Case Presentation: Caring For The Filters

At the end of the case presentation, the participants will be able to acquire the necessary knowledge, skills and attitude in delivering holistic care for patients diagnosed with chronic renal failure.

At the end of this case presentation, the participants will be able to: • Discuss the anatomy and physiology of Urinary System. • Define and familiarize chronic renal failure. • Learn about major etiologic causes of chronic renal failure • Know the different drugs and their actions and perform necessary nursing responsibilities for each drug. • Learn the basic principles of drug metabolism in CRF • Understand basic therapeutic strategies in CRF: Hemodialysis. • Know the Pathophysiology and identify clinical manifestations and risk factors of chronic renal failure • Identify the medical and surgical management appropriate for CRF • Formulate a nursing care plan applicable to a patient with CRF. • Establish a nurse-patient interaction through exchanging of information

N.D

G.D

P.A

Old age

86 y.o

Kidney Disease

B.D 45 y.o

G.D

DM

M.D 42 y.o HPN

J.D 21 y.o CRF, UTI, Anemia

Patterns c. Sleeping Patterns

d. Drinking Patterns e. Eating Patterns

At Home

At the Hospital

She sleeps at around 9 o’clock in the evening and she is satisfied with 2 pillows, one supporting her head and the other one is in between her thighs. And she is usually in a side lying position.

She sleeps for as early as 7:30 in the evening and can’t be comfortable if she doesn’t have three or more pillows surrounding her. And always in a high back rest or semi- fowler’s position with head tilted in left She drinks about 5-7side. glasses per

She can barely consume 3 glasses per day.

day.

Breakfast: Fried Fish and Rice. Lunch: Tinolang Bangus and Rice. Supper: Vegetables and Rice.

f. Elimination Pattern

She defecates twice a day with color brown and well formed stool.

She was not able to defecate since she had been hospitalized.

g. Personal Hygiene

She takes a bath and brushes her teeth twice a day, before going to school and after coming from school.

Since she has been hospitalized she never had taken a single bath nor brushes her teeth. But a sponge bath is being done to her by her mother thrice a day, once after every meal. The only thing she does is sleep and when awake have a little chat with her parents and visitors, if there is.

h. Recreation and Exercise

She watches telenovelas after coming home from school and reads pocketbooks as the form of her recreation. And her exercise is in the form of walking going to school and

Test

Results

Normal Values

Significance of abnormal results

Urea

09-13-08 (HI) 43.74 mmol/L

2.5 – 6-10 mmol/L

The result is high; thus it may indicate renal disease or renal failure

62-106 umol/L

Results were all above the normal level indicating chronic renal failure.

This test is ordered to detect a renal disorder or dehydration associated with increased BUN levels.

09-13-08 This test was ordered (HI) 1392.9 umol/L in order to evaluate 09-17-08 renal dysfunction. (HI) 519.8 umol/L

Creatinine

Sodium (Na) To evaluate Na balance in the body.

09-13-08 (LO) 136.7 mmol/L

137-145 mmol/L

Decreased value indicates renal failure.

3.50-5.10 mmol/L

Decreased levels (hypokalemia) may indicate renal failure

09-17-08 138.0 mmol/L

Potassium (K)

09-13-08 (LO) 2.81 mmol/L

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

09-14-08 (LO) 2.17 mmol/L 09-17-08 (LO) 1.93 mmol/L 09-18-08 (LO) 2.53 mmol/L 09-21-08 (LO) 3.06mmol/L

CBG To determine presence of glucose within the urine

09-14-08 (HI) 12.76 mmol/L 9-16-08 (HI) 9.24 mmol/L

4.10-5.90 mmol/L

Increased levels may indicate Diabetes Mellitus and renal glycosuria

Test

Results

Blood Type

“A” Rh (+)

WBC

09-13-08 (HI) 16.3

Determines any inflammation and infection

RBC Used to evaluate presence of Anemia.

Normal Values

Significance of Abnormal Results

4.5 – 11.0

Results were all above normal level. This shows presence of inflammation and infection

Female: 4.25.4 Male: 4.6-6.2

Result were all below the normal range thus, showing anemia and renal disease

09-17-08 (HI) 12.0 09-13-08 (LO) 1.63 09-17-08 (LO) 3.03

Hemoglobin The Hgb concentration is a measure of the total amount of Hgb in the peripheral blood, which reflects the number of RBC in the blood.

Hematocrit It measures the percentage of the total blood volume that is made up by the RBC. It is an integral part of the evaluation of anemic patients

09-13-08 (LO) 46

Female: 120-160 Male: 135-180

Result were all below the normal range thus, showing anemia and renal disease

Female: 0.370.47 Male: 0.40-0.54

Result were all below the normal range thus, showing anemia and renal disease

09-17-08 (LO) 86

09-13-08 (LO) 0.14 09-17-08 (LO) 0.26

MCV Indicates the size of RBC: microcytic, normocytic and macrocytic..

MCH Indicates the weight of hemoglobin in the RBC regardless of the size

09-13-08 81.0

80-96

09-13-08 28.3

27-31

MCHC Indicates the hemoglobin concentration per unit volume of RBC’s.

RDW Is the measurement of the width of the size distribution curve on a histogram. Useful in predicting anemias early, before MCV changes and before signs and symptoms occur.

