ESRD Secondary to Diabetic Nephropathy CASE STUDY.docx

ABSTRACT

This is a case study of an adult woman who had End-Stage Renal Disease Secondary to Diabetic Nephropathy admitted at Capitol University Medical City.

INTRODUCTION

 According to Dorothea Orem, who presented presented Self-Care Deficit Theory  – Her thought about nursing is, it must legitimate, based on the relationship between the patient and nurse that establishes a need for nursing and not some other  condition‖, such as a medical condition (Hartwig, 2001). Orem‘s grand theory continues to be modified and used around the world, encouraging people to take on the responsibility of their own physical health and psychological wellness. In life there are un-expectations with illness and disease causing the ―balance to shift‖ from self-care abilities to self-care demands that the nurse compensates for (Johnson & Webber, 2010). As nursing students, family members, human beings, we can each do our part to promote wellness thru the use of  self-care agencies and help others who are unable to do so. Background of the Study 

Patient X is a 60-year-old, female, admitted at Capitol University Medical City last January 27, 2013. She was admitted to the said hospital with chief complaint of  seizure. seizure . This was later on diagnosed as End-Stage Renal Disease secondary to Diabetic Neuropathy. End-stage kidney disease is the complete, or almost complete failure of the kidneys to function. The main function of the kidneys is to remove wastes and excess water from the body. End-stage kidney disease (ESRD) occurs when the kidneys are no longer  able to function at a level needed for day-to-day life. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of  normal. This is almost always follows chronic kidney disease. A person may have gradual worsening of kidney function for 10 - 20 years or more before progressing to ESRD.Patients who have reached this stage need dialysis or a kidney transplant. The incidence of ESRD in the developing world is difficult to estimate and ranges from 40

per million populations (pmp) to 340 pmp. The prevalence of ESRD can be more accurately recorded as the number of patients receiving renal replacement therapy. http://www.umm.edu/ency/article/000500.htm#ixzz2L3rQwIJp

It is very important to take really good care of our kidneys because they play a big role to our body which it filters our body wastes. Having discipline to ourselves regarding our  health could be a big help to prevent disease because most of us abuse that‘s why we had a lot diseases which developing to our body and most of them could lead to death. Having a good health is one of the largest treasures we could have; this could make us disease free of such serious illness. Regarding ESRD, we could only say that proper  nutrition and proper care of our kidneys is one of the important ways to prevent and to eliminate this disease to occur within us. As what we said earlier is that, one of the best way to a good health is to have a self-discipline regarding health care because we are the one who are deciding whether to have a disease or not. Living with a healthy lifestyle and good health is one of the achievable and could have a satisfying life.  As student nurses, we could help our patient by having a deep understanding understanding of the disease, that we may learn the proper intervention of the end-stage renal disease patients. In this way, we could render quality care for them. We could as well lead them to the proper treatment to lessen their agony brought by the kidney failure, in anyhow. By having a wide understanding of the disease, we could impart teachings on how we could prevent the occurrence of the disease. It is our responsibility to render information and impart health teachings to improve the condition to our patients to the best of our  abilities. One of the characteristics that we, student nurses, should have is to be informative and only through a keen of disease such as this way for us to gain all the information that we need to learn.

The scope of this study would include:

Data collected via assessment, interviews with the patient, family members and clinical records,any health problems for 3 days including the initial assessment and its appropriate nursing intervention that would be applied within her stay in the hospital, developing a plan of care that will reduce identified predicaments and complications, coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health.Further evaluations of the effectiveness of nursing interventions have been rendered to the client.  An  An ar array of fa factor tors in influencing ing th the lilimit mitatio tions of th this st study udy in include udes: Da Data co collected is is lilimit mited on only to to assessment assessment and interview to the patient‘s significant others, patient‘s chart and nurse on duty, the

per million populations (pmp) to 340 pmp. The prevalence of ESRD can be more accurately recorded as the number of patients receiving renal replacement therapy. http://www.umm.edu/ency/article/000500.htm#ixzz2L3rQwIJp

It is very important to take really good care of our kidneys because they play a big role to our body which it filters our body wastes. Having discipline to ourselves regarding our  health could be a big help to prevent disease because most of us abuse that‘s why we had a lot diseases which developing to our body and most of them could lead to death. Having a good health is one of the largest treasures we could have; this could make us disease free of such serious illness. Regarding ESRD, we could only say that proper  nutrition and proper care of our kidneys is one of the important ways to prevent and to eliminate this disease to occur within us. As what we said earlier is that, one of the best way to a good health is to have a self-discipline regarding health care because we are the one who are deciding whether to have a disease or not. Living with a healthy lifestyle and good health is one of the achievable and could have a satisfying life.  As student nurses, we could help our patient by having a deep understanding understanding of the disease, that we may learn the proper intervention of the end-stage renal disease patients. In this way, we could render quality care for them. We could as well lead them to the proper treatment to lessen their agony brought by the kidney failure, in anyhow. By having a wide understanding of the disease, we could impart teachings on how we could prevent the occurrence of the disease. It is our responsibility to render information and impart health teachings to improve the condition to our patients to the best of our  abilities. One of the characteristics that we, student nurses, should have is to be informative and only through a keen of disease such as this way for us to gain all the information that we need to learn.

The scope of this study would include:

Data collected via assessment, interviews with the patient, family members and clinical records,any health problems for 3 days including the initial assessment and its appropriate nursing intervention that would be applied within her stay in the hospital, developing a plan of care that will reduce identified predicaments and complications, coordinating and delegating interventions within the plan of care to assist the client to reach maximum functional health.Further evaluations of the effectiveness of nursing interventions have been rendered to the client.  An  An ar array of fa factor tors in influencing ing th the lilimit mitatio tions of th this st study udy in include udes: Da Data co collected is is lilimit mited on only to to assessment assessment and interview to the patient‘s significant others, patient‘s chart and nurse on duty, the

interaction, assessment and care were only limited to a total of 8 hours (2 days clinical duty) with actual nursing intervention done.

SIGNIFICANCE OF THE STUDY Nursing Education

This study can be a useful learning guide in nursing education as this can be used by students as a reference for future studies regarding End-Stage Renal Disease and related cases. This case study will enable the students to learn how to assess p atient‗s with any signs of kidney disorders and be able to provide appropriate nursing care and management. Furthermore, the students will learn about the nursing interventions and have an idea of  the rationale behind its actions. They can apply these interventions in the real setting when they encounter the same or similar condition. In this way, they are acquiring more knowledge about the disease that they can use to further develop their skills as student nurses and future nurses. It may open a new door in the practice of getting quality care. This study might also inspire other individuals to come up with their own research about this disorder or any similar condition. Nursing Practice

This case study can be used as a tool in nursing practice because it provides nursing interventions for patients with End-Stage Renal Disease. This study can give a good introduction to the disorder so that an established nursing action can be quickly utilized. Through this study, important information regarding this illness has been gathered which will be helpful on the researchers to have an in-depth understanding on the said disorder. Nursing Research

The case can be used as a baseline data for further research of the current management of patients with End-Stage Renal Disease. There might be some information in this study that can be of good use for future research. It is important to do research every now and then to gain new information, better interventions and techniques to provide to the patients. Aside from being beneficial as a simple academic informative material, this study might serve as a guide for orienting people about the substance of the disease, and how this disease affects people. Therefore through this study, the researchers should have introduced the symptoms (for early detection), treatment (for information), and management.

