CASE PRESENTATION

CHRONIC KIDNEY DISEASE- END STAGE SECONDARY TO

SEVERE ANEMIA
Chronic renal failure (CRF) or 
chronic kidney disease (CKD) is the
end result of a gradual, progressive loss
of kidney function.The loss of function
may be so slow that you do not have
symptoms until your kidneys have almost
stopped working.

The final stage of chronic kidney disease is

called end-stage renal disease (ESRD).
At this stage, the kidneys are no longer
able to remove enough wastes and
excess fluids from the body. At this point,
you would need dialysis or a kidney
transplant.
COMPREHENSIVE
NURSING HEALTH
HISTORY
BIOGRAPHICAL DATA

Name: ERNESTO JERUSALEM

Address: Brgy. Mahayag Villareal, Samar
Age: 37
Sex: Male
Civil Status: Single
Date of Birth: September 5, 1984
Religion: Roman Catholic
Occupation: Construction worker
REASON FOR SEEKING CARE (CHIEF COMPLAINT):

Chest pain and fatigue

Date of Admission: February 15, 2022

HISTORY OF PRESENT ILLNESS
 3 months PTA
- ( + ) Fatigue
- ( + ) lightheadedness
- ( + ) pruritis in the skin
- ( + ) chest pain
- Took paracetamol for
pain
- No consultation done
2 months PTA
- Persistent chest
pain
- ( + ) Severe fatigue
- ( + ) Bipedal Edema
- No consultation
done
 1 month PTA 3 days PTA

- ( + ) above mentioned - ( + ) Persistence

S/SX persisted mentioned S/SX
- ( + ) nausea - Decrease urine output
- ( + ) on and off cough with reddish in color
- Still no consultation - Sought consult to private
done doctor
- Laboratory shows
elevated creatinine and
BUN level
- Referred to EVMC for
co- management for
CKD
PAST HEALTH HISTORY

- No known allergies
- EPI completion
- No pertinent childhood illnesses
- Shoulder and back injury but no previous surgical
interventions.
 FAMILY HISTORY
LEGEND

Male Father
Mother

Female

Father

Mother
Mr. Jerusalem

Mr. Jerusalem

Hypertesion
 PSYCHOLOGICAL HISTORY AND LIFESTYLE
 Patient is working as a construction worker.
Non- smoker but reports previously drinking
alcohol beverages consuming 2-3 bottles of
beer at least 1-2 times per month.
 With preferences on taking soda and
caffeinated drinks every morning and
consuming only 4 glasses of water per day.
 Hobbies was gardening and whenever he is
stressed with work, he visits his friends to
relieve stress.
Pathophysiology of
Chronic Kidney
Disease
ETIOLOGY

● High blood pressure (Hypertension)

● Diabetes Mellitus
● Acute Kidney Injury
● Polycystic kidney disease
● Infection
● Nephrotoxic drugs: NSAIDS, aminoglycosides, chemo therapy drugs,
contrast dyes for testing procedures
 GORDON’S
FUNCTIONAL
HEALTH HISTORY
 
1. Health Perception - Health Management Pattern
Before Hospitalization: The patient claimed that he had never been admitted to a hospital for an illness.
He said that he never smoked, but he drinks alcohol occasionally. He doesn't take any maintenance
medications, so when he has a headache, fever, cough, or cold, he takes paracetamol or ibuprofen.
 
During Hospitalization: He claimed that he does not feel well because of his illness. He also claimed that
performing his everyday tasks would be difficult for him and that he might need assistance from his SO. He
can participate in the recovery process and take the medicine as directed.

2. Nutritional – Metabolic Management Pattern

Before Hospitalization: The patient eats three meals a day, as well as a snack in the afternoon. He enjoys
eating meat and salty foods. He drinks coffee in the morning, but mostly cold soft drinks and he enjoys
spicy foods. He only consumes 4 glasses of water a day. He doesn't take any vitamins or supplements of
any kind.
 
During Hospitalization: The patient is on a restricted low sodium diet. He's advised to avoid spicy and
caffeinated foods and soft drinks. The primary foods to eat are fruits and vegetables.

 
3. Eliminating Pattern
Before Hospitalization: Patient had oliguria or decrease in urine output approximately 16 mL/hr with
reddish color ( HEMATURIA). He defecates twice a day usually early in the morning with brown and formed
stool.

During Hospitalization: Received diuretic medication. Normally voided with adequate urine output.
4. Activity - Exercise Pattern
Before Hospitalization: Patient claimed that he don’t have any exercise regimen due to hectic schedule, but
his nature of work already requires physical exertion such as climbing ladders and lifting heavy objects as
claimed.
 