09-13-08 53.1

32-36

09-13-08 17.4

11-16

Neutrophils

Determinants of any acute bacterial infection. Eosinophils

To determine any allergic reaction of the body Basophils

To differentiate between the various types of WBC’s for diagnosing health problems. Lymphocytes

To know existence of any acute bacterial infection in the body.

09-13-08 (HI) 83.0

50-70

09-13-08 3.0

0-3

It indicates presence of acute bacterial infection.

09-13-08 0

09-13-08 (LO) 14.0 9-17-08 29.0

20-45

Results shows that patients has bacterial infection.

Monocytes Determines presence of any chronic bacterial infection or viral infection.

Platelet To check the platelet count and to monitor the platelet count during cancer chemotherapy.

09-13-08 0

0-8

09-13-08 234

150-350

Hepa Profile This is usually done before proceeding in hemodialysis. This is to determine if the patient was expose to the virus of if there is presence of hepatitis virus in the blood of the patient.

HBs Ag (Hepatitis B Surface Antigen) Anti- HBs (Hepatitis B Surface Antibody) HCV

Non- reactive

Results revealed that patient has no Hepatitis virus and was not Non- reactive exposed to any of it.

Negative

Urinalysis

Macroscopic

Result

To diagnose and monitor renal or urinary tract disease.

Color

(9-14-08) Pale Straw (9-16-08) Pale Straw

Transparency

(9-14-08) Hazy (9-16-08) Hazy

Reaction

(9-14-08) 5.0 (9-16-08) 6.0

Specific gravity (9-14-08) 1.010 (9-16-08) 1.010

Significance

Glucose

(9-14-08) Trace (9-16-08) 2+

Results may indicate presence of untreated Diabetes Mellitus. (Glycosuria).

Microscopic Amorph U/P

(9-14-08) Few (9-16-08) Few

RBC/hpf

(9-14-08) 1-4 (9-16-08) 32-40

WBC/hpf

(9-14-08) Numerous to count (9-16-08) 40-50

Epithelial cells

(9-14-08) occasional (9-16-08) Few

Results indicate presence of infection.

Bacteria

(9-14-08) Many

Results indicate infection.

(9-16-08) Many

Fine Granular / ipf Coarse Granular

(9-16-08) 0-1 (9-14-08) 0-2 (9-16-08) 0-1

Results may be associated with Acute Tubular Necrosis.

Fecalysis

Name of Examination Physical Color

Result

Consistency

Dark Brown Formed

Fat Globules

Many

Other Test Occult Blood

Negative

Significan ce

Name of Examination

Results

Normal Values

pH

7.448

7.35-7.45

PC02

12.6 mmHg

35-45 mmHg

PO2

166.7 mmHg

80-100 mmHg

HCO3

8.6 mmol/L

22-26 mmol/L

O2 Sat

20.1%

97-100%

Name of Examination

Results

Normal Values

pH

7.527

7.35-7.45

PC02

8.2 mmHg

35-45 mmHg

PO2

185.0 mmHg

80-100 mmHg

HCO3

6.8 mmol/L

22-26 mmol/L

O2 Sat

99.6%

97-100%

Drug

Action

Mechanism of Action

Plasil 10 mg IV q 8˚

GIT Regulators, Antiflatulents and Antiemetics

Chemical Effect: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GIT and accelerates gastric emptying. Therapeutic Effect: Decreased nausea and vomiting. Decreased symptoms of gastric stasis.

Indications

−Prevent ion of chemoth erapyinduced emesis. −Facilita tion of small bowel intubati on in radiogra phic procedu res. −Manag ement of esophag eal reflux. −Treatm ent of post surgical and diabetic gastric stasis

Contraindicat ions

Adverse Effects

− Hypersensiti vity − Possible GI obstruction or hemorrhage − History of seizure disorders − Pheochromo cytom − Parkinson’s Disease

CNS: drowsiness, extrapyramid al reactions, restlessness, anxiety, depression, irritability CV: Arrhythmias (supraventric ular tachycardia, bradycardia), hypertension, hypotension GI: constipation, diarrhea, dry mouth, nausea

Nursing Responsibilities −Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administratio n −Assess patient for extrapyramid al side effects −Assess for signs of depression, periodically throughout therapy

Drug

Action

Mechanism of Action

Indications

Contraindic ations

Adverse Effects

Cefuroxime (Profurex) 750 mg IV q 8˚ ( – 12 mn)

Cephalosporins

Chemical Effect: Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal

−Pre- & post-op prophylaxis, −respiratory tract infections −EENT infections, UTI, soft tissue infections −Bone & joint infections, O & G infection −Pelvic inflammatory diseases −Gonorrhea, septicemia, meningitis.

− Hypersensi tivity to cephalospo rins. − Anaphylact ic reaction to penicillins − Concurrent treatment w/ potent diuretics − Renal impairment Pregnancy

CNS: Dizziness, headache, malaise paresthesia GI: Abdominal cramps, anal pruritus, anorexia, diarrhea, dyspepsia, glossitis, nausea, pseudomembrano us colitis, tenesmus and vomiting GU: Genital pruritus and candidiasis Hematologic: Eosinophilia, hemolytic anemia, thrombocytopenia and transient neutropenia Respiratory: Dyspnea Skin: Masculopapular and erythematous rashes and urticaria

Therapeuti c Effect: Hinders or kills susceptible bacteria, including many gram positive organisms and enteric gram negative bacilli.

