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A Case Study on End-Stage Renal Disease secondary to Hydronephrosis secondary to Diabetes Milletus Type 2
Submitted to: Remedios Caubang, RN Clinical Instructor – Panelist of the Case Study
Submitted by: [Group 1B] Beltran, Maribel S. Bulosan, Von Rainer S. Cabonita, Kristi Ann J. Campaner,Marie Allexis I.
BSN-3H November 7, 2009
TABLE OF CONTENTS
Acknowledgement ............................................................................................................... 2
Objectives (General & Specific)................................................6
Family Background and Health History.....................................10
Definition of Complete Diagnosis..............................................21
VII. Physical Assessment...................................................................24
VIII. Anatomy and Physiology...........................................................28
Etiology and Symptomatology...................................................36
XII. Diagnostic Exam........................................................................55
XIII. Drug Study.................................................................................64
XIV. Surgical Procedure.....................................................................74
XV. Nursing Theories........................................................................81 XVI. Nursing Care Plan......................................................................86
In accomplishing great things, we must not only think, but believe in the power of our cognition; not only aim but make our visions tangible; and at the end of the day, not only smile at the thought of accomplishment, but look back to where the strength to achieve such success came from. The proponents would like to extend their warmest gratitude to all the people who helped make the success of this undertaking a reality. First and foremost, to the Almighty Father, for His unceasing love and blessings; for giving us enough power and fortitude to face all the hardships in the making of this task. To Him be all glory and praise!
To our Clinical Instructor, Mrs. Willyn Adrias, RN, for her invaluable time and effort rendered to us; for letting us have the chance to experience the joy and opportunity of learning from you. For being a friend and companion in the area. You have made us realize that not all CIs are intrinsically superfluous. To all other CIs that has been with us in the whole rotation, Maam Baniel and Maam Llamido , for always being there to guide us; for their unending help and understanding. To our dear parents, for supporting us financially in all our endeavors. Thank you for all your love and care. Lastly, to each and every one who helped realize this job into completion, may it be direct or indirect, no matter how minimal, the gratitude and pleasure for the achievement of this task is ours to share.
BSN-3H1 were given the opportunity to have a hospital exposure last November 12-14,2009 at Davao Medical Center – Med Ward; and on the said dates found a commendable case reasonable to be presented subgroup. The patient, to be mentioned in this paper as Aling D, was one of the patients admitted to Medicine Ward Nephro due to End Stage Renal Disease secondary to Hydronephrosis stage II secondary to Diabetes Mellitus Type II. End-Stage Renal Disease is the complete or almost complete failure of the kidneys to function at a level needed for day-to-day life. The kidneys can no longer remove wastes, concentrate urine, and regulate many other important body functions. It is an irreversible decline in a person's own kidney function, which is severe enough to be fatal in the absence of dialysis or transplantation. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of normal. ESRD almost always follows chronic kidney disease. A person may have gradual worsening of kidney function for 10 - 20 years or more before progressing to ESRD. The most common causes of ESRD in the U.S. are diabetes and high blood pressure. The incidence and prevalence of ESRD continue to grow worldwide. According to data collected from 120 countries with dialysis programs, at the end of 2005 about 1,900,000 people were receiving renal replacement therapy (RRT). Among these individuals, 1,297,000 (68%) received hemodialysis and 158,000 (8%) received peritoneal dialysis; although an additional 445,000 (23%) were living with a kidney for case study agreed by the whole
7 transplant. Precise estimates of ESRD incidence and prevalence remain elusive, because international databases of renal registries exclude individuals with ESRD who do not receive RRT. (http://clinicalevidence.bmj.com/ceweb/) Worldwide, the highest incidence and prevalence rates are reported from the USA, Taiwan, and Japan. In America, 34% of cases of ESRD each year are caused by diabetes, 25% by hypertension, 16% by glomerulonephritis, and 4% by kidney cysts. (Renal Data Report, ANS, 1999) End Stage Renal Disease is already the 7th leading cause of death among Filipinos. The population of ESRD patients requiring dialysis therapy in Asia is expanding at a faster rate than in the rest of the world. In Philippines, the dialysis population is growing at a rate of 10% or more annually. It is said that a Filipino is having the disease hourly or 120 Filipinos per million populations per year. This shows that about 10, 000 Filipinos need to replace their kidney function. Unfortunately though only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of the whole population probably just died without receiving any treatment. The group chose Aling D as their subject primarily because her case posed a very intricate case requiring due understanding and knowledge. The group recognizes their partial knowledge about End-Stage Renal Disease and the treatments involved in such condition, thus making this case a good avenue to broaden the proponents’ knowledge about the disease and the surgical procedures involved.
General Objective: The main goal of the group is to be able to present the case study of our chosen client that would provide a comprehensive discussion of the pathological mechanism of the disease to yield significant information for the case study.
Specific Objectives: In order to meet the general objective, the group aims to: • • • • • establish rapport to the patient and the patient’s significant others; interpret the pertinent data gathered from the patient and her significant others; state past and present health history of the patient; trace the family genogram; evaluate the present developmental stage of the patient according to the theories of Erikson, Kohlberg, and Havighurst; • • • • • • • • • define the complete diagnosis of the patient; present the cephalocaudal assessment obtained from the patient; discuss the anatomy and physiology of the organ involved in the patient’s disease; present the etiology and symptomatology of the patient’s disease; trace the pathophysiology of the patient’s disease; obtain and rationalize the doctor’s order; interpret the laboratory test results of the patient; discuss the nature of the drugs given to the patient; discuss the surgical procedure performed to the patient;
9 • relate the patient’s disease with the different nursing theories specifically those of Nightingale, Orem and King; • present a specific, measurable, attainable, realistic and time-bounded nursing care plans for the client; • • justify the client’s prognosis according to the different criteria; provide the patient and family with proper discharge planning (M.E.T.H.O.D); and • outline recommendations based on the case study’s findings.
Personal data: Patients Name: Age: Weight Height Gender: Birth date: Address: Nationality: Religion [Domination]: Civil Status: Educational Attainment: Occupation: Clinical/ Admitting Data: Date of admission: Time of admission: Hospital & Hospital Number: Ward [Room & Bed Numbers]: Admitting Physician: Attending Physician: Chief complaint: Admitting Diagnosis: November 9, 2009 11:30 am Davao Medical Center, Davao City  Medicine Ward- Nephro Bed No. 12 Dr. Jovino C. Aquino Dr. Gil Florida Epigastric pain End Stage Renal Disease secondary to Hydronephrosis secondary to Diabetes Mellitus Type II Source of information: Patient and Patient’s Chart Aling D 56 years old 130 lbs or 59kg 4’10 ft Female September 25, 1953 Dumanlas, Buhangin, Davao City Filipino Christian [Roman Catholic] Married College graduate Teacher (retired)
FAMILY BACKGROUND AND HEALTH HISTORY
HEALTH BACKGROUND A. Family Background Aling D is 56 years old, female. She is the 3rd child of 5 siblings. Both her parents are already dead, and she failed to mention the cause of their death. The patient verbalized that her father was diagnosed with Diabetes Mellitus. She failed to mention if her mother and siblings also have illnesses. Aling D has been married for 32 years. She was a gradeschool teacher but she already retired last 2005. Her husband is a government employee. They are blessed with 3 children, but one son is already dead due to cardiac arrest. The son died at the age of 23 who is the middle child. Her eldest son is 31 years old, and her youngest son is 28 years old. Her eldest son is already married and doesn’t live with them anymore. Generally, they have close family ties. Aling D told us that they share their daily experiences with each other. The family’s source of income is the patient and the husband. Her youngest son also contributes to the family’s income, since he is also a government employee particularly in the Department of Agriculture. Aling D’s pension per month is Php 15,000. Her husband’s income per month is Php 12,000, and her son’s income is Php 8,000. The family lives in Dumanlas, Buhangin, Davao City. Her family’s diet is composed of meat, fish and vegetables, however, due to her hospitalization she has been
12 following a low salt low fat diet. She also avoids protein-rich foods and foods high in sugar. She is a non-smoker and occasionally drinks alcohol.
B. History of Past Illness The patient was born via normal spontaneous vaginal delivery. She did not have any complications nor unusualities when she was delivered. The patient did not experience any serious illness or accident during her childhood. But she did experience having chicken pox when she was a child. Also, she only experienced common minor illnesses such as colds, fever, stomach aches, headaches, and constipation. She drinks over-the-counter drugs like paracetamol when she experiences fever. According to the patient, she had been diagnosed with hypertension 20 years ago and diabetes mellitus 15 years ago. She takes insulin shots for her Diabetes. She verbalized that she did not have strict compliance to her medications since her condition was not bad before.
C. Present Health History On October 2009, the patient experienced chest pain. She also experienced dyspnea occurring at night accompanied by bipedal edema. The patient also had cough and abdominal pain. She took a supplement called Relieve for 23 days to alleviate the symptoms she felt. She tolerated the symptoms until she had onset of epigastric pain. She had her check-up on UM Multitest. Along with her laboratory results, she was diagnosed with End Stage Renal Disease last October 15, 2009. However, she was not admitted by then. She sought medical attention when she experienced severe epigastric pain, and thus the admission.
13 D. Effects/ Expectations of Illness to Self/ Family The patient verbalized that after the diagnosis was determined; she and her family became bothered and worried. They did not expect that she will be diagnosed with a disease which is already in end stage. The doctor who gave the diagnosis advised dialysis to the patient, which added to the stress of the family and the patient. On the patient’s part, she felt nervous because she used to know someone who underwent dialysis and later died after 2 years of treatment. Nevertheless, she verbalized that she had already accepted her treatment, its limitations, and consequences. According to her, she does not want to be a burden to her family. On the family’s part, they worried about the finances they will have to spend for the treatment. But, they are very positive in facing the disease. Aling D stated that it must have really been God’s will and that they could do nothing about it. Despite her health problem, they still have hope and they pray that their family would be able to endure this and cope with all the inconvenience brought about by her condition.
* Deceased ** with Hypertension *** with Diabetes Mellitus
LOLO LOLA** LOLA A *** LOLO A
Human development: the science that studies how we learn and develop psychologically, from birth to the end of life. This very young science not only enables us to understand how each individual develops, it also gives us profound insights into who we are as adults. Each MAMA PAPA*** UNCLE A *** UNCLE B theory has its own viewpoint on the development of man.
Erikson's Stages of Psychosocial Development The Psychosocial Stages of Development developed by Erikson enumerates eight stages though which healthily developing human ALING D should pass from infancy to late adulthood. Every stage describes a task to be accomplished. These development stages can be seen as a series of crisis and each stage forms on the successful accomplishment of the earlier stages. Successful resolution of these crises supports a healthy self-development. Failure to resolve the crises damages the ego and maybe expected to reappear as problems in the future. Stage Description Result Justification
According to Erik Erikson, Middle Adulthood
Our clent, Aling D has achieved generativity
the developmental task in middle ACHIEVED as she is able to display behaviors that are adulthood is to form a sense of well acceptable for his age such as being there for her children. She is able to expand her interests at this time with her family’s support and has assumed the responsibilities of middle –aged person. Our client usually takes time to bond with her husband and children. Even though her children are all grown up and busy with their own life, but still they make time for each other and share to each other their daily experiences.
(25 to 65 generativity or the concern for years old) guiding the next generation. It is
GENERATI the concentration on this task that VITY vs. leads to typical adult behavior. adults must have and
STAGNATI Middle ON
altruistic actions, such as church work, social work, political work, community fund-raising drives and cultural endeavors. They should have time for companionship and recreation, thus making marriage more satisfying in the middle years
Furthermore, she manages to acknowledge her aging body and sees whatever she has now as part of her existence. According to her as well as her family, her condition never
of life. Generative middle-aged persons are able to feel a sense of comfort in their lifestyle and receive gratification from
altered her role of being a wife to his better half and a mother to her children. She is very responsible in her duty to her family, as a mother to her children, she has molded them into a better person they are today, good and
charitable endeavors. He knows well are what and he’s his he held
responsible sons; and as a wife to her husband, their expression of love is more intimate and they cherished every minute they are together. As a middle-aged adult, she is also engaged in various activities in the society in order to maintain a good societal functioning like participating in the
responsibilities recognizes that
accountable of whatever actions he take.
development of their own community.
Kohlberg's Stages of Moral Development This theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision.
Kohlberg's Stages of Moral Development This theory specifically addresses moral development in children and adults. The morality of an individual’s decision was not Kohlberg’s concern; rather, he focused on the reasons an individual makes a decision. Stage Conventional Stage and Description Result The conventional level of moral ACHIEVED is typical Justification In this stage of Kohlberg's Moral Development theory, the client must go after the laws in order to maintain a good functioning in the society as a morally upright citizen. Aling D is a good citizen.
