Case Presentation

7/15/2019 Case Presentation

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Chronic Kidney Disease 2to Diabetes Mellitus IIrelated to Hypertension,

Anemia 2 to Nephropathy

Group 1


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GROUP 1


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Arceo, Mari

Aguirre, Kim Leonard

Bermudez, Joanna Marie

Bongkingki, Janela Cassandra

De Guzman, Fredaline Dayle

De Guzman, Maria Cristina

Desvarro, Eric

Domingo, JenniferLeyva, Allan Mario

Seminiano, Haidy

Socias, Christian Anthony


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OUR LOVELY CLINICAL INSTRUCTOR


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Mrs.Angelica Hernandez


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Introduction


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I. Background of the studyPresenting a case of Patient H.F., 51 year-old female

admitted on the 24th of September , 2012 at 7:30 PMwith baseline vital signs of T- 37.1 C, PR-92bpm, RR-23

bpm, and a BP of 160/90mmHg. The patient was

admitted to the Mandaluyong City Medical Center, and

was given a final diagnosis of Chronic Kidney Disease 2to Diabetes Mellitus II related to Hypertension,

Anemia 2 to Nephropathy

Diabetes mellitus (DM) is a set of related diseases in

which the body cannot regulate the amount of sugar(specifically, glucose) in the blood. The blood delivers

glucose to provide the body with energy to perform all of

a person's daily activities.


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The liver converts the food a person eats into glucose. The glucose isthen released into the bloodstream.

In a healthy person, the blood glucose level is regulated by several

hormones, primarily insulin. Insulin is produced by the pancreas, a small

organ between the stomach and liver. The pancreas also makes other

important enzymes released directly into the gut that helps digest food.

Insulin allows glucose to move out of the blood into cells throughout

the body where it is used for fuel.

People with diabetes either do not produce enough insulin (type 1

diabetes) or cannot use insulin properly (type 2 diabetes), or both (which

occurs with several forms of diabetes).

In diabetes, glucose in the blood cannot move efficiently into cells, soblood glucose levels remain high. This not only starves all the cells that

need the glucose for fuel, but also harms certain organs and tissues

exposed to the high glucose levels.


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Type 2 diabetes (T2D): Although the pancreas still secretes insulin,the body of someone with type 2 diabetes is partially or completelyunable to use this insulin. This is sometimes referred to as insulin

resistance. The pancreas tries to overcome this resistance by secreting

more and more insulin. People with insulin resistance develop type 2

diabetes when they fail to secrete enough insulin to cope with their

higher demands.At least 90% of adult individuals with diabetes have type 2 diabetes.

Type 2 diabetes is typically diagnosed in adulthood, usually after age 45

years. It used to be called adult-onset diabetes mellitus, or non-insulin-

dependent diabetes mellitus. These names are no longer used because

type 2 diabetes does occur in younger people, and some people withtype 2 diabetes require insulin therapy. Type 2 diabetes is usually

controlled with diet, weight loss, exercise, and oral medications.

However, more than half of all people with type 2 diabetes require

insulin to control their blood sugar levels at some point in the course of

their illness.


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A. RATIONALE FOR CHOOSING THE CASE1. To know the anatomy and physiology of the pancreas and the associated

organs.

2. To know the pathophysiology of Diabetes Mellitus Type 2, its signs and

symptoms and its further complications.

3. To know the appropriate nursing intervention in accordance with itsscientific rationales.

4. To know the appropriate medical management in the treatment of the

disease.


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B. OBJECTIVES OF THE STUDYThis case study aims to identify and determine general health problems and

needs of the patient with a diagnosis Chronic Kidney Disease 2 to Diabetes

Mellitus II related to Hypertension, Anemia 2 to Nephropathy. This work

also intends to promote health and medical understanding of such condition

through the application of nursing process and skills.

Specific Objectives:The students will be able to improve their skills in conducting appropriate

assessment on the clients health condition.

The students will enhance their knowledge on the disease process and its

effect to the human body.The students will be able to formulate a scientific-based pathophysiology

based on the clients health history and presenting signs and symptoms.

The students will be able to formulate appropriate Nursing Care plan based

on the clients presented health problems and risks and effectively

improve/alleviate clients health condition.


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The students will be able to utilize the nursing process and critical

thinking skills in the management and care of the common problems

of the patient.

The students will be able to render quality care to patients guided

with scientific based rationale.

The students will be able to expand their knowledge on the drugs

through identification of its indication, side effects, adverse reactions

and mechanism of action on why it was prescribed to the patient and

specific nursing considerations.


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ASSESSMENT

Clients Profile Name : Patient F.H.