OBJECTIVES OF THE STUDY:

General Objective

This study aims to convey familiarity and to provide an effective nursing care to a patient diagnosed with End-stage Renal Disease through understanding the patient history, disease process and management.

Specific Objectives

1.

To present a thorough assessment, through Nursing Health History,

Gordon‘s Typology 11 Functional Pattern, Physical Assessment, and

the

interpretation of the laboratory examination done on the patient. 2.

To discuss the anatomy and physiology, pathophysiology of the patient‘s

condition, usual clinical manifestations and possible complications of this condition. 3.

To have knowledge to the client medication and be familiar familia r to that

medication. 4.

Thoroughly discuss, explain and elaborate the nature of the disease

process. 5.

To formulate a workable nursing care plan on the subjective and objective

cues gathered through nurse-patient interaction to be able to help the patient recover.

PATIENT’S PROFILE

Nursing Health History

The following nursing health history includes the health history of the patient. The researchers deemed it important to include assessing factors which may have contributed to the patient‘s present condition. Bibliographical Data

Patient X, a 60-years-oldwoman , Filipino, residing in Tagoloan, Misamis Oriental was admitted at Capitol University Medical City Intensive Care Unit last January 27, 2013. The whole family‘s religion is Roman Catholic. She weighs 72 kg and 154 cm long. Upon admission her vital signs are: BP: 170/90 mmHg, Temperature: 36.8 C, Pulse °

rate: 75 beats per minute and Respiratory rate: 28 cycles per minute. Chief Complaint

 According to her husband, she had episodes of seizure, had muscle twitching and body weakness and brought to the emergency room in Capitol University Medical City. History of Present Illness

Patient X is diagnosed of End-stage Renal Disease secondary to Diabetic Neuropathy. She was admitted at Northern Mindanao Medical Center at January 2013, advised for  hemodialysis but unable to comply. Since then patient had episodes of muscle twitching with body weakness. Family decided to allow patient to have hemodialysis in this institution. Family History of Illnes

Patient X parents are both positive for Diabetes Mellitus and Hypertension. Functional Health Pattern

Patient X used to smoke 1 pack per week for 10 years and used to drink alcoholic drinks 1 bottle a week for 15 years. She also drinks coffee and cola almost every day, She had no allergies and taking a maintenance drug for hypertension. Nutritional and Metabolic Pattern

When Patient X was not yet hospitalized she used to eat high fat foods, she ate 3 times a day and drinks 8 to 12 glasses of water a day. The day she was admitted, she is fed via nasogastric tube by OF 1000 kcal 1:1 dilution in 6 divided feeding 75 cc per feeding.

Elimination Pattern

Patient X‘s usual elimination pattern is firm brownish stool 2 times a day without drinking any laxatives. She doesn‘t have discomforts, incontinence or hemorrhoids. Her last bowel movement was on last February 6, 2013. She used to urinate 4 times a day with dark yellow to yellowish urine for about 1 cup urine per urination. Activity-Exercise Patterns

Patient X exhibited decreased tolerance to activities; the reason for mobility limitation is due to weakness of the muscles, had muscle twitching and pain. She was totally dependent in feeding, dressing, grooming and toileting (ADL=4), assisted with person in bathing, bed mobility, general mobility (ADL=2), andtotally dependent in meal preparation, and cleaning (ADL=4). Legend:

Level (0) - Full Self care Level (1) - Requires use of equipment or device Level (2) - Requires assistance or supervision from another person Level (3) - Requires assistance or supervision from another person or device Level (4) - dependent and does not participate Sleep-Rest Pattern

Patient X usually sleeps at 9 PM and awakens at 6 AM in the morning. She also had time to have a nap in the afternoon. Cognitive-Perceptual Pattern

Patient X‘s hearing is decreased but doesn‘t use hearing aid. She uses reading eye glasses when he read books and newspapers. Her primary language is Cebuano and she has no speech deficit. She is a college undergrad. She always complained pain on her stomach and her feet. Self-Perception and Self-Concept Pattern

―I feel so sickly nowadays‖, as verbalized by the patient. He feels lucky because her  family is there to help her in times of difficulties. She will be in debt when she will be discharged due to the long stay in hospital but she‘s still happy that she was given another chance to live.

Role-Relationship Pattern

She lived with her husband, children and grandchildren. Her three children was married and one is still single. She‘s a housewife making some opportunity to w ork. She had financial support on her children but not so often. She doesn‘t have problem with her  children because they have work and had been supporting her. Sexuality-Reproductive Pattern

She understood that she‘s getting told and her husband too so their sexual relationship has been stopped but still happy to be together. She had undergone oophorectomy when she was 40 years old. Her husband had no problem with the prostate and didn‘t perform monthly self-testicular exam. Coping-Stress Tolerance Pattern

In the hospital, she experienced a quality nurse-service experience. Everything was in order and on time. At home, she managed stress by watching television and conversations with her family and neighbors. She asked support from his family which is always there. Value-Belief Pattern

The family is Roman Catholic. They always go to church every Sunday. This is very important tothem because this is the only way to have them courage whenever aches and problems brought them down. Developmental data

Erik Erikson‘s Stages of development: Generativity vs. S tagnation During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- dissatisfaction with the relative lack of productivity. She is in the stage of Generativity vs. Stagnation.

PHYSICAL ASSESSMENT Integumentary System

Her skin was warm to touch, dehydrated, rough and her general color is pallor and dusky. Poor skin Turgor. Head, Eyes, Ears, Nose and Throat (HEENT)

Her head is normocephalic with closed fontanels, clean scalp, coarse hair and symmetrical facial movements. Pale lips, gums and mucosa.. The tongue is midline. Eyes are aligned and non-edematous. There is positive blink reflex and positive corneal reflex. Trachea is midline and thyroid is non-palpable. The pinnas of the ears are flexible, without deformity and are aligned with the external cantus of eyes. Respiratory System

There was irregular breathing pattern. Respiratory rate is 28cpm. With mechanical ventilator upon admission. Crackles heard upon auscultation on both lungs. Cardiovascular System

There is no cyanosis. Apical pulse is 75bpm. Precodial area is flat; point of maximal impulse is in the 5 th intercostal space midclavucular line. Peripheral pulses are symmetrical and capillary refill is 3 seconds. Gastrointestinal System

The abdomen is protuberant and the bowel sounds are normoactive. Percussion is tympanic and configuration is symmetrical. Anus is patent. . Genitourinary System

He has yellowish urine 3 times daily with no discomfort. Reproductive System

The genitalia is normal and no problem. Musculoskeletal System

He has a complete set of fingers and toes.Edematous Feet and fingers. No dimpling is observed; there are equal gluteal folds. Decreased range of motion. There are no fractures or dislocations; no clicks in the joints. Decreased muscle tone. Arms and legs are symmetrical in size and decreased movement.

