6100c73a72e89 3na Grand Case Presentation

XAVIER UNIVERSITY- ATENEO de CAGAYAN
COLLEGE OF NURSING
A CASE PRESENTATION OF A 68-YEAR OLD FEMALE PATIENT

DIAGNOSED WITH UREMIA 2° TO AKI ON TOP OF CKD 2° TO
OBSTRUCTIVE UROPATHY AND COMPLICATED UTI
In Partial Fulfillment of the Requirements in

NCM 112 - Medical-Surgical Nursing 1
Submitted by:
BSN - 3 NA
Submitted to:
Jesusa C. Gabule, RN, MN

Gemma V. Panal, RN, MN, LPT
Mildred N. Pinque, RN, MN
November 13, 2020

TABLE OF CONTENTS
Page Number
Acknowledgements 3
I. Introduction 5
A. General Objectives 8
B. Specific Objectives 9
C. Scope and Limitations 11
D. Significance of the Study 13
E. Definition of Terms 15
II. Assessment 18
A. Assessment Tool 18
B. Narrative Assessment 32
III. Laboratory and Diagnostic Results 36
IV. Pathophysiology 40
A. Narrative Pathophysiology 40
B. Schematic Diagram 47
V. Medical Management 50
VI. Drug Study 59
VII. Nursing Care Plan 109
VIII. Discharge Plan 163
IX. Prognosis 173
X. Conclusion 178
XI. Recommendations 180
XII. Bibliography 183
XIII. Appendices 186
A. Assessment Tool 186
B. Nurses’ Notes 200
C. Physician’s Orders 202
D. Vital Signs 203
E. Intake and Output 205
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F. Complete Names of Block NA Students 207
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ACKNOWLEDGEMENTS
In completion of our grand case presentation this could not have
been possible without the cooperation and support of so many people
whose names may not all be enumerated. We are so grateful for their
contributions that we sincerely appreciated and acknowledged them.
However, we, the 3rd year block NA nursing students, would like to
express our deepest gratitude and indebtedness particularly to the
following:
 To our Dean, Mrs. Mary Grace M. Paayas, RN, MN, and the 3 rd
year level faculty of the College of Nursing Xavier University, for
preparing us with knowledge, skills and attitude that molded us
to become competent, committed and conscientious nurses in
the future.
 To Ma’am Jesus C. Gabule, RN, MN, Ma’am Gemma V. Panal,
RN, MN, LPT, Ma’am Mildred N. Pinque, RN, MN, Ma’am Ma.
Jesseca P. Monsanto, RN, MAN, Ma’am Renzi R. Pepito, RN, MN,
and Ma’am Jennifer O. Asio, RN, MN, our most sincere
appreciation for becoming our instruments of extended ideas,
knowledge, suggestions, support and guidance for successfully
conceptualizing and completing our case presentation.
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 To our beloved family and support systems, who we
sincerely owe thanks and appreciation for their moral and
spiritual support. For the unending inspiration,
encouragement and support for every obstacle that
comes into our way in completion of the case.
 To 3rd year - Block NA students, we are grateful for the
time and effort of each student who dedicated and
compassionately discussed, planned and worked for the
successful completion of the case presentation.
 And lastly to our Heavenly Father, for making this case
presentation a successful one from start to the end. For
giving us with the gift of wisdom and knowledge to identify
the needs of our patient. For giving us the strength,
patience and determination to continue despite the
difficulties we faced in conceptualizing the most
appropriate nursing care, and lastly for giving us the skills to
make planned care correctly rendered especially to those
who are in need.
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I. INTRODUCTION
Older adults are highly susceptible to disorders which are primary
causes of functional loss. In a lot of cases, declines that come with
aging may be due to modifiable factors such as lifestyle, behavior,
diet, and environment (Besdine, 2019). The increase in the number of
elderly also increases medical problems such as acute and chronic
kidney disease. Kidney problems are very common in the elderly and it
significantly affects their quality of life (Balogun & Abdel-Rahman,
2015).
Patient IB, a 68-year-old female senior citizen was admitted at
Maria Reyna - Xavier University Hospital last August 15, 2020, at around
1:16 AM. The attending physician Dr. Antonio D. Carpio, M.D. provided
a final diagnosis of the patient which are "(1) Uremia secondary to
Acute Kidney Injury on top of Chronic Kidney Disease secondary to
Obstructive Uropathy and (2) Complicated UTI.‖
Uremia is a disease in which high levels of urea are found in the
blood and it is one of the main constituents of urine. There is an excess
on the end products of amino acid and protein metabolism in the
blood that are normally excreted in urine as urea and creatinine
(Alper, 2020). Manifestations are extreme tiredness or fatigue, cramping
in the legs, little or no appetite, headache, nausea, vomiting, and
trouble concentrating. Uremia causes severe and permanent damage
leading to chronic kidney disease wherein kidneys are no longer able
to function (Wells, 2017). According to Alper (2020), uremia more
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commonly develops with chronic kidney disease (CKD) but it may also
occur with acute kidney injury (AKI) if the loss of renal function is rapid.
The occurrence of uremia can be linked to nephrolithiasis which
is also called renal calculi or kidney stones that resulted in the build-up
of concretions from the mixture of different mineral salts and organic
matrix in the upper urinary tract. Most common clinical manifestation of
this condition is renal colic accompanied by pain, nausea and
vomiting. Naturally kidney stones are eliminated from the body but
increasing number and size result in the need of surgical interventions.
Acute kidney injury refers to an onset of renal dysfunction associated
with low urine output. To determine the occurrence of acute kidney
injury in relation to nephrolithiasis; the increasing size and number of
kidney stones resulted in an obstruction of the urinary outflow which
impairs the normal function of the kidney (Song, 2020).
Obstructive uropathy is one of the causative factors of chronic
kidney disease. It is a condition wherein the flow of urine is blocked
causing it to back up into the kidney leading to hydronephrosis. This
causes permanent and severe damage to the kidney often manifested
by flank pain, fever, weight gain, and swelling of the kidney. Problems
with passing urine also occur such as nocturia, hematuria,
incontinence, and increased in frequency and urge to urinate
(Preminger, 2019). Once chronic kidney disease has occurred a lot of
complications may develop such as high blood pressure, anemia, poor
nutritional health and nerve damage. It also increases the risk of having
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cardiovascular diseases. Early detection and treatment help keep
chronic kidney disease from getting worse. Once it further progresses, it
eventually leads to kidney failure, requiring dialysis or kidney transplant
in order to maintain life (National Kidney Foundation, 2017).
Uremia is a medical emergency that requires urgent treatment.
Most people with uremia will need dialysis. This involves a machine to
act as an ―artificial kidney‖ that filters the blood. (Villines, 2017)
Although dialysis does not completely cover the lost function of a
kidney, this still helps in the management of activities through diffusion
and ultrafiltration. Through this management, toxins from the body are
removed and prevents unnecessary accumulation (Vadaketh & Kandi,
2017).
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A. General Objectives
At the end of the grand case presentation, the Level III student
nurses of Xavier University-Ateneo de Cagayan from Block NA, A.Y.
2020-2021 will be able to present and defend the case of Patient IB
who is diagnosed with (1) Uremia secondary to Acute Kidney Injury on
top of Chronic Kidney Disease secondary to Obstructive Uropathy and
(2) Complicated UTI. The class would also be able to improve and
synthesize understanding of the mentioned conditions of patient IB with
regards to etiology, pathophysiology, medical management, and
nursing interventions as presented by the class. As the presentation
ends, the group will be able to use and enhance their critical thinking
skills in defending through the question and answer. This case study also
aims to contribute patient awareness and education to aid them in
identifying signs and symptoms they may encounter to verbalize their
concerns with regards to their condition to healthcare providers.
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B. Specific Objectives
At the end of the 3 hrs. grand case presentation, the Level III
student nurses of Block NA, A.Y. 2020-2021 will be able to:
KNOWLEDGE
● Understand the disease process and gain sufficient
knowledge to be able to present and analyze data with
regards to the patient’s condition.
● State the etiology, describe the pathophysiology in relation
to the manifestations of the patient’s condition.
● Identify predisposing and precipitating factors affecting a
patient's health which supports the formulation of diagnosis.
● Integrate knowledge on Medical-Surgical Nursing with the
Nursing Process to achieve quality nursing care to the
patient.
● To evaluate the outcomes of the interventions given in
relation to nursing goals.
SKILLS
● Identify and locate potential roots for complication for the
patient and swiftly provide preventive measures which are
necessary.
● Identify the risk, benefits, indications, and contraindications
of the medications prescribed through the Drug Study.
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● Demonstrate proper assessment to obtain accurate data
regarding the progress of the patient's condition.
● Apply evidence-based guidelines in planning appropriate
nursing care that should be provided to the patient.
● Exemplify ways for prevention and management of
complications in the condition of the patient.
ATTITUDE
 Demonstrate competency in comprehending and
understanding the progression of the patient’s condition
and providing the best care for the patient.
● Display positive attitude towards change and criticism and
manifestation of motivation for improvement of medical
knowledge and patient care skills.
● Uphold the values and principles of Jesuit Education to
portray an image of an Ideal Atenean student Nurse.
● Practice ethical principles in relation to patient care,
including obtaining informed consent and confidentiality.
● Build camaraderie with colleagues to establish a harmonious
relationship to the members of the team.
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C. Scope and Limitations
This study covers the medical surgical case handled by Xavier
University - College of Nursing Level III nursing students on their
converted skills laboratory or virtual clinics. The information and data
presented were sourced from the patient's chart and records which is
made available at the nurse’s station. With the aid of the student
nurses background knowledge and patient’s assessment through the
provided data sheets, these data are enhanced to improve and
formulate appropriate nursing care plans. This document includes
personal patient information, consent forms, doctors order, surgical
forms, medication sheets, patient’s fluid input and output sheet, vital
signs monitoring form, laboratory and diagnostic test results, TPR sheet,
emergency room assessment form, nurses’ notes. Moreover, the scope
and limitations include the problems encountered by the student
nurses such as limited information, absence of actual assessment forms,
communication constraints, and COVID related limitations. Thus, the
study is bounded within the limits of the information and documents
received from the clinical instructors, and personal research.
The study is limited to the case of a 68-year-old female who was
admitted at Maria Reyna - Xavier University Hospital on August 15, 2020
with an admission diagnosis of Uremia 2° Acute Kidney Injury 2°
Nephrolithiasis on top of Chronic Kidney Disease 2° Obstructive
Uropathy. The patient’s personal and health information were
collected from the documents provided by the clinical instructors. Thus,
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the students were not able to physically encounter the patient and
that details and answers presented are within the limits of the
document provided and the knowledge of the students.
Furthermore, as these information are not personally collected by
the student nurses, it is safe that we respect and uphold the patients’
rights to privacy and confidentiality. To give respect to the clients rights,
she would be referred to as Patient or Client IB. All information and
details at hand about the patient shall be kept private and used only
for academic purposes and requirements.
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D. Significance of the Study
This study aims to have an in-depth examination of a
specific situation as the case of this client in Maria Reyna - Xavier
University Hospital (MRXUH) of which have the specific problems
in Oxygenation, Fluid and Electrolytes, Inflammatory and
Immunologic Response, Cellular Aberrations, Acute and Chronic.
Xavier University- Ateneo de Cagayan College of Nursing,
College Dean and the Faculty of the College of Nursing. This
study helps them facilitate and evaluate the level of
competencies of the student nurses and critical thinking abilities
in the aforementioned case. This will be a guide to determine the
strengths and weaknesses of the program based on the
successful application of the knowledge and skills acquired
during online lectures.
Student Nurses. It is helpful for them as future nurses as it
helps improve their knowledge with regards to knowledge, skills
and attitude in terms of providing quality nursing care towards
patients with medical surgical related cases. This also gives
information and health teaching to the patient and their future
patients with similar conditions.
To the patient and the family. This study enables other
patients with similar medical surgical cases to gain
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comprehensive information about the condition. Furthermore, It
allows them to make smart decisions and for the family to
continue to take part in the course of their chosen care plan and
to be able to support the patient in performing interventions
independently.
Future researchers and Scholars. The information and results in
this study could be beneficial to future researchers and scholars
with medical surgical related research topics. The study will
enable future researchers and scholars to improve their output
and it can be applied along with its rationale as a guide for
enhancing patient care and nursing approach and strategies in
performing nursing care.
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E. Definition of Terms
1. Aberration- deviation from the normal and usual function or
irregularity.
2. Nephrolithiasis- a kidney stones also called renal calculi made of
phosphate, calcium and other components of foods that build
up in kidneys in small deposits.
3. Obstructive - a blockage in the bodily passageway which makes
the flow difficult or impossible.
4. Stupendous- great or remarkable output.
5. TPR sheet- temperature, pulse, and respiration rate sheet that is
used in recording and monitoring the patient.
6. Uremia- accumulation of creatinine and urea in the bloodstream
that is normally excreted through urine.
7. Uropathy- a disease in the urinary or urogenital organs.
8. Urinalysis - a test of your urine. It is used to detect and manage a
wide range of disorders like urinary tract infections, kidney
disease and diabetes. It involves checking the appearnce,
concentration and appearance of urine.
9. Ultrasound - this uses high-frequency waves to create images of
the inside of the body. They are safe because they use sound
waves or echos to make an image, instead of radiation.
10. Thyroid Ultrasound - also called ultrasound scanning or
sonography. It uses a small probe called a transducer and gel
placed directly on the skin. High-frequency sound waves travel
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from the probe through the gel into the body. An ultrasound of
the thyroid produces pictures of the thyroid gland and the
adjacent structures in the neck. The probe collects the sounds
that bounce back. A computer uses those sound waves to
create an image. Ultrasound exams do not use radiation (as
used in x-rays).
11. Chest PAL X RAY- also called as chest posteroanterior and
lateral x-ray. It is a standard chest examination consisting of PAL
x-ray, the films are read together. The PA exam is viewed as if the
patient is standing in front of you with their right side on your left.
The patient faces the left on a later view.
12. Cervical APL X RAY- also called as cervical x-ray anteroposterior
and lateral view. It is taken with the patient’s head in full flexion
(leaning as far forward as possible). The patient is asked to bend
the head forward as far as possible, and extend the neck
backwards as far as possible. It is used to identify cervical
vertebrae trauma.
13. Cystic Mass- A cyst is a sac that may be filled with air, fluid or
other material. A cyst can form in any part of the body, including
bones, organs and soft tissues. Most cysts are noncancerous
(benign), but sometimes cancer can cause a cyst.
14. Parathyroid Hormone- Parathyroid hormone is secreted from four
parathyroid glands, which are small glands in the neck, located
behind the thyroid gland. Parathyroid hormone regulates
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calcium levels in the blood, largely by increasing the levels when
they are too low.
15. Atherosclerosis thoracic aorta- a material called plaque (fat and
calcium) has built up in the inside wall of a large blood vessel
called the aorta. This plaque buildup is sometimes called
"hardening of the arteries."
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II. ASSESSMENT
A. Assessment Tool
Age: 68 years old

Name: Patient IB
Civil
Birthday: August 18, 1951 Status: Married
Occupation:
Sex: Nationality: Religion: Catholic
housewife
Female Filipino
Address: PUROK 5, Poblacion, Manticao

Admission Case: Philhealth: Senior
Spouse: - Emergency Room Citizen
Relation: Daughter
Informant: DIB
Time: 1:16 AM
Admission Date: 8/15/20
Chief -
Complaint
Attending Dr. RB, MD

Physician:
Uremia secondary to acute kidney infection secondary
Admitting to nephrolithiasis on top of chronic kidney disease
Diagnosis secondary to obstructive uropathy
1. Uremia secondary to acute kidney infection
secondary to nephrolithiasis on top of chronic
Final
kidney disease secondary to obstructive uropathy
Diagnosis:
2. Complicated urinary tract infection
IJ Catheter insertion right (8/15/2020)
Surgical
Procedure:
Discharge
8/23/20 2:15PM
Date and
Time:
Present Medical History
- Patient was admitted due to uremia (increase urea in blood)
- On august 15, patient was subject for dialysis via IJ catheter
- Patient's right kidney is surgically absent so left kidney compensates
and starts to
deteriorate.
Upon Assessment:
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Vital Signs: PR: 82b pm RR:21 cpm BP:110/60 mmHg Temp:36.0 Ht.:155
cm Wt.: 60 kg BMI: 25.0
Interpretation of BMI: Overweight (25- 29.9)
Admission Date & Day 1 Day 2 Day 3

Time: 8/15/20 8/16/20 8/17/20
1:16AM 12AM 12AM
ACTIVITY/REST
SUBJECTIVE
Leisure Time Activities: - - -
Limitations Imposed by - - -
Condition:
Number of Hours of - - -
Sleep:
Naps: - - -
Aids: - - -
Difficulty in Sleeping: - - -
Feeling on Awakening: - - -
Others/Comments: - - -
OBJECTIVE
Observed Response to - - -
Activity:
Cardiovascular: Adynamic - -
precordium
Respiratory: 21cpm 19 cpm 21 cpm
O2 Sat: 97% O2 Sat: 97%
Mental Status: GCL 15 - -
Posture: - - -
Limitation of Motion - - -
(LOM):
Tremors: - - -
CIRCULATION
SUBJECTIVE
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History of - - -
Hypertension:
Heart Trouble: - - -
Ankle/Leg Edema: - - -
Claudication: - - -
Cough/Hemoptysis: - - -
Numbness in - - -
Extremities:
Tingling in Extremities: - - -
Change in - - -
Frequency/Amount
of Urine:
OBJECTIVE
Blood Pressure:
Right Arm: 110/60mmHg 110/60mmHg 110/60mmHg

