UNIVERSAL COLLEGE OF PARANAQUE

Dr. A Santos Avenue, Sucat Paranaque City

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

Chronic Kidney Failure

Secondary to Type 2 Diabetes Mellitus

Submitted to:
Elenita Blasco
Dean of CAHS

Submitted by
Eco, Jr. Job and Singh, Mary Ann
 Table of Content
I. Introduction --------------------------------------------------------------
----------
II. Demographic Data ---------------------------------------------------- -
----------
III. Physical Assessment ---------------------------------------------------
----------
IV. Gordon’s Functional Pattern ------------------------------------------
----------
V. Course in the Ward -----------------------------------------------------
----------
VI. Laboratory and Diagnostic Exam -------------------------------------
----------
VII. Anatomy and Physiology ----------------------------------------------
-----------
VIII. Pathophysiology --------------------------------------------------------
------------
IX. Drug Study ---------------------------------------------------------------
-----------
X. Nursing Care Plan ------------------------------------------------------
------------
XI. Discharge Plan ----------------------------------------------------------
------------
I. Introduction
CKD Secondary to DM

The group C of BSN level IV students were given the opportunity to have exposure at
Medical Center of Paranaque – ICU; and on that day me and my partner in this case presentation
Ms. Singh found a commendable case reasonable to be presented for case study. The patient, to
be mentioned in this paper as Mrs. J.M, was one of the patients admitted to the ICU. She was 60
years of age. She was admitted due to CKD secondary to DM.

A person with Stage 5 CKD has end stage renal disease (ESRD) with a GFR of 15 ml/min or
less. At this advanced stage of kidney disease, the kidneys have lost nearly all their ability to do
their job effectively, and eventually dialysis or a kidney transplant is needed to live. Symptoms
that can occur in Stage 5 CKD include loss of appetite, nausea or vomiting, headaches, being
tired, being unable to concentrate, itching, making little or no urine, swelling, especially around
the eyes and ankles, muscle cramps, tingling in hands or feet, changes in skin color and increased
skin pigmentation.

If you are diagnosed with stage 5 CKD, you will need to see a nephrologist immediately. This is
a doctor who is trained in kidney disease, kidney dialysis and transplant. The doctor will help
you decide which treatment is best for you— hemodialysis, peritoneal dialysis or kidney
transplant—and will recommend an access for dialysis. Your nephrologist will develop your
overall care plan and manage your health care team.

Healthy kidneys do many important jobs. They filter your blood, keep fluids in balance,
and make hormones that help your body control blood pressure, have healthy bones, and make
red blood cells. If you have kidney failure, it means your kidneys have stopped working well
enough to do these important jobs and keep you alive. As a result: Harmful wastes build up in
your body

 Your blood pressure may rise

 Your body may hold too much fluid
 Your body cannot make enough red blood cells

Diabetes happens when your body does not make enough insulin or cannot use insulin
properly. Insulin is a hormone. It controls how much sugar is in your blood. A high level of
 sugar in your blood can cause damage to the very small blood vessels in your kidneys. Over
time, this can lead to kidney disease and kidney failure.

Type 2 diabetes, once known as adult-onset or noninsulin-dependent diabetes, is a chronic

condition that affects the way your body metabolizes sugar (glucose), your body's important
source of fuel.
With type 2 diabetes, your body either resists the effects of insulin — a hormone that
regulates the movement of sugar into your cells — or doesn't produce enough insulin to
maintain a normal glucose level.
More common in adults, type 2 diabetes increasingly affects children as childhood obesity
increases. There's no cure for type 2 diabetes, but you may be able to manage the condition
by eating well, exercising and maintaining a healthy weight. If diet and exercise aren't
enough to manage your blood sugar well, you also may need diabetes medications or insulin
therapy.
Signs and symptoms of type 2 diabetes often develop slowly. In fact, you can have type 2
diabetes for years and not know it. Look for: increased thirst and frequent urination
,increased hunger, weight loss, fatigue, blurred vision, slow healing sores, and areas of
darkened skin.
According to Philippines institute of health metrics and evaluation in 2005 diabetes was
in rank number 5 and in 2016 it become in rank number 6 with a percentage of 44.9% in
mortality rate

II. Demographic Data

Patient Name: Mrs. J.M

Age: 60 years old

Birth Date: December 3, 1958

Civil Status: Married

Occupation: manager in shipping company

Address :Brgy. San Isidro, Paranaque City

Religion: Roman Catholic

Clinical/ Admitting Data:

Chief Complaint:

Dizziness with body weakness

History of The Present Illness:

2 weeks prior to admission patient experienced dizziness with body weakness prompting the
patient to seek medical consult

Past Medical History:

Patient was diagnosed with Diabetes Mellitus Type 2 since June 2018

(+) DM type 2, (+) Smoker

Date of Admission:

August 31,2018

Time of Admission:

11:46am

Attending Physician:

Dr. Alcantara

Admitting Diagnosis:

CKD secondary to DM

Final Diagnosis:

CKD secondary to DM

Vital Signs on admission:

T= 37.8°C

CR= 93

RR= 21cpm

BP= 140/100mmHg
 Source of Information

Husband Nurse on Duty Chart

III. PHYSICAL ASSESSMENT:

September 7,2018

Vital signs:

T=38.0

CR=80

RR=mechanical ventilator (22bpm)

BP=140/100
 - weak and pale looking
- with foul breath
- conscious and coherent
General Appearance
- with Heplock
- on OGT
- restlessness
- with ET tube and Mechanical Ventillator