Neurological

Unconscious upon admission.

Day 1 (February 1, 2013)

Neurological: Unconscious

Respiratory: RR 28 cpm,crackles on both lungs

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed, eyes: positive blink reflex and positive corneal reflex. Trachea is midline and thyroid is non-palpable.

Cardiovascular: BP 170/90 mmHg, HR: 75 bpm. Integumentary: Pallor, dusky, rough texture, poor turgor, dry moisture, Temp: 36.8 degrees Celsius

Genitourinary: no nodules and discharges

Gastrointestinal: No rmoactive bowel sounds, muscle guarding, pain in abdominal area

Capillary refill time: 3 seconds

Musculoskeletal: Generalized weakness, decreased range of  motion of extremities, uncoordinated gait

Day 3 (February 8, 2013)

Neurological: Conscious and drows

Respiratory: RR 27 cpm,crackles on both lungs

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed, eyes: positive blink reflex and positive corneal reflex. Trachea is midline and thyroid is non-palpable.

Cardiovascular: BP 150/90 mmHg, HR: 76 bpm, Integumentary: Pallor, dusky, rough texture, poor turgor, dry moisture, Temp: 36.5 degrees Celsius

Gastrointestinal: No rmoactivebowel sounds.

Genitourinary: no nodules and discharges

Capillary refill time: 3 seconds

Musculoskeletal: Generalized weakness, decreased range of  motion of extremities.

Day 2 (February 11, 2013)

Neurological: Conscious and res onsive

Respiratory: RR 25 cpm,crackles on both lungs

Head, Eyes, Ears, Nose and Throat (HEENT): skull symmetrical, fontanels closed, eyes: positive blink reflex and positive corneal reflex. Trachea is midline and thyroid is non-palpable.

Cardiovascular: BP 140/90 mmHg, HR: 71 bpm. Integumentary: Pallor, dusky, rough texture, poor turgor, dry moisture, Temp: 36.9 degrees Celsius

Gastrointestinal: No rmoactivebowel sounds.

Genitourinary: no nodules and discharges

Capillary refill time: 3 seconds

Musculoskeletal: Weak, decreased range of  motion of extremities.

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

The

kidneys

are

two

main

shape

structures which lie in the retroperitoneal space between the 12 thoracic and third lumbar vertebra. The left kidney sets slightly behind the spleen, while the right kidney sets behind the liver and is slightly lower than the left. Each kidney is enclosed in a tough fibrous capsule and is supported and protected by fat tissue. There is a fissure in the central content portion of the kidney where the blood vessels enter and leave. This is called the hilus. Also coming from the hilus, are to

the ureters which connect the kidney to the bladder. The cortex is a brownishtissue which covers the outer third of the kidney. The medulla are light-colored and cone-shaped, these are the renal pyramids. The papilla are formed by the free ends of the pyramids which opens into the renal pelvis. Therenal pelvis is made up of calyces, which drained up or lower hands of the kidney. Days unite with a renal pelvis at the upper end of the ureter. The functional unit of the kidney are the nphrons, each kidney contains approximately 1.2 million of these. Within each nephron there is a glomerulus and a tubule. Within the glomerulus, there is a structure called Bowman's Capsule which contains a network of capillaries. fluid in particles from the blood and are filtered through this membrane. Water, nutrients and electrolytes, as well as other substances, are reabsorbed as they pass through these tubulars. There is collecting duct which collects fluid from several nephrons and passes this fluid into the renal pelvis. Two capillary beds, a glomerulus, and a peritubular network supply the nephron. The glomerulus is a unique, high pressure capillary filtration system that is located between

two arterioles, the afferent and efferent arterioles. The low-pressure reabsorptive system of the peritubular capillary network arises from the efferent arteriole. Excretory functions 1. Filtration - the process of removing fluids and small particles from the blood.

a. the glomerulus, which lies between two arterioles, allows for high-pressure filtration system. Capillary filtration pressure in the glomerulus is 2-3 times as high as that of  other capillary beds in the body. The filtration pressure and the glomerular filtration rate (GFR) are regulated by the constriction or relaxation of the afferent and efferent arterioles. During strong sympathetic stimulation, which causes marked constriction of  the afferent arteriole, the filtration pressure is reduced to the point where GFR drops to almost 0. b. Capillary membrane of the glomerulus is composed of 3 layers: 1. endothelial layer of the capillary 2. basement membrane 3. a layer of epithelial cells that line Bowman's capsule c. Glomerular capillary permeability is 100-1000 times as great as capillaries elsewhere in the body. All 3 layers allow water and dissolved particles, such as electrolytes, to leave the blood and pass rapidly into Bowman's capsule. Blood cells and plasma proteins are too large to pass through the glomerular membrane of a healthy kidney. d.Glomerular filtration rate (GFR) is normally about 125 ml per minute. GFR can provide a measure to assess renal function, and can be measured clinically by collecting timed samples of blood and urine.

2. Creatinine - product of creatine metabolism by the muscle. Is filtered by the kidney,

but not absorbed in the renal tubule. Formula for creatinine clearance: C=UV P C = clearance rate U = urine concentration V = urine volume P = plasma concentration

Normal creatinine clearance is 115-125 ml/min (corrected for body surface area) Usually 24 hour collection with blood drawn when urine collection is completed.