During – Hospitalization: Patient lies down in his bed and rests as instructed to prevent injuries caused chest
pain and fatigue.

5. Sleep - Rest Pattern

Before Hospitalization: The patient sleeps 5-7 hours daily and doesn’t take a nap due to work. He goes to
bed around 12 a.m. and gets up around 6 a.m. He has trouble sleeping because of insomnia, especially
when chest pain attacks.
 
During – Hospitalization: Patient claimed that he is unable to sleep well due to a different resting
environment and sometimes distraction from medication administration.
6. Cognitive - Perceptual Pattern
Before Hospitalization: Patient was oriented to time, place, and person. He was able to answer the
questions clearly and concisely. Vision, hearing, touch, and sense of smell are good.
 
During – Hospitalization: The patient is still oriented to his environment and can answer clearly with
the question that has been asked to him. Vision, hearing, touch, smell, taste, and balance are still
intact.
 
7. Self - Perception – Self-Concept Pattern
Before Hospitalization: The patient is able to interact with other people. He is very approachable
and friendly.

During Hospitalization: The patient is looking forward to a quick recovery and believes that being
admitted to the hospital will help him deal with his condition
 
8. Roles – Relationships Pattern
Before Hospitalization: The patient is single and is living with his family in Samar. He doesn’t have
any problems in the family. He always hang out with friends.
 
During Hospitalization: The patient is well-supported by his family and friends by frequently calling
and supporting the expenses of hospitalization.
9. Sexuality - Reproductive Pattern
Before Hospitalization: The patient was circumcised at the age of 13. He became sexually active at the age of
16.
 
During Hospitalization: The patient is sexually inactive due to hospitalization

10. Coping - Stress Tolerance Pattern

Before Hospitalization: The patient stated that his way of coping stress is through hanging out with friends and
doing gardening. Whenever he is stressed with work, he visits his friends to relieve stress.
 
During – Hospitalization: The patient shares his thoughts about his health status and medical outcomes to his
family and health care providers.

11. Values - Beliefs Pattern

Before Hospitalization: The patient is a devout Roman Catholic who believes in God. He does not, however,
attend mass on a regular basis and pray either.
 
During – Hospitalization: The patient's faith in God became stronger. He also prays and meditates every day
while listening to relaxing music.
 
 PHYSICAL EXAMINATION
 General Appearance: Awake, conscious, and coherent. Ambulatory with minimal assistance with good muscle strength.
Vital : Temperature – 36.1 Celsius
Signs Heart Rate – 95 bpm
Respiratory Rate – 21 cpm
Blood Pressure – 160/100 mmHg
O2 saturation- 98% room air
Skin: (+) Pruritus in the upper area of arm. Dry, scaly skin on both upper and lower extremities.
 
Eyes: (+) Conjunctival pallor in both eyes. Symmetrically blinking. Round and equal iris.
 
Ears: No discharges on external ear. Can hear clearly.
 
Respiratory: (+) on and off cough, (+) dyspnea, lungs clear to auscultation bilaterally, no wheezes or crackles
 
Cardiac: Normal hear rate sound, regular rate, and normal rhythm.
 
Urinary: Urine output 16ml/hour, (+) dark- colored urine, (+) Hematuria
 
Extremities: (+) bipedal Edema, Normal capillary refill.
 
Neuro: Oriented to time, place and person but cannot responds to questions and statements appropriately.
REVIEWS OF SYSTEM
1. Constitutional:
-Patients shows weakness and fatigue, denies any fever and chills. No sudden change of weight.
 
2. Head, Eyes, Ears, Nose, Throat (HEENT):
-No headaches noted. No pain or any traumatic injuries.
- (+) Conjunctival pallor in both eyes. No changes to vision, infections, double vision, tearing.
- No changes to hearing, no discharge noted from ears.
- No discharge, epistaxis, sinus pain, obstruction.
- Positive for dry mouth and dysphagia. No dental problems, hoarseness, or bleeding gums.
 
3. Respiratory:
-Noted on and off cough prior to admission. Negative for RT-PCR test.
 
4. Cardiac:
-Chest pain noted, dyspnea, History of Hypertension shown in HPI.
 
5. Vascular:
-Edema on both lower extremities. No jaundice or any discoloration.
 
6. Gastrointestinal:
-Nausea, and vomiting noted. No PICA, heartburn, change in bowel habits or bowel texture. No blood in the
stool.
7. Genitourinary:
-Hematuria and proteinuria seen in his urinalysis. High level of bacteria shown in his urinalysis. No history of
sexual transmitted infections.
 
8. Neuromuscular:
-There is no history of seizures, stroke, syncope, memory changes
 
9. Emotional:
-Positive for emotional distress due to illness and anxiety for medical expenses.
 
10. Hematological:
- No signs of bleeding and bruising.
- Received 1 unit of PRBC during admission due to low hemoglobin level.
 
