I. INTRODUCTION

a) IMPORTANCE OF THE CASE STUDY

Knowing the different kinds of diseases in our community, it is

important for us to know how to prevent these kinds of diseases and

what is the management we are going to use if we encountered one of

these sicknesses. According to our source, disease management has

been defined as a system of coordinated care interventions in which

patient’s self care efforts are significant. For this case study, our

purpose in doing this is to provide an overview of Acute Renal Failure

and impart ways on how to prevent and manage this disease.

b) OBJECTIVES

Introduce what Acute Renal Failure is.

Differentiate between Acute Renal Failure and Chronic Renal

Failure.

Discuss the Anatomy and Physiology of systems which can be

damaged by Acute Renal Failure.

Explain the Pathophysiology of the disease.

Discuss the predisposing and precipitating factors of the disease.

Discuss the signs and symptoms of the disease.

Discuss the possible complications of Acute Renal Failure.

Present diagnostic and laboratory procedures in detecting Acute

Renal Failure.

State management goals for a patient with Acute Renal Failure.

List the types of oral and IV medications for Acute Renal Failure

and their mechanisms of action.

Impart the role of Renal Failure self-management education in

assisting patients with Acute Renal Failure to make required

attitude changes to manage their disease.

Acute Renal Failure

Acute renal failure (ARF) is the rapid breakdown of renal (kidney)

function that occurs when high levels of uremic toxins (waste products

of the body’s metabolism) accumulate in the blood. ARF occurs when

the kidneys are unable to excrete (discharge) the daily load of toxins in

the urine.

Based on the amount of urine that is excreted over a 24-hour

period, patients with ARF are separated into two groups: Oliguric: patients who excrete less than 500 milliliters

per day (< 16 oz/day) Nonoliguric: patients who excrete more than 500

milliliters per day (> 16 oz/day)

In Nonoliguric patients, the urine is of poor quality (i.e., contains little waste) because the blood is not well filtered, despite the fact that an adequate volume of urine is excreted.

Both kidneys are failing when ARF occurs. One normally functioning kidney can maintain adequate blood filtering.

Chronic Renal Failure

Chronic, or irreversible, renal failure is a progressive reduction of

functioning renal tissue such that the remaining kidney mass can no

longer maintain the body’s internal environment. CRF can develop

insidiously over many years, or it may result from an episode of ARF

from which the client has not recovered.

Precipitating Factors of ARF:

Diet (Eating salty and fatty foods)

Lifestyle (Smoking And drinking)

Predisposing Factors:

Age

Heredity

Signs and Symptoms of ARF

The patient may manifest the following:

Oliguria

Tachycardia and hypotension

Dry mucous membranes and flat neck veins

Lethargy

Cool, clammy skin

Azotemia

Electrolyte imbalances

Nausea and vomiting

Constipation

Irritability and Fatigue

Complications of Acute Renal Failure

Ischemic acute tubular necrosis can lead to renal shutdown.

Electrolyte imbalance, metabolic acidosis, and other severe effects

follow as the patient becomes increasingly uremic, and renal

dysfunction disrupts other body systems. If left untreated, the elderly

patient is particularly susceptible to volume overload, precipitating

acute pulmonary edema, hypertensive crisis and infection.

Diagnostic and Laboratory Tests to Detect Acute Renal Failure

Blood studies: BUN, serum creatinine, potassium,

bicarbonate, hematocrit, and hemoglobin, pH, serum

osmolality

Urinalysis, protein, osmolality, sodium

Creatinine clearance

Electrocardiogram

Ultrasonography

X-ray of abdomen, kidney-ureter-bladder radiography

Excretory urography, retrograde pyelography

Renal scan, CT scan and nephrotomography

II. NURSING ASSESSMENT

A.PERSONAL HISTORY

Mr. R resides at Sta. Lucia Sasmuan Pampanga, and he is 57

years old. His wife is elementary teacher and he has a son who is in

college at present. Due to financial difficulties of the family of Mr. R in

his times, he is not able to finish his elementary course and finished

grade four. Their religion is Catholic.

Mr. R lives a sedentary lifestyle. He likes to eat salty and fatty

foods such as chicken, pork and instant noodles. He also states that

everyday, his day is not complete if he is not able to eat his favorite

food which is noodles. He smokes and drinks alcoholic beverages

whenever there is occasion but it’s neither a vice nor a habit. More

often, he sleeps around 7:30pm and wakes at 5:00am. He usually stays

at home and prepare their meal everyday, sometimes he play cards

with his neighbors. Mr. R does not exert effort on having exercise. His

wife supports them financially.

B.HISTORY OF PAST ILLNESS

Mr. R doesn’t remember if he had mumps or chickenpox before

nor completed his immunization. He had never been hospitalized

before. He has an allergic in penicillin. Their family doesn’t have

history of renal failure or any hereditary diseases. They believed on

traditional beliefs and seek for albularyo when their sick.

C.HISTORY OF PRESSENT ILLNESS

Mr. R condition started a week before he was admitted to the

hospital. He had fever and chills then took biogesic. On the second day

he had hypogastric pain and vomited that’s why they sought

consultation to a nearby hospital (Diosdado Macapagal Hospital).

He was admitted with the impression of Acute Renal Failure.

Because his condition becomes worst, they decided to transfer him to

JBLMRH last December 11, 2005 at 4:30 pm. He was brought to

Medicine Ward. His vital signs upon admission are as follows: BP:

120/80, CR: 89, RR: 22. His blood type is B. His doctor suggested

submitting himself for dialysis but he refused due to their financial

status. December 13, 2005, he was subjected for blood transfusion.

Because of his anxiety and fear of pain made by needle prick, he

refused to subject himself for CBC and withdraws for any kind of care

give to him; he even refuses to take his vital signs. Mr. R is suffering

from oliguria, uremia and anemia.

Usually the family argues about Mr. R diet. His wife stated that

Mr. R is hard headed but they can’t do anything because he is the one

who usually prepare their meal.

D.PHYSICAL ASSESSMENT

A. General Appearance

Mr. Romeo Velasco is 57 year old. He was brought to JBLMRH last

December 11, 2005 with a chief complaint of general body weakness.

Appears to be untidy (uncombed hair).Vital signs are as follows: BP:

120/80, CR: 90, RR: 22.

B. Review of Systems

SKIN: fair complexion, dry skin, no jaundice, cold to touch and

patient is pale

HEAD: head is proportional to the body, no tenderness observed,

and no inflammation

EYES: (+) Perrla, eyebrows are well-distributed, no cataract

observed, eyelids are able to blink

EARS: are symmetrical, no tinnitus, no discharges, no lesion

NOSE AND SINUSES: no epistaxis, no discharges, and no

tenderness observed

MOUTH AND THROAT: dry lips, hoarseness of voice, tongue can

be protruded, and no inflammation observed

NECK: able of full neck motion without pain, there is no

inflammation upon palpation, no lump and no swollen lymph node

RESPIRATORY: no sputum and no asthma

CARDIAC: hypertensive

GASTROINTESTINAL: low appetite, allergic to penicillin

URINARY: has oliguria (with average urine output of 10mL/hour)

GENITAL: not assessed

PERIPHERAL VASCULAR: nail beds are pale, with an impaired

capillary refill time

MUSKULOSKELETAL: with impaired mobility

NEUROLOGIC: general body weakness

HEMATOLOGIC: redness, pain in areas where transfusion was

done, has a decrease hgb count upon laboratory results

PSYCHIATRIC: patient is nervous and anxious

NO HISTORY OF FAMILIAL DISEASES

Domingo Velasco Purificacion Sanchez Virgilio Roman

Laura Roman

Narcisa Roman

Cecilia RomanVirginia Velasco

Julia Velasco

Aries Velasco

Rufina Aguilar

Antonio Velasco

Romeo Velasco (allergic in penicillin, has ARF)

III. ANATOMY AND PHYSIOLOGY

KIDNEYS

The kidneys are bean shaped organs, each about the size of a

tightly clenched fist. They lie on the posterior abdominal wall, behind

the peritoneum, with one kidney on either side of the vertebral column.