Left Arm: 110/60mmHg 110/60mmHg 110/60mmHg
Pulse Pressure: 50mmHg 50mmHg 50mmHg
Point of Maximal - - -
Impulse (PMI):
Heart Rate/Sounds: 84 bpm, - -

distinct heart
sound
Rhythm: regular - -
Pulse: 82 bpm 97 bpm 89 bpm
Vascular Bruit: - - -
Breath Sounds: rhonchi or - -

low-pitched
wheezing
sounds
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Jugular Vein - - -
Distention:
Extremities: - - -
Temperature
Color: - - -
Capillary Refill Time: - - -
Homan’s Sign: - - -
EGO INTEGRITY
SUBJECTIVE
Reports of Stress - - -
Factors:
Ways of Handling - - -
Stress:
Financial Concerns: - - -
Relationship Status:
Lifestyle: - - -
Recent Changes: - - -
Feelings of - - -
Helplessness:
Feelings of - - -
Hopelessness:
Feelings of - - -
Powerlessness:
OBJECTIVE
Emotional Status: - - -
Observed Physiologic - - -
Response:
ELIMINATION
SUBJECTIVE
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Usual Bowel Pattern: - - -
Character of Stool: - - -
Last Bowel Movement: - - -
Laxative Use: - - -
History of Bleeding: - - -
Hemorrhoids: - - -
Constipation: - - -
Diarrhea: - - -
Usual Voiding Pattern: - - -
Incontinence: - - -
Urgency: - - -
Retention: - - -
Frequency: - - -
Pain/Burning/Difficulty - - -
in Voiding:
History of Kidney/ - - -
Bladder Disease:
OBJECTIVE
Abdomen Flat, soft - -
Tender:
Soft/Firm:
Palpable Mass: No palpable - -
mass
Size/Girth: - - -
Other comments: - - -
Bowel Sounds: normoactive - -
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Bladder Palpable: - - -
Distended: - - -
FOOD AND FLUIDS

SUBJECTIVE
Usual Diet: - - -
No. of Meals a Day: - - -
Last Meal Intake: - - -
Loss of Appetite: - - -
Nausea/Vomiting: - - -
Dentures: - - -
Allergies/Food - - -
Intolerance:
Heartburn/Indigestion: - - -
Swallowing Problems: - - -
Weight - - -
Usual:
Changes: - - -
Diuretics: Furosemide 40mg 1cap BID
OBJECTIVE
Current Weight: 60 kg - -
Height: 155 cm - -
Body Build: - - -
Skin Turgor: - - -
Mucous Membranes: - - -
Hernia/Masses: - - -
Edema: General - - -
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Dependent:
Periorbital: - - -
Ascites: - - -
Thyroid Enlarged: - - -
Halitosis: - - -
Condition of Teeth: - - -
Appearance of - - -
Tongue:
SUBJECTIVE
Activities of Daily - - -
Living
Mobility: - - -
Hygiene: - - -
Toileting: - - -
Feeding: - - -
Dressing: - - -
Others: - - -
Equipment/ Presence Wheelchair - -

of Devices Required:
Assistance Provided - - -
by:
OBJECTIVE
General Appearance: - - -
Manner of Dress: - - -
Habits: - - -
Body Odor: - - -
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Condition of Scalp: - - -
Presence of Vermin: - - -
SUBJECTIVE
Fainting Spells/ - - -
Dizziness:
Headache: - - -
Location: - - -
Frequency: - - -
Tingling/Numbness/ - - -
Weakness Location:
Seizures: - - -
Aura: - - -
How Controlled: - - -
Eyes - - -
Vision Loss:
Last Examination: - - -
Glaucoma: - - -
Cataract: - - -
Sense of Smell: - - -
Epistaxis: - - -
Others/Comments: Anicteric - -
sclera, pink
palpebral
conjunctiva
OBJECTIVE
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Alert: - - -
Stuporous: - - -
Combative: - - -
Drowsy: - - -
Lethargic: - - -
Comatose: - - -
Cooperative: - - -
Affect: - - -
Delusions: - - -
Hallucinations: - - -
Memory - - -
Recent:
Remote: - - -
Speech Pattern: - - -
Congruence: - - -
Glasses: - - -
Contacts: - - -
Hearing Aids: - - -
Pupil Size Reaction: - - -

Left: - - -
Right: - - -
Facial Droop: - - -
Swallowing: - - -
Handgrip/Release - - -
Right:
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Left: - - -
Posturing: - - -
Deep Tendon Reflex: - - -
Paralysis: - - -
Others/Comments: Musculoskele - -
tal is intact
SUBJECTIVE
Onset: - - -
Duration: - - -
Location: - - -
Frequency: - - -
Intensity (1-10): - - -
Quality: - - -
Description of Pain: - - -
Precipitating Factors: - - -
Aggravating Factors: - - -
How Relieved: - - -
Associated Symptoms: - - -
OBJECTIVE
Observed Symptoms: - - -
SUBJECTIVE
Dyspnea related to: - - -
Cough/Sputum of: - - -
Smoker: No
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Packs: - - -
Brand: - - -
Number of Years: - - -
Use of Respiratory - - -
Aids:
Oxygen: - - -
OBJECTIVE
Respiratory Rate: 21 cpm 19 cpm 21 cpm
Depth: - - -
Symmetry: - - -
Use of Accessory - - -
Muscles:
Nasal Flaring: - - -
Fremitus: - - -

low-pitched
wheezing
sounds
Cyanosis: - - -
Clubbing of Fingers: - - -
Sputum - - -
Characteristics:
Restlessness: - - -
SUBJECTIVE
Allergies/Sensitivity: - - -
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Reaction: - - -
History of STD - - -
(Date/Type):
Blood Transfusion - - -
Number:
When: - - -
History of Accidental - - -
Injuries:
Fractures/Dislocations: - - No fractures
or dislocations
noted
Arthritis/Unstable - - -
Joints:
Back Problems: - - -
Changes in Moles: - - -
Enlarged Nodes: none - -
Prosthesis: - - -
Ambulatory Devices: - - -
Expression of Ideation - - -
of Violence (Self/
Others)
Others/Comments: - - Presence of IJ
catheter in
the right
OBJECTIVE
Temperature: 36.0 37.1 37.5
Diaphoresis: - - -
Skin Integrity: Dry, - -

hypopigment
ed
Scars: - - -
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Rashes: - - -
Lacerations: - - -
Ulcerations: - - -
Bruises - - -
Blisters: - - -
Burns (Degree %) - - -
Drainage (Note - - -
Location):
General Strength: - - -
Muscle Tone: - - -
Gait: - - -
Paresthesia/Paralysis: - - -
Sexually Active: - - -
Sexual Concerns/ - - -
Difficulties:
Recent Changes in - - -
Frequency /Interest:
SUBJECTIVE
Marital Status: Married
Years in Relationship: - - -
Living with: - - -
Concerns/Stresses: - - -
Extended Family: - - -
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Other Support Person: - - -
Role within Family - - -

Structure:
Reports of Problems - - -
related to Illness-
Condition:
SUBJECTIVE
Dominant Language: - - -
Literate: - - -
Educational Level: - - -
Health - - -
Beliefs/Practices:
(-) Not properly assessed

Medications
Date Name, Dose, Route

8/15/2020 Ketoanalogue (Renalog) 2mg TID PO
Sodium Bicarbonate 650 mg 1 tab TID
8/16/2020 Furosemide (Lasix) 40mg 1 cap BID (hold if SBP
<90mmHg)
8/16/2020 Ambroxol 75mg 1 cap OD PO
NaCl 125mg 1 tab TID PO
Clonazepam (Rivotril) 2 mg ½ tab OD PO
Paracetamol 500 mg 1 tab PRN PO
8/18/2020 Omeprazole (Omepron) 40 mg tab OD ACBT
NaHCO3 650mg tab TID PO
Ferrous Sulfate + Folic Acid 1 tab OD
Atorvastatin 20 mg 1tab, 1 tab OD
EPO 6000 IV SQ 1x1 week
Levocetirizine + montelukast (Stelix) 10/5mg tab OD
8/20/2020 Meropenem (Gopenem) 500mg IV q24H ANST (-)
Levofloxacin 250mg 1tab, 1tab OD every 48hrs.
8/22/2020 Kalium Durule 1tab TID x 4doses. SD: 8102 1pm LD: 8124
8am
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B. Narrative Assessment
Patient IB is a 68 year-old female, born on August 18,1951. She
lives at PUROK 5, Poblacion, Manticao. She is married however her
spouse was not clearly stated. She is a Filipino and a Roman Catholic.
She was diagnosed with uremia or the increase of urea in the blood.
Her right kidney is surgically absent and her left kidney does all the
compensation. Patient IB is also not a smoker.
She was admitted on August 15, 2020 at 1:16 AM at Maria Reyna-
Xavier University Hospital accompanied by her daughter. Her admitting
diagnosis states uremia secondary to acute kidney infection secondary
to nephrolithiasis on top of chronic kidney disease secondary to
obstructive uropathy. Upon admission, the patient had the following
vital signs: blood pressure 110/60 mmHg; pulse rate 82 bpm; respiratory
rate 21 cpm; temperature 36.0 °C; height 155 cm; weight 60 kg ; body
mass index of 25.0 which is interpreted as overweight. In addition,
objective findings are Adynamic precordium, GCL 15, pulse pressure of
50 mmHg, distinct heart sound, regular rhythm, rhonchi breath sounds,
flat and soft abdomen, no palpable mass, normoactive bowel sounds,
anicteric sclera, pink palpebral conjunctiva, musculoskeletal is intact,
absence of enlarged nodes and, dry and hypopigmented skin. Patient
is also taking diuretics and using a wheelchair. The final diagnosis was
first, uremia secondary to acute kidney infection secondary to
nephrolithiasis on top of chronic kidney disease secondary to
32
obstructive uropathy; and the second one is complicated urinary tract
infection.
Later that day, she was subject for dialysis via an IJ catheter. The
surgical procedure started at 2:32 PM. From her wheelchair, she was
placed in a supine position with her head tilted left. Prior, a local
anesthesia was administered at the right posterior sacral at 2:30 PM.
The needle was inserted on her right internal jugular vein. Her
anesthesia and her operation ended at 2:44 PM. On the same day, she
had her chest PAL imaging, which showed that her heart is not
enlarged but she has a sclerotic aorta, and since her trachea is
deviated to the right, there is a higher possibility of thyroid mass. The
test also showed that she has a spondylosis on her thoracic spine. At
5:31 PM, she had her urinalysis. Upon the examination of her urine, it
was light yellow in color, and clear. It has a specific gravity of 1.025,
and acidity of 6.0; sugar was negative, and her protein in her urine is
1+. Her urinalysis also showed that her WBC’s and her RBC’s are
significantly higher than the normal range. Her WBC is 206/0.11 per uL,
and her RBC is 24/0.11 per uL. Lastly, the epithelial cells and the
bacteria present in her urine are rare.
On August 16, 2020, objective findings are respiratory rate of 19
cpm, O2 saturation of 97%, 110/60 mmHg blood pressure, pulse
pressure of 50 mmHg, pulse rate of 97 bpm and, 37.1 C temperature.
She was still admitted and still under the custody of the hospital.
Prescribed medications were administered accordingly. Necessary
33
interventions were performed, and her vital signs, intake and output,
and physical status were kept monitored.
On August 17, 2020, objective findings are respiratory rate of 21
cpm, O2 saturation of 97%, 110/60 mmHg blood pressure in both arms,
pulse pressure of 50 mmHg, pulse rate of 89 bpm, 37.5C temperature.
Also, there are no fractures and dislocations noted and there is still a
presence of an IJ catheter in the right side. On this day, she had her
imaging test on her cervical apl. Findings are intact cortical outlines, no
fracture and dislocation, no lytic or blastic focus, intact pedicles, intact
processes, intact intervertebral spaces, and unremarkable soft tissues.
On August 18, 2020, she had her neck ultrasound. Findings are
right lobe thyroid gland: 4.98 x 1.95 x 1.61 cm which indicates a normal
right lobe, left lobe of thyroid gland: 4.6 x 3.23 x 3.50 cm which needs a
follow up study or biopsy on well defined predominantly cystic mass on
left lobe, right lobe shows homogenous echopattern, and there are no
enlarged lymph nodes noted.
On August 19, 2020, an ultrasound on her kidneys, ureters, and
urinary bladder was done. Her right kidney was surgically absent and
left kidney is normal in size an echopattern. Dimensions of the kidney is
10.89 x 4.74 cm with cortical thickness of 1.35 cm. Findings also showed
persistent dilation of the left pelvicalyceal system and entire length of
the left ureter, distended bladder with estimated volume of 169 mL,
wall not thickened, and low level intraluminal echoes are found in the
ultrasound.
34
The patient was prescribed with several medications:
Ketoanalogue (Renalog), Furosemide, Ambroxol, NaCl, Clonazepam
(Rivotril), Omeprazole (Omepron), NaHCO3, Ferrous Sulfate,
Atorvastatin, Levocetirizine + montelukast (Stelix), Levofloxacin, Kalium
Durule, are PO medications. Medications such as EPO 6000, and
Meropenem (Gopenem) were given via IVTT. Her Furosemide
medication was said to be put on hold if her systolic blood pressure
decreases to less than 90mmHg. She was also given paracetamol
indicated for fever. Most of her medications were given post-
operatively.
35
III. Laboratory and Diagnostic Results
URINALYSIS: August 15, 2020
TEST NAME RESULTS FLAG NORMAL RANGE
Physical Examination
COLOR LIGHT YELLOW Yellow (Light/Pale to
Dark/Deep amber)
TRANSPARENCY CLEAR Clear or Cloudy
Chemical Parameters
SPECIFIC GRAVITY 1.025 1.010 – 1.025
PH 6:0 4.5 – 8.0
SUGAR NEGATIVE NEGATIVE
PROTEIN 1+ NEGATIVE
Microscopic
WBC 206 H 0-11
RBC 24 H 0-11
EPITHELIAL CELLS RARE 0-11
BACTERIA RARE 0-111
INTERPRETATION
36
WBC: High WBC indicates a presence of urinary tract infection
RBC: High RBC indicates presence of infection, urinary trauma, presence of
tumors and kidney stones. At risk for acquiring glomerulonephritis.
Ultrasound Kidneys/Ureters/Urinary bladder (KUB): August 19, 2020
FINDINGS IMPRESSION
The right kidney is surgically absent S/P RIGHT NEPHRECTOMY.
The left kidney is normal in size and PERSISTENT MILD

echo pattern measuring about URETEROHYDRONEPHROSIS.
10.89 x 4.74 cm with cortical NON-VISUALIZATION OF THE
thickness of 1.35 cm. There is PREVIOUSLY NOTED LITHIASIS IN THE
persistent dilatation of the left URETEROVESICAL JUNCTION.
pelviccalyceal system and entire
length of the left ureter. The
previously noted lithiasis in the left
ureterovesical junction is no longer
appreciated in the study.
CONSIDER HEMATURIA, PYURIA OR
The urinary bladder is physiologically URINE SEDIMENTS. CORRELATE WITH
distended with an estimated volume URINALYSIS.
of 169mL. The wall is not thickened.
Low level intralumina echoes seen.
37
CHEST PAL: August 15, 2020
FINDINGS IMPRESSION
Heart is not enlarged. The aorta is ATHEROSCLEROSIS THORACIC

sclerotic. AORTA.
The lung fields are clear. Hemi SPONDYLOSIS THORACIC SPINE

diaphragms and sulci are intact.
There are osteophytes at the TRACHEA DEVIATED TO THE RIGHT

thoracic spine. RAISING THE POSSIBILITY OF A
Trachea is deviated to the right. THYROID MASS LEFT WITH
INTRATHORACIC EXTENSION.
CERVICAL APL: August 17, 2020
FINDINGS IMPRESSION
The cortical outlines are intact. UNREMARKABLE STUDY