11. Rheumatic:
-No history of gout, rheumatic arthritis, or lupus.
 
12. Endocrine:
- (+) signs of fatigue, (+) oliguria
 
13. Dermatological:
- (+) Pruritus in the upper area of arm. Dry, scaly skin on both upper and lower extremities.
 
LABORATORY SHEET
Laboratory test: Urinalysis
Component Normal Values Results Implication

COLOR Yellow/Clear Reddish color Red or pink urine can

  be caused by blood
(hematuria) indicates
infection in urinary
tract and kidney
failure.

BLOOD Negative ( - ) +++ In hematuria, your

kidneys or other parts
of your urinary tract
allow blood cells to
leak into urine. These
occur when bacteria
enter your body
through the urethra
and multiply in your
bladder.
Component Normal Values Results Implication

PROTEIN Negative ( - ) ++++ If your urine protein

  levels are consistently
high, it may
indicate kidney
damage or other
medical condition.

PUS CELLS 0-3/hpf 883.30 The presence of pyuria

  often occurs in a
urinary tract infection
(UTI)
Component Normal Values Results Implication

 0-3/hpf 865.00 A higher-than-normal

RED CELLS   number of RBCs in the
urine may be due to
kidney and other
urinary tract problems,
such as infection, or
stones and kidney
injury.

BACTERIA  Few 196.90 A "positive" or

abnormal high test is
when bacteria or yeast
are found in the
culture. This likely
means that you have a
urinary tract infection
or bladder infection.
Laboratory test: Blood Chemistry

Component Normal Values Results Implication

CREATININE 0.6 to 1.1 mg/dL 1296.93 mg/dL Elevated creatinine

level signifies
  impaired kidney
function or kidney
disease.

SGGPT/ALT 0-35 mg/L 78.80 High levels of these

enzymes can be a
sign that the liver is
injured or irritated,
and the enzymes are
leaking out of the liver
cells..
Laboratory test: Complete Blood
Count
Component Normal Values Results Implication

HEMOGLOBIN 13.2-16.6 g/dL 3.9 g/dL Low hemoglobin

levels lead to anemia,
  which causes
symptoms like fatigue
and trouble breathing.
.

WHITE BLOOD CELLS
4.5 to 11.0 × 109/L 13.94 WBC defend your
body against
infections and
disease. But, when
there are too many
white blood cells,
it usually means you
have infection or
inflammation in your
body. 
DRUG STUDY
  by blocking the tubular reabsorption of associated with congestive Derma: ERYTHEMA Monitor daily weight
Brand/Trade absorption of sodium and chloride in heart failure, cirrhosis of MULTIFORME, STEVENS-JOHNSON Monitor intake and output ratios
SYNDROME, TOXIC EPIDERMAL Assess for amount and location of
Name: sodium, the proximal and distal the liver, and renal NECROLYSIS, photosensitivity, edema
Lasix chloride, and tubules, as well as in disease, including the pruritus, rash, urticaria Auscultate the lung sounds
  water from the the thick ascending nephrotic syndrome, in EENT: hearing loss, tinnitus Assess for skin turgor, and mucous
Route: filtered fluid in loop of Henle. This adults and pediatric Endo: hypercholesterolemia, membranes.
Oral, the kidney diuretic effect is patients. hyperglycemia, hypertriglyceridemia, Monitor BP and pulse before and
Intravenous tubules, achieved through the - Oral furosemide is hyperuricemia during administration
  causing a competitive inhibition indicated alone for the GI: anorexia, constipation, diarrhea, dry
Dosage: profound of sodium-potassium- management of mild to mouth, dyspepsia, ↑ liver enzymes,
Oral: 40 mg increase in the chloride cotransporters moderate hypertension or nausea, pancreatitis, vomiting
GU: ↑ BUN, excessive urination,
IV: 10mg/mL output of urine (NKCC2) expressed severe hypertension in
nephrocalcinosis
  (diuresis).  along these tubules in combination with other Hemat: APLASTIC
Frequency: the nephron, antihypertensive ANEMIA, AGRANULOCYTOSIS,
Oral: BID preventing the medications. hemolytic anemia, leukopenia,
IV: OD transport of sodium - Intravenous furosemide thrombocytopenia
  ions from the luminal is indicated as adjunctive MS: muscle cramps
  side into the therapy in acute Neuro: paresthesia, blurred vision,
  basolateral side for pulmonary edema when a dizziness, headache, vertigo
  reabsorption. This rapid onset of diuresis is
 
