End Stage Renal Disease Secondary To Hydronephrosis Secondary To Diabetes Mellitus Type Two

A Case Study
Presented to the Faculty of
The Ateneo de Davao University
College of Nursing
A Case Study on
End-Stage Renal Disease secondary to
Hydronephrosis secondary to Diabetes Milletus
Type 2
Submitted to:
Remedios Caubang, RN
Clinical Instructor – Panelist of the Case Study
Submitted by:
[Group 1B]
Beltran, Maribel S.
Bulosan, Von Rainer S.
Cabonita, Kristi Ann J.
Campaner,Marie Allexis I.
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BSN-3H
November 7, 2009
TABLE OF CONTENTS
i. Acknowledgement
...............................................................................................................
I. Introduction................................................................................4
II. Objectives (General & Specific)................................................6
III. Patient’s Data.............................................................................8
IV. Family Background and Health History.....................................10
V. Developmental Data...................................................................14
VI. Definition of Complete Diagnosis..............................................21
VII. Physical Assessment...................................................................24

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VIII. Anatomy and Physiology...........................................................28
IX. Etiology and Symptomatology...................................................36
X. Pathophysiology.........................................................................42
XI. Doctor’s Order............................................................................47
XII. Diagnostic Exam........................................................................55
XIII. Drug Study.................................................................................64
XIV. Surgical Procedure.....................................................................74
XV. Nursing Theories........................................................................81
XVI. Nursing Care Plan......................................................................86
XVII. Discharge Plan (M. E. T. H. O. D.) & Prognosis
....................................................................................................
118
XVIII.Recommendation
....................................................................................................
128
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XIX. References
....................................................................................................
131
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i.
ACKNOWLEDGEMENT
In accomplishing great things, we must not only think, but believe in the power of
our cognition; not only aim but make our visions tangible; and at the end of the day, not
only smile at the thought of accomplishment, but look back to where the strength to
achieve such success came from.
The proponents would like to extend their warmest gratitude to all the people who
helped make the success of this undertaking a reality.
First and foremost, to the Almighty Father, for His unceasing love and blessings;
for giving us enough power and fortitude to face all the hardships in the making of this
task. To Him be all glory and praise!
To our Clinical Instructor, Mrs. Willyn Adrias, RN, for her invaluable time and
effort rendered to us; for letting us have the chance to experience the joy and opportunity
of learning from you. For being a friend and companion in the area. You have made us
realize that not all CIs are intrinsically superfluous. To all other CIs that has been with us
in the whole rotation, Maam Baniel and Maam Llamido , for always being there to guide
us; for their unending help and understanding.
To our dear parents, for supporting us financially in all our endeavors. Thank you
for all your love and care.
Lastly, to each and every one who helped realize this job into completion, may it
be direct or indirect, no matter how minimal, the gratitude and pleasure for the
achievement of this task is ours to share.

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INTRODUCTION
BSN-3H1 were given the opportunity to have a hospital exposure last November
12-14,2009 at Davao Medical Center – Med Ward; and on the said dates found a
commendable case reasonable to be presented for case study agreed by the whole
subgroup.
The patient, to be mentioned in this paper as Aling D, was one of the patients
admitted to Medicine Ward Nephro due to End Stage Renal Disease secondary to
Hydronephrosis stage II secondary to Diabetes Mellitus Type II.
End-Stage Renal Disease is the complete or almost complete failure of the
kidneys to function at a level needed for day-to-day life. The kidneys can no longer
remove wastes, concentrate urine, and regulate many other important body functions. It is
an irreversible decline in a person's own kidney function, which is severe enough to be
fatal in the absence of dialysis or transplantation. It usually occurs when chronic kidney
disease has worsened to the point at which kidney function is less than 10% of normal.
ESRD almost always follows chronic kidney disease. A person may have gradual
worsening of kidney function for 10 - 20 years or more before progressing to ESRD. The
most common causes of ESRD in the U.S. are diabetes and high blood pressure.
The incidence and prevalence of ESRD continue to grow worldwide. According
to data collected from 120 countries with dialysis programs, at the end of 2005 about
1,900,000 people were receiving renal replacement therapy (RRT). Among these
individuals, 1,297,000 (68%) received hemodialysis and 158,000 (8%) received
peritoneal dialysis; although an additional 445,000 (23%) were living with a kidney
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transplant. Precise estimates of ESRD incidence and prevalence remain elusive, because
international databases of renal registries exclude individuals with ESRD who do not
receive RRT. (http://clinicalevidence.bmj.com/ceweb/)
Worldwide, the highest incidence and prevalence rates are reported from the
USA, Taiwan, and Japan. In America, 34% of cases of ESRD each year are caused by
diabetes, 25% by hypertension, 16% by glomerulonephritis, and 4% by kidney cysts.
(Renal Data Report, ANS, 1999)
End Stage Renal Disease is already the 7th leading cause of death among
Filipinos. The population of ESRD patients requiring dialysis therapy in Asia is
expanding at a faster rate than in the rest of the world. In Philippines, the dialysis
population is growing at a rate of 10% or more annually. It is said that a Filipino is
having the disease hourly or 120 Filipinos per million populations per year. This shows
that about 10, 000 Filipinos need to replace their kidney function. Unfortunately though
only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of
the whole population probably just died without receiving any treatment.
The group chose Aling D as their subject primarily because her case posed a very
intricate case requiring due understanding and knowledge. The group recognizes their
partial knowledge about End-Stage Renal Disease and the treatments involved in such
condition, thus making this case a good avenue to broaden the proponents’ knowledge
about the disease and the surgical procedures involved.

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General Objective:
The main goal of the group is to be able to present the case study of our
chosen client that would provide a comprehensive discussion of the pathological
mechanism of the disease to yield significant information for the case study.
Specific Objectives:
In order to meet the general objective, the group aims to:
• establish rapport to the patient and the patient’s significant others;
• interpret the pertinent data gathered from the patient and her significant others;
• state past and present health history of the patient;
• trace the family genogram;
• evaluate the present developmental stage of the patient according to the theories
of Erikson, Kohlberg, and Havighurst;
• define the complete diagnosis of the patient;
• present the cephalocaudal assessment obtained from the patient;
• discuss the anatomy and physiology of the organ involved in the patient’s disease;
• present the etiology and symptomatology of the patient’s disease;
• trace the pathophysiology of the patient’s disease;
• obtain and rationalize the doctor’s order;
• interpret the laboratory test results of the patient;
• discuss the nature of the drugs given to the patient;
• discuss the surgical procedure performed to the patient;

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• relate the patient’s disease with the different nursing theories specifically those of
Nightingale, Orem and King;
• present a specific, measurable, attainable, realistic and time-bounded nursing care
plans for the client;
• justify the client’s prognosis according to the different criteria;
• provide the patient and family with proper discharge planning (M.E.T.H.O.D);
and
• outline recommendations based on the case study’s findings.

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PATIENT’S DATA
Personal data:
Patients Name: Aling D

Age: 56 years old
Weight 130 lbs or 59kg
Height 4’10 ft
Gender: Female
Birth date: September 25, 1953
Address: Dumanlas, Buhangin, Davao City
Nationality: Filipino
Religion [Domination]: Christian [Roman Catholic]
Civil Status: Married
Educational Attainment: College graduate
Occupation: Teacher (retired)
Clinical/ Admitting Data:
Date of admission: November 9, 2009

Time of admission: 11:30 am
Hospital & Hospital Number: Davao Medical Center, Davao City [1604730]
Ward [Room & Bed Numbers]: Medicine Ward- Nephro Bed No. 12
Admitting Physician: Dr. Jovino C. Aquino

Attending Physician: Dr. Gil Florida
Chief complaint: Epigastric pain
Admitting Diagnosis: End Stage Renal Disease secondary to Hydronephrosis secondary
to Diabetes Mellitus Type II
Source of information: Patient and Patient’s Chart

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FAMILY BACKGROUND AND HEALTH HISTORY
HEALTH BACKGROUND
A. Family Background
Aling D is 56 years old, female. She is the 3rd child of 5 siblings. Both her parents
are already dead, and she failed to mention the cause of their death. The patient
verbalized that her father was diagnosed with Diabetes Mellitus. She failed to mention if
her mother and siblings also have illnesses.
Aling D has been married for 32 years. She was a gradeschool teacher but she
already retired last 2005. Her husband is a government employee. They are blessed with
3 children, but one son is already dead due to cardiac arrest. The son died at the age of 23
who is the middle child. Her eldest son is 31 years old, and her youngest son is 28 years
old. Her eldest son is already married and doesn’t live with them anymore. Generally,
they have close family ties. Aling D told us that they share their daily experiences with
each other.
The family’s source of income is the patient and the husband. Her youngest son
also contributes to the family’s income, since he is also a government employee
particularly in the Department of Agriculture. Aling D’s pension per month is Php
15,000. Her husband’s income per month is Php 12,000, and her son’s income is Php
8,000. The family lives in Dumanlas, Buhangin, Davao City. Her family’s diet is
composed of meat, fish and vegetables, however, due to her hospitalization she has been
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following a low salt low fat diet. She also avoids protein-rich foods and foods high in
sugar. She is a non-smoker and occasionally drinks alcohol.
B. History of Past Illness
The patient was born via normal spontaneous vaginal delivery. She did not have
any complications nor unusualities when she was delivered. The patient did not
experience any serious illness or accident during her childhood. But she did experience
having chicken pox when she was a child. Also, she only experienced common minor
illnesses such as colds, fever, stomach aches, headaches, and constipation. She drinks
over-the-counter drugs like paracetamol when she experiences fever. According to the
patient, she had been diagnosed with hypertension 20 years ago and diabetes mellitus 15
years ago. She takes insulin shots for her Diabetes. She verbalized that she did not have
strict compliance to her medications since her condition was not bad before.
C. Present Health History
On October 2009, the patient experienced chest pain. She also experienced
dyspnea occurring at night accompanied by bipedal edema. The patient also had cough
and abdominal pain. She took a supplement called Relieve for 23 days to alleviate the
symptoms she felt. She tolerated the symptoms until she had onset of epigastric pain. She
had her check-up on UM Multitest. Along with her laboratory results, she was diagnosed
with End Stage Renal Disease last October 15, 2009. However, she was not admitted by
then. She sought medical attention when she experienced severe epigastric pain, and thus
the admission.
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D. Effects/ Expectations of Illness to Self/ Family
The patient verbalized that after the diagnosis was determined; she and her family
became bothered and worried. They did not expect that she will be diagnosed with a
disease which is already in end stage. The doctor who gave the diagnosis advised dialysis
to the patient, which added to the stress of the family and the patient. On the patient’s
part, she felt nervous because she used to know someone who underwent dialysis and
later died after 2 years of treatment. Nevertheless, she verbalized that she had already
accepted her treatment, its limitations, and consequences. According to her, she does not
want to be a burden to her family. On the family’s part, they worried about the finances
they will have to spend for the treatment. But, they are very positive in facing the disease.
Aling D stated that it must have really been God’s will and that they could do nothing
about it. Despite her health problem, they still have hope and they pray that their family
would be able to endure this and cope with all the inconvenience brought about by her
condition.
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E. GENOGRAM
LEGEND:
* Deceased
** with Hypertension
*** with Diabetes
Mellitus
DEVELOPMENTAL DATA
LOLO LOLA** LOLA A *** LOLO A

Human development: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young
science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each
MAMA PAPA*** UNCLE A *** UNCLE B
theory has its own viewpoint on the development of man.
Erikson's Stages of Psychosocial Development
The Psychosocial Stages of Development developed

ALINGbyDErikson enumerates eight stages though which healthily developing human
should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a
series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports
a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future.
Stage Description Result Justification

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According to Erik Erikson, Our clent, Aling D has achieved generativity
Middle the developmental task in middle ACHIEVED as she is able to display behaviors that are
Adulthood adulthood is to form a sense of well acceptable for his age such as being
(25 to 65 generativity or the concern for there for her children. She is able to expand
years old) guiding the next generation. It is her interests at this time with her family’s
GENERATI the concentration on this task that support and has assumed the responsibilities
VITY vs. leads to typical adult behavior. of middle –aged person. Our client usually
STAGNATI Middle adults must have takes time to bond with her husband and
ON motivations for charitable and children. Even though her children are all
altruistic actions, such as church grown up and busy with their own life, but
work, social work, political work, still they make time for each other and share
community fund-raising drives and to each other their daily experiences.
cultural endeavors. They should Furthermore, she manages to acknowledge
have time for companionship and her aging body and sees whatever she has
recreation, thus making marriage now as part of her existence. According to
more satisfying in the middle years her as well as her family, her condition never
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of life. Generative middle-aged altered her role of being a wife to his better
persons are able to feel a sense of half and a mother to her children. She is very
comfort in their lifestyle and responsible in her duty to her family, as a
receive gratification from mother to her children, she has molded them
charitable endeavors. into a better person they are today, good and
He knows well what his responsible sons; and as a wife to her
responsibilities are and he husband, their expression of love is more
recognizes that he’s held intimate and they cherished every minute
accountable of whatever actions he they are together. As a middle-aged adult, she
take. is also engaged in various activities in the
society in order to maintain a good societal
functioning like participating in the
development of their own community.

