I.

INTRODUCTION
The millennium paved way for a fast paced life coupled with oodles of unhealthy habits and lifestyles. Fast food chains sprouted from the streets like crazy and became the source of staple food for a lot of the working class. Economies of vices like cigarettes smoking and drinking were at their peak and are at their highest. Parallel to the rampant shift of trends accompanied the rise of modifiable lifestyle diseases like hypertension, diabetes mellitus and kidney failure. According to the Department of Health, from year 2001-2005, an average of 69,741 out of 100,000 population suffer from diseases of the heart and in 2006 there was an increase to 83, 081. On the other hand, Diabetes Mellitus covered a rate of 18.5 % on average in the year 2001-2005 and after a year it increased to 23.3 %. Chronic kidney disease (CKD) is an important source of long-term morbidity and mortality. It has been estimated that CKD affects more than 20 million people in the United States. Given that most patients are asymptomatic until the disease has significantly progressed, they remain unaware of the condition. Renal failure is the ninth leading cause of death among Filipinos according to the survey conducted by the Philippine Information Agency dated June 4, 2012. In addition, the Philippine Renal Disease Registry as disclosed by Estela Ilagan, Nurse Coordinator of the Department of Health (DOH) in Region XII said that 1 Filipino develops Chronic Renal Failure every hour or about 120 Filipinos per million populations per year. More than 5,000 Filipino patients are presently undergoing dialysis. CKD is a worldwide public health problem. It is recognized as a common condition that is associated with an increased risk of cardiovascular disease and chronic renal failure (CRF). In the United States, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. On the other hand, in the country, the National Kidney and Transplant Institute (NKTI) Executive Director, Dr. Aileen Reigo-Javier said based on the Philippine Renal Disease Registry (PRDR), the top causes of kidney failure in the country is
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diabetes (44.6%), followed by the high blood pressure (23%) and inflammation of the kidneys (19.3%).

Chronic kidney disease, also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease.

All individuals with a glomerular filtration rate of less than 60 mL/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. The rationale for including these individuals is that reduction in kidney function to this level or lower represents loss of half or more of the adult level of normal kidney function, which may be associated with a number of complications.

CKD is classified into five stages. Stage I is the mildest, usually causing few symptoms like slightly diminished function; kidney damage with normal or relatively high GFR of 90 mL/min/1.73 m2. On the other hand, stage 5 is established kidney failure of GFR <15 mL/min/1.73 m2 and permanent renal replacement therapy. (Kidney Disease Outcome Quality Initiative, 2009) Stage V is also referred to as established CKD, also called EndStage Renal Disease (ESRD), Chronic Kidney Failure and Chronic Renal Failure. The prevalence of kidney disease has been an increasing trend, especially the End-Stage Renal Disease as reported in the Philippine Renal Disease Registry. As aforementioned in the above paragraphs, Diabetes and Hypertension individually aggravates the risk of developing chronic kidney disease. But in the case of patient EVG, she possesses both the co-morbidity thereby increasing her risk two-folds. As critical care nurses, our interest rocketed and our desire to understand and explore this scenario jolted us to choose the case of the patient.

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A. GENERAL OBJECTIVES This case presentation aims to identify and determine the general and specific health problems and needs of the patient with an admitting diagnosis of Chronic Kidney Disease secondary to Diabetic Nephropathy and Hypertensive Nephrosclerosis.. This presentation also intends to help patient promote health and medical understanding of such condition through the application of the nursing skills.

B. SPECIFIC OBJECTIVES

To be able to identify causes and risk factors in developing end-stage

renal disease as well as the relationship of co-morbidities with its prevalence To be able to understand the pathophysiology of Chronic Kidney

Disease according to the patients pattern To be able to provide sufficient and innermost information to patient as

well as their families regarding the course of management of Chronic Kidney Disease with regards to medical and surgical management that would further improve compliance

To be able to identify specific nursing interventions that will help the

patient cope up with Chronic Kidney Disease and improve long term patient outcomes.

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II. SIGNIFICANCE OF THE

STUDY

The focus of our case study is the chronic kidney disease. Thorough study of the disease makes us aware and familiar with its course, recovery and interdisciplinary care for the patient. The prevalence of kidney/renal diseases have been in an increasing trend, especially the end-stage renal disease , just as Dr. Aileen Riego-Javier said about 120 Filipinos per million population develop kidney failure. This implies that an estimated 10, 000 Filipinos need to replace their kidney function each year. Only around 86 percent, however, could undergo dialysis, while about 14% could afford transplantation, because these treatments are quite expensive. Moreover, everyone must look out for the warning signs of chronic kidney diseases. And abnormality in kidney function often serves as early warning sign of potentially more serious problem, providing both doctor and patient with an excellent window of opportunity to address such problems before they worsen. If detected early, kidney disease can be treated, thereby reducing other complications. To reverse the trend, we would like to urge the public to observe healthy lifestyle. With the rising number of CKD patients related to hypertension, diabetes mellitus and the like. We as critical care nurses should be able to equip ourselves with adequate knowledge about the disease itself, its progression and the flow of management. Continuous upgrading of information equips us to be able to provide high quality patient care that would help our patient attain the highest possible level of wellness. We could not just be instruments of cure but through the knowledge that we could gain through this paper, we will be able to be soldiers of protection to halt the threat of diseases which could easily be modified and prevented.

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III. ANATOMY & PHYSIOLOGY

Urinary system works through its organs, like the kidneys, ureters, bladder and urethra, to eliminate waste products from the body in the form of urine. Learn more about its vital function. The urinary system, also known as the excretory system, is concerned with the removal of water-soluble waste products from the body in the form of urine. The various components or organs of the urinary system are associated with the production, storage, and then expulsion of urine from the body. At the same time, the system also takes part in several vital functions of the body. The main components of the urinary system are two kidneys, two ureters, a urinary bladder, two sphincter muscles and the urethra. Each of these organs performs some specific functions, associated with the elimination of waste products generated within our body, during the metabolic processes. The kidneys are bean-shaped organ and are located just below the rib cage, near the middle of the back, while the ureters are two narrow tubes. On
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the other hand, bladder is a triangular hollow organ, located in the lower abdominal region. The urethra is a tube like structure that carry urine from the bladder for expulsion. The basic functions are removal of waste products from the body in the form of urine. Each part of the system is concerned with some specific functions. The kidneys are concerned with elimination of the urea from the bloodstream. Urea is the waste product generated during protein metabolism. Generally, all the nutrients present in our food are absorbed by the body to perform the vital functions, while the waste products are left behind either in the blood or the bowel. Urinary system collects the waste products from the bloodstream with the help of the kidneys. Kidneys while eliminating wastes from the blood, helps to maintain the blood volume, and thereby regulate blood pressure. In addition to this, kidneys secrete an enzyme, known as renin that is associated with the regulation of blood pressure. Kidneys also secrete a hormone, erythropoietin, which can activate the production of red blood cells. So, kidneys or the urinary system eliminates urea from the blood, combine it with water and other waste products (ammonia, creatinine and bilirubin) to form urine, promote red blood cell production, regulates blood pressure, blood volume and blood pH, and takes part in the synthesis of vitamin D. Kidneys are also associated with maintaining the ionic composition of blood, by regulating the quantities of sodium, calcium, potassium and chloride ions. The urine formed in both the kidney is carried to the bladder by two narrow tubes, known as ureters. Ureters prevent the back flow of urine during urination, when the bladder contracts to pass urine to the urethra. If this function of the ureters is impaired, then diseases like, cyctitis and kidney infection may occur. The urinary bladder is a triangular hollow organ, which stores urine, until it is expelled from the body. It is located in the lower abdomen region, and it has the ability to expand for storing urine and then, contract to expel it. Urine is expelled though the urethra, which is a tube like structure. The sphincter muscles are circular muscles that play an important role in keeping the urine within the bladder. In other words, they prevent the leakage of urine, by closing tightly around the opening of the bladder. The nerves present in the bladder controls the process of urination or micturition. When the bladder is full and it is time urinate, the nerves of the bladder transmit this information to the brain. The brain then, signals the bladder muscles to contract and sphincter muscles to relax, so as to facilitate urination.
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Excretion of nitrogenous waste products is the main function of the urinary system, which, if not eliminated from body can become toxic, and cause the death of an individual. Along with this crucial function, maintenance of the volume of blood, blood pressure and blood pH, and stimulating the synthesis of red blood cells and vitamin D are its other functions. It functions in proper coordination with other organ systems, like the skin, lungs and intestine to excrete all types of waste products generated while carrying out the vital life processes. Any kind of injury or damage to any part of the urinary system can impair the whole process of excretion, leading to accumulation of toxic substances, and giving rise to a number of health problems. A. FUNCTIONS EXCRETION OF WASTES The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes called "urea", from protein catabolism, as well as uric acid, from nucleic acid-metabolism. Formation of urine is also the function of the kidney. The concentration of nitrogenous wastes in the urine of mammals and some birds is dependent on an elaborate countercurrent multiplication system. This requires several independent nephron characteristics to operate: a tight hair pin configuration of the tubules, water and ion permeability in the descending limb of the loop, water impermeability in the ascending loop and active ion transport out of most of the ascending loop. In addition, countercurrent exchange by the vessels carrying the blood supply to the nephron is essential for enabling this function. ACID-BASE HOMEOSTASIS Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the maintenance of pH around a relatively stable value. The lungs contribute to acid-base homeostasis by regulating carbon dioxide (CO2) concentration. The kidneys have two very important roles in maintaining the acid-base balance: to reabsorb bicarbonate from urine, and to excrete hydrogen ions into urine

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OSMOLALITY REGULATION Any significant rise in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels. ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane, allowing water to leave the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the body. There are two systems that create a hyper osmotic medulla and thus increase the body plasma volume: Urea recycling and the 'single effect.' Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyper osmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not. The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not permeable to water but is permeable to NaCl. This allows for a countercurrent exchange system whereby the medulla becomes increasingly concentrated, but at the same time setting up an osmotic gradient for water to follow should the aquaporins of the collecting duct be opened by ADH. BLOOD PRESSURE REGULATION & RENIN-ANGIOTENSIN SYSTEM Although the kidney cannot directly sense blood, long-term regulation of blood pressure predominantly depends upon the kidney. This primarily occurs through maintenance of the extracellular fluid compartment, the size of which depends on the plasma sodium concentration. Renin is the first in a series of important chemical messengers that make up the renin-angiotensin system. Changes in renin ultimately alter the
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output of this system, principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both increase the kidney's

absorption of sodium chloride, thereby expanding the extracellular fluid compartment and raising blood pressure. When renin levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption, expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely, when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid compartment, and decreasing blood pressure.

HORMONE SECRETION The kidneys secrete

variety

of hormones, including erythropoietin, and the enzyme renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the renal reabsorption of phosphate. Part
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of the renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of aldosterone levels. B. PARTS AND THEIR FUNCTIONS
I.

RENAL VEIN

The renal veins are veins that drain the kidney. They connect the kidney to the inferior vena cava. Because the inferior vena cava is on the right half of the body, the left renal vein is generally the longer of the two. Unlike the right renal vein, the left renal vein often receives the left gonadal vein (left testicular vein in males, left ovarian vein in females). It frequently receives the left suprarenal vein as well.
II.

RENAL ARTERY

The renal arteries normally arise off the abdominal aorta and supply the kidneys with blood. The arterial supply of the kidneys is variable and there may be one or more renal arteries supplying each kidney. Due to the position of the aorta, the inferior vena cava and the kidneys in the body, the right renal artery is normally longer than the left renal artery. The right renal artery normally crosses posterior to the inferior vena cava. The renal arteries carry a large portion of the total blood flow to the kidneys. Up to a third of the total cardiac output can pass through the renal arteries to be filtered by the kidneys.
III.

URETERS

The ureters are two tubes that drain urine from the kidneys to the bladder. Each ureter is a muscular tube about 10 inches (25 cm) long. Muscles in the walls of the ureters send the urine in small spurts into the bladder, (a collapsible sac found on the forward part of the cavity of the bony pelvis that allows temporary storage of urine). After the urine enters the bladder from the ureters, small folds in the bladder mucosa act like valves preventing backward flow of the urine. The outlet of the bladder is controlled by a sphincter muscle. A full
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bladder stimulates sensory nerves in the bladder wall that relax the sphincter and allow release of the urine. However, relaxation of the sphincter is also in part a learned response under voluntary control. The released urine enters the urethra.
IV .

URINARY BLADDER The

urinary bladder is hollow, muscular distensible elastic organ that

a and or sits

on the pelvic floor (superior to the prostate in males). On its anterior border lies the pubic symphysis and, on its posterior border, the vagina (in females) and rectum (in males). The urinary bladder can hold approximately 17 to 18 ounces (500 to 530 ml) of urine; however the desire to micturate is usually experienced when it contains about 150 to 200 ml. When the bladder fills with urine (about half full), stretch receptors send nerve impulses to the spinal cord, which then sends a reflex nerve impulse back to the sphincter (muscular valve) at the neck of the bladder, causing it to relax and allow the flow of urine into the urethra. The Internal urethral sphincter is involuntary. The ureters enter the bladder diagonally from its dorsolateral floor in an area called the trigone. The trigone is a triangular shaped area on the postero-inferior wall of the bladder. The urethra exits at the lowest point of the triangle of the trigone. The urine in the bladder also helps regulate body temperature. A bladder when operating normally empties completely upon a complete discharge, otherwise it is a sign that its elasticity is compromised, when it becomes completely void of fluid, it may cause a chilling sensation due to the rapid change of body temperature.
V.

URETHRA

The urethra is a muscular tube that connects the bladder with the outside of the body. The function of the urethra is to remove urine from the body. It measures about 1.5 inches (3.8 cm) in a
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woman but up to 8 inches (20 cm) in a man. Because the urethra is so much shorter in a woman it makes it much easier for a woman to get harmful bacteria in her bladder this is commonly called a bladder infection or a UTI. The most common bacteria of a UTI is E-coli from the large intestines that have been excreted in fecal matter. In the human female, the urethra is about 1-2 inches long and opens in the vulva between the clitoris and the vaginal opening. Men have a longer urethra than women. This means that women tend to be more susceptible to infections of the bladder (cystitis) and the urinary tract. In the human male, the urethra is about 8 inches long and opens at the end of the head of the penis. The length of a male's urethra, and the fact it contains a number of bends, makes catheterization more difficult. C. KIDNEYS
AND

THEIR STRUCTURE

The kidneys are a pair of bean shaped, brown organs about the size of your fist. It measures 10-12 cm long. They are covered by the renal capsule, which is a tough capsule of fibrous connective tissue. Adhering to the surface of each kidney is two layers of fat to help cushion them. There is a concaved side of the kidney that has a depression where a renal artery enters, and a renal vein and a ureter exit the kidney. The kidneys are located at the rear wall of the abdominal cavity just above the waistline, and are protected by the ribcage. They are considered retroperitoneal, which means they lie behind the peritoneum. There are three major regions of the kidney, renal cortex, renal medulla and the renal pelvis. The outer, granulated layer is the renal cortex. The cortex stretches down in between a radially striated inner layer. The inner radially striated layer is the renal medulla. This contains pyramid shaped tissue called the renal pyramids, separated by renal columns. The ureters are continuous with the renal pelvis and are the very center of the kidney.

I.

RENAL CORTEX
The renal cortex is part of the

kidneys containing mostly nephrons and blood vessels. Its function is to

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filter the blood and remove waste products inside the body. Nephrons are the basic functional units of the kidneys, with each kidney having one million or more of these important structures. In each nephron there is a glomerulus and a renal tubule, which is divided into sections. The renal tubule is a long tube that winds through both the renal cortex and the renal medulla, a number of triangle-shaped structures in the kidney.
II .

RENAL MEDULLA
Renal medulla is the innermost

part of the kidney. The renal medulla is split up into a number of sections, known as the renal pyramids. Blood enters into the kidney via the renal artery, which then splits up to form the arcuate arterioles. The arcuate arterioles each in turn branch into interlobular arterioles, which finally reach the glomeruli. At the glomerulus the blood reaches a highly unfavorable pressure gradient and a large exchange surface area, which forces the serum portion of the blood out of the vessel into the renal tubules. Flow continues through the renal tubules, including the proximal tubule, the Loop of Henle, through the distal tubule and finally leaves the kidney by means of the collecting duct, leading to the renal ureter. The renal medulla contains the structures of the nephrons responsible for maintaining the salt and water balance of the blood. These structures include the vasa rectae (both spuria and vera), the venulae rectae, the medullary capillary plexus, the loop of Henle, and the collecting tubule.[1] The renal medulla is hypertonic to the filtrate in the nephron and aids in the reabsorption of water. The portion of blood that is passed through the glomerulus is the plasma, not serum. Blood is filtered in the glomerulus, and is not a selective process. Ions such as sodium, chloride, potassium, and calcium are easily filtered, as is glucose, because filtration is based on size.
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Proteins are not passed through the glomerular filter because of their large size, and do not appear in the filtrate or urine unless a disease process has affected the glomerular capsule or the proximal and distal tubules of the nephron
III .