 
inhibition results in desired
 
increased excretion of
  water along with
  sodium, chloride,
  magnesium, calcium,
hydrogen, and
potassium ions. As
with other loop
diuretics, furosemide
decreases the
excretion of uric acid.
Name: spectrum mucopeptide synthesis (respiratory, skin, soft COLITIS, diarrhea, cholelithiasis, including diarrhea, abdominal pain,
Ceftriaxone cephalosporin in the bacterial cell tissue, UTI, ENT) caused sludging in the gallbladder. fever, pus or mucus in stools, and
antibiotic used wall.10,11 The beta- by susceptible Derm: rashes, urticaria. Hemat: other severe or prolonged GI
  for the lactam moiety of organisms.11 Organisms bleeding, eosinophilia, hemolytic problems.
Brand/ treatment of ceftriaxone binds to that are generally anemia, leukopenia,  Monitor signs of allergic reactions
Trade bacterial carboxypeptidases, susceptible to ceftriaxone thrombocytosis. and anaphylaxis, including
infections in endopeptidases, and include S. pneumoniae, S. Local: pain at IM site, phlebitis at IV pulmonary symptoms or skin
Name: various transpeptidases in the pyogenes (group A beta- site. reactions.
Rocephin locations, such bacterial cytoplasmic hemolytic streptococci), Misc: ALLERGIC REACTIONS, Monitor signs of blood dyscrasias,
as in the membrane. These coagulase-negative INCLUDING ANAPHYLAXIS, including eosinophilia, hemolytic
  respiratory enzymes are involved staphylococci, Some superinfection. anemia, leukopenia,
Route: tract, skin, soft in cell-wall synthesis Enterobacter spp, H. thrombocytopenia, or
IV, IM tissue, and and cell division. influenzae, N. thrombocytosis (headache,
urinary tract.  Binding of ceftriaxone gonorrhoeae, P. mirabilis, dizziness, chest pain, fainting,
  to these enzymes E. coli, Klebsiella spp, M. visual disturbances, numbness or
Dosage: causes the enzyme to catarrhalis, B. burgdorferi, tingling in the hands and feet).
lose activity; therefore, and some oral anaerobes Monitor injection site for pain,
IV: 1 the bacteria produce swelling, and irritation. 
g/50mL defective cell walls,
causing cell death.
IM: 250 mg
 
Frequency:
IV: OD
IM: OD
 
 
 
 
 
 
 
 
 
 
Generic  Amlodipine Amlodipine is Amlodipine may be used CNS: headache, dizziness, fatigue.   Assess heart rate and report a
belongs to a considered a peripheral alone or in combination CV: peripheral edema, angina, rhythm disturbances or sympto
Name: class of drugs arterial vasodilator that with other antihypertensive bradycardia, hypotension, of increased arrhythmias, inclu
Amlodopine known as exerts its action directly and antianginal agents for palpitations.  palpitations, chest pain, shortn
calcium channel on vascular smooth the treatment of the GI: gingival hyperplasia, nausea.  of breath, fainting, and
  blockers. It muscle to lead to a following conditions Label: Derma: flushing fatigue/weakness.
Brand/ works by reduction in peripheral   Monitor blood pressure
Trade relaxing blood vascular resistance, • Hypertension Assess episodes of angina pe
vessels so causing a decrease in   at rest and during exercise..
Name: blood can flow blood pressure. • Coronary artery disease Assess peripheral edema usin
Norvasc more easily. Amlodipine is a   girth measurements, volume
Amlodipine is dihydropyridine calcium • Chronic stable angina displacement, and measureme
and also used to antagonist (calcium ion   pitting edema.
Katerzia. prevent certain antagonist or slow- • Vasospastic angina Report increased swelling in fe
  types of chest channel blocker) that (Prinz metal’s or Variant and ankles due to peripheral
pain (angina). It inhibits the influx of angina) vasodilation.
Route: may help to calcium ions into both   Assess dizziness and fatigue t
Oral increase your vascular smooth • Angiographically might affect gait, balance, and
ability to muscle and cardiac documented coronary functional activities.
  exercise and muscle. A stronger artery disease in patients
Dosage: decrease the effect of amlodipine is without heart failure or an
frequency of exerted on vascular ejection fraction < 40%
5 mg-10 mg angina attacks smooth muscle cells
  than on cardiac muscle
Frequency: cells label. Direct
actions of amlodipine
OD on vascular smooth
muscle result in
 
reduced blood pressure
 
 
 
 
 