3. Tubular reabsorption and secretion

The filtrate from the glomerulus passes through: 1. proximal tubule 2. loop of Henle 3. distal tubule 4. collecting duct

Then it reaches the pelvis and kidney Reabsorption: water, sodium, and other substances leave the lumen of the tubule and enter the blood. Secretion: substances from the blood enter lumen of the tubule. Glucose and amino acids - completely reabsorbed Filtered water - 99% reabsorbed Urea - about 50% reabsorbed Creatinine - none Electrolytes - determined by need

3. Urine concentrating ability of the kidney: 2 mechanisms (SLIDE)

1. Increased solute concentration in the medullary area surrounding the collecting tubules. Loop on Henle and peritubular capillary (vasa recta) descending into the renal medulla. Here a countercurrent mechanism controls water ans solute flow. As a result, water is kept out of the peritubular area surrounding the tubules, and sodium and urea are retained. 2. Selective permeability of collecting tubules (controlled by ADH) During dehydration, the kidney plays a major role in maintaining water balance. Osmoreceptors in the hypothalamus sense the increase in extracellular osmolality and stimulate release of   ADH from posterior pituitary. Collecting tubules (under influence of ADH) become permeable to water. In the absence of ADH, the renal tubules remain impermeable to water and a dilute urine is formed. Specific gravity (osmolality) of urine varies with its concentration of solutes. Specific gravity provides index of hydration status and functional ability of the kidneys. Concentrated urine: 1.030 - 1.040 (SLIDE) Marked hyration or dilute: 1.000 4. Sodium and potassium regulation

Sodium and potassium regulation (SLIDE) glomerular filtrate reabsorbed in proximal tubule. Na and KC1 pumped (requires energy) into intercellular spaces, and absorbed into peritubular capillaries. Water movement accompanies the movement of these particles. Na reabsorption in distal tubule is variable and dependent on aldosterone. In the presence of aldosterone, almost all of sodium is reabsorbed and urine becomes almost sodium free.

5. Potassium regulation

Potassium regulation - aldosterone mediated secretion of K into tubular fluid. (Can be reabsorbed in distal and collecting tubules, but since dietary intake far exceeds need, secretion usually exceeds reabsorption.) 6. Endocrine fuctions

1. Renin - released by special cells located near the glomerulus (juxtaglomerular cells) in response to: Reduction in GFR Sympathetic stimulation - Combines with angiontensinogen, a plasma protein that circulates in the blood to form angiotensin I, then converted to angiotensin II (potent vasoconstrictor and stimulator of aldosterone release). 2. Erythropoietin - released in response to hypoxia. Acts on bone marrow to stimulate production and release of RBCs. Persons with chronic hypoxia often have increased RBCs (polycythemia) due to increased erythropoietin levels. Examples: congestive heart failure, chronic lung disease, living at high altitude. 3. Vitamin D - activated and converted in kidney. Affects calcium metabolism.

DECREASED CARDIAC OUTPUT

Subjective:

Objective: -Non-pitting edema -Cold Clammy skin -Prolonged capillary refill -Decreased peripheral pulses -Increased Blood pressure -Oliguria

NURSING DIAGNOSIS: Decreased Cardiac Output related to altered heart rate and increased blood pressure of /

Goals and Objectives: Long Term: After 8 hours of nursing care the patient will be able to lower her blood pressure from 148/84 to 130/80 .

INTERVENTION:

INDEPENDENT: 

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Keep client on bed in position of comfort R: Decreases oxygen consumption and risk of decompensation Monitor vital signs frequently R: To note response to activities interventions Monitor rate of Intravenous drugs closely using infusion pup as appropriate R: To prevent from overdose Assess urine output hourly noting total fluid balance R: To allow for timely alterations in therapeutic regimen Provide quiet environment R: To promote adequate rest. Avoid use of restraints whenever possible if client is confused R: May increase agitations and increase the cardiac workload

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Encourage relaxation techniques R: To reduce anxiety and conserve energy Dependent: Administer blood or fluid replacement ,antibiotics and diuretics per doctors order  as indicated R: To determine therapeutic ,adverse or toxic effects of therapy. Use sedation and analgesics as indicated with caution R: To achieve desired effect without compromising hemodynamic readings. EVALUATION:  After 8 hours of nursing care goals partially met the patients blood pressure lowers down from 148/84 to 135/85

FLUID VOLUME EXCESS

SUBJECTIVE:

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OBJECTIVE: Non- pitting edema Weight gain over short period of time Oliguria Pulmonary Congestion Blood pressure changes Decreased hemoglobin Nursing Diagnosis: Fluid Volume excess related to blood pressure changes , intake exceeds output such as oliguria as evidenced by non pitting edema

Planning:  After 8 hours of nursing care the patient will be able to stabilize fluid volume as evidenced by balanced Intake and Output vital signs within client‘s normal limits and free from signs of edema

Intervention: 

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Place in semi-fowlers position as appropriate R: To facilitate movement of diaphragm thus improving respiratory effort Assess neuromuscular reflexes R: To evaluate for presence of electrolyte imbalances such as hypernatremia Observe skin and mucous membranes R: For presence of decubitus or ulceration Note fever  R: Client could be at increased risk of infection Set an appropriate rate of fluid intake or infusion throughout 24 hours period R: To prevent peaks and valleys in fluid level and thirst

DEPENDENT: 

Administer medications such as diuretics and plasma or albumin volume per  doctors order  R: To determine effects of therapy

EVALUATION:

 After 8 hours of nursing care goals partially met the patient was able to have a stabilize blood pressure from 148/84 to 135/85 and was free from any signs of edema

IMPAIRED GAS EXCHANGE SUBJECTIVE:

OBJECTIVE:   

Lethargic Dusky skin Nasal flaring

Nursing diagnosis: Impaired Gas Exchange related to irregular breathing rate and rhythm and altered oxygen supply Planning:  After 30 minutes of nursing care the patient will improve ventilation and adequate oxygenation  After 8 hours of nursing care the patient will be able to have an absence of symptoms of  respiratory distress Intervention: 

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Elevate head of Bed and position client appropriately provide airway adjuncts and suction as needed R: To maintain airway Evaluate Pulse oximetry R: To determine oxygenation and level of carbon dioxide retention

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Maintain adequate Intake and Output R: For mobilization of secretions, but avoid fluid overload Avoid use of face mask in emaciated client R: As oxygen can leak out around the mask because of poor fit and mask can increase client‘s agitation Encourage adequate rest and limit activities to within client tolerance .Promote calm ,restful environment R: Helps limit oxygen needs and consumption Minimize blood loss from procedures (hemodialysis) R: To limit adverse affects of anemia

DEPENDENT: Administer medications as indicated such as antibiotics and bronchodilators per  doctors order  R: To treat underlying cause

INEFFECTIVE PERIPHERAL TISSUE PERFUSION Subjective:

    

Objective: Diminished pulses Altered skin characteristics (color, elasticity ,nails ,sensation and temperature) Skin color pale on elevation Non pitting edema Altered motor function

Nursing Diagnosis: Ineffective Peripheral Tissue perfusion related to non pitting edema Planning :  After 8 hours of nursing care the patient will be able to minimize perfusion and free from discomfort

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Intervention: Assess presence, location and degree of swelling or edema formation .Measure circumference of extremities, noting differences in size. R: Useful in identifying or quantifying edema in involved extremity Measure capillary refill R: To determine adequacy of systemic circulation Inspect lower extremities for skin texture(reddened skin) and skin breaks or  ulcerations R: That often accompany diminished peripheral circulation Provide interventions R: To promote peripheral circulation and limit complications associated with poor  perfusion and tissue injury DEPENDENT: Administer medications such as antiplatelet agents, and antibiotics per docrors order  R: To improve tissue perfusion or organ function Administer fluids ,electrolytes and oxygen as indicated by the doctor  R: To promote optimal blood flow, organ perfusion and function Collaborative: Collaborate in treatment of underlying conditions such as diabetes, hypertension and other conditions R: To maximize systemic circulation and organ perfusion. EVALUATION:  After 8 hours of nursing care goals partially met the patient is able to have a peripheral pulses and free from pain and any discomfort.