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Kohlberg's Stages of Moral Development
This theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not
Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision.
Kohlberg's Stages of Moral Development
This theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not
Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision.
Stage Description Result Justification

Conventional The conventional level of moral ACHIEVED In this stage of Kohlberg's Moral
Stage (Law reasoning is typical Development theory, the client must
and Order of adolescent and adults. Those go after the laws in order to
Orientation) who reason in a conventional maintain a good functioning in the
way judge the morality of society as a morally upright citizen.
actions by comparing them to Aling D is a good citizen.
society's views and According to her, she is a registered
expectations. In this stage, it is voter in order to exercise her right

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important to obey to vote for a leader suited to our
laws, dictums and social country, she offered her services
conventions because of their during election periods when she
importance in maintaining a was still working as a teacher. She's
functioning society. Moral also an active GKK or Gagmayng
reasoning in stage four is thus Kristohanong Katilingban member
beyond the need for individual in their barangay and actively
approval exhibited in stage participates for the development of
three which is interpersonal their community. For her, it is really
accord and conformity driven. important to observe the rules
Meaning the self enters society inculcated by the society in order to
by filling social roles; therefore maintain peace and order. She also
society must learn to transcend stated that as a constituent of the
individual needs. A central society, she should be a good
ideal or ideals often prescribe example for the future generations
what is right and wrong, such to come.

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as in the case of Aling D said that the simplest way
fundamentalism. If one person to become a good citizen is that you
violates a law, perhaps must not disobey any simple rules
everyone would—thus there is and regulations which the society
an obligation and a duty to dictates you to follow and abide,
uphold laws and rules. When because if one does not follow rules
someone does violate a law, it it is already considered in this stage
is morally wrong; culpability is to be morally wrong. So, one must
thus a significant factor in this maintain a good reputation without
stage as it separates the bad any stain of misdemeanor done.
domains from the good ones.

In the stage four of Conventional
Most active members of society
level, it is said that following the
remain at stage four, where
laws and dictums of the society is
morality is still predominantly
important to maintain a good
dictated by an outside force.
functioning in the society, so we
have concluded that Aling D has

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done her part in the society as a
good citizen. She follows and obeys
the rules and she had become a
good example to everybody,
especially to her children.
Havighurst’s Developmental Task
Havighurst (1972) defines a developmental tasks as one that arises at a certain period in our lives, the successful achievement of
which leads to happiness and success with later tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks He
identifies three sources of developmental tasks (Havighurst, 1972).
• Tasks that arise from physical maturation
• Tasks that arise from personal values
• Tasks that have their source in the pressures of society

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Havighurst also identified Six Major Stages in human life covering birth to old age which are the following:
1. Infancy & early childhood (Birth till 6 years old)
2. Middle childhood (6-12 years old)
3. Adolescence (13-18 years old)
4. Early Adulthood (19-30 years old)
5. Middle Age (30-60years old)
6. Later maturity (60 years old and over)
Our client belongs to the fifth stage which is the middle age, wherein men and women in this stage reach the peak of their
influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is
the time of life to which they have looked forward during their adolescence and early adulthood.
The following are the developmental task that a middle age adult must fulfill or achieve:
DEVELOPMENTAL TASK ACHIEVED OR NOT JUSTIFICATION
ACHIEVED
Helping teenage children to Achieved The client's children are all old
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become happy and enough to understand what their
responsible adults mother taught them; especially
the moral values that would
make them become better
persons and become good
example to others.
Achieving adult social and Achieved According to her, she
civic responsibility participates in barangay activities
for the development of their
community and she is an active
member of their GKK. She is
also registered voter in order to
do her duty as a good citizen of
the country.
Reaching and maintaining Achieved Since the client has already met
satisfactory performance in her expectations in her job in the
one’s occupational career past and have already fulfilled

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her dream of becoming a teacher.
Now, she is already retired from
her work.
Developing adult leisure time Achieved The client as an adult develops
activities leisure time activities together
with her family like having
meaningful conversations with
her children or sharing their daily
experiences and watching
television shows to strengthen
their bonding as a family.

Relating oneself to one’s Achieved The client and her husband have
spouse as a person been there for each and never
leave each other’s side. They
have been married for a long
time already. Whenever they
have problems, they’ve talked

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about it and together they decide
on how to solve their
predicament. Now that the client
has been hospitalized, her
husband has been there to
support her emotionally through
sending her text messages or
calling her sometime.

To accept and adjust to the Achieved The client has adjusted to the
physiological changes of changes on her body. She already
middle age. have wrinkled skin and easily
gets tired but she has learned to
accept this reality.

Adjusting to aging parents. Achieved The client has already adjusted to
her aging parents in the past
when her parents were still alive.

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DEFINITION OF COMPLETE DIAGNOSIS
END -STAGE RENAL DISEASE
End-stage renal disease occurs when 90% of the nephrons are lost. Patients at this stage experience chronic and persistent
abnormal kidney function.
Hopper P.D., Williams, L.S.; Understanding Medical Surgical Nursing 3rd edition
Kidney or renal end-stage disease is defined as a point at which kidney is so badly damaged or scarred that dialysis or
transplantation is required for patient survival.
Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition
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During this stage, renal function is less than 10% to 15% of normal; all renal functions are severely decreased; and homeostasis is
significantly altered.
Ray A. Hargrove-Huttel; Medical Surgical Nursing
HYDRONEPHROSIS
Hypdronephrosis is the abnormal dilation of kidneys caused by obstruction of urine flow.
Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition
Hydronephrosis develops when urinary obstructions block the outflow of the kidneys. Hydronephrosis may be gradual, partial or
intermittent.
Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

14
Enlargement of kidney resulting from urine accumulation in the upper urinary tract caused by a blockage of the urinary tract.
Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified
DIABETES MELLITUS
Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or action result in high blood sugar level.
Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion,
insulin action, or both (The American Diabetes Association, 1997). Type II DM is formerly known as Non-insulin Dependent Diabetes
Mellitus. Type 2 diabetes usually occurs at any age but most cases occur after age 30. More than 80% of the clients are overweight and do
always experience classic symptoms.
Kowalski, M.T., Rosdahl, C.B.;Basic Nursing

16
Diabetes mellitus occurs when beta cells are unable to produce insulin (Type I DM) or produce an insufficient amount of insulin
(Type II DM). As a result, glucose does not enter cells but remains in the blood.
Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified

14
PHYSICAL ASSESSMENT
I. Personal data:
Date of Assessment: November 13, 2009
Time of Assessment: 11:30 pm
Location of Assessment: Bed No. 12, Medicine Ward Nephro, Davao Medical Center
II. General Survey:
During assessment, the patient was lying supine on bed with ongoing Intravenous Fluid infusion of Plain Normal Saline Solution,
1 liter to run at KVO rate at the level of 750 cc, infusing well on her left metacarpal vein. Patient was awake, conscious, coherent, and
oriented to time, place, person and reason for admission. She was calm, cooperative and responsive. The quality and organization of
speech is understandable and in moderate pace and it exhibits thought association. The relevance and organization of thought is also
logical and has a sense of reality. General physical appearance is good; however, poor personal hygiene is evident.
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III. Vital Signs:
Temperature: 36.9°C
Pulse rate: 88 beats per minute
Respiratory rate: 22 cycles per minute
Blood pressure: 150/100 mm Hg
IV. The Integument
a. Skin
The patient’s skin color was brown and sallow, and generally uniform in distribution except for areas that are not
usually exposed to the sun. Pallor is noted on her palms, soles and nail beds. The palms and the soles are calloused.
The capillary refill took 3 seconds. Age spots are also highly visible on the face and the body. Poor skin turgor was
noted when the skin was pinched. No other lesions or deformities were noted.
b. Hair
Hair is evenly distributed over the scalp. Most hair on the scalp is gray as a result of advanced age. Dandruff is not
present. Fine hairs are evenly distributed on both extremities.

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c. Nails
The patient’s nails were untrimmed with pail nail beds, with normal angle curvature. Surrounding tissues were
intact; neither lesions nor lacerations were observed.
V. The Head
a. Skull and Face
The patient’s head is normocephalic and proportional to body size. The skull is also noted to be smooth in contour.
Presence of nodules or masses is not noted. Facial features and movements are symmetrical. The patient is able to raise
her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight tiredness.
b. Eyes
The hairs of the eyebrows are evenly distributed which are also symmetrically aligned. Eyelashes are equally
distributed and slightly curled outward. The skin of the eyelids is intact, no visible discharge, and discoloration is
noted. The eyelids close symmetrically. The sclera is white in color. The conjunctiva is shiny and pink in color. The
color of her iris is dark brown. The details of the iris are also visible. The eyes do not appear sunken. The client’s
pupils are round, black and are 3mm in diameter each pupil. When a pupil is illuminated, both pupils constrict. Both
eyes have coordinated movements; move in unison and with parallel alignment. According to her, when looking
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straight ahead, she can see objects in periphery. There was no edema or tenderness noted over her lacrimal glands. The
patient was not wearing any glasses or contact lenses.
c. Nose and Sinuses
The external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with
the entire face. No tenderness was noted during palpation. Both nares were patent. Air could move freely when
breathing in and out. The nasal septum is intact and is to be found in the midline. The frontal and maxillary sinuses
were not tender. Sense of smell is present and good since the patient was able to differentiate alcohol from coffee by
means of scent.
d. Ears
The auricles are smooth. The patient’s ears have the same color with her facial skin. The ears are symmetrical in
terms of size and position. The ears are normoset since both ears are located in line with the outer canthus of his eyes.
The auricles are firm and not tender. The pinna recoils after it is folded. The patient has no difficulty hearing normal
and whispered voice tone. No discharge was noted.
e. Mouth and Oropharynx
The lips are pink in color and glistening. The lips are also moist. The patient is able to purse her lips. The teeth are
white and shiny. Some teeth are also missing. The gums are moist and pink in color, with no signs of bleeding. The
15
tongue is positioned in the center. It is pink in color. No lesions observed. The papillae of the tongue are raised. The
tongue is able to move freely and the base has prominent veins. No swelling or ulcerations noted. The uvula is
positioned in midline of the soft palate. Tonsils are pink and not inflamed. The patient is able to swallow with no
difficulty.
VI. Neck
The muscles in the neck are symmetrical and the head movement is coordinated. There was no limited range of motion
noted as the patient turns her head from left to right; up and down; and circular motion. Trachea was located centrally in the
midline of the neck. No lymph nodes noted on any of the areas of the neck. Moreover, no neck blood vessels were distended
around the neck area.
VII.Chest and Lungs
The patient has a regular and normal breathing pattern. She has quiet, rhythmic, and effortless respirations with a
respiratory rate of 22 cycles per minute. There was a full and symmetric chest expansion. Chest pain was not reported.
Crackles were heard on both lung fields upon auscultation.

