Case Study CKD Pinakafinal Na Talaga

Republic of the Philippines
CATANDUANES STATE UNIVERSITY

Virac Catanduanes
CASE PRESENTATION:
Chronic Kidney Disease V
multiple organ failure
In partial fulfillment of
The course requirement
For related learning experience
Submitted by:
BSN 4A GROUP 1 & GROUP 2
April 4, 2023
Virac Catanduanes
Virac Catanduanes
TABLE OF CONTENTS
I. PATIENT’S PROFILE
II. ANATOMY AND PHYSIOLOGY
III. PATHOPHYSIOLOGY
IV. DIAGNOSTICS PROCEDURES AND LAB RESULTS
V. DRUG STUDY
VI. PROGNOSIS
VII. NURSING CARE PLANS

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I. PATIENT’S PROFILE
Case Scenario:
Presenting client C. V, 63 years old with chief complaints of poor appetite for 7 days. Rushed to
IHMH on March 12, 2023 with following manifestations: severe weakness and poor appetite. Seen and
examined, the patient presents the following: BP: 120/80, PR: 74, Temperature: 36. 5 oC, SpO2: 99%, with
admitting diagnosis of Chronic Kidney Disease secondary to obstructive nephropathy. Upon admission, he
was given Totilac 50ml IV and PNSS 1L KVO.
Name of Patient: C. V
Duration of Hospitalization: March 12, 2023- March 19, 2023
Patient’s Demographic Data:
Age: 63 years old Sex: Male

Address: Bigaa, Virac, Catanduanes
Nationality: Filipino
Medical Data
Chief Complaints: poor appetite
Tentative Diagnosis: Chronic Kidney Disease secondary to obstructive nephropathy
Final Diagnosis: Chronic Kidney Disease V secondary to obstructive nephropathy, hypertensive,
multiple organ failure
Attending Physician: R. MD
Personal History
C, V., a 63-year-old, male, the eldest from the 7 siblings, a father of 4 children, the eldest is 24 years
old while the youngest is 21 years old. He was married to E. V. in the year 1998. They are presently residing
in Bigaa, Virac, Catanduanes. His nationality is Filipino. He began working as an office worker in the year
1988 however he is now retired.
Past Medical History:

In 2012, C.V experienced Hypertension and went to EBMC for check-up. It is found out that there are
kidney stones. EBMC referred C, V to NKTI. S/P Nephrolithiasis; Nephrolithotomy performed. He had
consultations every three months in NKTI. He was unable to return to NKTI for check-up during the 2020
pandemic. In the year 2022, went back to NKTI for check-up as C, V experienced body weakness and cough.
He has been receiving hemodialysis since 2022 after being diagnosed with end-stage renal disease. He
unfortunately developed Hospital Acquired Pneumonia in NKTI. In the same year, C, V got COVID-19 and
was not able to undergo hemodialysis for 1 month. He was transported to a dialysis center to continue
hemodialysis after testing COVID-19 negative in the NKTI. According to the wife, patient has a history of
smoking for about 3- 4 sticks per week and occasionally alcohol drinker before being diagnosed with ESRD.
He returns to the province to resume hemodialysis three times a week in CDHI. He took NaHCO3 and
Atorvastatin as maintenance medications. C.V likes to eat fatty and salty foods and no food preferences and
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has a sedentary lifestyle. C, V wife denies other comorbidities such as Diabetes Mellitus and Cancer. He has
no known allergies to food and medications.
Socio-economic.
In the 1988, C.V. started to work in Virac, Capitol as office worker. This became his major
source of income for almost 3 decades. This was a well-paying job that allow him sustain his daily
needs and was able to provide and support financially to his family. At 2022, he then retired on his
long-term work as office worker due to current illness.
Activity of Daily Living (Diet, Nutrition, Habits/Vices, etc)
C.V wife stated that he eats at least three times a day however experienced loss of appetite
sometimes so he consumes foods less amount than usual which was the reason of current consult. He
eats vegetables and fruits; however, he also consumes salty and fatty foods and has been reported
drinking coffee every day. Ever since before he was diagnosed of CKD, he doesn’t have any diet
restriction. He mostly eats what’s food available at the table and not a picky eater. Most of the food
he eats was homemade however he occasionally eats outside with his family. No fluid restriction
was ordered so he drinks water as tolerated and never drink milk. He was reported smokes 3-4 sticks
of cigarettes per week and drinks alcohol occasionally.
C.V has sedentary lifestyle which was he is not physically active even before because he
doesn’t have time and he is not into physical activities. Due to his recent work as office worker, he
spends most of his time sitting for about 6-8 hours with few breaks. At weekdays, C.V wife stated
that he doesn’t have time to exercise because he was busy at work and don’t have the energy to work
out. During weekends he played Tongits with his friends and as they lost track of time, he usually
eats cup noodles and holds the urge to urinate.
Family Health History
C.V wide denies heredofamilial diseases like Respiratory Diseases, Cancer, Diabetes Mellitus
except Hypertension in his father side.
Health Seeking Practices:
According to C. V’s wife, if someone become ill in the family, they take OTC medication
then after go to hospital for consult and received prompt intervention. They were not dependent on
herbal medicine and superstitious belief.
Present Health History:

On March 12, 2023, admitted to IHMH with chief complaints of weakness and 7 days of poor
appetite. He was severe weak when he arrived. His initial vital signs were as follows: BP: 120/80; PR: 74; T:
36.5 C; O2Sat: 99% with admitting diagnosis of chronic kidney disease secondary to obstructive nephropathy.
He received Totilac 50 ml IV and PNSS 1L at KVO upon admission.
Physical Examination
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● PRIOR TO ADMISSION: Patient is severe weak with inital vital signs of BP: 120/80, PR: 74,
TEMP: 36.5 C, O2 SAT: 99%
Predisposing Factor
● Smoking- 3- 4 sticks of cigarettes per week before diagnosed of ESRD.
● Alcohol- occasional drinking of alcohol.
● Sedentary Lifestyle- no food preference and no exercise.
Precipitating Factor
● Pre-existing disease- diagnosed with End-Stage Renal Disease since 2022.
Timeline
2012
 C.V experienced Hypertension and was done consultation at EBMC. He took NaHCO3 and
Atorvastatin as maintenance medications. He was said to have kidney stone.
 He was referred to NKTI with S/P of Nephrolithiasis and a Nephrolithotomy was performed.
Since then, he had consultations every three months in NKTI.
2020
 Due to Covid 19 pandemic outbreak, C.V was unable to comply to his check-up schedule.
2022
 C.V experienced body weakness and cough so he went back to NKTI for check-up
consultation.
 C.V started receiving hemodialysis after being diagnosed with end-stage renal disease.
 He developed Hospital Acquired Pneumonia in NKTI.
 C.V got COVID-19 and was not able to undergo hemodialysis for 1 month. He was
transported to a dialysis center to continue hemodialysis after testing COVID-19 negative in
the NKTI.
 He then returns to the province and was able to resume his hemodialysis three times a week
in CDHI.
2023
 On March 12, 2023, admitted to IHMH with chief complaints of weakness and 7 days of poor
appetite. He is experiencing severe weakness when he arrived. His initial vital signs were as
follows: BP: 120/80; PR: 74; T: 36.5 C; O2Sat: 99% with admitting diagnosis of chronic
kidney disease secondary to obstructive nephropathy. He then received Totilac 50 ml IV and
PNSS 1L at KVO upon admission.
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HAVIGHURST’S DEVELOPMENTAL TASKS
Age Range Developmental Task Developmental Task

achieved
Infancy and Early Childhood  Learn to walk Relationship with family

members started at home
0-5 years old  Learn to use the toilet with parents and siblings
 Learn to talk who lives with him
 Learn to form relationship

with others
Middle childhood  Learn school-related skills  Had good

such as reading relationship with
6-12 years old
peers and family.
 Learn about conscience and
values  Imparted by
parents with the
 Learn to be independent value of
Independence and
Responsibility as
the eldest sibling.
Adolescence  Establish emotional  Started going out

independence with friends and
13-17 years old
establishing
 Learn skills needed for relationship.
productive occupation
 Described as
 Achieve gender-based social someone who is
role easy to get along
 Establish mature with.
relationships with peers  Struggled
financially and had
to start working
early.
Early Adulthood  Choose a life partner  After graduating

high school,
18-35 years old  Establish a family
 Started working at
 Take care of a Home a pansitan in
Manila.
 Establish a career
 Had to work early
because he was the
breadwinner
among the 7
siblings.
 Was not able to
meet a partner yet.
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Middle Age  Maintain a standard of living  Started working at