Structures that are behind the peritoneum are said to be

retroperitoneal. A connective tissue renal capsule surrounds each

kidney. Around a renal capsule is a thick layer of fat, which protects

the kidney from mechanical shock. On the medial side of each kidney

is the hilum, where the renal artery and nerves enter and where the

renal vein and ureter exit the kidney. The hilum opens into cavity

called the renal sinus, which contains blood vessels, part of the system

for collecting urine and fat

The kidney is divided into an outer cortex and an inner medulla,

which surround the renal sinus. The bases of several cone- shaped

renal pyramids are located at the boundary between the cortex and

the medulla, and the tips of the renal pyramids project towards the

center of the kidney. A funnel shaped structure called a calyx

surrounds the tip of each renal pyramid. The calyces from all the renal

pyramids join to form a larger funnel called the renal pelvis. The renal

pelvis then narrows to form a small tube, the ureter, which exits the

kidney and connects to the urinary bladder. Urine passes from the

kidney and connects to the urinary bladder. Urine passes from the tips

of the renal pyramids into the calyces. From the calyses urine collects

in the renal pelvis and exits the kidney through the ureter.

The functional unit of the kidney is the nephron and there are

approximately 1.3 million of them in each kidney. Each nephron

consists of a renal corpuscle, a proximal tubule, a loop of Henle, or

nephronic loop and a distal tubule. Fluid enters the renal corpuscles

and then flows into the proximal tubule. From there it flows into the

loop of Henle, each loop of Henle has a descending limb, which

extends towards the renal sinus and an ascending limb. Which extends

back toward the cortex. The fluid flows through the ascending limbs of

the loop of Henle to the distal tubule. Many distal tubules empty into a

collecting duct, which carries the fluid from the cortex, through the

medulla. Many collecting ducts empty intro a papillary duct and the

papillary ducts empty their contents into a calyx.

The renal corpuscles and both convoluted tubules are in the

renal cortex. The collecting duct and loop of Henle enter the medulla.

Approximately 15 % of the nephrons called juxtamedullary nephrons

have loop of Henle that extends deep into the medulla of the kidney.

The other nephrons called cortical nephrons have loop of Henle that do

not extend deep into the medulla.

The renal corpuscles of the nephrons consist of Bowman’s

capsule and the glomerulus. Bowman’s capsule consist of the enlarge

end of the nephron, which is extended to form a double walled

chamber. The indention is occupied by a tuft of capillaries called

glomerulus, which resembles a ball of yarn. The cavity of Bowman’s

capsule opens into the proximal tubule, which carries fluid away from

the capsule. The inner layer of Bowman’s capsule surrounds the

glomerulus and consists of specialized cells called podocytes. The

outer layer of the Bowman’s capsule consists of simple squamous

epithelial cells.

The glomerular capillaries have pores in their walls, and the

podocytes have cell processes with gaps between them. The

endothelium of the glomerular capillaries, the podocytes and the

basement membrane between them form a filtration membrane. In the

first step of urine formation, fluid called filtrate is filtered from the

glomerular capillaries into Bowman’s capsule through the filtration

membrane.

Most of the nephron and collecting duct are made up of simple

cuboidal epithelium. However, the thin segments of the descending

and ascending limbs of Henle’s loop have very thin walls up of simple

squamous epithelium. The cells of proximal, thick segment of the

ascending limb of Henle’s loop, distal tubules and collecting ducts have

microvilli and many mitochondria. The proximal tubule, thick segment

of the ascending limb of Henle’s loop and the collecting duct actively

transport molecules and ions across the wall of the nephron. The thin

segment of the descending limb of the Henle’s loop is very permeable

to water and solutes and the thin segment of the ascending limb is

permeable to solutes but not to water.

URETERS, URINARY BLADDER, and URETHRA

The ureters are small tubes that carry urine from the renal pelvis

of the kidney to the posterior inferior portion of the urinary bladder.

The urinary bladder is a hallow muscular container that lies in the

pelvic cavity just posterior to the symphysis. Its function to store urine

and its size depends on the quantity of urine present. The urinary

bladder can hold from a few millimeters to a maximum of about 1000

ml of urine. When the urinary bladder reaches a volume of a few

hundred ml, a reflex is activated, which causes the smooth muscle of

the urinary bladder to contract and most of the urine flows out of the

urinary bladder through the urethra

The urethra is a tube that exits the urinary bladder inferiorly and

anteriorly. The triangle shaped portion of the urinary bladder located

between the opening of the ureters and the opening of the urethra is

called tragone. The urethra carries from the urinary bladder to the

outside of the body.

The ureters and the urinary bladder are lined with transitional

epithelium, which is specialized to stretch. As the volume of the

urinary bladder increases the epithelial cells, and the number of

epithelial cell layers decreases. As the volume of the urinary bladder

decreases, transitional epithelial cells assume their columnar shape

and form a greater number of cell layers.

The walls of the ureter and urinary bladder are composed of

layer of smooth muscle and connective tissue. Regular waves of

smooth muscle contractions in the ureters produce the force that

causes urine to follow from the kidneys to the urinary bladder.

Contractions of smooth muscle in the urinary bladder force urine to

flow from the bladder through the urethra.

At the junction of the urinary bladder and urethra, the smooth

muscle of the bladder wall forms the internal urinary sphincter in

males. No well defined internal urinary is found in females. Elastic

fibers at the junction of the urinary bladder and urethra keep urine

from passing through the urethra until the urinary bladder pressure

increases. The internal urinary sphincter of males is under involuntary

control. Contraction of the internal urinary sphincter during ejaculation

prevents semen from entering the urinary bladder and keeps urine

from flowing through the urethra. The external urinary sphincter is

formed of skeletal muscle that surrounds the urethra as the urethra

extends through the pelvic floor. The external urinary sphincter is

under involuntary and voluntary control. It controls the flow of urine

through the urethra.

In male, the urethra extends to the end of the penis, where it

opens to the outside. The female urethra is much shorter

(approximately 4 cm) than the male urethra (approximately 20 cm)

and opens into the vestibule anterior to the vaginal opening.

IV. PATIENT AND HIS ILLNESS

A. PATHOPHYSIOLOGY (book based)

The driving force for glomerular filtration is the pressure gradient

from the glomerulus to the Bowman space. Glomerular pressure is

primarily dependent on renal blood flow (RBF) and is controlled by

combined resistances of renal afferent and efferent arterioles.

Regardless of the cause of ARF, reductions in RBF represent a common

pathologic pathway for decreasing GFR. The etiology of ARF comprises

3 main mechanisms.

Pre-renal failure is brought about by diminished blood flow to the

kidneys. GFR is depressed by compromised renal perfusion. Such

decreased flow may result fro hypovolemia, shock, embolism, blood

loss, sepsis, pooling of fluid in ascites or burns, and cardiovascular

disorders, such as congestive heart failure, arrhythmias and

tamponade.

Intrinsic renal failure results from damage to the kidneys

themselves, usually resulting from acute tubular necrosis. Such

damage may also result from acute poststreptococcal

glomerulonephritis, systemic lupus erythematosus, periarteris nodosa,

vasculitis, sickle-cell disease, bilateral renal vein thrombosis,

nephrotoxins, ischemia, renal myeloma and acute pyelonephritis.