Nursing Responsibiliti es −Assess the patient’s infection before therapy. −Before giving first dose, obtain specimen for culture and sensitivity test. −Before giving first dose, ask patient about previous reactions to cephalosporin or penicillin. −Be alert for adverse reactions and drug interaction −If adverse GI reactions occur, monitor patients hydration.

Drug

Action

Mechanism of Action

Indications

Contraindic ations

Adverse Effects

Nursing Responsibiliti es

Ciprofloxacin 500 mg 1 tab BID (8am – 6pm)

Antibiotic; Anti-infective

Chemical Effect: Bactericidal effects may result from inhibition of bacterial DNA gyrase and prevention of replication in susceptible bacteria. Therapeutic Effect: Kills susceptible bacteria.

−Mild to moderate UTI −Severe or complicated UTI −Severe or complicated Infections −Respiratory Tract Infections −Febrile neutropenia

−Contraindic ated in patients hypersensitiv e to Fluoroquinol ones −Used cautiously in patients with CNS disorders and those at increased risk for seizures. May cause CNS stimulation.

CNS: Confusion, hallucination, headache, lightheadedness, paresthesia, restlessness, seizures and tremors CV: Thrombophlebitis GI: Crystalluria, interstitial nephritis Hematologic: Eosinophilia, leucopenia, neutropenia and thrombocytopenia Musculoskeletal: Achiness, arthralgia, joint inflammation, joint or back pain, joint stiffness, neck or chest pain Skin: Photosensitivity, rash, StevensJohnson Syndrome

−Assess patients infection before therapy and regularly throughout −Before giving first dose, obtain specimen for culture and sensitivity test. −Be alert for adverse reactions and drug interactions. −If adverse GI reactions occur, monitor patient’s hydration

Drug

Action

Mechanism of Action

Diazepam 5 mg IV

Anticonvulsa nts, Anxiolytics Skeletal muscle relaxant

Chemical Effect: May depress CNS at limbic and subcortical levels of brain; suppresses spread of seizure, activity produced by epileptogenic fosi in cortex, thalamus, and limbic system Therapeutic Effect: Relieves anxiety, muscle spasms and seizures; promotes calmness, and sleep.

Indications

−Anxiet y −Acute alcohol withdra wal −Muscle spasm −Adjunc t in seizure disorder s −Status Epilepti cus −To control acute repetitiv e seizure activity in patient’ s already taking anticon vulsant s

Contraindic ations −Contr aindica ted in patient s hypers ensitiv e to drugs or any of its compo nents and in those with angleclosure glauco ma, shock, coma or acute alcohol ic intoxic ation.

Adverse Effects

Nursing Responsibili ties

CNS: Anterograde amnesia, ataxia, depression, drowsiness, fainting, hangover, headache, insomnia, lethargy, pain, restlessness, slurred speech and tremors. CV: Bradycardia, CV collapse, transient hypotension EENT: Blurred vison, diplopia, nystagmus GI: Abdominal discomfort, constipation, nausea and vomiting GU: Incontinence, urine retention Respiratory: Respiratory depression Skin: Desquamation, rash, urticaria

−Obtain history of patients underlying condition before therapy and re-assess regularly −Periodically monitor liver, kidney and hematopoiet ic function. −Look for adverse reactions and drug interactions

Drug

Action

Mechanism of Action

Indications

Contraindicati ons

Adverse Effects

Nursing Responsibilit ies

Zantac 150 mg/tab 1 tab BID ()

Antacids, Antireflux Agents & Antiulcerants

Chemical Effect: Competitivel y inhibits action of H2 at receptor sites of parietal cells, decreasing gastric acid secretion.

−Intractable duodenal ulcer −Duodenal and gastric ulcer −Gastroesop hageal reflux disease −Erosive esophagitis

−Contrandic ated in patients hypersensitiv e to the drug or any of its components. −Use cautiously in patients with hepatic dysfunction.

CNS: Vertigo and malaise

−Assess patient’s GI condition before starting therapy and regularly thereafter to monitor drug’s effectivenes s −Zantac EFFERdose contains phenylalani ne −Be alert for adverse reactions and drug interactions .

Therapeutic Effect: Relieves GI discomfort.

EENT: Blurred vision Hematologic: Reversible leucopenia, pancytopenia, thrombocytop enia Hepatic: Jaundice

Drug

Action

Mechanism of Action

Nitropatch 5 mg to ACW

Anti-Anginal Drugs

Chemical Effect: Reduces cardiac oxygen demand by increasing left ventricular and diastolic (preload) and to a lesser extent, systemic vascular resistance (afterload). Also increases blood flow through collateral coronary vessels. Therapeutic Effect: Prevents or relieves acute angina, lowers blood pressure, and helps minimize heart failure caused by MI.

Indications

−Angina pectoris due to coronary artery disease. −Preventi on of chronic anginal attacks −Hyperte nsion related to surgery; heart failure, linked to MI; angina pectoris in acute situation ; to produce controlle d hypotens ion −Hyperte nsive crisis

Contraindicati ons −Contrai ndicated in patients hypersen sitive to nitrates and in those with early MI, severe anemia, increase d intracran ial pressure, angleclosure glaucom a, orthostat ic hypotens ion and allergy to adhesive s.

