspecific, and might include feeling generally
unwell and experiencing a reduced appetite. Often, chronic kidney disease is
diagnosed as a result of screening of people known to be at risk of kidney problems,
such as those with high blood pressure or diabetes and those with a blood relative
with chronic kidney disease. Chronic kidney disease may also be identified when it
leads to one of its recognized complications, such as cardiovascular disease,
anemia or pericarditis (National Kidney Foundation, 2002).

End-stage renal disease (ESRD) occurs when 90% of the nephrons are lost,
Patients at this stage experience chronic and persistent abnormal kidney Function.
The BUN and creatinine levels are always elevated. These patients may make urine
but not filter out the waste products, or urine production may cease. Dialysis or a
kidney transplant is required to survive. ( Medical-Surgical Nursing, Linda S.
Williams, et.al. : 2003)

Nephrosclerosis refers to the changes in the nephron, specifically the afferent and
the efferent arterioles and the glomerular capillary loops. The vessel walls thicken,
and the vessel lumen narrows. As a result, renal blood flow is decreased and
interstitial tissue changes occur. Over time, ischemia and fibrosis develop.

Nephrosclesosis is associated with benign essential hypertension or


malignant hypertension and the effects of atherosclerosis. A history of diabetes
mellitus is also common. The effects of essential hypertension on renal vasculature
may be controlled with adequate blood pressure control. (Medical-Surgical Nursing
2nd edition, 2002: 2101).

Kidney disease is on the rise and is an important cause of death in the


Philippines. Statistics show that kidney disease among the Filipinos is shooting
up every year. Almost 10,000 Filipinos requiring either dialysis for life or a kidney

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transplant for survival. About 31% of them have the most advanced stage of the
disease.

The main cause of kidney disease seems to be the increasing diabetic


conditions among the Filipinos. It is seen that about 55% of Filipinos develop kidney
disease when they suffer from diabetes. The Philippine Society of Nephrology (PSN)
issued the statement that diabetes is the single most common cause of kidney
failure among diabetes mellitus nephropathy patients.

Significance of the Study

This study aims to educate the people about the disease of the kidneys
specifically chronic kidney disease. Many of us know that most of our country men
like to eat food that is salty. They don’t control themselves in terms of that
physiological activity. This study also aims to be their eye opener for understanding
how important our body is and how important is its functions to our daily life
activities. Lastly, this study aims to be the advocate of good health and wellness to
those people who will read it.

CHAPTER II

PATIENT PROFILE

A. Biographic and Demographic data

The reporter names his patient “Mila,” from Alalum, San Pascual, Batangas.
Mila was born on September 20, 1943 in Mindoro. She is 66 years and 10 months
old, single and retired teacher. She is a devoted roman catholic who regularly
attends most of the church’s programs. For her health-care financing support she
uses her “Phil-health card,” “GSIS,” and her monthly retirement pension. She was
admitted in the ICU department of Mary Mediatrix Medical Center on July 20, 2010
at 10:00 am. Most of the information of the patient where taken from her, through
writing, chart, and her sister.

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B. Health History

1. Chief complaints

Patient Mila was admitted with her chief complaints of difficulty of breathing.

2. History of present illness

3 days prior to admission, patient Mila developed productive cough and colds
with series of unrecorded fever and shortness of breath. Patient Mila had chest pain
due to increasing severity of cough and effort of shortness of breath, and diarrhea.

1 day prior to admission, patient was brought to the ER for consultation and
ordered for admission but refused and signed consent for refusal. Patient was given
Levofloxacin and Fluimucil. Few hours prior to admission; due to severe dyspnea,
patient consulted and was admitted.

3. past medical history

She is hypertensive; she was diagnosed to have hypertension when she was
45 years old.She takes metroprolol only when she feels faint or pain at her nape. At
same age, she was also diagnosed of having diabetes mellitus. She has no history of
pulmonary tuberculosis or cancer. Her sister stated that she has no allergies to any
drugs or foods. She is not taking any vitamins or supplements.

4. Family history

According to patient Mila’s sister, theirfamily have a history of hypertension


from both of their parents; diabetes mellitus from their mother; and death of their
cousin of renal disease 3 years ago.

5. Lifestyle

Personal habits

Patient Mila’s habits were sewing table clothes and gardening as what
she wrote.

Diet

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The typical diet of patient Mila was food rich in protein such as meat
and fish. Vegetable dishes were served 3 times a week as written by the
patient.

Activities of daily living

Patient Mila stays most of the time inside their house sewing table
clothes and doing most of the household chores.

Recreation and hobbies

Besides sewing, patient Mila spends time in reading the Bible and
watching television.

6. Social data

Patient Mila is the eldest among her 6 siblings; she is most attached to her 3rd
younger sister who brought her to the hospital. She speaks tagalog, she resides in
San Pascual, Batangas. She belongs to a senior citizen group who are also active in
participating church’s activities. She is a retired elementary teacher. She stays with
her sister and her sister’s family. She has no problem with her neighbours.

C. Developmental theories

Erick Erickson’s Psychosocial Theory

Integrity versus despair

Ability to adapt changes in lifestyle, functioning level, and family structure.

After the retirement of patient Mila, as what previously stated she spends
time in sewing, reading the Bible and joining senior citizen group were they
participate in most of the church’s activities. She stays with her sister and her
sister’s family.

Sigmund Freud’s Psychosexual Theory

Genital Stage

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It is the stage where full sexual maturity and function development of skills
needed to cope with the environment (Kozier, et. al., 2008 p.352).

Patient Mila had reached full sexual maturity and full potential of being a
woman. She never regrets her single status, her first love was teaching. Being a
teacher already feels like being a mother as what she wrote.

Jean Piaget’s Cognitive theory

Formal Operations Phase

This phase manifests use of critical thinking and reasoning is deductive and
futuristic (Kozier, et. al., 2008 p.357).

Patient Mila has achieved formal operational phase, with her almost 40 years
of being a teacher she is able to decide on her own. As what observed, she is able
to decide on her hospitalization needs, she instructs her sister by hand writing.

Lawrence Kohlberg’s Moral Evolution theory

Post- Conventional (Social Contract Legalistic Orientation)

In this stage the person lives autonomously and defines moral values and
principles that are distinct from personal identification with group values. She lives
according to principles that are universally agreed on and that the person considers
appropriate for life, universal focus. In social contract legalistic orientation, the
social rules are not the sole basis for decisions and behaviour because the person
believes a higher moral principle applies such as equality, justice, or due process
(Kozier,et. al., 2008 p.359).

Patient Mila has a good attitude when it comes to dealing with other people
despite her present condition. She has formulated her own principle from the
experience she had gone through.

Robert Havighurst’sAge periods and Developmental Tasks

Late Maturity

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This stage of development showcases in adjusting to decreasing physical
strength and health, retirement and reduced income, establishing an affiliation with
one’s age group, adopting and adapting social roles in a flexible way, and
satisfactory physical living space.