Age : 51 years old

Gender : Female

Birth Date : December 22, 1960

Civil status : Married

Occupation : Housewife

Nationality : Filipino

Religion : Catholic


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Date of Admission : September 24, 2012

Time of admission : N/A

Admitting Diagnosis : Chronic Kidney Disease 2 to

Diabetes Mellitus II related toHypertension, Anemia 2 to

Nephropathy

B. Chief Complaint : Generalized body weakness


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C. History of Present Illness : Three days prior to admission, client

experienced loss of Appetite, generalized

body weakness and easy fatigability.

Symptoms persisted which promptedconsult.

D. Past Medical History : DM Type II for ten yearsPeripheral Vascular Disease

Accidents : N/A

Hospitalization : Last hospitalization: July, 2012.

Medications taken : Glucovance 2.5 mg

Losartan 50mg


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GrandfatherGrandmother

Father

Mother

Patient

Brother 1

SisterBrother 2

Hypertension

Diabetes

Heart Disease

Deceased

E. Family History

Legends


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E. Family HistoryThe following figure shows the family genogram of the patient.

GrandfatherGrandmother Grandfather

Grandmother

FatherMother

Patient

H.F

Husband

Fatherside Motherside

LEGEND:

Deceased

Diabetes Mellitus

Colon Cancer

Hypertension

Nephropathy

Male

Female


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F. Gordons Functional Health Pattern Health Perception and Health Management

Before hospitalization, she knows that being healthy is important, but she is

not fond of doing exercise. Her perception of a healthy person is anyone who

can perform their daily task and one who doesnt have a disease. She drinks

alcoholic beverages occasionally and does not smoke. When the patient is

hospitalized, she perceived herself as an unhealthy person.

Nutrition and Metabolism

Before hospitalization, the client states that she loves to eat. She loves to

eat everything including those foods that are not advisable for her to eat.

During hospitalization, the client is advised to be on a Low salt, low fat, DM

Diet. She becomes more aware of her condition and states that she will try

her best to follow the advised diet.


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24 Hour Diet-Recall

Meal Food QuantityBreakfast Rice Half cup

Chicken Breast Small serving

Coffee 1 cup

Lunch Lugaw with egg 1 bowl

Orange juice 1 glass (250 ml)


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EliminationPrior to hospitalization, the client defecates brownish, formed stool 6-7

times a week. She urinates clear-yellowish urine 6-7times a day. During

hospitalization, client stated that she defecates once in every two days and

she urinates 6-7 times per shift. She also stated that she perspires just right.

Activity ExerciseBefore hospitalization, clients household chores serve as her way of

exercising. Whenever she is doing something like cleaning the house or

washing the chores, she gets tired easily. During hospitalization, walking is

her only activity.

Sleep RestPrior to hospitalization, client normally gets 6-7 hours of sleep. She does

not have any difficulty sleeping. She claimed that hospitalization affects her

sleeping pattern; she cannot sleep comfortably and wakes up easily.


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Cognitive PerceptualThe client can recall past memories when being asked. She has no

hearing problems. The client is oriented with time, place, people and date.

She is able to follow instructions. Client claimed that her memory hasnt

changed even during hospitalization.

Self Perception / Self ConceptClient claimed that she was already satisfied with her life. She states that

prior to hospitalization, she perceives herself as a loving wife and mother.

She perceives herself as a healthy person. Upon hospitalization, client sees

herself as unhealthy.

Role Relationship PatternPrior to hospitalization, client lives with her husband and they have 7

children. Their child supports their financial needs. She and her husband

take part in decision-making. They have open communication with each

other. The client presently feels the support of her family and she is happy

about it. Upon hospitalization, clients husband takes responsibility indecision-making.


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Sexuality ReproductiveThe client stated that they do not practice family planning ever since.

Despite of their age, theyre still able to maintain a satisfying sexual

relationship. The couple engages in sexual activity once or twice a month.

During hospitalization, client doesnt engage with sexual activity anymore.

Coping Stress TolerancePrior to hospitalization, Clients usual cause of stress is misunderstandingwith her husband and children. She easily gets irritated with arguments and

cries whenever depressed. During hospitalization, she claims that she gets

stressed whenever she experiences body weakness. Client would just vent out

to her husband and try to sleep.Value BeliefThe client states that she is a religious person and usually goes to

church every Sunday. During hospitalization, client claimed that she becomes

closer to God and that she never forgets to pray for her faster recovery.


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G. Physical ExaminationGeneral SurveyThe patients body built is proportionate with coordinated posture and gait.

Client is lethargic but coherent and oriented to time, place and person. Clientappears to be physically weak upon assessment.

Vital SignsHer temperature is 37.1 C, axillary with a regular pulse rate of 75 bpm. The

respiratory rate is 34 cpm, deep and her bp is 180/110 mmHg taken in a lyingposition.

