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

Old age 86 y.o

45 y.o

B.D M.D

P.A G.D

Kidney Disease

DM

42 y.oHPN

J.D21 y.o

CRF, UTI, Anemia

Patterns At Home At the Hospitalc. Sleeping Patterns 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 side.

d. Drinking Patterns She can barely consume 3 glasses per day.

She drinks about 5-7 glasses per day.

e. Eating Patterns 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.

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

coming home.

The only thing she does is sleep and when awake have a little chat with her parents and visitors, if there is.

Test Results Normal Values

Significance of abnormal results

UreaThis test is ordered

to detect a renal disorder or dehydration

associated with increased BUN

levels.

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

CreatinineThis test was ordered

inorder to evaluaterenal dysfunction.

09-13-08(HI) 1392.9

umol/L

09-17-08(HI) 519.8

umol/L

62-106 umol/L

Results were all above the normal level indicating chronic renal

failure.

Sodium (Na)To evaluate Na balance in the

body.

09-13-08(LO) 136.7

mmol/L

09-17-08138.0 mmol/L

137-145 mmol/L Decreased value indicates

renal failure.

Potassium (K)

To evaluatefluid and

electrolyteimbalance

andidentify

renaldysfunction

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

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

3.50-5.10 mmol/L Decreased levels

(hypokalemia) may indicate renal failure

CBGTo 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 Normal Values Significance of Abnormal Results

Blood Type “A” Rh (+)

WBCDetermines

anyinflammationand infection

09-13-08(HI) 16.3

09-17-08(HI) 12.0

4.5 – 11.0 Results wereall above

normal level.This showspresence of

inflammationand infection

RBCUsed to evaluate

presence of Anemia.

09-13-08(LO) 1.63

09-17-08(LO) 3.03

Female: 4.2-5.4

Male: 4.6-6.2

Result were allbelow the

normal rangethus, showing

anemia andrenal disease

HemoglobinThe Hgb

concentration is a measure of the total amount of

Hgb in the peripheral blood, which reflects the number of RBC in

the blood.

09-13-08(LO) 46

09-17-08(LO) 86

Female: 120-160Male: 135-180




HematocritIt 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) 0.14

09-17-08(LO) 0.26

Female: 0.37-0.47

Male: 0.40-0.54




MCVIndicates the size of RBC: microcytic,

normocytic and macrocytic..

09-13-0881.0

80-96

MCHIndicates the

weight of hemoglobin in

the RBC regardless of

the size

09-13-0828.3

27-31

MCHCIndicates the hemoglobin

concentration per unit volume of

RBC’s.

09-13-0853.1

32-36

RDWIs 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.

09-13-0817.4

11-16

NeutrophilsDeterminants of any

acute bacterial infection.

09-13-08 (HI) 83.0

50-70 It indicates presence of

acute bacterial infection.

EosinophilsTo determine any

allergic reaction of the body

09-13-083.0

0-3

BasophilsTo differentiate

between the various types of WBC’s for diagnosing health

problems.

09-13-080

LymphocytesTo know existence

of any acute bacterial infection in

the body.

09-13-08 (LO) 14.0

9-17-08

29.0

20-45 Results shows that patients has

bacterial infection.

MonocytesDetermines

presence of any chronic bacterial

infection or viral infection.

09-13-080

0-8

PlateletTo check the

platelet count and to monitor the platelet count during cancer chemotherapy.

09-13-08234

150-350

Hepa ProfileThis 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)

Non- reactive Results revealed that

patient has no Hepatitis virus

and was not exposed to

any of it.

Anti- HBs(Hepatitis B

Surface Antibody)

Non- reactive

HCV Negative

UrinalysisTo diagnose and monitor

renal or urinary tract disease.

Macroscopic Result Significance

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

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

Results indicate presence of infection.

Epithelial cells (9-14-08) occasional

(9-16-08) Few

Bacteria (9-14-08) Many

(9-16-08) Many

Results indicate infection.

Fine Granular / ipf (9-16-08) 0-1

Coarse Granular (9-14-08) 0-2

(9-16-08) 0-1

Results may be associated with Acute

Tubular Necrosis.

Fecalysis Name of Examination

Result Significance

Physical

Color Dark Brown

Consistency Formed

Fat Globules Many

Other Test

Occult Blood Negative

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

Indications Contraindications

Adverse Effects

Nursing Responsibilitie

s

Plasil 10 mg IV q 8˚

GIT Regulators, Antiflatulent

s 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.