No demonstrable fracture or
dislocation noted.
No lytic or blastic focus seen
Pedicles, processes and
intervertebral spaces are intact.
The soft tissues are unremarkable.
IJ catheter is seen in the right.
NECK ULTRASOUND: August 18, 2020
FINDINGS IMPRESSION
The right lobe of the thyroid gland WELL DEFINED COMPLEX

measures about 4.98 x 1.95 x 1.61cm PREDOMINANTLY CYSTIC MASS
while the left lobe measures about ALMOST REPLACING THE LEFT
4.6 x 3.23 x 3.50 cm. The right lobe THYROID LOBE.
shows homogeneous echo pattern. SHORT INTERVAL FOLLOW-UP STUDY
There is a well-defined complex OR BIOPSY MAY BE DONE
mass predominantly cystic that
38
almost replacing the entire left lobe
measuring around 3.03 x 3.21 x 3.34
cm. No discrete mass lesion in the
right thyroid lobe. The isthmus is
grossly unremarkable measuring 0.38
cm.
No enlarged lymph nodes are NORMAL RIGHT THYROID LOBE

identified in the submental region
and in both sides of the neck. Small
subcentimeter nodes are noted
bilaterally but without abnormal
calcification or areas of necrosis.
The parotid and submandibular NO ENLARGED LYMPH NODES SEEN

glands appear normal. Small
intraparotid lymph nodes are also
seen.
39
IV. PATHOPHYSIOLOGY
A. Narrative Pathophysiology
Patient IB is a 68 year-old female, admitted on August 15, 2020 at
1:16 AM at Maria Reyna- Xavier University Hospital. She had been
diagnosed with (1) uremia secondary to acute kidney infection on top
of chronic kidney disease secondary to obstructive uropathy and (2)
complicated UTI. The predisposing factor consists of an advanced age
of 68 years old and gender which is female. Precipitating factors
include sedentary lifestyle and prescription of multiple medications.
The Patient presented with acute kidney injury (AKI), also known
as acute renal failure (ARF). This is a sudden episode of kidney failure or
kidney damage that happens within a few hours or a few days. AKI
causes a build-up of waste products in your blood and makes it hard
for your kidneys to keep the right balance of fluid in your body. Acute
kidney injury can often occur due to nephrolithiasis or kidney stones.
These kidney stones can block the collecting system which will result in
obstructive uropathy causing the urine to flow back to the kidneys. This
mechanism of urine reflux resulted in the patient manifesting chronic
kidney disease or also known as CKD. Chronic kidney disease (CKD) is
an umbrella term that describes kidney damage or a decrease in the
glomerular filtration rate (GFR) for 3 or more months (Thomas-Hawkins &
Zazworsky, 2005). CKD is associated with decreased quality of life,
increased health care expenditures, and premature death. Untreated
40
CKD can result in end-stage renal disease (ESRD) and necessitate renal
replacement therapy (dialysis or kidney transplantation)
Thyroid ultrasound showed a well-defined complex
predominantly cystic mass on the left thyroid gland. The increasing size
of this cystic mass stimulates the parathyroid hormone, which is located
just behind the thyroid glands, to release parathyroid hormone. Once
PTH is released, it commands the osteoclast to do its job. The osteoclast
has a vital and unique function, mobilizing massive quantities of
calcium from mineralized cartilage or bone by walling off and
acidifying the tissue. This initiation of bone breakdown for calcium
release increases the serum calcium in the blood. This mechanism
usually happens in order to compensate for a detected decrease of
serum calcium in the blood but in this case, it is mediated by the
abnormal development of a cystic mass. The increased serum calcium
in the blood triggers supersaturation of urine with stone forming
constituents such as calcium and phosphate ions which activates the
physico-chemical change in the state of supersaturation and
promoting crystal aggregation and growth thereby the formation of
crystals or renal stones.
The initiation of bone breakdown for calcium release also
predisposes the formation of spondylosis thoracic spine in the patient in
a process that is initiated by a shock on the absorbing discs between
each vertebrae bone and the cartilage starts to wear away resulting to
41
bone rubbing on bone. To confirm this diagnosis, the patient’s chest
PAL X-ray showed (+) spondylosis thoracic spine. In order to
compensate, the body stimulates the release of osteoblasts to build
new bones in the presence of osteophytes, which are bony lumps
(bone spurs) that grow on the bones of the spine or around the joints.
On the other hand, the increased serum calcium in the blood allows
excess calcium to buildup in arteries leading to a formation of plaques
and eventually complicates the development of atherosclerosis
thoracic aorta which was confirmed through chest PAL x-ray.
Moreover, the crystal formation prompts the development of
nephrolithiasis. These renal calculi start to freely flow in the entire urinary
system and eventually dislodge to the left ureterovesical junction
leading to an obstructive uropathy. The onset of the obstructive
uropathy blocks the flow of urine which enables urine to be
accumulated in the left ureter attracting the colonization of pathogens
in the ureterovesical junction and periphery which leads to the
development of complicated UTI. This was later confirmed through a
urinalysis with the results showing that the patient has a high WBC count
of 206/uL accompanied by intermittent fever, indicating an infection.
The onset of obstructive uropathy that blocks the flow of urine
leads to the development of postrenal acute kidney injury. This occurs
because of the obstruction in the urinary flow. Because of the
blockage, there is a backflow of urine back to the kidneys. The rise in
42
ureteral pressure leads to changes in renal blood flow where there is
insufficient oxygen supply. This leads to endothelial damage confirmed
through the patient’s urinalysis that showed hematuria with a RBC
count of 24/uL. Then leukocytes are activated and there is an
inflammatory response causing the swelling and dilation of the ureter
and pelvis of the left kidney. KUB ultrasound showed there is a
development of mild ureterohydronephrosis. Consequently, due to the
reduced renal function, the production of erythropoietin is decreased.
This influences the reduced production of red blood cells by the bone
marrow. Thus, there is a low RBC in the body, causing the patient to be
pallor and experience anemia.
In an effort to excrete urine, the fluid in the glomerular capsule
creates pressure pushing fluid out of the glomerular capsule back into
the glomerulus. With this, there is an increased pressure on the
Bowman’s capsule and decrease in glomerular filtration rate. If low GFR
is present, there is decreased fluid flow. The fall in the blood pressure of
the arteriole initiated the secretion of renin by the juxtaglomerular cells.
Then, the renin enters the blood circulation. Through the renin, there is a
conversion of angiotensinogen, a protein released by the liver, to form
angiotensin I. After which, the angiotensin converting enzyme in the
lungs further metabolizes angiotensin I to angiotensin II. The effects of
angiotensin II are vasoconstriction and release of aldosterone from the
adrenal medulla. Aldosterone is a steroid hormone that causes an
43
increase in sodium reabsorption and sodium retention, resulting in an
increase in plasma/fluid. With this, there is an occurrence of pulmonary
interstitial edema that is from the leakage of fluid caused by increased
microvascular permeability. Due to the lungs’ compensatory
mechanism to metabolic acidosis and continued, repeated injury to
the bronchial tree, there is an inflammatory response where the
increased capillary permeability results in edema of mucous
membrane. In that case, there is a hypersecretion of mucus and
persistent cough where the mucus is trapped in the airway which
resulted in the development of chronic bronchitis.
The vasoconstriction and increase in plasma fluid caused by the
aldosterone, prompted the increase in blood pressure in which the
patient presented a BP of 125/91 mmHg along with tachycardia. In
hypertension, there is a reduced number of arterioles/capillaries in the
vascular bed, affecting the tissue perfusion and thereby reducing the
renal tissue perfusion. In consequence, the kidneys are unable to filter
and excrete metabolic waste which causes the patient to have dry
skin and experience hyperesthesia. Then, there is a retention of
nitrogenous wastes and buildup of uremic toxins in the body that led
into the occurrence of uremia, a condition of having high levels of urea
in the blood.
In an attempt to control the severity and complications from
arising, medical and pharmacological management were provided to
44
the patient by administering the following: Furosemide (Lasix) 40mg
1CAP BID, PO to treat elevated blood pressure and fluid retention as
evidenced by generalized edema. Kalium Durule 1 tab TID, was
ordered as an electrolyte replenisher for potassium.Treatment for the
increase levels of blood urea nitrogen (BUN) and Creatinine, NaHCO3
650mg 1 tab TID, PO and Clonazepam (Rivotril) 2 mg, ½ tab, OD, PO
were ordered. Ketoanalogue (Renalog) 2 mg TID PO an essential
amino acid and Sodium Chloride (Slo-Salt) 1 tab TID, PO an electrolyte
replenisher for sodium, both are used to treat complications caused by
AKI. In addition, EPO 6000 IV SQ 1x/week, and Ferrous Sulfate + Folic
Acid 1 tab OD, to treat the decreased production of erythropoietin
that leads to low red blood cells and to treat hematuria with acute
kidney injury. Omeprazole 40 mg 1 tab OD to treat metabolic acidosis.
Meropenem 500mg IV q12h ANST(-), Levofloxacin 250mg 1 tab, OD,
q48h, and Paracetamol 500 mg, 1tab, Q6h PRN for Fever, PO, was
ordered to treat intermittent fever as an inflammatory response of the
body during infection. Atorvastatin (Lipitor) 20mg, 1 tab, OD, PO, was
given as a prophylaxis of cardiovascular events such as MI, fatal and
nonfatal strokes, angina and heart failure related to atherosclerosis.
Levocetirizine + Montelukast (Stelix) 10/5mg tab OD, was also
administered to reduce bronchial inflammation and treat chronic
bronchitis. And Ambroxol 75mg 1 cap OD, 6PM, PO, for bronchial
infection, as well as to reduce the bronchial secretions.
45
When the kidneys are unable to keep up with the waste and
fluid clearance they can develop to a complete or near-complete
kidney failure at which dialysis or a kidney transplant are the two most
important management for the patient. A donated kidney can come
from a close relative or a friend or someone who had recently died. But
a patient must be assessed prior to surgery to ensure that the transplant
surgery will not be more harmful than helpful to the patient.
46
B. Schematic Diagram
47
48
49
V. MEDICAL MANAGEMENT
August 15, 2020
− Labs: Urinalysis, Chest PAL
− (+) Loss of appetite − Repeat Crea Post-HD
− (+) Epigastric pain − Elevate lower extremities
− Obtained informed consent
for Hemodialysis and CT

PRE-HD
Stonogram
− Weight: 60 kg
− I&O Q shift
− BP: 130/80 mmHg
− HR: 89 bpm
− IVF: PNSS 1L 10 cc/hr IV
− RR: 22 cpm
− Omeprazole 40 mg 1 tab OD,
− Temp: 36.7 C
6AM
− O2 Sat: 99%
− Ketoanalogue (Renalog) 2 mg
TID PO
POST-HD
− NaHCO3 650mg 1 tab TID, PO
− Weight: 60 kg
− Furosemide (Lasix) 40mg 1CAP
− BP: 110/60 mmHg
BID, PO
− HR: 100 bpm
− Ferrous Sulfate + Folic Acid 1
− RR: 20 cpm
tab OD
− Temp: 36.7 C
− Atorvastatin (Lipitor) 20mg, 1
− O2 Sat: 99%
tab, OD, 8PM, PO
− NaCl 1 tab, TID
50
− EPO 6000 IV SQ 1x/week
August 16, 2020
6AM
tab OD
tab, OD, 8PM, PO
− NaCl 1 tab, TID
− Sodium Chloride (Slo-Salt) 1
tab TID, 8AM, 1PM, 6PM, PO
− Levocetirizine + Montelukast
(Stelix) 10/5mg tab OD
− Clonazepam (Rivotril) 2 mg, ½
tab, OD, 8PM, PO
− Meropenem 500mg IV q12h
ANST(-)
− Ambroxol 75mg 1 cap OD,
6PM, PO
− Paracetamol 500 mg, 1tab,
Q6h PRN for Fever, PO
August 17, 2020
51
− Labs: Cervical APL
6AM
tab OD
tab, OD, 8PM, PO
− NaCl 1 tab, TID
tab, OD, 8PM, PO
ANST(-)
6PM, PO
August 18, 2020
− Lab: Neck Ultrasound
− Secured consent for referral
for urologic intervention
52
6AM
tab OD
tab, OD, 8PM, PO
− EPO 6000 IV SQ 1x/week
tab, OD, 8PM, PO
ANST(-)
6PM, PO
August 19, 2020
(-) Fever − Labs: Ultrasound Kidneys /
(-) vomiting, nausea Ureters / Urinary Bladder (KUB)
(+) Cough − For repeat CBC, UA for AM
- HR: 83 bpm
- RR: 21 cpm − Omeprazole 40 mg 1 tab OD,
6AM
53
12:00 NN − Atorvastatin (Lipitor) 20mg, 1
− Temp: 38.1 C tab, OD, 8PM, PO

4:00 PM
− Temp: 37.7 C
ANST(-)
6PM, PO
August 20, 2020
− Defer ordered CBC in AM
5:20 AM − AD Updated
− (-) SOB − For urine GS/CS
− (-) Chest Pain
− IVF: PNSS 1L 20 gtts/min IV

− (-) Dizziness
− Awake, coherent
6AM
7:36 AM − NaHCO3 650mg 1 tab TID, PO
− (+) Cough ↓ − Ferrous Sulfate + Folic Acid 1
tab OD
− (+) Febrile episodes
− Levofloxacin 250mg 1 tab,
− (-) Dysuria
OD, q48h
− (-) SOB
54
− (-) Chest Pain ANST(-)
− Furosemide (Lasix) 40mg 1CAP

− Awake, oriented
BID, PO
− Pinkish conjunctiva
− Clear breath sounds tab, OD, 8PM, PO
− Regular rate & rhythm
− Full pulses
− Flabby, soft, non-tender 6PM, PO
− No edema
August 21, 2020
− Ff-up Lab results
− Ff-up urine culture result