 ACUTE PAIN SUBJECTIVE:

OBJECTIVE:      

Guarding behavior  Facial mask Restless Change in blood pressure Increased heart rate and respiratory rate Reduced interaction with people NURSING DIAGNOSIS:  Acute pain related to stomach pain secondary to peptic ulcer  Planning : Short Term:  After 30 minutes of nursing care the patient will be able to relieve the pain from 8/10 to 6/10. Long Term: After 8 hours of nursing care the patient will be able to reduce the pain and have a – facial grimace and – guarding behavior noted.

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Intervention: Assess for referred pain, as appropriate , R: To help determine possibility of underlying condition or organ dysfunction requiring treatment. Monitor skin color and temperature and vital signs ( increased temperature,pulserate,respiratory rate and blood pressure) R: Which are usually altered in acute pain Provide comfort measures (touch, repositioning,quite environment and calm environment) R: To promote non pharmacological pain management Encourage adequate rest periods R: To prevent fatigue DEPENDENT: Administer analgesics as indicated per doctors order  R: To maintain acceptable level of pain and meet pain control goal EVALUATION:

 After 30 minutes of nursing care goals met the patients pain was relieved and shows a negative guarding behavior and negative facial grimace noted as the blood pressure was stabilized

IDEAL DIAGNOSTIC/LABORATORY TEST

Complete blood count is monitored for any hematologic abnormalities and to monitor presence of infections. The complete blood count or CBC test is used as a broad screening test to check for such disorders as anemia, infection, and many other  diseases. It is actually a panel of tests that examines different parts of the blood and includes the following:

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White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant.

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White blood cell differential looks at the types of white blood cells present. There are five different types of white blood cells, each with its own function in protecting us from infection. The differential classifies a person's white blood cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils.

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Red blood cell (RBC) count is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions.

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Hemoglobin measures the amount of oxygen-carrying protein in the blood.

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Hematocrit measures the percentage of red blood cells in a given volume of whole blood.



The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of  platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.



Mean corpuscular volume (MCV) is a measurement of the average size of  your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.



Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.



Mean corpuscular hemoglobin concentration (MCHC) is a calculation of  the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.



Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such aspernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes an increase in the RDW.

BLOOD GLUCOSE TEST

Blood glucose test is done to monitor serum glucose, patient may risk for  hypoglycemia since patient will be on NPO status.

 A blood glucose test measures the amount of a type of sugar, called glucose, in your blood. Glucose comes from carbohydrate foods. It is the main source of energy used by the body. Insulin is a hormone that helps your body's cells uses the glucose. Insulin is produced in the pancreas and released into the blood when the amount of  glucose in the blood rises.

Normally, your blood glucose levels increase slightly after you eat. This increase causes your pancreas to release insulin so that your blood glucose levels do not get too high. Blood glucose levels that remain high over time can damage your eyes, kidneys, nerves, and blood vessels.

BLOOD TYPING TEST

Blood type tests are done before a person gets a blood transfusion and to check a pregnant woman's blood type. Human blood is typed by certain markers (called antigens) on the surface of red blood cells.

Blood is often grouped according to the ABO blood typing system. This method breaks blood types down into four categories: 

Type A



Type B



Type AB



Type O

Your blood type (or blood group) depends on the types that are been passed down to you from your parents.

BLOOD CROSSMATCH

 A blood crossmatch (BCM) is performed to detect serological incompatibility by identifying antibodies in donor or recipient plasma against recipient or donor red blood cells. A BCM is divided into two parts: the major crossmatch consists of mixing the patient‗s plasma with the donor‗s red blood cells; the minor crossmatch consists of  mixing the donor‗s plasma with the patient‗s red blood cells. Of the two tests, the major  blood crossmatch is much more important in determining survival of the transfused red blood cells.

ACTUAL DIAGNOSTIC/LABORATORY TEST

February 08, 2013

TEST Potassium

CLINICAL CHEMISTRY

RESULTS 6.3

NORMAL VALUE 3.5-5.3 mg/dl

INTERPRETATION Hyperkalemia. Due to decreased renal excretion of potassium and renal failure. Decreases the resting membrane potential.

Calcium

11.3

8.4-10.4 mg/dl

Sodium

128

135-145 mg/dl

Hypercalcemia. Can cause muscle spasms. Caused by an increased protein binding which elevates the serum total calcium concentration without any rise in the serum ionized calcium concentration Hyponatremia.

Phosphorus

5.0

3.0-4.5 mg/dl

Hyperphosphatemia

BUN

27

8-25 mg/ml

Creatinine

1.9

0.6-1.5 mg/ml

The body is either splitting off too much Nitrogen, or  the body is not excreting it like it should. kidneys aren't working well. Creatinine level may temporarily increase if  dehydrated, have a low blood volume, eat a large amount of meat or take certain medications.

February 08, 2013

TEST

URINALYSIS

RESULTS

NORMAL VALUE

Protein

Traced + 3

RBC

Traced 6

February 09, 2013

TEST RBC Count WBC Count

0-8 mg/dl 0-4/hpf

INTERPRETATION Proteinuria. Hematuria

COMPLETE BLOOD COUNT

RESULTS 3.10 13,600

NORMAL VALUE 3.8-5.1cell/mm 5,000-10,000 cell/mm

INTERPRETATION  Anemia The body is attempting to fight an infection and response to injury