Order of adolescent and adults. Those who reason in a conventional way judge the morality of actions by comparing them to society's views and
According to her, she is a registered voter in order to exercise her right
expectations. In this stage, it is
to vote for a leader suited to our country, she offered her services during election periods when she was still working as a teacher. She's also an active GKK or Gagmayng Kristohanong Katilingban member in their barangay and actively participates for the development of their community. For her, it is really important to observe the rules inculcated by the society in order to maintain peace and order. She also stated that as a constituent of the society, she should be a good example for the future generations to come.
laws, dictums and social conventions because of their importance in maintaining a functioning society. Moral
reasoning in stage four is thus beyond the need for individual approval exhibited in stage three which is interpersonal
accord and conformity driven. Meaning the self enters society by filling social roles; therefore society must learn to transcend individual needs. A central
ideal or ideals often prescribe what is right and wrong, such
Aling D said that the simplest way to become a good citizen is that you must not disobey any simple rules and regulations which the society dictates you to follow and abide, because if one does not follow rules it is already considered in this stage to be morally wrong. So, one must maintain a good reputation without any stain of misdemeanor done. In the stage four of Conventional level, it is said that following the laws and dictums of the society is important to maintain a good
fundamentalism. If one person violates a law, perhaps
everyone would—thus there is an obligation and a duty to uphold laws and rules. When someone does violate a law, it is morally wrong; culpability is thus a significant factor in this stage as it separates the bad domains from the good ones. Most active members of society remain at stage four, where morality is still predominantly dictated by an outside force.
functioning in the society, so we have concluded that Aling D has
done her part in the society as a good citizen. She follows and obeys the rules and she had become a good example to everybody,
especially to her children.
Havighurst’s Developmental Task Havighurst (1972) defines a developmental tasks as one that arises at a certain period in our lives, the successful achievement of which leads to happiness and success with later tasks; while leads to unhappiness, social disapproval, and difficulty with later tasks He identifies three sources of developmental tasks (Havighurst, 1972). • • • Tasks that arise from physical maturation Tasks that arise from personal values Tasks that have their source in the pressures of society
Havighurst also identified Six Major Stages in human life covering birth to old age which are the following: 1. Infancy & early childhood (Birth till 6 years old) 2. Middle childhood (6-12 years old) 3. Adolescence (13-18 years old) 4. Early Adulthood (19-30 years old) 5. Middle Age (30-60years old) 6. Later maturity (60 years old and over) Our client belongs to the fifth stage which is the middle age, wherein men and women in this stage reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the time of life to which they have looked forward during their adolescence and early adulthood.
The following are the developmental task that a middle age adult must fulfill or achieve:
ACHIEVED OR NOT ACHIEVED
Helping teenage children to
The client's children are all old
become happy and responsible adults
enough to understand what their mother taught them; especially the moral values that would make persons them and become become better good
example to others. Achieving adult social and civic responsibility Achieved According to her, she
participates in barangay activities for the development of their community and she is an active member of their GKK. She is also registered voter in order to do her duty as a good citizen of the country.
Reaching and maintaining satisfactory performance in one’s occupational career
Since the client has already met her expectations in her job in the past and have already fulfilled
her dream of becoming a teacher. Now, she is already retired from her work. Developing adult leisure time activities Achieved The client as an adult develops leisure time activities together with her family like having meaningful conversations with her children or sharing their daily experiences and watching
television shows to strengthen their bonding as a family. Relating oneself to one’s spouse as a person Achieved The client and her husband have been there for each and never leave each other’s side. They have been married for a long time already. Whenever they have problems, they’ve talked
about it and together they decide on how to solve their
predicament. Now that the client has been has hospitalized, been there her to
support her emotionally through sending her text messages or calling her sometime. To accept and adjust to the physiological middle age. changes of Achieved The client has adjusted to the changes on her body. She already have wrinkled skin and easily gets tired but she has learned to accept this reality. Adjusting to aging parents. Achieved The client has already adjusted to her aging parents in the past when her parents were still alive.
DEFINITION OF COMPLETE DIAGNOSIS
END -STAGE RENAL DISEASE
End-stage renal disease occurs when 90% of the nephrons are lost. Patients at this stage experience chronic and persistent abnormal kidney function. Hopper P.D., Williams, L.S.; Understanding Medical Surgical Nursing 3rd edition
Kidney or renal end-stage disease is defined as a point at which kidney is so badly damaged or scarred that dialysis or transplantation is required for patient survival.
Mosby’s Pocket Dictionary of Medicine, Nursing & Health Professions 5th edition
During this stage, renal function is less than 10% to 15% of normal; all renal functions are severely decreased; and homeostasis is significantly altered.
Ray A. Hargrove-Huttel; Medical Surgical Nursing
Hypdronephrosis is the abnormal dilation of kidneys caused by obstruction of urine flow.
Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition
Hydronephrosis develops when urinary obstructions block the outflow of the kidneys. Hydronephrosis may be gradual, partial or intermittent.
Kowalski, M.T., Rosdahl, C.B.;Basic Nursing
Enlargement of kidney resulting from urine accumulation in the upper urinary tract caused by a blockage of the urinary tract.
Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified
DIABETES MELLITUS Diabetes mellitus is a group of metabolic diseases in which defects in insulin secretion or action result in high blood sugar level.
Hopper P.D., Williams, L.S. ; Understanding Medical Surgical Nursing 3rd edition
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both (The American Diabetes Association, 1997). Type II DM is formerly known as Non-insulin Dependent Diabetes Mellitus. Type 2 diabetes usually occurs at any age but most cases occur after age 30. More than 80% of the clients are overweight and do always experience classic symptoms. Kowalski, M.T., Rosdahl, C.B.;Basic Nursing
Diabetes mellitus occurs when beta cells are unable to produce insulin (Type I DM) or produce an insufficient amount of insulin (Type II DM). As a result, glucose does not enter cells but remains in the blood.
Digiulio, M., Keogh, J., Jackson,D.; Medical-Surgical Nursing Demystified
I. Personal data: Date of Assessment: November 13, 2009 Time of Assessment: 11:30 pm Location of Assessment: Bed No. 12, Medicine Ward Nephro, Davao Medical Center
II. General Survey: During assessment, the patient was lying supine on bed with ongoing Intravenous Fluid infusion of Plain Normal Saline Solution, 1 liter to run at KVO rate at the level of 750 cc, infusing well on her left metacarpal vein. Patient was awake, conscious, coherent, and oriented to time, place, person and reason for admission. She was calm, cooperative and responsive. The quality and organization of speech is understandable and in moderate pace and it exhibits thought association. The relevance and organization of thought is also logical and has a sense of reality. General physical appearance is good; however, poor personal hygiene is evident.
III. Vital Signs: Temperature: 36.9°C Pulse rate: 88 beats per minute Respiratory rate: 22 cycles per minute Blood pressure: 150/100 mm Hg
IV. The Integument a. Skin The patient’s skin color was brown and sallow, and generally uniform in distribution except for areas that are not usually exposed to the sun. Pallor is noted on her palms, soles and nail beds. The palms and the soles are calloused. The capillary refill took 3 seconds. Age spots are also highly visible on the face and the body. Poor skin turgor was noted when the skin was pinched. No other lesions or deformities were noted. b. Hair Hair is evenly distributed over the scalp. Most hair on the scalp is gray as a result of advanced age. Dandruff is not present. Fine hairs are evenly distributed on both extremities.
c. Nails The patient’s nails were untrimmed with pail nail beds, with normal angle curvature. Surrounding tissues were intact; neither lesions nor lacerations were observed.
V. The Head a. Skull and Face The patient’s head is normocephalic and proportional to body size. The skull is also noted to be smooth in contour. Presence of nodules or masses is not noted. Facial features and movements are symmetrical. The patient is able to raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight tiredness. b. Eyes The hairs of the eyebrows are evenly distributed which are also symmetrically aligned. Eyelashes are equally distributed and slightly curled outward. The skin of the eyelids is intact, no visible discharge, and discoloration is noted. The eyelids close symmetrically. The sclera is white in color. The conjunctiva is shiny and pink in color. The color of her iris is dark brown. The details of the iris are also visible. The eyes do not appear sunken. The client’s pupils are round, black and are 3mm in diameter each pupil. When a pupil is illuminated, both pupils constrict. Both eyes have coordinated movements; move in unison and with parallel alignment. According to her, when looking
straight ahead, she can see objects in periphery. There was no edema or tenderness noted over her lacrimal glands. The patient was not wearing any glasses or contact lenses. c. Nose and Sinuses The external nose is symmetrical, straight and uniform in color. Nasal flaring was not noted. Color is the same with the entire face. No tenderness was noted during palpation. Both nares were patent. Air could move freely when breathing in and out. The nasal septum is intact and is to be found in the midline. The frontal and maxillary sinuses were not tender. Sense of smell is present and good since the patient was able to differentiate alcohol from coffee by means of scent. d. Ears The auricles are smooth. The patient’s ears have the same color with her facial skin. The ears are symmetrical in terms of size and position. The ears are normoset since both ears are located in line with the outer canthus of his eyes. The auricles are firm and not tender. The pinna recoils after it is folded. The patient has no difficulty hearing normal and whispered voice tone. No discharge was noted. e. Mouth and Oropharynx The lips are pink in color and glistening. The lips are also moist. The patient is able to purse her lips. The teeth are white and shiny. Some teeth are also missing. The gums are moist and pink in color, with no signs of bleeding. The
tongue is positioned in the center. It is pink in color. No lesions observed. The papillae of the tongue are raised. The tongue is able to move freely and the base has prominent veins. No swelling or ulcerations noted. The uvula is positioned in midline of the soft palate. Tonsils are pink and not inflamed. The patient is able to swallow with no difficulty.
VI. Neck The muscles in the neck are symmetrical and the head movement is coordinated. There was no limited range of motion noted as the patient turns her head from left to right; up and down; and circular motion. Trachea was located centrally in the midline of the neck. No lymph nodes noted on any of the areas of the neck. Moreover, no neck blood vessels were distended around the neck area.
VII.Chest and Lungs The patient has a regular and normal breathing pattern. She has quiet, rhythmic, and effortless respirations with a respiratory rate of 22 cycles per minute. There was a full and symmetric chest expansion. Chest pain was not reported. Crackles were heard on both lung fields upon auscultation.
VIII.Heart and Blood vessels The point of maximal impulse was located at the fifth left intercostal space. The patient has a cardiac rate of 85 beats per minute. Abnormal heart sounds or murmurs were not noted upon auscultation. The patient’s pulse is regular in rhythm and has a thrusting characteristic.
IX. Abdomen As observed, the patient’s abdomen has uniform skin color. Also, the abdominal contour is rounded or convex. The umbilicus is medially located and shows no signs of inflammation. It also has a symmetric contour. When breathing, there is symmetric movement which is caused by respiration. Bowel sounds are present upon auscultation.
X. Genito-urinary The patient reported that there were no lesions, tenderness and masses in her perineum and anus. Patient has dark yellow colored urine. She also has oliguria. Upon palpation distended bladder was noted.
XI. Musculoskeletal a. Upper Extremities
Patient’s peripheral pulses were symmetrical and regular, however, they are weak. The patient’s nails took 3 seconds for the capillary refill. The patient was able to exhibit strong hand grip on both arms. She was able to extend and flex her both arms. Hand tremors were not noted. b. Lower Extremities Bipedal pitting edema grade 2+ was noted. She has difficulty ambulating because of the muscle removed from her right foot.
ANATOMY AND PHYSIOLOGY
The Urinary System is
the system of organs that produces and excretes urine from the body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess water, salts, and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs that continuously filter substances from the blood and produce urine. Urine flows from the kidneys through two long, thin tubes called ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the tubelike urethra. An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products. The kidneys lie embedded in fat tissue on either side of the backbone at about waist level. Each fist-sized kidney is reddish-brown, weighs 140 to 160 g (5 to 6 oz), and is similar in shape to the kidney beans sold at the supermarket.