Anthropometric MeasurementsHer height is 52 and her weight is 136 lbs (upon admission), 129lbs (upon

referral).


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SkinHer skin color is pale, with venoclysis on right metacarpal vein .She has no

edema. She has dry skin, cool upon touch and show poor turgor.

HairHer hair is evenly distributed, thick and silky. There is presence of sparse

leg hair. There is no presence of infestations.

NailsHer nails are convex 160 in curvature and angle. The texture is smooth

with pale nail beds. The surrounding tissues are intact and capillary refills in

4 seconds.

Skull and FaceThe skull is normocephalic, has smooth contour, has symmetrical facial

features.


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Eye Structures and Visual AcuityHer eyebrows are evenly distributed, eyelashes are equally distributed, intact

skin, and eyes close symmetrically and have 15-20 involuntary blinks. She

has pale conjunctiva and has transparent cornea, PERRLA. Her eye is

coordinated in extraocular movement and she is able to read newspaper.There is a presence of peritorbital edema on both eyes.

Ears and HearingThe pinna of her ears has a uniform skin color and symmetrical. The ear

canal has presence of dry cerumen .The tympanic membrane is pearly gray

and the hearing acuity is intact.

Nose and SinusesShe has symmetrical nasolabial fold. Her septum is in midline, non-deviated

and has no perforation. Its mucosa is dry but has no discharges. It is both

patent. She has symmetrical gross smell. Sinuses are not tender.


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Mouth and OropharynxHer lips are dry, pale and with few lesions. She has 4 missing teeth; 1right,

upper lateral incisor, 1st right, upper premolar, 2nd left, lower molar, 3rd left,

lower molar. Tongue is in midline, pinkish, smooth and movable. Her

palate is light pink and smooth with uvula is in midline. The oropharynx isalso pink and smooth. Tonsils are not inflamed. The gag reflex is intact.

NeckHer neck muscles are equal in size with a coordinated movement, full range

of motion and equal muscle strength. The lymph nodes are not palpable.

The trachea is in midline, the thyroid gland is not visible with a symmetrical

carotid pulse. The jugular veins are not visible.

Thorax and LungsHer breathing pattern is rapid and deep. The shape and symmetry of the

thorax and lungs is symmetrical, the spine is aligned with a smooth skin. The

respiratory excursion is full and symmetric.


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Breast and Axilla

Her breast and axillas shape is rounded. The skin is smooth with round

areola. The nipples are round.

AbdomenThe abdomen contour is rounded and the symmetry is symmetrical. The

bowel sounds are normoactive with a tymphanic percussion and relaxed

palpation.

Upper and Lower ExtremitiesThe upper and lower extremities have an equal muscle size, firm muscle

tone with equal muscle strength. Her range of motion is limited.


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H. Laboratory and Diagnostic Study


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PROBLEM IDENTIFICATION


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A. Anatomy of PancreasThe pancreas is an elongated, tapered organ located across the ba

ck of theabdomen, behind the stomach. The right side of the organ(called the head) is the widest part of the organ and lies in the curve

of the duodenum (the first section of the small Intestine). The

tapered left side extends slightly upward (called the body of the

pancreas) and ends near the spleen (called the tail).The pancreas are

made up of two types of tissue:


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Exocrine tissue the exocrine tissue secretes digestive enzymes. These

enzymes are secreted into network of ducts that join the main pancreatic duct,which runs the length of the pancreas.

Endocrine tissue the endocrine tissue, which consists of the islets of

Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine tissue in the pancreas help break down

carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel

down the pancreatic duct into the bile duct in an inactive form. When they

enter the duodenum, they are activated. The exocrine tissue also secretesbicarbonate to neutralize stomach acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin

and glucagon (which regulate the level of glucose in the blood), and somatostatin

(which prevents the release of the other two hormones.


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Anatomy of kidney

The kidneys play key roles in body function, not only by filtering the blood

and getting rid of waste products, but also by balancing levels

of electrolytes in the body, controlling blood pressure, and stimulating

the production of red blood cells.


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The kidneys are located in the abdomen toward the back,

normally one of each side of the spine. They get their blood supply

through the renal arteries directly from the aorta and send blood back

to the heart via the renal veins to the vena cava. (The term renal" is

derived from the Latin name for kidney.)The kidneys have the ability

to monitor the amount of body fluid, the concentrations of

electrolytes like sodium and potassium, and the acid-base balanceof the body. They filter waste products of body metabolism, like urea

from protein metabolism and uric acid from DNA breakdown. Two

waste products in the blood can be measured: blood urea

nitrogen (BUN) and creatinine (Cr).Kidneys are also the source

of erythropoietin in the body, a hormone that stimulates the bonemarrow to make red blood cells. Special cells in the kidney

monitor the oxygen concentration in blood. If oxygen levels fall,

erythropoietin levels rise and the body starts to manufacture more red

blood cells.