Post obstructive renal failure initially causes an increase in

tubular pressure, decreasing the filtration driving force. This pressure

gradient soon equalizes, and maintenance of a depressed GFR is then

dependent upon renal afferent vasoconstriction. Post-renal failure is a

bilateral obstruction of urinary out-flow results. Its multiple causes

include kidney stones, blood clots, papillae from papillary necrosis,

tumors, benign prostatic hyperplasia, strictures and urethral edema

from catheterization.

Patients with chronic renal failure also may present with

superimposed ARF from any of the aforementioned etiologies.

Depressed RBF eventually leads to ischemia and cell death. This

initial ischemic insult triggers production of oxygen free radicals and

enzymes that continue to cause cell injury even after restoration of

RBF. Tubular cellular damage results in disruption of tight junctions

between cells, allowing back leak of glomerular filtrate and further

depressing effective GFR. In addition, dying cells slough off into the

tubules, forming obstructing casts, which further decrease GFR and

lead to oliguria.

B. PATHOPHYSIOLOGY (CLIENT CENTERED) WITH DIAGRAM

The patient’s condition that leads to acute renal failure is related

to nephrotoxins (diet, lifestyle). There is an increase in BUN and

creatinine that indicates impaired renal function .There is also an

increase in WBC, neutrophils, and lymphoctes that indicates of

infection /inflammation. The doctor’s order is to check the CBC, RBC,

BUN, CREATININE, Na, K Cl, and for Urinalysis. The patient was advice

to submit himself for dialysis because he is anemic and to take

Furosemide as diuretics. The doctor prescribed CaCo3 because of

hypocalcemia and Kalium Durule because of hypokalemia.

While there is decrease in renal blood flow the symphathetic

response is to increase the production of Renin and Angiotensin II that

cause hypertension, thus the doctor order manidipine for the patient.

PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE (Client Center)

Nephrotoxins

Symphatetic Response

Increase Renin and Angiotensin II

Circulatory Inadequacy

Increase BUN and Creatinine

Decrease K, Na Hypokalcemia

Uremia /Severe Anemia

Hypertension

Increase WBC, Neutrohils, Lymphocytes

Med’s given

C. DIAGNOSTIC AND LABORATORY PROCEDURES

DATE ORDERED: DECEMBER 11, 2005

HEMATOLOGY

DIAGNOSTIC

PROCEDURE

RESUL

T

NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

MCH 32.4 27-33 pg Normal

MCV 90.1 82-92 fl Normal

MCHC 36 31-36g / dL Normal

reticulocyte

count

2.5 1- 5 % Normal

DATE ORDERED: DECEMBER 11, 2005

DIAGNOSTI

C

PROCEDUR

E

RESUL

T

NORMAL

VALUES

INTERPRETATI

ON

NURSING

REPONSIBILITI

ES

Hgb 77 M:125-175g/L

F:115-155g /L

> Indication of

severe anemia

>Notify the

physician

>Continue

monitor the

laboratory

results

>Advise the

patient to eat

foods rich and

iron

>Encourage the

patient to take

iron

supplements

Hct 0.23 M 0.40 – 0.52

F 0.38 – 0.48

> Indication of

anemia from

dietary

deficiency,

malnutrition and

kidney diseases.

>Notify

physician

>Monitor lab

results

WBC 12.0 > Indication of

infection or

inflammation.

> Notify

physician

Neutrophil

s

0.90 0.20- 0.35 > Indication of

infection

> Notify

physician

Lymphocyt

es

0.08 0.02 – 0.05 > Indication of

infection

> Notify

physician

Stab 0.02 0.02 – 0.05 Normal

Platelet 163 Normal

DATE ORDERED: DECEMBER 11, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

FBS 6.64 3.85 – 9.0

mmol / L

Normal

BUN 13.1 1.7 – 8.3

mmol / L

> Indication of

renal failure or

glomerulonephritis

.

Creatinine 1,939 M = 60 –

120 mmol / L

F = 58 – 100

mmol / L

> Indication of

urinary tract

failure or high

protein diet

Sodium 137 136 – 145

mmol / L

Normal

Potassium 2.3 3.5 – 5.0

mmol / L

> Indication of

hypokalemia or

loss of potassium

in the body

because of severe

vomiting.

>Notify Resident

on Duty

>Encourage to

take potassium

supplements and

foods rich in

potassium such as

banana etc.

Chloride 109 101 – 111

mmol / L

Normal

Calcium 1.71 2.05 – 2.60

mmol / L

Phosphorus 1.1 0.81 – 1.62

mmol / L

Normal

DATE ORDERED: DECEMBER 11, 2005

URINALYSIS

COLOR Light yellow

REACTION Acidic

SPECIFIC GRAVITY 1.020

COARSE GRANULAR 2.4 / LPF

PUS CELLS 8.10 / HPF

RC 3.5 / HPF

EPITHELIAL CELLS Few

DATE ORDERED: DECEMBER 12, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

FBS 95.9 70 – 105

mg / dL

Normal

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

Potassium 3.0 3.5 – 5.0

mmol / L

> Indication of

mild hypokalemia

or mild loss of

potassium in the

body because of

vomiting.

>Notify resident on

duty

>Encourage the

patient to take

potassium

supplements and

foods rich in

potassium such as

banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

Sodium 135 136 – 145 > Indication of

mmol / L mild

hyponatremia,

renal insufficiency

and uremia.

Potassium 3.1 3.5 – 5.0

mmol / L

> Indication of

mild hypokalemia

or mild loss of

potassium in the

body because of

vomiting.

>Notify resident on

duty

>Encourage the

patient to take

potassium

supplements and

foods rich in

potassium such as

banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

Hgb 73 M =125-

175g/L

F = 115 –

155g/L

> Indication of

severe anemia

>Notify the

physician

>Continue monitor

the laboratory

results

>Advise the

patient to eat

foods rich and iron

>Encourage the

patient to take

iron supplements

Hct .20 M =.40-.52

F = .38

-.48

> Indication of

anemia from

dietary deficiency,

>Notify physician

>Monitor lab

results

malnutrition and

kidney diseases.

DATE ORDERED: DECEMBER 14, 2005

DIAGNOSTIC

PROCEDURE

RESULT NORMAL

VALUES

INTERPRETATIO

N

NURSING

REPONSIBILITIES

Hgb 83 M = 125 –

175 g / L

> Indication of

severe anemia

>Notify the

physician

>Continue monitor

the laboratory

results

>Advise the patient

to eat foods rich and

iron

>Encourage the

patient to take iron

supplements

Hct 0.25 M =.40-.52

F =.38-.48

> Indication of

anemia from

dietary deficiency,

malnutrition and

kidney diseases.

>Notify physician

>Monitor lab results

Potassium 3.0 3.5 – 5.0

mmol / L

> Indication of

mild hypokalemia

>Notify resident on

duty

>Encourage the

patient to take

potassium

supplements and

foods rich in

potassium such as

banana, etc.

V. PATIENT AND HIS CARE

A. PLANNING (NURSING CARE PLAN)

NCP#1

CUES NURSING DIAGNOSIS

SCIENTIFIC EXPLANATIO

N

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective: Objective: >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.6 >Patient manifest generalized body weakness >Patient is

>Fatigue related to decreased Hgb count.

>A decrease in Hgb count would be a factor in having fatigue because RBC plays an important role in our cells and muscle to function normally. Patient with ARF may suffer to anemia because our kidney is one of the

>After 4 hours of nursing intervention, the patient will demonstrate an improve ability to participate in desired activities and he will verbalize an increase energy level.

>Establish rapport

>Discuss with the patient the need for activity. Plan schedule with the patient and identify the activities that leads to fatigue.