Interpretation
Normal
Assessed Technique Day 1 Day 2
Findings

A. Head and Face

Head Inspection Head must be - normocephalic - normocephalic No problem
and palpation rounded, - symmetrical in - symmetrical in identified
normocephalic shape shape
& symmetrical. - no masses, no - no masses no
lesions lesions

Hair Inspection Thick coarse or - evenly - evenly distributed Indicates lack

smooth, silky distributed over over the scalp of hygiene due
there are no the scalp - with white, straight to
signs of - with white, and thick hair immobilization
infestation. straight and thick - dandruff is present
hair
- dandruff is
present
B. Eyes C.
Eyebrows Inspection Hair evenly - Hair evenly Hair evenly normal
distributed; distributed; distributed; eyebrows
 eyebrows eyebrows symmetrically
symmetrically symmetrically aligned
aligned. aligned
Show equal
movement.
Eyelids Inspection No - lids close - lids close
and discoloration; symmetrically symmetrically Pale
conjunctiva Meets - no edema, and no - no edema, and conjunctiva
completely discharges no discharges indicates low
when the eyes - pale - pale supply of RBC
are closed,
pinkish
conjunctiva
Involuntary
blink 15-20x
per minute
Schlera Inspection White whitish whitish Normal
Pupils Inspection Black in color, - symmetrical in - symmetrical Normal
equal in size; size in size
Round, reactive - round and dark - round and
to light and brown dark brown
accommodation
D. Ears E.
Ears Palpation & The auricles are - equal in size - equal in size Normal
Inspection aligned with the - auricles are - auricles are
outer canthus of smooth and smooth and
eye. symmetrical symmetrical
Auricle are - pinna recoils - pinna recoils
mobile, from & after it is folded after it is
not tender - with dry cerumen folded
with dry cerumen
 F. Nose G.
Nose Palpation and When lightly - color is the same - color is the normal
Inspection. palpated, there with the entire same with the entire
were no face face
tenderness & - lesions and - lesions and
lesions. tenderness were tenderness
both absent
nasal mucosa was
pinkish
External Inspection Symmetric and - the external nose - the external Normal
>shape straight; no is symmetrical nose is
>size discharge or and straight symmetrical
>skin flaring and air - both left and right and straight
>color moves freely in nares were patent - both left and
>patency and out. - The nasal septum right nares
is intact and in were patent
midline without - The nasal
abnormalities. septum is
intact and in
midline
without
abnormalities
Sinuses Palpation No tenderness - No tenderness No tenderness Normal
H. Mouth I.
Mouth Inspection & Lips uniformly - appear dry and . - appear dry and Indicates lack
Palpation pink, moist and pale pale of hygiene due
symmetric. (+) mouth sore to
Have smooth immobilization
texture.
Tongue Inspection & It is pink in - tongue was dry Due to fluid
Palpation color, moist & and slightly pale restriction
 slightly rough, - tongue moves
there is a freely
presence of thin - uvula is in
whitish coating. midline
J. Neck K.
Neck Inspection & The neck is - neck movement - neck normal
Palpation straight; No was coordinated movement
visible mass or and difficulty in was
lumps; moving was not coordinated
Symmetrical noted and difficulty
- free from lumps in moving
and no tenderness was not noted
- free from
lumps and no
tenderness
L. Chest M.
Chest Inspection, Symmetrically - no masses and - no masses and Crackles sounds
Palpation, aligned. tenderness upon tenderness indicates
Percussion & palpation upon presence of
Auscultation. - crackles sound palpation fluid in the
upon auscultation - crackles lungs
on right lung sound upon - calciphy
fields auscultation laxis
- (+) calciphylaxis on right lung indicates
- Dry skin fields abnorma
l
calcium
and
phospha
te
 - dry skin
indicates
dehydrat
ion
Breast Inspection Areola is - round in shape, Normal
and Palpation rounded or oval no lumps, no - round in
with same masses shape, no
color. - areola dark lumps, no
Nipples are brown in color masses
rounded, - nipples round, - areola dark
everted, same equal in size brown in
size & equal in color
color. nipples round, equal
No obvious in size
mass noted.
N. Abdomen O.
Abdomen Inspection, Skin color is - same color of the - same color of normal
Auscultation, uniform; No body the body
Palpation, lesions
Percussion
Skin Inspection, Skin color is - (+) calciphylaxis - (+) Indicates
palpation uniform; no - (+) dry skin calciphylaxis dehydration and
lesions - (+) poor skin - (+) dry skin low level or
turgor - (+) poor skin RBC
- Pale skin turgor
P. Upper Extremities Q.
Upper Inspection, Extremities, - presence of Indicates
extremities Palpation & symmetrical in - presence of calciphylaxis, dehydration
Percussion size & length. calciphylaxis, dry skin and
Muscles - can extend arms poor skin
normally firmed without difficulty turgor
 & showed - dry skin can extend arms
coordinated - poor skin turgor without difficulty
movement.
R. Lower Extremities S.
Lower Inspection. Extremities are - skin uniform in - skin uniform Indicates
Extremities Palpation & equal in size. color in color dehydration
Percussion Color is even. - with grade 1 - flaky skin
edema - bed sore
- flaky skin pale nail bed
- bed sore
- pale nail bed
Motor Inspection Equal Strength - with limited . with limited Indicates
Strength on both side movement movement difficulty of
movements
T. Genitalia U.
Genitalia Inspection & normal normal normal normal
Palpation
IV. Gordon’s 11 Functional Health Pattern