7:35 AM
− ↑ IVF to 25 gtts/min
− (-) Chest pain
− CT Stonogram result noted
− (-) SOB
− (-) fever
− IVF: PNSS 1L @ 20 gtts/min
− (-) abdominal pain − Omeprazole 40 mg 1 tab OD,
6AM
− (+) better appetite
− awake, oriented
55
- Temperature: 37.2 C tab OD
- RR: 22 cpm − Meropenem 500mg IV q12h
- HR:74 bpm ANST(-)
- BP: 130/60 − Furosemide (Lasix) 40mg 1CAP
- Pinkish conjunctiva BID, PO
- Clear breath sounds − Atorvastatin (Lipitor) 20mg, 1
- Regular rate & rhythm tab, OD, 8PM, PO
- No edema − Levocetirizine + Montelukast
- Non-tender (Stelix) 10/5mg tab OD
- Full pulses − Ambroxol 75mg 1 cap OD,
6PM, PO
8:00 PM
− Temp: 37.9 C
August 22, 2020
- (+) Febrile episodes − IVF: PLR 1L 20 gtts/min IV
- ↓ Dry cough − Ferrous Sulfate + Folic Acid 1
tab OD
- BP: 120/70
- HR: 67 bpm
tab, OD, 8PM, PO
- RR: 18 cpm − EPO 6000 IV SQ 1x/week
- O2 Sat: 97%
- Pinkish conjunctiva
56
- Clear breath sounds 6PM, PO
- Regular rhythm
PRE-HD
− Weight: 63.6 kg
− BP: 120/80 mmHg
− HR: 68 bpm
− RR: 19 cpm
− Temp: 36.9 C
− O2 Sat: 99%
POST-HD
− Weight: 62.2 kg
− BP: 120/70 mmHg
− HR: 97 bpm
− RR: 19 cpm
− Temp: 36.9 C
− O2 Sat: 99%
August 23, 2020
- Repeat UTZ of KUB after 2-3
12:00 AM weeks
− Temp: 37.6 C − FF-up once with repeat UTZ
− Ff-up: Next HD on wednesday
57
6AM
ANST(-)
− Furosemide (Lasix) 40mg 1tab
BID, PO
− Kalium Durule 1 tab TID
58
VI. DRUG STUDY
Generic Name Dosage, Classification Indications Mechanism of Action Side Effects Nursing Considerations
(Brand Name) & Timing, and General Class Enumerate and Illustrate
Date Ordered Route and Family underscore specific
indication
Furosemide 40mg 1CAP Therapeutic ● Edema Inhibits sodium and CNS: vertigo, ● To prevent nocturia,
(Lasix) BID Class: ● Hypertension chloride reabsorption headache, give early in morning
8am/6pm, Antihypertensive at the proximal and dizziness, and give second dose
8/15/2020 PO s distal tubules and the paresthesia, 6 to 8 hours after
ascending loop of weakness, morning dose in the
(hold if SBP Pharmacologic Henle. restlessness, fever early afternoon
<90 mmHg) Class:
Loop diuretics CV: orthostatic ● Store tablets in light-
hypertension resistant container to
prevent discoloration
EENT: transient
59
deafness, blurred ● Monitor BP, weight,
or yellowed and pulse rate
vision, tinnitus routinely
GI: abdominal ● Stop drug if oliguria or
discomfort and azotemia develops
pain, diarrhea,
anorexia, ● Monitor fluid intake
nausea, and output,
vomiting, electrolyte, BUN, and
constipation, carbon dioxide levels
pancreatitis frequently
GU: azotemia, ● Watch for signs of
nocturia, hypokalemia
polyuria,
frequent ● Consult dietitian about
urination, oliguria a high-potassium diet
60
Hematologic: ● Monitor uric acid level
agranulocytosis,
aplastic anemia, ● Monitor elderly
leukopenia, patients, who are
thrombocytopeni susceptible to
a, anemia excessive diuresis,
because circulatory
Hepatic: Hepatic collapse and
dysfunction, thromboembolic
jaundice complications are
possible
Metabolic:
volume ● Monitor patients with
depletion and severe symptoms of
dehydration, urine retention
asymptomatic
hyperuricemia,
61
impaired glucose
tolerance,
hypokalemia,
hypochloremic
alkalosis,
hyperglycemia,
dilutional
hyponatremia,
hypocalcemia,
hypomagnesemi
MS: muscle
spasm
Skin: dermatitis,
purpura,
photosensitivity
62
reactions, toxic
epidermal
necrolysis,
Stevens-Johnson
syndrome,
erythema
multiforme
63
(Brand Name) & Timing, and General Class
Date Ordered Route and Family
Ketoanalogue 2 mg TID PO Therapeutic ● Prevention Ketoanalogues are Hypercalcemia ● Document
(Renalog) Class: and therapy transaminated to the may develop administration of the
8 AM, 1PM, Ketoanalogues of damages corresponding drug
8/15/ 2020 6PM and Amino due to faulty essential amino acids
Acids or deficient by taking nitrogen ● Instruct patient to report
protein from non-essential immediately if
Pharmacologic metabolism in amino acids, thereby symptoms of
class: chronic renal decreasing the hypercalcemia occurs
Nutritional disease in formation of urea by like muscle weakness,
supplement connection re-using the amino constipation
with limited group. Hence, the
protein in accumulation of ● Monitor calcium levels.
food of < 40g uraemic toxins is Signs of hypercalcemia
day in reduced. This and electrolyte levels.
patients with normalizes metabolic
64
GFR <25 processes, promoting ● Monitor vital signs
mL/min recycling product especially cardiac
exchange, and changes.
reduces ion
concentration of ● Monitor electrolyte
potassium, levels, especially serum
magnesium, and calcium levels
phosphate. periodically
● Explain therapeutic
value of drug
● Assess allergy to the
drug
● Caution patient of the
different side effects
65
● Assess vital signs
● Proper preparation of
the drug especially
cardiac changes
● If hypercalcemia
occurs, reduce intake
of Vitamin D
● In case of persisting
hypercalcemia, the
dose of the product as
well as the intake of any
other calcium sources
has to be reduced.
66
indication
Ambroxol 75mg 1 cap Therapeutic ● Chronic Enhances pulmonary GI: Nausea, ● Monitor for signs and
OD, 6PM, Class: Bronchial surfactant production vomiting, symptoms of aspiration
8/16/ 2020 PO Mucolytic Infection and stimulates ciliary diarrhoea, of excess secretions,
● Secretolytic activity. These actions dyspepsia, dry and for bronchospasm
Pharmacologic therapy in acute result in improved mouth or throat, and withhold drug and
Class: and chronic mucus flow and abdominal pain, notify physician
Aromatic amine bronchopulmon transport. heartburn immediately
ary diseases Enhancement of fluid
associated with secretion and Rarely: ● Assess the quantity and
abnormal mucus mucociliary clearance anaphylactic consistency of sputum
secretion and facilitates reactions to help document
impaired mucus expectoration and (anaphylactic whether this drug is
support eases cough. shock, successful in reducing
angioedema, the viscosity of
67
rash, urticaria, respiratory secretions
pruritus).
● Obtain laboratory test:
Arterial blood gases
and pulmonary
function status
● Monitor vital signs
especially pulse
oximetry
● Ensure that suction
apparatus is readily
available in case
increased volume of
respiratory fluid occurs
to establish and
maintain an open
68
airway
● Assess client for
difficulty with clearing
airway or if respiratory
distress occurs
69
indication
Sodium Chloride 1 tab TID, Therapeutic ● Prevention of or Sodium is a major CNS: ● Assess for allergic
(Slo-Salt) 8AM, 1PM, Class: Electrolyte management of cation in extracellular headache, reactions
6PM, PO replacements volume fluid and helps dizziness,
8/16/ 2020 depletion due to maintain water restlessness, ● Assess fluid balance
Pharmacologic salt restriction or distribution, fluid and irritability, and throughout therapy
Class: heat prostration electrolyte balance, weakness
Sodium salt when excessive acid-base equilibrium, ● Assess for symptoms
sweating occurs and osmotic pressure. CV: congestive of hyponatremia or
during exposures Chloride is a major heart failure, hypernatremia
to high anion in extracellular pulmonary
temperature fluid and is involved in edema, edema, ● Monitor serum
maintaining acid- tachycardia, sodium, potassium,
base balance. hypertension bicarbonate, and
Solutions of NaCl chloride
70
resemble extracellular F and E: concentrations and
fluid. Reduces corneal hypernatremia, acid-base balance
edema by an osmotic hypokalemia, periodically when
effect. thirst, reduced receiving prolonged
salivation, and therapy
lachrymation
Therapeutic effect: IV,
● Explain to patient
PO: Replacement in
Local: IV – the purpose of the
deficiency states and
extravasation, medication
maintenance of
irritation at IV
homeostasis.
site ● Advise patients at
risk for dehydration
Potentially fatal: due to exposure to
Intra-amniotic inj extreme
of hypertonic temperatures when
solutions: DIC, and how to take
renal necrosis, NaCl tablets
cervical and
71
uterine lesions, ● Explain to patients
pulmonary that undigested
embolism, tablets may be
pneumonia, passed in the stool
and death
72
indication
Levocetirizine + 10/5mg tab Levocetirizine ● Used in the It blocks the action of Montelukast ● Do not use it for
Montelukast OD 8pm Therapeutic systemic leukotriene D4 in the Dyspepsia, reversal of an acute
(Stelix) HS(bedtime Class: treatment of lungs resulting in abdominal pain, asthmatic attack.
) Antihistamines obstructive decreased rash, dizziness,
8/18/ 2020 airway inflammation and headache, ● Assess allergy
Pharmacologic diseases such relaxation of smooth fatigue, fever, symptoms (rhinitis,
Class: as chronic muscle. trauma, cough, conjunctivitis, hives)
H1-receptor bronchitis nasal before and
antagonist ● Reduces congestion, flu. periodically during
Montelukast bronchial therapy.
Therapeutic inflammation Levocetirizine
Class: Somnolence, ● Assess lung sounds
Antiasthmatic fatigue, and character of
nasopharyngitis, bronchial secretions.
73
Pharmacologic dry mouth &
Class: pharyngitis. ● Maintain fluid intake
Leukotriene of 1500–2000
receptor mL/day to decrease
antagonists viscosity of
secretions.
● Administer drug on
an empty stomach,
1 hour before or 2
hours after meals, to
increase the
absorption.
● Have patient void
before each dose to
decrease urinary
retention
74
● Advise patients not
to exceed the
recommended dose
or frequency of
administration.
● Instruct patient and
family/caregivers to
report other
troublesome side
effects, including
severe or prolonged
headache, fever,
cough, ear pain,
sinus inflammation,
nasal discharge, skin
rash, or GI problems
75
indication
EPO 6000 IV SQ Therapeutic ● Anemia Stimulates CNS: Seizures, ● Assess for allergic
1x/week Class: associated erythropoiesis, headaches reactions
8/18/ 2020 Antianemics with chronic maintains and may
renal failure elevate RBC’s, CV: ● Monitor blood
Pharmacologic and decreasing the need hypertension, pressure before and
Class: decreased for transfusions thrombotic during therapy to
Hormones production of events such as prevent
EPO myocardial hypertension
infarction or
stroke ● Monitor for
symptoms of
Derm: transient anemia
rashes
● Obtain laboratory
76
Endo: restored tests:
fertility, Assess serum ferritin,
resumption of transferrin, and iron
menses levels for need of
concurrent iron
Misc: increased therapy
mortality and
increased tumor ● Monitor hematocrit
growth before and twice
weekly during initial
therapy
● Monitor renal
function studies and
electrolytes closely
● Explain to the
patient the
77
importance of
compliance with
dietary restrictions,
medications, and
dialysis
● Explain rationale for
concurrent iron
therapy
78
indication
Atorvastatin 20mg, 1 Therapeutic ● Prophylaxis of Inhibits HMG-CoA CNS: ● History: Allergy to
(Lipitor) tab, Class: cardiovascular reductase, the Headache, atorvastatin,
OD 8 pm, Antilipemics events such as enzyme that insomnia fungal byproducts
8/20/20 PO MI, fatal and catalyzes the first
Pharmacologic nonfatal strokes, step in the EENT: ● Physical:
Class: angina and cholesterol synthesis nasopharyngitis Orientation, affect.
HMG – CoA heart failure pathway, resulting in , Muscle strength;
reductase related to a decrease in serum pharyngolaryn liver evaluation,
inhibitor atherosclerosis cholesterol, serum geal pain abdominal
LDLs (associated examination, lipid
with increased risk of GI: Flatulence, studies, LFTs, renal
CAD), and increases abdominal function tests
serum HDLs pain cramps,
(associated with constipation, ● Before treatment,
79
decreased risk of nausea, assess the patient
CAD) dyspepsia for underlying
causes for
Increases hepatic GU: UTI hypercholesterole
LDL recapture sites, mia and obtain a
enhances reuptake Skin: rash baseline lipid
and catabolism of profile.
LDL Musculoskeleta
l: ● Patient should
Lowers triglyceride Rhabdomyolysi follow a standard
levels s with acute cholesterol-
renal failure, lowering diet
arthralgia,
myalgia, ● Watch for signs of
extremity pain, myositis and
muscle spasms, myopathy
musculoskeletal (unexplained
pain muscle pain,
80
tenderness,
weakness,
malaise, dark
urine, fever). Drug
may need to be
discontinued
● Teach the patient
about proper
dietary
management,
weight control,
and exercise.
Explain their
importance in
controlling high fat
levels
81
● Tell patient to
inform prescriber
of all adverse
reactions, such as
muscle pain,
malaise, and fever
● Administer drug
without regard to
food, but at the
same time each
day, do not drink
grapefruit while
taking this drug
● Inform patient of
expected side
effects.
82
Generic Name Dosage, Classification Indications Mechanism of Side Effects Nursing Considerations
(Brand Name) & Timing, and General Class Enumerate and Action
Date Ordered Route and Family underscore specific Illustrate
indication
Plain Saline 1L 10 cc/hr Crystalloid Fluid ● Extracellular fluid Sodium ions are Fluid overload ● Assess level of IV fluid
Solution IV; replacement integral in the leading to and check and
1L 20 (dehydration, distribution of fluids pulmonary regulate the drop rate
8/15/2020; gtts/min IV hypovolemia, and other edema
8/20/2020 sepsis) electrolytes. ● Identify correct
● Mild sodium Chloride serves a Febrile response solution, medication
depletion role as a buffering and volume
agent within the Infection at the
lungs and tissues. site of injection ● Assess IV site insertion
Chloride promotes for swelling, redness
hemoglobin Venous and warmth
bonding between thrombosis, or
oxygen and carbon phlebitis ● Do periodic
83
dioxide. These ions extending from assessments of
are primarily the site of patient’s clinical and
controlled by the injection, laboratory findings
kidneys, which, by
absorption or Extravasation ● Monitor for signs of
excretion inside the infiltration
tubules, control Hypervolemia
homeostasis. ● Observe findings that
Sodium sustains may indicate fluid
homeostatic status (peripheral
concentrations and edema, lung crackles,
the circulation of dry or moist oral
water within these mucosa)
compartments.
Without disrupting ● Monitor any changes
ion concentration in electrolyte
or triggering concentrations,
significant fluid volume status and
84
changes acid-base
disturbances
● Observe for elevated
lactate and creatinine
concentration
(indicates inadequate
amount of volume)
● Assess urine output
target of 0.5 mL/kg/hr
as it indicates
adequate hydration
85
indication
Clonazepam 2 mg, ½ Therapeutic ● Prophylaxis for Clonazepam CNS: Transient, ● Monitor addiction-
(Rivotril) tab, Class: uremia- reduces the nerve mild drowsiness prone patients
OD @ 8 pm Anticonvulsant induced transmission in the initially,depressio carefully because
8/16/2020 HS, Oral Pharmacologic seizures due to motor cortex which n, lethargy, of their
Class: excess toxins suppresses the spike fatigue, predisposition to
Benzodiazepine and wave discharge disorientation habituation and
in absence seizures. hostility, drug dependence.
Its mechanism is episodes of
believed to be mania and ● Monitor liver
related to its ability hypomania, function and blood
to enhance the confusion, counts periodically
activity of GABA. crying, in patients on long-
Clinically, it improves headache, term therapy.
focal epilepsy and slurred speech,
86
generalized seizures. dysarthria, ● Monitor patient for
stupor, rigidity, therapeutic drug
tremor, levels: 20–80 ng/mL
dystonia,
vertigo, ● Arrange for a
euphoria, patient to wear a
nervousness, medical alert ID
vivid indicating the
dreams,psycho patient has epilepsy
motor and is receiving
retardation, drug therapy.
CV: ● Avoid alcohol,
Bradycardia, sleep-inducing, or
tachycardia, CV OTC drugs
collapse,
hypertension ● Report severe
and dizziness, weakness,
87
hypotension, drowsiness that
palpitations, persists, rash or skin
edema lesions, difficulty
voiding,
Dermatologic: palpitations,
Urticaria, swelling in the
pruritus, rash, extremities.
dermatitis
● Taper dosage
EENT: Visual and gradually after
auditory long-term therapy,
disturbances, especially in
diplopia, patients with
nystagmus, epilepsy; substitute
depressed another
hearing, nasal antiepileptic.
congestion
88
GI:
Constipation,
diarrhea, dry
mouth,
salivation,
nausea,
anorexia,
vomiting,
difficulty in
swallowing,
gastric disorders,
GU:
Incontinence,
urinary
retention,
Hematologic:
89
Elevations of
blood
enzymes—LDH,
alkaline
phosphatase,
AST, ALT; blood
dyscrasias:
agranulocytosis,
leukopenia
90
indication
Paracetamol 500 mg, Therapeutic ● Mild pain or Antipyretic: CNS: Headache ● Assess patient’s
1tab, Class: fever fever or pain: type

8/16/2020 Reduces fever by CV: Chest pain
Q6h PRN Analgesics of pain, location,
acting directly on and dyspnea,
for Fever, (Non- intensity, duration,
the hypothalamic myocardial
PO opioid)/Antipyre temperature, and
heat-regulating damage when
tic diaphoresis.
center to cause ingested
vasodilation and frequently for a

Pharmacologic ● Assess allergic
sweating which long period of
Class: reactions: rash,
helps dissipate heat. time.
Para- urticaria; if these
GI: Hepatic
aminophenol occur, drugs may
Analgesic: Toxicity and
derivative have to be
Failure,
Inhibits CNS discontinued.
Jaundice
prostaglandin
91
synthesis resulting in GU: Acute renal ● Tell patient to notify
a diminished failure, renal prescriber for
transmission of pain tubular necrosis pain/fever lasting
impulses. for more than 3

Hematologic:
days
Methemoglobin
emia-cyanosis,
● Teach patient to
hemolytic
recognize signs of
anemia,
chronic overdose:
hematuria,
bleeding, bruising,
anuria,
malaise, fever, sore
neutropenia,
throat
leucopenia,
pancytopenia,
thrombocytope
● Contraindicated
nia,
with:
hypoglycemia
Hypersensitivity to
Hypersensitivity: acetaminophen,
92
Rash, Fever alcohol intake
● Use cautiously in:
Impaired hepatic
function,
alcoholism,
pregnancy,
lactation.
93
indication
Omeprazole 40 mg tab, Therapeutic ● Reduction of Binds to an enzyme CNS: dizziness,
(Omepron) OD, PO Class: risk of peptic- on gastric parietal drowsiness, ● Instruct the patient to
Gastric acid ulcer bleeding cells in the presence fatigue, swallow capsules
8/18/2020 suppressant or upper of acidic gastric pH, headache, whole, not to open,
gastrointestina preventing the final weakness chew or crush them.
Pharmacologic l bleeding in transport of And to take the drug
Class: uremia hydrogen ions into CV: Chest pain before meals
Proton pump patients the gastric lumen.
inhibitors (PPI) ● Treatment of Thus, it diminishes GI: abdominal
GERD-like accumulation of pain, acid ● Caution should be
symptoms acid in the gastric regurgitation, exercised in patients
associated lumen with lessened constipation, with hepatic
with uremia gastroesophageal diarrhea, impairment
reflux, and healing flatulence,
94
of duodenal ulcers nausea, ● Assess dizziness that
vomiting might affect gait,
balance and other
Dermatology: functional activities
itching, rash
● Advise patient to
Others: allergic avoid alcohol and
reactions foods that may cause
an increase in GI
irritation such as
coffee, acidic, fatty
and fried foods
95
indication
Ferrous sulfate + 525mg 1 Ferrous sulfate ● Treatment of Ferrous sulfate Ferrous sulfate ● GI upset may be
Folic acid tab OD, PO Therapeutic anemia Provides elemental GI: nausea, related to dose
Class: related to iron, an essential constipation,
8/18/2020 Iron supplement insufficient component in the black stools, ● Enteric-coated
EPO formation of diarrhea, GI products reduce GI
Pharmacologic ● Iron hemoglobin discomfort upset but also
Class: deficiency reduce amount of
Hematinic Folic acid Other: iron absorbed
Folic acid Stimulates normal Temporarily
Therapeutic erythropoiesis stained teeth ● Monitor
Class: from liquid forms hemoglobin level,
Vitamin hematocrit, and
Folic acid reticulocyte count
96
Pharmacologic GI: Anorexia. during therapy
Class: Nausea,
Folic acid flatulence, bitter ● Patients with small-
derivative taste bowel resections
and intestinal
Respiratory: malabsorption may
Bronchospasm need parenteral
administration
Skin: Rash,
pruritus, and
erythema
CNS:
Altered sleep
pattern, general
malaise,
confusion,
irritability
97
indication
Meropenem 500 mg , Therapeutic ● Complicated Inhibits cell wall CNS: Seizures, ● If seizures occur
(Gopenem) Q12H Class: urinary tract synthesis in headaches. during therapy,
ANST(-) IVTT Antibiotics infections bacteria. Readily stop infusion and
8/20/20 penetrates the cell GI: CDAD, notify the
Pharmacologic wall of most gram- constipation, prescriber. Dosage
Class: positive and gram- diarrhea, adjustment may be
Carbapenems negative bacteria glossitis, nausea, needed.
to reach penicillin- vomiting.
binding protein ● Monitor signs and
targets. Respiratory: symptoms of
Apnea, superinfection.
pneumonia. Drugs may cause
overgrowth of
Skin: Pruritus, nonsusceptible
98
rash. bacteria or fungi.
Other: ● Periodic assessment
Anaphylaxis, of organ system
sepsis, functions, including
hypersensitivity renal, hepatic, and
reactions, hematopoietic
inflammation, function, is
pain recommended.
● Monitor the
patient's fluid
balance and
weight carefully.
99
indication
Levofloxacin 250mg 1 Therapeutic ● Acute Inhibits the enzyme Common ● Closely monitor
8/20/2020 tab every Class: bacterial DNA gyrase in Reactions: patients with renal
48 hours OD Antibiotic worsening of susceptible gram- Nausea, insufficiency
PO chronic negative and headache, ● Assess for severe
Pharmacologic bronchitis gram-positive diarrhea, diarrhea, which
Class: ● Complicated aerobic and insomnia, may indicate
Fluoroquinolone Urinary Tract anaerobic constipation, pseudomembrano
Infections bacteria, interfering dizziness, us colitis
with bacterial DNA abdominal ● Watch for the
synthesis pain, vomiting, hypersensitivity
dyspepsia, reaction. D/C drug
tendinitis immediately if rash
or other s/sx occur
GI: ● Watch for s/sx of
100
pseudomembra tendinitis or tendon
nous colitis rupture
GU: vaginitis ● Tell the patient to
Hematologic: stop taking drug
lymphocytopeni and contact
a, eosinophilia, prescriber if he
hemolytic experiences s/sx of
anemia hypersensitivity
Metabolic:
hypoglycemia
Respiratory:
allergic,
pneumonitis,
dyspnea
101
indication
Sodium 650mg 1 Therapeutic ● Metabolic Raises blood and CNS: Tetany ● Record Intake &
Bicarbonate tab TID Class: acidosis urinary pH by Output accurately,
8am/1pm/6 Antacid ● Prevention of dissociation to CV: Edema daily weight, edema
8/15/2020 pm contrast provide and lung sounds
Pharmacologic media bicarbonate ions, GI: Gastric
Class: nephrotoxicity which neutralizes distention, ● Observe for dry skin
Alkalinizer hydrogen ion belching, and mucous
concentration flatulence membranes,
which reverses polydipsia, polyuria,
clinical Metabolic: and air hunger; may
manifestation of hypokalemia, indicate a reversal of
acidosis. metabolic metabolic acidosis
alkalosis,
hypernatremia, ● Chew the tablet
102
hyperosmolarity thoroughly and take
only as prescribed.
Skin: Pain and Follow with a full glass
irritation at of water. Don’t take
injection site with milk or yogurt
● Monitor serum calcium,
sodium and potassium
bicarbonate
concentration
● IV should be closely
monitored.
Extravasation should
be avoided to prevent
tissue irritation or
cellulitis
103
indication
Kalium Durule Therapeutic ● Prevention of Principal intracellular CNS: mental ● Give while the
1 tab TID PO
(potassium Class: hypokalemia cation; essential for confusion, patient is sitting up
chloride) 8am/1pm/6 Electrolyte & related to use maintenance of irritability, or standing (never
pm water balance of loop intracellular listlessness in recumbent
08/22/2020 agent diuretics isotonicity, position) to prevent
particularly, transmission of nerve CV: drug–induced