Capitol
36-60 years old  Perform civic and social
responsibilities  Met his wife and
started their own
 Maintain a relationship with family, had 3 kids
spouse
 Was able to raise
 Adjust to physiological their children well
changes
 Diagnosed with
Hypertension and
was able to receive
treatment.
Later Maturity  Adjust to deteriorating health  Retired work last

year due to
Over 60 years old  Adjust to retirement deteriorating
 Meet social and civil health.
obligations
 Adjust to loss of spouse

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II. ANATOMY AND PHYSIOLOGY
The Urinary System's function is to filter blood and create urine as a waste by-product. The urinary system
keeps everything in balance by removing waste, like urea, extra salt, extra water and other things the body
does not need. The urinary system (renal system) consists of two kidneys, two ureters, a urinary bladder, and a
urethra. The kidneys alone perform the functions and manufacture urine in the process, while the other organs
of the urinary system provide temporary storage reservoirs for urine or serve as transportation channels to
carry it from one body region to another.
The Kidneys
The function of the kidneys are as follows:
1. Filter. Every day, the kidneys filter gallons of fluid from the
bloodstream.
2. Waste processing. The kidneys then process this filtrate,
allowing wastes and excess ions to leave the body in urine while
returning needed substances to the blood in just the right
proportions.
3. Elimination. Although the lungs and the skin also play roles in
excretion, the kidneys bear the major responsibility for
eliminating nitrogenous wastes, toxins, and drugs from the body.
4. Regulation. The kidneys also regulate the blood’s volume and
chemical makeup so that the proper balance between water and salts and between acids and bases is
maintained.
5. Other regulatory functions. By producing the enzyme renin, they help regulate blood pressure, and their
hormone erythropoietin stimulates red blood cell production in the bone marrow.
6. Conversion. Kidney cells also convert vitamin D to its active form.
The kidneys, which maintain the purity and constancy of our internal fluids, are perfect examples of
homeostatic organs.
• Location. These small, dark red organs with a
kidney-bean shape lie against the dorsal body wall
in a retroperitoneal position (beneath the parietal
peritoneum) in the superior lumbar region; they
extend from the T12 to the L3 vertebra, thus they
receive protection from the lower part of the rib
cage.
• Positioning. Because it is crowded by the liver,
the right kidney is positioned slightly lower than
the left.
• Size. An adult kidney is about 12 cm (5 inches)
long, 6 cm (2.5 inches) wide, and 3 cm (1 inch)
thick, about the size of a large bar of soap.
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• Adrenal gland. Atop each kidney is an adrenal gland, which is part of the endocrine system is a
distinctly separate organ functionally.
• Fibrous capsule. A transparent fibrous capsule encloses each kidney and gives a fresh kidney
a glistening appearance.
• Perirenal fat capsule. A fatty mass, the perirenal fat capsule, surrounds each kidney and acts
to cushion it against blows.
• Renal fascia. The renal fascia, the outermost capsule, anchors the kidney and helps hold it in place
against the muscles of the trunk wall.
• Renal cortex. The outer region, which is light in color, is the renal cortex.
• Renal medulla. Deep to the cortex is a darker, reddish-brown area, the renal medulla.
• Renal pyramids. The medulla has many basically triangular regions with a striped appearance, the
renal, or medullary pyramids; the broader base of each pyramid faces toward the cortex while its tip,
the apex, points toward the inner region of the kidney.
• Renal columns. The pyramids are separated by extensions of cortex-like tissue, the renal columns.
• Renal pelvis. Medial to the hilum is a flat, basinlike cavity, the renal pelvis, which is continuous with
the ureter leaving the hilum.
• Calyces. Extensions of the pelvis, calyces, form cup-shaped areas that enclose the tips of the pyramid
and collect urine, which continuously drains from the tips of the pyramids into the renal pelvis.
• Renal artery. The arterial supply of each kidney is the renal artery, which divides into segmental
arteries as it approaches the hilum, and each segmental artery gives off several branches
called interlobar arteries.
• Arcuate arteries. At the cortex-medulla junction, interlobar arteries give off arcuate arteries, which
curve over the medullary pyramids.
• Cortical radiate arteries. Small cortical radiate arteries then branch off the arcuate arteries and run
outward to supply the cortical tissue.
Nephrons
Nephrons are the structural and functional units of the kidneys.
 Nephrons. Each kidney contains over a million tiny structures called nephrons, and they are
responsible for forming urine.
 Glomerulus. One of the main structures of a nephron, a glomerulus is a knot of capillaries.
 Renal tubule. Another one of the main structures in a nephron is the renal tubule.
 Bowman’s capsule. The closed end of the renal tubule is enlarged and cup-shaped and
completely surrounds the glomerulus, and it is called the glomerular or Bowman’s capsule.
 Podocytes. The inner layer of the capsule is made up of highly modified octopus-like cells
called podocytes.
 Foot processes. Podocytes have long branching processes called foot processes that
intertwine with one another and cling to the glomerulus.
 Collecting duct. As the tubule extends from the glomerular capsule, it coils and twists before
forming a hairpin loop and then again becomes coiled and twisted before entering a collecting
tubule called the collecting duct, which receives urine from many nephrons.
 Proximal convoluted tubule. This is the part of the tubule that is near to the glomerular
capsule.
 Loop of Henle. The loop of Henle is the hairpin loop following the proximal convoluted
tubule.
 Distal convoluted tubule. After the loop of Henle, the tubule continues to coil and twist
before the collecting duct, and this part is called the distal convoluted tubule.
 Cortical nephrons. Most nephrons are called cortical nephrons because they are located
almost entirely within the cortex.
 Juxtamedullary nephrons. In a few cases, the nephrons are called juxtamedullary nephrons
because they are situated next to the cortex-medullary junction, and their loops of Henle dip
deep into the medulla.
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 Afferent arteriole. The afferent arteriole, which arises from a cortical radiate artery, is
the “feeder vessel”.
 Efferent arteriole. The efferent arteriole receives blood that has passed through the
glomerulus.
 Peritubular capillaries. They arise from the efferent arteriole that drains the glomerulus.
Ureters
The ureters do play an active role in urine transport.
 Size. The ureters are two slender tubes each 25 to 30 cm (10 to 12 inches) long and 6
mm (1/4 inch) in diameter.
 Location. Each ureter runs behind the peritoneum from the renal hilum to the posterior aspect
of the bladder, which it enters at a slight angle.
 Function. Essentially, the ureters are passageways that carry urine from the kidneys to the
bladder through contraction of the smooth muscle layers in their walls that propel urine into
the bladder by peristalsis and is prevented from flowing back by small valve-like folds of
bladder mucosa that flap over the ureter openings.
Urinary Bladder
The urinary bladder is a smooth, collapsible, muscular sac that stores urine temporarily.
 Location. It is located retroperitoneally in the pelvis just posterior to the symphysis pubis.
 Function. The detrusor muscles and the transitional epithelium both make the bladder
uniquely suited for its function of urine storage.
 Trigone. The smooth triangular region of the bladder base outlined by these three openings is
called the trigone, where infections tend to persist.
 Detrusor muscles. The bladder wall contains three layers of smooth muscle, collectively
called the detrusor muscle, and its mucosa is a special type of epithelium, transitional
epithelium.
Urethra
The urethra is a thin-walled tube that carries urine by peristalsis from the bladder to the outside of the body.
 Internal urethral sphincter. At the bladder-urethral junction, a thickening of the smooth