Health Perception and Health Management Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Pakipaliwanag ang 1. “Ang kalusugan ay Ineffective Airway Clearance
kahulugan ng pagkakaroon ng
kalusugan ayon sa maayos na
inyong palagay. At ang pangangatawan at
palagay mo sa iyong waalang karamdaman”
kalusugan sa ngayon. During Hospitalization:
Sa ngayon
nahihirapan siya
huminga kaya naka
mechanical ventilator
siya. Nalulungkot ako
2. Ano-ano ba ang iyong sa kalagayan ng
ginagawa para asawa ko sa ngayon.
mapangalagaan mo ang Before Hospitalization:
sariling kalusugan? 2. Para sa akin ang
pagkain ng tatlong
beses sa isang araw ay
sapat na upang ako’y
maging malusog at
pag eehersisyo”
During Hospitalization:
Sa ngayon ang kaya
nya nalang gawin ay
3. Nakakapagpacheck-up sumunod sa sinasabi
ka ba sa doktor? Saan, at pinapayo ng mga
gaano ito kalayo mula doctor at nurses
sa inyo at gaano naman
kadalas? Before Hospitalization:
3. nakapagpacheck sa
doctor kaya nalaman
namin dati na may
diabetes sya“
During Hospitalization:
Kampante ako
ngayon dahil nasa
ospital sya at ano
mang emergency na
4. Sino ang nagtutustos sa konektado sa
pangangailangan ng kondisyon nya madali
inyong pamilya? sino syang mapapagaling
ang sasagot sa
pagbabayad para sa
mga ganitong Before Hospitalization:
sitwasyon ? Kaano-ano 4. “Ang mga anak ko
mo naman siya? lahat sila ay nasa
ibang bansa,meron din
naman kaming ipon na
mag asawa at may
paupahan kami na
pinagkukunan pati na
5. Nagkasakit ka na ba rin pension at
dati maliban sa philhealth”
nararamdaman mo
ngayon?
During Hospitalization:
6. Meron ba sa lahi ng .
magulang mo ang Ang mga anak ko
maysakit? Kaninong lahat sila ay nasa
parte? At ano-anong ibang bansa,meron din
mga sakit ito? naman kaming ipon na
mag asawa at may
7. May allergy ka ba? paupahan kami na
pinagkukunan pati na
rin pension

Before Hospitalization

5. Nagkasakit na sya
dati, pangkaraniwan
lang naman lagnat,
ubo o sipon at yung
diabetes

During Hospitalization Ineffective Tissue Perfusion

Sa ngayon nilalagnat siya. At and Risk for Infection
medyo namumutla yung balat
niya.

Before Hospitalization
6. Ang tatay nya ay may
lahi ng diabetes at
hypertension
 7. Wala naman

Nutritional-Metabolic Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:  Imbalance nutrition
1. Ano-ano ba ang 1. Madalas hilig nya less than body
madalas mong kumain ng maaalat requirements
kinakain sa araw- tulad ng tuyo o dried
araw? Iniinom?ilang fish mahilig din sya sa
takal ng kanin at ilang desserts,madalas
piraso ng tuyo? nakakatatlong takal
sya ng kanin lalo na at
tuyo o daing ang ulam
,mga sampung piraso
ng tuyo at isang
2. Gaano ka kadalas platito ng lecheflan or
umiinom ng tubig? ice cream
(kung nagsosoftdrinks During Hospitalization:
o juice, pakitanong na Bawal daw ako
rin) kumain ng kahit anon
na di sinasabi ng
doctor at naka OGT na
sya
Before Hospitalization:
2. Siguro mga tatlong
basong tubig sya sa  Altered health
isang araw. Kadalasan maintenance
nag sosoftdrinks din
3. May bisyo ka ba? sya pag mainit.
Kung meron, ano-ano During Hospitalization:
ang mga ito, gaano Hindi pa po ako
karami ang nauubos pinapayagan na
mo sa isang araw at uminom ng tubig,
gaano kadalas mo ito basabasain lang daw
ginagawa? ang labi.

Before Hospitalization
 3. Paninigarilyo nakaka
walong stick sya sa
isang araw

Elimination Pattern

Questions Response PROBLEM IDENTIFIED

1. Gaano ka kadalas Before Hospitalization

dumumi? Ilang beses 1. Minsan po isang beses
sa isang araw? sa isang araw pero
pinakamatagal po
tatlong beses sa isang
linggo.
During Hospitalization:
Hindi pa po ako
nakakadumi ngayong
araw.

Before Hospitalization:
2. Apat hanggang lima
2. Gaano ka kadalas siguro.
umihi? Ilang beses sa During Hospitalization:
isang araw? (+) catheterization, 400
ml.