On the inner border of each kidney is a depression called the hilum, where the renal artery, the renal vein, and the ureter connect with the kidney (the adjective renal is from the Latin term renalis, meaning of or near the kidneys). The renal artery delivers over 1700 liters (450 gal) of blood to the kidneys each day, which these organs filter and return to the heart via the renal vein. Each kidney contains
about 1 million microscopic coiled channels, called nephrons, which perform this critical blood-filtering function and produce urine in the process. The bulblike upper portion of the kidney’s nephrons filters water; urea, the nitrogen-containing breakdown product of protein; salts; glucose; amino acids, the building blocks of proteins; yellow bile compounds from the liver; and other trace substances from the blood. As this material moves through a long, looped tubule, many of these filtered materials are reabsorbed into the blood to be reused by the body to maintain normal body functions. Less than 1 percent of the water and other materials remain behind to be excreted as waste products in the urine. These waste materials then pass from the nephrons into a funnel-shaped area called the renal pelvis. From the renal pelvis, waste trickles out of the kidney into the ureter, which is about 25 to 30 cm (10 to 12 in) long and about 0.5 cm (0.2 in) in diameter. The ureter empties into a hollow, muscular sac called the urinary bladder. A valvelike flap of tissue at the point of entry into the bladder prevents urine from flowing backward into the ureter. The urinary bladder is able to expand and contract according to how much urine it contains. As it fills with urine, the walls of the bladder stretch and become thinner, with the bladder itself lengthening to 12.5 cm (5 in) or more and holding up to about 0.5 liter (1 pt) of urine. A ringlike sphincter muscle surrounds the bladder’s outlet and prevents spontaneous emptying. As the bladder becomes full, stretch-sensitive receptors in its walls are stimulated, and the person becomes aware of the fullness. When the person is ready to urinate, or expel urine, the sphincter relaxes and urine flows from the bladder to the outside through the
urethra. In females, the urethra is about 3.8 cm (1.5 in) long and is strictly a urinary passage. In males, the urethra is about 20 cm (8 in) long; it passes through the penis and also serves to convey semen during sexual intercourse. Production of Urine. Blood enters the kidney through the renal artery. The artery divides into smaller and smaller blood vessels, called arterioles, eventually ending in the tiny capillaries of the glomerulus. The capillary walls here are quite thin, and the blood pressure within the capillaries is high. The result is that water, along with any substances that may be dissolved in it—typically salts, glucose or sugar, amino acids, and the waste products urea and uric acid—are pushed out through the thin capillary walls, where they are collected in Bowman's capsule. Larger particles in the blood, such as red blood cells and protein molecules, are too bulky to pass through the capillary walls and they remain in the bloodstream. The blood, which is now filtered, leaves the glomerulus through another arteriole, which branches into the meshlike network of blood vessels around the renal tubule. The blood then exits the kidney through the renal vein. Approximately 180 liters (about 50 gallons) of blood moves through the two kidneys every day. Urine production begins with the substances that the blood leaves behind during its passage through the kidney—the water, salts, and other substances collected from the glomerulus in Bowman’s capsule. This liquid, called glomerular filtrate, moves from Bowman’s capsule through the renal tubule. As the filtrate flows through the renal tubule, the network of blood vessels surrounding the tubule reabsorbs much of the water, salt, and virtually all of the nutrients, especially glucose and amino acids, that were removed in the glomerulus. This important process, called tubular reabsorption, enables the body to selectively keep the substances it needs while ridding itself of wastes. Eventually, about 99 percent of the water, salt, and other nutrients is reabsorbed.
At the same time that the kidney reabsorbs valuable nutrients from the glomerular filtrate, it carries out an opposing task, called tubular secretion. In this process, unwanted substances from the capillaries surrounding the nephron are added to the glomerular filtrate. These substances include various charged particles called ions, including ammonium, hydrogen, and potassium ions. Together, glomerular filtration, tubular reabsorption, and tubular secretion produce urine, which flows into collecting ducts, which guide it into the microtubules of the pyramids. The urine is then stored in the renal cavity and eventually drained into the ureters, which are long, narrow tubes leading to the bladder. From the roughly 180 liters (about 50 gallons) of blood that the kidneys filter each day, about 1.5 liters (1.3 qt) of urine are produced. Other functions. In addition to cleaning the blood, the kidneys perform several other essential functions. One such activity is regulation of the amount of water contained in the blood. This process is influenced by antidiuretic hormone (ADH), also called vasopressin, which is produced in the hypothalamus (a part of the brain that regulates many internal functions) and stored in the nearby pituitary gland. Receptors in the brain monitor the blood’s water concentration. When the amount of salt and other substances in the blood becomes too high, the pituitary gland releases ADH into the bloodstream. When it enters the kidney, ADH makes the walls of the renal tubules and collecting ducts more permeable to water, so that more water is reabsorbed into the bloodstream. The hormone aldosterone, produced by the adrenal glands, interacts with the kidneys to regulate the blood’s sodium and potassium content. High amounts of aldosterone cause the nephrons to reabsorb more sodium ions, more water, and fewer potassium ions; low levels
of aldosterone have the reverse effect. The kidney’s responses to aldosterone help keep the blood’s salt levels within the narrow range that is best for crucial physiological activities. Aldosterone also helps regulate blood pressure. When blood pressure starts to fall, the kidney releases an enzyme (a specialized protein) called renin, which converts a blood protein into the hormone angiotensin. This hormone causes blood vessels to constrict, resulting in a rise in blood pressure. Angiotensin then induces the adrenal glands to release aldosterone, which promotes sodium and water to be reabsorbed, further increasing blood volume and blood pressure. The kidney also adjusts the body's acid-base balance to prevent such blood disorders as acidosis and alkalosis, both of which impair the functioning of the central nervous system. If the blood is too acidic, meaning that there is an excess of hydrogen ions, the kidney moves these ions to the urine through the process of tubular secretion. An additional function of the kidney is the processing of vitamin D; the kidney converts this vitamin to an active form that stimulates bone development. Several hormones are produced in the kidney. One of these, erythropoietin, influences the production of red blood cells in the bone marrow. When the kidney detects that the number of red blood cells in the body is declining, it secretes erythropoietin. This hormone travels in the bloodstream to the bone marrow, stimulating the production and release of more red cells.
ETIOLOGY AND SYMPTOMATOLOGY
Predisposing Present/ Absent Factors Age Present In ESRD, the patient is The patient is aged 56 predisposed to the disease years old. by her age because with increased age, there is Rationale Justification
already wear and tear of the organs and diminished
ability of the kidneys to perform as they should. Also, major candidates for Diabetes Mellitus type 2
are seen to be of the adult population; this
predisposed the patient to the disease which lead to Family History Present ESRD. The risk secondary of ESRD Although family
to history of ESRD is present, it is
hydronephrosis secondary not to diabetes mellitus
is important to note that in this patient from the
substantially increased if ESRD either of a patient’s parents particular had diabetes. Diabetes is rooted often inherited (passed existent
from the parent to the diabetes child).
which runs in the paternal side of the patient’s family. The
father of the patient and some of the
family members in the father’s side of the patient has
diabetes mellitus. Precipitating Present/ Absent Factors Obesity Absent Rationale Researchers attribute most cases of Type 2 diabetes to obesity. Studies show that the risk for developing Type 2 diabetes increases by 4 percent for every pound of excess weight a person carries. Researchers are investigating the exact role that extra weight plays in preventing the proper utilization of insulin and why some overweight people develop the disease while others do not. The obese. Justification patient Her is not
which is 59kg or 130 lbs and height of 4’10 is suggestive of a BMI of 27 which may be overweight but is still not considered as
Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved. Sedentary lifestyle absent
A sedentary lifestyle may The
contribute to obesity which having
is said to be a factor which lifestyle as reported. can cause diabetes mellitus The patient claims that type two. she has been living a fairly active lifestyle. Although she does not exert any effort to jog or stretch habitually; she reports to do
chores at home such as doing the laundry,
watering her plants and
others. Increased dietary fat present intake The accumulation of too much fat in the body is associated with a variety of health problems. Studies show that individuals who are overweight or obese run a greater risk of developing diabetes mellitus, hypertension, coronary heart disease, stroke, arthritis, and some forms of cancer. Microsoft ® Encarta ® 2008. © 1993-2007 Microsoft Corporation. All rights reserved. The patient does not deny the fact that she used to have high
intake of fats prior to her hospitalization
B. SYMPTOMATOLOGY Symptoms Peripheral edema Present/Absent Rationale Justification present Edema is apparent, Bipedal edema with the score resulting from fluid of 2+ is noted. retention due to the impairment of the
ability of the kidneys Increased creatinine levels Flank pain absent present to excrete fluids. Increased creatinine The creatinine level of the levels suggest renal patient is 697.90mmOl/L insufficiency. Flank pain is one of The patient did not report any the classic symptoms experience of flank pain. Massive proteinuria absent of kidney damage. Protein is a macro molecule which is not supposed to cross the urine, cases however, of in
renal proper filtration
is damaged that the
macromolecules causing them to cross Electrolyte imbalances present the urine. One of the major Sodium levels are relatively functions of the high.
kidney is to regulate electrolyte levels in Anemia present the body. The kidneys produce The Blood test of the patient the hormone shows abnormally low levels of in RBCs, hemoglobin and
adults. This stimulates hematocrit. the production of red blood cells which
• • • Hemoglobin= 77 Hematocrit= 0.22 RBCs=2.60
carry oxygen in the body. RBCs Diminished is termed
Glucose in the blood Excessive thirst, generalized Cells do not respond to the effects weakness, excessive of insulin in type 2 diabetes urination, blurred vision, delayed wound healing Increased blood viscosity Stretching of intravascular spaces Hypertension
Diet and lifestyle modification Administration of medications
Excessive ESRD accumulati Stretching of capillaries on of metabolic Renal capillary collapse wastes • Kidneys Loss/ impaired of nephron function unable to If not treated maintain Treatment homeostasi A. Medications s • Diminished renal reserve 40-50% renal function NaHCO3 of excretory Loss • Psychologi • Diuretics Chronic renal function cal • Antihypertensive DEATH Renal Disease changes Renal Insufficiency 20-40% renal function drugs • 10-15% • Antacids Inefficient urine • Aluminum Hydroxide flow/ • Multivitamins Urine flow A. Dialysis Cardiovascular Neurologic Hematologic Musculoskeletal • Peritoneal HYDRONEPHROSIS Hypertension LOC changes Anemia Loss of muscle strength • Hemodialysis
Edema Weakness Fatigue Malaise
A. Renal Transplant B. Lifestyle and Diet Modifications ESRD
Due to Diabetes Mellitus type 2 resulting from etiologies, blood glucose levels start concentrating in blood because of the inability of the cells to respond to the effects of insulin. As blood glucose levels increase, blood viscosity also increases, thereby stretching intravascular spaces systemically leading to extensive dilation of capillaries. This overstretching also results to hypertension; however, the worst scenario that it can bring is the collapse of end capillaries especially in vital organs such as the kidneys. In this case, the extensive dilation of kidney capillaries result in renal capillary collapse which causes impairment in the renal function. The kidneys function as filtering devices in our body, it also excretes urine as wastes and secrete hormones essential to the body. With the destruction of proper renal functioning, several problems arise. On one hand, excreting function is impaired thus causing urinary retention leading to hydronephrosis. On the other end, impaired renal functioning will start progressing into chronic kidney disease in which leads to several discomforts and changes in the body such as edema, anemia, LOC changes, uremia and many others. These conditions, if still not properly managed and detected early will all lead to the dreadful end stage renal disease.
Date Novemb er 2009 9,
Order Pls admit to IMCU
The patient is admitted to IMCU Done because her condition fits in this department basing on disease
Low Fat Low Salt
categorization. The patient has hypertension, high Done intake of dietary sodium and fat may worsen the condition of the patient.
This is done in order to constantly Done monitor any changes in the vital signs of the patient which may indicate new advances or
worsening of the condition of the patient in order to be addressed Venoclysis: PNSS@KVO immediately. PNSS is given to the patient in Done order to serve as a line for her
A. Actual Laboratory Tests and Diagnostic Examinations Urinalysis Urinalysis is performed to screen for urinary tract disorders, kidney disorders, urinary neoplasm and other medical conditions that produce changes in the urine. This test also is used to monitor the effects of treatment of known renal or urinary condition. Normal Value / Date Laboratory Test O C T O B E Color Results Yellow, straw, amber Result Dark Yellow Colorless: Clinical Significance overhydration, diuretic Interventions therapy, Pretest: >Provide with Nursing
(normal) diabetes insipidus and mellitus
Dark red or pink: porphyria, hematuria, ingestion patient of red food coloring, beets, berries, fava beans, urine rhubarb Dark yellow: bile
container with lid.