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Diabetes Mellitus

Diabetes Mellitus type 2 is the most common form of Diabetes.

Formerly known as adult

onset diabetes, it usually affects people aged over 40 and progresses

gradually. In this type the pancreas has not ceased to produce insulin, butthe quantity is insufficient, or the hormone is not stimulating the glucose

uptake in muscles and tissues required for energy. The result is a build-upof glucose in blood and urine.

Although the cause of this malfunctioning is unclear, non-insulin dependent

diabetes mellitus tends to run in families. Other risk factors, such as

increasing age, obesity, and a sedentary lifestyle, probably contribute to its

increased incidence in developed countries. Non-insulin dependent diabetes

mellitus can often be controlled initially by diet alone, or in combinationwith tablets that reduce the amount of blood

glucose. There are two main types of blood glucose-reducing drugs:

sulphonylureas work mainly by stimulating the pancreass islet cells (known

as the islets of Langerhans) to produce more insulin and iguanids increase

the effectiveness of insulin on cells. Eventually, however, patients may need

insulin injections.


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Signs and Symptoms with Rationale Diabetes Mellitus

HYPERGLYCEMIA (INCREASED BLOOD SUGAR LEVEL)

May be due to lack of physiologically

active insulin that transportsglucose from extracellular to intracellular leadingto accumulation of glucose in the intravascular space. The glucose is not

utilized by the body and it remains in the blood streams.

POLYURIA

Increased frequency of urination. This may be due to the osmoticdiuretic effect of the glucose, wherein it attracts water during urination.

POLYDIPSIA

Increased thirst and fluid intake. This may be due to the activation of

thethirst center in the hypothalamus resulting form the intracellular dehydration or volume depletion.


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POLYPHAGIA

Increased hunger and food intake. This may be due to the decrease

glucose uptake by the cells leading the stimulation of the satiety center in

the hypothalamus resulting to the hunger sensation.

WEAKNESS/ FATIGUE

This is due to the decreased glucose uptake by the cells leading to

decreased energy production.

GLYCOSURIA

The kidney filters the blood, making it to its normal state. Glucose

was filtered out and excreted in the urine.

Due to the excess glucose ad compared to the kidney threshold,

which results to the excretion of glucose in the urine. GASTROPARESIS

(Stomach fullness)


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CONSTIPATION and BLOATING

This is due to changes in nerves and damages the blood vessels that

carry oxygen and nutrients to the nerves. Over time, high blood glucose

can damage the vagus nerve. The stomach fails to empty properly and is

likely due to the generalized neuropathy.

NAUSEA/ VOMITING

Due to stomach fullness, there will be an involuntary emptying

of stomach contents that are forcefully expelled by the mouth.

A compensatory mechanism due to acidity of body because of

decrease excretion of metabolic waste.

PALE

Due to decreased production of erythropoietin.


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B. Pathophysiology

C P bl Li t


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C. Problem List


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PLANNING

A Problem Prioriti ation


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A. Problem Prioritization

NURSING PROBLEM RANK JUSTIFICATION

1

2

3


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C. Discharge PlanningMedication Instruct the patient the importance of regularly taking of prescribed home

medications.

Amlodipine 10mg 1 tab / OD

Cefuroxime 500 mg 1 tab / BID

NaHCO3 1 tab / TID

CaCO3 1 tab / TID

Ferrous sulfate + Folic acid 1 tab / OD

Insulin

Ensure safety by providing health teaching about the side effects and adverse

effects of the drug.

Instruct the patient to continue with follow up medical care.

Advise the patient not to miss the intake of medication given by his physician.


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Exercise and Environment Encourage the patient mild exercise such as walking it is best to start slowly and

more as the patient get stronger. Exercising can make the heart stronger, lower

blood pressure and keep healthy. Exercise can benefit patient with CKD/DM

Nephropathy. Resistance training in particular helps reduce the catabolic effectsof a low-protein (0.6g/kg/day) diet, whereas aerobic exercise may help control

blood pressure and lipid level.Treatment Since the patient due to the loss of renal erythropoietin production and should

be treated with supplement iron and synthetic erythropoietin to reach a target

hemoglobin of 11-12g/ dL. Phosphate binders and dietary phosphorus restriction

are indicated to keep phosphate,


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Health Teaching Encourage the patient also have adequate rest periods and to have an adequate sleep

of at least of 8-10hrs.

Encourage the patient to eat a low-protein diet.

Instruct the patient to limit fluid intake.

Instruct the patient regarding limiting the amount of salt (sodium), potassium,

phosphorus and other electrolytes, getting enough calories, especially if patient is

losing weight.

Encourage the patient also have to Monitor of blood glucose levels.

