Course in the ward Drug Study Diagnostic Exam and results

Presented by: Athorney L. Corpuz R.N

Course in the ward

Assessment
Day 1 June 15, 2012

Order/intervention
UF Goal 1.5L Ice compress applied to the

Hemodialysis outpatient Previous wt. 83.7kg Pre wt. 85.7kg ( +2) Vital Signs Temperature: 36 Pulse Rate: 72bpm Respiratory Rate: 20 Blood Pressure: 130/90

affected area. After 30 mins of ice compress attempted to insert again but noticed clotted blood upon aspiration by Dr. Villena.
Defer Hemodialysis schedule.

Hemodialysis tomorrow instead.

(+) Clotted blood observed in

venous.

Assessment
Day 2 June 16, 2012

Order/Intervention

UF Goal 500ml 10:00 Set 5% Sodium. Nursing intervention Refer to Physician No Medication given. 11:00 VS Rechecked and return to his baseline patient was Cleared to go home.

Hemodialysis outpatient Previous wt. Pre wt. 83.7kg Vital Signs Temperature: 36 Pulse Rate: 60 Respiratory Rate: 19 Blood Pressure: 130/90 10:00AM 160/80 pulse 73 10:30 180/ 70 pulse 70 11:00 160/80 Post 83.5 (-2) PR 60 RR 19 Temp 36.5deg C

Assessment

Order/Intervention
UF Goal 600ml Recormon 5000 units its Subcut 9:05pm No lab works. Hemodialysis tolarated for

Day 3 June 19, 2012 Hemodialysis outpatient Previous wt. 83.5kg Pre wt. 84.6kg Vital Signs Temperature: 36.3 Pulse Rate: 64 Respiratory Rate: 19 Blood Pressure: 150/80 Temp 36.3deg C BP 150/80

four hours.

Post 84 (.6) PR 73 RR 20

Assessment
Day 4 June 22, 2012

Order/Intervention
UF Goal 700ml NO Lab Works and

Hemodialysis outpatient Previous wt. 84kg Pre wt. 84.7kg (0.7) Vital Signs Temperature: 35.9deg C Pulse Rate:68 Respiratory Rate: 19 Blood Pressure: 130/80 Temp 36 deg C BP 160/90

Medications given. hours.

Hemodialysis Tolarated for 4

Post 83.8kg (0.9) PR 70 RR 18

Assessment
Day 5 June 26, 2012

Order/Intervention
UF Goal 600ml Vitals sign stable. No lab

Hemodialysis outpatient Previous wt. 83.8kg Pre wt. 84.9kg (1.1) Vital Signs Temperature: 36.2deg C Pulse Rate:66 Respiratory Rate: 19 Blood Pressure: 140/90 Temp 36.2 deg C BP 140/90

works and medications given. hours.

Hemodialysis tolerated for 4

Post 84.4kg (0.5) PR 87 RR 19

Assessment
Day 6 June 29, 2012

Order/Intervention
UF Goal 1.5L BFR decreased to 150ml/mn massaging the affected part. Flushed 100ml saline as

Hemodialysis outpatient Previous wt. 84.4kg Pre wt. 85.6kg (1.2) 3:40pm Vital Signs Temperature:36.6deg C Pulse Rate: 72 Respiratory Rate: 19 Blood Pressure: 150/80

ordered

Set UF to zero. Hemodialysis tolerated for 4

5:10pm Patient Complained cramps at his right leg. Post wt. 83.9kg (1.7)

hours.

PR 71 RR 19 Temp 36.6deg C

DRUG STUDY

Generic name (Brand name) Epoetin beta (Recormon) Drug Classification Haematopoieti c Agents Dosage/ Frequency/ Route 5000 units Every after dialysis 2x a month Sub Cut

Mechanism of Action Epoetin beta stimulates RBC production in the bone marrows which transmits O2 throughout the body

Indication

Nursing Consideration And Responsibilities Treatment to Headache, seizures; *EPO is contraindicate in clients anemia assoc hypertension; thrombosis with; with chronic at vascular access sites, >uncontrolled hypertension >High platelet count renal failure on clotting in the dialyser, (thrombocytosis) >malignant disease or not on transient increases in >Chronic liver failure dialysis and platelet count, flu-like >known hypersensitivity to malignancy on symptoms including human albumin or not on chills, myalgia, *Follow the manufacturers chemotherapy. hyperkalaemia, skin preparation and administration rashes; hypertensive *Transferrin saturation should be crisis with at last 100ng/ml. encephalopathy-like symptoms, including *Evaluation of iron stores should headache and confusion, occur during the therapy.. generalised seizures *monitor for adverse reactions (patients with normal or like seizures and hyperkalemia. low blood pressure). Rarely, anaphylactoid reactions.

Adverse Effect

Generic name (Brand name) Telmisartan (Micardis) Drug Classification Angiotensin II antagonist. Dosage/Frequency/ Route 80mg/tab 1tab 1x a day Oral

Mechanism of Action

Indication

Adverse Effect UTI, upper resptract infections,anxiety, insomnia,depression, visualdisturbance,verti go, GIdisorders, eczema,athralgia, backpain, legcramps/pain,myalgi a, tendinitislike symptoms,chest pain,influenzalikesymptoms. Dyspnea, anemia,thrombocytope nia,eosinophilia. Bradycardia,tachycardi a,hypotension,orthosta tichypotension