 
  It is necessary Calcium Carbonate is a Calcium carbonate is GI: Constipation or laxative effect,  Note number and consistency
  for normal medication used to indicated for low serum acid rebound, nausea, stools. If constipation is a prob
 Generic Name: functioning of prevent or treat low calcium conditions, such eructation, flatulence, vomiting, fecal physician may prescribe altern
Calcium Carbonate nerves, cells, blood calcium levels in as osteoporosis, concretions.  combination therapy with a
  muscle, and people who do not get osteomalacia, Metabolic: Hypercalcemia with magnesium antacid or advise
Brand/Trade bone. If there is enough calcium from hypothyroidism, alkalosis, metastatic calcinosis, patient to take a laxative or sto
Name: not enough their diets. It may be hypoparathyroidism, hypercalciuria, hypomagnesemia, softener as necessary.
Tums, Tums calcium in the used to treat conditions pseudohypoparathyroidism hypophosphatemia (when phosphate Lab tests: Determine serum an
Chewy Delights, blood, then the caused by low calcium , DiGeorge syndrome, intake is low).  urine calcium weekly in patien
Tums Extra, Tums body will take levels such as bone kidney dysfunction, CNS: Mood and mental changes.  receiving prolonged therapy an
Freshers, Tums calcium from loss (osteoporosis), pancreatitis, rheumatoid Urogenital: Polyuria, renal calculi. patients with renal dysfunction
Kids, Tums bones, thereby weak bones arthritis, Fanconi Record amelioration of sympto
Regular, Tums weakening (osteomalacia/rickets), syndrome, pregnancy, hypocalcemia
Smoothies, and bones. Having decreased activity of nursing mothers, post- Observe for S&S of hypercalc
Tums Ultra or the right amount the parathyroid gland menopausal women, and in patients receiving frequent o
Children's Pepto. of calcium is (hypoparathyroidism), while using certain high doses, or who have impa
  important for and a certain muscle medications renal function
Route: building and disease (latent tetany).
Oral keeping strong
  bones
Dosage:
- 125 mg
-250 mg
-650 mg
- 750 mg,
-1.25 g
- 1.5 g tablets.
 
Frequency
TID
 
 
 
 
 
Generic  Clonidine is a Clonidine hydrochloride Clonidine is an CNS: drowsiness, depression, Monitor blood pressure and pu
Name: prescription is an imidazoline antihypertensive drug that dizziness, nervousness, nightmares.  rate frequently
Clonidine medication that derivative that acting lowers blood pressure and CV: bradycardia, hypotension Report an unusually slow hear
  is used alone or centrally on alpha-2 heart rate by relaxing the (increased with epidural), (HR) (bradycardia) or signs of
Brand/Trade with other adrenergic as an arteries and increasing the palpitations.  arrhythmias, including palpitat
Name: medications to agonist. The chemical blood supply to the heart; GI: dry mouth, constipation, nausea, chest discomfort, shortness of
Catapres, treat high blood name for clonidine is 2- it has other FDA-approved vomiting.  breath, fainting, and
Catapres-TTS, pressure, to ((2,6-dichlorophenyl) indications such as: GU: erectile dysfunction.  fatigue/weakness.
Duraclon, lower blood amino)-2-imidazoline Treatment of attention Derm: rash, sweating.  Be alert for signs of depressio
Jenloga, pressure to help hydrochloride.As an deficit hyperactivity F and E: sodium retention.  nervousness, or other change
Kapvay prevent strokes, alpha-adrenergic disorder (ADHD) in Metab: weight gain.  mood and behavior. 
  heart attacks agonist in the nucleus children Misc: withdrawal phenomenon. Assess peripheral edema usin
Route: and kidney tractus solitarii (NTS), Management of tics girth measurements, volume
Oral, IV, Patch problems. clonidine excites a commonly found with displacement, and measureme
  pathway that inhibits Tourette syndrome pitting edema 
Dosage: excitatory Adjunct therapy for Be alert for a rapid increase in
Oral: 0.1 mg, cardiovascular severing cancer-related and HR if clonidine is suddenly
0.2 mg, 0.3 neurons. Clonidine has pain[ discontinued (withdrawal
mg an alpha-antagonist phenomenon)
IV: 100 effect in the posterior
mcg/ml, 500 hypothalamus and
mcg/ml medulla. The final
Patch: response is reduced
0.1mg/day sympathetic outflow
0.2mg/day from the central
0.3mg/day nervous system (CNS),
  which clinically causes
Frequency: a decrease in arterial
OD blood pressure
   Carbon dioxide from Aggravated congestive heart failure (  
Generic Sodium bicarbo the tissues diffuses Used topically for CHF)
nate rapidly into red blood dermatitis’s, mouthwash, Cerebral hemorrhage  Keep sodium bicarbonate
Name:  reduces  cells, where it is vaginal douche, veterinary Swelling (edema)
ampules handy for emerg
stomach acid. It administration.
Sodium is used as an
hydrated with water to use as emergency emetic. High blood sodium levels
form carbonic acid. Occasionally, for Low blood calcium levels Monitor vital signs, labora
carbonate antacid to treat  This reaction is dermatitides topically as a Low blood potassium levels