RENAL CAPSULE
The renal capsule is a tough fibrous layer surrounding the kidney and

covered in a thick layer of perinephric adipose tissue. It provides some protection from trauma and damage.
IV.

MINOR CALYX
The minor calyx, in the kidney, surrounds the of the renal pyramids. Urine formed in

apex

the kidney passes through a papilla at the apex into the minor calyx then into the major calyx. Peristalsis of the smooth muscle originating in pace-maker cells originating in the walls of the calyces propels urine through the renal pelvis and ureters to the bladder.
V.

MAJOR CALYX
Two or three minor calyces converge to form

a major calyx. The major calyx, in the kidney, surrounds the apex of the renal pyramids. Urine formed in the kidney passes through a renal papilla at the apex into a minor calyx then into major calyx before passing through the renal pelvis into the ureter. Peristalsis of the smooth muscle originating in pace-maker cells originating in the walls of the calyces propels urine through the renal pelvis and ureters to the bladder
VI.

RENAL COLUMN
The renal column is a medullary extension of the renal cortex in

between the renal pyramids. It allows the cortex to be better anchored. Each column consists of lines of blood vessels and urinary tubes and a fibrous material.
VII.

RENAL PYRAMIDS
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Renal pyramids are kidney tissues that are shaped like cones. Another term for renal pyramids is malpighian pyramids. Between seven and eighteen pyramids exist in the innermost part of the kidney, which is called the renal medulla; in humans, there are usually only seven of the pyramids. The base of each pyramid faces the outer portion of the kidney, which is called the renal cortex. The renal cortex is located between the renal medulla and the renal capsule. The renal capsule is defined as the layer that surrounds the kidneys with tough fibrous. The capsule is covered in perinephric adipose tissue. Renal pyramids appear as though they are striped because they are situated in segments of parallel nephrons. The nephron is the basic functional and structural unit of the kidney that filters the blood that regulates water concentration and soluble substances such as sodium salts. After filtering, what is needed is reabsorbed and the rest is excreted as waste or urine. Once the waste is eliminated, the blood pressure and volume are regulated.

D. NEPHRON FUNCTIONAL UNIT OF THE KIDNEYS

The nephron is the tiny filtering structure in your kidneys. Each of your kidneys contain more than a million tiny filtering nephrons that help clean your blood.

Remove excess water, wastes and other substances from your blood. Return substances like sodium, potassium or phosphorus whenever any of these substances run low in your body. Each nephron is composed of two main structures: the glomerulus and renal

(kidney) tubule.

I. BOWMANS CAPSULE The Bowman's Capsule is part of a Nephron, which would be found in the Kidney. Its function is to collect the filtrate from the Glomerulus, passing it on to the Proximal Convoluted Tubules (PCT's), subsequently, to the rest of the Nephron
II .

GLOMERULUS
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In the kidney, a tubular structure called the nephron filters blood to form urine. At the beginning of the nephron, the glomerulus is a network (tuft) of capillaries that performs the first step of filtering blood. The glomerulus is surrounded by Bowman's capsule. The blood is filtered through the capillaries of the glomerulus into the Bowman's capsule. The Bowman's capsule empties the filtrate into a tubule that is also part of the nephron. A glomerulus receives its blood supply from an afferent arteriole of the renal circulation. Unlike most other capillary beds, the glomerulus drains into an efferent arteriole rather than a venule. The resistance of these arterioles results in high pressure within the glomerulus, aiding the process of ultrafiltration, where fluids and soluble materials in the blood are forced out of the capillaries and into Bowman's capsule. A glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic filtration unit of the kidney. The rate, at which blood is filtered through all of the glomeruli, and thus the measure of the overall renal function, is the glomerular filtration rate (GFR).
III .

AFFERENT ARTERIOLE
In the majority of the body all arterioles

are afferent as they take blood to the organs they supply. However the true afferent arterioles are only found in the functional unit of the kidney called the nephron. At the very start of the nephron is a bundle of capillaries that allows diffusion of the majority of the plasma and contents to diffuse out into another structure called the Bowmans capsule. From the Bowmans capsule the liquid travels through the nephron and any substances that the body still wants to keep diffuse back into the blood. The arteriole that carries blood to the glomerulus is the afferent arteriole and the arteriole that recollects the useful parts comes from the glomerulus and so is called the efferent arteriole.

IV. EFFERENT ARTERIOLE

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The arteriole that recollects the useful parts comes from the glomerulus and so is called the efferent arteriole. The efferent arteriole carries blood away from the glomerulus. Because it has a smaller diameter than the afferent arteriole, it creates some resistance to blood flow, producing the back-up of blood in the glomerulus which creates higher pressure in the glomerular cavity.
V.

PROXIMAL TUBULE
Hydrogen carbonate from the and

water nutrients and potassium are blood reabsorbed while proximal tubule back into the hydrogen ammonia are secreted from the blood into the proximal tubule The proximal tubule as a part of the nephron can be divided into an initial convoluted portion and a following straight (descending) portion. Fluid in the filtrate entering the proximal convoluted tubule is reabsorbed into the peritubular capillaries, including approximately two-thirds of the filtered salt and water and all filtered organic solutes (primarily glucose and amino acids).

VI.

DISTAL TUBULE
reabsorbs Na+ ions through coupled secretion of H+ or K+ ions into the tubular fluid, a process which requires the presence of the adrenal hormone aldosterone. By acidifying the urine the distal convoluted tubule plays an important role in acid-base balance.

normally is relatively impermeable to water. However in the presence of antidiuretic hormone (ADH) its permeability to water increases permitting concentration of the urine.

secretes ammonium ions and some drugs

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forms part of the juxtaglomerular apparatus. The distal convoluted tubule has a different structure and function to

that of the proximal convoluted tubule. Cells lining the tubule have numerous mitochondria to produce enough energy (ATP) for active transport to take place. Much of the ion transport taking place in the distal convoluted tubule is regulated by the endocrine system. In the presence of parathyroid hormone, the distal convoluted tubule reabsorbs more calcium and excretes more phosphate. When aldosterone is present, more sodium is reabsorbed and more potassium excreted. Atrial natriuretic peptide causes the distal convoluted tubule to excrete more sodium. In addition, the tubule also secernates hydrogen and ammonium to regulate pH.
VII .

THE JUXTAGLOMERULAR APPARATUS

It is important in

the control of systemic blood pressure and volume. Juxtaglomerular cells which are modified smooth muscle cells in the walls of the afferent arteriole that sense changes in blood pressure and secrete the enzyme renin. The macula densa, a region of the distal tubule that associates with the glomerulus as it loops back into the cortex. The cells at the side of the distal tubule closest to glomerulus become taller, more densely packed and possess prominent nuclei. The cells of the macula densa are thought to be able to detect Na+ concentration changes in the distal tubule and relay this information to juxtaglomerular cells. Extraglomerular mesangial cells (lacis cells) which support the complex.
VIII .

LOOP OF HENLE The main function of this structure is to The loop of Henle, also called the
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create a concentration gradient in the medulla of the kidney.

nephron loop, is a U-shaped tube that extends from the proximal tubule. It consists of a descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal straight tubule, extends into the medulla as the descending limb, and then returns to the cortex as the ascending limb to empty into the distal convoluted tubule. The primary role of the loop of Henle is to concentrate the salt in the interstitium, the tissue surrounding the loop. Considerable differences distinguish the descending and ascending limbs of the loop of Henle. The descending limb is permeable to water but completely impermeable to salt, and thus only indirectly contributes to the concentration of the interstitium. As the filtrate descends deeper into the hypertonic interstitium of the renal medulla, water flows freely out of the descending limb by osmosis until the tonicity of the filtrate and interstitium equilibrate. Longer descending limbs allow more time for water to flow out of the filtrate, so longer limbs make the filtrate more hypertonic than shorter limbs. Unlike the descending limb, the ascending limb of Henle's loop is impermeable to water, a critical feature of the countercurrent exchange mechanism employed by the loop. The ascending limb actively pumps sodium out of the filtrate, generating the hypertonic interstitium that drives countercurrent exchange. In passing through the ascending limb, the filtrate grows hypotonic since it has lost much of its sodium content.

III. BIOGRAPHIC DATA

Patient ID Number: 01-01-77-71

Admission Number: IP000177828 Patient Name: Address: Birthday: Age: EVG Hilario Street, Poblacion, Bustos, Bulacan Bulacan 3017 December 27, 1946 65 years old
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Marital Status: Religion: Occupation:

Married Christian None

The patient was admitted in the Medical Intensive Care Unit on September 26, 2012. During our exposure last October 11 to 12, 2012 the group decided to take the case of EVG. The source of our data is the patient herself as well as her husband who is both very cooperative and we had also incorporated pieces of information coming from the patients chart.

IV. NURSING HISTORY

A. CHIEF COMPLAINT:
Difficulty of Breathing

B. HISTORY OF PRESENT ILLNESS:

The patient experienced shortness of breath with exertion 3 days prior to admission. Patient had easy fatigability. No chest pain or discomfort felt. On the day of admission, patient had difficulty of breathing, no chest pain. Persistence of symptoms prompted consult at emergency room, hence this admission. Patient was in respiratory distress upon arrival at emergency room with oxygen saturation of 72 %, elevated BP of 189/90 as well as high CBG of 358 mg/dL and was immediately intubated. At the emergency room, the patient had an episode of pulseless electrical activity and underwent cardio-pulmonary resuscitation, thus admitted.

C. PAST MEDICAL HISTORY:

It was 1996 when the patient was diagnosed of Diabetes Mellitus Type II and Hypertension. From then on, she claims that she had been religiously taking her prescribed medications. Medication names were unrecalled by the patient and her husband. As a child, the patient did not experience any significant illness as claimed. Immunizations during childhood were also unrecalled. At present, the patient had no immunizations taken.

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In 2009, the patient had episodes of fainting which prompted Emergency Room treatment and later hospital admission. This admission paved way for the discovery of the starting Kidney Failure of the patient. The degree or stage of failure is unrecalled by the patient. They were advised dialysis treatment but they refused. The patient states that she had knowledge deficit regarding dialysis treatment. She thought that dialysis would only exhaust them financially without promise of a good prognosis. Therefore she refused and did not consult further regarding the condition of her kidneys. During this time, it was also known by her physician that OHA would not be sufficient rather she needed insulin injections to maintain her blood sugar levels. Medications for hypertension and Diabetes Mellitus was taken after diagnosis on 1996 but names were unrecalled. The patient declared that she had been incorporating a Chinese herbal medication. The herbal plant was introduced by a relative to the couple and they harvest the stalk of the plant and munch on it raw. It was only 2009 that the patient started Insulin injections which is continuously being done at present. Before this admission, the patient reports no blood transfusion of any other blood components. There were no known allergies of the patient on food, medication or environment.

D. FAMILY HISTORY:
Its eminent in the family history of the patient that hypertension is a familial health problem for the patients paternal relatives while Diabetes Mellitus is prominent in her maternal relatives. The patients father happens to die due to heart attack and was also a known hypertensive. Two of the patients uncle, who happens to be the fathers siblings also died of heart attack and were known hypertensive. On the other hand, two of the patients aunt who happens to be the sibling of her mother manifested Diabetes Mellitus. In addition, the patients second sibling is also under treatment for controlling of blood pressure. Her third sibling is currently taking Oral Hyperglycemic for control of Diabetes Mellitus and her youngest sibling manifest both hypertension and Diabetes Mellitus.

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E. PERSONAL & PSYCHOSOCIAL HISTORY

The patient belongs to a middle class family who has a monthly income of 29,000 pesos per month which comes from the retirement pension of both the couple. Generally, the patient claims to be satisfied with the socioeconomic status of their family before the exacerbation of her disease. At present, both sons of the patient have their own work and take part in the financial burden of the hospitalization coupled with the monthly income expected of the patient and her husband. Carbonated Beverages seem to be the culprit of her health problem as claimed by the patient. During her active days of work as auditor, her daily intake of carbonated drinks averages to 1.5 L. And coffee as well. She also claims that before the discovery of her health deficits, she is fun of eating junk food in between her regular meals but claims to enjoy vegetables more than meat. After the diagnosis of Diabetes Mellitus, she added bitter gourd leaves to her diet. The patient is a non smoker and a non alcoholic beverage drinker.

F. INITIAL PHYSICAL ASSESSMENT

Conscious, coherent, intubated BP 200/100 HR 85 reg RR 18 Afebrile Warm moist skin, no active dermatoses Pink palpebral conjunctivae, anicteric sclera No nasoaural discharge Supple neck, no cervical lymphadenopathies, no neck vein engorgement Symmetrical chest expansion, no retractions, (+) crackles bibasal

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Adynamic precordium, tachycardia, Apical Beat at 5th ICS LMCL, no heaves, no thrills, soft S1 and S2, no S3, S4 Globular abdomen, normal abdominal bowel sounds (NABS), soft, nontender No peripheral edema, cyanosis, pulses +2 Neuro examination: Awake, oriented to 3 spheres, No sensorimotor deficits

G. REVIEW

OF

SYSTEMS

Patient was seen lying in bed with head of bed elevated at a 35 degree angle. The patient appeared to be weak and unable to change her position but was alert and conscious of her surroundings. Her intrajugular venous access was newly inserted at that time. She was calm, coherent, patient and eager to answer our questions. SYSTEM PATIENT FINDING Urine output: 80 cc in 24 hours or 30 cc per hour. Dark yellow in color. (taken October 18, 2012) Renal (+) edema ANALYSIS The patient is oliguric which is indicative of renal failure. (Devarajan, 2012). The edema on the patients right arm is due to the inflammatory response to the repetitive trauma in the hand. This process promotes increased blood flow that leads to increase in temperature which is why this arm is warmer compared to the left. It also causes stretching of the skin because of the accumulation of fluid within the interstitial spaces which results to shiny skin.(Cunha, 2011). There is a fluid shift to the patients interstitial spaces caused by the presence of increased sodium in the body. Her body cannot excrete the excess amount of salt because it is not functioning properly, hence the accumulation of fluid in the interstitial spaces that lead to stretching of the skin. (Cunha, 2011). Crackles and cough indicate the
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Right arm: nonpitting edema Both legs: Grade 1 pitting edema

Respiratory

RR at 23 breaths per minute

presence of pleural effusion or Patient was on 0.5 L oxygen atelectasis: both of which the patient via nasal cannula has. (http://www.wilkes.med.ucla.edu/crac Symmetrical chest expansion klesmain.htm) (-) retractions (+) crackles both lungs (+) productive cough Cardiovascular 83 beats per minute regular There is decreased cardiac output as BP: 120/90 mmHg seen by weak pedal pulses and cool Pink palpebral conjunctiva extremities. Apical beat is at 5th intercostal space, left mid clavicular line Capillary refill Fingernails: <3 seconds Toenails: not assessed because of nail polish Peripheral pulses Right radial artery: 2+ Left radial artery: 2+ Right pedal pulse: 1+ Left pedal pulse: 1+ Skin temperature Right arm: warm to touch Left arm: cool to touch Right leg: warm to touch Left leg: cool to touch (-) neck vein distention (-) murmur Endocrine Blood glucose level: 122 mg/dl (taken at 6am of October 18, 2012) The patients blood sugar is above normal at this time and is indicative of insulin resistance and decreased production of insulin that facilitates the transport of glucose into the cells. (Khardori, 2012).

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Musculoskeletal Patient has difficulty moving in bed she requires assistance to shift her position. She is able to move her neck but with limitation. Motor function strength: Right arm 3/5 Left arm 5/5 Right leg 3/5 Left leg 3/5 Both of the patients lower legs were atrophied Integumentary There are several skin lesions present: Right side of neck: intrajugular venous access site Right arm: skin is darker Right inguinal area: femoral catheter access site Right hip blisters: 1 cm in diameter Left dorsal foot: dry scaly lesion healing

The pain caused by the insertion of a intrajugual venous access limits the neck movement of the patient.

There is limited movement in her legs because of prolonged bed rest and immobility that led to the atrophy of her leg muscles. (MedlinePlus, 2012).

The lesions have been caused by healthcare professionals in order to treat the patient. The intrajugular venous access and femoral catheter were used for the patients dialysis. Her right arm, was where the peripheral IV site was placed and where blood samples were repeatedly taken. The blister is caused by prolonged pressure on the hip. Since the patient has difficulty moving herself, moisture, friction, and prolonged dependency on the area has caused skin break down. The shininess of the skin is caused by edema which stretched the skin.