R 1 9 Appearance 2 0 0 9 Reaction 4.0-8.0 Clear to faintly hazy
Green: pseudomonas bacteriuria, urinary bile >Instruct pigments patient collect Clear Cloudy, smoky or hazy: pyuria, bacteriuria, sample (normal) phosphates in urine urine,
the to a of
preferably on 6.0 If >8.0, finding may be the result of UTI If <4.0, arising in the (normal) may indicate respiratory or metabolic acidosis morning; must not be contaminated Specific gravity 1.003- 1.030 1.042 increased in:dehydration, fever, profuse sweating, by (high) vomiting, diarrhea, glycosuria, proteinuria, CHF, paper, adrenal insufficiency, SIADH Decreased in: overhydration, water, toilet toilet feces
diuresis, or secretions.
hypotension, pyelonephritis, glomerulonephritis, >Women renal tubular dysfunction, severe renal damage, should not
positive Positive disorders, negative
hypertension, >Instruct patient collect midstream voided to a
diabetes mellitus, SLE, amyloidosis Positive in: hyperglycemia, diabetes mellitus
Posttest: Pus cells ≤ 4 cells/HPF 0-2 hpf Positive in: urinary tract infection (UTI) >The lid must be Red Blood Cells ≤ 2 rbc hpf sealed
Positive in indicates bleeding at some location completely in the urinary tract, from the glomeruli to and urethra, or leakage of rbc through the container the
glomerular membrane. Mucous threads ++
must labeled properly. >Specimen must delivered
the laboratory immediately.
COMPLETE BLOOD COUNT AND PLATELET COUNT The CBC is a series of different tests used to evaluate the blood and the cellular components of RBC’s, WBC’s and platelets. The CBC is used to assess the patient for anemia, infection, inflammation, polycythemia, hemolytic disease, and the effects of ABO incompatibility, leukemia and dehydration status
Normal Date Exam Value Novemb Hemoglobin er 2009 10, 115 – 175 The g/L test Rationale
Result of Remearks Patient that 96 the of per Low
Clinical Nursing Responsibilities Significance Increased in: polycythemia, dehydration, acute thermal injury, COPD Decreased in: hemorrhage, bleeding, anemia, hemolytic anemia, fluid overload, fluid retention, pregnancy, 4. Make sure patient is well 3. Assess the patient for any factor that affect will the 2. Inform the patient that no fasting is needed. 1. Discuss and explain the procedure and purpose of the test.
measures amount hemoglobin liter of blood
results of the test.
Normal Date Exam Value Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance cirrhosis of the liver, hyperthyroidis m A hemoglobin referred anemia. to low is as hydrated. Dehydration
elevates the test results.
The test measures the percentage of Hematocrit 0.36 – 0.48 RBC in the total blood volume RBC count 4.20 – 6.10 The test measures 3.58 the circulating Low 0.27 Low
A hematocrit referred anemia. to
low is as
Low RBC may indicate loss, blood anemia,
RBCs in 1 cubic
Normal Date Exam Value Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance hemorrhage, bone marrow 5. If patient is connected to IVF, make sure that the and blood is not taken from the arm connected to the IVF. Hemodilution
of failure, leukemia, malnutrition
The test measures all WBC count 5.0 – 10.0 leukocytes Normal Normal
causes false decrease of the test results.
present in 1 cubic 6.01 millimeter blood. of
55 – 75
Neutrophils serve 62 as the body's defense
6. After assess
puncture, site for
bleeding or bruising. 7. If patient is from under an
against infection through the
Normal Date Exam Value process phagocytosis. Usually used to diagnose specific type of illnesses. Lymphocyte 20 – 35 Lymphocytes initiate immunologic cresponses. test The of Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance infection, inform the
patient that the test will be repeated to monitor progress.
Abnormally high levels of lymphocytes can be due to flu, chicken pox, and some viral and bacterial infection.
8. Any abnormality noted will be reported to the physician.
lymphocyte blood count.
Normal Date Exam Value Monocytes have phagocytic action. It removes dead or injured cells, fragments, Monocyte 2 – 10 microorganism. This test is done to diagnose such an as cell and 9 Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance
inflammatory diseases. Eosinophils 1–8 Eosinophils initiate allergic 7 Normal Normal
Normal Date Exam Value responses and act against parasitic The to Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance
infestation. test is use
Basophils initiate Basophil 0–1 type 1 allergic 1 Normal Normal
responses The test measures all Platelet count 150 – 400 platelets Normal Normal
present in 1 cubic 214 millimeter blood. of
Normal Date Exam Value The test measures Potassium 3.5 – 5.5 Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance
potassium levels 4.0 of the blood.
sodium indicates retention The test measures Sodium 136 – 155 the sodium levels 168 in the blood. High of
sodium in the body and a
diminished filtration function of the kidneys.
The test usually Creatinine 53 - 115 indicates function. renal 697.90 High
Normal Date Exam Value Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance lower the level of creatinine in the body, the the
healthier kidneys are. Activated Partial Thromboplastin Time (APTT) Normal Date Exam Value The test measures Novemb er 13, 2009 APTT 29.4 – 38.4 the time in seconds for a specific clotting process to occur. APTT Control 26.0 – 31.0 If the test sample 28.5 takes longer than Normal Normal 34.0 Normal Normal Rationale Patient Result of Remearks Clinical
Nursing Responsibilities Significance
Normal Date Exam Value the control sample, it indicates decreased clotting function in the intrinsic pathway. Prothrombin Time (PT) Normal Date Exam Value PT Patient June 21, PT Control 2009 11.8 – 15.1 12.0 – 15.0 PT may be ordered when a patient is to undergo an invasive medical procedure, such as surgery, to ensure Rationale Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance
Result of Remearks Patient 14.6 13.5 Normal Normal
Clinical Nursing Responsibilities Significance Normal Normal
Normal Date Exam Value normal clotting ability. Rationale
Result of Remearks Patient
Clinical Nursing Responsibilities Significance
Brand Name Classification Suggested Dose
Apo-Furosemide, Furosemide Special IV, Furoemide, Lasix, Novo-semide, Uritol Loop diuretic Acute pulmonary edema (adult): 40 mg I.V. injection slowly over 1 to 2 minutes; then 80 mg I.V. in 60 to 90 minutes if needed Edema (adult): 20 to 80 mg P.O. daily in the morning. (infants and children): 2 mg/kg P.O. daily, increased by 1 to 2 mg/kg in 6 to 8 hours if needed Hypertension (adult): 40 mg P.O. b.i.d.
Mechanism Action Indication Contraindication Drug Interaction
(children): 0.5 to 2 mg/kg P.O. once or twice daily. ofInhibits sodium and chloride reabsorption at proximal and distal tubule and the ascending loop of Henle Pulmonary edema, edema in CHF, nephrotic syndrome, hypertension Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation and electrolyte depletion Amioglycosides antibiotics, cisplatin: may increase risl of hypokalemia. Antidiabetis: may decrease hypoglycemic effects Antihypertensives: may increase risk of hypertension Cardiac glycosides, neuromuscular blockers: may increase toxicity of these
drugs from furosemide-induced hypokalemia Chlorothiazide, chloothalidone, hydrochlorothiazide, indapamide,
metolazone: may cause excessive diuretic response, causing serious electrolyte abnormalities and dehydration. Ethacrynic acid: may increase risk of ototoxicity Lithium: may decrease lithium excretion, resulting in lithium toxicity NSAIDs: may inhibit diuretic response Side/Adverse Effects CNS: vertigo, headache, dizziness, paesthesia, weakness, restlessness, fever. CV: orthostatic hypotension, thrombophlebitis with I.V. admnistration. EENT: transcient deafness, blurred or yellowed vision, tinnitus. ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic alkalosis GI: abdominal discomfort and pain, diarrhea, anorexia, nausea, vomiting, constipation, pancreatitis GU: nocturia, polyuria, frequent urination, oliguria Hematologic: agranulocytosis, aplastic anemia, leucopenia,
thrombocytopenia, azotemia, anemia
Hepatic: hepatic dysfunction, jaundice Metabolic: volume depletion and dehydration and dehydration asymptomatic hyperuricemia, impaired glucose tolerance, hypokalemia, hypochloremic alkalosis, hyperglycemia, dilutional hyponatremia, hypocalemia,
hypomagnesemia Musculoskeletal: muscle spasm Skin: dermatitis, purpura, photosensitivity reactions, transcient pain at I.M. injection site Nursing Responsibilities Other: gout 1. Monitor potassium level closely, glucose level in diabetics patient and lithium level. 2. Monitor patient closely for signs and symptoms of excessive diuretic response. 3. Advise patient to avoid excessive sunlight exposure. 4. To prevent nocturia, give P.O. and I.M. preparations in the morning. Give second dose earlier afternoon. 5. Monitor weight, blood pressure, and pulse rate routinely with long-
term use and during rapid dieresis. Use can lead to profound water and electrolyte depletion. 6. If oliguria or azotemia develops or increases, drug may need to be stopped. 7. Monitor fluid intake and output and electrolyte, BUN, and carbon dioxide levels frequently. 8. Watch for signs of hypokalemia, such as muscle weakness and cramps. 9. Consult prescriber and dietitian about a high-potassium diet or potassium supplements. Foods rich in potassium include citrus fruits, tomatoes, bananas, dates, and apricots. 10. Drug may not be well absorbed orally in patient with severe heart failure. Drug may be given I.V. even if patient is taking other oral drugs. 11. Monitor uric acid level, especially in patients with a history of gout. 12. Advise patient to take drug with food to prevent GI upset, and to take in morning to prevent eed to urinate at night.
13. Inform patient of possible need for potassium or magnesium supplements. 14. Instruct patient to stand slowly to prevent dizziness and to limit alcohol intake and strenuous dizziness upon standing quickly.
Brand Name Classification Suggested Dose
Norvasc Calcium channel blocker Chronic stable angina vasospastic angina (Prinzmetal or variant) (adult): initially, 5 to 10 mg P.O. daily. (elderly): initially, 5 mg P.O. daily Hypertension (adult): initially, 2.5 to 5 mg P.O. daily.
(elderly): initially, 2.5 mg P.O. daily Mechanism of Action Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates coronary arteries and arterioles, and decreases blood pressure and Indication Contraindication myocardial oxygen demand. Chronic stable angina pectoris, vasospastic angina, hypertension Hypersensitive to drug , Sick sinus syndrome, 2nd-3rd degree heart block,
hypotension less than 90mmHg systole • Increased hypotension with antihypertensives, nitrates • • Neurotoxicity with lithium
Decreased hypertensive effects with NSAIDs headache, somnolence, fatigue, dizziness, light-headedness,
paresthesia CV: edema, flushing, palpitations GI: nausea, abdominal pain GU: sexual difficulties Musculoskeletal: muscle pain Respiratory: dyspnea Skin: rash, puritus
1. Monitor patient carefully. Some patients, especially those with severe obstructive coronary artery disease, have developed increased frequency, duration, or severity of angina or acute MI after initiation of calcium channel blocker therapy or at time of dosage increase. 2. Monitor blood pressure frequently during initiation of therapy. Because drug induced vasodilation has a gradual onset, acute hypotension is rare. 3. Notify prescriber if signs of heart failure occur, such as swelling of hands and feet or shortness of breath. 4. Abrupt withdrawal of drug may increase frequency and duration of chest pain. Taper dose gradually under medical supervision. 5. Don’t confuse amlodipine with amiloride. 6. Caution patient to continue taking drug, even when feeling better. 7. Tell patient S.L. nitroglycerin may be taken as needed when angina symptoms are acute. If patient continues nitrate therapy during adjustment of amlodipine dosage, urge continued compliance.
8. Administer once a day without regard to meals. 9. Instruct the patient to take the drug as prescribed, do not double or skip dose. 10. Evaluate for therapeutic response; decreased anginal pain, decreased BP, increased exercise tolerance.
Brand Name Classification Suggested Dose
Apo-Ferrous Sulfate, ED-IN-SOL, Feosol, Fer-gen-sol, Fer-In-Sol, Fer-iron Hematinic Iron deficiency (adult): 150 to 300 mg P.O. elemental iro daily in three divided doses. (children): 3 to 6 mg/kg P.O. daily in three divided doses.
As a supplement during pregnancy (adult): 15 to 30 elemental iron P.O. daily during last two trimesters. Mechanism of Action Provides elemental iron, an essential component in the formation of Indication hemoglobin. Prevention and treatment of iron deficiency anemias; dietary supplement for iron; unlabeled use: supplemental use during epoetin therapy to ensure Contraindication proper hematologic response to epoetin Patients with hemosiderosis, primary hemochromatosis, hemolytic anemia (unless patient also has iron deficiency anemia), peptic ulceration, ulcerative colitis, or regional enteritis and in those receiving repeated blood transfusions. Drug Interaction • Antacids and H2 blockers (cimetidine): Concurrent administration may decrease iron absorption. • • Chloramphenicol: Response to iron therapy may be delayed. Levodopa, methyldopa, penicillamine: Iron may decrease absorption when given at the same time. • Quinolones: Absorption may be decreased due to formation of a
ferric ion-quinolone complex • Tetracyclines: Absorption of oral preparation of iron and tetracyclines are decreased when both of these drugs are given together • Vitamin C: Concurrent administration of 200 mg vitamin C per 30 mg elemental iron increases absorption of oral iron.