results and level of
  heartburn,  accelerated by lotion. Medication (Vet): In Muscle spasms (associated with low consciousness frequently.
indigestion, and  carbonic anhydrase, an solution to cleanse skin, in calcium levels)
Brand/ upset stomach. enzyme presents in eczema, to soften scabs of Metabolic alkalosis  Watch out for signs of
Trade Sodium  high concentrations in ringworm. Belching decreasing level of
bicarbonate is a consciousness.
Name: very quick-
red blood cells. The Bloating
carbonic acid formed Excess fluid in the lungs (
Alka- acting antacid. It dissociates into pulmonary edema)
 Record intake and output
 accurately to monitor ren
Seltzer® should be used bicarbonate and Hyperosmolality function.
only for hydrogen ions. Most of Intracranial acidosis
Zegerid temporary relief. the bicarbonate ions Milk-alkali syndro  For management of vomi
OTC If you need to diffuse into the plasma. (common to metabolic
treat long-term  acidosis), position the pati
  stomach acid
Since the ratio of
to prevent aspiration.
H2CO3 to dissolved
Route: problems (such CO2 is constant at
as   Prepare for possible seizu
Oral equilibrium, pH may be  and administer appropria
peptic ulcer dise expressed in terms of
  ase
bicarbonate ion
precautions.
Dosage: , GERD)
concentration.  Provide good oral hygiene
-325mg incidences of vomiting. U
sodium bicarbonate wash
-650mg neutralize acid in the pati
  mouth.
Frequency:  
TID
Generic  Ferrous Iron is required to Ferrous sulfate is used GI: Nausea, heartburn, anorexia, Lab tests: Monitor Hgb and
sulfate maintain optimal for the prevention and constipation, diarrhea, epigastric reticulocyte values during
Name: health, particularly for pain, abdominal distress, black therapy.
replenishes treatment of iron
Ferrous helping to form red stools. Continue iron therapy for 2–
iron, an deficiency anemia in
Sulfate essential blood cells (RBC) that
adults and children Special Senses: Yellow-brown after the hemoglobin level ha
  carry oxygen around discoloration of eyes and teeth returned to normal
component in the body. A deficiency (liquid forms.) Large Chronic Monitor bowel movements a
Brand/ hemoglobin, in iron indicates that Doses in Infants: Rickets (due to constipation is a common
Trade myoglobin, the body cannot interference with phosphorus adverse effect.
Name: and various produce enough absorption). Massive Educate patient to take the
enzymes. It normal red blood Overdosage: Lethargy, medication with meals to
Feosol, replaces the cells. Iron deficiency drowsiness, nausea, vomiting, minimize gastrointestinal effe
Feratab iron that is anemia occurs when abdominal pain, diarrhea, local Educate patient that Ferrous
  usually found body stores of iron corrosion of stomach and small sulfate blackens feces and m
Route: PO in hemoglobin decrease to very low intestines, pallor or cyanosis, interfere with tests for occult
and levels, and the stored metabolic acidosis, shock, blood in the stool
  iron is insufficient to cardiovascular collapse, Instruct patient not to crush o
  myoglobin. support normal red convulsions, liver necrosis, coma, chew extended-release form
Dosage: 1 blood cell (RBC) renal failure, death. Educate that this medication
production. stain teeth
tab 325 Insufficient dietary
mg iron, impaired iron
  absorption, bleeding,
  pregnancy, or loss of
iron through the urine
Frequenc can lead to iron
y: OD deficiency
NURSING
CARE PLAN
CUES
Subjective cues:
“namamanas akon mga till ngan kinukurian ako pag
hihinga” as verbalized by the patient.

Objective Cues:
• (+) Bipedal Edema
• (+) Facial grimace (chest discomfort)
• Paleness
• High level of creatinine: 1296.93 mg/dl
• High level of SGPT/ALT: 78.80
• V/s:
BP – 160/100 mmHg
HR- 95 bpm
RR- 21 cpm
O2sat- 98%
T- 36.0 C
NURSING DIAGNOSIS
1. Fluid Volume
excess related to
inability of the
kidneys to maintain
body fluid balance
RATIONALE TO NURSING DIAGNOSIS

Renal failure

Decreased blood flow to the kidneys

Decreased perfusion in kidney

Decreased urinary output

water retention

Fluid volume excess

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 GOALS AND OBJECTIVES
Short Term:

 After 4- 8 hours of nursing intervention,

the patient shall demonstrate behaviors to
monitor fluid status and reduce recurrence of
fluid excess.