IDEAL MEDICAL MANAGEMENT Hemodialysis

In hemodialysis, blood is removed from the body and filtered through a man-made membrane called a dialyzer, or artificial kidney, and then the filtered blood is returned to the body. The average person has about 10 to 12 pints of blood; during dialysis only one pint (about two cups) is outside of the body at a time. To perform hemodialysis there needs to be an access created to get the blood from the body to the dialyzer and back to the body. There are three access types for hemodialysis: arteriovenous (AV) fistula, AV graft and central venous catheter. The AV fistula is the vascular access most recommended by the dialysis community; however, you and your doctor will decide which access is best for you. When a patient goes to hemodialysis, a nurse or technician will check vital signs and get the patient‘s weight. The weight gain will tell how much excess fluid the patient has to have removed during the treatment. Th e patient is then ―put on the machine‖. Patient with a vascular access (AV fistula or AV graft) will get two needle sticks in their access; one needle takes blood out of the body, the other needle puts it back. Patients with a central venous catheter will have the two tubes from their access connected to the blood tubes that lead to the dialyzer and back to the body. Once the patient is ―put on the machine‖, the dialysis machine is programmed and then treatment begins. Blood never actually goes through the dialysis machine. The dialysis machine is like a big computer and a pump. It keeps track of blood flow, blood pressure, how much fluid is removed and other vital information. It mixes the dialysate, or dialysis solution, which is the fluid bath that goes into the dialyzer. This fluid helps pull toxins from the blood, and then the bath goes down the drain. The dialysis machine has a blood pump that keeps the blood flowing by creating a pumping action on the blood tubes that carry the blood from the body to the dialyzer and back to the body. The dialysis machine also has many safety detection features. If you visit a dialysis center, you will likely hear some of  the warning sounds made by a dialysis machine. Renal Transplant Therapy (Kidney Transplant)

 A kidney transplant is a surgical procedure to place a functioning kidney from a donor  into a person whose kidneys no longer function properly. Your kidneys remove excess fluid and waste from your blood. When your kidneys lose their filtering ability, dangerous levels of fluid and waste accumulate in your body — a condition known as kidney failure. A kidney transplant is often the best treatment for  kidney failure.

Only one donated kidney is needed to replace two failed kidneys, making living-donor  kidney transplantation an option. If a compatible living donor isn't available for a kidney transplant, your name may be placed on a kidney transplant waiting list to receive a kidney from a deceased donor. The wait could be a few years. Peritoneal Dialysis

Peritoneal dialysis (PD) is a treatment for patients with severe chronic kidney disease. The process uses the patient's peritoneum in the abdomen as a membrane across which fluids and dissolved substances (electrolytes, urea, glucose, albumin and other  small molecules) are exchanged from the blood. Fluid is introduced through a permanent tube in the abdomen and flushed out either every night while the patient sleeps (automatic peritoneal dialysis) or via regular exchanges throughout the day (continuous ambulatory peritoneal dialysis). PD is used as an alternative to hemodialysis though it is far less commonly used in many countries, such as the United States. It has comparable risks but is significantly less costly in most parts of the world, with the primary advantage being the ability to undertake treatment without visiting a medical facility. The primary complication of PD is infection due to the presence of a permanent tube in the abdomen.

ACTUAL MEDICAL MANAGEMENT C l o n i d i n e  is a generc name of Catapres an Antihypertensive drug, given 10 mg

four times daily for the first 2-4 days, increase to 25 mg four times daily for the balance of the first week. This drug is centrally acting antiadrenergic derivative. Stimulates alpha2-adrenergic receptors in CNS to inhibit sympathetic vasomotor centers. Central actions reduce plasma concentrations of norepinephrine. It decreases systolic and diastolic BP and heart rate. Orthostatic effects tend to be mild and occur infrequently.  Also inhibits renin release from kidneys. This is use to treat hypertension, either alone or with diuretic or other antihypertensive agents. Epidural administration as adjunct therapy

for

severe

dizziness,nervousness,

pain.Adverse nightmares,

effects

hypotension

are

drowsiness,

(especially

with

depression, epiduraluse),

palpitations, bradycardia, nausea, vomiting, constipation, drymouth, urinary retention, nocturia, erectiledysfunction, sodium retention, rash, sweating, pruritus, and dermatitis. Contraindicated

to

patient‘sh ypersensitivity

to

components

of

adhesive

layer 

(transdermal form), infection at epidural injection site, bleeding problems (epidural use) and concurrent anticoagulant therapy. For nursing responsibilities, monitor patient for  signs and symptoms of adverse cardiovascular reactions, frequently assess vital signs, especially blood pressure and pulse and monitor patient for drug tolerance and efficacy.

Hydralazine is a generic name of Apresoline an Antihypertensive drug. It relaxes

vascular smooth muscles of arteries and arterioles, causing peripheral vasodilation and decreasing peripheral vascular resistance. These actions decrease blood pressure and increase heart rate, stroke volume, and cardiac output.Indicated as essential hypertension, alone or as an adjunct. Adverse effects are,dizziness, drowsiness, headache,peripheral neuritis,tachycardia, angina, orthostatic hypotension,lacrimation, nasal congestion, nausea, vomiting, diarrhea, constipation,anorexia, sodium retention,  joint

pain,

arthritis,rash,

lymphadenopathy,

edema,

blisters,

flushing,

lupuslike

syndrome .

pruritus,

urticaria,chills,

Contraindicated

with

fever, patient‘s

hypersensitive to drug or tartrazine, patients with coronary artery disease and mitral valvular rheumatic heartdisease. The nurse is responsible to monitor CBC, lupus erythematosus cell studies, and antinuclear antibody titers before and periodically during therapy, monitor blood pressure, pulse rate and regularity, and daily weight and to avoid rapid blood pressure drop, taper dosage gradually before discontinuing.

A x e r a  is a generic name of Cefepime an Anti-infective drug that use to interferes

with bacterial cell-wall synthesis and division by binding to cell wall, causing cell to die.  Active against gram-negative and gram-positive bacteria, with expanded activity against gram-negative bacteria.Exhibits minimal immunosuppressant activity. Indicated as a

treatment

for

urinary

tract

infections

(UTIs)

caused

by

Escherichia

coli,

Klebsiellapneumoniae, and Proteus mirabilis. Its adverse effects are phlebitis,

hypotension, palpitations, chest pain, vasodilation,hearing loss, nausea, vomiting, diarrhea,

abdominal

cramps,

oral

candidiasis,

pseudomembranous

colitis.

Contraindicated to patient‘s hypersensitive to cephalosporins or penicillins. The nurse should assess baseline CBC and kidney and liver function test results.Monitor for signs and symptoms of superinfection and other serious adverse reactions, monitor for  inflammation at infusion site and be aware that cross-sensitivity to penicillins may occur.

H y d r o c o r t i s o n e   is a geneic name of Cortef Fluid, is an anti-inflammatory

(steroidal) drug that suppresses inflammatory and immune responses, mainly by inhibiting migration of leukocytes and phagocytes and decreasing inflammatory mediators.

Indicated

as

replacement

therapy

in

adrenocortical

insufficiency;

hypercalcemia due to cancer; arthritis; collagen diseases; dermatologic diseases; autoimmune and hematologic disorders; trichinosis; ulcerative colitis; multiple sclerosis; proctitis;

nephrotic

syndrome;

aspiration

pneumonia

hydrocortisone,

hydrocortisonecypionate. Adverse effects are,headache, nervousness, depression,

euphoria, personality changes, psychoses, vertigo, paresthesia, insomnia, restlessness, conusmedullaris

syndrome,

meningitis,

increased

intracranialpressure,

seizures,hypotension, hypertension, thrombophlebitis,heart failure, shock, fatembolism, thromboembolism,

andarrhythmias.