Pharmacologic
Lasix impulses, Hypotension, esophagitis. Some
Class:
contraction of bradycardia; patients find it
Potassium cardiac, skeletal, cardiac difficult to swallow
supplement and smooth depression, the large sized KCl
muscles, arrhythmias, or tablet.
maintenance of arrest; altered
normal kidney sensitivity to ● Do not crush or
function, and for digitalis allow to chew any
104
enzyme activity. glycosides. ECG potassium salt
Plays a prominent changes in tablets. Observe to
role in both hyperkalemia: make sure the
formation and Tenting patient does not
correction of (peaking) of T suck tablet (oral
imbalances in acid – wave(especially ulcerations have
base metabolism in right been reported if
precordial the tablet is
leads), lowering allowed to dissolve
of R with in the mouth).
deepening of S
waves and ● Swallow the whole
depression of tablet with a large
RST; prolonged glass of water or
P-R interval, fruit juice (if
widened QRS allowed) to wash
complex, the drug down and
decreased to start esophageal
105
amplitude and peristalsis.
disappearance
of P waves, ● Lab test: Frequent
prolonged Q-T serum electrolytes
interval, signs of are warranted.
right and left
bundle block, ● Monitor for and
deterioration of report signs of GI
QRS contour ulceration
and finally (esophageal or
ventricular epigastric pain or
fibrillation and hematemesis).
death.
● Monitor I/O
GI: Nausea,
vomiting, ● Monitor PR and
diarrhea, Cardiac rate.
abdominal Irregular heartbeat
106
distension is usually the earliest
clinical indication
GU: Oliguria, of hyperkalemia.
anuria
● The risk of
Hema: hyperkalemia with
Hyperkalemia potassium
supplement
increases (1) in
older adults
because of
detrimental
changes in kidney
function associated
with aging, (2)
when dietary intake
of potassium
suddenly increases,
107
and (3) when
kidney function is
significantly
compromised.
108
VII. NURSING CARE PLANS
Nursing care plan 1: Ineffective Airway Clearance
ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION
Objective Ineffective Short Term: Independent Independent Short Term:
 (+) Airway At the end of 30  Assessed  To evaluate the At the end of 30 minutes of
Chronic Clearance R/ T minutes of nursing respiratory rate, degree of nursing interventions, the
Bronchiti increased mucus interventions, the depth, and respiratory client was able to:
s production 2° client will be able to: sounds every 2 distress and the  Goal met: maintain
Infection chronic bronchitis  Demonstrate hours . Note use chronicity of the clear, open airways as
 RR: 22 AEB tachypnea, improved of accessory disease. evidence by
cpm pallor, and dry ventilation and muscles, clear breath sounds
 To ease the
 (+) Dry cough adequate inspiratory and and respiration depth:
work of
cough oxygen expiratory ratio. Respiratory Rate of
breathing and
 Pallor  Perform  Elevated head of 20cpm; O2 Saturation
promote lung
methods to the bed at least of 98%;
expansion; helps
enhance 45 degrees,  Goal met:
prevent
109
secretion assisting the pulmonary demonstrate methods
removal patient to congestion. in removing secretions
Long Term: assume proper  To provide some such as turning,
At the end of 8 hours body alignment means to cope diaphragmatic pursed-
of nursing  Encouraged with or control lip breathing, coughing,
interventions, the abdominal or dyspnea and and deep-breathing
client : pursed-lip reduce air-

Long Term:
 Ventilation and breathing trapping.
At the end of 8 hours of
oxygenation is exercises.  Ambulation
nursing interventions, the
adequate to  Assisted to turn, promotes lung
client was able to:
meet self care cough, and expansion,
 Goal met: acquire
needs deep breathe ventilation of all
adequate ventilation
 Show no signs every 2 hours. If lung segments ,
and oxygen to meet
of respiratory ambulatory, and mobilizes
self care needs
distress allow to secretions
 Goal met: exhibit chest
ambulate as  A discolored
PAL results that shows
110
tolerated sputum is a sign lung fields are clear
 Observed of infection;  Goal met: Free from
sputum, noting thick secretions signs of respiratory
color, odor, increase airway distress
thickness, and resistance.
volume.  To conserve
energy and
 Encouraged
avoid fatigue
frequent rest
and
periods and
overexertion
taught to pace
activity. Dependent
Dependent  Helps in aiding
 Administered effective airway
Ambroxol 75 mg, clearance
OD at 6 PM, PO through
excreting mucus
111
 Administered  Used in systemic
Levocetirizine + treatment of
Montelukast chronic
(Stelix) 10/5mg bronchitis
tab, OD at 8PM,
PO  May correct or
 Administered prevent
supplemental worsening of
oxygen as hypoxia
prescribed by
 To mobilize
physician.
bronchial
 Provided postural
secretions; used
drainage,
as prescribed
percussion and
because it do
vibration as
harm if cardiac
ordered.
disease is
112
Collaborative present
 Obtained serial Collaborative
graph ABG and  Monitor
chest x-ray. progression or
regression of
disease process
complications.
113
Nursing Care Plan 2: Decreased Cardiac Output
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Objective Decreased Short Term Independent Independent Short Term
 BP: 125/91 Cardiac At the end of 1  Monitored vital  Note for At the end of 1
 PR: 109 Output R/T hour of nursing signs and presence of hour of nursing
 RR: 22 cpm altered interventions, the assessed dysrhythmias interventions, the
 Pallor preload AEB client will be able peripheral pulse. and weak client was be able
 Edema edema, to: pulses are to:
 Intake greater than pallor,  Perform  Maintained related to  Goal met:
output tachycardia, activities activity restriction reduced Obtain
Intake: 2700 ml and that and encouraged cardiac output adequate
Output: 1130 ml increased reduce adequate rest in  Adequate rest amount of
 (+)Atherosclerosis blood blood bed with proper help rest through
thoracic aorta pressure pressure wi positioning. compensate CBR and
 (+)Acute Kidney thin normal  Assisted in slightly cardiac avoiding
Injury range elevating the changes and strenuous
114
 Achieve legs. decreases activities
adequate oxygen  Goal met:

 Closely
cardiac demand demonstrate
monitored fluid
output as d decreased
intake and  Elevation
evidenced BP to
output allows fluid to
by stable 110/60mmHg
drain away from
vital signs, ; PR = 97
 Monitored the body
palpable BPM; RR =
weight daily and
pulse of  Decreased 20 CPM;
assessed weight
equal urinary output palpable
gain or fluid
quality, without pulse of
volume deficit.
and usual decreased equal quality;
level of intake indicates and oriented

 Performed active
mentation decreased to time,
or passive range
renal perfusion. place, and
of motion
Long Term  Body weight is person.
exercises to all
At the end of 2
115
days of nursing extremities every an indicator of
interventions, the 2 to 4 hours fluid or sodium Long Term
client was will be  Position in semi- retention or loss, At the end 2 days
able to: Fowler’s or high- to facilitate the of nursing
 Showed Fowler’s position early interventions, the
absence of Dependent identification client was able to:
pallor and  Maintained complications  Goal met:
edema in the dietary  To foster muscle have warm,
extremities restrictions as strength and dry skin and
 Remains free ordered. tone, maintain negative
of side effects  Administered joint mobility, signs of
from the oxygen as and prevent edema
medications ordered contractures  Goal met:
used to  Administered  To reduce have
achieve Furosemide(Lasix venous return negative
adequate ) as prescribed signs of
Dependent
116
cardiac by a physician.  To prevent fluid orthostatic
output retention or hypertension,
Collaborative dehydration vomiting,
 Monitored  To increase diarrhea, and
serial12-Lead supply to restlessness
ECG and myocardium.
changes in  Common
serum creatinine medications
levels. include
diuretics,
vasodilator
therapy,
antidysrhythmics
, ACE inhibitors,
and inotropic
agents.
117
Collaborative
 Serial ECG help
determine the
heart changes
or damage;
serum CR levels
helps indicate
poor cardiac
output
118
Nursing Care Plan 3: Altered Renal Tissue Perfusion
Objective: Altered Renal Short Term: Independent: Independent: Short Term:
 BP: 125/91 Tissue Perfusion At the end of 2 hours of  Assessed general  To obtain At the end of 2
 HR: 109 bpm R/T glomerular nursing interventions, the condition, and baseline data hours of nursing
 (+) Acute malfunction 2° client will be able to: monitor and for monitoring interventions, the
Kidney Injury to chronic  verbalize record vital signs progress of client was able to:
 Right kidney kidney disease understanding of  Monitored BP and treatment  Goal met:
is surgically AEB edema, risk factors, ascertain usual interactively

 GFR may
absent, left increased therapy regimen, range asked
increase
kidney serum urea, side effects of  Measured intake questions
Renin and
compensates excess protein medications and and output, urine about the risk
raise BP.
and starts to in urine, and when to contact output regularly factors and
 To assess
deteriorate low rbc count healthcare and weight daily showed
renal
 Positive Fluid providers  Noted mental great interest
perfusion and
Balance  Demonstrate status and review in the
function
119
(Intake: increased lab results therapy
2700ml and perfusion as  Increase BUN regime by

 Monitored
Output: individually and expressing his
patient’s clinical
1130ml; appropriate creatinine concerns
status and
Intake Long Term: may alter about the
response to
greater than At the end of 8 hours of mentation side effects
dialysis therapy
output) nursing interventions, the  To ensure the of the
 Rendered health
 Hematuria client will be able to: patient is medications.
teachings such as:
(Urinalysis:  Demonstrate receiving safe  Goal met:
a. Avoid straining.
RBC - 24) behaviors and and effective manifest
b. Deep breathing
 Proteinuria lifestyle changes dialytic increased
exercises
(Urinalysis: to improve therapy. perfusion as
c. Eat foods rich in
Protein 1+) circulation  Improves well evidenced
iron
 Uremia  Manifest being and by a urine
Dependent:
 Edema electrolytes within promotes sodium level
 Administered
 Anemia, Low normal range and independenc of more than
fluids, electrolytes,
120
RBC urine output of nutrients and e 20 mEq/L.
more than 30 ml/ oxygen as  Goal met:
hr. indicated. demonstrate

Dependent:
 Manifest stable  Administered IVF the nursing
 to promote
hemoglobin and as ordered interventions
optimal
hematocrit values are effective
 Administered blood flow,
and their
Furosemide(Lasix) organ
condition is
as ordered perfusion and
gradually
 Administered EPO function.
improving.
6000 IU SQ 1 dose  Maintain
per week Circulating Long Term:
 Administered volume to At the end of 8
Ferrous Sulfate + maximize hours of nursing
Folic Acid 1 tab , tissue interventions, the
once a day perfusion client was able to:
 Transferred to  To flush out  Goal met:
121
Dialysis area for cellular debris demonstrate
routine treatment and increase proper deep
urine output breathing
Collaborative:  To promote exercise,
 Referred to a increased choosing the
dietician for well- production of meals rich in
balanced, low erythropoietin iron such as
saturated fat, low  To promote liver, red
cholesterol diet or increased meat, and
other production of spinach
modifications as RBC  Goal met:
indicated. express that

 The
they could
remaining
void more
kidney (left) is
frequently.
deteriorating,
dialysis is
122
needed to
filter wastes
and
electrolytes
Collaborative:
 To meet the
metabolic
demands of
the client
123
Nursing Care Plan 4: Impaired Urinary Elimination
Objective Impaired Urinary Short Term Independent Independent Short Term
 Proteinuria (Urinalysis: Elimination At the end of 2  Assessed the usual  Many are At the end of 2 hours of
Protein 1+) R/T urinary tract hours of nursing pattern of incontinent nursing intervention,
 Pyuria (U/A: WBC - obstruction 2° to intervention, the urination and only in the the patient was be
206) nephrolithiasis patient will be occurrence of early morning able to:
 Hematuria (Urinalysis: AEB hematuria able to: incontinence. when the  Goal Met:
RBC - 24) and bladder  Explain bladder has verbalize

 Noted condition
 Uremia distention understandin stored a large understanding of
of skin and
 Distended bladder g of the urine volume the condition
mucous
 (+) kidney stones condition during sleep. and that the
membranes, color
 (+) Complicated UTI and how it  To assess level kidney stone
of urine.
 Persistent Mild affects the of hydration. caused an
 Asked the client
Ureterohydronephrosi urinary obstruction
to keep a bladder
s function.  Reduces the  Goal Met:
diary/bladder log.
124
 Positive Fluid Balance  Verbalize  Avoiding caffeine clients verbalize
(Intake: 2700ml and cooperation and use of discrepancies cooperation and
Output: 1130ml; for treatment. aspartame, and in recalling understanding of
intake 1570ml greater limiting intake  Alcohol, the importance

Long Term
than output) during late coffee, and of finishing the
At the end of 8
evening and at tea have a antibiotic
hours of nursing
bedtime. natural treatment.
intervention, the
Recommend use diuretic effect
patient will be Long Term
of cranberry and are
able to: At the end 8 hours of
juice/vitamin C. bladder
 Improve nursing intervention,
Dependent irritants.
balanced the client was able to:
 Administered
I&O with  Goal
antibiotics such as
clear, odor- Met: Improved
Meropenem Dependent
free urine, balance I&O
(Gopenem)500  Prompt
decreased with clear, odor-
mg IV Q 12H and treatment of
bladder free urine,
125
distension. Levofloxacin the patient's decreased
250mg 1 tab Q complicated bladder
48H, as indicated UTI to prevent distension, and
by physician further output 350ml
 Obtained damage. greater than
periodic urinalysis input (Input:
and urine culture 2900ml, output:
and sensitivity as  These tests 3250ml)
indicated. monitor renal
status. Colony
count over
100,000
indicates
presence of
infection
requiring
126
treatment.
127
Nursing Care Plan 5: Fluid Volume Excess
Objective Fluid Volume Short Term Independent Independent Short Term
 BP: 125/91 excess R/T At the end of 2 hours of  Reviewed  Imbalances in At the end of 2
 HR: 109 bpm renal nursing interventions, nutritional these areas hours of nursing
 Edema insufficiency the client will be able status. also interventions, the
 Clear lung sounds 2° to renal to: contribute to client was be

 Weighed daily
 Intake greater obstruction  Verbalize fluid retention able to:
at the same
than output; AEB edema, awareness of  This provides a
time, in the  Goal Met:
Intake: 2700 ml, increased behaviors comparative
same amount Verbalized
Output: 1130 ml blood essential to baseline and
of clothing, and adhering
 (+)Acute Kidney pressure, correct fluid evaluates the
with the same to fluid
Injury tachycardia excess effectiveness
scale. and
 KUB ultrasound: , and intake of therapies.
 Explain  Evaluated sodium
Right Kidney is greater than  Signs of
measures that mentation for restrictions
surgically absent output. decreased
can be taken to confusion, as
 Left kidney cerebral
128
compensates and treat or prevent personality oxygenation behaviors
starts to fluid volume changes. (e.g., cerebral essential
deteriorate excess such as  Reposition q 2 edema) or to correct
 Persistent Mild low sodium diet, hours, inspect electrolyte fluid
Ureterohydronephr restricted liquid skin for redness . imbalance. excess
osis intake, daily  Set an  To prevent skin

 Goal Met:
weighing, and appropriate breakdown
Verbalized
exercise rate of fluid
 to prevent the
intake or
 Describe exacerbation importanc
infusion
symptoms that of excess fluid e of
throughout the
indicate volume and monitoring
24-hr period.
prompt consulta peaks and their diet
 Promoted skin
tion with a valleys in fluid and liquid
integrity of
healthcare level. intake
edematous
provider such as  Elevation paired
areas by
large shifts in allows fluid to with
frequent
129
weight, swelling, repositioning drain away weight
difficulty of and elevation from the watching
breathing and of areas where body; and daily
chest pains. possible. Avoid massaging res exercise.
massaging ults in further