GI: nausea, epigastric pain, vomiting, constipation, black stools, diarrhea, anorexia Other: temporarily strained teeth from liquid forms.
1. GI upset may be related to dose. 2. Between-meal doses are preferable. Drug can be given with some foods, although absorption may be decreased. 3. Enteric-coated products reduce GI upset but also reduce amount of iron absorbed. 4. Oral iron may turn stools black. Tell patient that although this unabsorbed iron is harmless, it could be mask melema. 5. Monitor hemoglobin level, hematocrit, and reticulocyte count during therapy. 6. Don’t confuse different iron salts; elemental content may vary. 7. Tell patient to take tablets with juice (preferably orange juice) or water, but not with milk or antacids. 8. Instruct patient not to crush or chew extended-release forms. 9. Caution patient not to substitute one iron salt for another because amounts of elemental iron vary. 10. Advise patient to report constipation and change in stool color
consistency. 11. In administering liquid form, let patient take it with straw to avoid straining of teeth.
Brand Name Classification Suggested Dose
Dolcet, Dolotral, Milador, Siverol, Tramal Pharmacologic class: opioid agonist Therapeutic class: analgesic Adults: • Patients who require rapid analgesic effect: 50–100 mg PO q 4–6 hr; do not exceed 400 mg/day. • Patients with moderate to moderately severe chronic pain: Initiate at 25 mg/day in the morning and titrate in 25-mg increments q 3 days to reach 100 mg/day. Then, increase in 50 mg-increments q 3 days to reach 200 mg/day. After titration, 50–100 mg q 4–6 hr; do not exceed 400 mg/day. • • Patients with cirrhosis: 50 mg q 12 hr. Patients with creatinine clearance < 30 ml/min: 50–100 mg PO q 12 hr.
Maximum 200 mg/day. Pediatric Patients: • Safety and efficacy not established.
Geriatric patients or patients with renal or hepatic impairment> 75 yr: Do Mechanism Action Indication not exceed 300 mg/day. ofBinds to mu-opioid receptors and inhibits the reuptake of norepinephrine and serotonin; causes many effects similar to the opioids—dizziness, somnolence, nausea, constipation—but does not have the respiratory depressant effects. • Relief of moderate to moderately severe pain when non-opioid analgesics are not active enough • Contraindication • • Renal impairment Hepatic impairment Contraindicated with allergy to tramadol or opioids or acute intoxication with alcohol, opioids, or psychoactive drugs. • • • Opioid-dependent patients. Severe hepatic impairment. Patients on obstetric preoperative medication.
• • • Drug Interaction
Abrupt discontinuation. Children <16 years old. Use cautiously with pregnancy, lactation, seizures, concomitant use of
CNS depressants or MAOIs, renal dysfunction, or hepatic impairment. Drug – Drug • Carbamazepine. Significantly decreases tramadol levels (may need up to twice usual dose). • • MAO Inhibitors. Tramadol may increase adverse effects. Tricyclic Antidepressants, Cyclobenzaprine, Phenothiazines,
Selective Serotonin Reuptake Inhibitors (SSRI), MAO Inhibitors. May enhance seizure risk with tramadol. • Other CNS Depressants. May increase CNS adverse effects of tramadol.
Herbal: St. John's Wort. May increase sedation.
Side/Adverse Effects CNS: sedation, dizziness or vertigo, headache, confusion, dreaming, sweating, anxiety, CV: hypotension, tachycardia, bradycardia Skin: sweating, pruritus, rash, pallor, urticaria GI: nausea, vomiting, dry mouth, constipation, flatulence GU: urinary retention / frequency, menopausal symptoms, dysuria, menstrual disorder Other: potential for abuse
1. Assess for level of pain relief and administer prn dose as needed but not to exceed the recommended total daily dose. 2. Monitor vital signs and assess for orthostatic hypotension or signs of CNS depression. 3. Explain the drug action, purpose of drug and side effects. 4. Advise the patient to avoid activities that require mental alertness. 5. Assess for history of drug addiction, allergy to opiates or codeine or seizures.
6. Assess the patient’s skin color, texture, lesions; orientation, reflexes,
bilateral grip strength, affect; P, auscultation, BP; bowel sounds, normal output; LFTs, renal function tests. 7. Instruct the patient to lye down for a while after taking the drug. 8. Report severe nausea, dizziness, severe constipation. 9. Monitor input and output ratio. Check for decreasing output. 10. Instruct the patient to make position changes slowly. 11. Tell the patient and watcher to report symptoms of CNS changes, allergic
reactions. 12. Provide safety measures: side rails, night light, call bell within easy reach. Generic Name Metoclopramide
Brand Name Classification Indication Suggested Dose
Apo-Metoclop. Clopra, Maxeran, Maolon, Octamide PFS, Pramin, Reglan Dopamine antagonist and ➢ To prevent or reduce nausea and vomiting from emetogenic cancer chemotherapy: Adult: 1 to 2 mg/kg I.V. 30 minutes before chemotherapy; repeat q 2 hours for two doses, then q 3 hours for three doses. ➢ To prevent or reduce postoperative nausea and vomiting: Adult: 10
to 20 mg I.M. near end of surgical procedure, repeat q 4 to 6 hours, p.r.n. ➢ To facilitate small-bowel intubation, to aid in radiologic examinations: Adults and children older than age 14: 10 mg or 20 ml I.V. as a single dose over 1 to 2 minutes. Children ages 6 to 14: 2.5 to 5 mg or 0.5 to 1 ml I.V. Children younger than age 6: 0.1 mg/kg I.V. ➢ Delayed gastric emptying secondary to diabetic gastroparesis: Adult: 10 mg P.O. 30 minutes before each meal and at bedtime for mild symptoms. Give slow I.V. infusion over 1 to 2 minutes 30 minutes before each meal and at bedtime for up to 10 days for severe symptoms; then P.O. dose may be started and continued for 2 to 8 weeks. ➢ Gastroesophageal reflux disease: Adult: 10 to 15 mg P.O. q.i.d., p.r.n., 30 minutes before meals and at bedtime. ➢ Emesis during pregnancy: Adults: 5 to 10 mg P.O. or 5 to 20 mg I.V. Mechanism or I.M. t.i.d. ofStimulates motility of upper GI tract, increases lower esophageal sphincter
tone, and blocks dopamine receptors at the chemoreceptor trigger zone. • Hypersensitivity to drug and in those with oheochromocytoma r seizure disorders. • Stimulation of GI motility might be dangerous History f depression, Parkinson disease, or hypertension Substrate (minor) of CYP1A2, 2D6; Inhibits CYP2D6 (weak) Anticholinergic agents antagonize metoclopramide's actions Antipsychotic agents: Metoclopramide may increase extrapyramidal symptoms (EPS) or risk when used concurrently. • Opiate analgesics may increase CNS depression
Side/Adverse Effects CNS: anxiety, drowsiness, dystonic reaction, fatigue, lassitude, restlessness, neuroleptic, malignant syndrome, seizures, suicide ideation, akathisia, confusion, depression, dizziness, extrapyramidal ymptoms, fever, hallucinatins. Headache. Insomnia, tardive dyskinesia. CV: bradychardia, superventricular tachycardia, hypotension, transient hypertension. GI: bowel disorders, diarrhea, nausea GU: incontinence, urinary frequency Hematologic: aggranulocytosis, neuropenia Skin: rash, uricaria Other: loss of libido, prolactin secretion.
1. Assess for mental status; depression, anxiety and irritability. 2. Monitor bowel sounds. 3. Safety and effectiveness of drug haven’t been established for therapy lasting longer than 12 weeks. 4. Tell patient to avoid activities that require alertness for 2 hours after doses. 5. Urge patient to report persistent or serious adverse reactions promptly. 6. Advise patient not to drink alcohol during therapy. 7. Administer 1 ½ hour before meals for better absorption 8. Monitor vital signs, especially cardiac rate to monitor tachycardia. 9. Evaluate for therapeutic effects: absence of nausea, vomiting, anorexia and fullness.
Brand Name Classification Suggested Dose
Arm & Hammer Baking Soda, Bell/ans, Neut, Soda Mint Alkanizer Cardiac Arrest: Adults: 1 mEq/kg I.V. of 7.5% or 8.4% solution; then 0.5 mEq/kg I.V. q 10 minutes depending on arterial blood gas (ABG) level. Base further dosages on results of ABG analysis. If ABG level is unavailable, use 0.5 mEq/kg I.V. q 10 minutes until spontaneous circulation returns. Infants and children: 1 mEq/kg (1 ml/kg of 8.4% solution) I.V. slowly followed by 1 mEq/kg q 10 minutes of arrest. Don’t give more than 8 mEq/kg I.V. total; a
4.2% solution may be preferred.
Mechanism Action Indication Contraindication Drug Interaction
ofDissociates to provide bicarbonate ion which neutralizes hydrogen ion concentration and raises blood and urinary pH Metabolic acidosis, Systemic or urinary alkalanization, Antacid, Cardiac Arrest Alkalosis, hypernatremia, severe pulmonary edema, hypocalcemia, unknown abdominal pain • Decreased effect/levels of lithium, chlorpropamide, methotrexate, tetracyclines, and salicylates due to urinary alkalinization • Increased toxicity/levels of amphetamines, anorexiants, mecamylamine, ephedrine, pseudoephedrine, flecainide, quinidine, quinine due to urinary alkalinization
Side/Adverse Effects CNS: tetany CV: edema Metabolic: hypokalemia, metabolic alkalosis, hypernatremia,
hyperosmolarity with overdose Nursing Responsibilities Skin: pain and irritation a injection site 1. To avoid risk of alkalosis, obtain blood pH, partial pressue of arterial oxygen, partial pressure of arterial carbon dioxide, and electrolyte levels. Tell prescriber laboratory results. 2. Oral products may contain 27% sodium. 3. Tell patient not to take drug with milk because doing so may cause high levels of calcium in the blood, abnormally high alkalinity in tissues and fluids, or kidney stones. 4. Advise patient of milk-alkali syndrome if use is long-term; observe for extravasations when giving I.V. Generic Name Ketosteril
Brand Name Classification Suggested Dose Mechanism Action
Ketosteril Keto Analog of Essential Amino Acids Adult 70 kg 4-8 tab tid given if GFR is 5-15 mL/min. ofThis drug is combination of amino acids which promotes splitting of urea. It reduces ion concentration of K, Mg and Phosphate. This promotes recycling products exchanging and anabolism of protein while reducing urea
concentration in serum. Pre-ESRD in CKD & DN patients stage 3, 4, 5 together w/ a very low protein (0.3-0.6 g/kg body wt/day), high caloric diet in compensated & decompensated retention to reduce uremic symptoms, slow or arrest of the progression of renal failure, prevent the degradation of body protein, reduce
the daily urinary protein loss, normalisation of the carbohydrate metabolism, correct the disturbances in Ca & phosphate metabolism, secondary hyperparathyroidism & renal osteodystrophy, improve the disturbed serum lipid profile & delay the need for dialysis. Dialysis CKD patients together with high protein (1.2-1.3 g/kg body wt/day) to reduce uremic symptoms & Contraindication improve malnutrition status. Hypercalcemia, disturbed amino acid metabolism. In case of hereditary phenylketonurie it has to be taken into account that this product contains phenylalanine. Drug Interaction Side/Adverse Effects Tetracycline affects Ca absorption • • • Headache, dizziness, dry mouth, nervousness, flushing, or irritability Trouble sleeping, stomach cramps, hot flashes and leg cramps Chest pain, slow/fast/irregular heartbeat, swelling of the feet or ankles, difficulty urinating, swelling of the breasts or discharge from the nipple in men or women, menstrual changes, sexual difficulties. Nursing Responsibilities 1. Tell patient to inform prescriber of all prescriptions, OTC medications, or herbal products he is taking, and any allergies he have.