Before Hospitalization:
3. Wala naman po.
During Hospitalization:
Hindi ko po alam kase
3. Wala ka bang nakatubo sya kung ano
nararamdamang pakiramdam nya pero
kakaiba sa tuwing iihi sabi po ng nars kulay
o dudumi ka? tsaa ang ihi nya ngayon
a. Kulay
b. Hugis
c. Haba/laki
d. Itsura
Activity and Exercise Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Ano-ano ba ang mga 1. “Nakikipag
pinagkakaabalahan mo kwentuhan sya sa
sa tuwing libre ka sa kapit bahay,tuwing
araw ng iyong hapon po at nag
pahinga? Gaano mo mamaddjhong kasama
kadalas ito ginagawa? ng mga kaibigan nya”
Anong mga bagay ang During Hospitalization:
ginagawa mo ngayon Wala, nakahiga at
habang nandito sa natutulog
ospital?
2. May Before Hospitalization:
pinagkakaabalahan ka 2. Hindi po sya nag-
bang sports o eehersisyo pero
ehersisyo? Ano-ano madalas po syang
ang mga ito at gaano kumilos at gumagawa
mo kadalas ginagawa? ng gawaing bahay
Nagagawa mo pa rin katulad ng
ba ang mga ito sa paglalaba,pagluluto
ospital o may mga Tsaka naglalakad sya
bagay ka bang pag pupunta ng
ginagawa pamalit dito palengke araw-araw..
habang nasa ospital During Hospitalization:
ka? Hindi na dahil
nanghihina na sya at
nakaratay na lamang
sa higaan
3. May mga kakaiba ka
bang nararamdaman sa Before Hospitalization:  Activity intolerance
katawan kapag may 3. madali .
mga ginagawa ka na During Hospitalization:
gaya ng mga
 nabanggit mo na iyong Ngayon palagi syang
pinagkakaabalahan? aburido dahil siguro
palagi syang nakahiga
.

Cognitive-Perceptual Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Naaalala nya pa ba 1. “Oo maayos pa naman
ang pangalan nyo? ang kanyang memorya
“
During Hospitalization:
“Oo kase pag sinasabi ng nars
2. Ilan taon ka na ba? na darating mamaya asawa
mo di na sya aburido at pag
hinahawan ko mga kamay
niya humihigpit hawak nya at
3. Taga saan po kayo? tumatango namna sya pag
Saan po kayo kinakausap ko”
ipinanganak?
Before Hospitalization:
2. 60 na sya.
During Hospitalization:
4. Anong petsa po 60 na sya
ngayon? Before Hospitalization:
3. San Dionisio
Paranaque. Sa
Southern Leyte po.
During Hospitalization:

Before Hospitalization:
4.
During Hospitalization:

Sleep and Rest Pattern

 Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Sa tuwing anong oras 1. Mga alas-dose po ng
ka ba madalas gabi, tapos nagigising
nakakatulog? Ilang po sya ng ala s kwatro
oras ba kadalasan? At ng umaga.lagi
anong oras ka nagpupuyat at di daw
nagigising? sya makatulog”
During Hospitalization:
Nakakatulog na sya sa  Sleep deprivation due
gabi, pero sa umaga to skin condition
palagi kamot ng
kamot ng katawan
kaya di nakakatulog
Before Hospitalization:
2. Pinapanod nya muna
lahat ng tele serye
bago makakatulog
During Hospitalization:
2. May mga ritwal ka ba Ngayon wala.
bago makatulog?
Ano-ano ang mga ito? Before Hospitalization:
3. Naku maadalang sya
makatulog sa tanghali
kc palagi
nagmamadyong
3. Nakakatulog ka rin ba kasama ng mga  Sleep deprivation
sa tanghali? Gaano ito kaibigan
kadalas? During Hospitalization:
Minsan pero pag
naaburido at nangati
di daw makatulog sabi
ng mga nars

Self Perception Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Para sa akin po
maayos naman ang
 1. Pakilarawan ang
inyong sarili ayon sa
inyong palagay.
During Hospitalization:
hitsura nya , malinis
naman syang tingnan
bukod tingnan at
feeling ko medyo
mataba ako.
Ngayon nagbago na
itura nya nangitim na
sya gawa ng
pagdidialysis nya at
marami syang sugat
sugat at payat na payat
na sya

Before Hospitalization:  Disturbed Body

2. Pakilarawan ang 2. “Marami nagsasabi na Image
inyong sarili ayon sa palakaibigan, at
palagay ng ibang tao matulungin sya sa
sa inyo. ibang tao at maalaga
sa pamilya”.
During Hospitalization:
“Siguro na sa isip nila
na masungit sya, lagi
3. Ano-ano ang inyong kasi syang aburido”
palagay sa mga tao na
nasa paligid mo? Before
Hospitalization:
3. Okay naman sila .
During Hospitalization:
“Mababait naman ang
mga nars dito sa
kwarto at palgi naman
ako dumadalaw sa
kanya”

Role-Relationship Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Sila ang sandigan ko.
During Hospitalization:
1. Ano naman ang
pakahulugan sa iyo ng
pamilya?
Sila ay nagpapalakas
ng loob ko at
sumusuporta sa akin
ngayon, lagi nila akong
tinetext at pinapayuhan.

Before Hospitalization:
2. Ano ang kahulugan ng 2. Ang pagmamahal para
pagmamahal para sa sa akin ay isang bagay
iyo? na nagkokonekta sa
akin at sa pamilya ko.

3. May 3. Oo kami pa rin mag

asawa/kalaguyo/kinak asawa
asama ka ba ngayon?
Gaano na ba kayo
katagal na Before Hospitalization:
magkasama? 4. Ipinagluluto nya kami
ipinaglalaba ng mga
damit, inaalagaan at
inaasikaso.
4. Paano mo During Hospitalization:
ginagampanan ang Dahil hindi maayos
pagiging partner at ang kalagayan nya
nanay sa asawa at anak ngayon di nya na
mo? Bago ka nagagampanan ang
maospital at nagagawa mga Gawain na dati  Impaired parenting
mo ba yun hanggang nya ginagawa
ngayon?
Before Hospitalization:
5. Syempre naman pero
hindi naman mawawala
ang hindi
pagkakaunawaan.
During Hospitalization:
Maayos naman ang
5. Maayos ba ang relasyon naming mag
pakikitungo ninyo sa asawa at sa ganitong
isa’t isa? Masaya ka ba sitwasyon lagi ako
na kasama mo sila? nandito para sa kanya.
Gaano ba sila kahalaga
sa iyong buhay?
Kamusta ang relasyon
niyo sa ganitong
kalagayan?
Sexuality and Reproductive Pattern