 Manifest  Goal Met:
pressure points tissue trauma
alleviation of Described
or reddened
symptoms such warning
areas of skin
as blood pressure signs and
 Placed in Semi
and heart rate complicati
or High Fowler’s  To aid
returning to ons that
position breathing by
baseline come with
increasing
excess
Long Term chest
fluid such
At the end of 24 hours  Encouraged to expansion
as large
of nursing interventions, cough and and improving
shifts in
the client will be able deep breath ventilation
weight,
to: every 2 to 4  To prevent
130
 Exhibit a hours pulmonary swelling,
balanced intake  Note symptoms complications difficulty
and output of ventricular breathing,
 Perform hypertrophy  Fluid volume and chest
behaviors to (e.g peripheral excess may pains.
prevent excess or sacral cause heart
fluid volume edema, failure, as Long Term
 be respiratory rales, indicated by At the end 24
normovolemic as dyspnea, signs and hours of nursing
evidenced by orthopnea, symptoms of interventions, the
urine output distended neck respiratory or client was able
greater than or veins, and ECG systemic to:
equal to 30 changes) venous  Goal Met:
mL/hr, clear lung  Routinely congestion. Intake:
sounds, and (-) weighed, 2500,
edema. measured I&O, Output:25

 During
and monitored 00
131
BP and pulse hemodialysis,  Goal Met:
before and Hypertension Track fluid
after dialysis. and intake,
tachycardia follow fluid

Dependent
may result guidelines
 Administered
from fluid advised
Furosemide
overload. by doctor,
40mg 1CAP BID,
manage
PO as ordered
Dependent thirst with
Collaborative  To excrete the ice chips
 Consulted excess fluid and other
dietitians as low fluid
needed for food,

Collaborative
correct sodium weigh
 to develop
and potassium daily and
dietary plan
diet exercise
and identify
as
132
foods to be tolerated
limited or  Goal Met:
omitted Exhibit
urine
output of
40ml/hr,
clear lung
sounds,
and (-)
edema
133
Nursing Care Plan 6: Hyperthermia
Objective Hyperthermia Short Term: Independent: Independent: Short Term:
 Intermittent r/t At the end of 30  Assessed for any  Increased body At the end of 30
fever: inflammatory mins, the client will complaints or signs of temperature will mins of nursing
o 37.8 °C response to be able to: increased body show a variety of interventions, the
o 38.1 °C bacterial  Achieve an temperature changes symptoms such patient was able
o 37.7 °C invasion of the axillary as red eyes and to:
o 37.9 °C urinary system. temperature  Observed for elevated the body feels  Goal
o 37.6 °C below or vital signs, especially warm to touch. met: Have an
 HR: 109 equal to the axillary  To axillary
beats/min 37.5 °C. temperature, HR and determine and temperature
 U/A:  Identify BP readily apply below or
o WBC: ways to interventions that equal to 37.5

 Performed tepid
206/uL reduce help in reducing °C.
sponge bath
body hyperthermia  Increase fluid
 Encouraged client to
134
temperature increase fluid intake  Helps reduce intake and
.  Educated client of signs hyperthermia maintain cool
and symptoms of  Fluid loss temperature

Long Term:
hyperthermia and help contributes to in the room
At the end of 2
them identify factors fever, Water and remove
days, the client will
related to occurrence regulates body excess
be able to:
of fever ; discuss temperature clothing or
 Maintain ideal
importance of  Providing health bed covers.
values of Vital
increased fluid intake teachings to Long Term:
signs (HR, BP,
to avoid dehydration client could help At the end of 8
RR)
Dependent: client cope with hours of nursing
 Administered disease condition interventions, the
Paracetamol 500 and could help client was able to:
mg, 1tab, Q6h PRN, prevent further  Goal met:
as prescribed. complications of Maintained vital
 Start intravenous hyperthermia signs (Temp =
135
normal saline Dependent: 37C, BP=
solutions or as  Antipyretic acts 120/80mmHg
indicated. on and HR=76bpm)
Collaborative: hypothalamus, within normal
 Monitored and reducing limits.
conducted tests for hyperthermia
white blood cell  This is to replenish
(WBC) count. fluid losses during
shivering chills
 Referred to a Collaborative:
dietician to provide  An increasing
a high caloric diet or WBC count
as indicated by the indicates the
physician. body’s efforts to
 Discussed and combat
monitored pathogens; Very
136
nutritional status, low WBC count
weight, history of may indicate a
weight loss, and severe risk for
serum albumin. infection.
 To meet the
metabolic
demands of the
client
 Patients with
poor nutritional
status may be
anergic or
unable to muster
a cellular
immune response
137
to pathogens
making them
susceptible to
infection
138
Nursing Care Plan 7: Ineffective Thermoregulation
Objective: Ineffective Short Term: Independent: Independent: Short Term:
 Intermittent thermoregulation At the end of 4  Monitored for  Increase in At the end of 4
fever: R/T hormonal hours, the client will changes in vital heart rate hours, the client was
o 37.8 °C imbalance be able to: signs and blood able to:
o 38.1 °C secondary to  Achieve a pressure may  Goal met:
o 37.7 °C presence of left temperature accompany Achieve a

 Intake and
o 37.9 °C thyroid cyst below 37.5°C increasing temperature
output recorded
o 37.6 °C  Identify ways temperature. of 36.4°C
accordingly,
 HR: 109 to achieve  Fluid loss  Goal met:
and urged
beats/min lower contributes to verbalize
patient for
 Advanced temperature fever. ways to
increased fluid
age - 68 years through Hydration is achieve
intake
old changes in necessary for achieve lower
 Neck external  Attended to thermoregulat body
139
Ultrasound: factors patient’s needs: ion through temperatures
o Right lobe o Monitoring evaporative such as tepid

Long Term:
of thyroid environmental cooling. sponge bath,
At the end of 8
gland: 4.98 factors such as  Assisting the removing
hours, the client will
x 1.95 room patient allows excess
be able to:
x1.61cm temperature to the patient to clothing
 Maintain
o Left lobe of become have reduced
optimal Long Term:
thyroid conducive for activity which
thermoregulat At the end of 8
gland 4.6 x rest helps in
ion by hours, the client was
3.23 x o Eliminate lowering
maintaining able to:
3.50cm excessive temperature.
temperature  Goal met:
clothing and
within normal Maintain
covers
limits optimal
Dependent:
Dependent: thermoregulat
 Administered
 Antipyretic ion by
antipyretic
medication is maintaining
140
medication as indicated to temperature
prescribed lower body within normal
temperature limits (37 °C)
by acting
 Start IVF normal
upon the
saline solution,
synthesis of
regulated and
prostaglandin
monitored
s in the
hypothalamus
 To replenish
fluid loss and
to maintain
optimal
hydration
status
141
Nursing Care Plan 8: Chronic Pain
Objective Chronic Pain Short Term: Independent: Independent Short Term:
 (Lab Result : Chest related to At the end of 4 hours  Provided  Alternative At the end of 4 hours
PAL) Spondylo pressure on the of nursing comfort measures for nursing intervention,
sis Thoracic Spine surrounding intervention the measures pain control the patient was able
 (+) osteophytes nerves patient will be able (position are desirable to:
noted secondary to to: changes, for emotional  Goal met:
degeneration of  Report relief or massage, ROM benefit, to Verbalize relief or
joints and discs control of exercises, warm reduce pain control of
pain/discomfort or cold packs, medication pain/discomfort
 Identify ways to as indicated). need and  Goal met: Show
manage pain  Encouraged use undesirable interest in non-
of relaxation effects pharmacologic

Long Term:
techniques and  Cognitive- pain
At the end of 24 hrs
appropriate behavioral management
of nursing
142
intervention, the diversional strategies can techniques by
patient will be able activities restore a sense asking questions
to: of self-control, and ideas on
 Demonstrate  Instructed personal performing ways
relaxation skills patient to efficacy, and to manage pain
and diversional refrain from active such as position
activities as heavy lifting participation in changes,
individually and other their own care. massage, ROM
indicated. activities that  This might exercises, and
 Engage in require bending cause more relaxation
desired over or stooping stress to the techniques
activities  Provided back spine. Long Term:
without an support and At the end of 1 to 2
increase in pain teach proper weeks nursing
level. posture  Bad posture interventions, the
Dependent: may/can make patient was able to:
143
 Administered the pain worse.  Goal met: Perform
medication as non-
Dependent:
prescribed by pharmacologic
 May be desired
physician pain
to relieve
management
muscle spasm
Collaborative: techniques such
and pain
 Refer to a as relaxation skills
associated with
physical and diversional
spasticity or to
therapist for activities (deep
alleviate
assessment and breathing, music
anxiety and
evaluation. and art therapy,
promote rest.
massage etc.).
Collaborative:
 To help the
patient with
exercises to
promote
144
muscle strength
and joint
mobility,
therapies, and
relaxation
145
Nursing Care Plan 9: Fatigue
Objective: Fatigue R/T Short Term: Independent: Independent: Short Term:
 Pallor decreased At the end of 4 hours,  Provided a quiet  To promote At the end of 4
 Body production of the client will be able and warm adequate rest hours, the client
Weakne erythropoietin to: environment and restrict harsh was able to:
ss secondary to  Verbalize feeling during rest and environmental  Goal met:
 Body acute kidney less fatigued sleep; blankets, stimuli state she
malaise injury  Demonstrate closed curtains, feels less
energy saving eye mask  To reduce fatigue tired
techniques to  Assisted with ADLs and encourage compared
help decrease as necessary such independence before
fatigue as going to  Organization and  Goal met:
Long Term: bathroom management of Obtain
At the end of 2 days,  Educated on time can help adequate
the client will be able energy saving save energy and rest and
146
to: techniques such as avoid further sleep
 Show negative adequate sleep of fatigue

Long Term:
signs of pallor 7-8 hrs, simplifying
At the end of 2
 Establish and delegating
Dependent: days, the client
laboratory values tasks
 Provides was able to:
within the normal
elemental iron, an  Goal met:
range Dependent:
essential Have
 Administered
component in the decreased
Ferrous Sulfate +
formation of signs of
Folic Acid 525mg 1
hemoglobin pallor and
tab OD, PO
 Stimulates manifested
erythropoiesis, (+) pinkish

 Prescribed EPO
maintains and conjunctiva
6000 IV SQ
may elevate
1x/week
RBC’s  Goal met:
have Hgb
147
and Hct
within
normal
range 12.1
to 15.1 g/dL
and 36% to
48%,
respectively
148
Nursing Care Plan 10: Risk For Electrolyte Imbalance
Objective Risk for Short Term Independent Independent Short Term
 Ordered Electrolyte At the end of 2  Educated on the  To increase At the end of 2
Medication Imbalance hours of nursing cause of participation in hours of nursing
Lasix 40 mg (hypokalemia) interventions, the hypokalemia; treatment interventions, the
1 tablet BID R/T use of client will be able such as diuretic regimen. client was be able
PO diuretics 2° to to: use and renal to:
acute renal  Verbalize failure.  To identify and  Goal met:
injury. understandin  Monitored I & O monitor for Verbalize the
g on the by asking to keep imbalance in fluid signs and
causes of a daily record of intake and fluid symptoms of
hypokalemia intake and loss hypokalemia
and effects of output.  Abnormalities in such as leg
diuretic  Monitored heart heart conduction cramp, soft
therapy on rate and rhythm. and contractility and flabby
149
potassium are associated muscles, and
levels.  Instructed to eat with shallow
 Identify potassium rich hypokalemia. respirations
selection of foods like  Potassium Rich  Goal met:
foods rich in bananas, foods in the diet Adhere to
potassium. broccoli, green help maintain appropriate
leafy vegetables potassium dietary
but in a moderate balance sources suc

Long Term
amount. h as
At the end of 8
 Encouraged bananas,
hours of nursing  Respiratory muscle
deep breathing broccoli,
interventions, the weakness related
and coughing sweet
client will be able to hypokalemia
exercises. potatoes,
to: may progress to
and green
 Show lab paralysis leading
leafy
results of  Placed in supine to respiratory
vegetables.
serum or arrest
150
potassium Trendelenburg’s  Maximizes venous Long Term
range within position, PRN return if At the end of 8
normal range Dependent hypotension hours of nursing
 Administered occurs interventions, the
Kalium Durule 1 Dependent client was able to:
tab TID x 4 doses.  Potassium  Goal met:
supplement that is maintain

 Administered
indicated to treat serum
PNSS 1 Liter to run
hypokalemia. potassium
30 cc/hour.
 IV solution level within
Collaboration indicated for normal
 Monitored and source of range of 3.5-
conducted tests electrolytes and 5.5 mmol/L
for serum water for and
potassium. hydration. absence of
Collaboration signs and

 Referred with the
151
dietician to  To identify and symptoms
create a meal monitor progress in hypokalemia
plan suitable for the abnormality of .
health status. serum potassium
 Discussed the use  A balanced meal
of potassium plan replenishes
chloride salt electrolytes loss.
substitutes in
 KCl salts substitute
relation to long-
are
term use of
recommended
diuretics.
for receiving
diuretics to
replenish and
restore loss of
potassium
electrolytes
152
Nursing Care Plan 11: Risk For Injury
Objective Risk for Injury Short Term Independent Independent Short Term
 (+) R/T impaired At the end of 4 hours  Monitored vital  For baseline data At the end of 4 hours
Internal catheter nursing intervention, the signs q2 hrs. and check pt nursing intervention,
Jugular function 2° loss client will be able to: status; prevent Goals were met; the
 Monitored internal
catheter of catheter  Be free of injury. injury to the pt. client was able to:
IJV shunt patency
 Extremes patency, clot  Have a patent  Early assessment  Be free of injury as
q 30 mins to 1
of age: formation and vascular access for facilitates evidenced by
hour:
68 years blockage. dialysis. prompt absence of
old  Verbalize  Palpated for intervention and formation of
understanding of distal thrill and reduce thrombosis.
individual factors that auscultate for complications  Have patent
contribute to bruit.  Absence of a vascular access as
possibility of injury. palpable thrill or evidenced by
 Palpated skin audible bruit palpable distal
153
Long Term around the may indicate thrill, audible bruit
At the end of 1 to 2 weeks access site for blockage or and no kinks or
nursing interventions, the warmth. clotting in the damage to the
client will be able to:  Monitored access device; catheter.
 Demonstrate swelling of neck,  Coolness at the  Verbalize
behaviors, lifestyle chest, arm or leg skin access site understanding of
changes to reduce skin discoloration, indicates individual factors
risk factors and tingling and diminished blood that contribute to
protect self from numbness. flow; possibility of injury.
injury.  Assessed  swelling of neck,

Long Term
 Maintain patent condition of chest, arm or leg
At the end of 1 to 2
vascular access. catheter for skin discoloration,
weeks nursing
malposition, kinks tingling and
interventions, Goals
and damage. numbness
were met; the client
 Educated indicates
was able to:
regarding thrombosis.
 Demonstrate
154
importance of; behaviors, lifestyle
Hygiene, changes to reduce

 To prevent
Keeping dressing risk factors and
migration of
dry and clean protect self from
bacteria to the
 Instructed pt, injury; such as
catheter which
family and/or proper daily care
could lead to
main caregiver of access devices.
contamination.
NOT TO: Wear  Maintain patent
clothing that  Protects the CVC vascular access;
places pressure from external absence of air in
and pulls on the damage. the catheter
CVC, Use sharp lumen, thrombosis,
objects like scissors catheter
near the CVC. malposition, kinks

Collaborative:
Collaborative: and damage.
 Prophylaxis may
 Collaborated with
include
155
physicians unfractionated
regarding heparin, low-
appropriate molecular-
treatment for weight heparin
prophylaxis. to prevent clot
formation.
 Monitored PT,
 Provides
activated partial
information
thromboplastin
about
time (aPTT) as
coagulation
appropriate.
status.
156
Nursing Care Plan 12: Risk for Fall
Objective: Risk for fall Short Term: Independent: Independent: Short Term:
 Advanced age - related to At the end of 8 hours,  Assured that the  Keeping the At the end of 8
68 years old impaired the client will be able bed is at the beds closer to hours, the client
 AKI physical to: lowest possible the floor was able to:
 Weak in mobility  Verbalize position. reduces the risk  Goal met:
appearance secondary understanding of falls and Verbalized

 Guaranteed
 Pallor to post- of individual risk serious injury. understandi
appropriate
 HD pt hemodialysis factors that  Lighting an ng of
room lighting,
 Persistent Mild and existing contribute to unfamiliar individual
especially
Ureterohydronephr conditions. the possibility of environment risk factors
during the
osis falls helps increase that
night.
 Intake: 2700 ml  Demonstrate visibility. contribute
 Encouraged to
Output: 1130 ml behaviors and to the
don shoes or  This provides
 Urinary frequency lifestyle possibility of
slippers with sure footing
157
of 8x/day changes to nonskid soles with diminished falls such as
 Multiple drug reduce risk when walking. foot and toe lift advanced
intake (including factors and  Used side rails when walking age,
diuretics, protect self from on bed as  Side rails are alteration in
antihypertensives, injury needed. used as fluid and
anticonvulsants)  Modify hospital handheld grips electrolytes,
environment as for getting into and intake
indicated to  Instructed to call and out of of multiple
enhance safety for assistance bed. Thus, medication
when moving. reducing the s.