Prevention of chemotherapy-induced emesis.Facilitation of small bowel intubation in radiographic procedures.Management of esophageal reflux.Treatment of post surgical and diabetic gastric stasis

Hypersensitivity

Possible GI obstruction or hemorrhage

History of seizure disorders

Pheochromocytom

Parkinson’s Disease

CNS:drowsiness,

extrapyramidal reactions, restlessness,

anxiety, depression, irritability

CV:Arrhythmias (supraventric

ular tachycardia, bradycardia), hypertension, hypotension

GI:constipation, diarrhea, dry

mouth, nausea

Assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administrationAssess patient for extrapyramidal side effectsAssess for signs of depression, periodically throughout therapy

Drug Action Mechanism of

Action


Adverse Effects Nursing Responsibiliti

es

Cefuroxime (Profurex)

750 mg IV q 8˚( – 12 mn)

Cephalosporins

Chemical Effect:

Inhibits cell-wall

synthesis, promoting osmotic

instability; usually

bactericidal

Therapeutic Effect:Hinders or

kills susceptible bacteria, including

many gram positive

organisms and enteric

gram negative bacilli.

Pre- & post-op prophylaxis,respiratory tract infectionsEENT infections, UTI, soft tissue infectionsBone & joint infections, O & G infectionPelvic inflammatory diseasesGonorrhea, septicemia, meningitis.

Hypersensitivity to cephalosporins.

Anaphylactic reaction to penicillins

Concurrent treatment w/ potent diuretics

Renal impairmentPregnancy

CNS:Dizziness, headache,

malaise paresthesia

GI:Abdominal

cramps, anal pruritus, anorexia, diarrhea,

dyspepsia, glossitis, nausea, pseudomembran

ous colitis, tenesmus and

vomitingGU:

Genital pruritus and candidiasisHematologic:Eosinophilia,

hemolytic anemia,

thrombocytopenia and transient

neutropeniaRespiratory:

DyspneaSkin:

Masculopapular and

erythematous rashes and

urticaria

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 interactionIf adverse GI reactions occur, monitor patients hydration.



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 UTISevere or complicated UTISevere or complicated InfectionsRespiratory Tract InfectionsFebrile neutropenia

Contraindicated in patients hypersensitive to FluoroquinolonesUsed 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

tremorsCV:

ThrombophlebitisGI:

Crystalluria, interstitial nephritis

Hematologic:Eosinophilia, leucopenia,

neutropenia and thrombocytopeniaMusculoskeletal:

Achiness, arthralgia, joint

inflammation, joint or back pain, joint stiffness, neck or

chest painSkin:

Photosensitivity, rash, Stevens-

Johnson Syndrome

Assess patients infection before therapy and regularly throughoutBefore 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



Adverse Effects Nursing Responsibil

ities

Diazepam 5 mg IV

Anticonvulsants,

AnxiolyticsSkeletal 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 systemTherapeutic

Effect:Relieves

anxiety, muscle spasms and

seizures; promotes

calmness, and sleep.

AnxietyAcute alcohol withdrawalMuscle spasmAdjunct in seizure disordersStatus Epilepticus To control acute repetitive seizure activity in patient’s already taking anticonvulsants

Contraindicated in patients hypersensitive to drugs or any of its components and in those with angle-closure glaucoma, shock, coma or acute alcoholic intoxication.

CNS:Anterograde

amnesia, ataxia, depression,

drowsiness, fainting, hangover, headache, insomnia, lethargy, pain, restlessness, slurred speech and

tremors.CV:

Bradycardia, CV collapse, transient

hypotensionEENT:

Blurred vison, diplopia, nystagmus

GI:Abdominal discomfort,

constipation, nausea and vomiting

GU:Incontinence, urine

retentionRespiratory:Respiratory depression

Skin:Desquamation, rash,

urticaria

Obtain history of patients underlying condition before therapy and re-assess regularlyPeriodically monitor liver, kidney and hematopoietic function.Look for adverse reactions and drug interactions



Adverse Effects

Nursing Responsibili

ties

Zantac 150 mg/tab

1 tab BID()

Antacids, Antireflux Agents &

Antiulcerants

Chemical Effect:

Competitively inhibits

action of H2

at receptor sites of parietal

cells, decreasing gastric acid secretion.

Therapeutic Effect:

Relieves GI discomfort.

Intractable duodenal ulcerDuodenal and gastric ulcerGastroesophageal reflux diseaseErosive esophagitis

Contrandicated in patients hypersensitive to the drug or any of its components.Use cautiously in patients with hepatic dysfunction.

CNS:Vertigo and

malaise

EENT:Blurred vision

Hematologic:

Reversible leucopenia,

pancytopenia,

thrombocytopenia

Hepatic:Jaundice

Assess patient’s GI condition before starting therapy and regularly thereafter to monitor drug’s effectivenessZantac EFFERdose contains phenylalanineBe alert for adverse reactions and drug interactions.