Help the patient/ Family learn self-observational skills (Temperature, Pulse,Respirations, Blood Pressure, intake and output and weight) and record keeping.

Explain the benefits of consuming simple, basic foods such as lean meat, fresh orfrozen vegetables, and whole grained breads. Processed or prepared foods should

be avoided.


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Encourage the patient keep a food diary for several days. It should include

food eaten, portion size, and time of consumption so that together you canmodify the diet as needed.

Explain avoidance of infection.

Out patient Instruct the patient to come back for follow up check-up.

Emphasize the need to be present in medical procedure schedule.


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Diet Low total and animal protein

A prolonged high-protein intake is accompanied by an increase in GFR, 4

which in turn may cause intraglomerular hypertension and eventual loss of renal

function.

Sodium Restriction

Patient with CKD are often salt-sensitive, responding to elevated intakes of

sodium chloride with increase in glomerular filtration and proteinuria.

Water-Soluble Vitamins

Low-protein diets may increase the risk for deficiency of thiamine, riboflavin

and especially pyridoxine, and vitamin C levels are also often low in DM.


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Vitamin D Supplementation

Deficiency of vitamin D is present early in the course of DM, and

correction may prevent activation of key pathogenic mechanism in

cardiovascular disease. (e.g. Inflammation, Myocardial cell hypertrophy

and Proliferation and the renin-angiotensin system).

A Diet in Fiber and Low in saturated Fat and cholesterol

Most patients with Chronic Kidney Disease die from cardiovascular

causes before developing DM Nephropathy. Dietary and supplemental

source of fiber may be helpful for reducing the build up of nitrogenous

waste products in the blood that cause many symptoms of uremia.

Maintain on low salt and low fat.

Limit sodium, potassium, phosphorus and other electrolytes.

Limit fluid intake.


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The following table is a proposed 1 week diet of the patient:

Sunday Monday Tuesday Wednesday

Thursday Friday Saturday

BreakfastApple slices

Bread w/

tuna spread

Pineapple

juice.

Cereals

Fresh

milk

Oatmeal

Orange

juice

Brown

Rice

1/2cup

1 serving

of tinolang

manok

Grape

juice 1

glass

1 cup

fiber one

Original

cereal

1 cup

Skim milk

slice of

melon and

strawberrie

1 cup

Prepared

Oatmeal

cup

Skim milk

2 tbsp.

Seedless

raisins

1 servings

of oranges

2 oz cheddar

cheese, low

fat

2 slices of

wheat bread

Watermelon

2 servings

A glass of

Orange juice

Sunday Monday Tuesday Wednesd Thursday Friday Saturday


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ayLUNCH

Toast,

hardboiledeggs &

Orange.

Slices (340

calories)

1 slice whole

wheat toast

2 tsp. Jam

2 large Hard-

boiled eggs

1 mediumOrange, cut

into segments

100g Non-fat

fruit yogurt

Glass ofWater

Brown

Rice

1/2cup

Chicken

(280

calories)

2

servings

of

Papaya

slice

Steam

rice 1

cup

Ampalay

a with

scramble

s egg 2servings

Glass of

water

2 slices

whole

wheatbread

90g tuna,

canned

in water

1 tbsp.

Mayonn

aise

2 leaveslettuce

2 serving

of

pinakbet

Steam rice

1 cup

1 glass of

2 servings

of ripe

Kiwifruit

Glass of

water

1 serving

of

sinigangna

bangus

Brown

Rice1/2cup

1 glass of

Orange

juice

2 servings

of apple

slices

2 servings of

tortang talong

Steam rice 1

cup

Pineapple

juice

2 servings of

slices melon


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Sunday Monday Tuesday Wednesday

Thursday Friday Saturday

DINNER1

servings

Vegetabl

es salad

with tuna

Orange

juice

100 g

chicken

breast,

boneless,

skinless

cooked

1 cup

medium

grain

brown rice

(cooked)

2 cups

Green

beans,

steamed

1

servings

Pesang

dalag

with

miso

Brown

Rice

cup

2

servings

of ripe

mangoe

s

1

serving

s of

chopsue

y

Brown

Rice

cup

1 servings

Shrimp

sinigang

With

vegetables

BrownRice

cup

Pineapple

juice

1 servings

Paksiw

na isda

Brown

Rice

cup

2 servings

of

Papaya

slice

Glass of

water

100 g

chicken

breast,

boneless,

skinless

cooked

Brown Rice

cup


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Spiritual Counseling Encourage the patient not to lose hope and have faith in GOD.

Encourage the patient to seek the LORDs guidance and pray in

times of hopeless.


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IMPLEMENTATION


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GENERIC NAME : AmlodipineBRANDNAME : NorvascCLASSIFICATION : Cardiovascular agent

; Calcium channel

blocker; antihypertensive agent.