2. Advice patient not to take any new medication during therapy unless approved by prescriber. 3. Tell patient that he may take without regard to food. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. 4. Inform the patient that the drug is available in many forms and dosages. The patient must take the drug in a dosage ordered by the prescriber. 5. Tell patient to report episodes of hypersensitivity reaction immediately. 6. Tell the patient not to abruptly stop the medication unless ordered by the physician. 7. Ensure that the patient does npt manifest any condition contraindicated in taking this drug. 8. Warn patient to avoid alcohol.. 9. Tell woman to stop drug and notify prescriber immediately if she is or may be pregnant or if she’s breastfeeding. 10. Assess the efficacy of the drug by monitoring VS and laboratory results. Refer accordingly.
Brand Name Classification Suggested Dose
Lipitor, Atacor HMG-CoA reductase inhibitor Oral: Children 10-17 years (females >1 year postmenarche): HeFH: 10 mg once daily (maximum: 20 mg/day) Adults: Hyperlipidemias: Initial: 10-20 mg once daily; patients requiring >45% reduction in LDL-C may be started at 40 mg once daily; range: 10-80 mg once daily Primary prevention of CVD: 10 mg once daily
Dosing adjustment in renal impairment: No dosage adjustment is necessary. Dosing adjustment in hepatic impairment: Do not use in active liver disease. Mechanism Action Indication ofInhibits HMG-CoA reductase, an early (and rate-limiting) step in cholesterol biosynthesis. • Adjunct to diet to reduce LDL, total cholesterol, apolopoproteim B, and triglyceride levels in patients with primary hypercholesterolemia (heterozygous familial ad nonfamilial) and mixed dyslipideia (Fredrickson types IIa and IIb); adjunct to diet to reduce triglyceride level (Fredrickson type IV); primary dysbetalipoproteinemia
(Fredrickson type III) in patients who don’t respond adequately to diet. • Alone or as adjunct to lipid-lowering treatments, such as LDL apheresis, to reduce total and LDL cholesterol in patients with homozygous familial hypercholesterolemia • • Heterozygous familial hypercholesterolemia To reduce the risk of MI, stroke, angina, or revascularization
procedures in patients with multiple risk factors for CAD but who Contraindication don’t yet have the disease. Hypersensitivity to atorvastatin or any component of the formulation; active liver disease; unexplained persistent elevations of serum transaminases; Drug Interaction pregnancy; breast-feeding • Antacids: Plasma concentrations may be decreased when given with magnesium-aluminum hydroxide containing antacids (reported with atorvastatin and pravastatin). Clinical efficacy is not altered, no dosage adjustment is necessary
Cholestyramine and colestipol (bile acid sequestrants): Reduce absorption of several HMG-CoA reductase inhibitors; separate administration times by at least 4 hours. Cholesterol-lowering effects are additive.
Clofibrate and fenofibrate may increase the risk of myopathy and rhabdomyolysis.
CYP3A4 inhibitors: May increase the levels/effects of atorvastatin. Example inhibitors include azole antifungals, ciprofloxacin,
clarithromycin, diclofenac, doxycycline, erythromycin, imatinib, isoniazid, nefazodone, nicardipine, propofol, protease inhibitors, quinidine, and verapamil.
Digoxin: Plasma concentrations of digoxin may be increased by ~20%; monitor.
Grapefruit juice: May inhibit metabolism of atorvastatin via CYP3A4; more likely to occur with lovastatin or simvastatin; avoid high dietary intake of grapefruit juice
Niacin may increase the risk of myopathy and rhabdomyolysis.
Side/Adverse Effects CNS: headache, asthenia, insomnia CV: peripheral edema EENT: pharyngitis, rhinitis, sinusitis GI: abdominal pain, constipation, diarrhea, dyspepsia, flatulence, nausea. GU: UTI Musculoskeletal: rhbdomyolysis, arthritis, arthralgia, myalgia Skin: rash
Other: allergic reactions, flulike syndrome, infection 1. Tell patient to inform prescriber of all prescriptions, OTC medications, or herbal products he is taking, and any allergies he have. 2. Advice patient not to take any new medication during therapy unless approved by prescriber. 3. Tell patient that he may take without regard to food. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. 4. Inform patient drug can cause headache (consult prescriber for approved analgesic); diarrhea (buttermilk, boiled milk, or yogurt may help); euphoria, giddiness, or confusion (use caution when driving or engaging in tasks that require alertness until response to medication is known). 5. Tell patient to report unresolved diarrhea, unusual muscle cramping or weakness, changes in mood or memory, yellowing of skin or eyes, easy bruising or bleeding, or unusual fatigue. 6. Remind patient not to donate blood while taking this medication and for same period of time after discontinuing. 7. Teach patient about proper dietary management, weight control, and
exercise. Explain their importance in controlling high fat levels. 8. Warn patient to avoid alcohol.. 9. Advise patient that drug can be taken at any time of day, without regard to meals. 10. Tell woman to stop drug and notify prescriber immediately if she is or may be pregnant or if she’s breastfeeding. Generic Name Domperidone
Domperidone Maleate; Motilium®; Novo-Domperidone; Nu-Domperidone; Classification Suggested Dose ratio-Domperidone Antiemetic Oral: Adults: GI motility disorders: 10 mg 3-4 times/day, 15-30 minutes before meals; severe/resistant cases: 20 mg 3-4 times/day, 15-30 minutes before meals Nausea/vomiting associated with dopamine-agonist anti-Parkinson agents: 20
mg 3-4 times/day Dosage adjustment in renal impairment: Decrease dose to 10-20 mg 1-2 times/day Mechanism Action ofDomperidone has peripheral dopamine receptor blocking properties. It increases esophageal peristalsis and increases lower esophageal sphincter pressure, increases gastric motility and peristalsis, and enhance
gastroduodenal coordination, therefore, facilitating gastric emptying and Indication decreasing small bowel transit time. Symptomatic management of upper GI motility disorders associated with chronic and subacute gastritis and diabetic gastroparesis; prevention of GI Contraindication symptoms associated with use of dopamine-agonist anti-Parkinson agents Hypersensitivity to domperidone or any component of the formulation; patients with GI hemorrhage, mechanical obstruction, or perforation; patients Drug Interaction with prolactin-releasing pituitary tumor Substrate of CYP3A4 (minor) Anticholinergics: May decrease effects of domperidone. Domperidone may increase the rate of absorption of drugs from small bowel,
while slowing absorption of drugs from the stomach. Absorption of sustainedrelease or enteric-coated tablets may be altered. QTc-prolonging drugs: Use with caution in combination with domperidone; includes type Ia and type III antiarrhythmics, some fluoroquinolones, and selected antipsychotics (thioridazine, mesoridazine).
Side/Adverse Effects 1% to 10%: Central nervous system: Headache/migraine (1%); does not cross blood-brain barrier; fewer CNS effects compared to metoclopramide Gastrointestinal: Xerostomia (2%) <1%: Abdominal cramps, constipation, diarrhea, dizziness, dysuria, edema, extrapyramidal symptoms (EPS) rarely, galactorrhea, gynecomastia, heartburn, hot flashes, increased prolactin, insomnia, irritability, nervousness, thirst, lethargy, leg cramps, mastalgia, menstrual irregularities, nausea, palpitation, pruritus, rash, regurgitation, stomatitis, urinary frequency,
urticaria, weakness Nursing Responsibilities 1. Watch patient for agitation, irritability, confusion, and rarely EPS 2. In GI motility disorders, it should be taken 15-30 minutes prior to meals. 3. Inform patient to take drug as directed, 15-30 minutes prior to meals. 4. Advise patient not to increase dosage without consulting prescriber (adverse effects may occur with overuse). 5. Tell patient that drug may cause dizziness, headache, insomnia and irritability. 6. Tell patient to contact prescriber if experience abnormal, uncontrolled movements or confusion occur. 7. Advise patient to report breast pain or enlargement, milk production, menstrual irregularities, or impotence. Generic Name Sodium Chloride
Altamist [OTC]; Ayr® Baby Saline [OTC]; Ayr® Saline [OTC]; Ayr® Saline Mist [OTC]; Breathe Right® Saline [OTC]; Broncho Saline® [OTC]; Entsol® [OTC]; Muro 128® [OTC]; NaSal™ [OTC]; Nasal Moist® [OTC]; Na-Zone® [OTC]; Ocean® [OTC]; Pediamist® [OTC]; Pretz® Irrigation [OTC]; SalineX® [OTC]; SeaMist® [OTC]; Simply Saline™ [OTC]; Wound
Classification Suggested Dose
Wash Saline™ [OTC] Sodium salt Fluid and electrolyte replacement in hyponatremia caused by electrolyte loss or in severe salt depletion: Adults: dosage is individualized. Use 3% or
5 % solution only with frequent electrolyte level determination and only slow I.V. For 0.45% solution, 3% to 8% of body weight, according to deficiencies, over 18 t o 24 hours. For 0.9% solution, 2% t 6% of body weight, according to deficiencies, over 18 to 24 hours. For 0.9% solution, 2% to 6% of body weight, according to deficiencies, over 18 to 24 hours. Heat cramp caused by excessive perspiration: Adults: 1 g P.O. with each glass of water. Mechanism Action Indication ofPrincipal extracellular cation; functions in fluid and electrolyte balance, osmotic pressure control, and water distribution • Parenteral: Restores sodium ion in patients with restricted oral intake (especially hyponatremia states or low salt syndrome). In general, parenteral saline uses: • Bacteriostatic sodium chloride: Dilution or dissolving drugs for I.M., I.V., or SubQ injections • • Concentrated sodium chloride: Additive for parenteral fluid therapy Hypertonic sodium chloride: For severe hyponatremia and
hypochloremia • • • • • • Hypotonic sodium chloride: Hydrating solution Normal saline: Restores water/sodium losses Pharmaceutical aid/diluent for infusion of compatible drug additives Ophthalmic: Reduces corneal edema Oral: Restores sodium losses Inhalation: Restores moisture to pulmonary system; loosens and thins congestion caused by colds or allergies; diluent for bronchodilator solutions that require dilution before inhalation • • Intranasal: Restores moisture to nasal membranes Irrigation: Wound cleansing, irrigation, and flushing
Hypersensitivity to sodium chloride or any component of the formulation;
hypertonic uterus, hypernatremia, fluid retention Drug Interaction Decreased levels of lithium Side/Adverse Effects CV: aggravation of heart failure, thrombophlebitis, edema when given too
rapidly or in excess. Metabolic: hypernatremia, aggravation of existing metabolic acidosis with excessive infusion. Respiratory: pulmonary edema. Skin: local tenderness, tissue necrosis at injection site Other: abscess
1. Use with caution in patients with CHF, renal insufficiency, liver cirrhosis, hypertension, edema; sodium toxicity is almost exclusively related to how fast a sodium deficit is corrected; both rate and magnitude are extremely important; do not use bacteriostatic sodium chloride in newborns since benzyl alcohol preservatives have been associated with toxicity. 2. Monitor serum sodium, potassium, chloride, and bicarbonate levels; I & O, weight. 3. Explain use and administration of drug to patient and family 4. Tell patient to report adverse reactions promptly. 5. Tell patient that wax matrix may appear in stool.
Brand Name Classification Suggested Dose
Prilosec®; Prilosec OTC™ [OTC]; Zegerid™ Proton pump inhibitor Oral: Children 2 years: GERD or other acid-related disorders: <20 kg: 10 mg once daily 20 kg: 20 mg once daily Adults:
Active duodenal ulcer: 20 mg/day for 4-8 weeks Gastric ulcers: 40 mg/day for 4-8 weeks Symptomatic GERD: 20 mg/day for up to 4 weeks Erosive esophagitis: 20 mg/day for 4-8 weeks Mechanism Action Indication ofSuppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump • Symptomatic gastroesohageal reflux disease (GERD) without
esophageal lesions. • • • Erosive esophagitis and accompanying symptoms caused by GERD Maintenance of healing erosive esophagitis Pathologic hypersecretory conditions (such as Zollinger-Ellison syndrome) • • Duodenal ulcer (short-term treatment) Helicobacter pylori infection and duodenal ulcer disease, to eradicate H. pylori with clarithromycin and amoxicillin (triple therapy) • Short-term treatment of active benign gastric ulcer
Frequent heartburn (2 or more days a week) Hypersensitivity to omeprazole, substituted benzimidazoles (ie, esomeprazole, lansoprazole, pantoprazole, rabeprazole), or any component of the formulation
Zegerid™: Also contraindicated with metabolic alkalosis and hypocalcemia (due to sodium bicarbonate content)
midazolam, triazolam): Esomeprazole and omeprazole may increase
levels of benzodiazepines metabolized by oxidation. Carbamazepine: Esomeprazole and omeprazole may increase carbamazepine levels.