Adverse Effects

Nursing Responsibiliti

es

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.

Angina pectoris due to coronary artery disease.Prevention of chronic anginal attacksHypertension related to surgery; heart failure, linked to MI; angina pectoris in acute situation; to produce controlled hypotensionHypertensive crisis

Contraindicated in patients hypersensitive to nitrates and in those with early MI, severe anemia, increased intracranial pressure,angle-closure glaucoma, orthostatic hypotension and allergy to adhesives.

CNS:Headache, throbbing, dizziness, weakness

CV:Othostatic

hypotension, tachycardia,

flushing, palpitations,

faintingEENT:

Sublingual burning

GI:Nausea and

vomitingSkin:

Cutaneous vasodilation,

contact dermatitis

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.


Indications

Contraindications Adverse Effects Nursing Responsibilities

Hydrocortisone 250

mg IVq 8°

Adrenocortical steroid;Glucocortico

id

Chemical Effect:

Not clearly defined; may

stabilize leukocyte lysosomal

membranes, suppress immune

response, stimulate

bone marrow, and

influence nutrient

metabolism.

Therapeutic Effect:Reduces

inflammation,

suppresses immune

function, and raises

adrenocorticoid hormonal

levels.

Severe inflammation, adrenal insufficiencyAdjunct for ulcerative colitis and proctitisShock

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.

CNS:Euphoria, insomnia, psychotic behavior,

pseudomotor cerebri, seizures

CV:Heart failure, hypertension,

edema, arrhythmias,

thromboembolism

EENT:Cataracts, glaucoma

GI:Peptic ulceration, GI irritation, increased

appetite, pancreatitis

Metabolic:Hypokalemia,

hyperglycemia, carbohydrate intolerance

Musculoskeletal:Muscle weakness,

growth suppression in children,

osteoporosisSkin:

Hirsutism, delayed wound healing,

acne, various skin eruptions, easy

bruising

Assess patient’s condition before starting therapy and regularly thereafterMonitor patient’s weight, blood pressure, and electrolyte levelMonitor patient for stress. Fever, trauma, surgery and emotional problems may increase adrenal insufficiencPeriodically measure growth and development during high-dose or prolonged therapy in infants and children.Be alert for adverse reactions and drug interactions



Adverse Effects

Nursing Responsibilities

Furosemide (Lasix) 20 mg

IVTT

Loop diuretic;

Antihypertensive

Chemical Effect: Inhibits

sodium and chloride

reabsorption at proximal and distal

tubules and ascending

loop of henle.

Therapeutic Effect:Promotes water and

sodium excretion.

-Edema due to cardiac, hepatic & renal disease, burns; mild to moderate HTN-hypertensive crisis-acute heart failure-chronic renal failure-nephrotic syndrome-Hypercalcemia of malignancy

-Hypersensitivit, Cross sensitivity with thiazides and sulfonamides may occur-Pre-existing electrolyte imbalance, hepatic coma, anuria

CNS:Dizziness,

encephalopathy, headache,

insomnia, nervousness

EENT:Hearing loss,

tenitusCV:

HypotensionGI:

Constipation, diarrhea, dry

mouth, dyspepsia,

nausea, vomiting

GU:excessive urination

Skin:Photosensitivity

, rashesEndocrine:

Hyperglycemia

Assess fluid status during therapy

Monitor blood pressure and pulse before and during administration

Assess patient for tenitus and hearing loss

Assess for allergies to sulfonamides

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 administration of the drug



Adverse Effects


Renogen 2000u SQ

Antianemics

Chemical Effect:

Stimulates erythropoi

esis (production

of RBC)

Therapeutic Effect:Maintains and may elevate RBCs,

decreasing the need

for transfusion

s.

-Treatment of anemia associated w/ chronic renal failure (CRF).-Reduction of allogenic blood transfusion in surgery patients.

-Uncontrolled HTN.-Hypersensitivity to mammalian cell-derived products or to human albumin.

CNS:Seizures, headach

e

CV:Hyperten

sion, thrombotic events (hemodi

alysis patients)

Skin:Transient rshes

Endocrine:

Restored fertility, resumpti

on of menses

-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



Adverse Effects


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 heat-regulating

center.

Therapeutic Effect:

Relives pain or fever

Fever, Headache, Muscular aches and

pain

- Previous hypersensitivity products containing alcohol, aspartame, saccharine sugar, or tartrazine, should be avoided in patients who have hypersensitivity or intolerance to this compounds.