Generally, the patients skin is smooth, soft, moist and supple except for the following differences: Right arm: firm, moist, and shiny and is warm to touch. Left arm: smooth, moist, supple, and cool to touch. Right leg: light in color. There are brown spots on the

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dorsal front lower leg that extends up to the foot. The upper leg is smooth, moist, supple and warm to touch while lower leg is smooth, moist, shiny and warm. The foot is dry, scaly, and cool to touch. Left leg: leg is light in color. There are brown spots on the dorsal front lower leg that extends up to the foot. The upper leg is smooth, moist, supple and warm to touch while the lower leg is smooth, moist, shiny and cool. The foot is dry, scaly, and cool to touch. Nervous GCS 15 Oriented to time, person, and place Pupils reactive to light and accommodation and are 3 mm in size at the time of assessment There is decreased tactile sensitivity in both of the patients feet. The patients neurological status is intact. However, she has developed diabetic neuropathy due to her high blood sugar levels that damaged her nerves. (PubMed Health, 2012).

Gastrointestinal Unblemished smooth, supple, moist skin; uniform in color; round abdomen. (-) nausea or vomiting (-) tenderness (-) guarding (+) bowel sounds at >5 clicks per minute Reproductive Patient is menopausal.

NORMAL

NORMAL for patients age

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H. ADMITTING IMPRESSION:
Hypertensive Cardiovascular disease , Sinus Rhythm , New York Health Association Functional Capacity II; Acute Coronary Syndrome, Unstable Angina, Thrombolysis In Myocardial Infarction 2; Acute Respiratory Failure Type I secondary to Acute Pulmonary Edema probably secondary to Left Ventricular Dysfunction; Type 2 Diabetes Mellitus; Chronic Kidney Disease secondary to Diabetic Nephropathy/ Hypertensive Nephrosclerosis

I. FINAL DIAGNOSIS
Acute Respiratory Failure secondary to Pneumonia; Coronary artery Disease with Left Ventricular Dysfunction; Chronic Kidney Disease secondary to DM Nephropathy

V. PATHOPHYSIOLOGY (PLEASE SEE ANNEX I FOR THE DIAGRAM)

Chronic, irreversible renal failure is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the bodys internal environment. Numerous disease processes and injuries can interfere with the normal renal function. The case of EVG presents diabetes mellitus type 2 and hypertension as major factors for the development of the disease. The patients age, family history of DM and hypertension as well as previous history of too much intake of soft drinks and insufficient isotonic and isometric exercises predisposed the patient to the aforementioned extrarenal conditions. DM type II, Non-Insulin Dependent DM (NIDDM) or adult-onset DM is characterized by limited beta cell response to hyperglycemia. Beta cells chronically exposed to high blood levels of glucose become progressively inefficient when responding to further glucose elevation. Another pathologic process in this type of DM is resistance to the biologic activity of insulin in both the liver and peripheral tissues (insulin resistance). This decreased sensitivity to glucose levels results in continued hepatic glucose production, even with high blood glucose levels. Protein wasting due to lack of insulin, and elevated body lipid level due

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to increased fat metabolism result to glycoprotein and fat deposits in microvascular and macrovascular system. EVG experienced numbness and tingling in both upper and lower extremities, typical of DM neuropathy. Moreover, patients chest x-ray indicated atherosclerotic aorta while 2-dimensional echocardiography showed coronary artery disease in the right coronary artery and left circumflex distribution. These DM-related vascular changes aggravated the patients pre-existing

hypertension. Uncontrolled systemic high blood pressure caused prolonged increased ventricular pressure leading to hypertrophy. The resulting increase in the left atrial pressure led to pooling of fluid back to the pulmonary system. Increased hydrostatic pressure in the pulmonary vessel increases fluid filtration into the interstitial spaces of the lungs that exceeds the lymphatic capacity to drain fluid away. Fluid moves from pleural interstitium into alveolar walls. Persistence of the condition eventually damages the alveolar epithelium resulting to accumulation of fluid in the alveoli and alteration of the normal drainage of pleural fluid from the pleural spaces. This is evident in the patients chest x-ray showing pulmonary edema and effusion. On the other side of the coin, sustained systemic high blood pressure causes degenerative changes in the arterioles and interlobular arteries of the kidneys. Renovascular hypertension or reduced renal blood flow due to systemic hypertension activates the renin-angiotensin-aldosterone system. Sustained RAAS activation leads to uncontrolled hypertension. Diabetes mellitus and uncontrolled hypertension led to deterioration and destruction of nephrons with progressive loss of renal function. Total glomerular filtration rate start to change during the first stage of chronic renal failure. Nevertheless, no clinical manifestations are usually present during this time. Compensatory hypertrophy of nephrons occurs as they filter larger loads of solutes. Consequently, kidneys lose their ability to concentrate urine adequately. The tubules gradually lose their ability to reabsorb electrolytes. As renal damage advances and the number of functioning nephrons declines, the GFR decreases further and the body becomes unable to rid itself of excess water, salt and other waste products through the kidneys. Non-excretory renal functions are lost. Patient developed atherosclerotic aorta due to increased lipid production, elevated blood glucose level due to impaired insulin action, anemia due to failure of the kidney to produce erythropoietin to stimulate erythrocyte production by the bone marrow, and hypocalcemia due to failure of the kidney to convert inactive form of calcium to calcitriol. On the other hand, excretory renal functions are also
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damaged. This resulted to decreased sodium reabsorption in renal tubules causing water retention, thus further aggravating the patients hypertensive state, heart failure and edema. Decreased excretion of nitrogenous waste product led to uremia. This is evidenced by infection, dry skin and peripheral neuropathy that are present in the patient. The disease condition is controlled by pharmacologic management of hypertension and diabetes and more importantly, renal replacement therapy. If not treated, outcome of CRF is death.

VI. GORDONS FUNCTIONAL HEALTH PATTERN

Date of Interview: October 18, 2012 HEALTH PERCEPTION HEALTH MANAGEMENT PATTERN Before hospitalization Patient perceives a healthy person as someone who does not manifest illness. She claims that she has no vice like drinking alcoholic beverages and smoking. Patient also reports that in 1996, she was diagnosed of Diabetes Mellitus Type II and Hypertension and from then on visits her doctor regularly. According to her, she religiously takes her medications in congruence with an herbal supplement which she believes to be beneficial. In 2009 she was admitted and diagnosed of kidney disease. The patient verbalized that her doctor explained that the cause of the kidney disease is her intake of oral anti-hyperglycemic medications. Thus advised dialysis treatment at that moment, but she and her family rejected the management in the belief that they will only spend money without the promise of a good prognosis. During hospitalization Patient said that there are regret and guilt feelings regarding her prior decision to refuse dialysis treatment. That she could have just followed the advice of her doctor thereby not leading to her needing dialysis treatment twice a week during her entire existence. Now she, along with her family, follow the needed therapeutic regimen but they make sure that all procedures were thoroughly explained. They are now more open-minded to the course of therapy.

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NUTRITIONAL METABOLIC PATTERN Before hospitalization Patients daily intake comprises of breakfast, lunch and dinner, sometimes she includes snacks in between. Back when she was working as an auditor of Nissan Motor Philippines, Inc. in 1970s, she was fond of drinking cola, soft drinks and she also ate chips. As she describes, she can drink up to 1.5 of soft drinks per day. She also consumes coffee every morning. But she also said that she eats more vegetables, rarely meat. She cooks and prepares the food of the family. Despite of having dentures, she still had a good appetite. She has no known food allergy. When she was diagnosed with diabetes, she added boiled bitter gourd leaves in her usual meal. She also noticed and experienced numbness at her legs which became big, dry and shiny and resorts to her husbands massage. During hospitalization Based on patients record she weighs 70 kilograms and a height of 160 centimeters, with body mass index of 27.3. According to her she only ate what the hospital dietary department provides. Her fluid intake was limited only for 1000 ml per day. Upon assessment, there were non-pitting edema on right upper extremities, no complain of nausea and vomiting nor problem in swallowing. ELIMINATION PATTERN Before hospitalization Patient usually moves her bowel once a day every morning. She reports no problem when defecating. She urinates at least 4-5 times a day, but then, when she was told that she has kidney problem she noticed that her urination pattern changed, complaint of flank pain exists and scanty urine was noted. During hospitalization Upon assessment patient was on diaper. Hypoactive bowel sound was noted. She has a flabby abdomen soft and non-tender. No mass was palpated. She reported that she defecates 3 times of brown and formed stool a day. Patient was noted to have hemorrhoids; in consequence she had pain when passing stools. She says nurses instructed her to avoid straining while defecating. There was an increased urge to void but noticed decreased on amount of urine.
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ACTIVITY AND EXERCISE PATTERN Before hospitalization During her past time, patient watches television shows, reads health and lifestyle magazine. She does simple exercise on the upper and lower extremities by means of shaking and stretching. She also considered household chores as a form of exercise. Patient is completely independent on self-care. During hospitalization Patient was assessed and noticed to have a decreased in muscle strength, had limited range of motion and legs were atrophied. Patient was on oxygen inhalation at 1 liter per minute, per nasal cannula, noted with dry cough and crackles upon auscultation. Respiratory rate was 23 breaths per minute, pulse rate of 85 beats per minute, and blood pressure of 180/100mmHg. She requires help from another person to assist on daily activities such as feeding, bathing and hygiene, dressing and grooming and toileting. SLEEP REST PATTERN Before hospitalization Patient usually sleeps about seven to nine hours per night at around 9 oclock pm when she goes to bed and wakes up at 6 oclock in the morning. She doesnt want to take a nap in afternoon because she will have hard time to fall asleep. She uses 2 pillows to ease her breathing and to provide comfort when sleeping. If she experiences difficulty with sleeping, she reads the bible and prays. During hospitalization According to patient, due to her condition, she usually takes a lot of rest, but easily gets distracted and sleep is interrupted due to pain, administration of medication and visitors.

COGNITIVE PERCEPTUAL PATTERN Before hospitalization

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Patient had blurring of visions long before when she was diagnosed with Diabetes Mellitus. She used eyeglasses with prescription of 250. She was oriented to people, time and place. She doesnt have loss of hearing or speech, but tactile sensory function\ in the legs is diminished. With regard to decision making, she can easily incline to make decisions. During hospitalization Upon assessment, she was conscious and attentive when questions were asked. Hoarseness of voice was noted. She verbalized discomfort with prolonged lying on bed. She was afraid that her dialysis catheter might get dislodged and that her condition might get worse and will die soon, so she obediently follows the restriction of her physician.

SELF PERCEPTION SELF CONCEPT PATTERN Before hospitalization She perceived herself as a good wife and mother; she was helpful to her siblings and has been a responsible daughter to her parents. During hospitalization Though weak, she still manages to appear calm and relaxed. Now that her health is at stake, she reflects and ponders on her life. She felt regret, bitterness and despair, but the support, love and care from her family became her motivation to have positive outlook in life. ROLE RELATIONSHIP PATTERN Before hospitalization Patient lives with her loving husband and two children in their humble home. She was proud to her parenting skills because she nurtures her children well.

During hospitalization Even with illness she stills play the role of a mother by means of reminding important matters to her children; a nonstop teacher of good and right. Patients family says that her
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hospital confinement will cause significant changes but they will stick together to support each other. SEXUALITY REPRODUCTIVE PATTERN Before hospitalization According to the patient, she was 14 years old when she had her menarche. She had regular menstrual monthly period. She gave birth to two healthy male children. She never used artificial birth control. At the age of 45 she had her menopause. She reported no history of sexually transmitted disease or any infection affecting her genital. During hospitalization Patient says that obviously because of her age, she was not sexually active, but she loves her husband so much. COPING STRESS TOLERANCE PATTERN Before hospitalization When she feels stressed out, she copes up by doing household chores. When a problem arises, they talk and discuss it with the family and finds way to resolve it together. During hospitalization This event was stressful and traumatic not only for her but for the whole family. Gradually they accepted their situation and they just pray and hope that they will pass through this crisis. During her dialysis session, she likes it whenever her husband stays by her side, she feels at ease and comfortable. VALUE AND BELIEF PATTERN Before hospitalization Patient is a Christian, a member of Charismatic group. She has a strong faith in God. According to her she reads the bible a lot. She said that God, the creator and savior, is the source of her inspiration and strength. During hospitalization

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At first she doubted and questioned God that of all people, why she was the one chosen to be sick. Then she just realized all of this has a purpose. God will not give hardship if He knows that she cant do it.

VII. PHYSICAL ASSESSMENT

DATE ASSESSED: OCTOBER 16 & 18, 2012

AREAS ASSESSED

NORMAL FINDINGS

ACTUAL FINDINGS HEAD

ANALYSIS

Skull

Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour; absence of nodules or masses (Kozier, Fundamentals of Nursing, Seventh Edition, p. 544) Lighter in color than the complexion; free from lice, nits, and flakes; absence of masses, scars, or lesions; no areas of tenderness palpated (Kozier, Fundamentals of Nursing, Seventh Edition, p.541 ) Black, brown or burgundy depending on the race; evenly distributed hair; thick

The patients skull is proportionate to the size of her body; it is round; prominence in the frontal, parietal and occipital lobes are palpable; there is symmetry; gently curved; when palpated, no tenderness and nodules was felt The patients scalp is lighter than her skin, moist and oily; there are no lesions and scars; there are no lice and nits but dandruff is present; during palpation, no tenderness was felt

NORMAL

Scalp

NORMAL

Hair

The patients hair is black with some gray spots and is evenly distributed.

NORMAL

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hair; silky, resilient hair; no infection or infestation (Kozier, Fundamentals of Nursing, Seventh Edition, p. 541) Face Symmetric or asymmetric facial features; symmetric facial movements (Kozier, Fundamentals of Nursing, Seventh Edition, p. 545) Presence of wrinkles originating from the canthus of her eyes; facial movements are symmetrical DEVIATED FROM NORMAL As a person ages the epidermal cells become thinner and less sticky. The thinner cells make the skin look noticeably thinner. The decreased stickiness of the cells decreases the effectiveness of the barrier function allowing moisture to be released instead of being kept in the skin. This causes dryness. The number of epidermal cells decreases by 10% per decade. These changes in the scaffolding of the skin cause the skin to wrinkle and sag. The skin is dark because of nitrogen waste products that have accumulated because of her decreased renal function. (Nunley, 2012).

Skin is darker compared to the rest of the body.

EYES Eyebrows Hair evenly distributed; skin intact; symmetrically aligned; equal movement (Kozier, Fundamentals of Nursing, Seventh Edition, p. 548) The patients eyebrow is evenly distributed in both sides, symmetrically aligned and parallel; with equal movement NORMAL

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Eyelashes

Equally distributed; curled slightly outward (Kozier, Fundamentals of Nursing, Seventh Edition, p. 548) Shiny, smooth, and pink or red (Kozier, Fundamentals of Nursing, Seventh Edition, p. 548) Transparent, white in color, no yellowish discoloration, some capillaries may be visible (Kozier, Fundamentals of Nursing, Seventh Edition, p.548 ) Transparent, flat and round, depth of about 3 mm, no shadows of light (Kozier, Fundamentals of Nursing, Seventh Edition, p.549 ) Black in color; equally in size; normally 3 to 7 mm in diameter; round, smooth border, iris flat and round Illuminated pupil constricts (direct response)

The patients eyelashes are distributed equally in both sides and is slightly curved

NORMAL

Conjunctiva

The patients conjunctiva are smooth and pink.

NORMAL

Sclera

The patients sclera is white, no yellow discoloration seen.

NORMAL

Iris

The patients iris are dark brown in color in both sides, equal in size, round and flat.

NORMAL

Pupils

The patients pupils are both rounded; react to light by constricting when light is pointed and dilating when light is removed, and same way, it constricts when an object is moved closer and

NORMAL

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Nonilluminated pupil constricts (consensual response) Constricts when looking at near objects Dilate when looking at far objects Converge when near object is move toward nose (Kozier, Fundamentals of Nursing, Seventh Edition, p. 550)

dilates when moved away

Visual Acuity/ Visual Fields

Near vision - able to read newsprint When looking straight ahead, client can see objects in periphery (Kozier, Fundamentals of Nursing, Seventh Edition, p. 551)

BLURRING OF VISION The patient was unable to read the newsprint in the 1 foot distance and verbalized that she is wearing corrective glasses.

DEVIATED FROM NORMAL The exact cause is not well understood but is probably multifactorial associated with protein glycosylation, ischemia and hemodynamic mechanisms. Stress from increased blood viscosity is a hemodynamic mechanism that increase permeability and decrease elasticity of capillaries. Also, it can be attributed to the secondary chronic exposure of ocular lens and retina to hyperosmolar fluids. Retina, which is the most essential structure of the eye, has the highest rate of O2 consumption of any tissue in the body. Consequently, if the retina is deprived of O2 carrying blood secondary to destruction of its capillaries, tissue anoxia develops causing BOV. (Black J &Hawks J (2004) Medical-Surgical Nursing:
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Clinical Management for Positive Outcomes, p. 1281) EARS External Canal Distal third contains hair follicles and glands; dry cerumen, grayish-tan color; or sticky, wet cerumen in various shades of brown (Kozier, Fundamentals of Nursing, Seventh Edition, p. 556) Normal voice tone audible (Kozier, Fundamentals of Nursing, Seventh Edition, p. 558) Symmetric and straight; no discharge or flaring; uniform color; not tender; no lesions; nasal septum is intact and in midline (Kozier, Fundamentals of Nursing, Seventh Edition, p. 560) The patients external ear canal is pinkish in color in both sides and there is a moderate amount of sticky wet cerumen NORMAL

Hearing Acuity

The patients hearing is intact: can hear normal voice tone from a distance of 2 feet.

