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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
Result were allbelow the
normal rangethus, showing
anemia andrenal disease
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
Result were allbelow the
normal rangethus, showing
anemia andrenal disease
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
Indications Contraindications
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.
Drug Action Mechanism of Action
Indications Contraindications
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
Drug Action Mechanism of Action
Indications Contraindications
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
Drug Action Mechanism of Action
Indications Contraindications
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.
Drug Action Mechanism of Action
Indications Contraindications
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.
Drug Action Mechanism of Action
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
Drug Action Mechanism of Action
Indications Contraindications
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
Drug Action Mechanism of Action
Indications Contraindications
Adverse Effects
Nursing Responsibilities
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
Drug Action Mechanism of Action
Indications Contraindications
Adverse Effects
Nursing Responsibilities
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
Drug Action Mechanism of Action
Indications Contraindications
Adverse Effects
Nursing Responsibilities
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
Drug Action Mechanism of Action
Indications Contraindications
Adverse Effects
Nursing Responsibiliti
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.
Drug Action Mechanism of Action
Indications Contraindications
Adverse Effects
Nursing Responsibiliti
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
S/S in the TextbookS/Sx Manifested by
the PatientPULMONARY
Crackles Thick, tenacious
sputum Depressed cough
reflex Pleuritic pain Shortness of breath Tachypnea Kussmaul-type
respirations Uremia pneumonitis
S/S in the TextbookS/Sx Manifested by
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.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
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.