>Monitor vital signs

>to facilitate client and student nurse interaction

>education may provide motivation to increase activity level through patient may feel too weak initially

>indicates physiological

>After 4 hours of nursing intervention, goal was met as evidenced by: *clients verbalization of feeling of less fatigue and weakness *patient participates in some activities as much as he could

pale >Patient is dizzy >with poor muscle tone >the patient has a decreased Hgb count of 83. (Normal Value is 123-175g/L for males)

producers of erythropoietin that is one component for RBC production and RBC are the one who carries oxygen and nutrients to other cells and muscles for them to function. A decrease in erythropoietin production will tend to produce a small amount of RBC that would lead to a decreased supply of oxygen to different cells and muscles in the body. Therefore, leading to poor muscle tone and a problem

>Encourage the patient to eat

>Administer medications such as ferrous sulfate as prescribed

>Encourage/advise the patient to perform ROM exercise

>Encourage the patient to rest

>Promote overall health measures such as proper nutrition, adequate fluid intake and

level of tolerance

>to gain energy

>for the body to have enough RBC to supply the muscles and cells enough nutrients to function properly

>to increase the patients activity level in a step-by-step manner

>restoration of energy

>to correct the need of supply of RBC and to reduce fatigue by gaining

*patient is awake

with muscle contractility that could make the client feel that he is weak.

appropriate vitamin/iron supplement.

>Maintain strenuous activity restrictions.

energy

>to improve activity tolerance, avoid activities that requires too much energy

NCP #2

CUES NURSING DIAGNOSIS

SCIENTIFIC EXPLANATIO

N

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:Objective: >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2 >patient is oliguric average of 10mL/hour >Hgb: 73 Hct: 0.20(Normal Values:

>Excess fluid volume related to inability of the kidney to excrete waste products

>Kidneys are responsible for the elimination of waste products in our body. If there is an alteration on the normal functioning of the kidney, there would be a problem in the excretion of waste products. Making the waste to stay in the circulation and excessive fluid may be the result because

>After four hours of nursing interventions; *there would be a stabilized fluid volume by increasing the urine output of the patient *the client verbalize an understanding of individual dietary/fluid restriction

>Establish rapport

>Monitor vital signs

>Monitor I and O

>Assess appetite and note for nausea or vomiting

>to facilitate client and student nurse interaction

>to be able to monitor the changes in the condition of the client

>to monitor the normality of urine output

>to be able to know other reason which contributes to his condition

>After four hours, goal met as evidenced by: *an increase in urine output from 10mL to 30mL/hour *the client verbalized understanding of fluid restriction in his diet and began to implement it *patient is awake *patient always stay on bed

Hgb is 125-175g/L and Hct I 0.40-0.52 for male) >patient is restless

there are only intake but a limited amount of output because of the damaged of malfunctioning kidney.

>Restrict Na and fluid intake as indicated

>Administer medications such as diuretics as ordered

>Evaluate edematous extremities, change position frequently

>Discuss importance of fluid restriction and “hidden sources” of intake such as foods high in water content

>Identify “danger” signs requiring notification of healthcare provider.

>to avoid further excess fluid accumulation

>to promote elimination of waste products

>to reduce tissue pressure and risk of skin breakdown

>for better understanding on why the client needs t restrict his fluid consumption

>to ensure timely evaluation

NCP #3

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATIO

N

OBJECTIVE NURSING INTERVENTIO

N

RATIONALE EVALUATION

Subjective: Objective: >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2 = poor

sanitation = unable to

meet patients demands

>Risks for infection related to environmental condition

>Risk for infection is the state in which an individual is at risks for being invaded by pathogenic organisms / microorganisms due to poor environmental sanitation to its surroundings

>After 5 hours of patient and student nurse interaction the patient will verbalize understanding and identify intervention to reduce risk for infection

>Establish rapport

>Encourage the pt. and the S.O to practice proper hand washing techniques

>Encourage the patient and the SO to practice environmental sanitation

>Encourage the

> To gain the cooperation of the patient during the interaction

> To reduce or minimize the transfer of microorganisms

> To prevent the spread of microorganisms in the surroundings

> To avoid

>Goal met because the patient as well as the SO practicing the interventions given

for personal care

= poor hygiene

= presence of insects in the surroundings

patient to throw the garbage or trash properly

>Instruct the patient to eat foods rich in Vit. C like guava, oranges, calamansi etc…

>Encourage compliance to drug regimen

insects and other microorganisms that carries viruses

> To increase body resistance

> For protection against infection

NCP #4

ASSESSMENT NURSING DIAGNOSI

S

SCIENTIFIC EXPLANATIO

N

OBJECTIVE NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Objective: >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2 = refuse to

take the medication

>Ineffective therapeutic regimen management related to financial status

>Ineffective therapeutic regimen is the state in which the patient was unable to meet the demands in prevention and curing of illness because of financial problem

>After 5 hours of nursing intervention the patient and the SO will understand the importance in the compliance of drugs and other therapeutic regimen.

>Establish rapport

>Provide information about the patients condition

>Encourage to

>To gain the cooperation of the patient during the interaction

>To know the importance of therapeutic regimen and the value of treatment program

>Goal was partially met as evidence by the patient cooperation in some of the intervention given.

given = limited

social interaction

= lack of interest

=uncooperative

identify the patients and significant others perception and expectation of treatment regimen

>To identify causative factor

NCP #5

ASSESSMENT

NURSING DIAGNOSI

S

SCIENTIFIC EXPLANATIO

N

OBJECTIVE NURSING INTERVENTIO

N

RATIONALE

EVALUATION

Subjective: “ Bisa kung mangan babi”

Objective : >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs:

>Knowledge deficit related to disease condition

>Knowledge deficit is the state in which the patient lack of information about his condition

>After 5 hours of nursing intervention the patient verbalize understanding about his condition

>Establish rapport

>Assess for the patient’s readiness to learn

>To gain the cooperation of the patient during the interaction

>To evaluate if the patient is ready to learn the concept of wound cleaning

>Goal met because the patient participates in learning process.

BP: 110/80 PR: 79 RR: 20 Temp: 37.2 =uncoopera

-tive = lack of

interest = the pt.

frequently ask about his condition

= eating food which are restricted on his diet

>Determine client’s ability to learn.

>Determine blocks to learning. (Like language barriers, physical factors and physical stability)

>Provide information about the patient condition

>Encourage the patient to follow the right diet

>To assess what level of teaching we are going to impose.

>To identify possible hindrances that would affect in the teaching and learning process

>To understand the condition of the patient

>To avoid secondary problem and complication

NCP # 6

ASSESSMENT

NURSING DIAGNOSI

S

SCIENTIFIC EXPLANATIO

N

OBJECTIVE NURSING INTERVENTIO

N

RATIONALE EVALUATION

Subjective :

Objective : >Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO

Imbalanced nutrition less than body requirements related to disease condition

Imbalanced nutrition related to therapeutic dietary restrictions; as evidenced by lack of interest in food/eating

After 4 hours of client and student nurse interaction the client will be able to verbalize understanding of the therapeutic

>ascertain understanding of individual nutritional needs

>discuss eating habits, including food preferences

>to determine what information to be provide the client/SO

>to appeal to clients likes & desires

Goal was met as evidenced by the clients verbalization of understanding of the therapeutic dietary restrictions

>Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2>body weakness-numbness in the  lower extremities-dizziness-fatigue-dry skin-pale

dietary restriction

>assess drug interactions and use of diuretics

>assist in developing individualized diet regimen

>explain to the client the prescribed diet

>provide oral liquid preparation

>provide frequent mouth care

>these factors may be affecting appetite, food intake, or absorption

>to correct underlying causative factors

>in order to facilitate understanding and gain the clients participation to the diet regimen

>these will help in providing nutrients to the client

>to prevent stomatitis, remove bad taste,

>provide atleast 30-35 kcal/kg body weight/day

>restrict protein and maintain body weight

>restrict protein and phosphate at prescribed amount

increase patients comfort

>to minimize metabolism of body protein and maintain body weight

>to improve taste and increase carbohydrate/ calorie intake

>to decrease the metabolic end products of urea, potassium, phosphate and hydrogen