NORMAL

Nose

The patients nose is symmetrical; no tenderness felt during palpation; no nodules or lumps; nasal septum is in midline.

NORMAL

MOUTH Lips Uniform pink color; soft, moist, smooth texture; symmetry of contour; ability to purse lips (Kozier, Fundamentals of Nursing, Seventh Edition, p. 563) The patients lips are pinkish in color, moist, moves in symmetry; no edema; NORMAL

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Gums

Pink gums; moist, firm texture to gums; smooth, intact dentures; no discharge, swelling, and retraction (Kozier, Fundamentals of Nursing, Seventh Edition, p. 564) 32 adult teeth; smooth, white shiny tooth enamel; with or without dental fillings (Kozier, Fundamentals of Nursing, Seventh Edition, p. 564)

The patients gums are pinkish; moist; no swelling and no tenderness

NORMAL

Teeth

The patient has no more permanent teeth and is making use of dentures; no halitosis.

DEVIATED FROM NORMAL The enamel on the surface of the elderly peoples teeth becomes thinner with age and may expose the underlying dentin. Formation of dental caries or tooth decay is the result of the breakdown of enamel by acids produced by bacteria on the tooth surface. In addition, the gingival covering the tooth root recedes exposing the additional dentin. Many elderly people also lose teeth which can have a marked effect on eating habits that is why artificial teeth or dentures are also considered. (Seeley, Stephens and Tate (2005) Essentials of Anatomy and Physiology, 5th ed, page 485)

Tongue

Center position; pink color; moist; slightly rough; thin whitish coating; smooth, lateral margins; no lesions; raised papillae; moves freely. (Kozier, Fundamentals of

The patients tongue is positioned centrally; medium in size; pink in color; moves freely without tenderness; frenulum is also positioned centrally

NORMAL

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Nursing, 7th Ed, p. 564) Tonsils Pink and smooth; no discharge; of normal size or not invisible (Kozier, Fundamentals of Nursing, Seventh Edition, p. 565) The patients tonsil is pink in color; moist; positioned centrally; no discharges and inflammation noted; gag reflex is elicited. NECK Neck Muscles equal in size; head centered; coordinated, smooth movements with no discomfort; equal strength (Kozier, Fundamentals of Nursing, Seventh Edition, p. 568) Muscles are equal in size; no palpable lymph nodes. Neck is slightly swollen. Limited movement. The presence of a newly inserted intrajugular venous catheter triggered the inflammatory process at the site. Pain at the insertion site causes limited movement. NORMAL

CHEST Lungs Quiet, rhythmic, and effortless respirations; uniform temperature; no tenderness and masses (Kozier, Fundamentals of Nursing, Seventh Edition, p. 578) Upon auscultation, crackles where heard on both lungs DEVIATED FROM NORMAL Crackles indicate the presence of pleural effusion or atelectasis: both of which the patient has. http://www.wilkes.med.ucla.e du/cracklesmain.htm

Heart

No pulsation in aortic, pulmonic, and tricuspid areas; apical pulsation is visible in 50% of adults and palpable in most PMI in fifth LICS at or medial MCL; diameter of 1-2 cm (Kozier,

There are no pulsations felt or murmurs heard in the aortic, pulmonic, and tricuspid areas; apical pulse is palpable in the 5th LICS at the MCL.

NORMAL

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Fundamentals of Nursing, Seventh Edition, p. 583) Breast Rounded shape; slightly unequal in size; generally symmetric; skin uniform in color; areola is round or oval and bilaterally the same; color varies widely, from light pink to dark brown; nipples are round, everted, and equal in size; similar in color; soft and smooth; both nipples point in same direction; no discharge, except from pregnant or breastfeeding from puberty; no tenderness, masses, or nodules (Kozier, Fundamentals of Nursing, Seventh Edition, p. 590) The patient has NORMAL symmetrical breast and color same with the skin complexion with nevi sporadically distributed; areola is round and dark brown; nipples are even in size, darker in color, and everted; during palpation, no tenderness, masses or nodules felt

ABDOMEN Abdomen Unblemished skin; uniform color; silverwhite striae or surgical scars; flat, rounded, or scaphoid; no evidence of enlargement of liver or spleen; symmetric contour; symmetric movements caused by respiration; audible bowel sounds; absence of bruit; absence of friction rub (Kozier, Unblemished smooth, NORMAL supple, moist skin; uniform in color; round abdomen; no tenderness; no guarding; bowel sounds are heard at more than 5 clicks per minute

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Fundamentals of Nursing, Seventh Edition, pp. 594-595)

Skin

Varies from light pink to brown; from ruddy pink to light pink; from yellow overtune to olive; No edema; Uniform skin temperature; No bruises

Patients skin is brown with no signs of paleness. Normal skin turgor. Unequal skin temperature

DEVIATED FROM NORMAL

This is due to the inflammatory responses, fluid shift, and the cold environment. (CliniMed, 2012).

EXTREMETIES Upper Equal size on both sides of body; no contractures, fasciculation or tremors; muscles are normally firm; smooth coordinated movements; equal strengths on each body side; no bone deformities; no tenderness or swelling; joints moves smoothly (Kozier, Fundamentals of Nursing, Seventh Edition, p. 600-601) Skins temperature is uniform; within normal range (Kozier, Fundamentals of Nursing, Seventh Edition, p. 539) Right Arm: There is a non-pitting edema on the patients body part with measurements at 25 cm upper arm, 26 cm lower arm, 21 cm wrist. There is a lesion present in the patients inner arm. The skin is darker than the rest of the arm. Tenderness is felt. The arm is firm, moist, and shiny and is warm to touch. Capillary refill is <3 seconds. Radial pulse is 2+. Motor function is at 3/5 Motor function is impaired due to pain and the edema. There is edema on the patients right arm due to the many punctures she received to collect blood samples and for medications and hydration. According to the patients husband, they would insert needles in her 5 times each day. The edema is an inflammatory response to the repetitive trauma in the hand. This process promotes increased blood flow that leads to increase in temperature which is why this arm is warmer compared to the left. It also causes stretching of the skin because of the accumulation of fluid within the interstitial spaces which results to shiny skin.

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Left Arm: The left arm has no edema with measurements of 21 cm both upper arm and forearm and 19 cm for the wrist. The skin is smooth, moist, supple, and cool to touch. Capillary refill at <3 seconds. Radial pulse 2+ Motor function is at 5/5 Lower Equal size; no contractures, fasciculation or tremors; muscles are firm; smooth coordinated movements; equal strengths on each body side; no bone deformities; no tenderness or swelling; joints moves smoothly. Skins temperature is uniform; within normal range (Kozier, Fundamentals of Nursing, Seventh Edition, p. 600-601, 539) Right Leg: The patients leg is light in color. There are brown spots on the dorsal front lower leg that extends up to the foot.

The left arm is within normal parameters. The patients left arm is spared from needle punctures because the doctors are saving it for the establishment of an arteriovenous fistula.

Diabetic dermopathy is present due to hyperglycemia that causes increased permeability to the blood vessels that eventually lead to blood leaking into the skin tissue and appear as spots. The blister is caused by prolonged pressure on the hip. Since the patient has difficulty moving herself, moisture, friction, and prolonged dependency on the area has caused skin break down. The leg may be warmer due to the inflammatory process and increased blood circulation of the wound healing. There is a fluid shift to the patients interstitial spaces caused by the presence of increased sodium in the body. Her body cannot excrete the
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There is a blister on the patients hip at 1 cm in diameter. A lesion is also present due to the removal of the femoral vein catheter. (+) tenderness in the area. The upper leg is smooth, moist, supple and warm to touch.

The lower leg is smooth, moist, shiny and warm. Calf

circumference of 25 cm. Grade 1 pitting edema. The foot is dry, scaly and warm to touch.

excess amount of salt because it is not functioning properly, hence the accumulation of fluid in the interstitial spaces that lead to stretching of the skin. The patient has developed diabetic neuropathy due to her high blood sugar levels that damaged her nerves. There is limited movement in her legs because of prolonged bed rest and immobility that led to the atrophy of her leg muscles. Her pedal pulse is weak due to decreased cardiac output.

There is decreased tactile sensitivity to light touch. Pedal pulse 1+ Motor 2/5

Left Leg: The patients leg is light in color. There are brown spots on the dorsal front lower leg that extends up to the foot. There is a dry, scaly lesion healing on the patients dorsal foot. Tenderness Is present in her ankle. The upper leg is smooth, moist, supple and warm to touch. The lower leg is smooth, moist, shiny and cool. Calf

Diabetic dermopathy is present due to hyperglycemia that causes increased permeability to the blood vessels that eventually lead to blood leaking into the skin tissue and appear as spots. The dry skin is caused by her dialysis which decreases the function of her oil glands. Tenderness may be a sign of an impending skin break down. There is a fluid shift to the patients interstitial spaces caused by the presence of increased sodium in the body. Her body cannot excrete the excess amount of salt because it is not functioning properly, hence the accumulation of fluid in the interstitial spaces that lead to stretching of the
44 | P a g e

circumference of 25 cm. Grade 1 pitting edema. The foot is dry, scaly, and cool to touch. There is decreased tactile sensitivity to light touch. Pedal pulse 1+ Motor 2/5

skin. The cool temperature may be due to decreased circulation in her lower extremity. The patient has developed diabetic neuropathy due to her high blood sugar levels that damaged her nerves. There is limited movement in her legs because of prolonged bed rest and immobility that led to the atrophy of her leg muscles (MedlinePlus, 2012).

GLASGOW COMA SCALE AREAS ASSESSED Eye Opening Motor Response Verbal Response NORMAL FINDINGS Eye Opening Spontaneous (4) Motor Response Obeys Commands (6) Verbal Response Oriented (5) ACTUAL FINDINGS Eye Opening eyes opening spontaneously (4) Motor Response Follows commands (6) Verbal Response able to converse coherently (5) ANALYSIS The patients neurological state is normal. (Medscape, 2012).

NUTRITIONAL RISK ASSESSMENT AREAS ASSESSED Body Mass Index (BMI) NORMAL FINDINGS 18.5 - 24.9 (MedlinePlus, 2012) ACTUAL FINDINGS Height - 1.6 meters ANALYSIS Patient is overweight but is ideal for her age. A slightly
45 | P a g e

Weight - 70 kgs BMI 27.3

higher than normal BMI may protect people age 65 years and over from osteoporosis (MedlinePlus, 2012).

VITAL SIGNS AREAS ASSESSED TEMPERATURE PULSE RATE RESPIRATORY RATE NORMAL FINDINGS 35.8 - 37.3 C 60 - 100 beats/min 12 - 20 breaths/min ACTUAL FINDINGS 36.8C 83 beats/min 23 breaths/min

ANALYSIS Normal Normal Tachypnea is due to the collapse of her alveoli and pleural effusion that decreases the lung area for gas exchange. (Bye, 2011) (Rubins, 2012) Normal

BLOOD PRESSURE

Systolic BP: 120 mmHg Diastolic BP: 80 mmHg

Systolic BP: 120 mmHg Diastolic BP: 90 mmHg 6/10 on the neck, pain is sharp and constant, exacerbated to 8/10 by movement.

PAIN SCALE

0/10 No Pain

Normal There is a newly inserted intrajugular venous access site on her neck.

2/10 on right The right femoral access inguinal area, pain is site is still healing in her dull and triggered inguinal area. by movement. The heel pain is due to 2/10 on left heel. prolonged pressure on the Pain increases to area. 7/10 upon
46 | P a g e

movement.

TPR GRAPH

95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 26 28 30
BRADENS SCALE AREAS ASSESSED Sensory Perception NORMAL FINDINGS No Impairment (4) ACTUAL FINDINGS Slightly Limited (3) ANALYSIS There is decreased tactile sensation in both of the patients feet. Hyperglycemia has damaged the nerves in her extremities which decreased her sensitivity to touch. This is caused by prolonged periods of staying in one position. Heat is constantly trapped in the area, making it sweat.
47 | P a g e

10 12 14 16 18

Moisture

Rarely Moist (4)

Occasionally Moist (3)

Activity

Walks Frequently (4)

Bed Rest (1)

The patient is on bed rest since she cannot tolerate too much activity like walking. Due to acute respiratory failure, the patient was confined to her bed which resulted in muscle atrophy that also caused decreased muscle strength.

Mobility

No Limitations (4)

Very Limited (1)

Her mobility is limited because of generalized body weakness caused by her disease: Her body is still recovering from acute respiratory failure and currently still has pleural effusion and atelectasis in her lungs which decreases gas exchange. In addition to this, anemia, which is a consequence of CKD V, also impairs oxygen delivery. Any excessive movement will require more oxygen hence easy fatigability.

Nutrition

Excellent (4)

Adequate (3)

The patient has decreased but adequate appetite caused by the accumulated toxins in her body. Another reason may be due to easy fatigability.

Friction and Shear

No Apparent Friction (3)

Problem (1)

Since the patient cannot move on her own, other people need to move her
48 | P a g e

and this cannot be done without sliding against the sheets. Also, she cannot hold her own weight and she slides down the bed causing more shear and friction. TOTAL: 13 MODERATE RISK

FALL RISK ASSESSMENT TOOL AREAS ASSESSED Age Fall History No history of fall (0 points) NORMAL FINDINGS ACTUAL FINDINGS 65 years old (2 points) No history of fall

ANALYSIS Non-modifiable factor NORMAL Needs someone to turn her in bed. She cannot hold her own weigh because of lack of energy due to her disease. NORMAL Hyperglycemia has damaged the nerves in her legs causing decreased sensation. Different medications can cause side effects that can be compounded by each other. Having equipment attached to the patient can be a cause for fall should the patient get entangled in them and the like.

Mobility

Ambulates without assistance (0 points)

Ambulates or transfers with assistance (2 points) Can urinate and open bowels with ease (0 points)

Elimination

Normal pattern (0 points)

Mental Status Changes

Not affecting Affecting awareness awareness of of environment environment (0 points) (2 points) Taking 13 medications (5 points)

Medications

No medications (0 points)

Patient Care Equipment

No equipment/gadget attached (0 points)

IV line, nasal cannula attached (2 points)

Falls Risk Score: 13 points (High Risk for Fall)

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VENOUS THROMBOEMBOLISM RISK ASSESSMENT Normal Findings 0 risk factors Total Risk Score - 0 Actual Findings Age 65 years old 2 points Central Venous Access 2 points Swollen legs 1 point Congestive Heart failure (< 1 month) 1 point Serious lung disease including pneumonia (< 1 month) 1 point Medical patient currently at bed rest > 3 days 1 point Total Risk Score 8 Highest Risk PATIENT CLASSIFICATION Category A. Activities of Daily Living With assistance on feeding With assistance on grooming CBR without BRPs Voids/defecates freely Bath with assistance B. Assessment and Monitoring Non-invasive monitoring every 4 hours With 1 invasive access C. Medication and IV Therapy 1-5 oral medications and 1 plain IVF D. Nursing Procedures Minor (Oxygen Inhalation, HGT) Major (Dialysis) E. Communication Emotional and spiritual support F. Safety Precaution Raising of siderails Points Analysis The patient is at high risk for developing venous thromboembolism. Swollen legs and prolonged bed rest causes venous stasis that promote fibrin deposition that will eventually result in a thrombus.

2 2 2 1 1 1 3 3 12

10 2

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Total Score

39 Level II

VIII. LAB FINDINGS & REVIEW

A. ARTERIAL BLOOD GAS
ABG is performed to evaluate the clients acid-base balance and oxygenation. LEGEND: ____= Fully Compensated Metabolic. Acidosis/Alkalosis ____= Fully Compensated Respiratory Acidosis/Alkalosis ____ = Partially Compensated Metabolic. Acidosis/Alkalosis ____= Partially Compensated Respiratory Acidosis/Alkalosis ____ = Uncompensated Metabolic Acidosis/Alkalosis ____= Uncompensated Respiratory Acidosis/Alkalosis ____= Mixed Respiratory and Metabolic Acidosis/Alkalosis
VENT SET UP AC

DATE/ TIME 9/26/12 7:30PM 9/27/12 3PM 9/28/12 4:30PM 9/28/12 6PM 9/29/12 8:35A M 10/2/12 10/2/12 6:45PM

O2 THERAPY

PH

PCO2

PO2

HCO3

CO2

B.E.