Long Term:
 After 3 days of nursing intervention, the
patient will manifest stabilize fluid volume as
evidenced by:

 Balance I & O
 Normal VS
 Stable weight
 Free from signs bipedal of edema
 NURSING INTERVENTIONS RATIONALE

Independent:
 To obtain nurse-patient interaction.
  Establish rapport
 Monitor & record vital signs  To obtain baseline data

 To prevent fluid overload and monitor intake and output

 Assess patient’s appetite
 
 To monitor fluid retention and evaluate degree of excess.
 Note amount/rate of fluid intake from all
sources

 Record occurrence of dyspnea  To determine fluid retention

 May indicate increase fluid retention

 Note presence of Edema

 Restrict sodium and fluid intake  To monitor kidney function

 
Dependent:
 To excrete excess fluids
 Administer Diuretic as ordered

 To treat hypertension by counter acting effects of decreased

 Administer Antihypertensive as ordered
renal blood flow
EVALUATION
Short Term:

 After 8 hours goal was met as manifested by patient was able to

demonstrate behaviors to monitor fluid status and reduce recurrence
of fluid excess

Long Term:
 Stabilize fluid volume as evidenced by:
 Balance Intake & Output
 Normal VS as follows:
BP- 120/80
PR- 82
RR- 20
O2sat- 98
T- 36.2
 Free from signs of bipedal edema
CUES
Subjective cues:
“Pirmi ako nalilinop ngan hataas akon blood pressre” as
verbalized by the patient.
Objective Cues:

 Lethargic
 Decreased cardiac output
 Decreased stroke volume
 Increased peripheral vascular resistance
 VS taken as follows:
T: 36.0
PR: 95 bpm
RR: 21 cpm
O2sat: 98%
BP- 160/100 mmHg
NURSING DIAGNOSIS
2.Decreased Cardiac
Output secondary to
Hypertension
manifested by
decreased stroke
volume
RATIONALE TO NURSING DIAGNOSIS

Hypertension, also known as high

or raised blood pressure, is a
condition in which the blood
vessels have persistently raised
pressure. Blood is carried from the
heart to all parts of the body in the
vessels. Each time the heart beats,
it pumps blood into the vessels.

https://nurseslabs.com
 GOALS AND OBJECTIVES
Short Term:

 After 6 hours of nursing

interventions, the client will have no
elevation in blood pressure above
normal limits and will maintain
blood pressure within acceptable
limits

Long Term:

 After 5 days of nursing

interventions, the client will maintain
inadequate cardiac output and
cardiac index
 NURSING INTERVENTIONS RATIONALE
Independent:

 Monitor BP every1-2 hours, or every 5  Changes in BP may indicate changes in patient

minutes during active titration of vasoactive status requiring prompt attention
drugs

 Monitor ECG for dysrhythmias,  Decrease in cardiac output may result in changes
conduction defects and for heart rate in cardiac perfusion causing dysrhythmias

 It may decreases peripheral venous pooling that

 Suggest frequent position changes may be potentiated by vasodilators and
prolonged sitting or standing.

 Caffeine is a cardiac stimulant and may

 Encourage patient to decrease intake of adversely affect cardiac function
caffeine, cola and chocolates
 Peripheral vasoconstriction may result in pale,
 Observe skin color, temperature, capillary cool, clammy skin, with prolonged capillary
refill time and diaphoresis refill time
 NURSING INTERVENTIONS RATIONALE

Independent:

 Instruct client & family on fluid and  Restrictions can assist with decrease in
diet requirements and restrictions of fluid retention and hypertension,
sodium thereby improving cardiac output

 Promotes knowledge and compliance

 Instruct client and family on
with drug regimen
medications, side effects,
contraindications, and signs to
report.

Dependent:
 To promote wellness.
 Administer medicines as prescribed
by the physician
EVALUATION
Short Term:

After 6 hours of nursing interventions, the client’s

blood pressure lowered within normal range.

Long Term:

 After 5 days of nursing interventions, the client

maintained an adequate cardiac output and
cardiac index.
CUES
Subjective cues:
 “nanluluya akon lawas tas baga nalilinop ako” as verbalized by the
patient.
Objective Cues:

 (+) Lightheadedness
 Low Hemoglobin level- 39
 Noted to be pale
 V/s:
BP – 160/100 mmHg
HR- 95 bpm
RR- 21 cpm
O2sat- 98%
T- 36.0 C
NURSING DIAGNOSIS
3. Activity in
tolerance related to
Muscle weakness To
Decreased
hemoglobin level
RATIONALE TO NURSING DIAGNOSIS

Dec. oxygen carrying capacity of Hgb

Decreased nutrition in cells

Decreased ATP production since oxygen

is needed for oxidation of CHO/glucose

Decreased energy or muscle weakness

Activity intolerance

https://nurseslabs.com
Short Term:
GOALS AND OBJECTIVES
After 8 hours of nursing intervention, the patient will:
Be free from decubitus ulcer/bedsores or hematomas on
the most prominent parts of the body such as the back
and the buttocks.