Adverse Effects CNS: Headache, throbbing, dizziness, weakness CV: Othostatic hypotension, tachycardia, flushing, palpitations, fainting EENT: Sublingual burning GI: Nausea and vomiting Skin: Cutaneous vasodilation, contact dermatitis

Nursing Responsibiliti es −Assess patient’s condition before starting therapy and regularly thereafter to monitor the drug’s effectiveness . −Monitor vital signs and drug response. Be particularly aware of blood pressure. Excessive hypotension may worsen MI. −Be alert for adverse reactiosn and drug interaction.

Drug

Action

Mechanism of Action

Indicatio ns

Contraindications

Hydrocorti sone 250 mg IV q 8°

Adrenocortic al steroid; Glucocorticoi d

Chemical Effect: Not clearly defined; may stabilize leukocyte lysosomal membranes, suppress immune response, stimulate bone marrow, and influence nutrient metabolism.

−Severe inflammat ion, adrenal insufficie ncy −Adjunct for ulcerative colitis and proctitis −Shock

−Contraindicated in patients hypersensitive to drug or any of its components, and in those with systemic fungal infections. Hydrocortisone sodium succinate is contraindicated in premature infants. −Use cautiously in patients with recent MI and in those with GI ulcer, renal disease, hypertension and osteoporosis, DM, hypothyroidism, cirrhosis, diverticulitis, nonspecific ulcerative colitis, recent intestinal anastomoses, thromboembolic disorders, seizures, myasthenia gravis, heart failure, tuberculosis, ocular herpes simplex, emotional instability and psychotic tendencies.

Therapeutic Effect: Reduces inflammation , suppresses immune function, and raises adrenocortic oid hormonal levels.

Adverse Effects

Nursing Responsibilities

−Assess patient’s condition before starting therapy and regularly thereafter −Monitor patient’s CV: weight, blood Heart failure, pressure, and hypertension, edema, arrhythmias, electrolyte level −Monitor patient thromboembolism for stress. Fever, trauma, surgery EENT: Cataracts, glaucoma and emotional problems may GI: increase adrenal Peptic ulceration, GI insufficienc irritation, increased −Periodically appetite, pancreatitis measure growth and development Metabolic: during high-dose Hypokalemia, or prolonged hyperglycemia, therapy in infants carbohydrate and children. intolerance −Be alert for adverse reactions Musculoskeletal: and drug Muscle weakness, growth suppression interactions CNS: Euphoria, insomnia, psychotic behavior, pseudomotor cerebri, seizures

in children, osteoporosis Skin: Hirsutism, delayed wound healing, acne, various skin eruptions, easy bruising

Drug

Action

Mechanism of Action

Furosemide (Lasix) 20 mg IVTT

Loop diuretic; Antihypertens ive

Chemical Effect: Inhibits sodium and chloride reabsorption at proximal and distal tubules and ascending loop of henle.

Indications

-Edema due to cardiac, hepatic & renal disease, burns; mild to moderate HTN -hypertensive crisis -acute heart failure Therapeutic -chronic renal failure Effect: -nephrotic Promotes syndrome water and -Hypercalcemi sodium excretion. a of malignancy

Contraindi cations

Adverse Effects

Nursing Responsibilities

− Assess fluid CNS: -Hypersens status during Dizziness, itivit, Cross therapy encephalopathy sensitivity Monitor blood − , headache, with pressure and insomnia, thiazides pulse before nervousness and and during EENT: sulfonamid administration Hearing loss, es may − Assess patient tenitus occur for tenitus and CV: -Prehearing loss Hypotension existing − Assess for GI: electrolyte allergies to Constipation, imbalance, sulfonamides diarrhea, dry hepatic − Tell patient to mouth, report any coma, dyspepsia, adverse anuria nausea, reaction that vomiting may occur GU: − Before giving excessive the medication urination intravenously, Skin: check first the Photosensitivity patency of the , rashes IV site Endocrine: Hyperglycemia − Observe patient during administration of the drug

Drug

Action

Mechanism of Action

Renogen 2000u SQ

Antianemics

Chemical Effect: Stimulates erythropoie sis (production of RBC)

Indications

-Treatment of anemia associated w/ chronic renal failure (CRF). -Reduction Therapeuti of allogenic c Effect: Maintains blood and may transfusion in surgery elevate patients. RBCs, decreasing the need for transfusion s.

Contraindicati ons

Adverse Effects

Nursing Responsibilities

-Uncontroll ed HTN. -Hypersens itivity to mammalia n cellderived products or to human albumin.

CNS: Seizures, headache

-Monitor blood pressure before and throughout therapy -Inform physician and other helath care professional if severe hypertension is present or if blood pressure begins to increase. -Monitor response for symptoms of anemia -Monitor renal function studies and electrolytes closely; resulting increased sense of well-being may lead to decreased compliance for renal failure -Monitor hematocrit weekly until stable

CV: Hyperten sion, thrombot ic events (hemodia lysis patients) Skin: Transien t rshes Endocri ne: Restored fertility, resumpti on of menses

Drug

Action

Mechanism of Action

Indications

Paracetamol 300 mg IV q4˚

Analgesic; Antipyretic

Chemical Effect: May produce analgesic effect by blocking pain impulses by inhibiting prostaglandi n or pain receptor sene-sitizers. May relieve fever by acting hypothalami c heatregulating center.