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VIII.Heart and Blood vessels
The point of maximal impulse was located at the fifth left intercostal space. The patient has a cardiac rate of 85 beats per
minute. Abnormal heart sounds or murmurs were not noted upon auscultation. The patient’s pulse is regular in rhythm and has
a thrusting characteristic.
IX. Abdomen
As observed, the patient’s abdomen has uniform skin color. Also, the abdominal contour is rounded or convex. The
umbilicus is medially located and shows no signs of inflammation. It also has a symmetric contour. When breathing, there is
symmetric movement which is caused by respiration. Bowel sounds are present upon auscultation.
X. Genito-urinary
The patient reported that there were no lesions, tenderness and masses in her perineum and anus. Patient has dark yellow
colored urine. She also has oliguria. Upon palpation distended bladder was noted.
XI. Musculoskeletal
a. Upper Extremities
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Patient’s peripheral pulses were symmetrical and regular, however, they are weak. The patient’s nails took 3
seconds for the capillary refill. The patient was able to exhibit strong hand grip on both arms. She was able to extend
and flex her both arms. Hand tremors were not noted.
b. Lower Extremities
Bipedal pitting edema grade 2+ was noted. She has difficulty ambulating because of the muscle removed from her
right foot.
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ANATOMY AND PHYSIOLOGY
The Urinary System is
the system of organs that produces and excretes urine from the body. Urine is a transparent yellow fluid containing unwanted wastes,
mostly excess water, salts, and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs
that continuously filter substances from the blood and produce urine. Urine flows from the kidneys through two long, thin tubes called
ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal
adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the tubelike urethra.
An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter (1 pint) of
urine daily to get rid of its waste products.
The kidneys lie embedded in fat tissue on either side of the backbone at about waist level. Each fist-sized kidney is reddish-brown, weighs
140 to 160 g (5 to 6 oz), and is similar in shape to the kidney beans sold at the supermarket.
15
On the inner border of each kidney is a depression called the hilum, where the renal artery, the renal vein, and the ureter connect
with the kidney (the adjective renal is from the Latin term renalis, meaning of or near the kidneys). The renal artery delivers over 1700
liters (450 gal) of blood to the kidneys each day, which these organs filter and return to the heart via the renal vein. Each kidney contains
16
about 1 million microscopic coiled channels, called nephrons, which perform this critical blood-filtering function and produce urine in the
process.
The bulblike upper portion of the kidney’s nephrons filters water; urea, the nitrogen-containing breakdown product of protein;
salts; glucose; amino acids, the building blocks of proteins; yellow bile compounds from the liver; and other trace substances from the
blood. As this material moves through a long, looped tubule, many of these filtered materials are reabsorbed into the blood to be reused by
the body to maintain normal body functions. Less than 1 percent of the water and other materials remain behind to be excreted as waste
products in the urine.
These waste materials then pass from the nephrons into a funnel-shaped area called the renal pelvis. From the renal pelvis, waste
trickles out of the kidney into the ureter, which is about 25 to 30 cm (10 to 12 in) long and about 0.5 cm (0.2 in) in diameter. The ureter
empties into a hollow, muscular sac called the urinary bladder. A valvelike flap of tissue at the point of entry into the bladder prevents
urine from flowing backward into the ureter. The urinary bladder is able to expand and contract according to how much urine it contains.
As it fills with urine, the walls of the bladder stretch and become thinner, with the bladder itself lengthening to 12.5 cm (5 in) or more and
holding up to about 0.5 liter (1 pt) of urine. A ringlike sphincter muscle surrounds the bladder’s outlet and prevents spontaneous
emptying.
As the bladder becomes full, stretch-sensitive receptors in its walls are stimulated, and the person becomes aware of the fullness.
When the person is ready to urinate, or expel urine, the sphincter relaxes and urine flows from the bladder to the outside through the
17
urethra. In females, the urethra is about 3.8 cm (1.5 in) long and is strictly a urinary passage. In males, the urethra is about 20 cm (8 in)
long; it passes through the penis and also serves to convey semen during sexual intercourse.
Production of Urine. Blood enters the kidney through the renal artery. The artery divides into smaller and smaller blood vessels,
called arterioles, eventually ending in the tiny capillaries of the glomerulus. The capillary walls here are quite thin, and the blood pressure
within the capillaries is high. The result is that water, along with any substances that may be dissolved in it—typically salts, glucose or
sugar, amino acids, and the waste products urea and uric acid—are pushed out through the thin capillary walls, where they are collected in
Bowman's capsule. Larger particles in the blood, such as red blood cells and protein molecules, are too bulky to pass through the capillary
walls and they remain in the bloodstream. The blood, which is now filtered, leaves the glomerulus through another arteriole, which
branches into the meshlike network of blood vessels around the renal tubule. The blood then exits the kidney through the renal vein.
Approximately 180 liters (about 50 gallons) of blood moves through the two kidneys every day.
Urine production begins with the substances that the blood leaves behind during its passage through the kidney—the water, salts, and
other substances collected from the glomerulus in Bowman’s capsule. This liquid, called glomerular filtrate, moves from Bowman’s
capsule through the renal tubule. As the filtrate flows through the renal tubule, the network of blood vessels surrounding the tubule
reabsorbs much of the water, salt, and virtually all of the nutrients, especially glucose and amino acids, that were removed in the
glomerulus. This important process, called tubular reabsorption, enables the body to selectively keep the substances it needs while ridding
itself of wastes. Eventually, about 99 percent of the water, salt, and other nutrients is reabsorbed.
18
At the same time that the kidney reabsorbs valuable nutrients from the glomerular filtrate, it carries out an opposing task, called
tubular secretion. In this process, unwanted substances from the capillaries surrounding the nephron are added to the glomerular filtrate.
These substances include various charged particles called ions, including ammonium, hydrogen, and potassium ions.
Together, glomerular filtration, tubular reabsorption, and tubular secretion produce urine, which flows into collecting ducts, which
guide it into the microtubules of the pyramids. The urine is then stored in the renal cavity and eventually drained into the ureters, which
are long, narrow tubes leading to the bladder. From the roughly 180 liters (about 50 gallons) of blood that the kidneys filter each day,
about 1.5 liters (1.3 qt) of urine are produced.
Other functions. In addition to cleaning the blood, the kidneys perform several other essential functions. One such activity is
regulation of the amount of water contained in the blood. This process is influenced by antidiuretic hormone (ADH), also called
vasopressin, which is produced in the hypothalamus (a part of the brain that regulates many internal functions) and stored in the nearby
pituitary gland. Receptors in the brain monitor the blood’s water concentration. When the amount of salt and other substances in the blood
becomes too high, the pituitary gland releases ADH into the bloodstream. When it enters the kidney, ADH makes the walls of the renal
tubules and collecting ducts more permeable to water, so that more water is reabsorbed into the bloodstream.
The hormone aldosterone, produced by the adrenal glands, interacts with the kidneys to regulate the blood’s sodium and potassium
content. High amounts of aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer potassium ions; low levels
19
of aldosterone have the reverse effect. The kidney’s responses to aldosterone help keep the blood’s salt levels within the narrow range that
is best for crucial physiological activities.
Aldosterone also helps regulate blood pressure. When blood pressure starts to fall, the kidney releases an enzyme (a specialized
protein) called renin, which converts a blood protein into the hormone angiotensin. This hormone causes blood vessels to constrict,
resulting in a rise in blood pressure. Angiotensin then induces the adrenal glands to release aldosterone, which promotes sodium and water
to be reabsorbed, further increasing blood volume and blood pressure.
The kidney also adjusts the body's acid-base balance to prevent such blood disorders as acidosis and alkalosis, both of which
impair the functioning of the central nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen ions, the
kidney moves these ions to the urine through the process of tubular secretion. An additional function of the kidney is the processing of
vitamin D; the kidney converts this vitamin to an active form that stimulates bone development.
Several hormones are produced in the kidney. One of these, erythropoietin, influences the production of red blood cells in the bone
marrow. When the kidney detects that the number of red blood cells in the body is declining, it secretes erythropoietin. This hormone
travels in the bloodstream to the bone marrow, stimulating the production and release of more red cells.
ETIOLOGY AND SYMPTOMATOLOGY

14
A. ETIOLOGY
Predisposing
Present/ Absent Rationale Justification
Factors
Age Present In ESRD, the patient is The patient is aged 56
predisposed to the disease years old.
by her age because with
increased age, there is
already wear and tear of the
organs and diminished
ability of the kidneys to
perform as they should.
Also, major candidates for
Diabetes Mellitus type 2

15
are seen to be of the adult
population; this
predisposed the patient to
the disease which lead to
ESRD.
Family History Present The risk of ESRD Although family
secondary to history of ESRD is
hydronephrosis secondary not present, it is
to diabetes mellitus is important to note that
substantially increased if ESRD in this
either of a patient’s parents particular patient
had diabetes. Diabetes is rooted from the
often inherited (passed existent disease
from the parent to the diabetes mellitus
child). which runs in the
paternal side of the
patient’s family. The

14
father of the patient
and some of the
family members in
the father’s side of
the patient has
diabetes mellitus.
Precipitating
Present/ Absent Rationale Justification
Factors
Obesity Absent Researchers attribute most The patient is not
cases of Type 2 diabetes to
obesity. Studies show that obese. Her weight
the risk for developing
Type 2 diabetes increases which is 59kg or 130
by 4 percent for every
pound of excess weight a lbs and height of 4’10
person carries. Researchers
are investigating the exact is suggestive of a BMI
role that extra weight plays
in preventing the proper of 27 which may be
utilization of insulin and
why some overweight overweight but is still
people develop the disease
while others do not. not considered as
14
Microsoft ® Encarta ® obese.

2008. © 1993-2007
Microsoft Corporation.
All rights reserved.
Sedentary lifestyle absent A sedentary lifestyle may The patient is not
contribute to obesity which having a sedentary
is said to be a factor which lifestyle as reported.
can cause diabetes mellitus The patient claims that
type two. she has been living a
fairly active lifestyle.
Although she does not
exert any effort to jog
or stretch habitually;
she reports to do
chores at home such as
doing the laundry,
watering her plants and

15
others.
Increased dietary fat present The accumulation of too The patient does not
much fat in the body is
intake associated with a variety of deny the fact that she
health problems. Studies
show that individuals who used to have high
are overweight or obese
run a greater risk of intake of fats prior to
developing diabetes
mellitus, hypertension, her hospitalization
coronary heart disease,
stroke, arthritis, and some
forms of cancer.
Microsoft ® Encarta ®
2008. © 1993-2007
Microsoft Corporation.
All rights reserved.
B. SYMPTOMATOLOGY
Symptoms Present/Absent Rationale Justification

Peripheral edema present Edema is apparent, Bipedal edema with the score
resulting from fluid of 2+ is noted.
retention due to the
impairment of the
15
ability of the kidneys
to excrete fluids.
Increased present Increased creatinine The creatinine level of the
creatinine levels levels suggest renal patient is 697.90mmOl/L
insufficiency.
Flank pain absent Flank pain is one of The patient did not report any
the classic symptoms experience of flank pain.
of kidney damage.
Massive absent Protein is a macro
proteinuria molecule which is not
supposed to cross the
urine, however, in
cases of renal
impairment, proper
glomerular filtration
is damaged that the

16
macromolecules
causing them to cross
the urine.
Electrolyte present One of the major Sodium levels are relatively
imbalances functions of the high.
kidney is to regulate
electrolyte levels in
the body.
Anemia present The kidneys produce The Blood test of the patient
the hormone shows abnormally low levels of
erythropoietin in RBCs, hemoglobin and
adults. This stimulates hematocrit.
the production of red • Hemoglobin= 77
blood cells which • Hematocrit= 0.22
carry oxygen in the • RBCs=2.60
body. Diminished
RBCs is termed
15
anemia.
14
PATHOPHYSIOLOGY
Heredity Diet
Age Lifestyle
Glucose in the blood
Excessive thirst, generalized

Cells do not respond to the effects
weakness, excessive
of insulin in type 2 diabetes
urination, blurred vision,
Diet and lifestyle modification delayed wound healing
Administration of medications Increased blood viscosity
Stretching of intravascular spaces Hypertension

14
• Excessive
accumulati ESRD
Stretching of capillaries
on of
metabolic
Renal capillary collapse
wastes
• Kidneys
unable to Loss/ impaired of nephron function
maintain If not treated
Treatment
homeostasi A. Medications
s Diminished renal reserve 40-50% renal function• NaHCO3 Loss of excretory
•
Chronic Psychologi • Diureticsrenal function
Renal Disease cal DEATH • Antihypertensive
changes Renal Insufficiency 20-40% renal function drugs
• 10-15% • Antacids
Inefficient urine
• Aluminum
flow/ Hydroxide
• Multivitamins
Urine flow
Cardiovascular Neurologic Hematologic Musculoskeletal A. Dialysis
• Peritoneal
HYDRONEPHROSIS
Hypertension LOC changes Anemia Loss of muscle strength • Hemodialysis
Edema Weakness Malaise
Fatigue
A. Renal Transplant
B. Lifestyle and Diet
Modifications ESRD
GOOD PROGNOSIS
16
Due to Diabetes Mellitus type 2 resulting from etiologies, blood glucose levels start concentrating in blood because of the inability
of the cells to respond to the effects of insulin. As blood glucose levels increase, blood viscosity also increases, thereby stretching
intravascular spaces systemically leading to extensive dilation of capillaries. This overstretching also results to hypertension; however, the
worst scenario that it can bring is the collapse of end capillaries especially in vital organs such as the kidneys. In this case, the extensive
dilation of kidney capillaries result in renal capillary collapse which causes impairment in the renal function.
The kidneys function as filtering devices in our body, it also excretes urine as wastes and secrete hormones essential to the body.
With the destruction of proper renal functioning, several problems arise. On one hand, excreting function is impaired thus causing urinary
retention leading to hydronephrosis. On the other end, impaired renal functioning will start progressing into chronic kidney disease in
which leads to several discomforts and changes in the body such as edema, anemia, LOC changes, uremia and many others. These
conditions, if still not properly managed and detected early will all lead to the dreadful end stage renal disease.
18
Date Order Rationale Remarks

Novemb Pls admit to IMCU The patient is admitted to IMCU Done
er 9, because her condition fits in this
2009 department basing on disease
categorization.
Low Fat Low Salt The patient has hypertension, high Done
intake of dietary sodium and fat
may worsen the condition of the
patient.
VSq4 This is done in order to constantly Done
monitor any changes in the vital

DOCTOR’S Orders
signs of the patient which may
indicate new advances or
worsening of the condition of the
patient in order to be addressed
immediately.
Venoclysis: PNSS is given to the patient in Done
PNSS@KVO order to serve as a line for her

16
55
DIAGNOSTIC EXAM
A. Actual Laboratory Tests and Diagnostic Examinations
Urinalysis
Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that
produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition.
Normal Value / Nursing

Date Laboratory Test Result Clinical Significance
Results Interventions
O Color Yellow, straw, amber Dark Yellow Colorless: overhydration, diuretic therapy, Pretest:
C (normal) diabetes insipidus and mellitus >Provide
T Dark red or pink: porphyria, hematuria, ingestion patient with
O of red food coloring, beets, berries, fava beans, urine
B rhubarb container with
E Dark yellow: bile lid.

55
R Green: pseudomonas bacteriuria, urinary bile >Instruct the
1 pigments patient to
9 collect a
Appearance Clear to faintly hazy Clear Cloudy, smoky or hazy: pyuria, bacteriuria, sample of
2 (normal) phosphates in urine urine,
0 preferably on
0 Reaction 4.0-8.0 6.0 If >8.0, finding may be the result of UTI If <4.0, arising in the
9 (normal) may indicate respiratory or metabolic acidosis morning;
must not be
contaminated
Specific gravity 1.003- 1.030 1.042 increased in:dehydration, fever, profuse sweating, by toilet
(high) vomiting, diarrhea, glycosuria, proteinuria, CHF, paper, toilet
adrenal insufficiency, SIADH water, feces
Decreased in: overhydration, diuresis, or secretions.
hypotension, pyelonephritis, glomerulonephritis, >Women
renal tubular dysfunction, severe renal damage, should not

56
diabetes insipidus collect urine
during
Albumin Negative positive Positive in: nephrotic syndrome, renal menstruation.
disorders, associated with hypertension, >Instruct
negative diabetes mellitus, SLE, amyloidosis patient to
Sugar Negative Positive in: hyperglycemia, diabetes mellitus collect a
midstream
voided
Epithelial Cells- +++ 5-8 specimen.
Squamous
Posttest:
Pus cells ≤ 4 cells/HPF 0-2 hpf Positive in: urinary tract infection (UTI) >The lid must
be sealed
Red Blood Cells ≤ 2 rbc hpf Positive in indicates bleeding at some location completely
in the urinary tract, from the glomeruli to and the
urethra, or leakage of rbc through the container

56
glomerular membrane. must be
Mucous threads ++ labeled
properly.
>Specimen
must be
delivered to
the laboratory
immediately.
COMPLETE BLOOD COUNT AND PLATELET COUNT
The CBC is a series of different tests used to evaluate the blood and the cellular components of RBC’s, WBC’s and
platelets. The CBC is used to assess the patient for anemia, infection, inflammation, polycythemia, hemolytic disease, and the effects of
ABO incompatibility, leukemia and dehydration status

55
Normal Result of Clinical

Date Exam Rationale Remearks Nursing Responsibilities
Value Patient Significance
Novemb Hemoglobin 115 – 175 The test that 96 Low Increased in: 1. Discuss and explain the
er 10, g/L measures the polycythemia, procedure and purpose of
2009 amount of dehydration, the test.
hemoglobin per acute thermal
liter of blood injury, COPD 2. Inform the patient that
Decreased in: no fasting is needed.
hemorrhage,
bleeding,
anemia, 3. Assess the patient for
hemolytic any factor that will
anemia, fluid probably affect the
overload, fluid results of the test.
retention,
pregnancy, 4. Make sure patient is well

55

cirrhosis of the hydrated. Dehydration
liver, elevates the test results.
hyperthyroidis
A low
hemoglobin is
referred to as
anemia.
The test measures A low
the percentage of hematocrit is

Hematocrit 0.36 – 0.48 0.27 Low
RBC in the total referred to as
blood volume anemia.