SAO2

INTERPRETATION f. compensated met. Acidosis with moderate hypoxemia f.compensated met. Acidosis with more than adeq o2 f. compensated met. Acidosis with severe hypoxemia f.compensated resp. Alkalosis with adeq o2 f.compenssated met. Acidosis with adq o2 Uncompensated resp. Acidosis with mild hypoxemia Uncompensated met. Acidosis with moderate hypoxemia

FIO2 40%

7.390

30.3

70.2

17.9

18.9

-5.9

93.5%

AC TPIECE TPIECE TPIECE

FIO2 40%

7.366

32.1

110

17.9

18.9

6.2

98.4%

6LPM

7.352

33

58

17.9

18.3

-6.3

89%

6LPM

7.396

29.9

98

18

19.9

-5.4

97.3%

6LPM

7.392

31.7

92.4

18.9

19.8

-4.8

97.8%

4LPM FIO2 40%

7.315 7.280

46.3 44.4

79.8 72.6

22.9 20.4

24.3 21.7

-2.8 -5.6

95.1% 93.2%

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10/3/12 8:20A M 10/3/12 12:35P M 10/3/12 10/4/12 10/4/12

4LPM

7.133

72.1

83.2 106. 4 87.8 85.9 114. 3 125. 8 117. 3 115. 2 131

23.1

25.3

-6.8

92%

BIPAP BIPAP NIV FIO2 40, ET 6LTPX30 mins 6LTPX1o

7.140 7.215 7.073 7.409

67.7 56.3 87.9 31.7

22.1 21.9 24.5 19.7

24.1 23.7 27.2 20.6

-7.0 -5.6 -7.0 -3.9

97.5% 95.5% 94.6% 98.5%

Uncompensated resp. Acidosis with moderate hypoxemia Uncompensated resp. Acidosis with more than adeq o2 Mixed respiratory and metabolic Acidosis with adeq o2 Uncompensated resp. Acidosis with adeq o2 f. compensated resp. Alkalosis with more than adeq o2 f. compensated resp. Alkalosis with more than adeq o2 f. compensated resp. Alkalosis with more than adeq o2 Uncompensated resp. Alkalosis with more than adeq o2 Mixed resp. and met. Acidosis with more than adeq o2 Uncompensated met. Acidosis with more than adeq o2 Uncompensated met. Acidosis with more than adeq o2 Uncompensated met. Acidosis with more than adeq o2

10/5/12 10/5/12

7.441 7.417

29.8 34.7

19.9 21.9

20.8 23

-2.9 -1.6

98% 98.6%

10/5/12 FIO2 40%, PEEP

6LTPX2o

7.432

34

22.5

23.6

-0.8

97.2%

10/8/12

NIV

7.238

53.9

17.6

18.8

-8.0

98.5%

10/9/12 10/11/1 2 8:45A M 10/11/1 2 1PM

NIV

7.310

36.1

142

17.9

19.0

-7.1

99%

NIV

7.266

43.9

106

19.3

20.7

-7.0

96%

NIV

7.336

42.6

105

20.2

23.5

-3.0

91%

ANAL YSIS

The kidneys normally regulate blood pH by eliminating hydrogen ions produced in metabolic processes and regenerating bicarbonate. This is achieved through hydrogen ion secretion, sodium and bicarbonate reabsorption, and the production of ammonia, which acts as a buffer for titratable acids. With a decline in the renal function, these mechanisms become impaired and metabolic acidosis results. Respiratory system however responds to normalize pH by increasing respiratory rate. The rise in PCO2 on the other hand is directly related to the level of ventilation; reducing the ventilation by one half causes a doubling of the PCO2. Renal compensatory mechanism readjusts the
blood pH by increasing blood HCO3 levels.

B. SERUM ELECTROLYTE BLOOD TEST

Electrolyte tests are used for diagnosing dietary deficiencies, excess loss of nutrients due to urination, vomiting, and diarrhea, or abnormal shifts in the location of an electrolyte within the body
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(LEGEND:____ =Abnormally high, ____ =Normal, ____ =Abnormally low)

Electrolyte Parameters Na K Ionized calcium Magnesium Chloride

9-26-12 125 5.2 -

9-27-12 1.1 -

9-28-12 137 4.8 1.15 1.07 103

10-4-12 137 6.5 -

10-5-12 138 4.1 -

10-7-12 136 4.3 -

10-16-12 6-4 -

NORMAL VALUES 135-145 3.5-5.1 1.16-1.32 0.74-0.99 98-107

ANALYSIS

Electrolyte imbalance is altered by impaired excretion and utilization in the kidney. Although many patients maintain a normal serum sodium level, apparent hyponatremia may be a dilutional effect of water retention. Potassium levels usually remain within normal limits until late in the disease. However, catabolism, blood transfusion and acidosis contribute to potassium excess. Conversion of 25hydroxycholecalciferol to 1,25-dihydroxycalciferol (necessary to absorb calcium) is decreased, which results in reduced intestinal absorption of calcium, thus a problem of hypocalcemia.

C. BLOOD WORKS
Complete blood count evaluates the three major types of cells in the blood: red blood cells, white blood cells, and platelets. It also test for loss of blood, abnormalities in the production or destruction of blood cells, acute and chronic infections, allergies, and problems with blood clotting (LEGEND:____ =Abnormally high, ____ =Normal, ____ =Abnormally low)

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PARAMETERS RBC Hgb Hct WBC Platelet TROPONIN I

9-26-12 -

9-27-12 3.31

9-29-12 3.60

10-4-12 2.89

10-5-12 4.69

10-16-12 4.15

NORMAL VALUES 4.0-4.50

ANALYSIS

76 94 105 85 139 122 120-150 0.23 0.29 0.31 0.26 0.41 0.39 0.37-0.47 8.1 14.60 19.70 21.80 14.60 7.80 5.00-10.00 292 218 229 314 276 254 200-400 0.08 0.000.08 Chronic anemia is the most profound hematologic alteration that accompanies renal failure. Erythropoeitin production is usually insufficient to stimulate adequate red blood cell production by the bone marrow. The accumulation of uremic toxins futher suppresses red cell production in the bone marrow and the cells that are produced have a shortened life span. Altered immune response predisposed the patient to infection.

D. CHEST XRAY
Chest x-ray is use to evaluate respiratory status and cardiac size. It is also use to visualize lung fields and to rule out pathology. DATE 9-26-12 9-27-12 FINDINGS Seen pulmonary edema on both lungs With right pleural effusion Follow-up chest film dated Sept. 9, 2012 since Sept. 26, 2012, shows unchanged status of pulmonary edema. There is slight increase in the right pleural effusion with no significant change in the left Heart is magnified Aorta is tortuous and calcified ET tube is seen again in place No significant interval chest findings Ff-up chest film dated 9-28-12 since 9-27-12 shows partial clearing of pulmonary edema Heart is magnified Aorta is tortuous and calcified ET tube is seen again in place No significant interval chest findings Ff-up chest film dated 9-29-12 since 9-26-12 shows further clearing of pulmonary edema There is partial clearing of the bilateral pleural effusion Heart is magnified ET tube is no longer seen ANALYSIS Left ventricular dysfunction due to increased afterload by atherosclerotic aorta and uncontrolled hypertension; as well as fluid volume excess as a result of chronic reninangiotensinaldosterone system (RAAS) activation and diseased kidney, causes sustained elevated left atrial pressure. This in turn increases hydrostatic pressure in the lungs altering the drainage mechanism of the lymphatic system resulting to

9-28-12

9-29-12

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10-2-12

10-4-12 10-11-12 10-16-12

No significant interval chest findings Ff-up chest film dated 10-2-12 since 9-29-12 shows persistence of pulmonary congestion Slight progression of bilateral pleural effusion Atherosclerotic aorta Heart is magnified No significant interval chest findings Partial clearing of bilateral congestion Unchanged pleural effusion in the right lung t/c atelectasis on right base lung Ff-up chest film dated 10-16-12 since 10-11-12 shows no significant change in the moderate right sided pleural effusion with probable concomitant atelectasis The left and right upper lung are clear Atherosclerotic aorta Left hemidiaphragm is unremarkable A right transjugular catheter is now noted (with tip in the SVC right atrial junction) No significant interval chest findings

accumulation of fluids in the alveoli and pleural spaces. Diuretics and dialysis provides effective excretion of excess fluids and relief of congestion.

E. ULTRASONOGRAPHY
Kidney Ultrasound is a non-invasive procedure use to assess the size, location and shape of the kidneys and to detect cyst, tumors, abscess, obstruction and stones. The normal measurement of kidneys is about 9 to 13 cm long and about 5 to 7.5 cm (2 to 3 inches) wide. Right kidney is slightly lower than the left because of the anatomical position of the liver

DATE 10-4-12

FINDINGS Right kidney measures 9.1x4.4x4.3 cm with cortical thickness of 0.9 cm while the left kidney measures 6.6x3.1x2.9 cm with cortical thickness of 0.7 cm. Both kidneys exhibit increase parenchymal echogenicity with poor corticomedullary differentiation. Negative for neither calculi nor hydronephrotic changes. IMPRESSION: Normal sized right kidney with medical renal disease Small sized left kidney with medical renal disease Suggestive for chronic kidney disease

ANALYSIS Diabetes mellitus and chronic hypertension causes deterioration and destruction of nephrons with the degenerative changes that take place in the arterioles and interlobular arteries of the kidneys. Although a compensatory hypertrophy of nephrons takes place to filter a larger load of solutes, with advanced renal damage, a number of functioning nephrons decline resulting to shrunken kidneys.

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F. URINALYSIS
Urinalysis is a physical, chemical and microscopic examination of a urine sample to detect urinary tract or metabolic disease. It also measures various compounds that pass thru the urine.

(LEGEND: ____ =Abnormally high, ____ =Normal, ____ =Abnormally low) 9-29-12 Physical analysis: Color Transparency Specific gravity Chemical analysis: Ph Protein Sugar Bilirubin Urobilirubin Nitrites Leukocytes Kettones Ascorbic acid Automated Urine Microscopy analysis: RBC WBC Bacteria Epithelial cells Mucus threads FINDINGS Yellow Turbid 1.009 5.0 +1 Negative Negative Negative Positive +3 Negative Negative 36 312 Many Occasional Occasional NORMAL VALUES Yellow Clear 1.015-1.025 4.6-8.0 Negative Negative Negative Negative Negative Negative Negative Negative ANALYSIS Destruction of nephrons allowed passage of large molecules like protein and RBC. Proteinuria suggests a glomerular or tubulointerstitial damage. Urine sediment findings of RBC suggests proliferative glomerulonephritis. On the other hand, presence of WBCs is suggestive of interstitial nephritis or urinary tract infection. All aspects of inflammation and immune function is affected by high levels of urea and metabolic wastes, including decreased granulocyte count, impaired humoral and cell-mediated
56 | P a g e

<3/hpf <5/hpf Negative

immunity and defective phagocyte function

G. ECHOCARDIOGRAM
An echocardiogram is a test in which ultrasound is used to examine the heart. It also offers far more sophisticated and advanced imaging. This is known as twodimensional (2-D) Echo and is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle. Doppler is a special part of the ultrasound examination that assesses blood flow (direction and velocity). During the Doppler examination, the ultrasound beams will evaluate the flow of blood as it makes it way though and out of the heart. This information is presented visually on the monitor as color images or grayscale tracings and also as a series of audible signals with a swishing or pulsating sound.

9-26-12 2 DIMENSIONAL ECHO

FINDINGS Normal left ventricular dimension with hypertrophied walls with increase myocardial infarction of 147 gm/m2 and increased relative wall thickness of 0.48 with hypokinesia of the posterior interventricular septum, posterior and lateral left ventricular free wall from base to apex. The inferior left ventricular freewall from base to mid is likewise hypokinetic. The EF is 46%. Normal right ventricular dimension with adequate contractility and systolic function (RVFAC of 47%; TAPSE of 1.7cm). Normal right atrium, main pulmonary artery and aortic root dimension. Thickened aortic valve cusps with no restriction of motion, aortic annular calcification. Thickened mitral valve leaflets with no restriction of motion. Structurally normal tricuspid valve and pulmonic valve. No intra cardiac thrombus and no pericardial effusion noted.

ANALYSIS Diabetes-related increased fat metabolism increases lipid levels in the blood predisposing the patient to atherosclerosis. Furthermore anemia due to alteration in erythropoeisis produces a decrease in blood viscosity and a compensatory increase in heart rate. The decreased blood viscosity also exacerbates peripheral vasodilation and contributes to decreased vascular resistance. Cardiac output increases in a compensatory fashion to maintain

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COLOR FLOW DOPPLER STUDY

Mosaic color flow display noted across the tricuspid valve and mitral valve during systole and across the aortic valve and pulmonic valve during diastole. Normal mitral flow velocity ratio with reversed annular E/A with E/E of 32 Systolic pulmonary artery pressure of 35 mmhg by tricuspid regurgitation jet

tissue perfusion. These major factors along with fluid volume overload due to kidney failure causes a compensatory left ventricular hypertrophy.

CONCLUSION: Concentric left ventricular hypertrophy with multi segmental wall motion abnormality indicative of coronary artery disease (right coronary artery and left circumflex distribution) with depressed systolic function. There is Doppler evidence of grade 2 diastolic dysfunction(pseudomonal pattern) with evidence of filling pressure (LVEDP) Increased left atrial volume index Aortic sclerosis with trivial aortic regurgitation. Aortic annular calcification Mitral sclerosis with moderate mitral regurgitation Mild tricuspid regurgitation Normal pulmonary artery pressure with pulmonic regurgitation.

H. BLOOD WORKS
Glycosylated haemoglobin (HbAic) reflects serum glucose levels for the past 3-4 months. A normal non-diabetic HbA1C is 3.5-5.5%. In diabetes about 6.5% is good. The HbA1C test is currently one of the best ways to check diabetes is under control.

(LEGEND: ____ =Abnormally high, ____ =Normal, ____ =Abnormally low) PARAMETERS HbA1c Previous result brought by patient 8.20 NORMAL VALUES 3.5-5.5% ANALYSIS Excess glucose in the blood attaches to blood specifically hemoglobin. Lifespan of an RBC is 90-120 days, thus diabetic control for the past 3-4 months can be evaluated. Despite the patients claim of religiously taking her diabetic drugs, poor control was seen.

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BUN and creatinine blood test determines kidney function. Urea and creatinine are nitrogenous end products of metabolism. Urea is the primary metabolite derived from dietary protein and tissue protein turnover. Creatinine is the product of muscle creatinine catabolism.

(LEGEND: ____ =Abnormally high, ____ =Normal, ____ =Abnormally low) KIDNEY FUNCTION PARAMETERS Creatinine BUN NORMA L 9-27 9-29 10-1 10-4 10-7 10-16 VALUES mg/dL 0.63 0.76 0.85 0.63 0.52 0.09 0.72 0.05-0.12 39.27 62.46 65 69 8-20 Urea, a byproduct of protein metabolism, is one of the first nitrogenous wastes to accumulate in the blood due to alteration in the excretory function of the kidneys. Creatinine, a byproduct of muscle metabolism, is freely filtered in the glomerulus and is not reabsorbed in the renal tubules. Any creatinine that is filtered in the glomerulus is lost in the urine rather than being reabsorbed into the blood. Elevated levels of these waste products presents renal damage that has occurred in renal failure. 1018

9-26 0.63 -

ANALYSIS

I. CAPILLARY BLOOD GLUCOSE MONITORING

The method of capillary blood glucose measurement is a quick and simple technique that lets us know the blood-glucose level. (LEGEND:____ =Abnormally high, ____ =Normal, ____ =Abnormally low) DATE 10-1-12 TIME 6am 10:30am 2:30pm 6pm 10pm 2am 6am 10am 2pm 6pm 10pm 2am 6am BLOOD SUGAR RESULT 177mg/dl 176 mg/dl 178 mg/dl 240 mg/dl 204 mg/dl 164 mg/dl 64 mg/dl 180 mg/dl 176 mg/dl 248 mg/dl 255 mg/dl 156 mg/dl 127 mg/dl INSULIN AND ROUTE HR 2 u, SQ given HR 2 u, SQ given HR 2 u, SQ given HR 6 u, SQ given HR 4 u, SQ given HR 4 u, SQ given Given D5050 1 vial HR 2 u, SQ given HR 2 u, SQ given HR 6 u, SQ given HR 4 u, SQ given HR 2 u, SQ given No coverage INSULIN SLIDING SCALE 140-180 give 2 U HR SR 181-220 give 4 U HR SR 221-260 give 6 U HR SR 261-300 give 8 U HR SR
59 | P a g e

10-2-12

10-3-12

10-4-12

10-5-12

10-6-12

10-7-12 10-8-12 10-9-12 10-10-12 10-11-12

10-12-12 10-13-12 10-14-12 10-15-12 10-16-12 10-17-12

10am 206 mg/dl 2pm 253 mg/dl 6pm 106 mg/dl 10pm 71 mg/dl 2am 157 mg/dl 6am 250 mg/dl 10:30am 256 mg/dl 6pm 320 mg/dl 10pm 71 mg/dl 2Am 124 mg/dl 6am 147 mg/dl 10am 243 mg/dl 2pm 243 mg/dl 10pm 138 mg/dl 2am 152 mg/dl 6am 233 mg/dl 10am 234 mg/dl 2pm 96 mg/dl Decreased frequency to q8 10pm 147 mg/dl 6am 136 mg/dl 2pm 151 mg/dl 10pm 128 mg/dl 6am 115 mg/dl 2pm 126 mg/dl 10pm 161 mg/dl 6am 135 mg/dl 2pm 69 mg/dl 10pm 110 mg/dl 6am 100 mg/dl 2pm 98 mg/dl 10pm 111 mg/dl 5am 25 mg/dl 6am 146 mg/dl 2pm 85 mg/dl 10pm 110 mg/dl 6am 103 mg/dl 2pm 135 mg/dl 6am 90 mg/dl 11am 6pm 124 mg/dl 91 mg/dl 6pm 130 mg/dl 82 mg/dl 1am 69 mg/dl 2am 216 mg/dl 3am 187 mg/dl 6am 122 mg/dl

HR 4 u, SQ given HR 6 u, SQ given No coverage No coverage HR 2 u, SQ given HR 6 u, SQ given HR 6 u, SQ given HR 6 u, SQ given HR 6 u, SQ given HR 2 u, SQ given HR 6 u, SQ given HR 6 u, SQ given No coverage HR 2 u, SQ given No coverage No coverage Npo Npo Give d5050 1 vial D5050 given @hd -60 | P a g e

ANALYSIS Altered pancreatic insulin secretion, peripheral resistance to insulin and increase production of glucose by the liver, all these three major characteristics of type II Diabetes Mellitus contribute to uncontrolled blood glucose level. The condition is further aggravated by patients kidney disease as kidney malfunction prolongs insulin half-life altering its action.