Questions Response PROBLEM IDENTIFIED

Before Hospitalization:
1. Aktibo ka ba sa 1. Hinde na kase may
pakikipagtalik? Kung mga edad na kami
di mo mamasamain, masaya na kami na
gaano ito kadalas? nagyayakapan at
2. Wala ka bang nagkukuwentuhan
nararamdamang
kakaiba sa tuwing Before Hospitalization:
ikaw ay 2.Wala na
nakikipagtalik sa
kasama mo? Kung
meron, ano ano ang
mga ito?

Coping and Stress Tolerance Pattern

Response PROBLEM IDENTIFIED

Questions

Before Hospitalization:
1. Para sa iyo, ano ang 1. Ang problema ay
problema? Paano mo isang mahirap na
ito naaalalayan nang sitwasyon na
maayos? Sa ganitong dumarating sa ating
sitwasyon paano mo buhay, na naaayos din
ito kinakaya? sa tulong ng
pagdarasal at pag
paplano ng solusyon.
During Hospitalization:
Sa ngayon ay
pinagdadasal ko na
lamang ito at
 makakaya din naming
ito lagpasan.

2. Sa tuwing Before Hospitalization:

nagkakaproblema ka, 2. Kapag may pproblema
may mga sya ang kanyang
ipinagbabalingan ka libangan ay
para mailipat ang pagmamadyong o
iyong atensyon rito? kaya ay panonood ng
Anu ang iyong sine,kung minsan
ginagawa upang kahit naman pinag uusapan
papaano ay naming mag asawa
nakakalimutan mo During Hospitalization:
ang ganitong Alam ko na alam nya
sitwasyon? na mahirap ang
sitwasyon namin sa
3. Ano-ano o sino-sino ngayon pero Makita
ang mga nagpapalakas ko lang sya na maayos
ng iyong loob upang gumagaan
maharap mo ang mga pakiramdam ko
problemang Before Hospitalization:
dumarating sa iyong 3. Ang anak ko , asawa
buhay? Maituturing at ang pamilya ko.
mo ba ito inspirasyon During Hospitalization:
sa buhay mo ngayon? Oo, lalo na binibigyan
nila ako ng lakas ng
loob na malalampasan
ko ito.

Values and Belief Pattern

Response PROBLEM IDENTIFIED

Questions
Before Hospitalization:
1. May kinaaaniban ka 1. Isa po akong Romano
bang relihiyon? Ano Katoliko.
ito?
Before Hospitalization:
2. Nagsisimba po ako at
2. Bigyan mo ako ng nangungumpisal ako
kaunting detalye ukol kay father.
sa inyong Before Hospitalization:
 pinaniniwalaan ukol sa 3. Ang pananampalataya
iyong relihiyon? ay pinapasa Diyos ko
3. Ano ang kahulugan ng na lang lahat ng aking
pananampalataya at problema at suliranin
tiwala para sa iyo? Sa sa buhay.
ganitong problema During Hosptalization:
mas naging matibay ba Opo. Sapagka’t alam
ang iyong ko po na ang diyos ay
pananampalataya? lagi nandiyan at hindi
ako pababayaan.

V. Course in the Ward

Patient was admitted at his room of choice after hemodialysis under the service of Dr. Alcantara.
Patient put on diabetic diet. Diagnostics: Capillary Blood Glucose, Na, K, Crea and Bun, Chest
X-Ray, Complete Blood Count and Medications. Continue maintanance medications. To start
Amlodipine 5mg/tab once a day, Calcium + Vitamin D tab once a day, Sevelamer 800mg/tab 2
tabs thrice a day, Atoravastatin 40mg/tab once a day. For hemodialysis today. Complete Blood
Count after meals. Hook to nasal cannula.

On the first day of confinement, patient transfer to Intensive Care Unit. Intravenous Fluid:
D5NSS 1 liter to run at 40cc/hr NPO temporarily. Refer to endocrinologist for co-management.
Endocrinology notes: Diabetes Mellitus type 2 uncontrolled, Hypoglycemia secondary to insulin
and poor appetite and CBG every 1 hour. May start feeding if patient is comfortable. To give
renal diet mechanically soft and supplemented with nephro HD. Other medications and
management continued.

On the second day of confinement, For hemodialysis today. Limit oral fluid intake. Other
medications and management continued.

On the third day of confinement, patient may be transferred back to his room. For chest x ray
after hemodialysis.

On the fourth day of confinement, for hemodialysis today. For pro-calcitonin. Other medications
and management continued.

On the fifth dayof confinement, for hemodialysis and other medications and management
continued.