DOSAGE : 10 mg 1 tab//ODDRUG ACTION : These medications block the transport ofcalcium into the smooth muscle cells lining the coronary arteries and other arteries

of the body. Since calcium is important in muscle contraction, blocking calcium

transport relaxes artery muscles and dilates coronary arteries and other arteries of

the body.INDICATION : Chest pain or heart pain (angina) occursbecause of insufficient oxygen delivered to the heart muscles. Insufficient oxygen

may be a result of coronary artery blockage or spasm, or because of physicalexertion which increases heart oxygen demand in a patient with coronary artery

narrowing. Amlodipine is used for the treatment and prevention of angina resulting

from coronary spasm as well as from exertion. Amlodipine is also used in thetreatment of hi h blood ressure.

A. Drug Study


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ADVERSE REACTION: The two most common side effectsare headache and edema (swelling) of the lower extremities. Less common

side effects include dizziness, flushing, fatigue, nausea, and palpitationsNURSING RESPONSIBILITY: Monitor BP for therapeutic effectiveness. BP reduction is greatest after

peak levels of amlodipine are achieved 69 h following oral doses.

Monitor for S&S of dose-related peripheral or facial edema.

Monitor BP with postural changes. Report postural hypotension.

Monitor more frequently when additional anti hypertensives or diuretics

are added.


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GENERIC NAME : Cefuroxime

BRANDNAME : Zinacef

CLASSIFICATION : Cephalosporin

DOSAGE : 500mg 1 tab//BID

DRUG ACTION : Decreases or control the infection.

INDICATION : For the treatment of many different typesof bacterial infections such as bronchitis, sinusitis, tonsillitis, ear

infections, skin infections, gonorrhea, and urinary tract infections.

CONTRAINDICATION : Contraindicated in patients hypersensitive

to drug or other cephalosporin. CV: phlebitis, thrombophlebitis. GI:

diarrhea, anorexia, vomiting. Hematologic: hemolytic anemia,

thrombocytopenia, transient neutropenia, eosinophilia


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NURSING RESPONSIBILITY: Determine history of hypersensitivity reactions to cephalosporins, penicillins,

and history ofallergies, particularly to drugs, before therapy is initiated.

Report onset of loose stools or diarrhea

Monitor for manifestations of hypersensitivity. Discontinue drug and report

their appearance promptly.

Monitor I&O rates and pattern: Especially important in severely ill patients

receiving high doses. Report any significant changes.


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DRUG : NaHCO3

BRANDNAME : bakinSoda, Bell-Ans, Citrocarbonate, Neut, SodaMint

CLASSIFICATION : antiulcer agents, alkalinizing agent

DOSAGE : 1 tab//TID

DRUG ACTION : Sodium Bicarbonate acts as an alkalinizing agent by

releasing bicarbonate ions. Following oral administration of this medication, itreleases bicarbonate which is capable of neutralizing gastric acid.

INDICATION : > Management of metabolic acidosis

>Used to alkalinize urine and promote excretion of

certain drugs in over dosage situations.

>Used as an antacid

CONTRAINDICATION : Metabolic or respiratory alkalosisHypocalcemia, Excessive chloride loss. It is not recommended as an antidote

following ingestion of strong mineral acids. Patients on sodium restricted diet.

Renal failure, Severe abdominal pain of unknown cause especially if associated

with fever, Edema, Flatulence, Gastric distention, Metabolic alkalosis,

Hypernatremia, Hypocalcemia, Hypokalemia, Sodium and water retention,

Irritation at IV site, Tetany


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NURSING RESPONSIBILITY: Assess the clients fluid balance throughout the therapy.

Symptoms of fluid overload should be reported such as hypertension,

edema, difficulty breathing or dyspnea, rales or crackles and frothy sputum.

Signs of acidosis should be assessed such as disorientation, headache,

weakness, dyspnea and hyperventilation.

Assess for alkalosis by monitoring the client for confusion, irritability,

paresthesia, tetany and altered breathing pattern.

Hypernatremia clinical manifestations should be assessed and monitored

which includes: edema, weight gain, hypertension, tachycardia, fever, flushedskin and mental irritability.
http://nursingcrib.com/case-study/hypertension/http://nursingcrib.com/case-study/hypertension/


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Hypokalemia should also be assessed by monitoring signs and

symptoms such as: weakness, fatigue, U wave on ECG, arrhythmias,polyuria and polydipsia.

Monitor the clients serum calcium, sodium, potassium, bicarbonate

concentrations, serum osmolarity, acid-base balance and renal

function before and throughout the therapy. Tablets must be taken with a full glass of water.

For clients taking the medication as a treatment for peptic ulcers it

may be administered 1 and 3 hours after meals and at bedtime.