RBC count 4.20 – 6.10 The test measures 3.58 Low Low RBC may
the circulating indicate blood
RBCs in 1 cubic loss, anemia,

55

hemorrhage,
bone marrow 5. If patient is connected to

millimeter of
failure, IVF, make sure that the
blood.
leukemia, and blood is not taken from
malnutrition the arm connected to the

The test measures
IVF. Hemodilution
all leukocytes
causes false decrease of
WBC count 5.0 – 10.0 present in 1 cubic 6.01 Normal Normal
the test results.
millimeter of
blood.
6. After the puncture,
Neutrophil 55 – 75 Neutrophils serve 62 Low Normal
assess the site for
as the body's .
bleeding or bruising.
primary defense
7. If patient is under
against infection
treatment from an
through the
55

process of infection, inform the
phagocytosis. patient that the test will
Usually used to be repeated to monitor
diagnose specific progress.
type of illnesses.
Lymphocyte 20 – 35 Lymphocytes 37 High Abnormally
8. Any abnormality noted
initiate high levels of
will be reported to the
immunologic lymphocytes can
physician.
cresponses. The be due to flu,
test determines chicken pox, and
lymphocyte blood some viral and
count. bacterial
infection.
55

Monocytes have
phagocytic
action. It removes
dead or injured
cells, cell
fragments, and
Monocyte 2 – 10 9 Normal Normal
microorganism.
This test is done
to diagnose an
illness such as
inflammatory
diseases.
Eosinophils 1–8 Eosinophils 7 Normal Normal
initiate allergic
56
55

responses and act
against parasitic
infestation. The
test is use to
diagnose worm
infestation.
Basophils initiate
Basophil 0–1 type 1 allergic 1 Normal Normal
responses
The test measures
all platelets
Platelet count 150 – 400 present in 1 cubic 214 Normal Normal
millimeter of
blood.
Chemistry
55

The test measures
Potassium 3.5 – 5.5 potassium levels 4.0 Normal Normal
of the blood.
High Serum
sodium indicates
retention of
The test measures sodium in the

Sodium 136 – 155 the sodium levels 168 High body and a
in the blood. diminished
filtration
function of the
kidneys.
The test usually This measures
Creatinine 53 - 115 indicates renal 697.90 High renal
function. sufficiency.. The

55

lower the level
of creatinine in
the body, the
healthier the
kidneys are.
Activated Partial Thromboplastin Time (APTT)
The test measures
Novemb the time in
er 13, APTT 29.4 – 38.4 seconds for a 34.0 Normal Normal
2009 specific clotting
process to occur.
APTT Control 26.0 – 31.0 If the test sample 28.5 Normal Normal
takes longer than

55

the control sample,
it indicates
decreased clotting
function in the
intrinsic pathway.
Prothrombin Time (PT)
PT Patient 11.8 – 15.1 PT may be 14.6 Normal Normal
June 21, PT Control 12.0 – 15.0 13.5 Normal Normal
ordered when a
2009
patient is to
undergo an
invasive medical
procedure, such as
surgery, to ensure
55

normal clotting
ability.
Drug Study
Generic Name Furosemide

64
Brand Name Apo-Furosemide, Furosemide Special IV, Furoemide, Lasix, Novo-semide,
Uritol
Classification Loop diuretic
Suggested Dose Acute pulmonary edema (adult): 40 mg I.V. injection slowly over 1 to 2
minutes; then 80 mg I.V. in 60 to 90 minutes if needed
Edema (adult): 20 to 80 mg P.O. daily in the morning.
(infants and children): 2 mg/kg P.O. daily, increased by 1 to 2 mg/kg in 6
to 8 hours if needed
Hypertension (adult): 40 mg P.O. b.i.d.
(children): 0.5 to 2 mg/kg P.O. once or twice daily.

Mechanism ofInhibits sodium and chloride reabsorption at proximal and distal tubule and
Action the ascending loop of Henle

Indication Pulmonary edema, edema in CHF, nephrotic syndrome, hypertension
Contraindication Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation and
electrolyte depletion
Drug Interaction Amioglycosides antibiotics, cisplatin: may increase risl of hypokalemia.
Antidiabetis: may decrease hypoglycemic effects
Antihypertensives: may increase risk of hypertension
Cardiac glycosides, neuromuscular blockers: may increase toxicity of these

64
drugs from furosemide-induced hypokalemia
Chlorothiazide, chloothalidone, hydrochlorothiazide, indapamide,
metolazone: may cause excessive diuretic response, causing serious
electrolyte abnormalities and dehydration.
Ethacrynic acid: may increase risk of ototoxicity
Lithium: may decrease lithium excretion, resulting in lithium toxicity
NSAIDs: may inhibit diuretic response

Side/Adverse Effects CNS: vertigo, headache, dizziness, paesthesia, weakness, restlessness, fever.
CV: orthostatic hypotension, thrombophlebitis with I.V. admnistration.
EENT: transcient deafness, blurred or yellowed vision, tinnitus.
ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic
alkalosis
GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting,
constipation, pancreatitis
GU: nocturia, polyuria, frequent urination, oliguria
Hematologic: agranulocytosis, aplastic anemia, leucopenia,
thrombocytopenia, azotemia, anemia

64
Hepatic: hepatic dysfunction, jaundice
Metabolic: volume depletion and dehydration and dehydration asymptomatic
hyperuricemia, impaired glucose tolerance, hypokalemia, hypochloremic
alkalosis, hyperglycemia, dilutional hyponatremia, hypocalemia,
hypomagnesemia
Musculoskeletal: muscle spasm
Skin: dermatitis, purpura, photosensitivity reactions, transcient pain at I.M.
injection site
Other: gout
Nursing 1. Monitor potassium level closely, glucose level in diabetics patient and
Responsibilities lithium level.
2. Monitor patient closely for signs and symptoms of excessive diuretic
response.
3. Advise patient to avoid excessive sunlight exposure.
4. To prevent nocturia, give P.O. and I.M. preparations in the morning.
Give second dose earlier afternoon.
5. Monitor weight, blood pressure, and pulse rate routinely with long-
65
term use and during rapid dieresis. Use can lead to profound water and
electrolyte depletion.
6. If oliguria or azotemia develops or increases, drug may need to be
stopped.
7. Monitor fluid intake and output and electrolyte, BUN, and carbon
dioxide levels frequently.
8. Watch for signs of hypokalemia, such as muscle weakness and cramps.
9. Consult prescriber and dietitian about a high-potassium diet or
potassium supplements. Foods rich in potassium include citrus fruits,
tomatoes, bananas, dates, and apricots.
10. Drug may not be well absorbed orally in patient with severe heart
failure. Drug may be given I.V. even if patient is taking other oral
drugs.
11. Monitor uric acid level, especially in patients with a history of gout.
12. Advise patient to take drug with food to prevent GI upset, and to take
in morning to prevent eed to urinate at night.

64
13. Inform patient of possible need for potassium or magnesium
supplements.
14. Instruct patient to stand slowly to prevent dizziness and to limit
alcohol intake and strenuous dizziness upon standing quickly.

64
Generic Name Amlodipine
Brand Name Norvasc

Classification Calcium channel blocker
Suggested Dose Chronic stable angina vasospastic angina (Prinzmetal or variant)
(adult): initially, 5 to 10 mg P.O. daily.
(elderly): initially, 5 mg P.O. daily
Hypertension (adult): initially, 2.5 to 5 mg P.O. daily.
(elderly): initially, 2.5 mg P.O. daily

Mechanism of Action Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates
coronary arteries and arterioles, and decreases blood pressure and
myocardial oxygen demand.

Indication Chronic stable angina pectoris, vasospastic angina, hypertension
Contraindication Hypersensitive to drug , Sick sinus syndrome, 2nd-3rd degree heart block,
64
hypotension less than 90mmHg systole

Drug Interaction • Increased hypotension with alcohol, fentanyl, quinidine,
antihypertensives, nitrates
• Neurotoxicity with lithium
• Decreased hypertensive effects with NSAIDs
Side/Adverse Effects CNS: headache, somnolence, fatigue, dizziness, light-headedness,
paresthesia
CV: edema, flushing, palpitations
GI: nausea, abdominal pain
GU: sexual difficulties
Musculoskeletal: muscle pain
Respiratory: dyspnea
Skin: rash, puritus

64
Nursing 1. Monitor patient carefully. Some patients, especially those with
Responsibilities severe obstructive coronary artery disease, have developed increased
frequency, duration, or severity of angina or acute MI after initiation
of calcium channel blocker therapy or at time of dosage increase.
2. Monitor blood pressure frequently during initiation of therapy.
Because drug induced vasodilation has a gradual onset, acute
hypotension is rare.
3. Notify prescriber if signs of heart failure occur, such as swelling of
hands and feet or shortness of breath.
4. Abrupt withdrawal of drug may increase frequency and duration of
chest pain. Taper dose gradually under medical supervision.
5. Don’t confuse amlodipine with amiloride.
6. Caution patient to continue taking drug, even when feeling better.
7. Tell patient S.L. nitroglycerin may be taken as needed when angina
symptoms are acute. If patient continues nitrate therapy during
adjustment of amlodipine dosage, urge continued compliance.

64
8. Administer once a day without regard to meals.
9. Instruct the patient to take the drug as prescribed, do not double or
skip dose.
10. Evaluate for therapeutic response; decreased anginal pain, decreased
BP, increased exercise tolerance.
Generic Name Ferrous Sulfate
Brand Name Apo-Ferrous Sulfate, ED-IN-SOL, Feosol, Fer-gen-sol, Fer-In-Sol, Fer-iron

Classification Hematinic
Suggested Dose Iron deficiency (adult): 150 to 300 mg P.O. elemental iro daily in three
divided doses.
(children): 3 to 6 mg/kg P.O. daily in three divided doses.

64
As a supplement during pregnancy (adult): 15 to 30 elemental iron P.O.
daily during last two trimesters.

Mechanism of Action Provides elemental iron, an essential component in the formation of
hemoglobin.
Indication Prevention and treatment of iron deficiency anemias; dietary supplement for
iron; unlabeled use: supplemental use during epoetin therapy to ensure
proper hematologic response to epoetin

Contraindication Patients with hemosiderosis, primary hemochromatosis, hemolytic anemia
(unless patient also has iron deficiency anemia), peptic ulceration, ulcerative
colitis, or regional enteritis and in those receiving repeated blood
transfusions.
Drug Interaction • Antacids and H2 blockers (cimetidine): Concurrent administration
may decrease iron absorption.
• Chloramphenicol: Response to iron therapy may be delayed.
• Levodopa, methyldopa, penicillamine: Iron may decrease absorption
when given at the same time.
• Quinolones: Absorption may be decreased due to formation of a

65
ferric ion-quinolone complex
• Tetracyclines: Absorption of oral preparation of iron and
tetracyclines are decreased when both of these drugs are given
together
• Vitamin C: Concurrent administration of 200 mg vitamin C per 30
mg elemental iron increases absorption of oral iron.
Side/Adverse Effects GI: nausea, epigastric pain, vomiting, constipation, black stools, diarrhea,
anorexia
Other: temporarily strained teeth from liquid forms.

64
Nursing 1. GI upset may be related to dose.
Responsibilities 2. Between-meal doses are preferable. Drug can be given with some
foods, although absorption may be decreased.
3. Enteric-coated products reduce GI upset but also reduce amount of
iron absorbed.
4. Oral iron may turn stools black. Tell patient that although this
unabsorbed iron is harmless, it could be mask melema.
5. Monitor hemoglobin level, hematocrit, and reticulocyte count during
therapy.
6. Don’t confuse different iron salts; elemental content may vary.
7. Tell patient to take tablets with juice (preferably orange juice) or
water, but not with milk or antacids.
8. Instruct patient not to crush or chew extended-release forms.
9. Caution patient not to substitute one iron salt for another because
amounts of elemental iron vary.
10. Advise patient to report constipation and change in stool color

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consistency.
11. In administering liquid form, let patient take it with straw to avoid
straining of teeth.
Generic Name Tramadol hydrochloride

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Brand Name Dolcet, Dolotral, Milador, Siverol, Tramal

Classification Pharmacologic class: opioid agonist
Therapeutic class: analgesic

Suggested Dose Adults:
• Patients who require rapid analgesic effect: 50–100 mg PO q 4–6 hr; do
not exceed 400 mg/day.
• Patients with moderate to moderately severe chronic pain: Initiate at 25
mg/day in the morning and titrate in 25-mg increments q 3 days to
reach 100 mg/day. Then, increase in 50 mg-increments q 3 days to
reach 200 mg/day. After titration, 50–100 mg q 4–6 hr; do not exceed
400 mg/day.
• Patients with cirrhosis: 50 mg q 12 hr.
• Patients with creatinine clearance < 30 ml/min: 50–100 mg PO q 12 hr.