Patient knows that her present condition is part of being old as written by
her. She is a member of senior citizen in their place. She has a satisfactory physical
living space.

CHAPTER III

ASSESSMENT

A.Physical assessment

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System Normal Findings Standard Book Actual signs and
Picture Manifestations symptoms
manifested by the
patient
Neurological The patient appears Weakness and July 20, 2010:
relaxed, smooth gait, Fatigue; confusion;
12:30pm
and symmetrical body inability to
movements. The concentrate; Weak, Restless,
patient should be able to disorientation; irritable, with
correspond to verbal tremors; seizures; GCS of 9/15,
orders, oriented to time, astrexis; eyes open
person, and place. The restlessness of legs; spontaneously,
patient should have the burning of soles of with symmetrical
ability to concentrate or feet; behaviour body movements.
maintain attention span. changes.
2:30pm
A conscious patient
should correspond to Appears relaxed,
verbal, eye, and motor GCS of 11/15, eyes
orders. open
spontaneously,
with symmetrical
body movements.

July 21, 2010:

Alert, Relaxed,
GCS of 11/15

Respiratory Chest must be Crackles; thick, July 20, 2010:


symmetric, spine tenacious sputum;
(+)wheezes on
vertically aligned, skin depressed cough
both lungs, (+)
must be intact, chest reflex; pleuritic pain;
crackles, RR: 28,
wall intact, uniform shortness of breath;
SOB, O2 sat:
temperature, quiet, tachypnea;
78% uniform
rhythmic, effortless kussmaul-type
temperature, full
respirations, full respirations; uremic
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B. Diagnostic Test

Diagnostics and Laboratory tests

Chest X-ray

 Significance to patient
Evaluate known or suspected pulmonary and cardiovascular disorder.
Evaluate placement and position of an endotracheal tube.
Monitor effectiveness of treatment regimen.
 Result:
Shows bilateral pulmonary congestion and edema; bilateral minimal
pulmonary effusions are also seen
 Nursing considerations/responsibilities

Before

• Positively identify the patient using at least two unique identifiers


before providing care, treatment, or services
• Inform the patient that the procedure assesses cardiopulmonary
status.
• Obtain a history of patient’s symptoms and complaints, including a list
of known allergens
• Record the date of last menstrual period .
• Review the procedure with the patient. Address concerns about pain
and explain that no pain will be experience during the test.

Intra-test

• Ensure that the patient has removed all external metallic objects from
the area to be examined.
• Instruct the patient to remain still throughout the procedure, because
movements result unreliable results.
• Observed standard precautions

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Post-test

• The report will be sent to the requesting HCP, who will discuss the
result with the patient.
• Recognized anxiety related to the test results and be supportive of
impaired activity related to respiratory capacity and perceive loss of
physical activity.

Complete Blood Count

 Significance to patient
Detect haematological disorder, neoplasm, or immunological
abnormality
Monitor fluid imbalances
Monitor the progression of non-hematological disorders such as COPD,
and renal disease
Provide screening as part of CBC count in a general physical exam,
especially upon admission.
 Significant result
Norma Values July 19,2010 July 20,2010

BUN 2.50-6.07mmol/L 14.28

Creatinine 61.88-106.08mmol/L 928.20

Blood uric 0.15-0.35mmol/L 0.30


acid

WBC 5-11 10^3/uL 20.91

RBC 4.2-5.4 10^6/uL 3.53

HGB 12.0-16.0 mg/dL 10.2

HCT 38-47% 32.9

Neutrophil 0.55-0.77% 0.88

Serum Na 135-148mmol/L 129

Serum K 3.5-5.3mmol/L 3.8

Serum Ca 8.2-10.2mg/dL 6.8

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 Nursing considerations/responsibilities

Before

• There is no preparation necessary for a full blood count. It can be done


at any time of the day. However, if the blood test will be used not only
for a blood count but for other reasons (e.g., glucose or cholesterol
monitoring), you will be required to fast before hand. Therefore, this
test is better in morning.
During

• Ensure that the blood is not taken from the hand or arm that has
intravenous line. Hemodilution with intravenous fluids causes a false
decrease in the values of some test.
After

• Assess the puncture site for signs of bleeding or bruising of the skin. If
the platelet count or other clotting measures are decreased, clotting
will be slow to occur. To promote clotting, the nurse can use sterile
gauze to apply pressure to the site or raise the arm above the head
while maintaining pressure on the site.
• Arrange for prompt transport of the specimen. If there is an anticipated
delay, refrigerate the specimen.

12-lead ECG

 Significance to patient
• To help identify primary conduction abnormalities, cardiac
arrhythmias, cardiac hypertrophy, electrolyte imbalnces.
 Significant result

Normal Sinus Rhythm without dysrrhytmia

 Nursing responsibilities
Before

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• Explain the procedure to the patient
• Tell patient that she doesn’t need to restrict fluid or food
• Describe the test including who will perform it, where it will be done,
and how long it will last
• Tell patient that an electrodes will be attach in her arms, legs, and
chest and the procedure is painless
• Advise patient not to talk during the test
• Check patients medication history for use of cardiac drugs, and note
the use for such drugs on the test form

During and after test

• Confirm patient’s identity using two identifiers according to facility


policy
• Place patient on supine position
• Have the patient expose her chest and ankles, provide chest drapes
• Turn on the machine and check the paper supply
• When the machine finishes the tracing, remove the electrodes and
reposition the patient’s gown and bed cover
• Label each ECG strips with patient’s name
• Disconnect the equipment.
• Report any abnormal ECG findings to practitioner

Arterial Blood Gas analysis

 Significance to patient
• To evaluate the efficiency of pulmonary gas exchange
• To assess the integrity of the ventilator system
• To determine the acid-base level of the blood
• To monitory respiratory therapy
 Significant result
Normal Value July 20,2010 July 21,2010

pH 7.35-7.45 7.32

pCO2 35-45 33

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pO2 80-90 74

HCO3 22-26 20.1

O2 sat 96-100% 78 99%

 Nursing responsibilities
Before

• There is no preparation necessary for a full blood count. It can be done


at any time of the day. However, if the blood test will be used not only
for a blood count but for other reasons (e.g., glucose or cholesterol
monitoring), you will be required to fast before hand. Therefore, this
test is better in morning.

During

• Ensure that the blood is not taken from the hand or arm that has
intravenous line. Hemodilution with intravenous fluids causes a false
decrease in the values of some test.
After

• Assess the puncture site for signs of bleeding or bruising of the skin. If
the platelet count or other clotting measures are decreased, clotting
will be slow to occur. To promote clotting, the nurse can use sterile
gauze to apply pressure to the site or raise the arm above the head
while maintaining pressure on the site.
• Arrange for prompt transport of the specimen. If there is an anticipated
delay, refrigerate the specimen.