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 administration of the drug



Adverse Effects


Zinnat 500 mg

1 tab BID

Cephalosporins

Chemical Effect:Bind to

bacterial cell wall

membrane, causing cell death

Therapeutic

Effect:Bactericidal action

-Lower & upper resp tract infections-GUT infections, skin & soft tissue infections-gonorrhea including acute uncomplicated gonococcal urethritis & cervicitis.

-Hypersensitivity to cephalosporins.-Hypersensitivity to penicillins.-Pseudomembranous colitis.-Diabetics & phenylketonurics.

CNS:Seizures

(high doses)

GI:pseudomembranous 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 cephalosporins

Obtain specimens for culture and sensitivity before initiating therapy



Adverse Effects


es

Senokot 2 tab after

lunch

Laxatives Chemical Effect:Active

components of senna, alter water

and electrolyte transport in

the large intestine,

resulting in accumulation of water

and increased peristalsis

Therapeutic Effect:Laxative action

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

–Acute surgical abdomen, abdominal pain, nausea, vomiting or symptoms of appendicitis; intestinal hemorrhage or obstruction, persistent diarrhea.–Rectal fissures–Ulcerated hemmoroids

GI:Cramping, diarrhea, nausea

GU:Pink-red or

brown-black discoloration of urine.

Mild abdominal discomfort; diarrhea w/ excessive

loss of water &

electrolytes

Assess patient for abdominal distention, presence of bowel sounds and usual pattern of bowel function.

Assess color, consistency and amount of stool produced.



Adverse Effects


es

Na HCO 3 650 mg

1 tab, TID

Anti-Ulcer

agents

Chemical Effect:

Acts as an alkalinzing agent by releasing

bicarbonate ions.

Therapeutic Effects:

Neutralization of gastric

acids.

Antacid Use to

alkalinized urine and promote excretion of certain drugs and over dosage of situations

Hypocalcemia

Excessive chloride loss

ingestion of strong mineral acids

severe abdominal pain

CV:Edema

GI:Flatulence,

gastric distention,

Neuro:Tetany

Fluid and Electrolytes

:Hypokalemia, sodium and

water retention

Assess fluid balance (intake and output), Edema

Report of symptoms of fluid overload if they occur

Assess patient for epigastric or abdominal pain

Monitor urine pH frequently when used for urinary alkalinization

Drug Action Mechanism of action

Indication Side effects Contraindication

Nursing responsibilities

Combivent

Bronchodilators

Relaxes bronchial, uterine,

and vascular smooth muscle

by stimulating beta2 receptors

To prevent or threat bronchospasm in patients with reversible obstructive airway disease

CNStremor, nervousness, dizziness, insomnia,

headache, hyperactivity,

weakness, CNS stimulation, malaise.

CVtachycardia, palpitation,

hypertension.

EENTdry and irritated nose

and throat with inhaled form, nasal

congestion, epistaxis, hoarseness.

GIheartburn, nausea,

anorexia, altered taste, increased appetite.

Metabolic- hypokalemia.

Musculuskeletal- muscle cramps.

Respiratory- bronchospasm, cough,

wheezing, dyspnea, bronchitis, increase

sputum.

Patient with hypersensitivity to the drug or its ingredients.Use cotiusly in patients with cardiovascular disorders(including coronary insufficiency and hypertension), hypertyroidism or DM and those who are unusually responsive to adrenergies.

Drug 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 kidneysIn increased blood pressure → more urine outputIn decreased blood pressure → less urine output and release of renin

STAGE I

STAGE II

STAGE III

STAGE IV

DEATH

S/S in the TextbookS/Sx Manifested by

the PatientNEUROLOGIC

Weakness Confusion Inability to

concentrate

Disorientation Tremors Seizures Asterixis Restlessness of

legs Burning of soles

of feet Behavior Changes

S/S in the Textbook

S/Sx Manifested by the Patient

INTEGUMENTARY Gray-bronze

skin color

Dry, flaky skin Pruritus Ecchymosis Purpura Thin, brittle

nails Coarse,

thinning hair

S/S in the TextbookS/Sx Manifested by the

PatientCARDIOVASCULAR

Hypertension Edema (face, hands,

feet)

Periorbital edema Pericardial friction

rub Engorged neck veins Pericarditis Pericardial effusion Pericardial

tamponade Hyperkalemia Hyperlipidemia


the PatientPULMONARY

Crackles Thick, tenacious

sputum Depressed cough

reflex Pleuritic pain Shortness of breath Tachypnea Kussmaul-type

respirations Uremia pneumonitis


the PatientGASTROINTESTINAL

Ammonia odor to breath (uremic fector)