Long Term
 Placed risk for fall  Goal met:
At the end of 3 days,
frequently used during Demonstrat
the client will be able
items within ambulation. ed
to:
easy reach.  To prevent behaviors
 Maintain health
them from and lifestyle
behaviors and
Dependent
falling on bed. changes to
lifestyle
 Administered
158
changes to Kalium Durule  Stretching to reduce risk
reduce risk (Potassium get items from factors and
factors of falls Chloride) as bedside tables protect self
 Modify home prescribed by that are out of from injury
environment as the physician. reach can such as the
indicated to Collaborative disrupt donning of
enhance safety  Reviewed balance and non skid
 Be free of injury ongoing contribute to slippers and
medication falls. instructing
regimen, noting Dependent to call
number and  Prevention of assistance
type of drugs hypokalemia when
that could related to use ambulating.
impact fall of loop  Goal met:
potential. diuretics Modified
 Reviewed particularly, hospital
159
ongoing Lasix environmen
medication t by raising
Collaborative
regimen and up side rails
 Studies have
monitored its and
confirmed that
side effects. providing
use of four or
adequate
more
lighting to
medications
enhance
(polypharmac
safety.
y) increases
Long Term
the risk for falls.
At the end 3 days,
 Use of certain
the client was
medications
able to:
(e.g. narcotics,
 Goal Met:
antihypertensiv
Maintained
es, and
use of non-
diuretics) can
160
contribute to skid slippers
weakness, when
confusion, and walking and
balance and calls for
gait assistance
disturbances when
moving
 Goal Met:
Home has
been
modified to
include
chairs that
have a firm
seat and
arms on
161
both sides,
heavy
furniture, a
clear
pathway,
bathroom
handrails,
and bed at
a low
position
 Goal Met:
Free from
signs and
symptoms
of wounds
or trauma
162
VIII. DISCHARGE PLAN
METHODS Rationale/ Nursing Considerations/
Special Instructions
M - Medications:
● Levofloxacin - Anti-infective, used to treat
250mg, 1-tab OD, complicated urinary tract infections.
PO - Antacid, management of metabolic
● NaHCO3 650mg, acidosis due to renal diseases
1-tab TID, PO - Antihypertensive, treatment for
● Lasix 40mg, 1-tab, edema and hypertension
BID, PO - Iron supplement & vitamins, prevents
● Ferrous Sulfate + low blood levels of iron
Folic Acid, 1-tab, - Antilipidemic, reduces risk of stroke in
OD, PO patients with no evidence of heart
● Atorvastatin disease, but are at risk of other CV
(Lipitor), 20mg, 1- complications
tab, OD @8 pm, - Mucolytic, treatment of chronic
PO bronchial infection
● Ambroxol, 75mg 1 - Amino acids, prevention and
cap OD, 6PM, PO therapy of damage due to faulty or
● Ketoanalogue deficient protein metabolism in
163
(Renalog), 2 mg chronic renal insufficiency
TID PO, 8 AM and

Instructed the patient to take all
1PM
medications that were prescribed and
discuss the dosage, action, side effects,
and contraindications of those drugs.
Exact dosage is important as well as
proper timing for the drug to be effective.
Warn the patient of the side effects
because it may be uncomfortable to the
patient. Also, to tell the patient to avoid
taking medicines that are not prescribed
by the doctor. Remind the patient to
report to the physician if adverse effects
occur.
E - Exercise Patient was advised to stay in a calm,
quiet environment. Home environment

● Encourage the
must be free from slipping and accident
patient to do exercises
hazards. Reinforced the need to continue
such as:
exercises at home. Active Range of
Motion exercises increase muscle mass,
164
tone, strength pressure joint mobility and
improve cardiac and respiratory function.
Regular exercise also helps in digestion
and in increasing energy levels, allowing
the patient to do more.

Walking
- Take at least 15-

- Helps reduce the risk or
30-minute walk
development of cardiovascular
everyday
conditions
- Breathing exercises can help

Breathing Exercises
improve circulation and lessen
- Sit upright and fatigue during daily activities.
breathe deeply.
Inhale through
your nose and
exhale through
your mouth.
165
Discussed with the patient the purpose of
treatments to be done and continued at

T - Treatment
home and continue monitoring for any
complications. Encouraged patient to
continue submitting self to diagnostic
examinations to make sure that there are
no complications. And to follow advice of
physicians or any other health care
provider.
● Continued
regular checkups - Dialysis helps filter waste and water
and following of from the blood in the absence of a
dialysis schedules normal, functioning kidney.
● Regular checking
and cleaning of IJ
- The patient must make sure the
catheter
catheter is connected at all times,
clean and free from any debris that
may cause bacteria to build up and
cause an infection.
166
H - Health Teaching
● Educated the ● Too much sodium can cause
patient and excessive thirst, causing the patient
family about the to drink more liquid than necessary.
treatment plan This can cause swelling and alter
including the blood pressure in between dialysis
need to adhere sessions.
to a low sodium
diet, take
medications as
prescribed and
check with the
attending
physician before
taking any new
medications.
● Encourage ● This helps prevent dry skin for the
proper hygiene patient, and also reduces the risk for
and skin care. To infection.
keep the central
line of CVAD dry
by placing a
167
dressing and to
never go
swimming
● Advised to
● Prevents unwanted cross-
observe proper
contamination as the patient is
handwashing
susceptible to infection.
before after
having a contact
with the central
line. Do not touch
the catheter or
dressing unless it is ● Drastic weight changes may
needed. indicate complications of the
● The importance therapy and will need further
of recording the monitoring from the healthcare
weight daily and team.
to watch for signs
and symptoms of
complications
(Chills, >38oC
Fever, Pain or
burning in chest
and shoulder,
168
irregular
heartbeat).
O - Out-Patient, Patient was informed about the schedule
Follow-up Visit in visiting her physician for follow up
check-up this will help determine the
progress of the patient and to prevent
possible complications.
169
D - Diet
● Advised patient ● Sodium increases thirst, therefore
to eat 1,500 mg requiring the patient to drink more
or less of sodium fluids than necessary. This can cause
daily, avoid table edema and fluctuating blood
salt, salty foods, pressure levels.
salted butter and
margarine and all
ordinary canned
and frozen foods.

● To prevent muscle wasting
● Include
carbohydrates
and fat (e.g. rice,
potatoes,
● because urea, uric acid, and
avocado)
organic acids the breakdown
● Protein is
products of dietary and tissue
restricted
proteins accumulate rapidly in the
blood when there is impaired renal
clearance. The allowed protein must
be of high biological value (e.g.
dairy products, eggs, meats)
170
● Fluid allowance ● To prevent edema and an increase
per day is 500 mL in blood pressure, which in return
to 600 mL more makes the heart work harder and
than the previous exert more effort.
day’s 24-hour
urine output
● Eat less than 1,500 ● With the absence of function of one
mg to 2,700 mg kidney, potassium may build up in
of potassium the blood, causing hyperkalemia
daily. which then results to various
complications such as nausea,
weakness, numbness and slowing of
pulse.
Patient was instructed to communicate
with God by praying, asking for guidance,

S - Spirituality
good health, and strength at all times and
also don’t forget to thank all of His good
deeds. To gain strength and good health
from God and to ask for guidance
always. This is also a way to strengthen her
171
faith to God.
● Seeking
guidance in times ● This may help the patient find
of weakness comfort and solace in God, easing
during the the patient mentally and spiritually.
treatment
172
IX. PROGNOSIS
Legend:
Excellent (5) – Patient performs excellently; cooperative and
responds actively to nursing intervention; is independent
Good (4) – Patient performs well; responds actively to nursing
intervention, is independent is in some ways
Fair (3) – Patient performs weakly; responds minimally to nursing
intervention; dependent in some ways
Poor (2) – Patient performs poorly; does not respond to some
nursing intervention; very dependent to other person
Very Poor (1) – Patient doesn’t perform; does not respond to any
nursing intervention; very dependent to other person
CRITERIA 5 4 3 2 1 JUSTIFICATION
Physiologic response of / The patient's vital signs
the body to the disease are within normal range.
process The body fighting an
infection is evident in an
increase of white blood
cells in the urine (pyuria),
and an increase in body
173
temperature. The urinary
bladder is physiologically
distended with the
presence of pyuria and
hematuria. There are
also occasional reports
of chronic pain.
Relief of symptoms / The patient has
associated with disease recovered from fever
condition and lithiasis, vital signs
are within normal range.
Performance of daily / The patient is able to
living of the patient independently perform
during confinement some day to day living,
however needs
assistance as the patient
requires a wheelchair
and is attached to a
catheter.
Compliance of the / The patient shows
patient to the medication compliance and is
and therapy cooperative to all
174
interventions provided
by the healthcare team.
Adequacy of rest and / The patient is able to
periods of sleep maintain adequate
amount of rest
throughout her stay in
the hospital, however
mentions that her sleep
is disturbed by the
occasional vital signs
taking and
administration of drugs
and fluid.
Consumption of the / The patient is compliant
patient of the medication with all provided
and therapeutic regimen medication, expressing
interest in participating.
Compliant with the
insertion of catheter.
Patient’s perception of / The patient is seen to be
illness anxious about disease
however anxiety is lost
175
after patient education.
Patient’s Social / Patient is interactive and
interaction sociable throughout
hospitalization however
is seen to be groggy due
to the disease process.
FORMULA: (Total number/40) x 50 + 50 = Total Percentage (%)
EXCELLENT 2 x (5) 10
GOOD 3 x (4) 12
FAIR 3 x (3) 9
POOR 0 x (2) 0
VERY POOR 0 x (1) 0
Total percentage (31/40) x 50 + 50 = 88.75%
RATING SCALE:
90-100% - Excellent
77-89.99% - Good
68-76.99% - Fair
50-67.99% - Poor
50% below - Very Poor
176
By the criteria being focused as presented above, the overall
prognosis of the patient was good, with a percentage of 88.76%.
Despite the diagnosis given to the patient, the patient’s current
condition has improved since admission. The patient's vital signs are
within normal range. The body fighting an infection is evident with an
increase of white blood cells in the urine (pyuria), and an increase in
body temperature, there have been occasional reports of chronic pain
throughout the days. The urinary bladder is physiologically distended
with the presence of pyuria and hematuria. The patient requires a
wheelchair and has been inserted with a catheter limiting daily living
tasks that may be performed independently. The patient is compliant
with all medications and health modalities prescribed, the patient has
maintained being sociable and interactive throughout the hospital
stay. The patient is able to gain adequate rest however is occasionally
disturbed during vital signs taking. To conclude the patient prognosis is
seen to be good considering the patient's situation and diagnosis.
177
X. CONCLUSION
The study highlights the case of Patient IEB, a 68-year-old female
client from Bukidnon, who was admitted on August 15, 2020 at Maria
Reyna Xavier University Hospital Emergency Room in Cagayan de Oro
City, in which she had a final diagnosis of (1) uremia secondary to
acute kidney infection on top of chronic kidney disease secondary to
obstructive uropathy and (2) complicated UTI. The client had
undergone an operation for catheter insertion at the right intrajugular
vein for hemodialysis on the same day of admission. Necessary medical
information about the client was obtained and used as a basis for
constructing the priority nursing managements and for the successful
completion of the study.
The nursing process serves as a guide for the student-nurses to
comprehensively study the case of Patient IEB. Nursing actions include
thorough assessment, formulation of a nursing diagnosis, planning,
implementation, and evaluation of patient outcomes based on the
care assumed to be provided. The case study allowed the student-
nurses to obtain a deeper understanding of Patient IEB’s medical
complications including the factors that had contributed to the kidney
disease, its physiological signs and symptoms, and the progression of
the disease and how it will be managed based on the disease itself
and its manifestations. The diagnostic tests with subsequent
interpretations were also useful in providing a basis for diagnosing,
178
screening, monitoring, and evaluating the client. Furthermore, the drug
studies have supplemented the learning of the student-nurses on
Patient IEB’s medications which include their classifications, indications,
mechanisms of action, contraindications, adverse effects, and some
nursing considerations when the client is given a certain drug that was
prescribed. Some of the common drugs that were prescribed include
antacids, antibiotics, antihistamines, and supplements. Overall, the
case has truly allowed the student nurses to obtain learnings on the
perioperative nursing responsibilities.
Generally, the student nurses, with the support of the clinical
instructors, MRXUH nurses, Patient IEB and her family, and fellow
student-nurses, were able to gain essential information that could help
in enhancing their nursing knowledge, skills, and attitude, holistically.
179
XI. RECOMMENDATIONS
The study focused on a 68 year old female patient with a final
diagnosis of uremia secondary to acute kidney infection on top of
chronic kidney disease secondary to obstructive uropathy. These
recommendations would improve the patient’s overall health
condition and for the improvement of the case study itself.
The following are the recommendations formulated by the
students:
Patient. Adherence to the treatment regimen prescribed by the
physician is essential in controlling the progression of the disease, its
manifestations and possible fatal complications. This includes taking
note of the right dosage and timing for each medication and
monitoring any adverse effects. Minimal exercises that are considered
tolerable and safe by the physician should be practiced to maintain
active range of motion and improve cardiac and respiratory function.
Dietary restrictions should be strictly followed like decreasing one’s
sodium intake and staying within the range of the recommended fluid
allowance. In the light of the pandemic, proper hygiene and skin care
should be employed when dealing with the central line of the CVAD
and with oneself to avoid any form of infection. Follow-up schedules
should also be taken note of.
180
Student Nurses. Despite the fact that the students themselves
were unable to conduct the assessment of the patient firsthand, due to
the pandemic, the rest of the nursing process must be utilized and
formulated well in order to improve the patient’s quality of life. This must
start from applying learned concepts and theories regarding the case.
Next, is to properly deliver health teachings especially with the
presence of the ongoing global health crisis and the need to stay at
home. The scheduling of follow-up visits should also be relayed upon
discharge and a contact number should be provided in case of
emergency.
Family and Significant Others. The role of family members and
significant others is to guide, support and assist the patient. They help
her commit to the treatment plan. This may either be in maintaining the
central line of the CVAD, in remembering medication timings and
dosages or assisting in follow-up check-ups. They serve as sources of
inspiration and strength for the patient to move forward especially in
times of high anxiety, doubt or feelings of helplessness with regards to
the disease progression.
Future Researchers. In the fortunate instance that the curve
finally flattens and the pandemic is eradicated, the researchers
themselves must take into account a thorough assessment of the
181
patient. This is a vital step of the nursing process that should not be
shouldered or done by others aside from those conducting the case
study. Deviations in terms of observations and interpretations are highly
likely in the present situation. Home visits may also be conducted to
provide a private session with the patient to state her concerns and re-
assess her overall health status.
182
XII. BIBLIOGRAPHY
Balogun, S. A., & Abdel-Rahman, E. (2015). Caring for Elderly Patients
with Kidney Disease: The Geriatrician–Nephrologist Collaboration.
Retrieved November 10, 2020, from
https://www.kidneynews.org/kidney-news/special-
sections/geriatric-nephrology/caring-for-elderly-patients-with-
kidney-disease-the-geriatrician%E2%80%93nephrologist-
collaboration
Besdine, R. W. (2019, April). Physical Changes With Aging. Retrieved
November 10, 2020, from
https://www.msdmanuals.com/professional/geriatrics/approac
h-to-the-geriatric-patient/physical-changes-with-aging
Brazier, Y. (2017, June 23). How do ultrasounds work?. Retrieved
November 11, 2020 from
https://www.medicalnewstoday.com/articles/245491.
Chronic Kidney Disease (CKD) Symptoms and Causes. (2017, February
15). Retrieved November 11, 2020, from
https://www.kidney.org/atoz/content/about-chronic-kidney-
disease
CS Cervical Spine X Ray & Results Explained - HealthEngine. (2019,
October 18). From HealthEngine Blog website:
https://healthengine.com.au/info/cervical-spine-x-ray
183
Learning About Atherosclerosis of the Aorta. (n.d.). Retrieved
November 12, 2020, from
https://myhealth.alberta.ca/Health/aftercareinformation/pages/
conditions.aspx?hwid=abs1513
Mayoclinic.org. (2019, October 23). Urinalysis. Retrieved November 11,
2020 from https://www.mayoclinic.org/tests-
procedures/urinalysis/about/pac-20384907.
(n.d.). Retrieved November 12, 2020, from
https://www.yourhormones.info/hormones/parathyroid-hormone
Preminger, G. (2019, September). Obstructive Uropathy - Genitourinary
Disorders. Retrieved November 11, 2020, from
https://www.msdmanuals.com/professional/genitourinary-
disorders/obstructive-uropathy/obstructive-uropathy
Radiologyinfo. Org. (n.d.). Ultrasound - thyroid. Retrieved November 11,
2020 from https://www.radiologyinfo.org/en/info.cfm?pg=us-
thyroid.
Song, L., & Maalouf, N. M. (2020, March 9). Nephrolithiasis. Retrieved
November 11, 2020, from Nih.gov website:
https://www.ncbi.nlm.nih.gov/books/NBK279069/
184
Tumor vs. cyst: What's the difference? (2019, September 13). Retrieved
November 12, 2020, from https://www.mayoclinic.org/diseases-
conditions/cancer/expert-answers/tumor/faq-20057829
185
XIII. APPENDICES
A. Assessment Tool
Age: 68 years old

Name: Patient IB
Civil
Birthday: August 18, 1951 Status: Married
Occupation:
Sex: Nationality: Religion: Catholic
housewife
Female Filipino
Address: PUROK 5, Poblacion, Manticao

Admission Case: Philhealth: Senior
Spouse: - Emergency Room Citizen
Relation: Daughter
Informant: DIB
Time: 1:16 AM
Admission Date: 8/15/20
Chief -
Complaint
Attending Dr. RB, MD

Physician:
Uremia secondary to acute kidney infection secondary
Admitting to nephrolithiasis on top of chronic kidney disease
Diagnosis secondary to obstructive uropathy
3. Uremia secondary to acute kidney infection
secondary to nephrolithiasis on top of chronic
Final
kidney disease secondary to obstructive uropathy
Diagnosis:
4. Complicated urinary tract infection
IJ Catheter insertion right (8/15/2020)
Surgical
Procedure:
Discharge
8/23/20 2:15PM
Date and
Time:
Present Medical History

- Patient was admitted due to uremia (increase urea in blood)
- On august 15, patient was subject for dialysis via IJ catheter
- Patient's right kidney is surgically absent so left kidney compensates
and starts to
deteriorate.
186
Upon Assessment:
Vital Signs: PR: 82b pm RR:21 cpm BP:110/60 mmHg Temp:36.0 Ht.:155
cm Wt.: 60 kg BMI: 25.0
Interpretation of BMI: Overweight (25- 29.9)
Admission Date & Day 1 Day 2 Day 3