muscle forms the internal urethral sphincter, an involuntary sphincter that keeps the urethra
closed when the urine is not being passed.
 External urethral sphincter. A second sphincter, the external urethral sphincter, is fashioned
by skeletal muscle as the urethra passes through the pelvic floor and is voluntarily controlled.
 Female urethra. The female urethra is about 3 to 4 cm (1 1/2 inches) long, and its external
orifice, or opening, lies anteriorly to the vaginal opening.
 Male urethra. In me, the urethra is approximately 20 cm (8 inches) long and has three named
regions: the prostatic, membranous, and spongy (penile) urethrae; it opens at the tip of the
penis after traveling down its length.
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Physiology of the Urinary System
Every day, the kidneys filter gallons of fluid from the bloodstream. The normal physiology that takes place in
the urinary system are as follows:
Urine Formation
Urine formation is a result of three processes:
 Glomerular filtration. Water and solutes smaller than proteins are forced through the
capillary walls and pores of the glomerular capsule into the renal tubule.
 Tubular reabsorption. Water, glucose, amino acids, and needed ions are transported out of
the filtrate into the tubule cells and then enter the capillary blood.
 Tubular secretion. Hydrogen, potassium, creatinine, and drugs are removed from the
peritubular blood and secreted by the tubule cells into the filtrate.
Characteristics of Urine
In 24 hours, the marvelously complex kidneys filter some 150 to 180 liters of blood plasma through their
glomeruli into the tubules.
 Daily volume. In 24 hours, only about 1.0 to 1.8 liters of urine are produced.
 Components. Urine contains nitrogenous wastes and unneeded substances.
 Color. Freshly voided urine is generally clear and pale to deep yellow.
 Odor. When formed, urine is sterile and slightly aromatic, but if allowed to stand, it takes
on an ammonia odor caused by the action of bacteria on the urine solutes.
 pH. Urine pH is usually slightly acidic (around 6), but changes in body metabolism and
certain foods may cause it to be much more acidic or basic.
 Specific gravity. Whereas the specific gravity of pure water is 1.0, the specific gravity of
urine usually ranges from 1.001 to 1.035.
 Solutes. Solutes normally found in urine include sodium and potassium ions, urea, uric acid,
creatinine, ammonia, bicarbonate ions, and various other ions.
Micturition
Micturition or voiding is the act of emptying the bladder.
 Accumulation. Ordinarily, the bladder continues to collect urine until about 200 ml have
accumulated.
 Activation. At about this point, stretching of the bladder wall activates stretch receptors.
 Transmission. Impulses transmitted to the sacral region of the spinal cord and then back to
the bladder via the pelvic splanchnic nerves cause the bladder to go into reflex contractions.
 Passage. As the contractions become stronger, stored urine is forced past the internal urethral
sphincter into the upper part of the urethra.
 External sphincter. Because the lower external sphincter is skeletal muscle and voluntarily
controlled, we can choose to keep it closed or it can be relaxed so that urine is flushed from
the body.
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III. PATHOPHYSIOLOGY
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NORMAL
CHEST X- RAY
PATIENT C.V CHEST X-RAY
Patient Chest X-ray:

FINDINGS
 Poorly defined densities are noted in both lungs.
 Heart is enlarged.
 Aorta is partially calcified.
 Diaphragm and bony thorax are unremarkable.
IMPRESSION
 Pneumonia, Bilateral
 Cardiomegaly
 Atheromatous Aorta
1st ECG
 Sinus Rhythm
 Prolonged P-wave
 Left Ventricular Hypertrophy
 Possible Subsequent ST-T
abnormalities
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2nd ECG (03-19-2023)
 Poor T-wave progression (V4)

 Left ventricular hypertrophy
 Possible subsequent T-wave abnorality
3rd ECG (03-19-2023 – 23:12)
 Lead off (V1,V2,V3,V4,V5,V6)

 Asystole
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LAB RESULTS
HEMATOLOGY (3.12.23) 6:43 PM
RESULT REFERNCE FLAG SIGNIFICANCE
VALUE
HEMOGLOBIN 112 140-180g/L ↓LOW When your kidneys are damaged, they produce
less erythropoietin (EPO), a hormone that signals
your bone marrow—the spongy tissue inside most
of your bones—to make red blood cells. With less
EPO, your body makes fewer red blood cells, and
less oxygen is delivered to your organs and
tissues.
- If the hemoglobin level is low, your body
isn’t getting enough oxygen, making you feel tired
and weak.
RBC COUNT 3.63 4.70-6.10 x ↓LOW Low EPO levels cause your red blood cell count to
1012 /L drop and anemia to develop.
- A low RBC count could also indicate a

vitamin B6, B12 or folate deficiency. It may also
signify internal bleeding, kidney disease or
malnutrition (where a person’s diet does not
contain enough nutrients to meet their body’s
needs).
PLATELET 66 150-450 x ↓LOW deficiency in EPO production is the main cause of
COUNT 10^9 / L the development of anemia
- Low platelet levels make it difficult for

the body to form blood clots, which can cause
excessive bleeding.
NEUTROPHILS 80 40.0-74.0 % ↑HIGH Neutrophils increase naturally to fight infection,
but if your count is above normal levels, your
healthcare provider will detect and treat any
infection or reaction to medication that might be
the cause
LYMPHOCYTE 13 19.0-48.0 % ↓LOW low numbers of lymphocytes (lymphopenia), you
are at higher risk of infection.
Immature 0.8 <0.5 % ↑HIGH A high granulocyte count (granulocytosis) could
Granulocyte indicate a number of issues, including infection,
blood cell cancer or some type of autoimmune
disease.

VALUE
HEMATOCRIT 32 42-52% ↓LOW When your kidneys are damaged, they produce
tissues.
- A low hematocrit level means that the

person has too few red blood cells, is called
anemia.
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HEMOGLOBIN 110 140-180g/L ↓LOW If the hemoglobin level is low, your body isn’t
getting enough oxygen, making you feel tired and
weak.
RBC COUNT 3.54 4.70-6.10 x ↓LOW A low RBC count could also indicate a vitamin
1012 /L B6, B12 or folate deficiency. It may also signify
internal bleeding, kidney disease or malnutrition
PLATELET 63 150-450 x ↓LOW Low platelet levels make it difficult for the body
COUNT 10^9 / L to form blood clots, which can cause excessive
bleeding.
MCH 31.1 27.0-31.0 pg ↑HIGH High MCH scores are commonly a sign of
macrocytic anemia. This condition occurs when
the blood cells are too big, which can be a result of
not having enough vitamin B12 or folic acid in the
body.
the cause
disease.

VALUE
weak

RESULT REFERNCE FLAG
VALUE
HEMOGLOBIN 94 140-180g/L ↓LOW When your kidneys are damaged, they produce
tissues.

VALUE
HEMATOCRIT 38 42-52% ↓LOW A low hematocrit level means that the person has
too few red blood cells, is called anemia.
weak
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bleeding.
MCV 94.9 80-94 fL ↑HIGH Neutrophils increase naturally to fight infection,
the cause
NEUTROPHILS 88 40.0-74.0 % ↑HIGH low numbers of lymphocytes (lymphopenia), you
disease

VALUE
WBC COUNT 10.93 5.0-10.0 x ↑HIGH Elevated white blood cell (WBC) count is a well-
109 /L known predictor of chronic kidney disease (CKD)
progression.
- When there are too many white blood
cells, it usually means you have infection or
inflammation in your body. Less commonly, a
high white blood cell count could indicate certain
blood cancers or bone marrow disorders.
HEMATOCRIT 35 42-52% ↓LOW A low hematocrit level means that the person has
too few red blood cells, is called anemia.
weak
bleeding.
MCV 94.9 80-94 fL ↑HIGH High MCV means that the RBC are too large and
indicates macrocytic anemia. This condition can
be caused by several factors including low folate
or vitamin B12 levels or chemotherapy.
MCH 31.1 27.0-31.0 pg ↑HIGH High MCH scores are commonly a sign of
macrocytic anemia. This condition occurs when
the blood cells are too big, which can be a result of
not having enough vitamin B12 or folic acid in the
body.
the cause
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CLINICAL CHEMISTRY (3.13.23) 4:40 PM

RESULT REFERNCE VALUE FLAG SIGNIFICANCE
(S.I. UNIT)
BUN 35 <8.3 mmol/L ↑HIGH High BUN suggests kidney problems
that prohibit proper function, such as in
glomerular filtration. Thus, it's often
tied up with chronic kidney disease
(CKD) and uremia
CREATININE 1023.4 59-104 μmol/L ↑HIGH An increased level of creatinine may be
a sign of poor kidney function.
eGFR* 4 >60ml/min/1.73 m2 ↓LOW If your eGFR number is low, your
kidneys may not be working as well as
they should.
URIC ACID 1119 202.3-416.5 μmol/L ↑HIGH If too much uric acid stays in the body, a
condition called hyperuricemia will
occur. Hyperuricemia can cause crystals
of uric acid (or urate) to form. These
crystals can settle in the joints and cause
gout, a form of arthritis that can be very
painful. They can also settle in the
kidneys and form kidney stones
HDL 0.76 >1.45 mmol/L ↓LOW Having low levels of HDL cholesterol
can be of more concern, as it can
indicate that the person is at risk of
developing heart disease

(S.I. UNIT)
CREATININE 469.3 59-104 μmol/L ↑HIGH An increased level of creatinine may be
a sign of poor kidney function.
eGFR* 11 >60ml/min/1.73 m2 ↓LOW If your eGFR number is low, your
kidneys may not be working as well as
they should.