CHAPTER IV

Nursing Care Plan

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Problem #1:

Difficulty of Breathing

July 20, 2010

Cues:
Subjective:

Obejective:

(+)wheezes on both lungs

(+) crackles Weakness

RR: 28 Capillary refill: 4 seconds

Shortness of breath Cyanosis

ABG’s: ABG’s: pH- 7.32, pCO2- 33,


pO2- 74, HCO3-20.1, O2 sat- 78%
Tachycardia

Chest X-ray: Shows bilateral pulmonary congestion and edema; bilateral


minimal pulmonary effusions are also seen;

Nursing Diagnoses

- Ineffective airway clearance related to tracheal bronchial obstruction secondary to


edema formation as manifested by CXR result: Shows bilateral pulmonary
congestion and edema; bilateral minimal pulmonary effusions, RR: 28bpm,
wheezes, and crackles

-Impaired gas exchange related to altered oxygen and CO2 exchange secondary to
alveolar inflammation and presence of secretions as manifested by capillary refill of
4 sec, ABG’s: pH- 7.32, pCO2- 33, pO2- 74, HCO3-20.1, O2 sat- 78%

Rationale:
Pathoge
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Adheres to alveolar

Alveolar
inflammation
Airway
Alveolar
Formation of obstruction-
ineffective
Impaired gas airway

Planning

NOC: Respiratory status: airway patency and Gas exchange

Short term goal:

After 30 min of nursing intervention patient will display patent airway with breath
sounds clearing, absence of dyspnea, decrease RR from 28 to 12-20bpm

Demonstrate improved ventilation as manifested by capillary refill: 2-3sec,


O2 sat and ABGs within normal limit.
Long term goal:

After 1 day of nursing intervention patient will maintain patent airway and improved
ventilation.

Nursing Intervention

NIC: Respiratory monitoring and airway managemeny

Independent nursing intervetion:

1. Assessed rate/depth of respirations and chest movement.Tachypnea,


shallow respirations, and asymmetric chest movement are frequently present
because of discomfort of moving chest wall and/or fluid in lung. (Doenges: 2007)

2. Auscultated lung fields, crackles and wheezes.Decreased airflow occurs in


areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can

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also occur in consolidated areas. Crackles, and wheezes are heard on inspiration
and/or expiration in response to fluid accumulation, thick secretions, and airway
spasm/obstruction

3. Elevated head of bed, change position frequently. Lowers diaphragm,


promoting chest expansion, aeration of lung segments, mobilization and
expectoration of secretions.

4. Assisted patient with frequent deep-breathing exercises.


Demonstrate/help patient learn to perform activity, e.g., splinting chest
and effective coughing while in upright position.Deep breathing facilitates
maximum expansion of the lungs/smaller airways. Coughing is a natural self-
cleaning mechanism, assisting the cilia to maintain patent airways. Splinting
reduces chest discomfort, and an upright position favors deeper, more forceful
cough effort.(Gulanick and Myers: 2007)

5. Suction as indicated. Stimulates cough or mechanically clears airway.

6. Monitor pulse oximetry readings.Follows progress and effects of disease


process/therapeutic regimen, and facilitates necessary alterations in therapy.
(Doenges: 2006)

7. Perform chest physiotherapy such as Percussion.To help clear excessive


bronchial secretion from airways by shaking mucus from the walls of the airways
and draining them from the lungs. (Balita, 2006:71)

Dependent

8. Administered Duavent neb every shows, Performed treatments between


meals and limited fluids as appropriate.Facilitates liquefaction and removal of
secretions. Coordination of treatments/schedules and oral intake reduces likelihood
of vomiting with coughing, expectorations.

9. Administered Fluimucil 200mg/ sachet 1 sachet TID. Mucolytic that reduces


the viscosity of pulmonary secretions by splitting disulphide linkages between
mucoprotein molecular complexes.

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Collaborative

10. Assistedwith intubation, institution/maintenance of mechanical


ventilation. Development of/impending respiratory failure requires prompt life-
saving measures.

Evaluation

Short term: Goal partially met

After 30 min of nursing intervention has displayed absence of difficulty in breathing


but still have minimal wheezes, RR: 24, O2 sat 98%.

Long term: Goal met

After 1 day of nursing intervention patient had maintained patent airway and
improved ventilation as evidenced by: RR: 22, O2 sat: 99%, but still with minimal
wheezes.

Problem #2: Hypertension

July 20, 2010

Cues

Subjective:

Objective:

• Weak • HR: 63 bpm


• Restless • bounding pulse
• BP: 200/140mmhg • Serum Sodium:
• +1 bipedal edema 129mmol/L
• engorged neck veins

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Nursing Diagnosis

Decreased cardiac output related to increase vascular resistance as


manifested by BP of 200/140.

Rationale: Hypertension or High Blood Pressure, medical condition in which


constricted blood vessels increase the resistance to blood flow, causing an increase
in blood pressure against vessel walls. The heart must work harder to pump blood
through the narrowed arteries. As a result, blood flow to vital organs such as heart,
brain decreases (Microsoft ® Encarta ® 2006).
Vasoconstrict Increased
ion cardiac
output

Increased Increased
in blood flow
peripheral

Planning Increased Blood


Pressure
NOC: Circulation status

Short term Goal

After 4 hours of nursing intervention, patient will manifest reduction of blood


pressure to 130-140/90-100.

Long term Goal

After 2 days of nursing intervention patient will have no elevation of blood pressure
above normal limits and will maintain blood pressure within acceptable limits.

Nursing Intervention

NIC: Hemodynamic regulation

Independent Nursing intervention

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1. Monitor blood pressure every 1 hour. When possible obtain pressures
lying, sitting, and standing. Changes in blood pressure may indicate changes
in patient status requiring prompt attention. Comparing pressures in both
sides provides information as to amount of vascular involvement. Blood
pressure may vary depending on body position and postural hypotension
may result in syncope (Comer:73).
2. Note presence, quality of central and peripheral pulses. Bounding
carotid, jugular, radial, and femoral pulses may be observed/ palpated.
Pulses in the legs/ feet may be diminished, reflecting effects of
vasoconstriction (increased in systemic vascular resistance) and venous
congestion.
3. Observe skin color, moisture, temperature, and capillary refill time.
Presence of pallor; cool, moist skin; and delayed capillary refill time may be
due to vasoconstriction or reflect cardiac decompensation/ decreased output
4. Note dependent / general edema. May indicate heart failure, renal or
vascular impairment.
5. Provide calm, restful surroundings, minimize activity. Helps reduce
sympathetic stimulation, promotes relaxation.
6. Monitor response to medications to control blood pressure.Response
to drug therapy is dependent on both individual as well as the synergistic
effects of the drugs.

Dependent Nursing Intervention

Administer medications as ordered:

7. Adalat 60 mg/tab 1 tab once-a-day. May be necessary to treat severe


hypertension when a combination of a diuretic and a sympathetic inhibitor
does not sufficiently control BP. Vasodilation of healthy cardiac vasculature
and increased coronary blood flow are secondary benefits of vasodilator
therapy.
8. Catapres 75mg/tab 1 tab sublingually as needed for bp> 160/100.
Decreases blood pressure by stimulating alpha-adrenergic receptors to
inhibit sympathetic cardioaccelerator and vasoconstrictor centers.