Time: 8/15/20 8/16/20 8/17/20
1:16AM 12AM 12AM
ACTIVITY/REST
SUBJECTIVE
Leisure Time Activities: - - -
Limitations Imposed by - - -
Condition:
Number of Hours of - - -
Sleep:
Naps: - - -
Aids: - - -
Difficulty in Sleeping: - - -
Feeling on Awakening: - - -
OBJECTIVE
Observed Response to - - -
Activity:
Cardiovascular: Adynamic - -
precordium
Respiratory: 21cpm 19 cpm 21 cpm
O2 Sat: 97% O2 Sat: 97%
Posture: - - -
Limitation of Motion - - -
(LOM):
Tremors: - - -
CIRCULATION
187
SUBJECTIVE
History of - - -
Hypertension:
Heart Trouble: - - -
Ankle/Leg Edema: - - -
Claudication: - - -
Cough/Hemoptysis: - - -
Numbness in - - -
Extremities:
Tingling in Extremities: - - -
Change in - - -
Frequency/Amount
of Urine:
OBJECTIVE
Blood Pressure:
Right Arm: 110/60mmHg 110/60mmHg 110/60mmHg

Left Arm: 110/60mmHg 110/60mmHg 110/60mmHg
Pulse Pressure: 50mmHg 50mmHg 50mmHg
Point of Maximal - - -
Impulse (PMI):
Heart Rate/Sounds: 84 bpm, - -

distinct heart
sound
Rhythm: regular - -
Pulse: 82 bpm 97 bpm 89 bpm
Vascular Bruit: - - -

low-pitched
wheezing
188
sounds
Jugular Vein - - -
Distention:
Extremities: - - -
Temperature
Color: - - -
Capillary Refill Time: - - -
Homan’s Sign: - - -
EGO INTEGRITY
SUBJECTIVE
Reports of Stress - - -
Factors:
Ways of Handling - - -
Stress:
Financial Concerns: - - -
Relationship Status:
Lifestyle: - - -
Recent Changes: - - -
Feelings of - - -
Helplessness:
Feelings of - - -
Hopelessness:
Feelings of - - -
Powerlessness:
OBJECTIVE
Emotional Status: - - -
Observed Physiologic - - -
Response:
ELIMINATION
189
SUBJECTIVE
Usual Bowel Pattern: - - -
Character of Stool: - - -
Last Bowel Movement: - - -
Laxative Use: - - -
History of Bleeding: - - -
Hemorrhoids: - - -
Constipation: - - -
Diarrhea: - - -
Usual Voiding Pattern: - - -
Incontinence: - - -
Urgency: - - -
Retention: - - -
Frequency: - - -
Pain/Burning/Difficulty - - -
in Voiding:
History of Kidney/ - - -
Bladder Disease:
OBJECTIVE
Abdomen Flat, soft - -
Tender:
Soft/Firm:
Palpable Mass: No palpable - -
mass
Size/Girth: - - -
Other comments: - - -
Bowel Sounds: normoactive - -
190
Bladder Palpable: - - -
Distended: - - -
FOOD AND FLUIDS

SUBJECTIVE
Usual Diet: - - -
No. of Meals a Day: - - -
Last Meal Intake: - - -
Loss of Appetite: - - -
Nausea/Vomiting: - - -
Dentures: - - -
Allergies/Food - - -
Intolerance:
Heartburn/Indigestion: - - -
Swallowing Problems: - - -
Weight - - -
Usual:
Changes: - - -
Diuretics: Furosemide 40mg 1cap BID
OBJECTIVE
Current Weight: 60 kg - -
Height: 155 cm - -
Body Build: - - -
Skin Turgor: - - -
Mucous Membranes: - - -
Hernia/Masses: - - -
191
Edema: General - - -
Dependent:
Periorbital: - - -
Ascites: - - -
Thyroid Enlarged: - - -
Halitosis: - - -
Condition of Teeth: - - -
Appearance of - - -
Tongue:
SUBJECTIVE
Activities of Daily - - -
Living
Mobility: - - -
Hygiene: - - -
Toileting: - - -
Feeding: - - -
Dressing: - - -
Others: - - -
Equipment/ Presence Wheelchair - -

of Devices Required:
Assistance Provided - - -
by:
OBJECTIVE
General Appearance: - - -
Manner of Dress: - - -
Habits: - - -
Body Odor: - - -
192
Condition of Scalp: - - -
Presence of Vermin: - - -
SUBJECTIVE
Fainting Spells/ - - -
Dizziness:
Headache: - - -
Location: - - -
Frequency: - - -
Tingling/Numbness/ - - -
Weakness Location:
Seizures: - - -
Aura: - - -
How Controlled: - - -
Eyes - - -
Vision Loss:
Last Examination: - - -
Glaucoma: - - -
Cataract: - - -
Sense of Smell: - - -
Epistaxis: - - -
Others/Comments: Anicteric - -
sclera, pink
palpebral
conjunctiva
OBJECTIVE
193
Alert: - - -
Stuporous: - - -
Combative: - - -
Drowsy: - - -
Lethargic: - - -
Comatose: - - -
Cooperative: - - -
Affect: - - -
Delusions: - - -
Hallucinations: - - -
Memory - - -
Recent:
Remote: - - -
Speech Pattern: - - -
Congruence: - - -
Glasses: - - -
Contacts: - - -
Hearing Aids: - - -
Pupil Size Reaction: - - -

Left: - - -
Right: - - -
Facial Droop: - - -
Swallowing: - - -
Handgrip/Release - - -
Right:
194
Left: - - -
Posturing: - - -
Deep Tendon Reflex: - - -
Paralysis: - - -
Others/Comments: Musculoskele - -
tal is intact
SUBJECTIVE
Onset: - - -
Duration: - - -
Location: - - -
Frequency: - - -
Intensity (1-10): - - -
Quality: - - -
Description of Pain: - - -
Precipitating Factors: - - -
Aggravating Factors: - - -
How Relieved: - - -
Associated Symptoms: - - -
OBJECTIVE
Observed Symptoms: - - -
SUBJECTIVE
Dyspnea related to: - - -
Cough/Sputum of: - - -
Smoker: No
195
Packs: - - -
Brand: - - -
Number of Years: - - -
Use of Respiratory - - -
Aids:
Oxygen: - - -
OBJECTIVE
Respiratory Rate: 21 cpm 19 cpm 21 cpm
Depth: - - -
Symmetry: - - -
Use of Accessory - - -
Muscles:
Nasal Flaring: - - -
Fremitus: - - -

low-pitched
wheezing
sounds
Cyanosis: - - -
Clubbing of Fingers: - - -
Sputum - - -
Characteristics:
Restlessness: - - -
SUBJECTIVE
Allergies/Sensitivity: - - -
196
Reaction: - - -
History of STD - - -
(Date/Type):
Blood Transfusion - - -
Number:
When: - - -
History of Accidental - - -
Injuries:
Fractures/Dislocations: - - No fractures
or dislocations
noted
Arthritis/Unstable - - -
Joints:
Back Problems: - - -
Changes in Moles: - - -
Enlarged Nodes: none - -
Prosthesis: - - -
Ambulatory Devices: - - -
Expression of Ideation - - -
of Violence (Self/
Others)
Others/Comments: - - Presence of IJ
catheter in
the right
OBJECTIVE
Temperature: 36.0 37.1 37.5
Diaphoresis: - - -
Skin Integrity: Dry, - -

hypopigment
ed
Scars: - - -
197
Rashes: - - -
Lacerations: - - -
Ulcerations: - - -
Bruises - - -
Blisters: - - -
Burns (Degree %) - - -
Drainage (Note - - -
Location):
General Strength: - - -
Muscle Tone: - - -
Gait: - - -
Paresthesia/Paralysis: - - -
Sexually Active: - - -
Sexual Concerns/ - - -
Difficulties:
Recent Changes in - - -
Frequency /Interest:
SUBJECTIVE
Marital Status: Married
Years in Relationship: - - -
Living with: - - -
Concerns/Stresses: - - -
Extended Family: - - -
198
Other Support Person: - - -
Role within Family - - -

Structure:
Reports of Problems - - -
related to Illness-
Condition:
SUBJECTIVE
Dominant Language: - - -
Literate: - - -
Educational Level: - - -
Health - - -
Beliefs/Practices:
(-) Not properly assessed
Medications
Date Name, Dose, Route

8/15/2020 Ketoanalogue (Renalog) 2mg TID PO
Sodium Bicarbonate 650 mg 1 tab TID
8/16/2020 Furosemide (Lasix) 40mg 1 cap BID (hold if SBP
<90mmHg)
8/16/2020 Ambroxol 75mg 1 cap OD PO
NaCl 125mg 1 tab TID PO
Clonazepam (Rivotril) 2 mg ½ tab OD PO
Paracetamol 500 mg 1 tab PRN PO
8/18/2020 Omeprazole (Omepron) 40 mg tab OD ACBT
NaHCO3 650mg tab TID PO
Ferrous Sulfate + Folic Acid 1 tab OD
Atorvastatin 20 mg 1tab, 1 tab OD
EPO 6000 IV SQ 1x1 week
Levocetirizine + montelukast (Stelix) 10/5mg tab OD
8/20/2020 Meropenem (Gopenem) 500mg IV q24H ANST (-)
Levofloxacin 250mg 1tab, 1tab OD every 48hrs.
8/22/2020 Kalium Durule 1tab TID x 4doses. SD: 8102 1pm LD: 8124
8am
199
B. Nurses’ Notes
Date & Time Focus Data/Action/Response
8/15/2020 Admission D: Received from ER
3:45am A: Ushered to room of choice,
placed safely at bed, kept
monitored
R: Transitioned safely
8/15/2020 Hydration A: Encouraged patient to
8:00am Precaution increase oral fluid intake; IVF
monitored and prepared;
Intake and Output monitored
and recorded; Encouraged to
verbalize information
R: [+] Understanding
8/15/2020 Pretransfer notes D: Patient for IJ catheter
2:00pm A: Placed patient in bed
comfortably; fear verbalized;
V/S taken and recorded;
needs attended
R: Safety maintained
OK notes ➢ Received awake via
200
wheelchair
➢ For IJ catheter
➢ Ap updated
➢ Docked to cardiac
monitor
➢ Transported to stretcher
➢ Skin prep done
2:31pm aseptically
➢ Surgical drape applied
2:38pm ➢ Operation started
➢ IJ catheter inserted
➢ Operation ended
➢ PT sent to dialysis
immediately
➢ Endorsed to PM shift
NOD
201
C. Physician’s Orders
Date & Time Orders
8/20/2020 - Please refer ultrasound of
left KUB
- If with persistent
hydronephrosis with stones,
will do cystoscopy
- No hydronephrosis, no
stones
- may do CT sonogram
instead of UTZ KUB per
request
- Lasix 40 mg 1 tab BID
8/27/2020 12:28 pm - Repeat ultrasound KUB
after 2-3 weeks
- Follow up once with repeat
ultrasound
- Telephone order Dr. R.
Andutan
12:30 pm - Follow up next hemodialysis
on wednesday
202
- Telephone order Dr. A.
Carpio
D. Vital Signs
Date/Tim BP Pulse RR Temp O2
8AM 110/60 83 21 37.2
12 120/80 84 19 38.1
4 100/60 83 20 37.7
8 120/70 95 21 36.6 98
9:30 110/90 98 19 36.8 98
8/20 90/60 84 21 37
12
4 100/70 88 20 36.9
8 120/90 82 22 37.1 96
12 110/70 82 20 37.1 99
4 120/80 79 20 36.8
8 110/70 84 20 37.3
203
8/21 100/60 68 20 37.5
12
4 120/60 74 22 37.2 98
8 100/60 76 20 37.2
12 100/60 70 20 37.1
4 100/70 89 20 37.3
8 120/70 78 20 37.9
10 - - - 37.5
8/22 100/60 67 21 37.3
12
4 120/70 67 20 36.1 97
8 120/80 92 19 36.6 99
12 110/80 84 18 36.5
4 120/70 112 20 36.8 95
6 110/80 68 18 36.9 99
8 120/70 79 18 36.9 98
8/23 120/70 88 22 37.6
12
204
4 120/60 64 21 36.8
8 100/60 70 21 36.3
12 110/70 80 20 36.4
E. Intake/Output
Date: 8/21/2020
Input Output
Time Oral Paren- Total Time Urine NGT Drain Total

teral age
6-2 360 900 960 6-2 500 - - 500
2-10 240 600 840 2-10 300 - - 300
10-6 300 600 900 10-6 330 - - 330
Total 2700 Total 1130
Date: 8/22/2020
Input Output

teral age
6-2 400 800 1200 6-2 400 400
2-10 350 450 800 2-10 250 2000 2250
10-6 300 600 900 10-6 600 600
Total 2900 Total 3250
205
Date: 8/23/2020
Input Output

teral age
6-2 270 400 670 6-2 900 900
2-10 2-10
10-6 10-6
Total Total
206
F. Complete Names of Block NA Students
Albano, Bianca Marie F. Guadalquiver, Lindsay Tawnya
Avellana, Cray Arvin B. Gumisong, Autumn Nathalie N.
Barrientos, April Lauriene D. Halibas, Hazel Mae L.
Bedro, Bungee A. Hembrador, Jarod Joshua S.
Cabanos, Emilor James C. Idusma, Abel Jr C.
Cainhog, Aiken Raphael L. Liboon, Ayrand Nicolai O.
Callao, Arthur Dave B. Macapil, Khristelle Izy H.
Casinillo, Andrea V. Macua, Ryah Ryll Q.
Chen, Simon B. Maglangit, Ellric Joseph T.
Comendador, Noriza Gean D. Mancao, Neome Love J.
Cortez, Caitlynn A. Manubag, Angemel E.
Cua, Anton Raphael G. Marbas, Soleil Louise L.
Culanag, Mika Angelu R. Marbella, Mariano Ponce B.
Dano, Eloisa May V. Menchavez, Ynno Francis C.
Farrales, Christelle Ann G. Mendez, Jaira Emmarina P.
Fulache, Sophia Loise T. Mira, Kayce Xyza M.
Gaitera, Julie Ann O. Roxas, Eryka Thelline O.
Gamotin, Earl Gabriel S. Tarife Rhea Marie A.
Go, Jhudiel Gabriel M. Viloria, Doreen Gwenyth M.
Gonzaga, Sheena Mae D. Viudor, Eve Kathlynn L.
207

6100c73a72e89 3na Grand Case Presentation

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XAVIER UNIVERSITY- ATENEO de CAGAYAN

A CASE PRESENTATION OF A 68-YEAR OLD FEMALE PATIENT

In Partial Fulfillment of the Requirements in

Jesusa C. Gabule, RN, MN

November 13, 2020

In completion of our grand case presentation this could not have

been possible without the cooperation and support of so many people

contributions that we sincerely appreciated and acknowledged them.

express our deepest gratitude and indebtedness particularly to the

year level faculty of the College of Nursing Xavier University, for

preparing us with knowledge, skills and attitude that molded us

to become competent, committed and conscientious nurses in

 To Ma’am Jesus C. Gabule, RN, MN, Ma’am Gemma V. Panal,

Jesseca P. Monsanto, RN, MAN, Ma’am Renzi R. Pepito, RN, MN,

and Ma’am Jennifer O. Asio, RN, MN, our most sincere

appreciation for becoming our instruments of extended ideas,

knowledge, suggestions, support and guidance for successfully

conceptualizing and completing our case presentation.

sincerely owe thanks and appreciation for their moral and

spiritual support. For the unending inspiration,

encouragement and support for every obstacle that

comes into our way in completion of the case.

 To 3rd year - Block NA students, we are grateful for the

time and effort of each student who dedicated and

compassionately discussed, planned and worked for the

successful completion of the case presentation.

 And lastly to our Heavenly Father, for making this case

presentation a successful one from start to the end. For

giving us with the gift of wisdom and knowledge to identify

the needs of our patient. For giving us the strength,

patience and determination to continue despite the

difficulties we faced in conceptualizing the most

appropriate nursing care, and lastly for giving us the skills to

make planned care correctly rendered especially to those

who are in need.

Older adults are highly susceptible to disorders which are primary

causes of functional loss. In a lot of cases, declines that come with

aging may be due to modifiable factors such as lifestyle, behavior,

diet, and environment (Besdine, 2019). The increase in the number of

elderly also increases medical problems such as acute and chronic

significantly affects their quality of life (Balogun & Abdel-Rahman,

Patient IB, a 68-year-old female senior citizen was admitted at

a final diagnosis of the patient which are "(1) Uremia secondary to

Acute Kidney Injury on top of Chronic Kidney Disease secondary to

Obstructive Uropathy and (2) Complicated UTI.‖

Uremia is a disease in which high levels of urea are found in the

blood and it is one of the main constituents of urine. There is an excess

on the end products of amino acid and protein metabolism in the

blood that are normally excreted in urine as urea and creatinine

(Alper, 2020). Manifestations are extreme tiredness or fatigue, cramping

in the legs, little or no appetite, headache, nausea, vomiting, and

trouble concentrating. Uremia causes severe and permanent damage

leading to chronic kidney disease wherein kidneys are no longer able

to function (Wells, 2017). According to Alper (2020), uremia more

The occurrence of uremia can be linked to nephrolithiasis which

of concretions from the mixture of different mineral salts and organic

matrix in the upper urinary tract. Most common clinical manifestation of

this condition is renal colic accompanied by pain, nausea and

increasing number and size result in the need of surgical interventions.

Acute kidney injury refers to an onset of renal dysfunction associated

with low urine output. To determine the occurrence of acute kidney

injury in relation to nephrolithiasis; the increasing size and number of

kidney stones resulted in an obstruction of the urinary outflow which