NCP # 7

ASSESSMENT

NURSING DIAGNOSI

S

SCIENTIFIC EXPLANATIO

N

OBJECTIVE NURSING INTERVENTIO

N

RATIONALE EVALUATION

Subjective

Objective: - >Patient is conscious and coherent >with

Impaired urinary elimination related to disease condition

Usually occurs with urinary tract obstruction that affects the kidneys bilaterally such

After 4 hours of client and student nurse interaction the client will be able able to verbalize

>assess clients understanding of condition

>to be able to provide appropriate information that are needed by the client

Goal was met as evidenced by the clients verbalization of understanding

ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2>oliguria>irritability>decreased urine output

as prostatic hyperplasia

understanding of condition >provide time

for the client to have question and answer them in the simplest understandable form

> Determine clients previous elimination pattern of elimination and compare with current situation

>palpate bladder

>Emphasize importance of keeping the area clean and dry

>provide hard candy or gum>in order to facilitate understanding

>in order to assess deviation

>to assess retention

>to reduce risk of infection and/or skin breakdown

of condition

NCP # 8

ASSESSMENT NURSING DIAGNOSI

S

SCIENTIFIC EXPLANATIO

N

OBJECTIVES NURSING INTERVENTIO

N

RATIONALE EVALUATION

Subjective:

Objective: >Patient is conscious and

Social Isolation related to traumatic incidents

Aloneness experienced by the individual and perceived as

After 4o of nursing intervention the patient will be able

>Established rapport

>To improve client’s perception of self as a worthwhile

Goal met. After 4o of nursing intervention the patient

coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO >Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2>the patient manifest restlessness, incommunicable,projects hostility in behavior, poor eye contact.

causing physical pain.

imposed by others as a negative or threatening state.

to demonstrate willingness or desire to socialize with other.

>Encouraged the patient to express his feelings

>Identify support system available to the patient

>Provide positive reinforcement when client make moves toward others

>Be honest and keep all promises

>Be cautious with touch until trust has established.

person >to enhance client’s feelings of self worth >to maintain involvement with others

>to encourage continuation of efforts

>honesty and dependability promote a trusting relationship

>a suspicious client may perceive touch as a

was able to demonstrate willingness or desire to socialize with other.

>Introduce client to those with similar / shared interest and other supportive people

threatening gesture.

>provide role models, encourage problem solving.

NCP #9

Cues Nursing

Diagnosi

s

Scientific

Explanation

Desired

Outcome

Interventions Rationale Expected

Outcomes

Subjective

:

Anxiety

related to

Anxiety often

accompanies

After 30

minutes of

Create an

atmosphere

> Trust is an

essential first

After 30

Ø

Objective:

>Patient is conscious and coherent >with ongoing IV of D5 0.3 NaCl 500cc X KVO>Vital signs: BP: 110/80 PR: 79 RR: 20 Temp: 37.2

> poor eye

contact

>restless-

ness

>irritable

> increase

tension

> facial

pain. pain. The threat

of the unknown

and the

inability to

control the pain

or the events

surrounding it

often augment

the pain

perception. A

perception of

lacking control

or a sense of

helplessness

tends to

increase pain

perception.

nursing

intervention,

the patient

will appear

relaxed and

report

anxiety is

reduced to a

manageable

level.

that facilitates

trust.

Seek to

understand

client’s

perspective of a

stressful

situation.

Encourage

verbalization of

feelings,

perceptions,

and fears.

step in the

therapeutic

relationship

> To facilitate

planning for

the best

approach to

anxiety

reduction.

> To identify

specific

emotions

such as anger

or

helplessness,

distorted

perceptions

and

unrealistic

fears.

minutes of

nursing

intervention,

the patient

appears

relaxed and

reported

anxiety is

reduced to a

manageable

level.

tension

> facial

grimace

Identify

situations that

precipitate

anxiety

(describe what

the person

experienced

immediately

prior to feeling

anxious and

identify

associated

events).

> These will

enable the

client to

prevent or

recognize his

anxiety in

order to

initiate

problem

solving.

B. IMPLEMENTATION

1. MEDICAL / SURGICAL MANAGEMENT

INTRAVENOUS FLUID

Date Ordered: Date

Started/discontinued

IVF (type of

fluid and

regulation)

Fluid Description Nursing

Responsibility

Date Started: December

11, 2005 and December

15, 2005

Discontinue: December

16, 2005

Date Started: December

12, 2005 and December

14, 2005

Discontinue: Discontinue

after BT, replace

previous IVF

> D5 0.3

NaCl 500 cc

X KVO

>PNSS

500cc X KVO

> It is a solution of sodium

chloride in sterile water but in

much higher concentration.

>In medicine saline is a

solution of sodium chloride in

sterile water, used commonly

for intravenous infusion,

cleaning contact lenses, and

nasal irrigation or jala neti.

Sodium chloride (NaCl) is

ordinary salt.

> Watch out for

emptying of the

solution. Replace

solution whenever

necessary.

>Check for the

patency of IV lines.

MEDICATION AND DRUG STUDY

DRUG DATE ORDERE

D

ACTION INDICATION

DOSAGE: ROUTE OF

ADMINISTRATION, FREQUENCY

SIDE EFFECTS

NURSINGRESPONSIBILITIES

Generic Name:Paracetamol

December 11, 2005

Antipyretic

Analgesic

Analgesic- Antipyretic in patients with aspirin allergy, haemostatic disturbances and bleeding.

300 mg IV 30 min prior to BT

CNS: HeadacheGI: Hepatic toxicity and failure, jaundiceCV: Chest pain, dyspnea

Monitor Temperature

Assess for history of allergy to Paracetamol, impaired hepatic function, chronic alcoholism.

Physical assessment, skin color, lesions, liver evaluation; CBC, liver and renal function test.

Give drug with food if upset is noted.

Discontinue drug if hypersensitivity reactions occur.

Report skin rash, unusual bleeding or bruising, following of skin or eyes, changes, in voiding patterns.

DRUG DATE ORDERED

ACTION INDICATION

DOSAGE SIDE EFFECTS

NURSINGRESPONSIBILITIE

S

Generic Name:DiphenhydramineHydrochloride

Brand Name:Benadryl

December 11, 2005

Competitively blocks the effects of histamine at H1 receptor sites, has atropine- like an antipruritic, and sedative effects.

Relief of symptoms associated with allergic reactions to blood or plasma.

1 amp IV 30 min prior to BT

- Dizziness-Sedation-Drowsiness-Dry mouth

Assess history of allergy to antihistamines.

Physical assessment, skin color, lesions, texture, reflexes, PR, RR, BP, adventitious sounds; bowel sounds; prostate palpation; CBC with differential.

Inform patient about the following side effects that may occur.

Monitor for difficulty breathing, hallucinations, tremors, loss of coordination, unusual disturbances, and irregular heartbeat.

DRUG DATE ORDERED

ACTION INDICATION DOSAGE SIDE EFFECTS

NURSINGRESPONSIBILITIE

S

Generic Name:Calcium Carbonate

Brand Name:Caltrate

December 11, 2005

Essential element of the body; helps maintain the functional integrity of the nervous and muscular systems, helps maintain blood coagulation.

Dietary supplement when calcium intake is inadequate.

1 tab TID -constipation-nausea-GI upset-loss of appetite

Assess history o allergy to calcium; renal calculi; hypercalcemia ventricular fibrillation; digitalis toxicity.

Physical assessment, BP, peripheral perfusion, ECG; abdominal exam, bowel sounds, mucous membranes; serum electrolytes, urinalysis.

Monitor serum phosphorus levels periodically during long-term oral therapy.

Advice client to take drug between meals and at

bedtime. Chew tablets thoroughly before swallowing, and follow with a glass of water or milk.