(S.I. UNIT)
ALT / SGPT 57.8 0-38 U/L ↑HIGH In general, high levels of ALT may be a
sign of liver damage from hepatitis,
infection, cirrhosis, liver cancer, or
other liver diseases. The damage may
also be from a lack of blood flow to the
liver or certain medicines or poisons.
AST / SGOT 75.8 0-48 U/L ↑HIGH A high AST level often means there is
some liver damage
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ELECTROLYTE PROFILE (3.12.23) 6:43 PM

VALUE
(S.I. UNIT)
SODIUM 125 135-145 ↓LOW Too little sodium in the blood is called hyponatremia.
This can occur when your drink large amount of water
or if you have problems with your kidneys that can affect
your ability to urinate.

VALUE
(S.I. UNIT)
SODIUM 150 135-145 ↑HIGH Sodium blood test results that are higher than normal
may be a sign of a condition, such as: Dehydration, which
may be caused by not drinking enough, diarrhea, or
certain medicines called diuretics (water pills) A disorder
of the adrenal glands. A kidney disease
CHLORIDE 116 95-115 ↑HIGH Chloride is often measured with other electrolytes to
diagnose or monitor conditions, such as kidney disease,
heart failure, liver disease, and high blood pressure
lcalcium 1.05 1.15-1.33 ↓LOW A low level of calcium in your blood (hypocalcemia) can
hinder your body's ability to perform these important
functions
lower than normal may be a sign of: Low blood protein
levels, which may be caused by liver disease or
malnutrition
BLOOD Ph 7.54 7.20-7.60 ↑HIGH Increases in blood pH indicate alkalemia. Increases can
be a result of a respiratory (or metabolic) disturbance.

VALUE
(S.I. UNIT)
SODIUM 130 135-145 ↓LOW Too little sodium in the blood is called hyponatremia.
This can occur when your drink large amount of water
or if you have problems with your kidneys that can affect
your ability to urinate.
functions
malnutrition
VALUE
(S.I. UNIT)
functions
malnutrition
Virac Catanduanes
V. DRUG STUDY
DRUG
ORDER
MEC
(Generic name, HAN NURSE’S
dosage, route, POSSIBLE
ISM RESPON
frequency, SIDE
OF SIBILITI
classification, EFFECTS
ACT ES
date ION
ordered/discon
tinued)
Ca Rapi GI: Constip  N
Citrate/Caltrat d- ation or ot
e 1 Tab OD actin laxative e
g effect, acid n
antac rebound, u
id nausea, m
with eructation, f b
Classification high latulence, v er
FLUID AND neutr omiting, a
ELECTROLY alizi fecal n
TIC ng concretions. d
BALANCE capa c
AGENT; city o
REPLACEME and Metabolic: ns
NT relati Hypercalce is
SOLUTION; vely mia with te
ANTACID prolo alkalosis, n
nged metastatic c
durat calcinosis, y
ion hypercalciu of
Date Started:
of ria, st
03/12/2023 actio hypomagne o
n. semia, ol
Date Decr s.
hypophosph
Discontinued: eases If
atemia.
03/19/2023 gastr c
ic o
acidi CNS: Mood ns
ty, and mental ti
there changes. p
by at
inhib io
iting n
Urogenital:
prote is
Polyuria,
olyti a
renal
c
Virac Catanduanes
actio calculi. pr
n of o
pepsi bl
n on e
gastr m
ic ,
muc p
osa. h
Also ys
incre ic
ases ia
lowe n
r m
esop a
hage y
al pr
sphin es
cter cr
tone. ib
e
al
Alth te
ough rn
class at
ified e
as a or
non- c
syste o
mic m
antac bi
id, a n
sligh at
t to io
mod n
erate th
alkal er
osis a
usual p
ly y
devel w
ops it
with h
prolo a
nged m
thera a
py. g
n
es
Acid iu
Virac Catanduanes
rebo m
und, a
whic nt
h ac
may id
follo or
w a
even d
low vi
dose se
s, is p
thou at
ght ie
to be nt
caus to
ed ta
by k
relea e
se of a
gastr la
in x
trigg at
ered iv
by e
actio or
n of st
calci o
um ol
in so
small ft
intest e
ines. n
er
as
n
ec
es
sa
ry
.
 L
a
b
te
st
s:
D
et
Virac Catanduanes
er
m
in
e
se
ru
m
a
n
d
ur
in
e
ca
lc
iu
m
w
ee
kl
y
in
p
at
ie
nt
s
re
ce
iv
in
g
pr
ol
o
n
g
e
d
th
er
a
p
y
a
n
d
in
p
Virac Catanduanes
at
ie
nt
s
w
it
h
re
n
al
d
ys
fu
n
ct
io
n.
 R
ec
or
d
a
m
el
io
ra
ti
o
n
of
sy
m
pt
o
m
s
of
h
y
p
o
ca
lc
e
m
ia
.
Virac Catanduanes
 O
bs
er
v
e
fo
r
S
&
S
of
h
y
p
er
ca
lc
e
m
ia
in
p
at
ie
nt
s
re
ce
iv
in
g
fr
e
q
u
e
nt
or
hi
g
h
d
os
es
,
or
w
h
o
Virac Catanduanes
h
a
v
e
i
m
p
ai
re
d
re
n
al
fu
n
ct
io
n.
NaHCO3 Short GI: Belchin  B