- Previous Fever, hypersensiti Headache, vity Muscular products aches and containing pain alcohol, aspartame, saccharine sugar, or tartrazine, should be avoided in patients who have hypersensiti vity or intolerance to this compounds.

Therapeutic Effect: Relives pain or fever

Contraindicati ons

Adverse Effects

Nursing Responsibilities

− GI: Hepatic failure, hepatoxicity (overdose)

GU: − Renal failure (high doses/ chronic use) Skin: Rash, urticaria

−

−

−

Assess fever and note for the presence of associated signs, such as diaphoresis, tachycardia and malaise Check and monitor patient’s temperature before and after giving the medication Tell patient to report any adverse reaction that may occur Before giving the medication intravenously , check first the patency of the IV site Observe patient during administratio n of the drug

Drug

Action

Zinnat 500 mg 1 tab BID

Cephalospor ins

Mechanism of Action

Indications

-Lower & upper resp tract infections -GUT infections, skin & soft tissue infections Therapeu -gonorrhea tic Effect: including Bactericid acute al action uncomplicat ed gonococcal urethritis & cervicitis. Chemical Effect: Bind to bacterial cell wall membran e, causing cell death

Contraindica tions

Adverse Effects

-Hypersen sitivity to cephalosp orins. -Hypersen sitivity to penicillins . -Pseudom embranou s colitis. -Diabetics & phenylket onurics.

CNS: Seizures (high doses)

Nursing Responsibilities

−

GI: − pseudom embrano us colitis, nausea, vomiting, cramps Skin: Rashes, urticaria −

Assess patient for infection at beginning and after therapy. Before initiating therapy, obtain a history to determine previous use and reactions to penicillins or cephalospo rins Obtain specimens for culture and sensitivity before initiating therapy

Drug

Action

Mechanism of Action

Indications

Senokot 2 tab after lunch

Laxatives

Chemical Effect: Active components of senna, alter water and electrolyte transport in the large intestine, resulting in accumulatio n of water and increased peristalsis

–Functional constipation of hospitalized patient, –Functional constipation due to intake of certain drugs. –Neurologic constipation

Therapeuti c Effect: Laxative action

Contraindicati ons

Adverse Effects

Nursing Responsibiliti es

–Acute − GI: surgical Cramping, abdomen, diarrhea, abdominal nausea pain, nausea, GU: vomiting or Pink-red or symptoms brown-black of appendicitis discoloratio n of urine. ; intestinal Mild hemorrhage abdominal or obstruction, discomfort; diarrhea w/ persistent diarrhea. excessive –Rectal loss of water − fissures & –Ulcerated electrolytes hemmoroids

Assess patient for abdomin al distentio n, presence of bowel sounds and usual pattern of bowel function . Assess color, consiste ncy and amount of stool produce d.

Drug

Action

Mechanism of Action

Na HCO-3 650 mg 1 tab, TID

Anti-Ulcer agents

Chemical Effect: Acts as an alkalinzing agent by releasing bicarbonate ions. Therapeutic Effects: Neutralizatio n of gastric acids.

Indications

− −

Antacid Use to alkaliniz ed urine and promote excretio n of certain drugs and over dosage of situatio ns

Contraindica tions

− −

−

−

Adverse Effects

Nursing Responsibilitie s

− Hypoca CV: lcemia Edema Excessi ve GI: chlorid Flatulence, e loss gastric ingestio distention, − n of strong Neuro: mineral Tetany acids severe Fluid and abdomi Electrolytes: − nal Hypokalemia, pain sodium and water retention −

Assess fluid balance (intake and output), Edema Report of symptom s of fluid overload if they occur Assess patient for epigastri c or abdomin al pain Monitor urine pH frequentl y when used for urinary alkaliniz ation

Drug

Action

Mechanism of action

Relaxes Combi Bronchodi bronchial vent lators , uterine, and vascular smooth muscle by stimulati ng beta2 receptors

Indication

Side effects

To prevent or threat bronchosp asm in patients with reversible obstructiv e airway disease

CNS tremor, nervousness, dizziness, insomnia, headache, hyperactivity, weakness, CNS stimulation, malaise.

Contraindicati on

Patient with hypersensitiv ity to the drug or its ingredients. Use cotiusly in patients CV with tachycardia, cardiovascul palpitation, ar hypertension. disorders(inc luding EENT dry and irritated nose coronary and throat with inhaled insufficiency form, nasal congestion, and epistaxis, hoarseness. hypertension ), GI heartburn, nausea, hypertyroidis anorexia, altered taste, m or DM and increased appetite. those who Metabolicare hypokalemia. unusually Musculuskeletalresponsive to muscle cramps. Respiratoryadrenergies. bronchospasm, cough, wheezing, dyspnea, bronchitis, increase sputum.

Nursing responsibilities

rug may decrease sensitivity of spirometry used for diagnosis of asthma. >Patients mat used tablets and aerosol together. Monitor these patients closely for signs and symptoms for toxicity. > Warn patient about risk of paradoxical bronchospasm and to stop drug immediately after it occurs. >Teach patient to perform oral inhalation correctly.