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9. Prepare for Hemodialysis. Reduction or uremic toxins and correction of
electrolyte imbalances and fluid overload may limit/ prevent cardiac
manifestations such as hypertension.

Evaluation

Short term

Goal partially met:

After 4 hours of nursing intervention, patients blood pressure has decreased to


160/130mmhg but still above expected outcome.

Long term

Goal partially met:

After 2 days of nursing intervention, patient’s blood pressure is 150/100 mmhg


still above normal limit but no elevations noted.

Problem

#3: Joint Pain

July 20, 2010

Cues:
Subjective

Patient wrote 7/10 pain scale

Patient localizes pain on the joints

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Objective:

Serum Ca: 6.8mg/dL BP: 200/140

Serum K: 3.8 N Blood uric acid 0.30mmol/L

Grimace BUN: 14.

Nursing Diagnosis

Acute pain related to accumulation of uric acid to bones secondary to renal failure

Rationale:

Renal

Loss of excretory Loss of non-excretory

Inability to metabolize Decrease calcium Decreased calcium serum


vit D. absorption level

osteomalac Bones become weak and Bones become weak 21


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ia brittle brittle

swelli pai
Planning

NOC: Pain control

Short term:

After 2 hour of nursing intervention, patient will demonstrate relief from pain as
evidence by absence of facial grimace and reduce pain scale.

Long term:

After 1 day of nursing intervention, patient will maintain relief from joint pain.

Nursing intervention

NIC: Pain management

Independent nursing intervention

1. Assessed pain, noting location, characteristics, intensity. Assessing


the pain helps evaluate severity and intensity (Gulanick et. al, 1998)

2. Explained cause of pain and importance of notifying caregivers of


changes in pain occurrence and characteristics. Explanation provides
opportunity for timely administration of analgesics and alert caregivers to
possibility of passing stone or developing complications (Gulanick et. al,
1998)

3. Provided comfortable and restful environment. Comfortable and restful


environment promotes relaxation, reducing of muscle tension and
enhancement of coping (Gulanick et. al, 1998)

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4. Encouraged use of diversionalactivites and non-pharmacological
interventions to alleviate pain. Diversional activities redirects patients
attention and aidsin muscle relaxation (Gulanick et. al, 1998)

Dependent nursing intervention

5. Administered Caltrate plus 1 tab TID with meals. Calcium is an


essential mineral that is necessary for strong bones, normal functioning of
nerves and muscle and also plays a role in the formation of blood clots
6. Administer medication as indicated, e.g., analgesics. Relieves pain and
enhances comfort
7. Provide sitz bath. Relieves local discomfort.
8. Apply/ monitor effects of transcutaneous electrical nerve stimulator (TENS).
Used to block transmission of pain stimulus.
9. Prepare for hemodialysis. Reduction or uremic toxins and correction of
electrolyte imbalances

Evaluation

Short term: Goal partially met

After 2 hours of nursing intervention patient demonstrated less pain as evidenced


by writing “medyomasakitparinperohindiganunkasakitkanina,” and 5/10 pain scale,
with the absence of facial grimace.

Long term: Goal met

After 1 day of nursing intervention patient maintained relief from pain as evidenced
by absence of complaints from pain.

Problem #4

+1 Bipedal edema

July 20,2010

Cues

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Subjective:

Objective:

• +1 bipedal edema • HGB 10.2↓


• Capillary refill: 3 seconds • K: 3.9↓
• BP: 200/140mmhg • Output: 80cc
• Creatinine: 928.20 ↑
• HCT: 32.9↓

Nursing Diagnosis

Fluid volume excess r/t compromised kidney functions secondary to chronic kidney
disease

Rationale:

The kidney cannot concentrate or dilute the urine normally in end stage renal
diseases. Appropriate responses by the kidney to changes in the daily intake of
water and electrolytes, therefore, do not occur. Some patients retain sodium and
water, increasing the risk for edema, heart failure and hypertension(Smeltzer et.al,
Renal
2008 p. 1529)

Loss of excretory Loss of non-excretory

Inability of the kidneys to


maintain Fluid-electrolyte and
acid-base balance
Retention of +1 bipedal

Planning

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NOC: Fluid Balance

Short term goal:

After 4 hours of nursing intervention, patient will display appropriate urine output
and vital sign with normal limits

Long term goal:

After 2 days hours of nursing intervention the patient will experience no rapid
progression of the edema.

Nursing intervention

NIC: Fluid/ electrolyte management

Independent Nursing Intervention

1. Monitor strictly intake and output every 1 hour. Low output less than
400 cc/ml may be first indicator of acute failure, especially in high-risk
patient (Doenges,2002)
2. Assess skin, face and dependent areas for edema. Edema occurs
primarily in dependent tissues of the body (Doenges,2002)
3. Monitor blood pressure every 1 hour. Hypertension can occur because
of failure of the kidneys to excrete urine (Doenges,2002)
4. Assess level of consciousness. May reflect fluid shifts, accumulation of
toxins, acidosis, electrolyte imbalances, or developing hypoxia
(Doenges,2002)
5. Monitor laboratory (BUN, Creatinine, Na, K). Assesses progression and
management of renal dysfunction or failure (Doenges,2002)

Dependent Nursing intervention

6. Restrict fluids as indicated. Fluid management is usually calculated to


replace output from all sources plus estimated insensible losses is treated
with volume replacers and/ or vasopressors (Doenges,2002)
7. Prepare for hemodialysis as indicated. Done to correct volume overload,
electrolyte and acid-base imbalances and to remove toxins. (Doenges,2002)

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Evaluation

Short term:

Goal not met:

After 4 hours of nursing intervention, patient has still no urine output.

Long term:

Goal met:

After 2 days of nursing intervention, patient manifest absence of edema and urine
output of 200cc.

Problem #5:

Irritability

July 20,2010

Cues:

Subjective:

Objective

Shortness of breath

Weak ABG’s: pH- 7.32, pCO2- 33, pO2-


74, HCO3-20.1, O sat- 78%
Restless
Serum Sodium: 129mmol/L
Irritable
Creatinine: 928.20 ↑
Withdraws to touch
HCT: 32.9↓
GCS: 9/15
HGB 10.2↓

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27 | P a g e
Nursing Diagnosis

Disturbed thought processes related to accumulation of toxins, metabolic acidosis,


hypoxia, and electrolyte imbalances in the brain.

Rationale:

With advance renal disease, metabolic acidosis occurs because the kidney cannot
excrete increased loads of acid. As glomerular filtration decreases, the serum
creatinine and BUN levels increase. In renal failure, erythropoietin production
decreases and profound anemia results, producing fatigue, angina, and shortness
of breath. (Smeltzer, et.al., 2004)

Progressive accumulation of waste products in


the blood

Encepalopathy

Neurologic
disturbance

Planning

NOC: Cognition- Ability to execute complex mental processes

Short term Goal

After 4 hours of nursing intervention, patient will appear relax.