CYP2C8/9 substrates: Omeprazole may increase the levels/effects of CYP2C8/9 substrates. Example substrates include amiodarone, fluoxetine, glimepiride, glipizide, nateglinide, phenytoin, pioglitazone, rosiglitazone, sertraline, and warfarin.
CYP2C19 inducers: May decrease the levels/effects of omeprazole. Example inducers include aminoglutethimide, carbamazepine,
phenytoin, and rifampin.
CYP2C19 substrates: Omeprazole may increase the levels/effects of CYP2C19 substrates. Example substrates include citalopram,
diazepam, methsuximide, phenytoin, propranolol, and sertraline.
Itraconazole and ketoconazole: Proton pump inhibitors may decrease the absorption of itraconazole and ketoconazole.
Phenytoin: Elimination of phenytoin may be prolonged; monitor. Phenytoin may decrease omeprazole levels/effects.
Protease inhibitors: Proton pump inhibitors may decrease absorption of some protease inhibitors (atazanavir and indinavir).
Warfarin: Elimination of warfarin may be prolonged; monitor.
Side/Adverse Effects CNS: asthenia, dizziness, headache GI: abdominal pain, constipation, diarrhea, flatulence, nausea, vomiting Musculoskeletal: back pain Respiratory: cough, upper respiratory tract infection
Skin: rash Nursing Responsibilities
1. Inform patient that capsule should be swallowed whole; do not chew,
crush, or open. Best if taken before breakfast. May be opened and contents added to applesauce.
2. Administer drug via NG tube should be in an acidic juice. 3. Administer powder for oral suspension 1 hour before a meal.
4. Inform that drug Should be taken on an empty stomach; best if taken before breakfast.
5. Notify to take as directed, before eating. Do not crush or chew
capsules. 6. Inform patient to avoid alcohol.
7. Report changes in urination or pain on urination, unresolved severe
diarrhea, testicular pain, or changes in respiratory status. 8. Inform patient that breastfeeding is not recommended.
9. Patient may experience anorexia. Advice to take frequent meals may
help to maintain adequate nutrition.
Brand Name Classification Suggested Dose
Constulose®; Enulose®; Generlac; Kristalose™ Disaccharide Prevention of portal systemic encephalopathy (PSE): Oral: Infants: 2.5-10 mL/day divided 3-4 times/day; adjust dosage to produce 2-3 stools/day. Older Children: Daily dose of 40-90 mL divided 3-4 times/day; if initial dose causes diarrhea, then reduce it immediately; adjust dosage to produce 2-3 stools/day Constipation: Oral: Children: 5 g/day (7.5 mL) after breakfast. Adults: 15-30
mL/day increased to 60 mL/day in 1-2 divided doses if necessary Acute PSE: Adults: Oral: 20-30 g (30-45 mL) every 1-2 hours to induce rapid laxation; adjust dosage daily to produce 2-3 soft stools; doses of 30-45 mL may be given hourly to cause rapid laxation, then reduce to recommended dose; usual daily dose: 60-100 g (90-150 mL) daily Rectal administration: 200 g (300 mL) diluted with 700 mL of H20 or NS; administer rectally via rectal balloon catheter and retain 30-60 minutes every 4-6 hours Mechanism Action ofThe bacterial degradation of lactulose resulting in an acidic pH inhibits the diffusion of NH3 into the blood by causing the conversion of NH3 to NH4+; also enhances the diffusion of NH3 from the blood into the gut where conversion to NH4+ occurs; produces an osmotic effect in the colon with Indication Contraindication resultant distention promoting peristalsis Constipation, to prevent and treat hepatic encephalopathy, including hepatic precoma and coma in patients with severe hepatic disease. Hypersensitivity to lactulose or any component of the formulation; galactosemia (or patients requiring a low galactose diet) Contraindicated in
patients on galactose-restricted diet Drug Interaction Decreased effect: Oral neomycin, laxatives, antacids Side/Adverse Effects Frequency not defined: Gastrointestinal: Flatulence, diarrhea (excessive dose), Nursing Responsibilities abdominal discomfort, nausea, vomiting, cramping 1. Dilute lactulose in water, usually 60-120 mL, prior to administering through a gastric or feeding tube. Syrup formulation has been used in preparation of rectal solution.
2. Monitor blood pressure, standing/supine; serum potassium, bowel
movement patterns, fluid status, serum ammonia.
3. Contraindicated in patients on galacatose-restricted diet; may be mixed
with fruit juice, milk, water, or citrus-flavored carbonated beverages.
4. Inform patient drug is not for long-term use. 5. Tell patient to take as directed, alone, or diluted with water, juice or
milk, or take with food.
6. Inform patient that laxative results may not occur for 24-48 hours; do
not take more often than recommended or for a longer time than recommended. Do not use any other laxatives while taking lactulose.
7. Advice to increased fiber, fluids, and exercise may also help reduce
8. Tell patient not to use if experiencing abdominal pain, nausea, or
vomiting. Diarrhea may indicate overdose.
9. Inform drug may cause flatulence, belching, or abdominal cramping.
Report persistent or severe diarrhea or abdominal cramping.
10. Tell patient to consult prescriber if breast-feeding.
Nightingale’s Environmental theory Florence Nightingale, commonly known as the “Lady with the Lamp”, created the Environmental Theory which is still widely used nowadays. She affirmed in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969) and that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Environmental factors affecting health Defined in her environmental theory are the following factors present in the patient's environment: • • • Pure or fresh air Pure water Sufficient food supplies
• • •
Efficient drainage Cleanliness Light (especially direct sunlight)
Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. Emphasized in her environmental theory is the provision of a quiet or noise-free and warm attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient. In the case of our client, she was situated in the Medicine ward, she really needs a clean and quiet environment conducive for her condition, since Medicine ward is quiet noisy and not well sanitized. The patient and significant others should have sufficient knowledge about sanitation so that they can provide her a more clean environment which is helpful for her recovery. She should be provided with a more comfortable milieu and also she should eat more nutritious foods that would help boost her immune system and must avoid foods that could worsen her health condition. The client also needed to breathe fresh air and feel the heat of the sun outside the Medicine Ward, since every man needs it to meet personal needs and to attain a good health status.
Orem's Model of Nursing
The theory Orem is based upon the philosophy that all "patients wish to care for themselves". Orem’s theory emphasizes on client’s self-care needs. Client can recover faster and holistically if they are allowed to carry out their own self cares to the best of their ability. When self-care is not maintained, illness, disease and death will occur. She has self care deficit. She unable to take care of herself and was unable to perform activities of daily living without assistance, since she is an aging person and cannot tolerate doing some of the activities because of her illness. Although it is our job to provide care for our client, it is important to promote independence and self-reliance to the patient since it promotes holistic well-being. We, as nurses should persuade the patient to become self-reliant and independent through giving health teachings on how to do such things but since the client needed assistance in doing some of her activities, we must also instruct the significant others to offer themselves to the client.
King’s Goal Attainment Theory This theory wants to integrate the concept of the nurse and the patient jointly communicating information, establishing goals, and taking action to attain goals. It describes a situation in which two people, usually strangers, come together in a health care organization to help or be helped to sustain a state of health. The focus of the nurse is to help the individual maintain health and function in an appropriate
role. The Goal Attainment Theory addresses interaction, perception, time, space, communication, transaction, role, stress and growth and development. Our client had great interaction with the group and was able to set up goals and attain them. Since it’s the nurse’s role to assess the patient and discuss the problems with them, it is also the role of the patient to collaborate with the nurse not only with the assessment but most especially in the interventions, so that they will be able to achieve their desired goal. It is essential that not only the nurse will discover the problem but the client should also take part in acknowledging it so that there will be cooperation between them. So in this case, the patient was able to identify and cooperate with the group very well.
NURSING CARE PLAN
Name: Aling D Age: 56 years old Sex: Female Date Cues Needs
Medical Diagnosis: ESRD 2° HN 2° DM type II Attending Physician: Dr. Gil Florida
Plan of Care
November 13, 2009 @ 12:00 AM
SUBJECTIVE: “Malipong pud ko karon medyo usahay tapos luya
A C T I V I T
Diagnosis Ineffective At the end of 2 hours peripheral tissue perfusion related to low hemoglobin concentration in blood to • of nursing care, the patient will be able to:
1. Determine factors related to individual situation.
® To assess causative 2009 @ 2:00pm Verbalize understandin g of the condition; and Determine ways to improve circulation factor of the condition 2. Note customary baseline data. ® To At the end of 2 hours of nursing provide care, the patient with was able to: • Verbalize understan ding of a the condition “Mao diay
OBJECTIVE: • Hemogl obin (115175 g/Dl)= 77 • RBC (4.20-
Y E X E R C I S
comparison current findings
R: A decrease in oxygen
3. Review laboratory studies. ® To serve as
resulting in the failure nourish to the
scientific basis for the problem. 4. Encourage for a quiet
tissues at the
6.10)= 2.60 • Hemato crit (0.360.52)= 0.22 • Weak periphe ral pulses • Weakn ess • • Pallor CRT=3 sec
capillary level. Nurses’ Pocket
and restful atmosphere. ® To conserve energy and lowers tissue
malipong ko, dala dala pod diay ni sa akong sakit.”
P A T T E R N
oxygen demands 5. Perform assistive range of motion exercise. ® To promote
circulation. 6. Encourage early ambulation as much as possible. ® To enhance venous return. 7. Promote position
Skin cold to touch
changes and discourage staying at the same position for a long period of time. ® To maximize tissue perfusion.
8. Elevate head of bed or
add pillow when patient is lying on bed. especially at night. ® To increase blood
gravitational flow. 9. Discuss ways to
improve circulation such as eating iron
rich foods. ® To help patient 10. Administer medications with precautions. ® Drug response,
half-life and toxicity levels may be affected by altered tissue
perfusion. 11. Demonstrate and encourage the use of relaxation techniques such as deep breathing exercise. ® To decrease tension
OBJECTIVE OF CARE
N U T R I T I
After 4 hours of 1. Monitor vital signs q 4˚.
GOAL MET. After 4 hours of nursing
r 13, 2009 “Nanghupong akong tiil day,” verbalized by the client.
excess: extracellular nursing secondary to fluid shift secondary to altered GFR
intervention, the ® In order to have a client will be baseline able to: Verbalize understandi ng condition comparing data in
intervention, the patient
secondary to ESRD • as manifested by pitting edema R: There is an increased isotonic retention as manifested by pitting edema.
of the patient’s vital signs and determine
was able to verbalize understanding of her
O high serum N A L – M blood E T A B
of significant changes. 2. Monitor I & O.
sodium=168 • pitting edema=2 + •
and commit ® In order to monitor cooperation to hydration and
condition and committed cooperation.
the elimination status. 3. Monitor serum electrolyte levels.
procedures and therapy
pressure=150/ 100 mmHg
to be done ® Serum electrolytes to her with contribute largely to regards to retention of fluids in
NURSING DIAGNOSIS Activity Intolerance related to imbalance between oxygen
OBJECTIVE OF CARE Within the span of 3 hours, the client will:
a) Verbali ze techni ques
1. Determine patient's perception
November 14, 2009
Subj ectiv e:
A C T I V I
Goal met After 3 hours of
of nursing care, the
“Dali lang ko kapuyon.”
supply and demand secondary to anemia R: There is an
causes of fatigue or activity
client was able to:
a) verbalize techniqu es to
intolerance. R: Assessment guides treatment. 2. Monitor vital
Obje ctive :
T Y E X E
insufficient physiological psychological energy to endure or complete required or
to enhanc e activity toleran
enhance activity tolerance , saying
signs. R: To watch for in blood
-exertional discomfort noted
pressure, pulse and
-palmar pallor noted -hemoglobin level: 77 -hematocrit level: 0. 22 -red blood cell: 2.60 -CRT= 3 secs
ce; b) Partici pate willingl y in
respiratory rate after activities 3. Assist ADLs indicated. R: Assisting the with as
Guide by Doenges et. al.
magpahu wayhuma n ko
necess ary/des ired activiti es.
mulakawlakaw.” b) Participat e willingly
patient with ADLs allows conservation energy. 4. Encourage and sleep. R: In order to help relax the patient. 5. Provide a calm environment. R: To promote a rest for of
in necessar y/desired activities.
resful atmosphere. 6. Place necessary
NURSING DIAGNOSIS WITH ®
OBJECTIVE OF CARE
NURSING INTERVENTIONS WITH ®
November 14, 2009
S: • “Naka-ihi nako pero kaihion gihapon ko,” as verbalized by the client. O: • Residual urine • Dark-yellow urine • Distended urinary bladder • Oliguria • Concentrated urine • Urine specific gravity= 1.042 (1.0101030)
E L I M I N A T I O N P A T T E R N
Urinary infrequency related to altered Glomerular Filtration Rate secondary to ESRD. ® The patient has an ncomplete emptying of the bladder due to use of medications, psychological/ neurological factors or an underlying health condition. Nurses’ Pocket Guide by Doenges et. al.