650mg 1tab - g, gastric e
TID actin distention, f a
g, latulence. w
pote ar
Classification nt e
syste Metabolic: th
GASTROINTE mic at
Metabolic
STINAL antac lo
alkalosis;
AGENT; id. n
electrolyte
ANTACID; Rapi g-
imbalance:
FLUID AND dly te
sodium
ELECTROLY neutr r
overload
TE BALANCE alize m
(pulmonary
AGENT s us
edema),
gastr hypocalcem e
ic ia (tetany), of
Date Started: acid hypokalemi or
to a, milk- al
03/12/2023
form alkali pr
Date sodiu syndrome, e
Discontinued: m dehydration p
chlor . ar
03/19/2023 ide, at
carb io
on Other: Rapi n
dioxi d IV in w
de, neonates it
PRN:
and h
Virac Catanduanes
wate (Hypernatre m
r. mia, il
NaHCO3 250
After reduction in k
ml with PNSS
absor CSF or
25 ml to run
ption pressure, int ca
for 15 minutes.
of racranial lc
sodiu hemorrhage iu
m ). m
Date Started: bicar ca
03/15/2023 bona n
te, Skin: Sever ca
Date plas e tissue us
Discontinued: ma damage e
alkal following m
03/15/2023
i extravasatio il
reser n of IV k-
ve is solution. al
incre k
ased al
and Urogenital: i
exce Renal sy
ss calculi or n
sodiu crystals, dr
m impaired o
and kidney m
bicar function. e:
bona A
te n
ions or
are e
excre xi
ted a,
in n
urine a
, thus us
rend ea
ering ,
urine v
less o
acid. m
Not iti
suita n
ble g,
for h
treat ea
ment d
of ac
pepti h
c e,
Virac Catanduanes
ulcer m
beca e
use it nt
is al
short c
- o
actin nf
g, us
high io
in n,
sodiu h
m, y
and p
may er
caus ca
e lc
gastr e
ic m
diste ia
ntion ,
, h
syste y
mic p
alkal o
osis, p
and h
possi os
bly p
acid- h
rebo at
und. e
m
ia
,
so
ft
ti
ss
u
e
ca
lc
ifi
ca
ti
o
n,
re
n
Virac Catanduanes
al
a
n
d
ur
et
er
al
ca
lc
ul
i,
re
n
al
in
su
ff
ic
ie
n
c
y,
m
et
a
b
ol
ic
al
k
al
os
is.
 L
a
b
te
st
s:
U
ri
n
ar
y
al
k
al
Virac Catanduanes
in
iz
at
io
n:
M
o
ni
to
r
ur
in
ar
y
p
H
as
a
g
ui
d
e
to
d
os
a
g
e
(p
H
te
st
in
g
w
it
h
ni
tr
az
in
e
p
a
p
er
m
a
y
Virac Catanduanes
b
e
d
o
n
e
at
in
te
rv
al
s
th
ro
u
g
h
o
ut
th
e
d
a
y
a
n
d
d
os
a
g
e
a
dj
us
t
m
e
nt
s
m
a
d
e
ac
c
or
di
n
Virac Catanduanes
gl
y)
.
 L
a
b
te
st
s:
M
et
a
b
ol
ic
ac
id
os
is
:
M
o
ni
to
r
p
at
ie
nt
cl
os
el
y
b
y
o
bs
er
v
at
io
ns
of
cl
in
ic
al
c
Virac Catanduanes
o
n
di
ti
o
n;
m
ea
su
re
m
e
nt
s
of
ac
id
-
b
as
e
st
at
us
(b
lo
o
d
p
H
,
P
o2
,
P
c
o2
,
H
C
O
3
–
,
a
n
d
ot
h
er
Virac Catanduanes
el
ec
tr
ol
yt
es
,
ar
e
us
u
al
ly
m
a
d
e
se
v
er
al
ti
m
es
d
ai
ly
d
ur
in
g
ac
ut
e
p
er
io
d)
.
O
bs
er
v
e
fo
r
si
g
ns
Virac Catanduanes
of
al
k
al
os
is
 O
bs
er
v
e
fo
r
a
n
d
re
p
or
t
S
&
S
of
i
m
pr
o
v
e
m
e
nt
or
re
v
er
sa
l
of
m
et
a
b
ol
ic
ac
id
Virac Catanduanes
os
is.
Totilac 50ml Acti Body as a  M

IV Q4 ons Whole: Tin o
simil gling ni
ar to sensation. to
those With rapid r
of IV, E
Classification calci sensations C
FLUID AND um of heat G
ELECTROLY gluc waves a
TIC onate (peripheral n
BALANCE . vasodilation d
AGENT; Ioniz ), fainting, B
REPLACEME es P
NT more a
SOLUTION readi CV: (With n
ly rapid d
and infusion) o
thus hypotension bs
Date Started:
is , er
03/12/2023 more bradycardia v
pote , cardiac e
Date nt p
arrhythmias
Discontinued: than at
, cardiac
03/15/2023 calci arrest. ie
um nt
gluc cl
onate Skin: Pain os
and and burning el
more at IV site, y
irrita severe d
ting venous ur
to thrombosis, in
tissu necrosis g
es. and a
Provi sloughing d
des (with m
exce extravasatio in
ss n). is
chlor tr
ide at
ions io
that n.
prom I
Virac Catanduanes
ote V
acido in
sis je
and ct
temp io
orary n
(1–2 m
d) a
diure y
sis b
seco e
ndar ac
y to c
excre o
tion m
of p
sodiu a
m. ni
e
d
b
y
c
ut
a
n
e
o
us
b
ur
ni
n
g
se
ns
at
io
n
a
n
d
p
er
ip
h
er
al
v
Virac Catanduanes
as
o
di
la
ti
o
n,
w
it
h
m
o
d
er
at
e
fa
ll
in
B
P.
 O
bs
er
v
e
di
gi
ta
li
ze
d
p
at
ie
nt
s
cl
os
el
y
si
n
ce
a
n
in
cr
Virac Catanduanes
ea
se
in
se
ru
m
ca
lc
iu
m
in
cr
ea
se
s
ri
sk
of
di
gi
ta
li
s
to
xi
ci
ty
.
 L
a
b
te
st
s:
D
et
er
m
in
e
se
ru
m
p
H
,
ca
lc
Virac Catanduanes
iu
m
,
a
n
d
ot
h
er
el
ec
tr
ol
yt
es
fr
e
q
u
e
nt
ly
as
g
ui
d
es
to
d
os
a
g
e
a
dj
us
t
m
e
nt
s.
Iberet 1tab OD Vita Reportedly  O

min nontoxic. bt
B Slight ai
Classification com flushing n
plex and feeling a
essen of warmth ca
Virac Catanduanes
VITAMIN B9 tial following re

for IV fu
nucle administrati l
Date Started: oprot on. hi
ein st
03/12/2023 synth or
Date esis y
Discontinued: and of
main di
03/18/2023 tenan et
ce of ar
norm y
al in
eryth ta
ropoi k
esis. e
Acts a
again n
st d
folic dr
acid u
defic g
iency a
that n
impa d
irs al
thym c
idyla o
te h
synth ol
esis us
and a
resul g
ts in e
prod pr
uctio io
n of r
defec to
tive st
DNA ar
that t
leads of
to th
mega er
lobla a
st p
form y.
ation D
and ru
Virac Catanduanes
arres gs
t of re
bone p
marr or
ow te
matu d
ratio to
n. ca
us
e
fo
la
te
d
ef
ic
ie
n
c
y
in
cl
u
d
e
or
al
c
o
nt
ra
ce
pt
iv
es
,
al
c
o
h
ol
,
b
ar
bi
tu
ra
te
s,
Virac Catanduanes
m
et
h
ot
re
x
at
e,
p
h
e
n
yt
oi
n,
pr
i
m
id
o
n
e,
a
n
d
tri
m
et
h
o
pr
i
m
.
F
ol
at
e
d
ef
ic
ie
n
c
y
m
a
y
al
Virac Catanduanes
so
re
su
lt
fr
o
m
re
n
al
di
al
ys
is.
 K
ee
p
p
h
ys
ic
ia
n
in
fo
r
m
e
d
of
p
at
ie
nt
's
re
sp
o
ns
e
to
th
er
a
p
y.
 M
o
Virac Catanduanes
ni
to
r
p
at
ie
nt
s
o
n
p
h
e
n
yt
oi
n
fo
r
su
bt
h
er
a
p
e
ut
ic
pl
as
m
a
le
v
el
s.
Bitagen 500ml Incre Glucagon is  A

+ 6hours side asing associated ss
drip bloo with GI es
d upset, s
gluc nausea, and fo
Classification ose vomiting, r
by hypotension c
GLUCOSE- decre , headache, o
ELEVATING asing cerebral nt
Virac Catanduanes
AGENT insul ischemia, ra