Long term goal


After 1 day of nursing intervention, patient will maintain relax state.

Nursing intervention

NIC: Reality Orientation- Promotion of patient's awareness of personal identity,


time, and environment

28 | P a g e
1. Assess extent of impairment in thinking ability, memory, and
orientation. Uremic syndrome’s effect begins with minor confusion/
irritability and progress to altered personality or inability to assimilate
information and participate in care.
2. Ascertain from SO patient’s usual level of mentation. Provides comparison to
evaluate progression/resolution of impairment.
3. Provide SO with information about patient’s status. Some improvement in
mentation may be expected with restoration of more normal levels of BUN,
electrolytes, and serum pH.
4. Provide quiet/calm environment. Minimizes environmental stimuli to
reduce sensory overload/confusion while preventing sensory deprivation.
5. Reorient the surroundings, person, and so forth. Provide calendars
and clock. Provides clues in recognition of reality.
6. Communicate information/ instructions in simple, short
sentences.Ask direct yes/no questions. Repeat explanations as
necessary. May aid in reducing confusion, and increases possibility that
communications will be understood/remembered.
7. Establish a regular schedule for expected activities. Aids in
maintaining reality orientation and may reduce fear/confusion.
8. Promote adequate rest and undisturbed periods for sleep. Sleep
deprivation may further impair cognitive abilities.

Dependent nursing intervention

9. Monitor laboratory studies, e.g., BUN/Cr, serum electrolytes, glucose


level, and ABGs. Correction of elevations/imbalances can have profound
effects on cognition/mentation.
10.Provide supplemental 02 as indicated. Correction of hypoxia alone can
improve cognition.
11.Avoid use of barbiturate and opiates. Drugs normally detoxified in the
kidneys will have increased half-life/cumulative effects, worsening confusion.
12.Prepare dialysis. Marked deterioration of thought processes may indicate
worsening of azotemia and general condition, requiring prompt intervention
to regain homeostasis.

29 | P a g e
Evaluation

Short term

Goal met:After 4 hours of nursing intervention, patient manifested improved


condition as evidenced by relaxed appearance.

Long term

Goal met:
After 1 day of nursing intervention patient maintained calm and relaxed state.

Problem #6: Dry Skin

July 20,2010

Cues

Subjective:

Objective:

Dry lips;

Dry and flaky skin;

coarse, thinning hair;

+1 bipedal edema,

Decreased mobility

Nursing Diagnosis:

Risk for impaired skin integrity r/t alteration in skin turgor secondary to kidney
disease

Rationale

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Some degree of edema and hypertension is present in most patients with CKD.
Increased permeability of the glomerular membrane may also occur, with
associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty cast in the
urine (Smeltzer, et.al., 2008 p. 1517)

Progressive accumulation of waste products in


the blood

Integumentary
complication

Dry

Planning

NOC: Tissue Integrity: Skin & Mucous Membranes

Short term goal:

After 2 hours of nursing intervention, patient will demonstrate intact skin without
lesions or scratches.

Long term Goal:

After 1 day of nursing intervention, patient will still maintain intact skin in the
absence of lesions, scratches, or abrasions.

Nursing Intervention

NIC: Skin surveillance

Independent Nursing intervention

1. Inspect skin for changes in color, turgor, or vascularity. Indicates


areas of poor circulation/breakdown that may lead to decubitus
formation/infection.
2. Monitor fluid intake and hydration of skin and mucous membranes.
Detects presence of dehydration or overhydration that affects circulation and
tissue integrity at the cellular level.

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3. Inspect dependent areas for edema. Elevate legs as indicated.
Edematous tissues are more prone to skin breakdown. Elevation promotes
venous return, limiting venous stasis/ edema formation.
4. Change position frequently; move patient carefully ;pad bony prominences
with sheepskin, elbow/elbow heel protectors. Decreases pressure on
edematous, poorly perfused tissues to reduce schemia.
5. Provide soothing skin care. Avoid use of soaps. Apply ointments or
creams .Lotions and ointments may be desired to relieve dry, cracked skin..
6. Keep linens dry and wrinkle-free. Reduces dermal irritation and risk for
skin breakdown.

7. Encourage patient to report itching.Although dialysis has largely


eliminated skin problems associated with uremic frost, itching can occur
because the skin is an excretory route for waste products

DEPENDENT

8. Provide foam/ floatation mattress.Reduces prolonged pressure on tissues,


which can limit cellular perfusion, potentiating ischemia/ necrosis

Evaluation

Short term: Goal met

After 2 hours of nursing intervention, patient manifested intact skin as evidenced by


absence of lesions and scratches

Long term: Goal met

After 1 day of nursing intervention, patient maintained intact skin as evidenced by


absence of skin breakdown.

Problem #7

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Progressive accumulation of waste products in
the blood

Difficulty expressing needs verbally

July 20, 2010

Cues

Subjective:

Objective:

Inability to speak

Presence of mechanical ventilator

Irritable

Nursing Diagnosis:

Impaired verbal communication related to presence of endotracheal tube

Rationale:

Endotracheal tube passes between the vocal cords making the patient unable to
speak. (Williams: 2003)

Planning

NOC: Communication: expressive ability

Short term goal

After 1 hour of nursing intervention, patient will establish method in which needs
can be understood, e.g., writing and demonstrate satisfaction in the method of
communication made.

Long term goal

After 1 day of will maintain satisfaction on the chosen method of communication


like writing.

Nursing Intervention

NIC: Communication enhancement- Speech deficit

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Independent Nursing Intervention

1. Assessed patient’s ability to communicate by alternative means.


Method of communicating with patient is therefore highly individualized.
2. Established means of communication: Maintained eye contact; asked
yes/no questions; provide pen and paper. Eye contact assures patient of
interest in communicating, a great deal can be done with yes/no questions,
and writing provides the best way to communicate with patient.
3. Considered form of communication upon placing IV. IV positioned in
hand/wrist may limit ability to write or sign.
4. Placed call bell within reach. Makes the patient be able to relax, feel safe,
and breathe with the ventilator knowing that the nurse is vigilant and needs
will be met.
5. Place note at central call station informing staff that patient is unable to
speak. Alerts all staff members to respond to patient at the bedside instead
of over the intercom
6. Encourage family/SO to talk with patient, providing information about family
and daily happenings. Maintains contact with reality and enabling the patient
feel part of family unit can reduce feeling of awkwardness.
7. Reorient the surroundings, person, and so forth. Provide calendars
and clock. Provides clues in recognition of reality.

Evaluation

Short term: Goal met

After 1 hour of nursing intervention, patient was able to establish method of writing
in which needs are understood and demonstrated satisfaction on the method of
communication made as evidenced by writing “yes” when asked if she’s satisfied
with the way she communicates.