This

drug

is

contraindicated

with

patient‘ s

hypersensitive to drugs, alcohol, bisulfites, or tartrazine (with some products), patients with

systemic

fungal

infections,

concurrent

use

of

other

immunosuppressant

corticosteroids and concurrent administration of livevirus vaccines. The nurse should monitor blood pressure, weight, and electrolyte levels regularly.Assess blood glucose levels in diabetic patients. Expect to increase insulin or oral hypoglycemic dosage.

is a generic name of Buminate, a volume expanders, colloid drug that Albumin  provides colloidal oncotic pressure, which serves to mobilize fluid from extravascular  tissues back into the intravascular space and requires concurrent administration of  appropriate crystalloid. It indicates expansion of plasma volume and maintenance of  cardiac output in situations associated with fluid volume deficit, including shock, hemorrhage, and burns and temporary replacement of albumin in diseases associated with low levels of plasma proteins, such as nephrotic syndrome or end-stage liver  disease, resulting in relief or reduction of associated edema. Adverse effects are headache, pulmonary edema, fluid overload, hypertension, hypotension, tachycardia. increasedsalivation, nausea, vomiting, rash, urticaria,back pain, chills, fever and flushing. This drug is contraindicated to patient‘s allergic reactions, severe anemia, HF

and normal or increased intravascular volume. The nurse should monitor vital signs, CVP, and intake and output before and frequently throughout therapy. If fever, tachycardia, or hypotension occurs, stop infusion and notify physician immediately.  Antihistamines

may

be

required to

suppress

this

hypersensitivity response.

Hypotension may also result from infusing too rapidly. May be given without regard to patient's blood group.Assess for signs of vascular overload (elevated CVP, rales/crackles, dyspnea, hypertension, jugular venous distention) during and after  administration. F u r o s e m i d e  is a generic name of Lasix, a loop diuretic given 80 mg per orem

once a day. It inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis.Indicated as a treatment for edema associated with CHF, cirrhosis, renal disease, and hypertension.Adverse effects are dizziness, vertigo, paresthesias, xanthopsia, weakness, headache, drowsiness, fatigue, blurred vision, tinnitus, irreversible hearing loss, polyuria, nocturia, glycosuria, urinary bladder spasm muscle cramps and muscle spasms. Contraindicated to patients with allergy to furosemide, sulfonamides, allergy to tartrazine(in oral solution), anuria, severe renal failure, hepatic coma, pregnancy, lactation, use cautiously with SLE and gout, diabetes mellitus.The nurse should record intermittent therapy on a calendar or dated envelopes. When possible, take the drug early so increased urination will not disturb sleep. Take with food or meals to prevent GI upset. Weigh yourself on a regular basis, at the same time and in the same clothing, and record the weight on your calendar.Blood glucose levels may become temporarily elevated in patients with diabetes after starting this drug.Report loss or gain of more than 3 pounds in 1 day, swelling n you‘re ankles of  fingers, unusual bleeding or bruising, dizziness, trembling, numbness, fatigue muscle weakness or cramps. Combivent

(albuterol

s u l f a t e ) i s

generic

name

of

Novo-Salmol,

a

Sympatomimetic drug given 4mg per orem three times a day. This drug acts relatively selectively at beta2 adrenergic receptors to cause bronchodilation and vasodilatation; at higher doses, bta2 selectivity is lost, and the drug acts at beta2 receptros to cause typical sympathomimetic cardiac effects. An adjunct in treating serious hyperkalemia in dialysis patients; seems to lower potassium concentrations when inhaled by patients on hemodialysis. Adverse effects are, increased incidence of leiomyomas of uterus when given in higher than human doses in preclinical studies. Contraindicated with hypersensitivity

to

albuterol;

tachyarrhythmia,

tachycardia

caused

by

digitalis

intoxication; general anesthesia with halogenated hydrocarbons or cyclopropane (these sensitize the myocardium to catecolamines); unstable vasomotor system disorders;

hypertension; coronary insufficiency, CAD; history of CVA and COPD patients with degenerative heart disease. The nursing consideration are, use minimal doses for  minimal periods; drug tolerance can occur with prolonged use.Maintain a betaadrenergic blocker (cardio selective beta-blocker, such as atenolol, should be used with respiratory distress) on standby in case cardiac arrhythmias occur. Omeprazole is a generic name of Prilosec, an Antisecretory drug given 20 mg

per orem once a day. A gastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of aid production. Forshort-term treatment of active duodenal ulcer and first-line therapy in treatment of  the heart burn of symptoms of GERD. Adverse effect are rash, inflammation, urticaria, prurits, alopecia, dry skin, cancer in preclinical studies, back pain and fever. Contraindicated to patients with hypersensitivity to omeprazole or its components and use cautiously with pregnancy, lactation. The nurse should administer before meals. Caution patient to swallow capsules whole —not to open, chew, or crush them. If using oral suspension, empty packet into a small cup containing 2 tbsp of water. Stir and have patient drink immediately, fill cup with water and have patient drink this water. Do not use any other diluents. In s u l i n G l u l i s i n e  is a generic name of Apidra, an Antidiabetic drug injected

100units/ml intramuscular once a day. insulin is a hormone secreted by beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the body‘s fuels, facilitating the transport of metabolites and ions (potassium0 through cell membranes and stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids. Treatment for type 1 diabetes mellitus and type 2 diabetes mellitus that cannot be controlled by diet or oral drugs. Adverse effects are hypersensitivity: Rash, anaphylaxis or angioedema. Metabolic: Hypoglycemia and ketoacidosis. Contraindicated with allergy to pork products (varies with preparation; human insulin not contraindicated with pork allergy); history of smoking or lung disease (inhaled insulin). The nurse should ensure uniform dispersion of insulin suspensions by rolling the vial gently between hands; avoid vigorous shaking and give maintenance doses subcutaneously, rotating injection sites regularly to decrease incidence of lipodystrophy; give regular insulin IV or IM in severe ketoacidosis of diabetic coma.

N i t r o g l y c e r i n   is a generic name of Nitrolingual, an Antianginal drug given

5mg/ml IVTT as needed. This drug relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular  workload and decreases myocardial oxygen consumption.Treatment for acute angina and prophylaxis for angina. Adverse effects are headache, apprehension, restlessness, weakness, vertigo, dizziness, faintness and ethanol intoxication with high-dose IV use (alcohol in diluents). Contraindicated to patients with allergy to nitrates, severe anemia, early MI, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation. The nurse should give sublingual preparations under the tongue or in the buccal pouch. Encourage patient not to swallow. Ask patient if the tablet ―fizzles‖ or  burns. Always check the expiration date on the bottle; store at room temperature, protected from light. Discard unused drug 6 months after bottle is opened (conventional tablets); stabilizes tablets (Nitrostat) are less subject to loss of potency.