Advice client about following side effects that may occur.

Advice client to report loss of appetite; nausea, vomiting, abdominal pain, constipation, dry mouth, thirst, increased voiding.

DRUG DATE ORDERED

ACTION INDICATION DOSAGE SIDE EFFECTS

NURSINGRESPONSIBILITIE

S

Generic Name:Furosemide

Brand name:Lasix

December 11, 2005

Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubule and the loop of henle, leading to sodium, rich diuretics.

-Edema associated with renal disease.

80 mg IV post BT

-Increased volume and frequency of urination;- drowsiness-dizziness-feeling faint on arising-sensitivity to sunlight-loss of body potassium

Assess history: Allergy to furesemide, sulfonamides; tartazine; electrolyte depletion anuria, severe renal failure.

Physical assessment: skin color, lesions, edema, orientation, reflexes, hearing, pulses, baseline ECG, BP, orthostatic BP, perfusion; RR, liver evaluation, bowel sounds; urinary output patterns; CBC, serum electrolytes, blood sugar, liver and renal function tests,

uric acid, urinalysis.

Administer with food or milk to prevent GI upset.

Inform client about the side effects that may occur.

Report loss or gain of more than 3 lbs. in one day, swelling in ankles or fingers, unusual bleeding or bruising, dizziness, trembling, numbness, fatigue, muscle weakness or cramps.

DRUG DATE ORDERED

ACTION INDICATION DOSAGE SIDE EFFECTS

NURSINGRESPONSIBILITIE

S

Generic Name: Metoprolol Brand Name: Toprol XL

December 15, 2005

Competively blocks beta-adrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of rennin, and lowering BP; acts in the CNS to reduce

-Hypertension, alone or with other drugs, especially diuretics.-prevention of reinfarction in the MI pts who are hemodymacally stable or within 3-lod of acute MI-treatment of angina pectoris.

50 mg 1 tab BID

-Dizziness-Drowsiness-Light headedness-blurred vision-nightmares-depression-sexual impotence

Assess history of sinus bradycardia (HR < 45 beats/min)Second or third-degree heart block (PR interval > 0.24 sec), cardiogenic shock CHF, systolic BP < 100 mg Hg; diabetes or thyroxicosis; asthma or COPD.

Physical Assessment: weight, skin condition, neurologic status, PR, BP, ECG, respiratory status, kidney and thyroid function, blood and urine glucose.

sympathetic outflow and vasoconstrictor tone.

Inform clients regarding side effects that may occur.

Monitor difficulty breathing, night cough, swelling of extremities, slow pulse, confusion, depression, rash, fever and sore throat.

Name of Drug

Mechanism of

Action

Indication Dosage, Route of

administration and

Frequency(Date

Oredered)

Contraindication

Side Effects/Adverse

Effects

Nursing Implicatio

n

Generic Name:Manidipine

Brand Name:Caldine

Long-acting calcium antagonist, dilating blood vessels, mainly by calcium channel blockade

For patients with hypertension

Manidipine 20mg/tab OD

> December 14, 2005

It should not be taken by the patient who is pregnant or suspected of being pregnant.

Cardiovascular: Facial hot flushes, feeling of warmth, conjunctival congestion, palpitation or tachycardia. GI: Nausea, vomiting, stomach discomfort, enlarged feeling of abdomen, constipation or oral dryness. Psychoneurologic: Dizziness,

Blood Pressure should always be monitored.

Watch out for excessive drop of blood pressure so that appropriate measures such as dosage restriction

dizziness on standing up, headache, dull headache, sleepiness or numbness. Blood: Leukopenia.Liver: Elevation of GOT, GPT, g-GPT, LDH and alkaline phosphatase. Kidney: Elevation of BUN and serum creatinine. Hypersensitivity: Rash or pruritus. Others: General malaise, weakness, edema, pollakiuria and elevation of total serum Cholesterol, uric acid and triglycerides.

and cessation should be done.

Caution the patient that such symptoms like dizziness may occur.

Advise the patient to avoid hazardous activities requiring the alertness of the patient.

Watch out for adverse reactions.

Name of Drug

Mechanism of Action

Indication Dosage, Route of

administration and

Frequency(Date

Orederd)

Contraindication Side Effects/Adverse

Effects

Generic Name:ErythropoietinBrand Name:Eprex

Recombinant human erythropoietin (r-HuEPO) is a purified glycoprotein which stimulates erythropoiesis.

Symptomatic or transfusion requiring anaemia associated with chronic renal failure.

5000 iu / SC / once a week

>December 16, 2005

-uncontrolled hypertension-known hypersensitivity to mammalian-cell derived products-known hypersensitivity to any of the components of this product

Increased blood pressure and hypertensive encephalopathy-Flu-like symptoms, bone pain and chills following injections-Seizures-Headache-Pain in the subcutaneous area

Name of Drug

Mechanism of

Action

Indication Dosage, Route of

administration and

Frequency(Date

Ordered)

Contraindication

Side Effects/Advers

e Effects

Nursing Implication

Generic Name:KClBrand Name:Kalium Durule

Replaces potassium and maintain potassium levels

For patients with hypokalemia

Kalium Durule 1 tab TID

>December 13, 2005

Contraindicated for patients with hyperkalemia and renal insufficiency

Hyperkalemia, arrhythmias, weakness, confusion and hypotension.

Frequently monitor the potassium levels of the patient

Use the drug with caution for patients with cardiac disease.

The drug is commonly used orally with

potassium wasting diuretics to maintain potassium levels.

Watch out for adverse reactions.

SPECIAL PROCEDURES

DATE

ORDERED /

DATE

PERFORMED

PROCEDURE RESULT PROCEDURE

DESCRIPTION

NURSING

RESPONSIBILITIE

S

December 11,

2005

December 12,

2005

> Blood

Transfusion

(1 “u”)

> Blood

Transfusin

> No allergic

reactions

> No allergic

reactions

> Blood

transfusion is

performed to

supply any

blood loss or

any deficiency

in RBC.

> Blood

transfusion is

> Watch for allergic

reactions

> Watch for signs

of shock

> Watch for allergic

reactions> Watch for signs

December 14,

2005

(1 “u”)

> Blood

Transfusion

(1 “u”)

> No allergic

reactions

performed to

supply any

blood loss or

any deficiency

in RBC

> Blood

transfusion is

performed to

supply any

blood loss or

any deficiency

in RBC

of shock

> Watch for allergic

reactions> Watch for signs

of shock

VI. PATIENTS DAILY PROGRESS

Doctor’s Order

Name: Romeo Velasco Age: 57 Male Civil

Status: M

Address: Sasmuan, Pampanga Ward: Med

Hospital #: 130290

Date: December 11, 2005

Please admit to as under ORANGE

Secure consent for admission and NGT

TPR on shift

NPO temporarily except meds

# uremia

CBC 12 LEKG

RBC CXR PAV

BUN / Creatinine Renal UTZ

Na K CL Urinalysis

.Uremia / anemia 2° to ESRD prob. To CBN

BP = 130/80mmHg CR = 76 bpm Cra. = 3.1

IVF D5 0.3 NaCl 500cc x KVO, start KCL drip 10meqs + 90cc

PNSS x 1° x 4 doses then for serum K 1 hour after the last

dose.

CaCO3 500mg/tab 1 tab TID

Advise dialysis

# Anemia

Place MCV MCH MCHC PBC Retic G

prepare 3 “u” PRBC properly typed and matched

PNSS 500cc while on BT, replace previous IVF after each unit

Transfuse 1st unit once available

Paracetamol 300mg / IV and Diphenhydramine 50g /IV 30

minutes prior to BT

Furosemide 80mg/ IV / post BT

Insert Folley Catheter and do I & O q 1° and record pls.

Monitor vital signs q 1°.