Long term: Goal met

After 1 day of nursing intervention, patient was able to maintain satisfying method
of communication through writing.

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Drugs Ordered

1.Duavent neb every shows

Generic name: Ipratropium/salbutamol (Albuterol)

Classification

Pharmacologic Class: Symphathomimetic (beta2-adrenergic agonist)

Therapeutic class: Bronchodilator, anti-asthmatic

Indication:

To prevent or treat bronchospasm in patients with reversible


obstructive airway disease

Mechanism of Action: relaxes smooth muscles by stimulating beta2-


receptors, thereby causing bronchodilation and vasodilation.

Contraindication: Hypersensitivity to ketotifen or any other component of


the formulations.

Adverse reactions: Sedation, dry mouth, dizziness, weight gain.


Occasionally, CNS stimulation, visual acuity changes, dry eyes, headache,
fatigue. Rarely, cystitis; very rarely, increase in liver enzyme and
hepatitis.

Nursing Resposibilities:

-Stay alert hypersensitivity reactions and paradoxical bronchospasm. Stop


the drug immediately if these occur.

-Monitor serum electrolyte levels.

-Teach patient s/sx of hypersensitivity and paradoxical bronchospasm. Tell


her to stop taking drug immediately and contact prescriber if these occur.

35 | P a g e
-Instruct patient to notify the prescriber if prescribed dosage fails to
provide relief

2. Hydrocortisone 100mg IV every show

Brand name: Cortizan

Classification: Corticosteroid

Indication: Severe inflammation, adrenal insufficiency

Mechanism of action: Decreases inflammation, mainly by stabilizing


leukocyte lysosomal membranes; suppresses immune response;
stimulates bone marrow; and influences protein, fat, and carbohydrate
metabolism

Contraindication: Systemic fungal infection, IM use in ITP, administration of


live virus vaccines in patients receiving immunosuppressive corticoid
doses; psychosis; acute glomerulonephritis; amoebiasis; nonasthmatic
bronchial disease.

Adverse effects: depression, flushing, sweating, headache, mood changes,


hypertension, circulatory collapse, thrombophlebitis, embolism,
tachycardia, edema, fungal infection, increase intra-ocular pressure,
blurred vision, diarrhea, nausea and vomiting.

Nursing responsibilities:

– Determine whether patient is sensitive to other corticosteroids


– Monitor patient’s weight , blood pressure, and electrolyte level
– Watch out for adverse effects
– Elderly patients may be more susceptible to osteoporosis for prolonged use
– Teach patient signs and symptoms of adrenal insufficiency: fatigue, muscle
weakness, joint pain, fever anorexia, nausea, SOB, dizziness.

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3. Fluimucil 200mg/ sachet 1 sachet TID

Generic name: Acetylcysteine

Classification: Mucolytic type of respiratory drug

Indication: adjunct therapy for abnormal viscid or inspissated mucous


secretions in patients with pneumonia.

Action: Mucolytic that reduces the viscosity of pulmonary secretions by


splitting disulphide linkages between mucoprotein molecular complexes.

Contraindication: patient hypersensitive to drug, use cautiously in elderly or


debilitated patients with severe respiratory insufficiency

Adverse reactions: Nausea, vomiting and other GI symptoms, generalized


urticarial, accompanied by mild fever, hypotension, wheezing, dyspnea,
and stomatitis.

Nursing Responsibility:

– Inform patient that drug may have foul smell or taste, the
unpleasant odour will decrease after repeated use, the discoloration
of solution after bottle is opened does not impair its effectiveness.

4. Dilatrend 25mg/tab ½ tab OD

Generic name: Carvedilol

Classification: Antihypertensive

Indication: Hypertension

Action: Has a mixture of both alpha and beta adrenergic blocking activity.
It causes vasodilation and decreased peripheral resistance; reduces
exercise-induce tachycardia and reflex orthostatic hypotension.

Contraindication: Bronchial asthma, chronic bronchitis, pulmonary


emphysema, allergic rhinitis, swelling of laryngeal mucosa, sinus node

37 | P a g e
syndrome, SA block, 2nd and 3rd degree AV block, severe liver dysfunction,
metabolic acidosis

Adverse effect: dizziness, headaches, and tiredness. Slowed pulse rate or GI


upset or flu-like symptoms, breathing problem.

Nursing responsibility:

– Alert: patient receiving this therapy who have a history of severe


anaphylactic reaction to several allergens may be more reactive to
repeated challenge ( accidental, diagnostic, or therapeutic)
– Mild hepatocellular injury may occur during therapy. At first sign of
hepatic dysfunction, perform test for hepatic injury or jaundice; if
present stop drug
– If drug must be stop, do so gradually over 1 to 2 weeks
– Monitor patient with heart failure for worsened condition, renal
dysfunction, fluid retention; diuretics may need to be increase
– Monitor diabetic patient closely; drug may mask hypoglycaemia, or
hyperglycemia may be worsened
– Observe patient for dizziness or light-headedness for 1 hour after
giving each new dose
– Monitor elderly patients carefully; drug levels are about 50% higher
in elderly patients than in younger patients
– Monitor blood glucose level

5. Adalat 60mg/tab itab OD

Generic name: Nifedipine

Classification: Anti-anginals

Indication: Hypertension

Action: Inhibits calcium ion influx across cell membrane during cardiac
depolarization, produces relaxation of coronary vascular smooth muscle
and peripheral vascular smooth muscle, dilates coronary vascular arteries.

38 | P a g e
Contraindication: Hypersensitive to drug, used cautiously in patients with
HPON and elderly patient

Adverse effects: dizziness, flushing, headache, hypotension, peripheral


edema, tachycardia, and palpitations.

Nursing Responsibilities:

– Advise patient to report chest pain immediately.


– Monitor blood pressure frequently

6. Caltrate plus 1 tab TID with meals

Generic name: Calcium, elemental (as carbonate) 600mg, Vit. D 200IU,


magnesium 40mg, zinc 7.5mg, copper 1mg, manganese 1.8mg, boron
250mcg; tabs (sugar-free); assorted fruit-flavor chewable tabs (contain
sugar).
Classification: Calcium (different salts in combination) ; Belongs to the class
of calcium-containing preparations. Used as dietary supplements.

Indication: Supplement for Ca deficiency & conditions that require


increased Ca intake; may reduce the risk of osteoporosis later in life

Action: Calcium is an essential mineral that is necessary for strong bones,


normal functioning of nerves and muscle and also plays a role in the
formation of blood clots

Contraintication: Hypercalcemia and hypercalciuria (e.g.,


hyperparathyroidism, vitamin D overdosage, decalcifying tumors such as
plasmocytoma; bone metastases); severe renal disease; and in calcium

loss due to immobilization.

Adverse effects: GI discomfort, hypercalcemia, hypercalciuria.