in weakness, in
relea heart di
Date Started: se failure, and ca
and arrhythmias ti
03/17/2023 accel . o
Date erati ns
Discontinued: ng a
the n
03/17/2023 brea d
kdo ca
wn ut
of io
glyc ns
ogen :
in hi
the st
liver or
to y
relea of
se al
gluc le
ose. rg
y,
re
n
al
a
n
d
h
e
p
at
ic
d
ys
fu
n
ct
io
n,
pr
e
g
n
a
n
c
Virac Catanduanes
y
to
a
v
oi
d
a
d
v
er
se
ef
fe
ct
s.
 P
er
fo
r
m
a
c
o
m
pl
et
e
p
h
ys
ic
al
as
se
ss
m
e
nt
to
es
ta
bl
is
h
a
b
as
el
Virac Catanduanes
in
e
b
ef
or
e
b
e
gi
n
ni
n
g
th
er
a
p
y,
m
o
ni
to
r
ef
fe
ct
iv
e
n
es
s
of
th
er
a
p
y,
a
n
d
e
v
al
u
at
e
fo
r
a
Virac Catanduanes
n
y
p
ot
e
nt
ia
l
a
d
v
er
se
ef
fe
ct
s
d
ur
in
g
th
er
a
p
y.
 A
ss
es
s
or
ie
nt
at
io
n
a
n
d
re
fl
e
x
es
a
n
d
b
Virac Catanduanes
as
el
in
e
p
ul
se
,
bl
o
o
d
pr
es
su
re
,
a
n
d
a
d
v
e
nt
iti
o
us
so
u
n
ds
to
m
o
ni
to
r
th
e
ef
fe
ct
s
of
al
te
re
d
Virac Catanduanes
gl
u
c
os
e
le
v
el
s,
a
n
d
a
b
d
o
m
in
al
so
u
n
ds
a
n
d
fu
n
ct
io
n,
w
hi
c
h
c
o
ul
d
b
e
al
te
re
d
b
y
th
es
Virac Catanduanes
e
dr
u
gs
.
 M
o
ni
to
r
bl
o
o
d
gl
u
c
os
e
le
v
el
s
as
or
d
er
e
d
to
as
se
ss
th
e
ef
fe
ct
iv
e
n
es
s
of
th
e
dr
u
Virac Catanduanes
g
a
n
d
p
at
ie
nt
re
sp
o
ns
e
to
tr
ea
t
m
e
nt
.
 M
o
ni
to
r
th
e
re
su
lt
s
of
la
b
or
at
or
y
te
st
s,
in
cl
u
di
n
g
Virac Catanduanes
ur
in
al
ys
is,
to
e
v
al
u
at
e
fo
r
gl
u
c
os
ur
ia
,
se
ru
m
gl
u
c
os
e
to
e
v
al
u
at
e
re
sp
o
ns
e
to
th
er
a
p
y,
a
n
Virac Catanduanes
d
re
n
al
a
n
d
li
v
er
fu
n
ct
io
n
te
st
s
to
d
et
er
m
in
e
th
e
n
ee
d
fo
r
p
os
si
bl
e
d
os
e
a
dj
us
t
m
e
nt
or
id
Virac Catanduanes
e
nt
if
y
p
os
si
bl
e
to
xi
c
ef
fe
ct
s.
Clonidine Cent CV: Hypote  M

70mg SL rally nsion, o
actin postural ni
g hypotension to
Classification: antia , peripheral r
dren edema, B
CARDIOVAS ergic ECG P
CULAR deriv changes, cl
AGENT; CEN ative tachycardia, os
TRAL- . bradycardia el
ACTING Stim , flushing, y.
ANTIHYPERT ulate rapid D
ENSIVE; ANA s increase in et
LGESIC alpha BP with er
2- abrupt m
adre withdrawal. in
Date Started: nergi e
c p
03/12/2023
recep GI: Dry os
Date tors mouth, iti
Discontinued: in constipatio o
CNS n, abdomina n
03/12/2023 to al
l pain,
inhib pseudo- c
it obstruction h
symp of large a
athet bowel, n
ic altered g
vaso taste, es
moto nausea, (s
r vomiting, u
Virac Catanduanes
cente hepatitis, pi
rs. hyperbilirub n
Cent inemia, e,
ral weight gain. si
actio tti
ns n
redu CNS: Drow g,
ce siness, st
plas sedation, di a
ma zziness, n
conc headache, di
entra fatigue, n
tions weakness, g)
of sluggishnes .
nore s, dyspnea,
 M
pine vivid
o
phrin dreams,
ni
e. nightmares,
to
insomnia,
r
behavior
B
It changes,
P
decre agitation,
cl
ases hallucinatio
os
systo n,
el
lic nervousness
y
and ,
w
diast restlessness,
h
olic anxiety,
e
BP mental
n
and depression.
e
heart
v
rate.
er
Orth Skin: Rash,
a
ostati pruritus,
dr
c thinning of u
effec hair,
g
ts exacerbatio is
tend n of
a
to be psoriasis;
d
mild with
d
and transdermal e
occu patch:
d
r hyperpigme to
infre ntation,
or
quen recurrent
w
tly. herpes it
simplex, h
Also
skin dr
inhib
irritation,
Virac Catanduanes
its contact a
renin dermatitis, w
relea mild n
se erythema. fr
from o
kidn m
eys. Special th
Senses: Dry er
eyes. a
p
e
Urogenital: ut
Impotence, ic
loss of re
libido. gi
m
e
n.
 M
o
ni
to
r
I
&
O
d
ur
in
g
p
er
io
d
of
d
os
a
g
e
a
dj
us
t
m
e
nt
.
Virac Catanduanes
R
e
p
or
t
c
h
a
n
g
e
in
I
&
O
ra
ti
o
or
c
h
a
n
g
e
in
v
oi
di
n
g
p
at
te
rn
.
Nalbuphine Synt CV: Hypert  A

hydrochloride hetic ension, ss
narc hypotension es
2.5 mg IV @
otic , s
7:00 PM
analg bradycardia re
esic , sp
with tachycardia, ir
Classification: agon flushing. at
CENTRAL ist or
NERVOUS and y
weak GI: Abdomi ra
Virac Catanduanes
SYSTEM antag nal cramps, te

AGENT; ANA onist bitter b
LGESIC; NAR prop taste, nause ef
COTIC erties a, or
(OPIATE) . vomiting, dr e
AGONIST- Anal y mouth. dr
ANTAGONIS gesic u
T pote g
ncy CNS: Sedat a
is ion, d
Date Started: abou dizziness, n m
t 3 or ervousness, in
03/15/2023 4 is
depression,
Date times restlessness, tr
Discontinued: great crying, at
er euphoria, io
03/15/2023 than dysphoria, n.
that distortion of W
of body image, it
penta unusual h
zocin dreams, h
e and confusion, ol
appr hallucinatio d
oxim ns; dr
ately numbness u
equal and tingling g
to sensations, a
that headache, n
prod vertigo. d
uced n
by ot
equi Respiratory: if
valen Dyspnea, y
t asthma, res p
dose piratory h
s of depression. ys
morp ic
hine. ia
n
Skin: Prurit
if
us,
On a re
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weig sp
burning
ht ir
sensation, s
basis at
weaty,
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clammy
prod y
skin.
uces ra
respi te
rator fa
Virac Catanduanes
y Special ll
depr Senses: Mio s
essio sis, blurred b
n vision, el
abou speech o
t difficulty. w
equal 1
to 2.
that Urogenital:
 W
of Urinary
at
morp urgency.
c
hine;
h
howe
fo
ver,
r
in
al
contr
le
ast to
rg
morp
ic
hine,
re
dose
sp
s
o
>30
ns
mg
e
prod
in
uce
p
no
er
furth
so
er
ns
respi
w
rator
it
y
h
depr
su
essio
lfi
n.
te
se
ns
Anta
iti
gonis
vi
tic
ty
pote
.
ncy
is  A
appr d
oxim m
ately in
one is
fourt te
h r
that w
Virac Catanduanes
of it
nalo h
xone ca
and ut
abou io
t 10 n
times to
great p
er at
than ie
that nt
of s
penta w
zocin it
e. h
h
e
p
at
ic
or
re
n
al
i
m
p
ai
r
m
e
nt
.
 A
v
oi
d
a
br
u
pt
te
r
m
in
at
io
n
Virac Catanduanes
of
n
al
b
u
p
hi
n
e
fo
ll
o
w
in
g
pr
ol
o
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e
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us
e,
w
hi
c
h
m
a
y
re
su
lt
in
sy
m
pt
o
m
s
si
m
il
ar
to
n
ar
c
Virac Catanduanes
ot
ic
w
it
h
dr
a
w
al
:
n
a
us
ea
,
v
o
m
iti
n
g,
a
b
d
o
m
in
al
cr
a
m
ps
,
la
cr
i
m
at
io
n,
n
as
al
c
o
n
g
es
ti
Virac Catanduanes
o
n,
pi
lo
er
ec
ti
o
n,
fe
v
er
,
re
st
le
ss
n
es
s,
a
n
xi
et
y.
Non-Pharmacological:
 Hemodialysis & blood Transfusion (3/14/2023; 3/16/2023)