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Maximum 200 mg/day.
Pediatric Patients:
• Safety and efficacy not established.
Geriatric patients or patients with renal or hepatic impairment> 75 yr: Do
not exceed 300 mg/day.

Mechanism ofBinds to mu-opioid receptors and inhibits the reuptake of norepinephrine and
Action serotonin; causes many effects similar to the opioids—dizziness, somnolence,
nausea, constipation—but does not have the respiratory depressant effects.

Indication • Relief of moderate to moderately severe pain when non-opioid
analgesics are not active enough
• Renal impairment
• Hepatic impairment
Contraindication • Contraindicated with allergy to tramadol or opioids or acute
intoxication with alcohol, opioids, or psychoactive drugs.
• Opioid-dependent patients.
• Severe hepatic impairment.
• Patients on obstetric preoperative medication.

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• Abrupt discontinuation.
• Children <16 years old.
• Use cautiously with pregnancy, lactation, seizures, concomitant use of
CNS depressants or MAOIs, renal dysfunction, or hepatic impairment.

Drug Interaction Drug – Drug
• Carbamazepine. Significantly decreases tramadol levels (may need up
to twice usual dose).
• MAO Inhibitors. Tramadol may increase adverse effects.
• Tricyclic Antidepressants, Cyclobenzaprine, Phenothiazines,
Selective Serotonin Reuptake Inhibitors (SSRI), MAO Inhibitors.
May enhance seizure risk with tramadol.
• Other CNS Depressants. May increase CNS adverse effects of
tramadol.
Herbal: St. John's Wort. May increase sedation.

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Side/Adverse Effects CNS: sedation, dizziness or vertigo, headache, confusion, dreaming, sweating,
anxiety,
CV: hypotension, tachycardia, bradycardia
Skin: sweating, pruritus, rash, pallor, urticaria
GI: nausea, vomiting, dry mouth, constipation, flatulence
GU: urinary retention / frequency, menopausal symptoms, dysuria, menstrual
disorder
Other: potential for abuse

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Nursing 1. Assess for level of pain relief and administer prn dose as needed but not to
Responsibilities exceed the recommended total daily dose.
2. Monitor vital signs and assess for orthostatic hypotension or signs of CNS
depression.
3. Explain the drug action, purpose of drug and side effects.
4. Advise the patient to avoid activities that require mental alertness.
5. Assess for history of drug addiction, allergy to opiates or codeine or
seizures.
6. Assess the patient’s skin color, texture, lesions; orientation, reflexes,
bilateral grip strength, affect; P, auscultation, BP; bowel sounds, normal
output; LFTs, renal function tests.
7. Instruct the patient to lye down for a while after taking the drug.
8. Report severe nausea, dizziness, severe constipation.
9. Monitor input and output ratio. Check for decreasing output.
10. Instruct the patient to make position changes slowly.
11. Tell the patient and watcher to report symptoms of CNS changes, allergic
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reactions.
12. Provide safety measures: side rails, night light, call bell within easy reach.
Generic Name Metoclopramide
Brand Name Apo-Metoclop. Clopra, Maxeran, Maolon, Octamide PFS, Pramin, Reglan
Classification Dopamine antagonist
Indication and ➢ To prevent or reduce nausea and vomiting from emetogenic cancer
Suggested Dose chemotherapy: Adult: 1 to 2 mg/kg I.V. 30 minutes before
chemotherapy; repeat q 2 hours for two doses, then q 3 hours for three
doses.
➢ To prevent or reduce postoperative nausea and vomiting: Adult: 10

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to 20 mg I.M. near end of surgical procedure, repeat q 4 to 6 hours,
p.r.n.
➢ To facilitate small-bowel intubation, to aid in radiologic
examinations: Adults and children older than age 14: 10 mg or 20 ml
I.V. as a single dose over 1 to 2 minutes.
Children ages 6 to 14: 2.5 to 5 mg or 0.5 to 1 ml I.V.
Children younger than age 6: 0.1 mg/kg I.V.
➢ Delayed gastric emptying secondary to diabetic gastroparesis:
Adult: 10 mg P.O. 30 minutes before each meal and at bedtime for mild
symptoms. Give slow I.V. infusion over 1 to 2 minutes 30 minutes
before each meal and at bedtime for up to 10 days for severe symptoms;
then P.O. dose may be started and continued for 2 to 8 weeks.
➢ Gastroesophageal reflux disease: Adult: 10 to 15 mg P.O. q.i.d.,
p.r.n., 30 minutes before meals and at bedtime.
➢ Emesis during pregnancy: Adults: 5 to 10 mg P.O. or 5 to 20 mg I.V.
or I.M. t.i.d.
Mechanism ofStimulates motility of upper GI tract, increases lower esophageal sphincter
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Action tone, and blocks dopamine receptors at the chemoreceptor trigger zone.
Contraindication • Hypersensitivity to drug and in those with oheochromocytoma r seizure
disorders.
• Stimulation of GI motility might be dangerous
• History f depression, Parkinson disease, or hypertension

Drug Interaction • Substrate (minor) of CYP1A2, 2D6; Inhibits CYP2D6 (weak)
• Anticholinergic agents antagonize metoclopramide's actions
• Antipsychotic agents: Metoclopramide may increase extrapyramidal
symptoms (EPS) or risk when used concurrently.
• Opiate analgesics may increase CNS depression

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Side/Adverse Effects CNS: anxiety, drowsiness, dystonic reaction, fatigue, lassitude, restlessness,
neuroleptic, malignant syndrome, seizures, suicide ideation, akathisia,
confusion, depression, dizziness, extrapyramidal ymptoms, fever, hallucinatins.
Headache. Insomnia, tardive dyskinesia.
CV: bradychardia, superventricular tachycardia, hypotension, transient
hypertension.
GI: bowel disorders, diarrhea, nausea
GU: incontinence, urinary frequency
Hematologic: aggranulocytosis, neuropenia
Skin: rash, uricaria
Other: loss of libido, prolactin secretion.

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Nursing 1. Assess for mental status; depression, anxiety and irritability.
Responsibilities 2. Monitor bowel sounds.
3. Safety and effectiveness of drug haven’t been established for therapy
lasting longer than 12 weeks.
4. Tell patient to avoid activities that require alertness for 2 hours after
doses.
5. Urge patient to report persistent or serious adverse reactions promptly.
6. Advise patient not to drink alcohol during therapy.
7. Administer 1 ½ hour before meals for better absorption
8. Monitor vital signs, especially cardiac rate to monitor tachycardia.
9. Evaluate for therapeutic effects: absence of nausea, vomiting, anorexia
and fullness.
Generic Name Sodium Bicarbonate

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Brand Name Arm & Hammer Baking Soda, Bell/ans, Neut, Soda Mint
Classification Alkanizer
Suggested Dose
Cardiac Arrest: Adults: 1 mEq/kg I.V. of 7.5% or 8.4% solution; then 0.5
mEq/kg I.V. q 10 minutes depending on arterial blood gas (ABG) level. Base
further dosages on results of ABG analysis. If ABG level is unavailable, use
0.5 mEq/kg I.V. q 10 minutes until spontaneous circulation returns. Infants
and children: 1 mEq/kg (1 ml/kg of 8.4% solution) I.V. slowly followed by 1
mEq/kg q 10 minutes of arrest. Don’t give more than 8 mEq/kg I.V. total; a
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4.2% solution may be preferred.
Mechanism ofDissociates to provide bicarbonate ion which neutralizes hydrogen ion
Action concentration and raises blood and urinary pH

Indication Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac
Arrest
Contraindication Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown
abdominal pain
Drug Interaction • Decreased effect/levels of lithium, chlorpropamide, methotrexate,
tetracyclines, and salicylates due to urinary alkalinization
• Increased toxicity/levels of amphetamines, anorexiants,
mecamylamine, ephedrine, pseudoephedrine, flecainide, quinidine,
quinine due to urinary alkalinization

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Side/Adverse Effects CNS: tetany
CV: edema
Metabolic: hypokalemia, metabolic alkalosis, hypernatremia,
hyperosmolarity with overdose
Skin: pain and irritation a injection site

Nursing 1. To avoid risk of alkalosis, obtain blood pH, partial pressue of arterial
Responsibilities oxygen, partial pressure of arterial carbon dioxide, and electrolyte levels.
Tell prescriber laboratory results.
2. Oral products may contain 27% sodium.
3. Tell patient not to take drug with milk because doing so may cause high
levels of calcium in the blood, abnormally high alkalinity in tissues and
fluids, or kidney stones.
4. Advise patient of milk-alkali syndrome if use is long-term; observe for
extravasations when giving I.V.
Generic Name Ketosteril

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Brand Name Ketosteril

Classification Keto Analog of Essential Amino Acids
Suggested Dose Adult 70 kg 4-8 tab tid given if GFR is 5-15 mL/min.
Mechanism ofThis drug is combination of amino acids which promotes splitting of urea. It
Action reduces ion concentration of K, Mg and Phosphate. This promotes recycling
products exchanging and anabolism of protein while reducing urea
concentration in serum.
Indication Pre-ESRD in CKD & DN patients stage 3, 4, 5 together w/ a very low protein
(0.3-0.6 g/kg body wt/day), high caloric diet in compensated &
decompensated retention to reduce uremic symptoms, slow or arrest of the
progression of renal failure, prevent the degradation of body protein, reduce

64
the daily urinary protein loss, normalisation of the carbohydrate metabolism,
correct the disturbances in Ca & phosphate metabolism, secondary
hyperparathyroidism & renal osteodystrophy, improve the disturbed serum
lipid profile & delay the need for dialysis. Dialysis CKD patients together
with high protein (1.2-1.3 g/kg body wt/day) to reduce uremic symptoms &
improve malnutrition status.

Contraindication Hypercalcemia, disturbed amino acid metabolism. In case of hereditary
phenylketonurie it has to be taken into account that this product contains
phenylalanine.
Drug Interaction Tetracycline affects Ca absorption
Side/Adverse Effects • Headache, dizziness, dry mouth, nervousness, flushing, or irritability
• Trouble sleeping, stomach cramps, hot flashes and leg cramps
• Chest pain, slow/fast/irregular heartbeat, swelling of the feet or ankles,
difficulty urinating, swelling of the breasts or discharge from the
nipple in men or women, menstrual changes, sexual difficulties.

Nursing 1. Tell patient to inform prescriber of all prescriptions, OTC medications, or
Responsibilities herbal products he is taking, and any allergies he have.

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2. Advice patient not to take any new medication during therapy unless
approved by prescriber.
3. Tell patient that he may take without regard to food. Maintain adequate
hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake.
4. Inform the patient that the drug is available in many forms and dosages.
The patient must take the drug in a dosage ordered by the prescriber.
5. Tell patient to report episodes of hypersensitivity reaction immediately.
6. Tell the patient not to abruptly stop the medication unless ordered by the
physician.
7. Ensure that the patient does npt manifest any condition contraindicated in
taking this drug.
8. Warn patient to avoid alcohol..
9. Tell woman to stop drug and notify prescriber immediately if she is or
may be pregnant or if she’s breastfeeding.
10. Assess the efficacy of the drug by monitoring VS and laboratory results.
Refer accordingly.
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Generic Name Atorvastatin Calcium
Brand Name Lipitor, Atacor

Classification HMG-CoA reductase inhibitor
Suggested Dose Oral:
Children 10-17 years (females >1 year postmenarche): HeFH: 10 mg once
daily (maximum: 20 mg/day)
Adults: Hyperlipidemias: Initial: 10-20 mg once daily; patients requiring
>45% reduction in LDL-C may be started at 40 mg once daily; range: 10-80
mg once daily
Primary prevention of CVD: 10 mg once daily

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Dosing adjustment in renal impairment: No dosage adjustment is
necessary.
Dosing adjustment in hepatic impairment: Do not use in active liver
disease.
Mechanism ofInhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol
Action biosynthesis.
Indication • Adjunct to diet to reduce LDL, total cholesterol, apolopoproteim B,
and triglyceride levels in patients with primary hypercholesterolemia
(heterozygous familial ad nonfamilial) and mixed dyslipideia
(Fredrickson types IIa and IIb); adjunct to diet to reduce triglyceride
level (Fredrickson type IV); primary dysbetalipoproteinemia
(Fredrickson type III) in patients who don’t respond adequately to diet.
• Alone or as adjunct to lipid-lowering treatments, such as LDL
apheresis, to reduce total and LDL cholesterol in patients with
homozygous familial hypercholesterolemia
• Heterozygous familial hypercholesterolemia
• To reduce the risk of MI, stroke, angina, or revascularization

64
procedures in patients with multiple risk factors for CAD but who
don’t yet have the disease.