Nursing responsibilities:

39 | P a g e
– Record amount and consistency of stools. Manage constipation
with laxative or stool softener
– Monitor calcium level, especially in patient with renal impairment
– Watch for evidence of hypercalcemia (nausea, vomiting,
headache, confusion, and anorexia)

7. Piptaz 2.25mg IV every 12 hours

Generic name: Piperacillin Na


Classification: Piperacillin and enzyme inhibitor ; Belongs to the class of
penicillin combinations, including beta-lactamase inhibitors. Used in the
systemic treatment of infections.

Indication: Treatment of infections in the lower resp tract eg severe


community-aquired pneumonia & healthcare pneumonia; uncomplicated &
complicated skin & skin structure infections

Action: Piperacillin, an extended-spectrum penicillin, exerts its


antimicrobial action in growing and dividing bacteria by interfering with
septum formation and cell wall synthesis of susceptible bacteria. It binds
to penicillin-binding proteins on the bacterial cell wall and blocks
peptidoglycan synthesis. Peptidoglycan is a heteropolymeric structure
that gives the cell wall its mechanical stability. The final stage of the
peptidoglycan synthesis involves the completion of the cross-linking with
the terminal glycine residue of the pentaglycine bridge linking to the
fourth residue of the pentapeptide. The transpeptidase that performs this
step is inhibited by piperacillin. The bacterial cell wall weakens leading to
swelling and rupture of the microorganism

Contraindication: Hypersensitivity to penicillins, cephalosporins& β-lactam


inhibitors.

Adverse reaction: Rash, pruritus, fever; diarrhea, nausea, constipation,


vomiting, dyspepsia, stool changes, abdominal pain, transient leucopenia,

40 | P a g e
neutropenia, thrombocytopenia; hepatic & renal effects; headache,
insomnia, agitation, dizziness, anxiety; HTN, chest pain, edema,
moniliasis, rhinitis, dyspnea, hypotension, ileus, syncope, rigors, phlebitis,
pain, inflammation, thrombophlebitis.

Nursing Responsibilities:

-Assess CBC and kidney and liver function test results.

-Monitor for s/sx of superinfection and other serious adverse reactions.

-Be aware that cross-sensitivity to penicillins may occur.

-Instruct patient to take drug with food or milk to reduce the GI distress
and enhance absorption.

-Advise to patient not to take antacids within 2hours of drug.

-Tell patient to continue to take full amount prescribed even when he feels
better.

-Instruct patient to report s/sx of allergic response and other adverse


reactions, such as rash, easy bruising, bleeding, severe GI problems, or
difficulty breathing.

8. Asmavent neb every 12hours

Generic name: Budesonide

Classification: Belongs to the class of other inhalants used in the treatment


of obstructive airway diseases, glucocorticoids.

Indication: Use for the management of bronchial asthma

Action: Anti-inflammatory corticosteroid that exhibits potent glucocorteroid


activity and weak mineralocorticoid activity, have a wide-range of
inhibitory activities against such cell types as mast cells and macrophages
and mediators involved in all allergic and nonallergic inflammation.

41 | P a g e
Contraindication: hypersensitive to drugand in those with status
asthmaticus or other acute asthmatic episodes; use cautiously, if at all, in
patients with active or quiescent TB of the respiratory tract, ocular herpes
simplex, or untreated systemic fungal, bacterial, viral, or parasitic
infections.

Adverse reaction: Neck pain; cough, resp infection, rhinitis, sinusitis,


stridor. Gastroenteritis, oral candidiasis, abdominal pain, dry mouth,
nausea, vomiting, dyspepsia. Wt gain.Fracture, myalgia,
arthralgia.Hypertonia, migraine, asthenia, dystonia,
hyperkinesia.Ecchymosis, epistaxis, emotional liability.Contact dermatitis,
rash. Taste perversion

Nursing Responsibilities:

– When transferring from systemic corticosteroid to budesonide, use


caution and gradually decrease corticosteroid dose to prevent
adrenal insufficiency
– Drug doesn’t remove the need for systemic corticosteroid therapy in
some situations.
– If bronchospasm occurs after using this drug, stop therapy and treat
with bronchodilators
– Improved lung function has been observed within 24 hours of
starting budesonide treatment, although maximum benefit may not
be achieved for 1 to 2 weeks or longer.

9. Floxel 500mg/tab every 48 hours

Generic name: Levofloxacin

Classification: Fluoroquinolone

Therapeutic class: anti infective

42 | P a g e
Indication: Community-acquired pneumonia

-Acute bacterial exacerbation of chronic bronchitis

Action: Inhibits the enzyme DNA gyrase in susceptible gram-negative and


gram-positive aerobic and anaerobic bacteria, interfering with bacterial
DNA synthesis.

Contraindication: Epilepsy, history of tendon disorders related to


fluoroquinolone therapy, children or adolescent, pregnancy and lactation,
hypersensitive to drug.

Adverse reaction: Nausea, diarrhea, headache, dizziness, insomnia,


musculoskeletal effects, pain, reddening of the infusion site, phlebitis,
increase in liver enzyme, eosinophilia, leukopenia, asthenia,
superinfection, eye irritation, urticaria

Nursing responsibilities:

-Check vital signs especially BP. Too rapid infusion can cause hypotension.

-Assess for severe diarrhea which may indicate pseudomembranous


colitis.

-Watch for hypersensitivity reaction. Discontinue drug immediately if rash


or other s/sx occur.

-Tell patient to stop taking drug and contact prescriber if he experiences


the s/sx of hypersensitivity reactions or severe diarrhea.

-Instruct patient not to take with milk yogurt, multivitamins containing


zinc or iron, or antacids containing aluminium or magnesium.

-Caution patient to avoid driving and other activities that require mental
alertness until CNS effects of drugs are known.

10. Catapres 75mg/tab SL PRN for blood pressure >160/100

43 | P a g e
Generic name: Clonidine

Classification: antihypertensive

Indication: Essential and renal hypertension

Action: Stimulates alpha-adrenergic receptors to inhibit sympathetic


cardioaccelerator and vasoconstrictor centers.

Contraindication: hypersensitive to drug; transdermal form is


contraindicated in patients hypersensitive to any component of the
adhesive layer of transdermal center; epidural form is contraindicated in
patients receiving anticoagulant therapy, in those with bleeding diathesis,
in those with an injection site infection, and those who are
hemodynamically unstable or have severe CV disease; use cautiously in
patient with chronic renal failure.

Adverse Reaction: drowsiness, dry mouth, dizziness, headache, constipation,


depression, anxiety, fatigue, nausea, anorexia, parotid pain, sleep
disturbances, vivid dream, urinary retention, slight orthostatic
hypotension, burning and itching sensation.

Nursing Responsibilities:

– Drug may be given to lower blood pressure rapidly in some


hypertensive emergencies
– Monitor blood pressure frequently. Dosage is usually adjust in
patient’s blood pressure and tolerance
– Elderly patients may be more sensitive than younger ones to drug’s
hypotensive effect
– Observe patient tolerance to drug’s therapeutic effects, which may
require increase dosage
– Advise patient that stopping drug abruptly may cause severe
rebound high blood pressure. Tell her dosage must be reduced
gradually over 2 to 4 days as instructed by prescriber

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11. Prevacid FDT 30mg/tab OD-AM

Generic name: Lansoprazole

Classification: proton pump inhibitors (PPI)

Indication: used for treating ulcers of the stomach and duodenum,


gastroesophageal reflux disease (GERD) and Zollinger-Ellison Syndrome.