 Transferred to CDHI
Surgical:
Virac Catanduanes
 Internal Jugular Catcher at left site (3/03/2023)

o Due to busted fistula
o Physician ordered for cutdown
 Nephrolithotomy (2012)
o Check-up @ EBMC 2012 due to elevated blood pressure
o Referred to NKTI
o Identified that there is stone in both kidney
o Undergone nephrolithotomy
Virac Catanduanes
VI. PROGNOSIS
03/12/2023
5:20pm Patient CV was rushed and admitted to
Immaculate Heart of Mary Hospital (IHMH) with
a chief complaint of Body Weakness and Poor
Appetite for 7 days
-Upon admission patient was given PNSS 1L @

KVO rate
-With orders of CBC, PC, ECG, UA,
COMPLETE BLOOD COUNT, SERUM
ELECTROLYTE and TPAG
-Doctor R. prescribed Calcium Citrate to treat low
calcium level and NaHCO3 3x a day to relieve
heartburn and acid, and Iberet once a day to treat
or prevent vitamin deficiency due to poor diet and
certain illnesses
-For Hemodialysis as scheduled
-CBG:100
-patient was hooked to oxygen support with 2 lpm
-Patient’s Blood pressure raised to 170/110 with

6:00pm no dizziness and was given clonidine SL, to treat
high blood pressure by decreasing heart rate and
relaxing the blood vessels so that blood can flow
more easily through the body.
-Blood pressure went down to 160/100
-Via phone, Doctor ordered to give the patient

8:00pm Totilac 50ml IV every 4 hours to manage his body
weakness and Clonidine 75mg SL to manage his
blood pressure
-For repeat CBC, PC tomorrow before the
scheduled hemodialysis
03/13/2023
6am -Hemodialysis was cancelled due to busted fistula
and the patient was scheduled for Transhepatic
Intrajugular Portosystemic Shunt and was referred
to Dr. A. with consent for procedure signed by
relative
6:40pm -Left Internal Jugular catheter was inserted

-Chest X-Ray post procedure was ordered in order
to ensure the correct position of the catheter
03/14/2023
8am -With verbal order by Dr. R. for hemoglobin
Virac Catanduanes
-Patient complains body weakness and poor

7:30pm appetite, with body twitching. Safety and comfort
measures was provided and was advised to
position on his right side to avoid pressure on the
Internal Jugular Catheter.
03/15/2023
8:05am -Patient showed signs of shortness of breath

-His hemoglobin went down to 109, and was
ordered for Repeat Serum Electrolytes,
Creatinine, Hemoglobin and CBG
-Doctor ordered NaHCO3 25mL in PNSS 25mL
to run for 15 minutes to relieve heartburn and acid
since patient has low appetite.
4:00pm -Patient experienced gastric pain with pain scale

of 8 out of 10 and was referred to Dr. R. and
ordered Nalbuphine 2.5 mg given @ 7pm to
relieve moderate to severe pain.
-Patient was hooked to O2 support regulated at 2-
4 lpm, but still experienced fluctuating
O2Saturation ranging from 95% to 53% with
Respiratory Rate of 35 breaths per minutes.
4:55pm -The results for Hemoglobin was 94, and Sodium:

150, since his hemoglobin is low, the doctor
ordered to secure Type A+ after blood typing to
give BT with PRBC after proper cross matching
during hemodialysis
- order was given to discontinue Totilac and the
IVF was shifted to D5W1L @20gtts/min.
-For hemodialysis tomorrow
03/16/2023
6am -Patient was transferred to CDHI via ambulance

for scheduled hemodialysis
2pm -Status post hemodialysis and BT of 1unit PRBC
- Patient was given Blood Transfusion @8:05 pm,

8:05pm transfusion ended @8:55pm
03/17/2023
8:46am -Serum electrolyte, CBG: 136mg/dl
-For repeat hemodialysis tomorrow
-Vitagen 500ml was given to run for 6hrs as side
drip. Vitagen is used for nutritional deficiency,
since the patient has low appetite, this drip will
help to aid in providing nutrition that the body
needs.
8:00pm -Patient experienced shortness of breath, oxygen

Virac Catanduanes
support was maintained and was advised to

reposition comfortably and encouraged deep
breathing exercises as tolerated.
03/18/2023
8:05am -For hemodialysis today at CDHI 10 am
-Doctor ordered for repeat hemoglobin after
hemodialysis. It suggested to be a more accurate
reflection of the hemoglobin levels between
hemodialysis sessions, and to be a better reference
to improve in the patient’s treatment
-No signs of bleeding at IJ catheter site
-Before transferring to CDHI the patient was
experiencing body weakness
10:10am -Transferred to CDHI via ambulance for his

hemodialysis
4:00pm -The patient returned to IHMH after hemodialysis

but the patient still has body weakness
03/19/2023
6am -Still with body weakness
9:30am -For Whole Abdomen Ultrasound, ALT, AST, is

ordered to perform liver function test.
-with severe DOB
-For possible transfer to ICU and Endotracheal
Tube Intubation but the wife declined and signed
DNI status
-NaHCO3 was given of 25mL in PNSS 25mL to
run for 15 minutes
-Oxygen with facemask was ordered and
increased to @10 lpm to aid his difficulty of
breathing
12:19pm -Failed IV insertion 8x

-Patient was unable to tolerate oral feeding
-For cutdown, secure consent for procedure. Due
to failed IV insertion doctor ordered cutdown
allows for large-bore access and the rapid
infusions required in the critically ill trauma or
medical patient with difficult access.
-NGT insertion was ordered
-CBG: 122mg/dl
6pm -Still waiting for consent for cutdown

-NGT maintained open for drain with blackish in
color output, oxygen support maintained
11:11pm -Unresponsive with negative pulse and breathing

-CPR started and referred to ROD (Dr. B.)
-ECG done with no electrical activity, AP
informed
-No apparent signs of life, no response to stimuli,
Virac Catanduanes
no cardiac or pulmonary signs noted

-Patient’s family requested to stop resuscitation
effort
-At 11:11pm ROD declared that the patient died
due to multiple organ failure
-Post mortem care done

11:30pm
Virac Catanduanes
VII. NURSING CARE PLANS
Assessment Nursing Planning Implementation Evaluation

Diagnosis
Objective data: Ineffective Short Term Goal: Independent Short
 (+) SOB and use Breathing nursing action: Term
of accessory Pattern  Patient’s  Place patient with Goal:
muscles related to respiratory proper body
 RR- 35 Breaths SOB as rate will alignment for Patient’s
per minute. evidence by remain maximum breathing respiratory
 With fluctuated use of within pattern. rate remains
02 sat ranging accessory established  Encourage sustained within
from 95% to muscles for limits. deep breaths. established
53% respiration Techniques include limits.
Long term Goal: (1) using
 Patient demonstration:
maintains an highlighting slow
effective breathing inhalation, holding
pattern, as end inspiration for a
evidenced by few seconds, and
relaxed breathing passive exhalation;
at normal rate and (2) utilizing
depth and absence incentive spirometer
of dyspnea. and (3) requiring the
 Patient indicates, patient to yawn.
either verbally or  Encourage frequent
through behavior, rest periods and
feeling teach the patient to
comfortable when pace activity.
breathing.  Encourage small
 Patient frequent meals.
demonstrates  Teach the patient
maximum lung about pursed-lip
expansion with breathing,
adequate abdominal
ventilation. breathing,
performing
relaxation
techniques,
performing
relaxation
techniques, taking
prescribed
medications
(ensuring the
accuracy of dose
and frequency and
monitoring adverse
effects), scheduling
activities to avoid
fatigue, and provide
Virac Catanduanes
for rest periods.