J. ENDOTRACHEAL ASPIRATION C/S

The simplest non invasive means of obtaining respiratory secretions from patients receiving mechanical ventilation.

DATE 9-29-12

10-4-12

FINDINGS >25 pus cells per lpf <25 squamous epithelial cells/lpf Occasional gram positive cocci in pairs Heavy growth escherichia coli >25 pus cells per lpf <25squamous epithelial cells/lpf Few gram positive cocci singly Heavy growth Klebsiella Pneumoniae (ESBL+)

ANALYSIS Impairment of the immune system made the patient more susceptible to infection. Several factors are involved including depression of humoral antibody formation, suppression of delayed hypersensitivity and decreased chemotactic function of the leukocytes.

K. SPUTUM C/S
A sputum culture and sensitivity test is used to determine whether the patient's sputum (pulmonary secretion) contains pathogenic bacteria or other infectious agents and to identify the antibiotic that will be most effective for treating the infection. . DATE 9-30-12 FINDINGS >25 pus cells per lpf <25 squamous epithelial cells/lpf Occasional gram positive cocci singly and in pairs Culture: no significant pathogens isolated ANALYSIS Impairment of the immune system made the patient more susceptible to infection. Several factors are involved including depression of humoral antibody formation, suppression of delayed hypersensitivity and decreased chemotactic function of the leukocytes.

L. BLOOD C/S
Blood culture and sensitivity is used to identify the bacteria causing the infection and to identify the antibiotic that will be most effective for treating the infection.
61 | P a g e

DATE 10-9-12

10-8-12

10-13-12

FINDINGS Collected on 10-6-12 Anaerobic bottle: no growth after 3 days incubation Collected on 10-6-12 Aerobic bottle: no growth after 2 days incubation Collected on 10-6-12 Anaerobic bottle: no growth after 7 days incubation Aerobic bottle: no growth after 7 days incubation

ANALYSIS Although kidney failure alters the patients immune system, with pharmacologic regimen and other medical management, no invasion of pathologic microorganisms in the blood developed.

M. INTAKE & OUTPUT

One of the most basic methods of monitoring a client's health is measuring intake and output, commonly called I and O. By monitoring the amount of fluids a client takes in and comparing this to the amount of fluid a client puts out. The health care team can gain valuable insights into the client's general health as well as monitor specific disease conditions specifically for patients suffering from kidney problem. September 26, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 Hour TUBE 50 50 50 PARENTERAL 150 255 370 TOTAL 200 305 420 925 OUTPUT URINE 1200 600 790 TOTAL 1200 600 790 2590 FLUID BALANCE -1000 -295 -370 -1665

September 27, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 190 270 360 PARENTERAL 477 416 218 TOTAL 667 686 578 1931 OUTPUT URINE 1030 810 510 TOTAL 1030 810 510 2350 FLUID BALANCE -363 -124 +68 -419

September 28, 2012 INTAKE OUTPUT

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SHIFT 7-3 3-11 11-7 24 HOUR

TUBE 400 189 400

PARENTERAL 196 479.5 320

TOTAL 596 668.5 720 1984.5

URINE 420 730 640

TOTAL 420 730 640 1790

FLUID BALANCE +176 -61.5 +80 +194.5

September 29, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 220 430 430 PARENTERAL 134 230 130 TOTAL 354 660 560 1574 OUTPUT URINE 630 450 430 TOTAL 630 450 430 1510 FLUID BALANCE -276 +210 +130 +64

September 30, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 1, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 410 380 380 PARENTERAL 85 80 130 TOTAL 495 460 510 1465 OUTPUT URINE 350 100 200 + HD 2L TOTAL 350 100 2200 2650 FLUID BALANCE -145 +360 -1690 -1475 TUBE 460 460 460 PARENTERAL 135 50 130 TOTAL 595 550 590 1735 OUTPUT URINE 420 300 2080 TOTAL 420 300 2080 2800 FLUID BALANCE +175 +250 -1490 -1065

October 2, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 3, 2012
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OUTPUT TOTAL 550 560 450 1560 URINE 350 100+2000 ml (HD) 0 TOTAL 350 2100 0 2450 FLUID BALANCE +200 -1540 +450 -890

TUBE 420 420 400

PARENTERAL 130 140 50

INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 4, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 200 350 200 PARENTERAL 170 160 140 TOTAL 370 510 340 1220 TUBE 200 420 420 PARENTERAL 200 50 TOTAL 200 620 470 1300

OUTPUT URINE 0 0 + HD 2.5L 0 TOTAL 0 2500 0 2500 FLUID BALANCE +200 -1880 +470 -1210

OUTPUT URINE 0 0 2000 TOTAL 0 0 2000 2000 FLUID BALANCE +370 +510 -1660 -780

October 5, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 6, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 7, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 8, 2012
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OUTPUT TOTAL 490 650 500 1640 URINE 0 0 0 TOTAL 0 0 0 0 OUTPUT TOTAL 730 780 480 1990 URINE 0+HD 2.5L 0 0 TOTAL 2500 0 0 2500 FLUID BALANCE -1770 +780 +480 -510 FLUID BALANCE +490 +650 +500 +1640

TUBE 440 420 420

PARENTERAL 50 230 80

TUBE 650 650 400

PARENTERAL 80 130 80

OUTPUT TOTAL 440 810 430 1680 URINE 0 0 0 TOTAL 0 0 0 0 FLUID BALANCE +440 +810 +430 +1680

TUBE 360 520 350

PARENTERAL 80 290 80

INTAKE SHIFT 7-3 3-11 11-7 24 HOUR October 9, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 300 100 200 PARENTERAL 130 130 80 TOTAL 430 230 280 940 TUBE 180 70 60 PARENTERAL 80 230 130 TOTAL 260 300 190 760 0 0 0

OUTPUT URINE TOTAL 0 0 0 0 OUTPUT URINE 0 0+HD 2.5L 0 TOTAL 0 2500 0 2500 FLUID BALANCE +430 -2270 +280 -1560 FLUID BALANCE +260 +300 +190 +760

October 10, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 300 300 170 PARENTERAL 80 180 80 TOTAL 380 480 250 1110 0 0 0 OUTPUT URINE TOTAL 0 0 0 0 OUTPUT TOTAL 290 530 460 1590 URINE 0 0+HD 2.5L 0 TOTAL 0 2500 0 2500 80 230 10 FLUID BALANCE +290 -1970 +460 -1220 FLUID BALANCE +380 +480 +250 +1110

October 11, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 210 310 450 PARENTERAL

October 12, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 360 210 350 PARENTERAL 80 150 30 TOTAL 440 360 380 1180 OUTPUT URINE 100 30 0 TOTAL 100 30 0 130 FLUID BALANCE +340 +330 +380 +1050

October 13, 2012

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INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 480 370 350 PARENTERAL 180 90 80 TOTAL 660 460 430 1550

OUTPUT URINE 70 30 40 TOTAL 70 30 40 140 FLUID BALANCE +590 +430 +390 +1410

October 14, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 180 70 60 PARENTERAL 80 230 130 TOTAL 260 300 190 760 0 0 0 OUTPUT URINE TOTAL 0 0 0 0 FLUID BALANCE +260 +300 +190 +760

October 15, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 370 420 420 PARENTERAL 70 200 50 TOTAL 370 620 470 1460 0 0 0 OUTPUT URINE TOTAL 0 0 0 0 OUTPUT TOTAL 490 400 360 1250 URINE 70+2500 ml (HD) 0 50 TOTAL 2570 0 50 120 FLUID BALANCE -2080 +400 +310 +1370 FLUID BALANCE +370 +620 +470 +1460

October 16, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 410 310 350 PARENTERAL 80 90 10

October 17, 2012 INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 390 370 420 PARENTERAL 100 80 120 TOTAL 490 450 540 1480 OUTPUT URINE 0 120 30 TOTAL 0 120 30 150 FLUID BALANCE +490 +330 +510 +1330

October 18, 2012

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INTAKE SHIFT 7-3 3-11 11-7 24 HOUR TUBE 410 420 330 PARENTERAL 100 70 90 TOTAL 510 490 420 1420

OUTPUT URINE 0 + 2500 ml (HD) 80 0 TOTAL 2500 80 0 2580 FLUID BALANCE -1990 +410 +420 -1160

IX. MANAGEMENT
A. COURSE IN THE WARD
SUMMARY On admission to CCU, patient was intubated, NGT was inserted as well as foley catheter. Laboratories and diagnostics were also done such as (ECG, CXR, CBC, ABG, Crea,K, Mg, Na,Trop I, 2DED, HBAIC). She was then hooked to mechanical ventilator. Vital signs revealed 189/90 mmHg,HR was 102, RR was 24, O2 sat was 72%, CBG was 358 mg/dl. Isoket drip of 2mg/hour was also started. Magnesium was 0.a86 meq/L and calcium was 118, doctor ordered Ca gluconate of 1 amp and then MgSO4 of 25 mg for 2 hours. BP was 200/120 mmHg, patient was put on NPO temporarily, nicardipine was started @ 2mg/hr. Patients sensorium was also decreasing but was closely monitored. On the second hospital day, Blood sugar was monitored every 4 hours. She was also referred to Dr. Cecile Tady for Pulmonary management and to Dr. Ma. Cecilia Manalo for nephro consult and management due to an increase in creatinine level. On the third hospital day, CBC revealed Hgb of 76, Hct of 23, platelet count of 8.10 and WBC of 292. 2 units of PRBC were transfused to run for 4 hours. Feeding was also started of 1800kcal/day in 6 divided doses (renal and diabetic diet). On the fourth hospital day, cardiac monitor showed Atrial Fibrillation and amiodarone of 150 mg/IV was given and then 300 mg to run for 24 hours. Calcium level was 1.1 and Calcium gluconate 1 amp was given.

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Patient also had fever of 37.9 and paracetamol tablet was given. Isoket drip was also discontinued. On the fifth hospital day, nicardipine drip was discontinued. Since there was intermittent AF, lanoxin was started half tablet every other day. CBC results were low, Hgb was 94, Hct was 0.29, platelet count was 84 and WBC was 14.6, 1 unit PRBC was also transfused. Amiodarone drip was discontinued. She was still having fever of 38.1, 1 amp of paracetamol IV was given. Tazocin of 2.25 grams/IV every 8 hours and Levofloxacin of 500mg/IV EOD were also started. There was regression of congestion and effusion as seen in the CXR. Patient was then extubated and hooked to 4LNC. Patient showed stable hemodynamics and was then ordered to be transferred to private room of choice (APW) On the sixth hospital day, patient agreed to do dialysis and femoral catheter was inserted. Crackles were noted. Hemodialysis was done. Orders included duration: 3 hours, bicarb bath, UF 2L, LOPPS 16, BFR 200 ml/min and Recormon of 5000 units SQ post HD was given. On the seventh hospital day, sodium .bicarb was discontinued and furosemide IV was shifted to oral. Combivent neb was also discontinued, instead Salbutamol + 2 cc NSS was ordered. Patient was in respiratory distress, wheezes and rhonchi were heard so she was hooked back to NIV (Fi02 40% PS 8 PEEP %) and ABG was ordered after 1 hour. There was also a presence of thick, yellowish secretions. On the eighth hospital day, patient was in respiratory acidosis. On the ninth hospital day, pleural effusion and respiratory distress was noted and 2 units of PRBC were transfused. Decreased sensorium was also observed hence transfer to MICU. At MICU, Tazocin was shifted to Meropenem, and D50 50 + 10 units HR was given hourly. Patient was also re intubated and hooked back to NIV. HD was done (UF 2L) and 2 units PRBC were transfused. Foley catheter was also removed. Patient was also referred to Dr. Ang for IJ insertion On the tenth hospital day, pt was scheduled for Tuesday-ThursdaySaturday of HD.

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On the eleventh hospital day, they planned to remove NGT and start progressive diet. CBG was decreased to 8hours. Patient was stable, awake, comfortable but with occasional crackles and rhochi and haziness and infiltrates at right base. She was then extubated and hooked to 4LNC. On the twelfth hospital day, she was then hooked to LNC. On the thirteenth hospital day, NGT was pulled out. Patient was hooked back to BIPAP because of stridor. On the fourteenth hospital day, feeding was resumed. On the fifteenth day, patient was allowed to eat and off NIV was done On the sixteenth day, weaning was facilitated. They planned to transfer to ROC. On the seventeenth day, HD was done and CXR portable as well. NIV was discontinued and was hooked back to 3LNC. Patient was then transferred to a regular room On the eighteenth, nineteenth and twentieth hospital day, patient was stable. On the twenty first hospital day, IJ was inserted On the twenty second hospital day, blood sugar was fluctuating. Corrections were done by giving a vial of D5050. On the twenty third hospital day, HD was done. On the twenty fourth hospital day, may go home from renal standpoint, to continue as outpatient, AVF may be done as outpatient and femoral catheter was removed. alternate

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FOCUS OF CARE NURSING INTERVENTIONS Performed the procedures aseptically and take note of the settings of the NIV Allayed anxiety of the patient Prepared equipments and assist medical doctor

DATE ADMISSION DAY 1 (September 26, 2012)

FOCUS OF CARE Admission of patient to CCU. Problem was ACS, HCVD, CKD sec. to DM Nephropathy: BP189/90mmHg HR-102 RR-24 Afebrile O2 Sat- 72% CBG- 358 mg/dl ECG revealed ST Depression; GCS 13 Hypertensive state (BP of 200/120 mmHg)

LABORATORIES Troponin- 0.08 Hgb- 76 Hct- 0.23 WBC- 8.1 Creatinine0.63 Platelet- 292

INTERVENTION S Patient was intubated (ET Tube of 7.5) Inserted NGT and Foley Catheter and was then hooked to NIV: TV- 400 PEEP- 10 PF-40 FiO2- 100%

Isoket drip was also started of 2mg/hour and Nicardipine drip of 2mg/hour Calcium- 118 Magnesium0.86 Gave Calcium gluconate 1 amp SIVP and Magnesium Sulfate 2.5mg for 2 hours D50 50 + 10 units HR were given

Watched out for hypotension and bradycardia. Close monitoring of blood pressure and heart rate Administration of accurate dosage and giving the medication within 5 to 10 minutes Monitored for hypoglycemia Administered furosemide slowly as rapid injection would cause deafness. Blood pressure precaution done. Monitored for 70 | P a g e

Hypocalcemia and Hypomagnesem ia

Hyperglycemia Pleural Effusion revealed by CXR with signs of retractions and rales CBG of 80mg/dl Furosemide 40mg was given SIVP every 6 hours

DAY 2 (September 27, 2012)

D50 50 IV was given Hypoglycemia Creatinine of 0.63 Increased Creatinine Patient was referred to Dr. Cecilia Manalo for Nephro consult and management and to Dr. Tady for pulmo management Feeding of 1800kcal/day in 6 divided doses was started 2 units PRBC was transfused

blood glucose and level of consciousness

DAY 3 (September 28, 2012) Nutrition CBC Results were low as evidenced by: Hbg- 76 Hct-23 Platelet Count292 WBC- 8.10

Coordinate with dietary about patients nutrition Facilitate proper blood transfusion and crossmatching Watch out for any allergic reaction to blood transfusion

Abnormal CBC

DAY 4 (September 29, 2012 Atrial fibrillation in RVR Temperature of 37.9 Hyperthermia Calcium level of 1.1 Hypocalcemia Calcium gluconate 1 amp was given DAY 5 (September 30, 2012 Normal Blood Pressure 130/70 mmHG and heart rate of 80 Intermittent AF Isoket drip discontinued Hgb: 94 Hct: 0.29 Platelet Ct: 84 WBC: 14.6 Temperature of Paracetamol 1 tablet 500mg was given Encouraged TSB and provide comfort Monitored cardiac rate Monitored blood pressure Amiodarone 150 mg/IV was given then 300mg to run for 24 hours Administered the drug following the 10 Golden Rules of Drug Administration

Lanoxin tab was started EOD

Monitored cardiac rate 71 | P a g e

38.1 Low platelet count, low hemoglobin and low hematocrit WBC of 14.6 Hyperthermia Mg: 1.07 Na: 136 K: 4.8 iCa: 1.15 Paracetamol 300mg/IV was given Tazocin of 2.25 gm/I every 8 hours and Leofloxacin 500 mg/IV were started Decreased blood pressure of 135/70 mmHg and HR was 72 bpm Nicardipine, Isoket and Amiodarone drips were consumed. IVF was shifted to heplock and TFL was 1,200 ml/day 1 unit PRBC was transfued Allergies to the drug and inform patient that overdose can occur more easily if dehydrated As mentioned

Leukocytosis

As mentioned

Infused using perfusion pumps for accurate administration. Facilitated limitations on fluid intake Maintain patency of heplock Encouraged patient participation and relief of anxiety regarding weaning Facilitated progression of weaning Assessed for difficulty of breathing and signs of distress Watchd out for 72 | P a g e

Absence of chest pain, DOB and patient was conscious and alert.