After 4 hours of 1. Monitor I & O. R: In order to nursing follow up intervention, the hydration and patient will be elimination status/ able to: 2. Insert urinary • Verbalize catheter as relief from ordered. urinary R: To ensure infrequency; urinary and elimination. • Verbalize 3. Assess the understandin presence g of her pathological condition conditions which may underlie urinary infrequency. R: To properly address urinary infrequency, the underlying cause must be determined. 4. Administer diuretics as ordered. R: To help in urinary elimination. 5. Institute fluid
Goal met. The client was able to verbalize understanding of condition and verbalize relief from urinary infrequency.
ordered. R: To prevent further accumulation of fluids. 6. Explain to the patient importance of fluid restriction. R: To include the patient in the plan of care. 7. Establish infection precautions. R: Catheterizations may increase the risk for UTIs. 8. Encourage compliance with medications. R: To ensure continuity of therapy ordered. 9. Discuss with the patient the complications of incompliance to medications. R: To promote compliance. 10. Encourage patient
discomfort in urination including the frequency, consistency and color of urination. R: To help medical personnel address immediately to any discomforts experienced by the patient.
OBJECTIVE OF CARE
November 12, 2009 11:00pm 11 - 7shift
S: “Makatamad maligo, ana man pod ang ubang pasyente diari. Lisod jud maligo sa hospital.” O: -not well groomed -presence of body odor
A C T I V I T Y E X E R C I S E P A T T E R N
Self care deficit: After 2 hours of bathing / hygiene nursing related to lack of intervention, the motivation client will be able to recognize R: The patient has an self care need impaired ability to and enumerate provide self care the importance requisites due to of personal environmental and hygiene. psychological factors.
1. Assess client’s self care need. R: This will serve as a mark as to where the nurse will anchor her interventions. 2. Assess client’s physical condition relating to hygiene. R: This will point our any factors present in the patient physically that may hinder her capacity to meet the need. 3. Educate the patient on the importance of personal hygiene. R: Makes the patient realize
Goal met. After 2 hours of nursing intervention, the patient was able to verbalize understanding of the problem and the need to meet it. The patient was also able to point out several courses of action that she must undertake to promote hygiene aside from bathing,such as brushing the teeth and combing the hair.
related to health. 4. Let the patient enumerate her ideas on the importance of hygiene. R: Encourages the patient to understand the need. 5. Discuss ways to attain good personal hygiene such as bed bath. R: provides the patient options in performing bathing. 6. Provide and maintain privacy. R: Makes the patient secure that she can perform bathing without risking her
enumerate her own ideas as to the ways and other techniques that she can undertake in order to attain good personal hygiene thru bathing. R: Involves the patient in the plan of care. 8. Discuss the possible negative implications of not taking a bath such as infections and odor. R: Broadens the patient’s idea about the problem and encourages her to meet the need. 9. Encourage
questions regarding hygiene. R: Clears up any ambiguities in the patient’s mind and improves understanding. 10. Appreciate the patient’s understanding of the things discussed. R: Lets the
patient feel that her idea is well considered by the nurse and that her wellness and understanding of the importance of the need is the best interest of the nurse.
Onset of the illness
GOOD FAIR POOR JUSTIFICATION ☻ It was during June 1994 that the patient was diagnosed of Diabetes Mellitus type II. Her DM II that is 15 years ago eventually lead to
Hydronephrosis and ESRD. Duration of illness ☻ After experiencing the signs and symptoms of Diabetes Milletus type 2, the patient immediately went to the hospital for medical help. Yet it was 15 years ago when she was diagnosed with Diabetes Milletus type 2. Sad to say her diabetes lead her to hydronehprosis and eventually to end-stage renal Precipitating factors ☻ disease. Even after being diagnosed of Diabetes Milletus and Hydronephrosis, the patient still doesn’t strictly adhere to medical advices regarding her Willingness to take medications and treatment ☻ nutrition. The patient submits herself to the treatment regimen which is required for her to take but she is not complying with the treatment properly. She has the knowledge of the purpose of the treatment he undergoes. Yet the patient is able to buy all the Age ☻ medicines being ordered. Aling D is already 56. As the age increases, it puts
12 the patient into higher risk of having ESRD especially Environmental factors ☻ she also has diabetes and
hydronephrosis. The client’s home as reported is conducive for rest and sleep. The patient lives in a therapeutic environment. There are smaller chances of pollution and noise. It can be said that the environment as well was generally peaceful and calm is very favorable for rest and promotes better
health. The family has been very supportive throughout the whole process. Her sons visited the patient constantly. Throughout our duty the group only sees her sons and never saw her husband. The support, most especially from her husband could help the patient accept her situation. Computation: ➢ Poor: (4*1)/7 ➢ Fair: (2*2)/7 = 4/7 = 4/7 = 3/7 1.57
➢ Good: (1*3)/7 Total 3 2 2 Total: General Prognosis: 1-1.6 = POOR
1.7-2.3 = FAIR 2.4-3.0 = GOOD
12 Rationale for a Good Prognosis
As shown by the calculated prognosis in relation to the different factors involved, the patient has a poor chance of survival. The factors presented in relation to prognosis shows that patient can poorly cope up after being discharged. The condition was diagnosed 15 years ago and eventually her diagnosed Diabetes Milletus lead to End-Stage Renal Disease. The patient submits herself to treatment yet not complying to it properly. In addition, support has been given by the family members to make the patient feel that she is not alone in what she’s going through. Finally, it is seen that the patient has lesser chance of coping up wither illness. Yet she could help herself, with the help of her family to accept any possibilities that might result from her illness.
DISCHARGE PLAN (M.E.T.H.O.D.)
Instruct client to continue take her prescribed medications Orient the client about the name of drugs, their actions, the exact dosage, the frequency and the route of administration.
• • •
Instruct client to follow the instruction when administering medication. Encourage the significant others not to leave the client during medication Explain to the client the side effects and adverse effects of the drugs she takes by prescribing its manifestations.
Encourage the client not to stop intake of prescribed medications, unless approved by the physician.
Encourage the client to report to the physician immediately if any adverse effects or side effects had occurred.
Exercise • • Instruct client to balance activities with adequate rest periods. Educate client on proper body mechanics to prevent muscle strain and enable client to relax. • Encourage early ambulation, assist the client if needed.
12 • • Educate client the importance of drug compliance. Discuss to the client the complication of the condition because knowledge about the condition supports learning that will decrease deficit and anxiety. Hygiene • • Encourage client to do daily hygiene. Discuss to the client the importance of proper hygiene to promote enhancement of knowledge regarding its importance. • Encourage client to ask assistance if needed.
Outpatient orders Call the doctor if any of the following occur:
• • • • • • • • You cannot make it to your follow-up or dialysis visit. Have itchy skin and develop skin rashes. You are passing little to no urine. Experience nausea and vomiting. You heart is beating fast or you are breathing fast. You have a seizure (convulsion). You have chest pain or trouble breathing all of a sudden. You have questions or concerns about your care, medicine, or treatment.
Diet • • To promote wellness, eat a balanced diet rich in fresh fruits and vegetables. Instruct the client to eat foods low in sodium, low in Potassium and low in sugar content.
12 • Encourage protein intake to be high biologic value like non-fat or low-fat milk, egg white and meat.
This case study has provided the proponents with important information about the patient’s disease. In order to ensure that optimal health is restored and maintained, the group would like to recommend the following:
To the patient Whenever there is, the onset of a certain disease it implies one to contribute her cooperation and willingness to be responsible for her own health. The patient must submit herself to palliative care for her to reducing the severity of her disease. The goal is to prevent and relieve suffering and to improve quality of life for people facing serious, complex illness. The patient must be sensitive of her own needs and be able to expect liability for her actions. She is also encouraged to verbalize her own thoughts and feelings concerning how she perceives her condition affect her life and her acceptance of her disease. She is advised to take part in complying with the treatment designed for her. She should realize the importance of complying with her medication and the benefits this practice would bring to her and her family’s well-being. Moreover, she must not hesitate on seeking medical assistance whenever she feels any unusualities in her body.
To the patient’s family The patient’s family plays an important role in the patient’s illness and palliative care. The family should make themselves physically present so that the patient would somehow feel
13 their support and concern. They are encouraged to be the patient’s source of strength and inspiration as she undergoes painful, traumatic and harrowing situation. In addition, it is of prime importance that they are oriented and educated basic facts regarding the patient’s condition so that they will understand her even better and assist her in her daily activities.
To the student nurses: This case study would help them better understand the patient’s condition. What is entrusted to student nurses is the life of their patient. Even with the clinical instructor’s presence, they can still make mistakes and errors, which can harm the patient. Hence, they are encouraged to equip themselves with necessary knowledge that will enable them to render quality and holistic nursing care and intervention to patients in need. It is known that nurses play a major role in helping the client and family implement healthy behaviors and help them monitor the client’s health. Thus, anticipatory guidance and knowledge about health should be supplied to help clients attain, maintain, or regain an optimal level of health. Student nurses should prioritize interaction with family members and significant others to provide support, information, and comfort in addition to caring for the patient. Thus, they should prepare themselves with the reality that they are soon to become health professionals. Genuineness, empathy, and respect are key elements for the nurse to possess. Student nurses must develop patience, love for our work, and empathy to our patients. They must assist in facilitating a remarkable experience as well as share our knowledge regarding the case. They must also continue to study different cases and be able to impart this to other student nurses, patients and their significant others.
12 To the Ateneo de Davao University- College of Nursing The AdDU- College of Nursing is the source that provides student nurses with exposures that enable them to apply the knowledge they have gained and practice the skills they honed necessary for their profession. The faculty and staff are encouraged to continue improving the standards of the Ateneo Nursing Curriculum by providing quality education to students. Also they, themselves, must be well-trained to delegate learning to student nurses. It is important that they continue to inspire generations of today to perceive nursing as a gift and act of charity rather than a mere means to success.
To the Professional Medical World End Stage Renal Disease is a class of disease that can affect every person. Therefore, it is recommended that there should be facilities or institutions that are made for the research of how to prevent end-stage renal disease . Also, the proponents recommend that medical practitioners work hand in hand in order to improve the welfare of the society, promote optimum health, and prevent the spread of diseases. They should have proper information dissemination in order for the community to be aware and be well informed about the different diseases, their manifestations, and how they can be prevented and cured. They should teach the public proper hygienic practices, proper sanitation and handling of foods, and healthy lifestyle. They must also do further research, inventions, and discoveries in the field of medicine in order to save more lives. In partnership with other health sectors, attaining the goal in establishing optimum health to the whole population is possible.
• • •
Kozier and Erb’s Fundmentals of Nursing 8th Edition Nursing Pocket Guide to Diagnoses, Prioritized Interventions and Rationale Doenges et. al. Textbook of Medical Surgical Nursing 11th Edition Lippincot and Willers Adrogué HJ, Madias NE (September 1981). "Changes in plasma potassium concentration during acute acid-base disturbances". Am. J. Med. 71 (3): 456–67.
National Institute for Health and Clinical Excellence. Clinical guideline 73: Chronic kidney disease. London, 2008.
Ruggenenti P, Perna A, Gherardi G, Gaspari F, Benini R, Remuzzi G (October 1998). "Renal function and requirement for dialysis in chronic nephropathy patients on long-term ramipril: REIN follow-up trial. Gruppo Italiano di Studi Epidemiologici in Nefrologia (GISEN). Ramipril Efficacy in Nephropathy". Lancet 352 (9136): 1252–6.
Lewis EJ, Hunsicker LG, Clarke WR, et al. (2001). "Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes". N Engl J Med 345: 851-60.
Brenner BM, Cooper ME, de ZD, et al. (2001). "Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy". N Engl J Med 345: 861-9.
Perazella MA, Khan S (March 2006). "Increased mortality in chronic kidney disease: a call to action". Am. J. Med. Sci. 331 (3): 150–3.
WEBSITES National Kidney Foundation (2002). "K/DOQI clinical practice guidelines for chronic kidney disease". http://www.kidney.org/professionals/KDOQI/guidelines_ckd.
s.pdf MedPAC ESRD program overview • http://www.empiremedicare.com/pdf/combined/mmr2008-1.pdf Medicare Monthly Review • http://www.cahabagba.com/part_b/msp/providers_general_info.htm Cahaba GBA