Contraindication Hypersensitivity to atorvastatin or any component of the formulation; active
liver disease; unexplained persistent elevations of serum transaminases;
pregnancy; breast-feeding
Drug Interaction • Antacids: Plasma concentrations may be decreased when given with
magnesium-aluminum hydroxide containing antacids (reported with
atorvastatin and pravastatin). Clinical efficacy is not altered, no dosage
adjustment is necessary
• Cholestyramine and colestipol (bile acid sequestrants): Reduce
absorption of several HMG-CoA reductase inhibitors; separate
administration times by at least 4 hours. Cholesterol-lowering effects
are additive.
• Clofibrate and fenofibrate may increase the risk of myopathy and
rhabdomyolysis.
• CYP3A4 inhibitors: May increase the levels/effects of atorvastatin.
Example inhibitors include azole antifungals, ciprofloxacin,

64
clarithromycin, diclofenac, doxycycline, erythromycin, imatinib,
isoniazid, nefazodone, nicardipine, propofol, protease inhibitors,
quinidine, and verapamil.
• Digoxin: Plasma concentrations of digoxin may be increased by
~20%; monitor.
• Grapefruit juice: May inhibit metabolism of atorvastatin via
CYP3A4; more likely to occur with lovastatin or simvastatin; avoid
high dietary intake of grapefruit juice
• Niacin may increase the risk of myopathy and rhabdomyolysis.

Side/Adverse Effects CNS: headache, asthenia, insomnia
CV: peripheral edema
EENT: pharyngitis, rhinitis, sinusitis
GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea.
GU: UTI
Musculoskeletal: rhbdomyolysis, arthritis, arthralgia, myalgia
Skin: rash
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Other: allergic reactions, flulike syndrome, infection

Nursing 1. Tell patient to inform prescriber of all prescriptions, OTC medications, or
Responsibilities herbal products he is taking, and any allergies he have.
2. Advice patient not to take any new medication during therapy unless
approved by prescriber.
3. Tell patient that he may take without regard to food. Maintain adequate
hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake.
4. Inform patient drug can cause headache (consult prescriber for approved
analgesic); diarrhea (buttermilk, boiled milk, or yogurt may help);
euphoria, giddiness, or confusion (use caution when driving or engaging in
tasks that require alertness until response to medication is known).
5. Tell patient to report unresolved diarrhea, unusual muscle cramping or
weakness, changes in mood or memory, yellowing of skin or eyes, easy
bruising or bleeding, or unusual fatigue.
6. Remind patient not to donate blood while taking this medication and for
same period of time after discontinuing.
7. Teach patient about proper dietary management, weight control, and

64
exercise. Explain their importance in controlling high fat levels.
8. Warn patient to avoid alcohol..
9. Advise patient that drug can be taken at any time of day, without regard to
meals.
10. Tell woman to stop drug and notify prescriber immediately if she is or
may be pregnant or if she’s breastfeeding.
Generic Name Domperidone

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Brand Name Alti-Domperidone; Apo-Domperidone®; Dom-Domperidone; FTP-
Domperidone Maleate; Motilium®; Novo-Domperidone; Nu-Domperidone;
ratio-Domperidone
Classification Antiemetic
Suggested Dose Oral: Adults:
GI motility disorders: 10 mg 3-4 times/day, 15-30 minutes before meals;
severe/resistant cases: 20 mg 3-4 times/day, 15-30 minutes before meals
Nausea/vomiting associated with dopamine-agonist anti-Parkinson agents: 20

64
mg 3-4 times/day
Dosage adjustment in renal impairment: Decrease dose to 10-20 mg 1-2
times/day
Mechanism ofDomperidone has peripheral dopamine receptor blocking properties. It
Action increases esophageal peristalsis and increases lower esophageal sphincter
pressure, increases gastric motility and peristalsis, and enhance
gastroduodenal coordination, therefore, facilitating gastric emptying and
decreasing small bowel transit time.

Indication Symptomatic management of upper GI motility disorders associated with
chronic and subacute gastritis and diabetic gastroparesis; prevention of GI
symptoms associated with use of dopamine-agonist anti-Parkinson agents

Contraindication Hypersensitivity to domperidone or any component of the formulation;
patients with GI hemorrhage, mechanical obstruction, or perforation; patients
with prolactin-releasing pituitary tumor

Drug Interaction Substrate of CYP3A4 (minor)
Anticholinergics: May decrease effects of domperidone.
Domperidone may increase the rate of absorption of drugs from small bowel,
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while slowing absorption of drugs from the stomach. Absorption of sustained-
release or enteric-coated tablets may be altered.
QTc-prolonging drugs: Use with caution in combination with domperidone;
includes type Ia and type III antiarrhythmics, some fluoroquinolones, and
selected antipsychotics (thioridazine, mesoridazine).
Side/Adverse Effects 1% to 10%:
Central nervous system: Headache/migraine (1%); does not cross blood-brain
barrier; fewer CNS effects compared to metoclopramide
Gastrointestinal: Xerostomia (2%)
<1%: Abdominal cramps, constipation, diarrhea, dizziness, dysuria, edema,
extrapyramidal symptoms (EPS) rarely, galactorrhea, gynecomastia,
heartburn, hot flashes, increased prolactin, insomnia, irritability, nervousness,
thirst, lethargy, leg cramps, mastalgia, menstrual irregularities, nausea,
palpitation, pruritus, rash, regurgitation, stomatitis, urinary frequency,

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urticaria, weakness
Nursing 1. Watch patient for agitation, irritability, confusion, and rarely EPS
Responsibilities 2. In GI motility disorders, it should be taken 15-30 minutes prior to meals.
3. Inform patient to take drug as directed, 15-30 minutes prior to meals.
4. Advise patient not to increase dosage without consulting prescriber
(adverse effects may occur with overuse).
5. Tell patient that drug may cause dizziness, headache, insomnia and
irritability.
6. Tell patient to contact prescriber if experience abnormal, uncontrolled
movements or confusion occur.
7. Advise patient to report breast pain or enlargement, milk production,
menstrual irregularities, or impotence.
Generic Name Sodium Chloride

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Brand Name Altamist [OTC]; Ayr® Baby Saline [OTC]; Ayr® Saline [OTC]; Ayr® Saline
Mist [OTC]; Breathe Right® Saline [OTC]; Broncho Saline® [OTC];
Entsol® [OTC]; Muro 128® [OTC]; NaSal™ [OTC]; Nasal Moist® [OTC];
Na-Zone® [OTC]; Ocean® [OTC]; Pediamist® [OTC]; Pretz® Irrigation
[OTC]; SalineX® [OTC]; SeaMist® [OTC]; Simply Saline™ [OTC]; Wound
Wash Saline™ [OTC]

Classification Sodium salt
Suggested Dose Fluid and electrolyte replacement in hyponatremia caused by electrolyte
loss or in severe salt depletion: Adults: dosage is individualized. Use 3% or

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5 % solution only with frequent electrolyte level determination and only slow
I.V. For 0.45% solution, 3% to 8% of body weight, according to deficiencies,
over 18 t o 24 hours. For 0.9% solution, 2% t 6% of body weight, according to
deficiencies, over 18 to 24 hours. For 0.9% solution, 2% to 6% of body
weight, according to deficiencies, over 18 to 24 hours.
Heat cramp caused by excessive perspiration: Adults: 1 g P.O. with each
glass of water.
Mechanism ofPrincipal extracellular cation; functions in fluid and electrolyte balance,
Action osmotic pressure control, and water distribution

Indication • Parenteral: Restores sodium ion in patients with restricted oral intake
(especially hyponatremia states or low salt syndrome). In general,
parenteral saline uses:
• Bacteriostatic sodium chloride: Dilution or dissolving drugs for I.M.,
I.V., or SubQ injections
• Concentrated sodium chloride: Additive for parenteral fluid therapy
• Hypertonic sodium chloride: For severe hyponatremia and

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hypochloremia
• Hypotonic sodium chloride: Hydrating solution
• Normal saline: Restores water/sodium losses
• Pharmaceutical aid/diluent for infusion of compatible drug additives
• Ophthalmic: Reduces corneal edema
• Oral: Restores sodium losses
• Inhalation: Restores moisture to pulmonary system; loosens and thins
congestion caused by colds or allergies; diluent for bronchodilator
solutions that require dilution before inhalation
• Intranasal: Restores moisture to nasal membranes
• Irrigation: Wound cleansing, irrigation, and flushing
Contraindication Hypersensitivity to sodium chloride or any component of the formulation;
hypertonic uterus, hypernatremia, fluid retention

Drug Interaction Decreased levels of lithium
Side/Adverse Effects CV: aggravation of heart failure, thrombophlebitis, edema when given too
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rapidly or in excess.
Metabolic: hypernatremia, aggravation of existing metabolic acidosis with
excessive infusion.
Respiratory: pulmonary edema.
Skin: local tenderness, tissue necrosis at injection site
Other: abscess
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Nursing 1. Use with caution in patients with CHF, renal insufficiency, liver
Responsibilities cirrhosis, hypertension, edema; sodium toxicity is almost exclusively
related to how fast a sodium deficit is corrected; both rate and
magnitude are extremely important; do not use bacteriostatic sodium
chloride in newborns since benzyl alcohol preservatives have been
associated with toxicity.
2. Monitor serum sodium, potassium, chloride, and bicarbonate levels; I
& O, weight.
3. Explain use and administration of drug to patient and family
4. Tell patient to report adverse reactions promptly.
5. Tell patient that wax matrix may appear in stool.
Generic Name Omeprazole

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Brand Name Prilosec®; Prilosec OTC™ [OTC]; Zegerid™

Classification Proton pump inhibitor
Suggested Dose Oral:
Children 2 years: GERD or other acid-related disorders:
<20 kg: 10 mg once daily
20 kg: 20 mg once daily
Adults:
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Active duodenal ulcer: 20 mg/day for 4-8 weeks
Gastric ulcers: 40 mg/day for 4-8 weeks
Symptomatic GERD: 20 mg/day for up to 4 weeks
Erosive esophagitis: 20 mg/day for 4-8 weeks

Mechanism ofSuppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP
Action pump
Indication • Symptomatic gastroesohageal reflux disease (GERD) without
esophageal lesions.
• Erosive esophagitis and accompanying symptoms caused by GERD
• Maintenance of healing erosive esophagitis
• Pathologic hypersecretory conditions (such as Zollinger-Ellison
syndrome)
• Duodenal ulcer (short-term treatment)
• Helicobacter pylori infection and duodenal ulcer disease, to eradicate
H. pylori with clarithromycin and amoxicillin (triple therapy)
• Short-term treatment of active benign gastric ulcer

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• Frequent heartburn (2 or more days a week)

Contraindication • Hypersensitivity to omeprazole, substituted benzimidazoles (ie,
esomeprazole, lansoprazole, pantoprazole, rabeprazole), or any
component of the formulation
• Zegerid™: Also contraindicated with metabolic alkalosis and
hypocalcemia (due to sodium bicarbonate content)

Drug Interaction • Benzodiazepines metabolized by oxidation (eg, diazepam,
midazolam, triazolam): Esomeprazole and omeprazole may increase
levels of benzodiazepines metabolized by oxidation.

• Carbamazepine: Esomeprazole and omeprazole may increase
carbamazepine levels.
• CYP2C8/9 substrates: Omeprazole may increase the levels/effects of
CYP2C8/9 substrates. Example substrates include amiodarone,
fluoxetine, glimepiride, glipizide, nateglinide, phenytoin, pioglitazone,
rosiglitazone, sertraline, and warfarin.
• CYP2C19 inducers: May decrease the levels/effects of omeprazole.
Example inducers include aminoglutethimide, carbamazepine,

64
phenytoin, and rifampin.
• CYP2C19 substrates: Omeprazole may increase the levels/effects of
CYP2C19 substrates. Example substrates include citalopram,
diazepam, methsuximide, phenytoin, propranolol, and sertraline.
• Itraconazole and ketoconazole: Proton pump inhibitors may decrease
the absorption of itraconazole and ketoconazole.
• Phenytoin: Elimination of phenytoin may be prolonged; monitor.
Phenytoin may decrease omeprazole levels/effects.
• Protease inhibitors: Proton pump inhibitors may decrease absorption
of some protease inhibitors (atazanavir and indinavir).
• Warfarin: Elimination of warfarin may be prolonged; monitor.

Side/Adverse Effects CNS: asthenia, dizziness, headache
GI: abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting
Musculoskeletal: back pain
Respiratory: cough, upper respiratory tract infection

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Skin: rash
Nursing 1. Inform patient that capsule should be swallowed whole; do not chew,
Responsibilities crush, or open. Best if taken before breakfast. May be opened and
contents added to applesauce.
2. Administer drug via NG tube should be in an acidic juice.
3. Administer powder for oral suspension 1 hour before a meal.
4. Inform that drug Should be taken on an empty stomach; best if taken
before breakfast.
5. Notify to take as directed, before eating. Do not crush or chew
capsules.
6. Inform patient to avoid alcohol.
7. Report changes in urination or pain on urination, unresolved severe
diarrhea, testicular pain, or changes in respiratory status.
8. Inform patient that breastfeeding is not recommended.
9. Patient may experience anorexia. Advice to take frequent meals may
help to maintain adequate nutrition.

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Generic Name Lactulose
Brand Name Constulose®; Enulose®; Generlac; Kristalose™

Classification Disaccharide
Suggested Dose Prevention of portal systemic encephalopathy (PSE):
Oral: Infants: 2.5-10 mL/day divided 3-4 times/day; adjust dosage to produce
2-3 stools/day. Older Children: Daily dose of 40-90 mL divided 3-4
times/day; if initial dose causes diarrhea, then reduce it immediately; adjust
dosage to produce 2-3 stools/day
Constipation: Oral: Children: 5 g/day (7.5 mL) after breakfast. Adults: 15-30
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mL/day increased to 60 mL/day in 1-2 divided doses if necessary
Acute PSE: Adults: Oral: 20-30 g (30-45 mL) every 1-2 hours to induce
rapid laxation; adjust dosage daily to produce 2-3 soft stools; doses of 30-45
mL may be given hourly to cause rapid laxation, then reduce to recommended
dose; usual daily dose: 60-100 g (90-150 mL) daily
Rectal administration: 200 g (300 mL) diluted with 700 mL of H20 or NS;
administer rectally via rectal balloon catheter and retain 30-60 minutes every
4-6 hours
Mechanism ofThe bacterial degradation of lactulose resulting in an acidic pH inhibits the
Action diffusion of NH3 into the blood by causing the conversion of NH3 to NH4+;
also enhances the diffusion of NH3 from the blood into the gut where
conversion to NH4+ occurs; produces an osmotic effect in the colon with
resultant distention promoting peristalsis

Indication Constipation, to prevent and treat hepatic encephalopathy, including hepatic
precoma and coma in patients with severe hepatic disease.