# Glucoserum

FBS in AM

HBAC

CBC q 12° and record pls.

Inform service residence.

Complete Hx / pls.

Refer accordingly.

December 12, 2005

BP = 110/ 70mmHg (+) body weakness (-) N / V

Repeat serum K after 4th dose KC

Low salt, low protein diet.

Transfuse 1 unit PRBC properly typed and matched to run for 4

hours.

Furosemide 80mg / post BT.

For renal UTZ

Repeat with in 6 hours post BT.

Continue meds.

December 13, 2005 7:30am

(-) pallor

For repeat H & H.

Romeo Velasco – refused dialysis.

8:00am

BP = 120/80mmHg; T = 35.8 °C; RR = 21; PR = 79bpm

(+) nausea (+) vomiting of coffee

Transfuse 1 “u” PRBC properly typed and matched to run for 6

hours.

Furosemide 80mg / IV.

Insert NGT.

Fecalysis with occult blood

Still for dialysis.

Monitor VS, I & O q 1°

Continue meds.

Consent for blood transfusion.

Meds:

1. Furosemide 80mg TID

2. CaCO3 TID

4:20pm

Start Kalium Durules 1 tab. TID

December 14, 2005

BP = 180/ 100mmHg: CR = 94bpm; (+) anorexia

Manidipine 200mg / tab OD

For H/H.

For removal of NGT.

Start tube feeding at 1600 kcal in 6 divided doses.

Continue meds.

VS q 4°

12-14-05 6:50pm

BP = 140/90 mmHg CR = 82bpm T = 37.2 °C

(+) upper arm twitching (-) DOB (-) chest pain

May remove NGT.

For K and Albumin

Prepare and transfuse 1 “u” of PRBC properly typed and

matched.

H/H 6° prior to BT

Furosemide 80mg / post BT, watch for transfusion reaction.

VS q 1°

December 15, 2005 4:00pm

BP = 170/90mmHg

start metoprolol 50mg / tab BID

H/H prior to BT

Continue meds.

VS q 1°

Refused medications, VS q 1° and BT.

December 16, 2005

BP = 110/80mmHg

MGH

home meds

1. Erythropoietin 5,000 u/ sc once a week

2. CaCO3 / tab TID.

3. Manidipine 20mg /tab OD

Follow up check up:: January 11, 2006

Discharged @ 4:30pm 12/16/05

Daily Progress Table

12-11-2005 12-12-2005 12-13-

2005

12-14-2005 12-15-

2005

12-16-2005

Vital Signs

at 12PM

T: 37

PR: 90

RR: 22

BP: 120/80

T: 36.7

PR: 76

RR: 20

BP: 110/70

T: 35.8

PR: 79

RR: 21

BP: 120/80

T: 37.2

PR: 82

RR: 22

BP: 140/90

T: 37

PR: 83

RR: 20

BP: 170/90

T: 37.2

PR: 79

RR: 21

BP: 110/80

Lab

Procedure

*Blood

Chemistry*

>MCH – 32.4

>MCV – 90.1

>MCHC – 36

>Reticulocyte

count– 2.5%

>Hgb – 77

>Hct – 0.23

>WBC – 12.0

>Neutrophils –

0.90

>Lymphocytes –

0.08

>Stab – 0.02

*Blood

Chemistry*

>FBS – 95.9

>K – 3.0

>Hgb – 73

>Hct – 0.20

*Blood

Chemistry

*

>K – 3.0

>Hgb – 73

>Hct –

0.20

*Blood

Chemistry*

>Hgb – 83

>Hct – 0.25

>K – 3.0

REFUSED REFUSED

>Platelet – 163

>RBS – 6.64

>BUN – 13.1

>Crea – 1939

>Na – 137

>K – 2.3

>Chloride – 109

>Ca – 1.71

>Phosphorus – 1.1

*Urinalysis*

>Color: Light

Yellow

>Reaction – Acidic

>Specific Gravity

– 1.020

>Coarse Granular

– 2.4/LPF

>Puss Cells –

8.1/HPF

>RC – 3.5/HPF

>Epithelial cells –

few

Medication

s

>CaCO3

500mg/tab TID

>Paracetamol 300

mg IV

>Diphenhydramid

e 50mg IV 30

mins prior to BT

>Furosemide

80mg IV Post BT

Continue meds:

>CaCO3

500mg/tab TID

BT meds:

>Diphenhydramid

e 50mg IV 30

mins prior to BT

>Furosemide

80mg IV Post BT

New Meds:

>Kalium

Durule

1tab TID

Continue

meds:

>CaCO3

500mg/ tab

TID

New Meds:

>Manidipine

200mg/tab OD

Continue meds:

>CaCO3

500mg/tab TID

>Kalium Durule

1tab TID

BT meds:

>Diphenhydramid

e 50mg IV 30

mins prior to BT

>Furosemide

80mg IV Post BT

New Meds:

>Metoprolo

l 50mg/tab

TID

Continue

meds:

>Manidipin

e

200mg/tab

OD

>CaCO3

500mg/tab

TID

>Kalium

Durule 1tab

TID

MGH

Home meds:

>Erythropoietin

5,000 u/ sc

once a week>CaCO3 / tab

TID.

>Manidipine

20mg /tab OD

IVF >D5 0.3 NaCl

500cc X KVO

>PNSS 500cc X

KVO

>PNSS 500cc X

KVO

>PNSS 500cc X

KVO

>D5 0.3

NaCl X KVO

Special

Procedure

s

>1st unit BT

9:40PM

>2nd unit BT

11:30AM

>3rd unit BT

9:00PM

NORMAL VALUES:

* Normal Values

Hgb M: 125 – 175g/L F: 115 – 155g/L

Hct M: 0.40 – 0.52F: 0.38 – 0.48

WBC

Neutrophils 0.45 – 0.65

Lymphocyte 0.20 – 0.35

Stab 0.02 – 0.05

Platelet

RBS 3.85-9.0mmol/L

BUN 1.7-8.3

Creatinine M: 60 – 120F: 58 – 100

Sodium 135 – 145

Potassium 3.5 – 5.0

Calcium 2.02 – 2.60

Phosphorus 0.81 – 1.62

Chloride 101 – 111

FBS 4.1 – 6.1 mmol/L

MCH 27 – 33 pg

MCV 82 – 92 fl

MCHC 31 – 36 g/dL

Reticulocyte count 1 – 5%

PATIENTS DAILY PROGRESS

12-11-05

The patient was transferred from Diosdado Macapagal Hospital at Lubao, Pampanga, and was admitted to JBLMRH under orange service.The vital signs taken were BP 130/80, PR 76. The ongoing diagnosis is Uremia/Anemia 2 to ESRD prob. 2 to CBN.

He was hooked with an IVF of D5 0.3 NaCl 500cc x KVO, started KCl drip 10 meqs + 90 cc PNSS x 1x 4 doses then for serum K 1 after the last dose.

CaCO3 500 mg 1 tad TID was ordered as meds

Patient is refusing dialysis, that’s why dialysis was advised

# Anemia1st unit of 3 U pack RBC was transfused. Pre BT meds are given and they are as follows: Paracetamol 300 mg IV, Diphenhydramine 50 g IV 30 mins prior to BT and furosimide 80 g IV was given post BT.

Foley catheter was inserted

# Glucoserum

FBS in AM was takenHBAC

CBG was ordered to be done q 12.

12-12-05

The patient BP was 110/70. There was (+) body weakness and (-) N/V. Serum K after 4th dose KCl was repeated. Low salt, low protein diet was prescribed.

1 unit of packed RBC was transfused, consumed within 4 hours, furosemide 80 mg was given post BT.

For renal UTZ, H/H was repeated within 6 hours post BT.