DISCHARGE PLANNING Medication o

Informed client to take medications on time, or as directed for the full course of  therapy, even feeling better.

o

Inform the client about the possible side effects of the medication.

o

Encouraged the client to report or inform the physician, if any of these side effects occur.

o

Informed and explained to the client in simple terms that the other drugs, such over the counter drugs that she is taking, will probably have other effects of the medication given moreover emphasize the right of timing or taking the right interval of these drugs to maximize its effects and avoid further complications

o

Provided information for better understanding regarding the therapeutic regimen.

Exercise

o

Remember, it‘s normal to have times when you feel energetic and times when you feel exhausted. Daily changes in your energy level are common.

o

Plan your daily activities around the times when you feel more energetic. These periods are usually in the morning or after a nap.

o

Rest frequently throughout the day.

o

Avoid strenuous exercise. Short walks spread out through the day will keep you fit without exhausting you.

o

Do one thing at a time.

o

To save energy while getting dressed, lay out your clothes and accessories in one area where it‘s easy for you to reach everything. Try to avoid making extr  a trips back and forth to your closet or dresser drawers.

o

Install grab bars in your shower or tub to make it easier to get in and out. A shower chair may also be helpful.

o

Exercise can help keep your blood sugar level steady and decrease your risk of  heart disease. Exercise for at least 30 minutes, 5 days a week. Work with your  primary healthcare provider to plan the best exercise program for you. You may need to eat a carbohydrate snack before, during, or after you exercise. Do not exercise if your blood sugar level is less than 100 mg/dL.

Treatment

o

Lifestyle changes often help you continue your daily activities.

o

Scheduling rest periods

o

Avoiding stress and heat exposure, which can make symptoms worse

o

Several medications may make symptoms worse and should be avoided. Therefore, it is always important to check with your doctor about the safety of a medication before taking it.

o

Crisis situations, where muscle weakness involves the breathing muscles, may occur without warning with under- or overuse of medications. These attacks seldom last longer than a few weeks. Hospitalization and assistance with breathing may be required during these attacks.

Health teaching

o

You may need yearly eye exams to check for retinopathy and yearly urine tests to check for kidney problems. Write down your questions so you remember to ask them during your visits.

o

You will be taught how to use a glucose monitor. You may need to check your  blood sugar level at least 3 times each day. Ask your primary healthcare provider  when and how often to check during the day. Ask what your blood sugar levels should be before and after you eat. Write down your results, and show them to your primary healthcare provider. He may use the results to make changes to your medicine, food, or exercise schedule

o

Protect yourself from infection.

o

Wash your hands often; keep them away from your face. Most germs are spread by hand-to-mouth contact.

o

Get a flu shot every year. Ask your doctor about a pneumonia vaccination.

o

Stay out of crowds, especially in rainy days when more people have colds and flu.

o

Avoid drinking alcohol. Alcohol can increase weakness.

Out Patient

o

Remind client on the arrangements to be made with a physician for follow up checkups.

o

Follow up on checkups regularly in order to monitor and properly manage patient.

o

Continue medications as ordered.

o

Instruct the client and significant others to report for any unusualities.

o

Diet

o

Limit in phosphorus, potassium, sodium.

o

Low fat for heart disease.

o

Encourage the client take well-balanced diet.

o

Advice the guardians to be watchful/ careful enough of the diet that could promote proper nutrition of the patient.

Spiritual o

Always ask God for guidance in everything especially with her condition.

o

Praying also for all the people who are helping her with her ups and downs.

CONCLUSION AND RECOMMENDATIONS

End-stage Renal Disease is an irreversible and progressive disease. It is causeby many factors. Knowing the precipitating factors leading to the development of this health problem, people should have an extra care when it comes to health. Giving care to a patient whether pediatric, geriatric, a medical case or surgical case makes no difference. Rendering care to everyone who needs it is areal sense of  responsibility. In making this case study, We were able to work the best we can be because this may help for the patient‘s coping strategy regarding his/her condition by encouraging them either medical or nursing management and also we help them enable for better understanding towards therapeutic regimen. On the other hand, this study also helps us enhance our capability for future nurses and helps us obtain more knowledge. We

can

say

that nursing

Itis therefore significan t for

is

significant

therapeutic

and

dynamic

the nurse caring for the

process. patient

to wholeheartedlyunderstand what he/she is doing like in carrying out some basic skills in relation toidentified goals, comfort and care, interventions and prevention of illness.

DEFINITION OF TERMS Blood clot is a thickened mass in the blood formed by tiny substances called platelets.

Clots form to stop bleeding, such as at the site of cut. But clots should not form when blood is moving through the body; when clots form inside blood vessels or when blood has a tendency to clot too much, serious health problems can occur. Blood Urea Nitrogen (BUN) Test measures the amount of urea nitrogen that's in your 

blood. It reveals important information about how well your kidneys and liver are working. Calciumis a major mineral and is the most abundant mineral in the human body. Most

of it is stored in the bones and teeth (about 99 percent), and the rest is in your blood, muscles and extracellular fluid. It is necessary for strong bones and teeth, plus it plays an important role in blood clotting, muscle contraction, hormonal secretion and normal nervous system function. Creatinin is a chemical waste molecule that is generated from muscle metabolism.

Creatinine is produced from creatine, a molecule of major importance for energy production in muscles. Approximately 2% of the body's creatine is converted to creatinine every day. Creatinine is transported through the bloodstream to the kidneys. The kidneys filter out most of the creatinine and dispose of it in the urine. Diabetic Nephropathyis a progressive kidney disease caused by angiopathy of capillaries in the kidney glomeruli. It is characterized by nephrotic syndrome and diffuse glomerulosclerosis. It is due to longstanding diabetes mellitus, and is a prime indication for  dialysis in many Western countries.

Glomerular filtrationthe filtrate, free of cells and major plasma proteins, that passes

from the blood through a renal glomerulus into the lumen of a nephron in the kidney. Phosphorusis a major mineral and most of it is stored in your bones. Lesser amounts

are found in your teeth, DNA, and cell membranes throughout your body. It's necessary for building strong bones and is important for many biochemical reactions such as converting the foods you eat into the energy your body needs every day. Phosphorus also helps with muscle contraction, nerve conduction and normal kidney function. Potassium is a major mineral that is necessary for normal growth and for making

proteins from amino acids that come from your diet. It's also needed for metabolizing carbohydrates.