Nursing Consideration And Responsibilities Assess patients condition before therapy and regularly thereafter to monitor drug effectiveness. Assess for heart failure because in patients whose renal function depend on rennin-angiotensinaldosterone system, use of ACE inhibitors andangiotensin-receptorantagonist maybe related to oliguria or progressive azothemia. Obtain baseline renal and liver status before therapy: BUN, creatinine,AST, ALT and biliribin. Assess for obstructive jaundice because drug level may elevate due to inability to excrete drug.Drug is not removed by hemodialysis, closely monitor blood pressure and pulse (rate, rhythmand quality). Monitor for possible drug induced adverse reactions:CNS: dizziness, pain fatigue, headache; CV:chest pain, hypertension,peripheral edema; EENT:pharyngitis, sinusitis; GI:abdominal pain, diarrhea,dyspepsia , nausea; GU:UTI; Musculoskeletal: backpain, myalgia,;Respiratory: cough, URTI;Other: flu-like symptoms. Monitor serum electrolytelevels: potassium, sodium,chloride. Assess hydrationstatus: skin turgor andmucus membrane (moistor dry)

Blocks the Treatment of vasoconstrictive and hypertension adolsterone secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the AT1 receptor in many tissue (vascular smooth muscles and adrenal gland)

Allopurinol Drug Classification Antigout drug Dosage/Freq uency/ Route 150mg/tab 1tab Every other day

Inhibits the enzyme responsible for the conversion of purines to uric acid, thus reducing the production of uric acid with a decrease in serum and sometimes in urinary uric acid levels, relieving the signs and symptoms of gout.

Management of the sign and symptoms of primary and secondary gout management of patients with malignancies that result in elevations of serum and urinary uric acid . management of patients with recurrent calcium oxalate calculi whose daily uric acid excretion exceeds 800 mg/day(males) or 750mg/day (females)

Rash; alopoecia; GI disorders, taste disturbances, nausea, vomiting, abdominal pain, diarrhoea; paraesthesia, peripheral neuropathy, vertigo, headache, hepatic necrosis, drowsiness, neuritis, arthralgia; hypertension. Potentially Fatal: StevensJonhson and/or Lyell's Syndrome (urticaria, fever, lymphadenopathy, arthralgia). Occasionally, thrombocytopaenia, agranulocytosis and aplastic anaemia.

* Assess for pain-Monitor uric acidlevels q2 wk-Monitor CBC,AST, BUN,creatinine beforestartingtreatmentMonitornutritionalstatus:discourage organmeat, sardines,salmon, legumes(high purine),gravies,alcohol

Generic name (Brand name) Sevelamer Drug Classification Dosage/Frequ ency/ Route 800mg/tab 1 tab 3xday oral

Mechanism of Action it binds with phosphates present in the intestines and inhibits intestinal phosphate absorption, which results in decreased serum phosphorus concentration s

Indication

Nursing Consideration And Responsibilities Treatment Headache, infection, pain, Give other drugs at least 1 hour before or for Hyperphosph hypertension, hypotension, 3 hours after sevelamer to prevent atemia in patients thrombosis, diarrhoea, interaction. on dialysis flatulence, dyspepsia, Be aware that severe hypophosphatemia nausea, vomiting, may occur in patient with dysphagia, constipation and cough. major GI tract surgery, or severe GI Pruritus, rash and abdominal motility disorder (including severe pain. constipation) because drug prevents phosphate absorption. Monitor blood pressure absorption. Monitor serum phosphorus level to determine drugs effectiveness; monitor other serum electrolyte levels, especially bicarbonate and chloride, to detect imbalances.

Adverse Effect

Generic name Mechanism Indication (Brand name) of Action Ferrous sulfate + folic acid Drug Classification Antianemics Dosage/Frequ ency/ Route Elevates the serum iron concentratio n which then helps to form high or trapped in the reticuloendot helial cells for storage and eventual conversion to a usable form of iron. treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body).

Adverse Effect Dizziness, N & V, Nasal, Congestion, Dyspnea, Hypotension, CHF, MI, Muscle, cramps and Flushing.

Nursing Consideration And Responsibilities Advise patient to take medicine as prescribed. Caution patient to make position changes slowly to minimize orthostatic hypotension. Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting the physician. Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hyotension occurs. Inform patient that angina attacks may occur 30 min. after administration due reflex tachycardia. Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle changes and stress management.

Laboratory and Diagnostic Tests Latest monthly Chemistries as of 6/8/12

CBC FINDINGS: Hemgbin Hematcrit RBC WBC Neutrophil .lymphocyte Monocyte Eosinophil Basophil

Increase -

Decrease + + -

Result 115 0.33 3.89 6.40 0.64 0.26 0.07 0.03

Units . g/L

Reference Range 135-170 0.40 0.54

X10*12/L X10*9/L

4.60 - 6.20 4.50 - 10.00 0.56 0.66 0.22 0.40 0.04 - 0.08 0.01 -0.03

Platelet
2.Blood Urea Nitrogen 3.Ionized Calcium 4.Phosphorus 5.Sodium + -

157
55.18 4.4 4.24 138

X10*9/L
Mg/dl Mg/dl . mg/dl Mmol/l

140 - 440
8.40 25.77 4.52 5.28 2.29 4.71 136 - 145

6. ALT
7.Potasium 8.Serum Creatinine 9.Serum Albumin 10. Uric Acid

29
4.1 5.37

U/L
Mmol/l Mg/dl

0.00 55.00
3.50 5.10 0.70 1.30

10.4

Total Protein and A/G Ratio

Total CHON = 6.60 g/dl 6.40 8.30 Albumin Globulin A/G Ratio = 3.90 g/dl = 2.70 g/dl 1.44 3.50 5.00 2.90 3.30 (1.21 1.52)

Urinalysis
Color Transparency Reaction Specific gravity Erythrocytes Protein Glucose Ketones Bilirurubin Nitrates

Yellow Clear 5.0 1.020 Positive Positive Negative Normal Negative Negative