Diagnosis
Objective data: Excess fluid Short Term Goal: Independent Nursing Short Term
Recently diagnosed volume After the shift, the Actions: Goal:
by CKD related to client’s weight will be Assess fluid status After the shift,
(+) non- pitting decreased maintained within and advise strict the client’s
edema urine output, clients acceptable fluid intake and weight
(+) SOB dietary normal range dietary intake. maintained
excesses, and Promote intake of within
retention of Present with clear high-biologic –value acceptable
Laboratory results as
sodium and breath sounds and protein foods: eggs, normal range
follows:
water normal respiratory rate dairy products,
meats. Present with
 Sodium: 150 Long Term Goal: Dependent Nursing clear breath
mmol/L The client will follow Actions: sounds and
(High) strict dietary and fluid  Medications. Alter normal
 Chloride: intake. schedule of respiratory
116 mmol/L medications so that rate
(High) they are not given
 Creatinine: immediately before
469.3 meals.
umol/L  Hemodialysis: a
(High) procedure where a
 (+) SOB and dialysis machine
use of and a special filter
accessory called an artificial
muscles kidney, or a
 With
dialyzer, are used to
Oxygen clean your blood
Support @ 3
LPM via
nasal
cannula
 Weight: 54
kg

Diagnosis
Subjective:  Impaired Short term  Administer  The patient
“Gaihi an pero Urinary goal: diuretics as produced at
patak-patak na Eliminati  The patient indicated. least 120-
sana” as on related will Diuretics 160 mL of
veralized by to produce at promote urine per 24
watcher. impaired least 120- urinary hours
renal 160 mL of elimination
Objective: function urine per 24 and prevent  The patient
(+) Oliguria: as hours fluid will not
<15ml per hour evidenced  The patient overload in experience
Virac Catanduanes
by will not patients with complicatio

oliguria experience CRF. ns from
complicatio  Administer oliguria
ns from fluids with
oliguria caution.
Fluid
therapy can
help with
promoting
urinary
elimination
but can
cause
worsening
fluid
retention
and
electrolyte
imbalances.
Monitor
closely.
 Educate on
expectations
.
With CRF,
urine
production
may increase
and
decrease.
Educate the
patient that
as the
disease
progresses
urine
production
will slow
and may
stop
completely.
 Prevent
infections.
Patients who
are receiving
dialysis due
to severe
CFR are
at risk for
infections fr
om dialysis
catheters
and fistulas.
Virac Catanduanes
Monitor for
fever
and abdomi
nal pain.

Diagnosis
Objective data: Activity Short Term Goal: Independent Short Term Goal:
 (+) intolerance related  At the end of the Nursing Actions:  At the end of the
Body to post- shift, client will  Assess the shift, client
weakne hemodialysis demonstrate physical activity demonstrated
ss procedure as methods of level and mobility methods of
 (+) Poor evidenced by controlled of the patient. controlled
appetite body weakness breathing (RR. PR, SatO2) breathing
 (+) technique to  Investigate the technique to
SOB conserve energy. patient’s conserve energy.
and use Long Term Goal: perception of
of  Patient will causes of activity
accessor describe intolerance.
y adaptive  Determine the
muscles techniques to patient’s level of
perform activity
activities of intolerance.
daily living.  Assess the
patient’s
nutritional status.
 Have the patient
perform the
activity more
slowly, in a
longer time with
more rest or
pauses, or with
assistance if
necessary.
 Encourage
verbalization of
feelings regarding
limitations.
Provide a positive
atmosphere.
Virac Catanduanes

Diagnosis
Objective Risk for Short term  Administer Short term
data: electrolyte goal: lactulose. goal:
 Sodium: 150 imbalance The patient Hyperkalemia is The patient’s
mmol/L related to will maintain the most electrolytes are
(High) renal failure normal serum common significantly
potassium, electrolyte changing
 Chloride: 116
sodium, imbalance in
mmol/L
calcium, CRF and has
(High)
magnesium, the potential to
 Creatinine:
and cause serious
469.3 umol/L
phosphorus cardiac
(High)
levels arrhythmias.
Lactulose
promotes the
fecal excretion
of electrolytes
as well as
ammonia, urea,
and creatinine.
 Administer
loop diuretics.
Loop diuretics
are potassium-
wasting and will
rid the body of
potassium. Loop
diuretics are
most beneficial
when used with
thiazide.
 Provide or
restrict
nutrition based
on lab work.
Electrolytes are
found in many
foods and
fluids. Restrict
intake when
levels are high
or provide
additional
sources if
deficient.
 Educate the
patient about
signs of high
potassium and
other risks.
Patients with
CRF are
Virac Catanduanes
susceptible to
hyperkalemia
and
hyponatremia.
Hyperkalemia
can cause
muscle
weakness,
restlessness,
cramping, and a
slow heart rate.
Hyponatremia
can cause
muscle cramps,
nausea,
disorientation,
and alterations
in mental status.
Assessment Nursing Diagnosis Planning Implementation Evaluation
Objective:  Risk for Short Term Promote Short
 Sodium: Decreased sodium Term
150 mmol/L Cardiac After 8 hours restriction
(High) Output of nursing and adequate After 8 hours
 Chloride: Related To intervention, nutritional of nursing
116 mmol/L Alteration the client will intake intervention,
(High) In Rate, maintain Reduction in the client
rhythm, and cardiac output salt intake may maintained
 Creatinine:
cardiac as evidenced slow the cardiac output
469.3
conduction by BP and progression of as evidenced
umol/L
heart rate diabetic CKD, by BP and
(High)
within the at least in part heart rate
 (+) SOB use
client’s by lowering within the
of accessory normal range blood pressure client’s
muscles
Administer normal range
 RR- 35 medications as
Breaths per indicated
minute Prepare for
 With dialysis
fluctuated Reduction of
02 sat uremic toxins
ranging and correction
from 95% of electrolyte
to 53% imbalances
and fluid
overload may
limit and
prevent
cardiac
manifestations
Virac Catanduanes

Case Study CKD Pinakafinal Na Talaga

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Republic of the Philippines

CATANDUANES STATE UNIVERSITY

II. ANATOMY AND PHYSIOLOGY

IV. DIAGNOSTICS PROCEDURES AND LAB RESULTS

VII. NURSING CARE PLANS

Patient’s Demographic Data:

Age: 63 years old Sex: Male

Past Medical History:

Family Health History

Present Health History:

HAVIGHURST’S DEVELOPMENTAL TASKS

Age Range Developmental Task Developmental Task

Infancy and Early Childhood  Learn to walk Relationship with family

 Learn to form relationship

Middle childhood  Learn school-related skills  Had good

Adolescence  Establish emotional  Started going out

Early Adulthood  Choose a life partner  After graduating

Middle Age  Maintain a standard of living  Started working at

Later Maturity  Adjust to deteriorating health  Retired work last

 Adjust to loss of spouse

II. ANATOMY AND PHYSIOLOGY

The ureters do play an active role in urine transport.

 Internal urethral sphincter. At the bladder-urethral junction, a thickening of the smooth

Physiology of the Urinary System

Urine formation is a result of three processes:

Micturition or voiding is the act of emptying the bladder.

PATIENT C.V CHEST X-RAY

Patient Chest X-ray:

2nd ECG (03-19-2023)

 Poor T-wave progression (V4)

3rd ECG (03-19-2023 – 23:12)

 Lead off (V1,V2,V3,V4,V5,V6)

- A low RBC count could also indicate a

- Low platelet levels make it difficult for

HEMATOLOGY (3.13.23) 1:40 PM

- A low hematocrit level means that the

HEMATOLOGY (3.14.23) 1:10 PM

HEMATOLOGY (3.15.23) 2:30 PM

HEMATOLOGY (3.16.23) 4:40 PM

HEMATOLOGY (3.18.23) 5:00 PM

CLINICAL CHEMISTRY (3.13.23) 4:40 PM

CLINICAL CHEMISTRY (3.15.23) 4:40 PM

CLINICAL CHEMISTRY (3.19.23) 4:40 PM

ELECTROLYTE PROFILE (3.12.23) 6:43 PM

ELECTROLYTE PROFILE (3.15.23) 4:00 PM

ELECTROLYTE PROFILE (3.17.23) 4:40 PM

NaHCO3 Short GI: Belchin  B

Totilac 50ml Acti Body as a  M

Iberet 1tab OD Vita Reportedly  O

VITAMIN B9 tial following re

Bitagen 500ml Incre Glucagon is  A

AGENT insul ischemia, ra

Clonidine Cent CV: Hypote  M

Nalbuphine Synt CV: Hypert  A

SYSTEM antag nal cramps, te

 Hemodialysis & blood Transfusion (3/14/2023; 3/16/2023)

 Internal Jugular Catcher at left site (3/03/2023)

-Upon admission patient was given PNSS 1L @

-patient was hooked to oxygen support with 2 lpm

-Patient’s Blood pressure raised to 170/110 with

-Via phone, Doctor ordered to give the patient

6:40pm -Left Internal Jugular catheter was inserted