12-13-05

7:30 amThere was (-) pallor. The patient was for H/H

The patient refused dialysis

8:00 amThe patients vital signs were as follows: BP: 120/80, T: 35.8C, RR: 21, PR: 79. The patient has (+) nausea and vomiting.

He was transfused with 1 U PRBC consumed for 6 hours; furosemide 80 mg IV was given. He was inserted with NGT. For fecalysis with occult blood.The patient was for dialysis but still he is still refusing.

4:20 pm

Kalium Durule TID was started.

12-14-05

The patients vital signs are as follows; BP: 180/100, CR: 94. Manidipine 200 mg 1 tab OD was started. For H/H. Tube feeding was 1600 kcal in 6 divided doses. The NGT was removed due to the anxiety of the patient.

12-14-05

6:50 pm

The patients vital signs were as follows BP: 140/90, CR: 82, T: 37.2°C. There was positive arm twitching, negative DOB, negative chest pain. He was for K, Ca, and Albumin count.

12-15-05

The patient BP was 170/90. Metropolol 50 mg 1 tab BID was started. For H/H post BT.

The patient was lying on bed and not talking and would not open his eyes. He refused H/H, and all his oral meds.

12-16-05

The patient BP was 110/80. The he was sitting on bed, and verbalizes that he does not remember that he had refused all to take all his medications. There was (+) dizziness and loss of appetite due to therapeutic diet prescribed. He is still refusing dialysis.May go home. Home meds were as follows: Erythropoietin 5,000 IU SC once a week, CaCO3 1 tab TID, and Manidipine 20 mg 1 tab OD.

He was scheduled to have his checked up on Jan.11, 2006. The patient was discharged at 4:30 pm.

VII. DISCHARGE PLANNING

Medications:

Erythropoietin 5000 IU, SC once a week

CaCO3 1 tab TID

Manidipine 20mg 1 tab OD

Exercise:

Encouraged to perform ROM exercise

Limit activities that requires too much movement

May perform ADL in a limited range

Treatment:

Medication as prescribed by ROD

Low salt – low fat diet and Uremic diet

Health Teaching:

Advised patient to eat nutritious food like fruits, fish and

vegetables.

Advised to limit salt and fat intake

Advised patient to monitor intake and output.

Advised patient to perform light exercises

Out-Patient Visit

Instructed patient to be back on January 11, 2006 for

follow up check-up.

Diet:

Low fat – low salt diet, Uremic diet

VIII: Conclusion and Recommendation

Acute Renal Failure is a kind of disease that is suddenly

manifested by people who are not aware of what they are eating.

People who manifest ARF have same manifestations and these are

high in creatinine, hyperkalemia, oliguria, anemia and the worst is

uremia. Uremia is a toxic manifestation of this disease in which a

person has urine in its blood because of inability of the kidney to

excrete the waste from the body because of its damage. Having

uremia in a person with ARF can lead to its worst condition and if

cannot be prevented, it can lead to death of the person. However,

there is still hope in treating Acute Renal Failure in compare with

Chronic Renal Failure. There are different prevention strategies,

diagnostic screening methods and treatments that can be applied in

patients with Acute Renal Failure.

Renal Failure can be acute or chronic. Chronic Renal Failure

affects patients for a long period of time and can only be treated by

kidney transplant. Unlike Acute Renal Failure, the normal functioning of

the kidney can be achieved by spontaneous treatment and

hemodialysis if advised by the doctor. Though, hemodialysis can be

performed for persons with CRF, however, the normal functioning of

the kidney could not be achieved. To manage the patient with this kind

of condition (ARF), it should be done with complete cooperation of the

patient and its family. The client with ARF must be endowed to accept

self-management and learn how to control himself in times of

temptation of doing wrong things that could affect his condition.

Clients with ARF should have a consistent check-up, updating and

monitoring his own condition.

Proper education should be imparted in clients with ARF. They

should be educated on what are the things that they should be aware

of. This includes his diet, his activities of daily living and his

medications. Proper monitoring of his urine output should also be

included in educating them. In addition to the diet of the client, we

should also present substitutes for foods that the patient wants that

could not affect his condition. A uremic and a low-salt low-fat diet

should be imposed on patients with ARF. We should also include that

they should abide the orders of the physician in order for him to be

treated in his condition. As nurses, we should also take in consideration

the financial stability and the degree of knowledge our client has so

that we can come out with nursing interventions that is appropriate to

his level of understanding.

Health care providers should be aware of the risk and

complications of acute renal failure to patients. We should always

monitor their fluid and electrolyte balance and other laboratory results

for us to be updated of the patient’s progress in the hospital.

Acute Renal Failure is a major disease condition. We should be

careful of what we are eating and doing. We can avoid having this

disease by following a healthy diet and regular exercise. As a famous

saying from the medical field, “Prevention is better than cure”.

Current Trends on Acute Renal Failure

Taken from: RenaMed Biologics and Genzyme Announce Worldwide Collaboration to Advance Investigational Treatment for Acute Renal Failure-- Data from Phase II study, completed by RenaMed, to be presented at ASN in November –

Sep 28, 2005

LINCOLN, R.I., and CAMBRIDGE, Mass., Sept. 28 – RenaMed Biologics, Inc. (RenaMed™), formerly Nephros Therapeutics, Inc., and Genzyme Corporation (NASDAQ = GENZ ) announced today that they have entered into a strategic collaboration to jointly develop and commercialize RenaMed’s Bio-Replacement Therapy™ for the treatment of acute renal failure. The product utilizes physiologically active renal epithelial cells, administered ex vivo in a hollow-fiber cartridge, intended to treat a sudden loss of kidney function with the ultimate goal of improving survival rate. Genzyme and RenaMed will undertake a collaborative

effort to advance the product through clinical development, manufacturing, and commercialization on a worldwide basis.

The joint development and commercialization agreement calls for a 50/50 sharing of costs and profits. Genzyme will contribute funding of approximately $23 million through the third quarter of 2006 to support the next stage of clinical development, and may make additional payments to RenaMed upon completion of certain developmental milestones. These additional payments could total $20 million. Thereafter, the agreement calls for shared program funding, and for potential additional milestone payments by Genzyme at approval. Genzyme also made an equity investment in a recent private financing completed by RenaMed in June 2005.

Reaction:

It is a fact that acute renal failure is one of the major diseases that occur in this world. There are lots of treatments that are being presented today to treat acute renal failure. These include hemodialysis, medications and many more. But recently, corporations which are the RenaMed and the Genzyme joined forces to develop and commercialize a new product to treat Acute Renal Failure; the Bio-Replacement therapy which utilizes epithelial cells and so on to treat the sudden loss of function of our kidney and improve the survival rate of the patient who possess this kind of disease.

This latest trend in medicine will contribute a lot in treating this kind of disease. As individuals here in this society, we should support this kind of breakthroughs because this will not just benefit the elite people in our society but also to indigent people who cannot afford the expensive therapies that should be done in treating acute renal failure. Even though this kind of treatment was discovered and developed, we should always be careful on what we are doing so that the probability of having the disease will decrease. But the most important is, early prevention and detection of the disease is one of the main goal to avoid renal failure such as limit intake of salty and fatty foods.

IX. BIBLIOGRAPHY / REFERENCES

Laboratory Procedures and Results/ Reference unit HAU Library www.yahoo.com Medical-surgical book by Black Angeles City Library (Nursing Books specifically Pathophysiology

Book) Anatomy and Physiology (Official book of CON-HAU)

JBLMRH (Patient’s Records)

Holy Angel University College of Nursing

In Partial Fulfillment of the requirement in Related Learning Experience

A case study about

Presented by : Group - 1

Acoba, Anna Mary Golda G. Angeles, Leonardo Jr. M.

Antido, Arleen Bognot, Mariel

Castilllo, Christine C

Presented to: Mr. John Paul Cuengco, R.N