On the sixth to eigth day of confinement, hook to face mask at 5-10lpm for repeat CXR. Insert
NGT and start Nephro HP
VI. Diagnostic and Laboratory Exams

Date: 8-31-2018
COMPLETE BLOOD COUNT
S.I. Reference Range Interpretations
Hemoglobin 113.0 140.00-170.00gm/L Decreased of
capacity to carry
Oxygen in RBC
Hematocrit 0.35 0.41- 0.51 Decreased
Concentration of
Blood
RBC Count 4.42 4.60-5.20
WBC Count 6.0 4.60-11.0
Platelet Count 533.0 200.00-400.00 Increased Clotting
Time
 RED BLOOD CELLS INDICES
MCV 81.0 83.-101.00 fL Interpretations
MCH 25.6 27.00 -32.00 pg
MCHC 316.00 315.00-345.00 g/L
RDW 44.7 39.00 – 46.00 fL

DIFFERENTIAL COUNT
Interpretations
SEGMENTERS 0.86 0.55- 0.65 Indicates presence of
Infection
N. STABS CELL
LYMPHOCYTES 0.14 0.25-0.35 Indicates presence of
Infection
EOSINOPHILS
MONOCYTES
BASOPHILS

Laboratory Result (CONV.) Reference Range Interpretations

Examination (CONV.)
Urea Nitrogen 09.94 7.98-20.17 mg/dL
Creatinine 6.31 0.80-1.30 mg/dL
Sodium 129.00 136.00-145.00 Decreased levels of
mEq/L Sodium
Potassium 4.30 3.50-5.10 mEq/L

Date: 09-19-18

Complete Blood Count

S.I. Reference Range Interpretations

Hemoglobin 93 140.00-170.00gm/L Decreased of

capacity to carry
Oxygen in RBC
 Hematocrit 0.31 0.41- 0.51 Decreased
Concentration of
Blood

RBC Count 3.63 4.60-5.20 Decreased of RBC

WBC Count 9.2 4.60-11.0

Platelet Count 343 200.00-400.00

RED BLOOD CELLS INDICES

Interpretations
MCV 85.7 83.-101.00 fL

MCH 25.6 27.00 -32.00 pg

MCHC 299 315.00-345.00 g/L

RDW 53.1 39.00 – 46.00 fL

DIFFERENTIAL COUNT
Interpretations
SEGMENTERS 0.92 0.55- 0.65 Presence of
Infection
N. STABS CELL
LYMPHOCYTES 0.05 0.25-0.35 Presence of
Infection
EOSINOPHILS 0.03 0.02-0.05
MONOCYTES
BASOPHILS

VII. Anatomy and Physiology

KIDNEY - The kidneys are the primary functional organ of the renal system. They are essential in

homeostatic functions such as the regulation of electrolytes, maintenance of acid–base balance,

and the regulation of blood pressure (by maintaining salt and water balance). They serve the body

as a natural filter of the blood and remove wastes that are excreted through the urine. The kidneys

are a pair of bean-shaped, brown organs about the size of your fist. They are covered by the renal

capsule, which is a tough capsule of fibrous connective tissue. Adhering to the surface of each

kidney are two layers of fat to help cushion them. The asymmetry within the abdominal cavity

caused by the liver typically results in the right kidney being slightly lower than the left, and left

kidney being located slightly more medial than the right. The right kidney sits just below the

diaphragm and posterior to the liver, the left below the diaphragm and posterior to the spleen.

RENAL CORTEX - A layer of tissue that is also covered by renal fascia (connective tissue) and

the renal capsule. The renal cortex is granular tissue due to the presence of nephrons—the

functional unit of the kidney—that are located deeper within the kidney, within the renal pyramids

of the medulla. The cortex provides a space for arterioles and venules from the renal artery and

vein, as well as the glomerular capillaries, to perfuse the nephrons of the kidney. Erythropotein, a

hormone necessary for the synthesis of new red blood cells, is also produced in the renal cortex.

RENAL MEDULLA - The medulla is the inner region of the parenchyma of the kidney.

The medulla consists of multiple pyramidal tissue masses, called the renal pyramids, which are

triangle structures that contain a dense network of nephrons. At one end of each nephron, in the

cortex of the kidney, is a cup-shaped structure called the Bowman’s capsule. It surrounds a tuft of
capillaries called the glomerulus that carries blood from the renal arteries into the nephron, where

plasma is filtered through the capsule.

 NEPHRON - A nephron is the basic structural and functional unit of the kidneys that

regulates water and soluble substances in the blood by filtering the blood, reabsorbing what

is needed, and excreting the rest as urine. Its function is vital for homeostasis of blood

volume, blood pressure, and plasma osmolarity. It is regulated by the neuroendocrine

system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.

 GLOMERULUS - The glomerulus is a capillary tuft that receives its blood supply from an

afferent arteriole of the renal circulation. Here, fluid and solutes are filtered out of the blood

and into the space made by Bowman’s capsule. The glomerulus is a capillary tuft that

receives its blood supply from an afferent arteriole of the renal circulation. Here, fluid and

solutes are filtered out of the blood and into the space made by Bowman’s capsule.

 BOWMAN’S CAPSULE - is a cup-like sack at the beginning of the tubular component

of a nephron in the mammalian kidney that performs the first step in the filtration of blood

to form urine.

 JUXTAGLOMERULAR APPARATUS - Secretes an enzyme called renin, due to a

variety of stimuli, and it is involved in the process of blood volume homeostasis.

 PROXIMAL CONVULATED TUBULES - The proximal tubule is the first site of water

reabsorption into the bloodstream, and the site where the majority of water and salt

reabsorption takes place. Water reabsorption in the proximal convoluted tubule occurs due

to both passive diffusion across the basolateral membrane, and active transport from

Na+/K+/ATPase pumps that actively transports sodium across the basolateral membrane.
 LOOP OF HENLE - The loop of Henle is a U-shaped tube that consists of a descending

limb and ascending limb. It transfers fluid from the proximal to the distal tubule. The

descending limb is highly permeable to water but completely impermeable to ions, causing

a large amount of water to be reabsorbed.