Blood pressure control by kidneys In increased blood pressure → more urine output In decreased blood pressure → less urine output and release of renin

STAGE I

STAGE II

STAGE III

STAGE IV DEATH

S/Sx Manifested by S/S in the Textbook the Patient NEUROLOGIC  Weakness   Confusion  Inability to  concentrate  Disorientation   Tremors   Seizures   Asterixis  Restlessness of legs  Burning of soles of feet  Behavior Changes 

      

S/S in the S/Sx Manifested Textbook by the Patient INTEGUMENTARY Gray-bronze skin  color Dry, flaky skin  Pruritus Ecchymosis Purpura Thin, brittle nails Coarse, thinning hair

         

S/Sx Manifested by the S/S in the Textbook Patient CARDIOVASCULAR Hypertension Edema (face, hands,  feet) Periorbital edema Pericardial friction rub Engorged neck veins Pericarditis Pericardial effusion Pericardial tamponade Hyperkalemia Hyperlipidemia

S/Sx Manifested by the S/S in the Textbook Patient PULMONARY  Crackles   Thick, tenacious sputum  Depressed cough reflex  Pleuritic pain  Shortness of breath   Tachypnea  Kussmaul-type respirations  Uremia pneumonitis

S/Sx Manifested by the S/S in the Textbook Patient GASTROINTESTINAL  Ammonia odor to breath (uremic fector)  Metallic taste  Mouth ulcerations and bleeding  Nausea, and vomiting  Anorexia   Hiccups  Constipation   Diarrhea  Bleeding from gastrointestinal tract

         

S/Sx Manifested by the S/S in the Textbook Patient HEMATOLOGIC Anemia  Thrombocytopenia REPRODUCTIVE Amenorrhea Testicular atrophy Decreased libido MUSCULOSKELETAL Muscle cramps Loss of muscle strength  Renal osteodystrophy Bone pain Bone fractures

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective: “Ginahapo siya!” as verbalized by the father. Objective: -RR: 31 bpm (Upon admission) -Diagnosed with Chronic Renal Failure and Anemia. -GCS = 13 Laboratory Results: (9/13/08) - RBC = 1.63 - Hgb = 46 - Hct = 0.14 ABG Results: - PC02 = 12.6 mmHg - HCO3 = 8.6 mmol/L - O2 Sat = 20.1% Respiratory Alkalosis

Impaired gas exchange related to altered oxygen carryingcapacity of the blood.

After performing all the intervention patient will demonstrate improved ventilation and adequate oxygen as evidence by normalization of her O2 Saturation and GCS of 15.

Dependent: 2.Administer Oxygen at 4 lpm via nasal cannula as ordered. 3.Administer medication as indicated: Combivent 1 neb (6am – 2pm – 10pm) Renogen 2000u SQ 7.Monitor ABG as ordered. Independent: 9.Monitor GCS q°. 10.Position patient in a semi-fowler’s position with upright posture at 45°. 11.Encourage adequate rest and limit activities to within patient’s tolerance. Promote calm environment.

RATIONALE -To prevent hypoxemia and respiratory failure. -It is a bronchodilator that relaxes bronchial, uterine and vascular smooth muscle by stimulating beta2 receptors. -Antianemics. Stimulates erythropoiesis (production of RBC). -Evaluates therapy needs and effectiveness. -Being in a 45° upright increased oxygenation and ventilation. -Changes in mental status can detect effectiveness of intervention. -It helps limit oxygen needs and consumption.

EVALUATION

Goal met. Patient’s O2 saturation has normalized to 99.6% as of 9/14/08 and ventilation has improved as evidenced by no complained of SOB by the patient and GCS = 15.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective: “Daw wala man halos unod man ginadrain mo pa?” As verbalized by the folks. Objective: -She has a foley catheter. -She has a lower than normal urine output of 10cc (Sept. 15, 2008; 6:00 PM). -She has edema in the face. -She is diagnosed with Chronic Renal Failure. -KUB Radiography impression of diffuse renal parenchymal disease bilateral. Laboratory Results: (9/13/08) - Urea = 43.74 mmol/L - Creatinine = 1392.9 umol/L - Na = 136.7 mmol/L - K = 2.81 mmol/L - RBC = 1,63 - Hct = 0.14 Urinalysis result: (09-16-08) - Protein = 2+ - Glucose = 2+

Impaired urinary elimination related to renal dysfunction.

4 hours after performing the interventions patient will have normal urine output of 30cc/°.

Dependent: •Administer medication as prescribed: Furosemide (Lasix) 20 mg IVTT. Independent: •Monitor intake and output q°. •Observe for changes in mental status, behavior or LOC. Monitor GCS q°. •Assess for the present edema and for new edema. •Assess characteristics and amount of urine (note for presence of blood and decrease urine output).

RATIONALE -Inhibits the reabsorption of Na and Cl from the loop of Henle and distal renal tubule. Increases renal excretion of water, Na, Cl, Mg, Hydrogen and Ca. Effectiveness persists in impaired renal function. -Provides information about kidney status and presence of complications. -Accumulation of uremic waste and electrolyte imbalances can be toxic to the CNS. -Presence of edema indicates renal dysfunction and formation of new edema shows worsening of the patient’s condition.. -Identifies the condition of the urinary system.

EVALUATION

Goal met. At around 8:00 in the evening at the same day patient was able to urinate 30cc and had a normal urine output in the succeeding hours.

ASSEESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective: “Nahapo ako.” As verbalized. Objective: -Patient has no sensation to urinate. -Presence of face edema. -Patient is restless. -She diagnosed with Chronic Renal Failure. -Her intake is greater than output as of 9/15/08; 6:00 PM. I = 10 cc O = 140 cc Laboratory Result: (9/13/08) - RBC = 1.63 - Hgb = 46 - Hct = 0.14 - urea = 43.74 mmol/L - Creatinine = 1392.9 umol/L - Na = 136.7 mmol.L - K = 2.81 mmol.L

Excess fluid volume related to compromis ed regulatory mechanism

After 8˚, patient will display normal urine output of 30 cc/hr and normalization of the laboratory values.

Dependent •Administer furosemide 20 mg IVTT OD as ordered. •Limit fluid intake for 1 L/day as ordered. •Insert foley catheter as indicated •Prepare for dialysis as indicated •Monitor sodium as prescribed •Monitor K as prescribed Independent •Monitor I&O every hr and decreasing urine output in relation to fluid intake •Monitor for the development of condition. Increase the client’s risk for excess fluid volume •Explain the patient and so the rationale for fluid restriction

RATIONALE

EVALUATION

−Loop diuretics. Restricting the sodium in the diet in favor the renal expression of excess fluid. Decreasing Na can be just as important as restricting fluid intake with fluid overload −This provides means of accurate monitoring of urine output −Done to drain urinary bladder since she has no sensation to urinate. −Hyponatremia may result from fluid overload (dilutional) or inability of kidney to conserve sodium −Lack of renal excretion and selective retention of K to excrete excess hydrogen ions leads to hyperkalemia −Accurately measuring I&O is very important for determining renal function, fluid replacement needs, and reducing risk of fluid overloads −Renal failure result in decreased glomerular filtration rate and fluid retention −Understanding promotes patient and family cooperation with fluid restriction −Measures the kidney’s ability to concentrate urine

Goal partially met. After 2 hours patient was able to display normal urine output of 30cc and has been maintain for the following hours but all laboratory results are still altered. (9/17/08) - Creatinine = 519.8 umol/L - RBC = 3.03 - Hgb = 86 - Hct = 0.26 (9/21/08) - K = 3.06

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective: “Gapanghina gid ko ya kag daw ginahapo ako.” As verbalized. Objective: -Diagnosed with Chronic Renal Failure and Anemia. -Limited ROM, pt. can’t even sit. -Patient is easily irritated. -Patient appears to be pale, weak and lethargic. -She is easily irritated. Laboratory Results: (9/13/08) - RBC = 1.63 - Hgb = 46 - Hct = 0.14 ABG Results: - PC02 = 12.6 mmHg - HCO3 = 8.6 mmol/L - O2 Sat = 20.1% -Respiratory Alkalosis

Activity intolerance related to imbalance between oxygen supply and demand.

After the shift, the negative factors affecting activity tolerance will be identified and their effects will be reduced. And will demonstrate increase in activity tolerance that can be evidenced by increase in ROM and doing things alone like sitting. And after 4 days altered laboratory results will be normalized.

Dependent: •Administer medication as prescribed by the physician: Renogen 2000u SQ •Administer O2 at 4 lpm via nasal cannula as ordered. Independent: •Note patient’s reports of weakness, fatigue, pain and difficulty in accomplishing task. •Monitor v/s and GCS q° and assess for the adverse effect of the medication. •Encourage the patient to move extremities and other body parts up to what she could tolerate. •Promote comfort measures. •Encourage complete bed rest. •Assist patient in doing certain activities and give her enough time to accomplish certain activity.

RATIONALE -Antianemics. Stimulates erythropoiesis (production of RBC). -To fill O2 insufficiency needed by the patient’s body. -Symptoms may be results of/or contribute to activity intolerance. -To know the response of the patient on the medication being administered. And to detect if it is effective or worsening the patient’s condition. To determine level of consciousness. -To exercise and gradually improve activity tolerance. -To enhance ability of the patient to participate in activities. -To enhance energy level. -To prevent injury or fall. And when the patient is time-pressured, she may lose interest of what she is doing.

EVALUATION Goal partially met. Negative factors were identified and effects were reduced. However, it took 24 hours for her to demonstrate increase in activity tolerance because she sometimes refused to participate in the activities. Patient seemed to be more alert and can sit on her bed without the assistance of others. Only her O2 saturation had normalized with the new result of 99.6% as of 9/14/08 but most had improved. 9/17/08 - RBC = 3.03 - Hgb = 86 - Hct = 0.26 - PCO2 = 8.2 mmHg - HCO3 = 6.8 mmol/L

ASSESSMENT Objective: - Temp = 37.9°C (9/16/08; 3:00 P.M.) - Diagnosed with Urinary Tract Infection. Laboratory Result: (9/13/08) - WBC = 16.3 (indicates presence of infection) - Neutrophils = 83.0 - Lymphocytes = 14.0 Urinalysis Result: (9/14/08) -WBC/hpf – numerous to count. -Bacteria - Many

DIAGNOSIS

Infection related to invasion of pathogens

PLANNING

INTERVENTION

And after a week of intervention the patient’s infection will be reduced or eliminated if possible as evidenced by normalization of the altered laboratory results.