Action: block the production of acid by the stomach

Contraindication: patients with known hypersensitivity to any component of


the formulation of PREVACID. Amoxicillin is contraindicated in patients
with a known hypersensitivity to any penicillin. Clarithromycin is
contraindicated in patients with a known hypersensitivity to
clarithromycin, erythromycin, and any of the macrolide
antibiotics. Concomitantadministration of clarithromycin with cisapride,
pimozide, astemizole, or terfenadine is contraindicated.

Adverse reaction:
diarrhea, nausea, vomiting, constipation, rash and headaches. Dizziness,
nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps and
water retention rarely occur.

Nursing Responsibilities:

Assessment

· History: Hypersensitivity to lansoprazole or any of its components; pregnancy;


lactation

· Physical: Skin lesions; body T; reflexes, affect; urinary output, abdominal


examination; respiratory auscultation

Interventions

· Administer before meals. Caution patient to swallow capsules whole, not to


open, chew, or crush. If patient has difficulty swallowing, open capsule and sprinkle
granules on apple sauce, Ensure,yogurt, cottage cheese, or strained pears; for NG

45 | P a g e
tube, mix granules from capsule with 40 mL apple juice and inject through tube,
flush tube with additional apple juice; or granules for oral suspension can be added
to 30 mL water, stir well, and have patient drink immediately.

· WARNING: Arrange for further evaluation of patient after 4 wk of therapy for


acute gastroreflux disorders if symptomatic improvement does not rule out gastric
cancer, which did occur in preclinical studies.

· Switch to oral drug from IV as soon as patient is able to take oral drugs. Use of
IV drug for > 7 days is not approved.

Teaching points

· Take the drug before meals. Swallow the capsules whole—do not chew, open, or
crush. If you are unable to swallow capsule, open and sprinkle granules on apple
sauce, or use granules, which can be added to 30 mL water, stirred, and drunk
immediately.

· Arrange to have regular medical follow-up care while you are taking this drug.

· You may experience these side effects: Dizziness (avoid driving a car or
performing hazardous tasks); headache (medications may be available to help);
nausea, vomiting, diarrhea (proper nutrition is important, consult with your dietitian
to maintain nutrition); symptoms of URI, cough (reversible; do not self-medicate,
consult with your health care provider if this becomes uncomfortable).

· Report severe headache, worsening of symptoms, fever, chills.

46 | P a g e
CHAPTER V

CONCLUSION

End-stage renal disease (ESRD) is the most feared consequence of kidney disease. ESRD
results when kidney function has deteriorated and is no longer adequate to sustain life, and renal
replacement therapy-- dialysis or transplantation -- becomes necessary to maintain life. Conditions that
may lead to ESRD include hypertension, diabetes, and fluid in the kidneys. Efforts should be directed at
improving quality of life, providing patient education, and preventing progression to ESRD

The patient has been undergoing dialysis to maintain life. On the second day
of her admission in the ICU, she showed improvement after undergoing dialysis. She
was admitted with a blood pressure of 200/140mmhg, appropriate treatment was
than but still her blood pressure is above her normal limit.

CHAPTER VI

RECOMMENDATION

47 | P a g e
Whenever there is, the onset of a certain disease it implies one to contribute
hercooperation and willingness to be responsible for her own health. The patient
must submitherself to palliative care for her to reducing the severity of her disease.
The goal is to prevent andrelieve suffering and to improve quality of life for people
facing serious, complex illness. Thepatient must be sensitive of her own needs and
be able to expect liability for her actions. She isalso encouraged to verbalize her
own thoughts and feelings concerning how she perceives hercondition affect her life
and her acceptance of her disease. She is advised to take part incomplying with the
treatment designed for her. She should realize the importance of complyingwith her
medication and the benefits this practice would bring to her and her family’s well-
being.Moreover, she must not hesitate on seeking medical assistance whenever she
feels anyun-usualities in her body

This case study must be a pattern that other individuals must follow. The
Nursing Education circle must be involved in sharing the different facets of diseases
especially the diseases common to our country. Also, we must educate the people
through seminars, immersions and case studies so that the people might be able to
benefit from nursing education.

This case study must be the basis of succeeding batches of clinical nurses
who are also going to make this kind of reports. This case study might not be
efficient but important data gathering and research was done to make this research
possible.

BIBLIOGRAPHY

BOOKS

Catagnus, J. M. & Hager, L.(Eds.).(2008). Deciphering Diagnostic Tests. Hong Kong:


Wolters Kluwer, Lipincott Williams and Wilkins.

Daniels, R.(2006). Delmar’s Manual of Laboratory and Diagnostic Tests.Singapore:


Thomson Learning Asia.

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Deglin, J. H. &Vallerand, A. H.(2005). Davis’s Drug Guide for Nurses (9thed).
Thailand: F. A. Davis Company.

Doenges, M., et. al. (2002).Nursing Care Plans: Guideline for Individualizing Patient
Care. (6thed). Thailand: F. A. Davis Company.

Gulanick, M., et. al. (1998).Nursing Care Plans: Nursing Diagnosis and Intervention.
(4thed). Missouri, USA.

Handbook of Medical-Surgical Nursing.(4THed). (2005). Tokyo: Lippincott, Williams


and Wilkins: Wolters Kluwer Health.

Kozier, B., et.al.(2008). Fundamentals of Nursing (8thed). Singapore: Pearson


Education South Asia Pte Ltd.

Smeltzer, S & Bare, Brenda. (1992). Brunner and Suddarth’s Textbook of Medical-
Surgical Nursing (7thed). USA: J. B. Lippincott Company

Smeltzer, S et.al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical


Nursing (11thed). USA: Lippincott Williams and Wilkins.

Williams, L et. Al. (2003). Medical-Surgical Nursing ( second edition).USA: F.A. Davis
company

INTERNET

Kidney diseases and their complications, an alarming scenario in the


Philippines.Bio-medicine. Retrieved on August 11, 2009 from

49 | P a g e
http://www.bio-medicine.org/medicine-news/Kidney-diseases-and-their-
complications--an-alarming-scenario-in-the-Philippines-8303-1/.

MIMS Hong Kong.Gascon tab. Retrieved August 11, 2009, from

http://www.mimsonline.com/Page.aspx?
menuid=mng&name=Gascon+tab&h=gascon,tab&CTRY=HK.

National Kidney Foundation.“K/DOQI Clinical Practice Guides for Chronic Kidney


Disease”. Retrieved August 24, 2009, from

http://www.kidney.org/professionals/KDOQI/guidelines_CKD.

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