 DISTAL CONVULATED TUBULES - it is impermeable to water and permeable to ions,

driving the osmolarity of fluid even lower. However, anti-diuretic hormone (secreted from

the pituitary gland as a part of homeostasis) will act on the distal convoluted tubule to

increase the permeability of the tubule to water to increase water reabsorption. This

example results in increased blood volume and increased blood pressure. Many other

hormones will induce other important changes in the distal convoluted tubule that fulfill

the other homeostatic functions of the kidney.

 COLLECTING DUCT - similar in function to the distal convoluted tubule and generally

responds the same way to the same hormone stimuli. It is, however, different in terms of

histology. The osmolarity of fluid through the distal tubule and collecting duct is highly

variable depending on hormone stimulus. After passage through the collecting duct, the

fluid is brought into the ureter, where it leaves the kidney as urine.

 RENAL PELVIS - The renal pelvis contains the hilium. The hilum is the concave part of

the bean-shape where blood vessels and nerves enter and exit the kidney; it is also the point

of exit for the ureters—the urine-bearing tubes that exit the kidney and empty into the

urinary bladder. The renal pelvis connects the kidney to the rest of the body.

 URETER - the duct by which urine passes from the kidney to the bladder.

 URINARY BLADDER - is a muscular sac in the pelvis, just above and behind the pubic

bone.
VIII. Pathophysiology
 IX. Drug Study

Name of Drug Classification Mechanism Indication Contraindication Side Nursing

of Action Effects Consideration
GENERIC Neurotropic Citicoline is CVA in acute Coadministration Dizziness,  Instruct
name: a derivative and recovery with Rash, patients to
Citicoline of choline phase. azathioprine, Nausea, contact
(cytidine and cytidine Symptoms mercaptopurine, Abnormal health care
diphosphate involved in and signs of or theophylline. LFTs, provider if
choline) the cerebral ADVERSE Arthralgia they
Brand name: biosynthesis insufficiency., experience
Brainact, of lecithin. dizziness, chest pain,
CholinervDose:1 It is claimed headache, rash,
gm q8 IV to increase poor shortness of
blood flow concentration, breath, or
and oxygen memory loss, neurologic
consumption disorientation. symptoms
in the brain Recent cranial suggesting
trauma. a stroke.

 Advise
patients that
product
may be
taken
without
regard to
meals.
 Advise
patient that
concomitant
prophylaxis
with an
NSAID or
colchicine
for gout
flares may
be used

Name of Classification Mechanism Indication Contraindication Side Effects Nursing

Drug of Action Consideration
GENERIC Xanthine Decreases Atenurix is a Coadministration Dizziness,  Instruct
name: oxidase serum uric xanthine with azathioprine, Rash, patients to
Febuxostat inhibitor acid by oxidase (XO) mercaptopurine, Nausea, contact
inhibiting inhibitor or theophylline. Abnormal health care
BRAND xanthine indicated for ADVERSE LFTs, provider if
name: oxidase the chronic Arthralgia they
Atenurix management experience
oxidase of chest pain,
inhibitor hyperuricemia rash,
in patients shortness of
DOSAGE: with gout. breath, or
PO Start Atenurix is neurologic
with 40 mg not symptoms
once daily. recommended suggesting
The dosage for the a stroke.
may be treatment of
increased to asymptomatic  Advise
80 mg once hyperuricemia patients that
daily for product
patients may be
who do not taken
achieve a without
serum uric regard to
acid less meals.
than 6  Advise
mg/dL after patient that
14 days. concomitant
prophylaxis
with an
NSAID or
colchicine
for gout
flares may
be used

Name of Classification Mechanism Indication Contraindication Side Effects Nursing

Drug of Action Consideration
GENERIC Xanthine Decreases Atenurix is a Coadministration Dizziness,  Instruct
name: oxidase serum uric xanthine with azathioprine, Rash, patients to
Febuxostat inhibitor acid by oxidase (XO) mercaptopurine, Nausea, contact
inhibiting inhibitor or theophylline. Abnormal health care
BRAND xanthine indicated for ADVERSE LFTs, provider if
name: oxidase the chronic Arthralgia they
Atenurix management experience
oxidase of chest pain,
inhibitor hyperuricemia rash,
in patients shortness of
DOSAGE: with gout. breath, or
PO Start Atenurix is neurologic
with 40 mg not symptoms
once daily. recommended suggesting
The dosage for the a stroke.
may be treatment of
increased to asymptomatic  Advise
80 mg once hyperuricemia patients that
daily for product
patients may be
who do not taken
achieve a without
serum uric regard to
acid less meals.
than 6  Advise
mg/dL after patient that
14 days. concomitant
prophylaxis
with an
NSAID or
colchicine
for gout
flares may
be used

X. Nursing Care Plan

 Assessment Diagnosis Planning Interventio Rationale Evaluation
n
Subjective: Subjective: At the end Keep the  To Goal met
of the shift, patients prevent the patient
“Nakakatulog na “Nakakatulog na the patient fingernails increase was able to
sya sa gabi pero sya sa gabi pero will be able cut skin demonstrat
paputol putol gawa paputol putol gawa to damage e an
ng pangangati ng ng pangangati ng demonstrat Apply tepid undisturbed
balat nya, pero sa balat nya, pero sa e an sponge bath  To sleep a
umaga palagi umaga palagi undisturbed freshen sleep as
kamot ng kamot ng kamot ng kamot ng sleep the manifested
katawan kaya di katawan kaya di patient by absence
nakakatulog” as nakakatulog” as Apply of
verbalized by the verbalized by the moisturizer scratching
patients husband patients husband or
nonallergic
lotion  It keeps
Objective: Objective: the skin
moisturiz
Keep the e for
 Restlessnes  Restlessnes environment relaxation
s s clean and
 (+)pruritus  (+)pruritus quiet It helps the
 Frequent  Frequent patient to relax
scratching scratching
 Frequent  Frequent
yawning yawning