Weaning was initiated

Patient tolerated weaning and no signs of respiratory distress No DOB observed and has 100% Saturation

Patient was extubated and hooked to 4LNC O2 was decreased to 2 LNC

DAY 6 (October 1, 2012)

Transfer to Adult Pay Ward

signs of desaturation and DOB Serum Bicarbonate: 0.18 Facilitated transfer of patient and proper endorsement of patient information and status Informed patient about their fluid limit

Elevated Creatinine and BUN Crea: 8.5 BUN: 65 WBC: 19,000

Suggested Dialysis Fluid restriction was decreased to 1L/day and weighed patient once daily Sodium Bicarbonate 650 mg/tab Thrice a day was started Femoral catheter was inserted Recormon 5000 units SQ was given post HD Nebulization of salbutamol + 2 cc of NSS

Elevated Bicarbonate levels DAY 7 (October 2, 2012)

For HD Duration: 3 hours Bicarb bath LOPPS 16 UF 2L BFR 200ml/min O2 sat of 91 % CXR was done

Patient agreed to do dialysis

Secured consent. Monitored vital signs.

Abnormal breath sounds present (Rhonchi)

Tachypneic Wheezes Rhonchi DAY 8 (October 3, 2012)

Increased O2 to 4LNC Nebulization of salbutamol neb + 2 cc NSS 15 minutes apart for 3 doses

Proper assessment of the breath sounds and giving the nebulization appropriately Encourage deep breathing and coughing exercises Assess progression of symptoms

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only ABG was done pH: 7.140 PCO2: 67 PO2: 106.4 HCO3: 22 O2 Sat: 97 Presence of Rhonchi GCS 13 Hooked back to NIV FiO2 40% PEEP 5 PS 8 Suctioned secretions Revised NIV settings FiO2: 40% PS: 12 PEEP: 6 Suctioned aseptically Encouraged coughing and deep breathing exercises Bronchial tapping done

DAY 9 (October 4, 2012)

Presence of thick and yellowish secretions Respiratory acidosis

Progression and persistent pleural effusion and respiratory acidosis and decreased sensorium Hemodialysis

Na: 137 K: 6.5 Crea: 0.63

Patient was transferred to MICU. Watched out for DOB and monitored vital signs Patient had HD again UF of 2.5L) Suggestion of IJ insertion and Blood transfusion 2 units PRBC was transfused with repeat CBC 6 hours post BT Tazocin was shifted to Meronem 500mg/IV OD D50 50 + 10 units HR was given hourly 74 | P a g e

RBC: 2.89 Hgb: 85 Hct: 0.26

WBC: 21, 000 Abnormal CBC

CBG: 256 mg/dl Infection SaO2: 78 % Hyperglycemia

Patient was in respiratory distress

for 4 doses Patient was intubated again and hooked to NIV FiO2: 60% PEEP:% BUR: 20 Foley catheter was removed Nutrition ET tube was adjusted to level 22 O2 sat of 95% Inquiry about IJ insertion OF of 1800 kcal 2:1 dilution 60% CHO 80 grams CHON and the rest is Fats in 6 equal feedings O2 Sat of 98% Patient was then referred to Dr. Ang for IJ insertion Patient had HD and UF of 2L and 2 units PRBC was transfused while in dialysis. She was scheduled for Tuesday, Thursday and Saturday dialysis while admitted Weaning was also started and eventually extubated and hooked to 4LNC

Watched out for hypoglycemia

DAY 10 (October 5, 2012)

Watched out for DOB and monitored vital signs

Maintained proper placement

DAY 11 and 12 (October 6 and 7, 2012)

Alert, awake, afebrile

Checked placement of NGT before feeding.

DAY 13 (October 8, 2012)

Patient was stable, awake, comfortable but with occasional crackles and rhochi and haziness and infiltrates at right base Nutrition

Monitor for signs and symptoms of respiratory distress

O2 Sat 95%

DAY 14 (October 9,

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2012) DAY 15 (October 10, 2012) DAY 16 (October 11, 2012) DAY 17 (October 12, 2012)

Presence of stridor, rales, retractions Removed NGT and was put on NPO except meds Nutrition Hooked back to BIPAP Watch out for signs and symptoms of respiratory distress

No DOB, good air ventilation Feeding was resumed

DAY 18,19,20 (October 13,14 and 15, 2012) DAY 21 (October 16, 2012) DAY 22 (October 17, 2012)

Plan to transfer to ROC Alternated off NIV Monitor for signs and symptoms of infection

Renal No DOB

Facilitated weaning Patient was hemodynamicall y stable Hemodynamics D/C NIV and hooked to 3 LNC Patient was stable except that blood sugar was fluctuating Renal Transferred to ROC

s/p HD (UF 2.5L)

DAY 23 (October 18, 2012) DAY 24 (October 19, 2012

Discharge Plan

s/p double lumen catheter insertion via Right intrajugular vein 76 | P a g e

Corrections were done by giving D50 50

Monitored vital signs

s/p HD 2.5L

May go home with Renal standpoint, AVF may be done as outpatient s/p Fem cath removal

Provided discharge planning using METHODS

B. SURGICAL MANAGEMENT
Patient EVG was known for having chronic kidney disease; she also had a progressively increased creatinine and blood urea nitrogen level. Thus on the sixth day of hospital stay she was advised to underwent hemodialysis, therefore a vascular access was needed. An access to the vascular system must be established to allow blood to be removed, cleansed and then returned to the patients vascular system. A temporary access was done to the patient by means of femoral vein catheterization. But on a 21st hospital stay, they transfer her vascular access from femoral to jugular vein; notice that the creatinine level is still high despite of dialysis, concluding that the femoral access is not sufficiently function as well as it should be to thoroughly cleanse the blood of the patient. There are two types of dialysis accesses. The first type involves the creation of permanent connection between an artery and vein under the skin. The two kinds of permanent access are the, arteriovenous fistulas and arteriovenous grafts. The other type of access involves the direct placement of dialysis catheter into large vein in the neck (internal jugular), chest (subclavian) or groin (femoral).

DIALYSIS CATHETER

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Catheters are flexible, hollow tubes which allow blood flow in and out of the body. The most commonly used as a temporary access for up to three weeks or waiting for a fistula or graft to mature. The subclavian and internal jugular catheter are contraindicated for patients with acute respiratory distress who cannot be positioned either supine or in the trendelenburg position while femoral catheter is used for acutely ill patients confined to bed.

A special nursing management is necessary with this catheter. Aseptic technique when initiating and when terminating dialysis is of utmost importance. All catheters are prone to infection. The caps and ports should be wrapped in a 4 x 4 dressing soaked in an approved disinfectant before initiating or ending dialysis. It is of the utmost importance that the caregiver is aware of the type of catheter the patient has placed in order to be able to provide the appropriate site care. The appearance of the exit site, especially if there is redness or drainage, must be reported.

C. MEDICAL MANAGEMENT
Blood Transfusion Blood transfusion is a safe, common procedure in which you receive blood through an intravenous (IV) line inserted into ones circulation intravenously. Transfusions are used in a variety of medical conditions to replace lost components of
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the blood. They are typically only recommended when a persons hemoglobin levels fall below the normal range which is 120-150 mg/dL. Date September 26, 2012 Component 2 Units Packed Red Blood Cells Number Type B+ Blood Bag number: PHC#D12-7574 Type B+ Blood Bag number: PHC#D12-7459 1 Unit Packed Red Blood Cells 2 Units Packed Red Blood Cells Type B+ Blood Bag number: PHC#D12-6917 Type B+ Blood Bag number: PHC#D12-7967 Type B+ Blood Bag number: PHC#D12-7900 HEMODIALYSIS Hemodialysis is a method that is used to achieve the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of renal failure. It is indicated when nitrogenous wastes and the water and electrolyte balance cannot be kept under control by other means. Date October 02, 2012 Pre-Dialysis Assessment: LOC: 15 Vital Signs: BP-140/80 mmHg CR - 96 RR 19 bpm Temp 36.1 Mobility Restrictions confined to bed Allergies no known allergies Diet 1800 Kcal/day Contraptions IV line, NGT, O2 at 1 LPM Access Right Femoral (10/01/12) Post-Dialysis Assessment: LOC: 15 Vital Signs: BP-110/80 mmHg CR - 106 RR 28 bpm Temp 36.6 Orders: Time Started - 3:00 PM Time Ended 6:00 PM Net Ultrafiltration 2 L Analysis The patient blood works on the same date showed Hemoglobin of 76 mg/dL and Hematocrit of 0.23 which is very low compared to the normal value of 120-150 mg/dL. Blood work results on September 27, 2012 showed hemoglobin of 94 mg/dL and hematocrit of 0.29 mg/dL. Blood work on the same date showed hemoglobin of 85 mg/dL and hematocrit of 0.26 mg/dL

September 28, 2012 October 4, 2012

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Orders: Duration 3 hours Blood Flow 200 ml/min Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2 L October 03, 2012 Assessment: LOC: GCS 15 Vital Signs: BP-170/100 mmHg CR - 87 RR 24 bpm Temp 36.1 Mobility Restrictions confined to bed Allergies no known allergies Diet 1800 Kcal/day Contraptions IV line, NGT, O2 at 1 LPM, Foley Catheter Access Right Femoral (10/01/12) Orders: Duration 4 hours Blood Flow 200 ml/min Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2.5 L Special Notation: Hold Amlodipine Temporarily With NGT CBG every 4 hours Bicarb bath Assessment: LOC: 15 Vital Signs: BP-180/100 mmHg CR - 81 RR 20 bpm Temp 37.1 Mobility Restrictions confined to bed Allergies no known allergies Diet OF Contraptions IV line Access Right Femoral (10/01/12) Assessment: LOC: GCS 15 Vital Signs: BP-140/80 mmHg CR - 78 RR 20 bpm Temp 36.6 Orders: Time Started - 2:45 PM Time Ended 6:45 PM Net Ultrafiltration 2.5 L Special Notation: HGT at 6 PM 106 mg/dl

October 6, 2012

Assessment: LOC: 15 Vital Signs: BP-140/80 mmHg CR - 78 RR 19 bpm Temp 36.8 Orders: Time Started - 11:00 AM Time Ended - 3 PM Net Ultrafiltration 2.52 Pressure Dressing Due -

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Orders: Duration 4 hours Blood Flow 200 Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2.5 L October 9, 2012 Assessment: LOC: GCS 11, conscious Vital Signs: BP-160/90 mmHg CR 84 RR 21 Temp 37.4 Mobility Restrictions bed rest Allergies no known allergies Diet OF Contraptions IV line Access Right Femoral (10/01/12) Orders: Duration 4 hours Blood Flow 200 Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2 L October 12, 2012 Assessment: LOC: GCS 15, conscious Vital Signs: BP-170/90 mmHg CR - 81 RR 22 Temp 36.9 Mobility Restrictions bed rest Allergies no known allergies Diet OF Contraptions IV line Access Right Femoral (10/01/12) Orders: Duration 4 hours Blood Flow 200 Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2 L Assessment: LOC: GCS 11 Vital Signs: BP-150/71 mmHg CR - 71 RR 20 bpm Temp 37.4 Orders: Time Started - 9:00 AM Time Ended - 1:00 PM Net Ultrafiltration 2 L Assessment: LOC: GCS 11 Vital Signs: BP-150/71 mmHg CR - 71 RR 20 bpm Temp 37.1 Orders: Time Started - 9:00 PM Time Ended - 1:00 AM Net Ultrafiltration 2 L Pressure Dressing Due -

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October 16, 2012

Assessment: LOC: GCS 15, conscious Vital Signs: BP-160 / 80 mmHg CR - 71 RR 20 Temp 36 Mobility Restrictions bed rest Allergies no known allergies Diet Progressive DM Diet Contraptions IV line Access Right Femoral (10/01/12) Orders: Duration 4 hours Blood Flow 200 Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2.5 L

Assessment: LOC: GCS 15, conscious Vital Signs: BP-130 / 80 mmHg CR - 96 RR 24 Temp 36.4 Mobility Restrictions bed rest Orders: Time Started - 8:30 Time Ended 12:30 Net Ultrafiltration 2.5 L Duration 4 hours Special Notation: - Episode of slight chest pain - Left Arm precaution Assessment: LOC: GCS 15, conscious Vital Signs: BP-130 / 75 mmHg CR - 81 RR 18 Temp 37.1 Mobility Restrictions bed rest Orders: Time Started - 12:30 Time Ended 4:30 Net Ultrafiltration 2.5 L Duration 4 hours

October 18, 2012

Assessment: LOC: GCS 15, conscious Vital Signs: BP-160 / 80 mmHg CR - 80 RR 20 Temp 36.7 Mobility Restrictions confined to bed Allergies no known allergies Diet Progressive DM Diet Contraptions Heplock Right Access Right Intrajugular cath Hepatitis Profile Non-reactive (09/28/12) Orders: Duration 4 hours Blood Flow 200-250 Dialysate Flow Rate 500 Anti-coagulant Low Molecular Weight Heparin Target Net Ultrafiltration 2.5 L Actual UF Volume 602 Set UF Volume 2800

ANALYSIS

Upon admission on September 26, Laboratory Work on Creatinine

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had been performed with elevated value at 0.6mg/dL followed by another blood work the following day with creatinine at 0.63 and Blood, Urea, Nitrogen at 39.27 both higher than normal. It was only on October 02 that hemodialysis therapy had been initiated after a progressive increase in creatinine levels reaching 0.8mg/dL on October 01 as well as BUN levels of 62.46 mg/dL. Another hemodialysis session was conducted on October 03 and scheduled every 2-3 days after each session as prescribed by the physician. In addition to blood works, ultrasonography of the kidneys reveal a small sized left kidney with medical renal disease which is suggestive of chronic kidney disease. For clarification purposes, no pre-hemodialysis weight is available for reasons that the patient had difficulties maintaining a posture for weight to be measured. The intake and output of the patient becomes the basis for the target net ultrafiltration set by the dialysis nurses.

X. DRUG STUDY (SEE ANNEX II)

XI. LIST OF PRIORITIZED NURSING PROBLEMS

DATE IDENTIFIED 10/15/2012 NURSING PROBLEM IDENTIFIED Excess Fluid Volume related to impaired renal and cardiovascular function as evidenced by peripheral and pulmonary edema CUES SUBJECTIVE: Nahihirapan akong huminga tsaka napapansin kong namamaga ang binti ko. OBJECTIVE: (+) crackles Tachypnea (+) Orthopnea Positive fluid JUSTIFICATION Health Threat Actual problem Lifethreatening Physiolo gic need (homeostasis) Circulati on Fluid PRIORITY NUMBER 1

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10/15/2012 Decreased Cardiac Output related to altered stroke volume, altered afterload and altered contractility

balance (+1460) Oliguric Elevated BUN (69) and creatinine (0.59) levels Kidney ultrasound showed small sized left kidney suggestive of chronic kidney disease Grade I pitting edema on both lower extremities Chest X-ray revealed pulmonary edema and pleural effusion with probable concomitant atelectasis ABG showed respiratory acidosis and hypoxemia Hyperkalemia

overload is a major factor affecting respiratory and cardiovascular system. Sustained fluid volume excess will aggravate left ventricular failure and pulmonary congestion. All efforts to preserve cardiovascular function and to improve ventilation will be ineffective unless this problem is controlled.