Contraindication Hypersensitivity to lactulose or any component of the formulation;
galactosemia (or patients requiring a low galactose diet) Contraindicated in

64
patients on galactose-restricted diet

Drug Interaction Decreased effect: Oral neomycin, laxatives, antacids
Side/Adverse Effects Frequency not defined: Gastrointestinal: Flatulence, diarrhea (excessive dose),
abdominal discomfort, nausea, vomiting, cramping

Nursing 1. Dilute lactulose in water, usually 60-120 mL, prior to administering
Responsibilities through a gastric or feeding tube. Syrup formulation has been used in
preparation of rectal solution.
2. Monitor blood pressure, standing/supine; serum potassium, bowel
movement patterns, fluid status, serum ammonia.
3. Contraindicated in patients on galacatose-restricted diet; may be mixed
with fruit juice, milk, water, or citrus-flavored carbonated beverages.
4. Inform patient drug is not for long-term use.
5. Tell patient to take as directed, alone, or diluted with water, juice or
milk, or take with food.
6. Inform patient that laxative results may not occur for 24-48 hours; do
not take more often than recommended or for a longer time than
recommended. Do not use any other laxatives while taking lactulose.
7. Advice to increased fiber, fluids, and exercise may also help reduce
65
constipation.
8. Tell patient not to use if experiencing abdominal pain, nausea, or
vomiting. Diarrhea may indicate overdose.
9. Inform drug may cause flatulence, belching, or abdominal cramping.
Report persistent or severe diarrhea or abdominal cramping.
10. Tell patient to consult prescriber if breast-feeding.

64
NURSING THEORIES
Nightingale’s Environmental theory
Florence Nightingale, commonly known as the “Lady with the Lamp”, created the Environmental Theory which is still widely
used nowadays. She affirmed in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his
recovery" (Nightingale 1860/1969) and that it involves the nurse's initiative to configure environmental settings appropriate for the
gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and
physiologic processes, and his development.
Environmental factors affecting health
Defined in her environmental theory are the following factors present in the patient's environment:
• Pure or fresh air
• Pure water
• Sufficient food supplies

74
• Efficient drainage
• Cleanliness
• Light (especially direct sunlight)
Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status.
Emphasized in her environmental theory is the provision of a quiet or noise-free and warm attending to patient's dietary needs by
assessment, documentation of time of food intake, and evaluating its effects on the patient.
In the case of our client, she was situated in the Medicine ward, she really needs a clean and quiet environment conducive for her
condition, since Medicine ward is quiet noisy and not well sanitized. The patient and significant others should have sufficient knowledge
about sanitation so that they can provide her a more clean environment which is helpful for her recovery. She should be provided with a
more comfortable milieu and also she should eat more nutritious foods that would help boost her immune system and must avoid foods
that could worsen her health condition.
The client also needed to breathe fresh air and feel the heat of the sun outside the Medicine Ward, since every man needs it to meet
personal needs and to attain a good health status.
Orem's Model of Nursing

76
The theory Orem is based upon the philosophy that all "patients wish to care for themselves". Orem’s theory emphasizes on
client’s self-care needs. Client can recover faster and holistically if they are allowed to carry out their own self cares to the best of their
ability. When self-care is not maintained, illness, disease and death will occur.
She has self care deficit. She unable to take care of herself and was unable to perform activities of daily living without assistance,
since she is an aging person and cannot tolerate doing some of the activities because of her illness.
Although it is our job to provide care for our client, it is important to promote independence and self-reliance to the patient since it
promotes holistic well-being. We, as nurses should persuade the patient to become self-reliant and independent through giving health
teachings on how to do such things but since the client needed assistance in doing some of her activities, we must also instruct the
significant others to offer themselves to the client.
King’s Goal Attainment Theory
This theory wants to integrate the concept of the nurse and the patient jointly communicating information, establishing goals, and
taking action to attain goals. It describes a situation in which two people, usually strangers, come together in a health care organization to
help or be helped to sustain a state of health. The focus of the nurse is to help the individual maintain health and function in an appropriate
86
role. The Goal Attainment Theory addresses interaction, perception, time, space, communication, transaction, role, stress and growth and
development.
Our client had great interaction with the group and was able to set up goals and attain them. Since it’s the nurse’s role to assess the
patient and discuss the problems with them, it is also the role of the patient to collaborate with the nurse not only with the assessment but
most especially in the interventions, so that they will be able to achieve their desired goal. It is essential that not only the nurse will
discover the problem but the client should also take part in acknowledging it so that there will be cooperation between them. So in this
case, the patient was able to identify and cooperate with the group very well.
NURSING CARE PLAN
Name: Aling D Medical Diagnosis: ESRD 2° HN 2° DM type II
Age: 56 years old Attending Physician: Dr. Gil Florida
Sex: Female
Date Cues Needs Nursing Plan of Care Nursing Interventions Evaluation

86
Diagnosis
November SUBJECTIVE: A Ineffective At the end of 2 hours 1. Determine factors GOAL MET
13, 2009 “Malipong pud C peripheral of nursing care, the related to individual
@ ko usahay T tissue patient will be able situation. November 13,
12:00 AM karon tapos I perfusion to: ® To assess causative 2009 @ 2:00pm
medyo luya V related to low • Verbalize factor of the condition
11-7 akong lawas” I hemoglobin understandin 2. Note customary At the end of 2
T concentration g of the baseline data. hours of nursing
OBJECTIVE: Y in blood condition; ® To provide care, the patient
• Hemogl - secondary to and comparison with was able to:
obin E anemia • Determine current findings • Verbalize
(115- X R: A decrease ways to 3. Review laboratory understan
175 E in oxygen improve studies. ding of
g/Dl)= R resulting in the circulation ® To serve as a the
77 C failure to scientific basis for the condition
• RBC I nourish the problem. “Mao
(4.20- S tissues at the 4. Encourage for a quiet diay

86
6.10)= E capillary level. and restful malipong
2.60 Nurses’ Pocket atmosphere. ko, dala
• Hemato P guide by ® To conserve energy dala pod
crit A Doenges et.al. and lowers tissue diay ni sa
(0.36- T oxygen demands akong
0.52)= T 5. Perform assistive sakit.”
0.22 E range of motion
• Weak R exercise.
periphe N ® To promote
ral circulation.
pulses 6. Encourage early
• Weakn ambulation as much as
ess possible.
• Pallor ® To enhance venous
• CRT=3 return.
sec 7. Promote position

86
• Skin changes and
cold to discourage staying at
touch the same position for a
long period of time.
® To maximize tissue
perfusion.
8. Elevate head of bed or
add pillow when
patient is lying on bed.
especially at night.
® To increase
gravitational blood
flow.
9. Discuss ways to
improve circulation
such as eating iron

87
rich foods.
® To help patient
10. Administer
medications with
precautions.
® Drug response,
half-life and toxicity
levels may be affected
by altered tissue
perfusion.
11. Demonstrate and
encourage the use of
relaxation techniques
such as deep breathing
exercise.
® To decrease tension
87
levels.
86
DATE CUES NEED NURSING OBJECTIVE NURSING EVALUATION
DIAGNOSIS OF CARE INTERVENTIONS

86
Novembe S: N Fluid volume After 4 hours of 1. Monitor vital signs GOAL MET.
r 13, 2009 “Nanghupong U excess: extracellular nursing q 4˚. After 4 hours
akong tiil day,” T secondary to fluid intervention, the ® In order to have a of nursing
verbalized by the R shift secondary to client will be baseline data in intervention,
client. I altered GFR able to: comparing regularity the patient
T secondary to ESRD • Verbalize of the patient’s vital was able to
I as manifested by understandi signs and determine verbalize
O: O pitting edema ng of significant changes. understanding
• high serum N R: There is an condition 2. Monitor I & O. of her
sodium=168 A increased isotonic and commit ® In order to monitor condition and
• pitting L retention as cooperation hydration and committed
edema=2 + – manifested by to the elimination status. cooperation.
• oliguria M pitting edema. procedures 3. Monitor serum
• high blood E and therapy electrolyte levels.
pressure=150/ T to be done ® Serum electrolytes
100 mmHg A to her with contribute largely to
B regards to retention of fluids in

86
DIAGNOSIS OF CARE INTERVENTIONS

November • Subj A Activity Intolerance Within the span 1. Determine Goal met
14, 2009 ectiv C related to imbalance of 3 hours, the patient's After 3 hours of
e: T between oxygen client will: perception of nursing care, the
“Dali lang ko causes of fatigue

I supply and demand a) Verbali client was able to:
or activity
kapuyon.” V secondary to anemia ze a) verbalize
intolerance.
I R: There is an techni techniqu
R: Assessment guides
• Obje T insufficient ques es to
treatment.
ctive Y physiological or to enhance
2. Monitor vital
: enhanc activity
- psychological signs.
-exertional e tolerance
E energy to endure or R: To watch for
discomfort activity , saying
X complete required changes in blood
noted toleran “Kinahan
E daily activity. pressure, pulse and
87
-palmar pallor Nurses’ Pocket ce; respiratory rate after glan jud
noted Guide by Doenges b) Partici activities nako
-hemoglobin et. al. pate 3. Assist with magpahu
willingl ADLs as wayhuma

level: 77
y in indicated. n ko
-hematocrit
R: Assisting the
necess mulakaw-
level: 0. 22
patient with ADLs
ary/des lakaw.”
-red blood cell:
allows for
ired b) Participat
2.60
conservation of
activiti e
-CRT= 3 secs energy.
es. willingly
4. Encourage rest
in
and sleep.
necessar
R: In order to help
y/desired
relax the patient.
activities.
5. Provide a calm
environment.
R: To promote a
resful atmosphere.
6. Place necessary
87
86

DIAGNOSIS WITH OF CARE INTERVENTIONS
® WITH ®
86
November S: E Urinary infrequency After 4 hours of 1. Monitor I & O. Goal met.

14, 2009 • “Naka-ihi L related to altered nursing R: In order to The client was
nako pero ka- I Glomerular intervention, the follow up able to verbalize
ihion gihapon M Filtration Rate patient will be hydration and understanding of
ko,” as I secondary to ESRD. elimination status/ condition and
verbalized by N able to: 2. Insert urinary verbalize relief
the client. A • Verbalize catheter as from urinary
T ® The patient has an relief from ordered. infrequency.
O: I ncomplete emptying urinary R: To ensure
• Residual O of the bladder due to infrequency; urinary
urine N use of medications, and elimination.
• Dark-yellow psychological/ • Verbalize 3. Assess the
urine P neurological factors understandin presence
• Distended A or an underlying g of her pathological
urinary T health condition. condition conditions which
bladder T Nurses’ Pocket may underlie
• Oliguria E Guide by Doenges urinary
• Concentrated R et. al. infrequency.
urine N R: To properly
• Urine specific address urinary
gravity= infrequency, the
1.042 (1.010- underlying cause
1030) must be
determined.
4. Administer
diuretics as
ordered.
R: To help in
urinary
elimination.
5. Institute fluid
87
ordered.
R: To prevent
further
accumulation of
fluids.
6. Explain to the
patient importance
of fluid restriction.
R: To include the
patient in the plan
of care.
7. Establish infection
precautions.
R:
Catheterizations
may increase the
risk for UTIs.
8. Encourage
compliance with
medications.
R: To ensure
continuity of
therapy ordered.
9. Discuss with the
patient the
complications of
incompliance to
medications.
R: To promote
compliance.
10. Encourage patient
87
discomfort in
urination including
the frequency,
consistency and
color of urination.
R: To help
medical personnel
address
immediately to
any discomforts
experienced by the
patient.
86
DATE CUES NEED NURSING OBJECTIVE OF NURSING EVALUATION

DIAGNOSIS CARE INTERVENTIONS
87
November S: A Self care deficit: After 2 hours of 1. Assess client’s Goal met. After
12, 2009 C bathing / hygiene nursing self care need. 2 hours of
“Makatamad T related to lack of intervention, the R: This will nursing
11:00pm maligo, ana I motivation client will be serve as a mark intervention, the
man pod ang V able to recognize as to where the patient was able
11 - 7shift ubang pasyente I R: The patient has an self care need nurse will to verbalize
diari. Lisod jud T impaired ability to and enumerate understanding of
maligo sa Y provide self care the importance anchor her the problem and
hospital.” - requisites due to of personal interventions. the need to meet
E environmental and hygiene. 2. Assess client’s it. The patient
O: X psychological physical was also able to
E factors. condition point out several
-not well R relating to courses of action
groomed C hygiene. that she must
-presence of I R: This will undertake to
body odor S point our any promote hygiene
E factors present aside from
in the patient bathing,such as
P brushing the
physically that
A teeth and
T may hinder her combing the
T capacity to hair.
E meet the need.
R 3. Educate the
N patient on the
importance of
personal
hygiene.
R: Makes the
patient realize
87
related to
health.
4. Let the patient
enumerate her
ideas on the
importance of
hygiene.
R: Encourages
the patient to
understand the
need.
5. Discuss ways
to attain good
personal
hygiene such as
bed bath.
R: provides the
patient options
in performing
bathing.
6. Provide and
maintain
privacy.
R: Makes the
patient secure
that she can
perform
bathing without
risking her
87
enumerate her
own ideas as to
the ways and
other
techniques that
she can
undertake in
order to attain
good personal
hygiene thru
bathing.
R: Involves the
patient in the
plan of care.
8. Discuss the
possible
negative
implications of
not taking a
bath such as
infections and
odor.
R: Broadens
the patient’s
idea about the
problem and
encourages her
to meet the
need.
9. Encourage
87
questions
regarding
hygiene.
R: Clears up
any
ambiguities in
the patient’s
mind and
improves
understanding.
10. Appreciate the
patient’s
understanding
of the things
discussed.
R: Lets the
patient feel that
her idea is well
considered by the
nurse and that her
wellness and
understanding of
the importance of
the need is the best
interest of the
nurse.
12
PROGNOSIS
GOOD FAIR POOR JUSTIFICATION

Onset of the ☻ It was during June 1994 that the patient was
illness diagnosed of Diabetes Mellitus type II. Her DM II
that is 15 years ago eventually lead to
Hydronephrosis and ESRD.