Assessment Diagnosis Planning Intervention Rationale Evaluation

 Fluid After 8 hours of Independent:  Accurate
SUBJECTIVE: volume nursing I&O is Goal
“Hindi na, excess r/t intervention,the  Record necessary met,patient has
dahil compromis patient will accurat for displayed
nanghihina na ed display e determini appropriate
sya at regulatory appropriate intake ng renal urinary output
nakaratay na mechanism urinary output and functions with specific
lamang sa with specific output and fluid gravity/laborato
higaan gravity/laborato (I&O) replaceme ry studies near
namamanas pa ry studies near  Weigh nt needs normal;stable
ang paa niya” normal; stable daily at and weight,and
as verbalized weight, vital same reducing absence of
by the patients signs within time of risk of edema
husband normal range day,on fluid
;and absence of same overload
edema scale,a  Daily
nd body
OBJECTIVE: clothin weight is
 Venous g best
distenti  Assess monitor
on for of fluid
 Body edema status and
weakne Plan oral fluid edema
ss as replacement
observe with multiple
d restrictions
 (+)ede
ma
 v/s
taken as
follows
T-35 C
P-50
RR-17
BP-140/100
 Assessment Diagnosis Planning Intervention Rationale Evaluatio
n
Imbalance After of nursing Independent:  To gain
SUBJECTIVE: nutrition intervention patients Goal
“Madalas hilig less than patients may able  Record trust partially
nya kumain ng body to demonstrate accurate met
maaalat tulad ng requirement behaviors,lifestyl intake
tuyo o dried fish s e change to and  To assess
mahilig din sya regain and output contributin
sa maintain an (I&O) g factors
desserts,madalas appropriate  Weigh
nakakatatlong weight daily at  To provide
takal sya ng same comparativ
kanin lalo na at time of e baseline
tuyo o daing ang day,on
ulam ,mga same To establish
sampung piraso scale,an nutritional plans
ng tuyo at isang d
platito ng clothing
lecheflan or ice  Assess
cream”as for
verbalized by edema
the husband of Plan oral fluid
the patient replacement
with multiple
OBJECTIVE: restrictions

 Pale skin
 Weaknes
s
 Body
weight
from 56
kg to 40
kg
Assessment Diagno Planning Intervention Rationale Evaluation
sis
Risk After 8 hours  Keep fingernails  Reduc
SUBJECTIV for of nursing short e risk Goal met after
E: impaire intervention of 8 hours of
d skin patients may be  Inspect skin for derma nursing
“Ngayon integrit able to changes in l intervention
wala naman y demonstrate color,turgor,vascul injury patients
palagi lang behaviors/techn arity,note demonstrate
sya iques to redness,excoriation  Indica behaviors/tech
nagkakamot” prevent skin .Observe for tes nique to
as verbalized breakdown/inju ecchymosis and areas prevent skin
by the nurse ry purpura of breakdown/inj
on duty poor ury as
circul manifested by
ation reduction of
OBJECTIVE or scratching and
: break maintain intact
down skin
 (+)pr  Inspect dependent that
uritus areas for edema, may
 Dry elevate legs as lead
skin indicated to
 Frequ decub
ently itus
scratc forma
hing tion
 Irritat and
ed infecti
on

 Edem
atous
tissue
s are
more
prone
to
break
down
.Eleva
tion
prom
otes
venou
s
return
,
limiti
ng
venou
s
XI. Discharge Planning

Medications:
 Instruct to comply strictly with the following home medications
 Report any adverse effect when taking the prescribed drug
 Instruct not to take other medications without consulting with the physician to prevent any
harmful drug-drug interaction
Exercise and Environment:
 Encourage patient to have adequate rest periods and sleep to promote faster recovery
 Do light exercises like stretching or walking slowly and carefully; seek assistance for safety
measure
 Advised client and family member to maintain safe, clean and comfortable environment
Treatment:
.
 Emphasized to the husband the importance of regular follow-up check-ups and as
instructed by physician
 Advised the husband to seek medical advice if any strange arises
 Encouraged the husband to let her be monitored by the health care provider until complete
recovery is met
 Encourage the husband of the patient to change lifestyle and diet of patient
Health Teachings:
 Encouraged to elevate the part where there is edema
 Teach the client to follow all the instructions including medications, diet regimen, and dos
and don’ts that was instructed to her by the physician
 Teach patient to ensure rest for herself as much as possible

Out Patient:
 Reminded the husband that even though she feels better, it is important to have the doctor
monitor her progress. The patient is scheduled for her follow up check up one week after
her discharge from the hospital in Out-Patient Department in Medical Center of Paranaque
to evaluate her recovery.
  Encourage to comply in scheduled dialysis
Diet:
 Encourage to eat nutritious food and drink natural fruit juices for fast recovery.
 Get plenty of rest. Increase fluid intake.
Spirituality:
 Encouraged the husband to continue to seek God’s guidance and to continue to have a
positive outlook in life
 Emphasized the importance of prayers in healing
 Encouraged the husband to pray for her fast recovery and gave words of encouragement