Dependent: 2.Monitor renal function by checking for the creatinine and urea level. 3.Administer medication as prescribed for her infection: Cefuroxime Profurex) 750 mg IV q 8˚. Ciprofloxacin 500 mg 1 tab BID. Zinnat 500 mg1 tab BID 3. Monitor WBC, lymphocytes and neutrophils. Independent: 1. Monitor v/s q°. 2. Assess for any adverse effect of the medications. 3. Promote good handwashing technique.

RATIONALE -Renal function influenced choice and dosage of antibiotics. -Cephalosporins. Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal -Antibiotic. Bactericidal effects may result from inhibition of bacterial DNA gyrase and prevention of replication in susceptible bacteria. -Cephalosporins -Bind to bacterial cell wall membrane, causing cell death -Altered values indicate infection. To test effectiveness of treatment. -To monitor effectiveness of intervention. - Presence of this indicates the need for change of treatment or lowering of dosage. - To prevent spreading of contamination.

EVALUATION Goal partially met. After 4 days of treatment patient’s WBC decreases and Lymphocytes normalized. But urinalysis results is still altered after 3 days of intervention. 09-16-08 WBC/hpf = 40-50 Bacteria = Many 09-17-08 WBC = 12.0 Lymphocyte = 29.0

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective “Mainit siya bala, may lagnat siya guro.” as verbalized by the folks. Objective -Patient has increased body temperature = 37.9˚C (9/16/08; 3:00 P.M.) -She has a flushed skin which is warm to touch -She has dry lips -She is restless. -She is diagnosed with Urinary Tract Infection. Laboratory results: (9/13/08) - WBC = 12.0 - neutrophils = 83.0 Urinalysis Result: (9/14/08) -WBC/hpf – numerous to count. -Bacteria - Many

Hyperthermia related to invasion of pathogens

After an hour, patient’s body temperature will decreased from 37.9˚C to a normal range 36.5˚C – 37.5˚C

Dependent •Administer medication as indicated: Paracetamol 300 mg IV q4° PRN for Temp. > 37.8°C. •Administer D5 NSS 1L x 40 cc/˚ as ordered. Independent 5.Provide tepid sponge bath. 6.Monitor body temperature q 30 min. until it decreases to normal range of 36.5 – 37.5°C. 7.Make the patient comfortable and divert its attention. 8.Promote complete bed rest.

RATIONALE −Antipyretic inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. −To replace fluid loss, promote circulating volume and prevent dehydration. −It helps reduce fever in the process of conduction. −To assess patient’s condition, recognize the pattern of fever and determine if there are changes. −Diverting the patient’s attention may reduce his/her psychological status. −To reduce metabolic demands.

EVALUATION

Goal Met. At around 4:00 in the afternoon, an hour after receiving Paracetamol together with other interventions, patient’s temperature decreased from 37.9°C to 37.4°C.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective: “Gasakit akon tiyan.” As verbalized. Objective: -She has limited oral intake up to 1L/day. -She wasn’t able to defecate for 3 days. -She is experiencing fatigue. -She is pale, weak and lethargic.

Constipation related to decreased fluid intake and daily activity.

Patient will resume normal bowel movement after 8 hours.

Dependent 2.Administer medication as prescribed: Senokot 2 tab after lunch OD. Independent 1. Encourage patient to be engage in activities within her capacity 5.Ascertain usual dietary pattern of food choices 6.Suggest adding fresh fruits, vegetables and fiber to diet when indicated within restriction 7.Provide privacy and bedside commode

RATIONALE −It is a laxative that stimulates and increases peristalsis, probably by the direct on smooth muscle of the intestine. −Moving and doing activity promotes peristalsis. −Although restriction may be present, thoughtful consideration of many choices can aid in controlling problem −Provide bulk foods, which improves stool consistency −Promote psychologic comfort needed for elimination

EVALUATION

Goal partially met. 24 hours after the administratio n of Senokot, patient was able to defecate.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective “Umpisa sang naospital siya, wala pa siya kapaligo kag katilaw panutbrush.” As verbalized by the folks. Objective - She is unable to carry out proper hygiene. -She is unable to carry out ADLs. -Her hair is sticky in texture and there are presence of dandruffs in her head. -Her nails are untrimmed and dirty. -Her lips are dry. -There are visible cracks in the sole of her feet. -She has a notable body odor.

Self Care Deficit related to decreased strength

After 8 hours patient will perform self-care activities within level of own ability and with the help of her parents and will learn its importance.

Independent 2.Determine patients ability to participate in self-care activities. 3.Provide assistance with activities as necessary. 4.Recommend scheduling of activities to allow patient sufficient time to accomplish tasks to fullest extent of ability. 5.Explain to the patient the importance of proper hygiene. 6.Do a bed bath every morning and sponge bath before sleeping and teach the folks how to do proper bed bathing. 7.Perform oral hygiene to the patient and teach her ways to do it on her own.

RATIONALE −Underlying condition will dictate level of deficit/needs. −This is to meet needs while supporting patient participation and independence. −Unhurried approach reduces frustrations, promotes patient participation and enhancing selfesteem −For her to understand how necessary it is to do proper hygiene. −To maintain proper hygiene and avoid complications due to accumulation of bacteria. −To prevent dryness of oral mucous and to remove bacteria that may have accumulated in her mouth.

EVALUATION

Goal met. Patient learned how to perform self- care activities and realized its importance and together with her parents demonstrated the proper hygienic techniques. She was able to perform oral hygiene on her own and bed bath with the help of her parents.