Long Term:

 Ability to participate in activities of daily living

without feeling excessive fatigue.

 Maintain the patient’s respiratory and cardiovascular

functions during activities

 Demonstrate measurable/progressive increase in

tolerance for activity with heart rate/rhythm and BP
within client’s normal limits and skin warm, pink
and dry.
 NURSING INTERVENTIONS RATIONALE

Independent:

  Inspect all skin areas, noting capillary

blanching/ refill , redness and swelling. Pay  Skin is specially prone to breakdown because of
particular attention to back of head and folds changes in peripheral circulation, inability to sense
where skin continuously touches pressure, immobility, altered temperature
regulation.

 Enhances venous return. Reduces edema formation

 Elevate lower extremities periodically if
tolerated.

 Improves skin circulation and reduces pressure

 Reposition the patient periodically every 2 time on bony prominences
hours whether in bed or in sitting position

 Establishes client’s capabilities/ needs and

 Evaluate client’s response to activity. Note facilitated choice of interventions.
reports of dyspnea, increased weakness/ fatigue,
and changes in vital signs during and after
activities.
 NURSING INTERVENTIONS RATIONALE
Independent:

 Instruct client in energy-conserving techniques;  Energy-saving techniques reduce the energy

e.g., using chair when showering, sitting to brush expenditure, thereby assisting in equalization of oxygen
teeth or comb hair, carrying out activities at a supply and demand.
slower pace.

 Gradual activity progression prevents a sudden increase

 Encourage progressive activity/self-care when in cardiac workload. Providing assistance only as
tolerated. Provide assistance as needed. needed encourages independence in performing
activities

 Provide assistance with self-care activities as

indicated. Intersperse activity periods with rest  Meets client’s personal care needs without undue
periods. myocardial stress/excessive oxygen demand.

 Review signs/symptoms reflecting intolerance of

present activity level or requiring notification of  Palpitations, pulse irregularities, development of chest
nurse/physician. pain, or dyspnea may indicate need for changes in
exercise regimen or medication
 NURSING INTERVENTIONS RATIONALE
Collaborative

 Implement graded cardiac  Strengthens and improves cardiac

function under stress if cardiac
rehabilitation/activity program.
dysfunction is not irreversible. Gradual
increase in activity avoids excessive
myocardial workload and oxygen
consumption
EVALUATION
Short Term:

After 8 hours of nursing intervention, the patient will:

 Be free from decubitus ulcer/bedsores or hematomas on the most
prominent parts of the body such as the back and the buttocks.

LongTerm:

 Ability to participate in activities of daily living without feeling excessive

fatigue.

 Maintain the patient’s respiratory and cardiovascular functions during

activities

 Demonstrate measurable/progressive increase in tolerance for activity

with heart rate/rhythm and BP within client’s normal limits and skin
warm, pink and dry.
CASE: Jerusalem
LOCATION: Male Medical Ward EVMC
EVALUATION: Poor prognosis

 The patient has poor potential to meet expected outcome due to severe anemia,
hemoglobin is 3.9g/dl ,compare to normal value of 13.3 -16.6 gl/dl. Creatine is very
high which is 1296.93 mg/dl (normal values 0.6 -1.1 mg/dl)Hematuria +++,
Proteinuria+++ .
 The blood test and urinalysis result of the patient suggest that he has kidney failure,
and this is irreversible. Patient cannot proceed to do dialysis unless anemia will be
corrected.

 In people with CKD, severe anemia can increase the chance of developing 
heart problems because the heart is getting less oxygen than normal and is working
harder to pump enough red blood cells to organs and tissues. People with CKD and
anemia may also be at an increased risk for complications due to strokes .
(https://www.niddk.nih.gov/health-information/kidney-disease/anemia)
 Hemodialysis is the best action to alleviate patient suffering.
This course of action, however, will only allow the patient to
maintain his quality of life. It will not help with nor extend his
life expectancy.
 Without dialysis, the life expectancy for stage 5 kidney failure
is not a hard and fast answer, as it varies depending on each
kidney patient’s unique medical history. Generally, life
expectancy without dialysis can be anywhere from days to
weeks, which depends on:
Amount of kidney function
Severity of symptoms
Overall medical condition
 Without dialysis, toxic waste and fluid will build up in the
patient body. Kidney transplant is necessary in order to live.
(https://responsumhealth.com/chronic-kidney-disease/stages/
stage-5)