OBJECTIVE: Easy fatigability Heart Rate: 98 bpm (+) signs of dysnea: RR27, (+) use of accessory muscles (+) Atrial Fibrillation noted (+) Grade I

Health Deficit Actual problem Lifethreatening Physiolo gic need (homeostasis) Circulati on Left ventricular hypertrophy as a

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pitting edema on both lower extremities Unequal temperature on lower extremities Right: 35.7 Left: 36.1 (+) Weaker peripheral pulse at right extremity Chest X-ray showed atherosclerotic aorta 2-Decho revealed concentric left ventricular hypertrophy with multi segmental wall motion abnormality indicative of coronary artery disease (right coronary artery and left circumflex distribution) with depressed systolic function Ejection Fraction: 46% 10/15/2012 Impaired Gas Exchange related to ventilation perfusion imbalance and alveolarcapillary membrane SUBJECTIVE: Medyo hinihingal ako paminsan minsan OBJECTIVE: PR: 89 RR: 27

result of uncontrolled hypertension and fluid volume overload affects major organs of the body like the brain, kidney while it directly affects the respiratory system as ineffective pumping of the heart causes pooling of fluid back to the pulmonary system causing congestion.

Health Deficit Actual problem Lifethreatening Physiolo gic need (breathing)

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changes

02 sat: 89% (+) nasal flaring (+) restlessness (+) use of accessory muscles (+)diaphoresis Abnormal ABG pH- 7.28 PCO2-44.4 HCO3 20.4

Airway Heart failure due to chronic hypertension aggravated by excess fluid volume results to congestion in the pulmonary system, thus ventilation and perfusion mismatch. Management of left sided failure and fluid volume overload will facilitate treatment of pulmonary problems. Health Deficit Physiolo gic need (food) Abnorma lities of calcium, phosphate and Vitamin D metabolism occur in renal failure causing hypocalcemia and skeletal complications. Erythropoietin production is insufficient to stimulate adequate red blood cell production by the bone marrow. When untreated, anemia causes or contributes to weakness, fatigue, depression, insomnia and decreased cognitive function. 4

10/15/2012

Imbalance Nutrition: Less than Body Requirements related to altered metabolic processes

SUBJECTIVE: Madalas akong walang ganang kumain OBJECTIVE: Muscle weakness Poor muscle tone Decreased subcutaneous fat/muscle mass (atrophy) Hypocalcemia Anemia

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10/15/2012

Impaired Skin OBJECTIVE: Integrity 1 cm blister on related to the right hip altered Muscle mobility atrophy Motor strength 2/5 on both lower extremities Dry skin

Health threat Actual problem Physiolo gic need All aspects of inflammation and immune function may be affected adversely by high levels of urea and metabolic wastes, including a decrease in granulocyte count. Intact skin should be maintained to prevent infection. Health threat Actual problem Physiolo gic need (excretion) Constipat ion triggers valsalva maneuver which alters cardiac rate affecting cardiac output and tissue perfusion. With the presence of coronary artery disease, chest pain could occur with decreased coronary perfusion. Health deficit Actual problem Physiolo gic need

10/15/2012

Constipation OBJECTIVE: related to fluid Irregular and dietary defecation restrictions and habits, (-) decreased bowel activity level movement for more than 2 days Restricted fluid intake (1000ml/day) Insufficient physical activity Electrolyte imbalance

10/15/2012

Fatigue related SUBJECTIVE: to anemia and Verbalized altered inability to metabolic state maintain usual routines

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OBJECTIVE: Low hemoglobin levels Muscle atrophy Motor strength 2/5 on both lower extremities Decreased performance of ADLs 10/15/2012 Impaired Physical Mobility related to decreased muscle strength, discomfort and neuromuscular and musculo skeletal impairment SUBJECTIVE: Madalas nakahiga lang ako. OBJECTIVE: Muscle atrophy Motor strength 2/5 on both lower extremities

(homeostasis) Correctio n of anemia and control of altered metabolic processes will help regain muscle strength

Health threat Actual problem Physiolo gic need (homeostasis) Regainin g muscle and bone strength requires time especially with the existing chronic condition. Health threat Actual problem Physiolo gic need (homeostasis) Chronic kidney disease and prolonged immobility promotes bone resorption. Furthermore, diabetic neuropathy affects neuromuscular responses. This requires time to recover.

10/15/2012

Activity Intolerance related to generalized weakness and complete bed rest status

OBJECTIVE: Generalized weakness Muscle atrophy Motor strength 2/5 on both lower extremities On bedrest Confined to bed Neuro muscular/ musculo skeletal impairment

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10/15/2012

Self-Care Deficit: bathing/ hygiene, dressing/ grooming, feeding, toileting related to muscular weakness, discomfort and impaired mobility status

OBJECTIVE: Generalized weakness Muscle atrophy Motor strength 2/5 On bedrest Confined to bed Neuro muscular/ musculo skeletal impairment

Health threat Actual problem Physiolo gic need (homeostasis) This requires treatment or control of underlying cardiovascular, respiratory and renal problems. Does not require immediate attention. Potential Problem Foreseea ble Crisis Physiolo gic need (homeostasis) Altered immune response due to chronic renal disease and diabetes predisposes the patient to acquiring infections. Maintaining aseptic technique and following universal precautions prevents its occurrence.

10

10/15/2012

Risk for Infection related to depression of immunologic defenses

OBJECTIVE: Previous infection Previous blood works showed elevated WBC Endotracheal aspiration C/S showed heavy growth of escherichia coli and growth Klebsiella Pneumoniae Sputum G/S showed occasional gram positive cocci singly and in pairs Inadequate primary defenses (broken skin, stasis of body fluids, change in pH secretions) Inadequate

11

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secondary defenses (decreased hemoglobin, suppressed inflammatory response) 10/15/2012 Risk for Fall related to muscle atrophy, neuropathy, difficulty with gait and body weakness OBJECTIVE: High risk on fall risk assessment tool Anemia Blurred vision Impaired physical mobility Neuropathy Muscle atrophy Motor strength 2/5 on both lower extremities Potential problem Foreseea ble Crisis Safety (security of health and family) Altered physical mobility, body weakness, decreased peripheral sensation and impaired visual acuity predisposes the patient to fall. Precautionary measures like raising siderails at all times and maintaining good lighting prevents occurrence. Potential problem Foreseea ble Crisis Safety (security of health and family) Hyperten sion and diabetes requires lifetime intake of medication while chronic kidney disease requires lifetime dialysis or kidney transplant. 12

10/15/2012

Risk for Ineffective Family and Individual Therapeutic Regimen Management related to excessive demands made on patient and family

OBJECTIVE: Diagnosed chronic kidney disease, diabetes and hypertension On continuous renal replacement therapy Lifetime management of chronic disease

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Family members should have sufficient knowledge of the illness and its sequelae. These are financially demanding management.

XII. NURSING CARE PLAN (SEE ANNEX III)

XIII. DISCHARGE PLANNING

MEDICATIONS
Medication Atorvastatin (Lipitor) 40mg/tablet Dosage/Route/ Frequency 1 tablet once a day taken orally every 8:00 in the morning 1tablet once a day taken orally every 8:00 in the evening Action It lowers the level of cholesterol in the blood. Patient Teaching

Ferrous Sulfate 300mg/tablet

Amlodipine (Norvasc) 5mg/tablet Lantus Long acting insulin 139mg/dl and

1 tablet once a day taken orally every 8:00 in the morning Inject Subcutaneously Once a day before breakfast

-Advice patient that drug can be taken with or without meals. -Warn patient to avoid alcohol. -Tell patient to inform prescriber of adverse reaction such as muscle pain, malaise and fever. Aids in formation of -Instruct patient not to crush or hemoglobin. chew the tablet -Tell patient to take tablet with juice(preferably orange juice) or water but not with milk or antacid. For easy absorption. -Advise patient to report constipation and change in stool color or consistency. Used treat high -Check blood pressure regularly blood pressure -Caution patient to continue taking drug even when feeling better Is long acting insulin -Check blood glucose level first used to control blood before administration sugar levels. - Instruct the patient to rotate the injection site to avoid lipodystrophy.
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below-no coverage 140-180mg/dl give 2 units 181-220mg/dl give 4units 221-260mg/dl give 6 units 261-300mg/dl give 8units

Sodium Bicarbonate 600mg/tablet Diphenhyramine Hydrochloride (Benadryl) 50mg/tablet

2 tablets twice a day taken orally every 8:00 in the morning and 8:oo in the evening 1tablet once a day taken orally every 8:00 in the evening

Neutralizes excess acid in the body

-Tell patient to take dose once daily at the same time each day. -Educate patient about sign and symptoms of low glucose level such as, fatigue weakness, confusion, profuse sweating and pallor. -Urge patient to wear or carry medical identification at all times. -Encourage patient to always carry hard candies in case of a low glucose episode. -Inform patient to avoid alcohol which lowers glucose levels. -Give drug with water, not milk; drug may cause hypercalcemia, alkalosis or possibly renal calculi

Used to promote sleepiness. To decrease sensation of pruritus.

Digoxin (Lanoxin) 0.125mg/tablet

tablet twice a day taken orally every 10:00 in the morning and 6:00 in the evening

To strengthen heart muscle contractility.

-Warn patient not to take this drug with any other products diphenhydramine. -Tell patient to take with food or milk to reduce GI distress -Warn patient of possible photosensitivity reactions. Advise use of a sunblock. -Teach patient or relative that before taking the drug obtain radial pulse for 1full minute. -Withhold drug and notify prescriber if theres excessively low pulse rate(6o beats per minute or less) -Advise patient to avoid the use herbal drugs or to consult physician before taking one.

EXERCISE
Discuss to the patient and relatives the importance of maintaining activity level to avoid further osteodystrophy and bone demineralization. Instruct a significant other to assist the patient in doing a Passive ROM (Range of motion) exercise for example: Should be done once per day.

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 Do each exercise 10 times or move to the point of resistance and hold for 30 seconds. Begin exercises slowly, doing each exercise a few times only and gradually build up to more. Try to achieve full range of motion by moving until you feel a slight stretch, but don't force a movement. Move only to the point of resistance. Do not force the movement. Keep limbs supported throughout motion. Move slowly, watching the patient's face for response to ROM. If the patient can able to walk, advise to do ambulation and to do simple ADL that she can tolerate to promote self care independence and promote good circulation to body.

TREATMENT
Encourage to monitor blood glucose level regularly and to instruct patient and relative the proper way to use a glucometer: Wash hands with warm water to help get blood to the fingertips Squeeze the finger you are going to prink until it turns red Prick finger with lancet Put a drop of blood to the strip Use blood glucose glucometer to display result Record result Encourage patient to continue hemodialysis twice a week or according to the scheduled date.

HEALTH TEACHING
Take your medication as directed. Instruct the patient the importance of monitoring the blood glucose before Instruct patient to check blood glucose 30 minutes before meal and 2 hours Advise the patient to eat food rich in fiber such as green leafy vegetables to

meals, at bedtime and/or two hours after eating. after eating. promote easy defecation.
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With regard to dialysis catheter insertion site instruct the patients relative to

clean the site with a betadine solution from the incision site up to the tip of the lumen. Protect the site by covering it with a gauze pad. Secure with first aid tape to help keep out dirt and germs and to prevent infection and further contamination. Check for bleeding, pain, redness, or swelling in the dialysis catheter insertion site. doses. Patient should engage in diversional activities for relaxation and stress Instruct the patients relative to assist in activities of daily living such as Patient should brush her teeth three times a day (after breakfast, after lunch avoidance. feeding, bathing, dressing, grooming and toileting. and after dinner) to prevent mouth from drying out. Use soft bristle toothbrush to prevent gum bleeding. Patient should keep her finger/toe nails properly trim to prevent cuts and abrasions Always follow the special diet plan made by your dietitian Patient should be advice to adequate sleep and rest. Patient should follow the proper time of taking medications and its required

OUT - PATIENT FOLLOW-UP

Patient should see the doctor on the scheduled date. Patient should bring the discharge form/clinical abstract on the day of the consultation. Patient should bring recent laboratory/ diagnostic results for any adjustments to be made especially with the medication. In case of emergency, patient should not hesitate to call her physician or to go to the nearest clinic/hospital.

DIET
Wise food choices are a foundation of dialysis treatment. A registered dietitian can help you design a meal plan.
Limit fluid intake to prescribed volume of the physician to avoid pulmonary

congestion, swelling and high blood pressure.

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 Avoid foods such as soup, ice cream, jelly ace and fruits that contains plenty of water such as melon, grapes, apples, oranges, and tomatoes. Keep your fluids down by drinking from smaller cups or glasses. Freeze beverages in an ice cube tray and eat it like a popsicle. Keep track on the total fluid allowance to prevent too much fluid build up
Limit food high in potassium such as avocados, bananas, peaches, and vegetables

such as carrots, potatoes, mushroom and tomatoes. Potatoes contain high potassium but it can remove some of the potassium from potatoes by dicing or shredding them and then boiling them in water. Generally fruit and vegetables contain high amount of potassium. Cooking helps remove potassium
Control intake of foods rich in phosphorus such as cola drinks, peanut butter,

sardines, chicken/beef liver, nuts, caramels, and beers.

High quality protein is advise such as egg whites and white meat (fish, chicken

breasts)
Limit table salt intake to teaspoon per day. Avoid canned foods, frozen dinners, salty or smoked meats, such as corned beef,

ham, tocino and longganisa. Look for products with labeled Low Sodium

SUGGESTED SAMPLE MENU PLAN

BREAKFAST 1 piece fresh fruit 1 piece fried egg cup fried rice 1 tsp oil for cooking 4 tbsp low fat milk/ 3 scoops Nutritional AM SNACK 1 piece boiled camote 2 tbs grated coconut LUNCH 60 gms chicken breast tinola with 1 cup vegetable 2 tsp oil for cooking 1 cup rice 1 cup sugar free gelatine PM SNACK 2 pcs garlic toast 1 cup green tea DINNER 1 cup vegetable soup 70 gms fish sarciado 1 cup sayote guisado 2 tsp oil for cooking cup rice 1 pc fresh fruit

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SPIRITUAL
Motivate the patient to spiritual groups for further enlightenment and self-acceptance.

XIV. BIBLIOGRAPHY
BOOK REFERENCES:

Black JM, Hawks JH. (2005). Medical-Surgical Nursing, Clinical Management for Positive Outcomes 7th Edition. Elsevier PTE LTD.
Doenges, M.E. et. al. (2002). Nursing Care Plans: Guidelines for Individualizing Patient Care 6th Edition. Thailand: F.A. Davis Company.

Hargrove-Huttel, Ray. (2004). Medical-Surgical Nursing, 4th Edition. Lippincott Williams & Wilkins.
Nettina, S.M. (2006). Lippincott Manual of Nursing Practice, 8th Edition. USAL: Lippincott Williams & Wilkins.

Porth CM. (2007). Essentials of Pathophysiology, Concepts of Altered Health States 2nd Edition. Lippincott Williams and Wilkins. Saladin KS. (2007). Anatomy and Physiogy, The Unit of Form and Function 4th Edition. McGraw-Hill. Udan, J.Q. (2002). Medical-Surgical Nursing : Concepts and Clinical Application : A Reference Book and Study Guide. Manila: Educational Pub. House.

WEBSITE REFERENCES:

National Kidney Foundation, Inc. (2002). KDOQI Clinical Practice Guidelines for Chronic Kidney Disease www.kidney.org. Retrieved October 28, 2012, from http://www.kidney.org/professionals /KDOQI/ guidelines_ckd /p4_class_g1.htm

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Muscle atrophy. (2012). MedlinePlus: Trusted Health Information for You. Retrieved on October 29, 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/003188.htm. Body mass index. (2012). MedlinePlus: Trusted Health Information for You. Retrieved on October 29, 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/007196.htm. Bye, M. (2011). Pulmonary atelectasis: Pathophysiology. Medscape Reference: Drugs, Diseases & Procedures. Retrieved on October 29, 2012 from http://emedicine.medscape.com/article/1001160-overview#a0104. Rubins, J. (2012). Pleural effusion. Medscape Reference: Drugs, Diseases & Procedures. Retrieved on October 29, 2012 http://emedicine.medscape.com/article/299959-overview#a0101 Glasgow Coma Scale. (2012). Medscape Reference: Drugs, Diseases & Procedures. Retrieved on October 29, 2012 http://reference.medscape.com/calculator/glasgow-coma-scale Phases of Wound Healing. (2012). CliniMed. Retrieved on October 29, 2012 from http://www.clinimed.co.uk/Wound-Care/Education/WoundEssentials/Phases-of-Wound-Healing.aspx Nunley, J. (2012). Dermatologic manifestations of renal disease. Medscape Reference: Drugs, Diseases & Procedures. Retrieved on October 29, 2012 from http://emedicine.medscape.com/article/1094846-overview#aw2aab6b4 Devarajan, P. (2012). Oliguria. Medscape Reference: Drugs, Diseases & Procedures. Retrieved on October 29, 2012 from http://emedicine.medscape.com/article/983156-overview#a0101 Cunha, J. (2011). Edema. MedicineNet.com. Retrieved on October 29, 2012 from http://www.medicinenet.com/edema/page5.htm#why_does_edema_occur_in_ patients_with_kidney_disease Diabetic neuropathy. (2012). PubMed Health. Retrieved on October 29, 2012 from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001713/

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