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DRUG : CaCO3 Calcium CarbonateCLASSIFICATION : Class of calcium-containing preparations. Used as

dietary supplements.

DOSAGE : 500mg 1tab//TID

DRUG ACTION : Decreases total acid load of GI tract. Increase

esophageal sphincter tone.

INDICATION : Antacid, calcium supplement, osteoporosis.CONTRAINDICATION : Patients with Ca renal calculi or history of renal

calculi; hypercalcaemia; hypophosphataemia. Patients with suspected digoxin

toxicity. Constipation, flatulence; hypercalcaemia; metabolic alkalosis; milk-alkalisyndrome, tissue-calcification. Gastric hypersecretion and acid rebound (with

prolonged use).

NURSING RESPONSIBILITY:

Administer as antacid 1 hour after meal and at bed time

Administer as supplement 1 hrs after meal and at bed time

Advice patient to increase fluids to 2L unless contraindicated


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DRUG : FeSO4 + Folic

CLASSIFICATION : Iron preparationDOSAGE : 1tab//OD

DRUG ACTION : Elevates the serum iron concentration on which then helps

to form high or trapped in the reticulo endothelial cells for storage and eventual

conversion to a usable form of iron.

INDICATION : Prevention and treatment of iron deficiency

anemia. Dietary supplement for iron.

CONTRAINDICATION : Hypersensitivity, Severe Hypotension, Dizziness, N & V,

Nasal Congestion, Dyspnea, Hypotension, CHF, MI,

Muscle cramps, Flushing

NURSING RESPONSIBILITY :

Advice patient to take medicine as prescribed.

Caution patient to make position changes slowly to minimize orthostatic hypotension.

Instruct patient to avoid concurrent use of alcohol or OTC medicine without consulting

the physician.

Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and

feet and hypotension occurs.


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Inform patient that angina attacks may occur 30 min. after

administration due reflex tachycardia.

Encourage patient to comply with additional intervention for

hypertension like proper diet, regular exercise, and lifestyle

changes and stress management.


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GENERIC NAME : Glipizide

BRANDNAME : GlucotrolCLASSIFICATION : It belongs to the sulfonylurea class of drugs

which also includes glimepiride (Amaryl), glyburide (Micronase, Diabeta),

tolbutamide (Orinase) and tolazamide (Tolinase).

DOSAGE : 2.5mg 1tab//OD

DRUG ACTION : Patients with type 2 diabetes have high

glucose (sugar) levels in their blood because the cells in their bodies are

resistant to the glucose-removing effect of the insulin, and the liver

produces too much glucose. In addition, in type 2 diabetes the pancreas is

unable to produce the increased amounts of insulin that are necessary toovercome the resistance. Glipizide reduces blood glucose by stimulating the

pancreas to produce more insulin

INDICATION : Glipizide is used together

with diet and exercise to reduce blood glucose in patients with type 2

diabetes.
http://www.medicinenet.com/script/main/art.asp?articlekey=755http://www.medicinenet.com/script/main/art.asp?articlekey=755


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CONTRAINDICATION : Contraindicated with allergy to sulfonylureas;

diabetes with ketoacidosis, sole therapy of type 1 diabetes or diabetescomplicated by pregnancy, diabetes complicated by fever, severe infections,

severe trauma, major surgery, ketosis, acidosis, coma (insulin is indicated); type

1 diabetes, serious hepatic impairment, serious renal impairment. Side effects of

glipizide are possible, such as dizziness, diarrhea, and nervousness. In many

cases, these side effects are minor and easily treated by you or your healthcare

provider. However, some glipizide side effects should be reported to your

doctor, including chest pain, shortness of breath, or signs of an allergic reaction.

NURSING RESPONSIBILITY:

Give drug 30 min before breakfast; if severe GI upset occurs or more than

15 mg/day is required, dose may be divided and given before meals.Monitor urine or serum glucose levels frequently to determine drug

effectiveness and dosage.

C. Course in the ward


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September 24, 2012 (7:45pm)Diagnostic Procedure: CBC, Na, K, Crea , BUN, RBS, U/A, CXR

Diet: Diabetic diet/ low fat, low salt

Exercise/Activity: Ambulatory

Treatment: (not yet handled)A Patient 51 yr. old female admitted to FMW under charity. Received by a

wheel chair; Endorsed by ER nurse and transferred to bed safely with

(+) generalized body weakness and (+) dyspnea. With on going IVF PNSS 1L

x 6 regulated as ordered. Treatment given D50-50 1 vial TIV

NaHCO3 or CaCO3 500 mg / tab TID. FeSO4 + FA 1 tab TID, Clonidine75 mg/tab PRN for BP 140 / 90mmHg it is administered by NOD.