Duration of illness ☻ After experiencing the signs and symptoms of
Diabetes Milletus type 2, the patient immediately
went to the hospital for medical help. Yet it was 15
years ago when she was diagnosed with Diabetes
Milletus type 2. Sad to say her diabetes lead her to
hydronehprosis and eventually to end-stage renal
disease.
Precipitating ☻ Even after being diagnosed of Diabetes Milletus
factors and Hydronephrosis, the patient still doesn’t
strictly adhere to medical advices regarding her
nutrition.
Willingness to ☻ The patient submits herself to the treatment
take medications regimen which is required for her to take but she is
and treatment not complying with the treatment properly. She
has the knowledge of the purpose of the treatment
he undergoes. Yet the patient is able to buy all the
medicines being ordered.

Age ☻ Aling D is already 56. As the age increases, it puts
12
the patient into higher risk of having ESRD
especially she also has diabetes and
hydronephrosis.
Environmental ☻ The client’s home as reported is conducive for rest
factors and sleep. The patient lives in a therapeutic
environment. There are smaller chances of
pollution and noise. It can be said that the
environment as well was generally peaceful and
calm is very favorable for rest and promotes better
health.
Family Support ☻ The family has been very supportive throughout
the whole process. Her sons visited the patient
constantly. Throughout our duty the group only
sees her sons and never saw her husband. The
support, most especially from her husband could
help the patient accept her situation.

Computation:
➢ Poor: (4*1)/7 = 4/7
➢ Fair: (2*2)/7 = 4/7
➢ Good: (1*3)/7 = 3/7
Total 3 2 2 Total: 1.57
General Prognosis:
1-1.6 = POOR
1.7-2.3 = FAIR
2.4-3.0 = GOOD
12
Rationale for a Good Prognosis
As shown by the calculated prognosis in relation to the different factors involved,
the patient has a poor chance of survival. The factors presented in relation to prognosis shows
that patient can poorly cope up after being discharged. The condition was diagnosed 15 years ago
and eventually her diagnosed Diabetes Milletus lead to End-Stage Renal Disease. The patient
submits herself to treatment yet not complying to it properly. In addition, support has been given
by the family members to make the patient feel that she is not alone in what she’s going through.
Finally, it is seen that the patient has lesser chance of coping up wither illness. Yet she could
help herself, with the help of her family to accept any possibilities that might result from her
illness.
12
DISCHARGE PLAN (M.E.T.H.O.D.)
Medication
• Instruct client to continue take her prescribed medications
• Orient the client about the name of drugs, their actions, the exact dosage, the frequency
and the route of administration.
• Instruct client to follow the instruction when administering medication.
• Encourage the significant others not to leave the client during medication
• Explain to the client the side effects and adverse effects of the drugs she takes by
prescribing its manifestations.
• Encourage the client not to stop intake of prescribed medications, unless approved by the
physician.
• Encourage the client to report to the physician immediately if any adverse effects or side
effects had occurred.
Exercise
• Instruct client to balance activities with adequate rest periods.
• Educate client on proper body mechanics to prevent muscle strain and enable client to
relax.
• Encourage early ambulation, assist the client if needed.
Treatment
12
• Educate client the importance of drug compliance.
• Discuss to the client the complication of the condition because knowledge about the
condition supports learning that will decrease deficit and anxiety.
Hygiene
• Encourage client to do daily hygiene.
• Discuss to the client the importance of proper hygiene to promote enhancement of
knowledge regarding its importance.
• Encourage client to ask assistance if needed.
Outpatient orders
Call the doctor if any of the following occur:
• You cannot make it to your follow-up or dialysis visit.
• Have itchy skin and develop skin rashes.
• You are passing little to no urine.
• Experience nausea and vomiting.
• You heart is beating fast or you are breathing fast.
• You have a seizure (convulsion).
• You have chest pain or trouble breathing all of a sudden.
• You have questions or concerns about your care, medicine, or treatment.
Diet
• To promote wellness, eat a balanced diet rich in fresh fruits and vegetables.
• Instruct the client to eat foods low in sodium, low in Potassium and low in sugar content.
12
• Encourage protein intake to be high biologic value like non-fat or low-fat milk, egg white
and meat.
14
RECOMMENDATION
This case study has provided the proponents with important information about the
patient’s disease. In order to ensure that optimal health is restored and maintained, the group
would like to recommend the following:
To the patient
Whenever there is, the onset of a certain disease it implies one to contribute her
cooperation and willingness to be responsible for her own health. The patient must submit
herself to palliative care for her to reducing the severity of her disease. The goal is to prevent and
relieve suffering and to improve quality of life for people facing serious, complex illness. The
patient must be sensitive of her own needs and be able to expect liability for her actions. She is
also encouraged to verbalize her own thoughts and feelings concerning how she perceives her
condition affect her life and her acceptance of her disease. She is advised to take part in
complying with the treatment designed for her. She should realize the importance of complying
with 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 any
unusualities in her body.
To the patient’s family
The patient’s family plays an important role in the patient’s illness and palliative care.
The family should make themselves physically present so that the patient would somehow feel
13
their support and concern. They are encouraged to be the patient’s source of strength and
inspiration as she undergoes painful, traumatic and harrowing situation. In addition, it is of prime
importance that they are oriented and educated basic facts regarding the patient’s condition so
that they will understand her even better and assist her in her daily activities.
To the student nurses:
This case study would help them better understand the patient’s condition. What is
entrusted to student nurses is the life of their patient. Even with the clinical instructor’s presence,
they can still make mistakes and errors, which can harm the patient. Hence, they are encouraged
to equip themselves with necessary knowledge that will enable them to render quality and
holistic nursing care and intervention to patients in need.
It is known that nurses play a major role in helping the client and family implement
healthy behaviors and help them monitor the client’s health. Thus, anticipatory guidance and
knowledge about health should be supplied to help clients attain, maintain, or regain an optimal
level of health. Student nurses should prioritize interaction with family members and significant
others to provide support, information, and comfort in addition to caring for the patient. Thus,
they should prepare themselves with the reality that they are soon to become health
professionals.
Genuineness, empathy, and respect are key elements for the nurse to possess. Student
nurses must develop patience, love for our work, and empathy to our patients. They must assist
in facilitating a remarkable experience as well as share our knowledge regarding the case. They
must also continue to study different cases and be able to impart this to other student nurses,
patients and their significant others.

12
To the Ateneo de Davao University- College of Nursing
The AdDU- College of Nursing is the source that provides student nurses with exposures
that enable them to apply the knowledge they have gained and practice the skills they honed
necessary for their profession. The faculty and staff are encouraged to continue improving the
standards of the Ateneo Nursing Curriculum by providing quality education to students. Also
they, themselves, must be well-trained to delegate learning to student nurses. It is important that
they continue to inspire generations of today to perceive nursing as a gift and act of charity rather
than a mere means to success.
To the Professional Medical World
End Stage Renal Disease is a class of disease that can affect every person. Therefore, it is
recommended that there should be facilities or institutions that are made for the research of how
to prevent end-stage renal disease . Also, the proponents recommend that medical practitioners
work hand in hand in order to improve the welfare of the society, promote optimum health, and
prevent the spread of diseases. They should have proper information dissemination in order for
the community to be aware and be well informed about the different diseases, their
manifestations, and how they can be prevented and cured. They should teach the public proper
hygienic practices, proper sanitation and handling of foods, and healthy lifestyle. They must also
do further research, inventions, and discoveries in the field of medicine in order to save more
lives. In partnership with other health sectors, attaining the goal in establishing optimum health
to the whole population is possible.

14
REFERENCES
• Kozier and Erb’s Fundmentals of Nursing 8th Edition
• Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al.
• Textbook of Medical Surgical Nursing 11th Edition
• Lippincot and Willers
• Adrogué HJ, Madias NE (September 1981). "Changes in plasma potassium concentration
during acute acid-base disturbances". Am. J. Med. 71 (3): 456–67.
• National Institute for Health and Clinical Excellence. Clinical guideline 73: Chronic kidney
disease. London, 2008.
• Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G (October 1998). "Renal
function and requirement for dialysis in chronic nephropathy patients on long-term ramipril:
REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN).
Ramipril Efficacy in Nephropathy". Lancet 352 (9136): 1252–6.
• Lewis EJ, Hunsicker LG, Clarke WR, et al. (2001). "Renoprotective effect of the
angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2
diabetes". N Engl J Med 345: 851-60.
• Brenner BM, Cooper ME, de ZD, et al. (2001). "Effects of losartan on renal and
cardiovascular outcomes in patients with type 2 diabetes and nephropathy". N Engl J Med
345: 861-9.
12
• Perazella MA, Khan S (March 2006). "Increased mortality in chronic kidney disease: a call
to action". Am. J. Med. Sci. 331 (3): 150–3.
WEBSITES
 National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney
disease". http://www.kidney.org/professionals/KDOQI/guidelines_ckd.
 http://www.medscape.com/viewarticle/590644
 http://www.medicalnewstoday.com/articles/139028.php
• http://www.medpac.gov/publications/other_reports/Sept06_MedPAC_Payment_Basics_dialysi
s.pdf MedPAC ESRD program overview
• http://www.empiremedicare.com/pdf/combined/mmr2008-1.pdf Medicare Monthly Review
• http://www.cahabagba.com/part_b/msp/providers_general_info.htm Cahaba GBA

End Stage Renal Disease Secondary To Hydronephrosis Secondary To Diabetes Mellitus Type Two

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End Stage Renal Disease Secondary To Hydronephrosis Secondary To Diabetes Mellitus Type Two

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A Case Study

Presented to the Faculty of

The Ateneo de Davao University

End-Stage Renal Disease secondary to

Hydronephrosis secondary to Diabetes Milletus

Clinical Instructor – Panelist of the Case Study

Bulosan, Von Rainer S.

Cabonita, Kristi Ann J.

II. Objectives (General & Specific)................................................6

III. Patient’s Data.............................................................................8

IV. Family Background and Health History.....................................10

VI. Definition of Complete Diagnosis..............................................21

VII. Physical Assessment...................................................................24

VIII. Anatomy and Physiology...........................................................28

IX. Etiology and Symptomatology...................................................36

XI. Doctor’s Order............................................................................47

XII. Diagnostic Exam........................................................................55

XIII. Drug Study.................................................................................64

XIV. Surgical Procedure.....................................................................74

XV. Nursing Theories........................................................................81

XVI. Nursing Care Plan......................................................................86

XVII. Discharge Plan (M. E. T. H. O. D.) & Prognosis

achieve such success came from.

helped make the success of this undertaking a reality.

task. To Him be all glory and praise!

us; for their unending help and understanding.

for all your love and care.

achievement of this task is ours to share.

Hydronephrosis stage II secondary to Diabetes Mellitus Type II.

End-Stage Renal Disease is the complete or almost complete failure of the

an irreversible decline in a person's own kidney function, which is severe enough to be

The incidence and prevalence of ESRD continue to grow worldwide. According

individuals, 1,297,000 (68%) received hemodialysis and 158,000 (8%) received

receive RRT. (http://clinicalevidence.bmj.com/ceweb/)

diabetes, 25% by hypertension, 16% by glomerulonephritis, and 4% by kidney cysts.

(Renal Data Report, ANS, 1999)

Filipinos. The population of ESRD patients requiring dialysis therapy in Asia is

population is growing at a rate of 10% or more annually. It is said that a Filipino is

about the disease and the surgical procedures involved.

chosen client that would provide a comprehensive discussion of the pathological

In order to meet the general objective, the group aims to:

• establish rapport to the patient and the patient’s significant others;

• state past and present health history of the patient;

• trace the family genogram;

of Erikson, Kohlberg, and Havighurst;

• define the complete diagnosis of the patient;

• present the cephalocaudal assessment obtained from the patient;

• present the etiology and symptomatology of the patient’s disease;

• trace the pathophysiology of the patient’s disease;

• obtain and rationalize the doctor’s order;

• interpret the laboratory test results of the patient;

• discuss the nature of the drugs given to the patient;

• discuss the surgical procedure performed to the patient;

Nightingale, Orem and King;

• present a specific, measurable, attainable, realistic and time-bounded nursing care

plans for the client;

• justify the client’s prognosis according to the different criteria;

• outline recommendations based on the case study’s findings.

Patients Name: Aling D

Clinical/ Admitting Data:

Date of admission: November 9, 2009

Admitting Physician: Dr. Jovino C. Aquino

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