Metallic taste Mouth ulcerations

and bleeding Nausea, and

vomiting Anorexia Hiccups Constipation Diarrhea Bleeding from

gastrointestinal tract

S/S in the TextbookS/Sx Manifested by the

PatientHEMATOLOGIC

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 RATIONALE EVALUATION

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

Impaired gas exchange related to

altered oxygen

carrying- capacity 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:1.Administer Oxygen at 4 lpm via nasal cannula as ordered.2.Administer medication as indicated:Combivent 1 neb (6am – 2pm – 10pm)

Renogen 2000u SQ1.Monitor ABG as ordered.Independent:1.Monitor GCS q°. 2.Position patient in a semi-fowler’s position with upright posture at 45°.3.Encourage adequate rest and limit activities to within patient’s tolerance. Promote calm environment.

-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.

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.


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 = 0.14Urinalysis 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:1.Administer medication as prescribed: Furosemide (Lasix) 20 mg IVTT.Independent:1.Monitor intake and output q°. 2.Observe for changes in mental status, behavior or LOC. Monitor GCS q°.3.Assess for the present edema and for new edema.4.Assess characteristics and amount of urine (note for presence of blood and decrease urine output).

-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.

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 RATIONALE EVALUATION

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 ccO = 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

compromised

regulatory mechanism

After 8˚, patient will display

normal urine output of 30

cc/hr and normalization of the laboratory

values.

Dependent1.Administer furosemide 20 mg IVTT OD as ordered.2.Limit fluid intake for 1 L/day as ordered.3.Insert foley catheter as indicated4.Prepare for dialysis as indicated5.Monitor sodium as prescribed6.Monitor K as prescribedIndependent1.Monitor I&O every hr and decreasing urine output in relation to fluid intake2.Monitor for the development of condition. Increase the client’s risk for excess fluid volume3.Explain the patient and so the rationale for fluid restriction

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 overloadThis 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 sodiumLack of renal excretion and selective retention of K to excrete excess hydrogen ions leads to hyperkalemiaAccurately measuring I&O is very important for determining renal function, fluid replacement needs, and reducing risk of fluid overloadsRenal failure result in decreased glomerular filtration rate and fluid retentionUnderstanding promotes patient and family cooperation with fluid restrictionMeasures 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


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 = 0.14ABG 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:1.Administer medication as prescribed by the physician: Renogen 2000u SQ1.Administer O2 at 4 lpm via nasal cannula as ordered.Independent:1.Note patient’s reports of weakness, fatigue, pain and difficulty in accomplishing task.2.Monitor v/s and GCS q° and assess for the adverse effect of the medication.3.Encourage the patient to move extremities and other body parts up to what she could tolerate.4.Promote comfort measures.5.Encourage complete bed rest.6.Assist patient in doing certain activities and give her enough time to accomplish certain activity.

-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.

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


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

Infection related to invasion of pathogens

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:1.Monitor renal function by checking for the creatinine and urea level.2.Administer medication as prescribed for her infection:CefuroximeProfurex) 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.

-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.

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.

09-16-08WBC/hpf = 40-50Bacteria = Many

09-17-08WBC = 12.0

Lymphocyte = 29.0


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

Dependent1.Administer medication as indicated:Paracetamol 300 mg IV q4° PRN for Temp. > 37.8°C.

2.Administer D5 NSS 1L

x 40 cc/˚ as ordered.Independent1.Provide tepid sponge bath.2.Monitor body temperature q 30 min. until it decreases to normal range of 36.5 – 37.5°C.3.Make the patient comfortable and divert its attention.4.Promote complete bed rest.

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.

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.


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.

Dependent1.Administer medication as prescribed: Senokot 2 tab after lunch OD.

Independent1. Encourage patient to be

engage in activities within her capacity

1.Ascertain usual dietary pattern of food choices2.Suggest adding fresh fruits, vegetables and fiber to diet when indicated within restriction3.Provide privacy and bedside commode

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 problemProvide bulk foods, which improves stool consistencyPromote psychologic comfort needed for

elimination

Goal partially met. 24 hours

after the administration of Senokot, patient was

able to defecate.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSubjective “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.

Independent1.Determine patients ability to participate in self-care activities.2.Provide assistance with activities as necessary.3.Recommend scheduling of activities to allow patient sufficient time to accomplish tasks to fullest extent of ability.4.Explain to the patient the importance of proper hygiene.5.Do a bed bath every morning and sponge bath before sleeping and teach the folks how to do proper bed bathing.6.Perform oral hygiene to the patient and teach her ways to do it on her own.

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 self-esteemFor 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.

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.

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