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September 25 2012 (12: 45pm)Diagnostic Procedure: CBG, BT s/p

Diet: Low Salt, Low Fat diet, Diabetic diet


Treatment: (not yet handled)

CBG monitored And done cross matched for BT. V/ S q4

monitored and recorded. Informed in ROD and referred

accordingly.


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September 25 2012 (12: 45pm)Diagnostic Procedure: CBG




With venoclysis PNSS 1l x 12 regulated as ordered.


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September 27, 2012 (6:00pm)Diagnostic Procedure: Repeat U/A ,CBC TID , BT,




Hooked and regulated IVF PNSS 1L x KVO. For BT 1U and

2 U PRBC properly typed and crossed matched. Repeated

CBC for 2ndU of BT. Each unit to run for 4 hours with 4

hours intervals. Pre-BT meds given prior to first unit of PRBC.paracetamol 500 mg/tab 1 tab PO and Diphenhydramine 25

mg/IV given by the NOD. Cefuroxime 500 mg/ 1 tab BID.


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September 28, 2012Diagnostic Procedure: Hgb & Hct,




With the same venoclysis regulated @ desired amount.

Administered plasil 10 mg TIV q 8 PRN for vomiting. Given

furosemide 80 mg TIV for BT. Done repeated UTZ.


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September 29, 2012 (2:00pm)Diagnostic Procedure: Repeat CBC, Hct & Hgb




Transfused 3 U PRBC with IVF PNSS 1l x KVO. After the

last PRBC has been transfused, CBC and Hgb & Hct

repeated. Treatment of NaHCO3 1 tab TIDAmlodipine 10 g/ 1 tab OD, Cefuroxime 500 mg/ 1 tab BID x 5

days , Glipizide 2.5 mg/ 1 tab OD CaCO3 500 mg/ 1 tab TID ,

FeSO4 + Folic 1 tab TID , given by the NOD.


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September 30, 2012 (2:00pm)Diagnostic Procedure: ABG




With the same venoclysis and regulated at the same ordered.

Treatment given is Amlodipine 10 g/ 1 tab OD, Cefuroxime

500 mg/ 1 tab BID x 5 days , NaHCO3 1 tab TID, Glipizide 2.5mg/ 1 tab OD CaCO3 500 mg/ 1 tab TID , FeSO4 + Folic 1

tab OD , given by the NOD.


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October 1, 2012 (2:00pm)Diagnostic Procedure: Repeat CBC , Na , K , CBG, Urinalysis




Client is conscious and coherent, on DM diet, low salt, low

fat. V/S taken and recorded. Due meds. given. I & O

measured and recorded.


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EVALUATION

A. Summary


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This study is about 51 year old women, who was admitted at theMandaluyong City Medical Center and was diagnosed with Chronic Kidney

Disease 2 to Diabetes Mellitus II related to Hypertension, Anemia 2 to

Nephropathy, her suspicious and concern about her condition led her to seek

for medical assistance together with her relatives. Her chief complaint

generalized body weakness. The patient examined by her attending physician.

Her diagnosis is worthy to study to find out how she end up on having thatkind of condition with her permission and blessing, We as a student nurse of

BSN level 4 (Old curriculum) Group 1A and 1B have decided to make a study

regarding her condition. Patients having this kind of condition serve as achallenge not just in the health care system but also in the field of nursing. More

than caring, caring is the essential component of nursing the best way to help

patient is to render a service that is honesty and full of compassion.This study also aims to widen the knowledge about the problem known in

the pathophysiology of the study, the appropriate interventions and

management for patient who are under this condition.

B C l i


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This data was studied and gathered by the BSN 4 (Old Curriculum)

Group 1A and 1B to present a simple but yet concise information based on casestudy presentation. Nursing students were able to apply the proper nursing

action to the patient during assessment. Students were able to identify causes of

patient condition with the use of different taught of the group base on the

knowledge gain.

Students were able to formulate a scientific based pathophysiology that is

parallel with the patient condition from the risk factors to the disease process

manifesting signs and symptoms based on the physical assessment, medical

procedure and Laboratory results.

Actual and probable health problems to determine based from the highestto the least priority in order to prevent further complications caused by

conditions. Nursing care plans to classified using SMART, specific, measurable,

attainable, realistic, and time bounded. Nursing interventions was rendered to

give the proper care that client needed. As the Student nurses tried their best in

rendering the ideal and not just the ordinary care that can be seen in the hospital

now days.

B. Conclusion


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We, the nursing students determined the actions, classifications,

indications, contraindications, side effects and adverse reaction and

most importantly the appropriate nursing considerations. We future

nurse need to know that in giving medications prioritizing the 10Rs is

needed to avoid medication error. We need to assure that obligation

to our patient is not just giving the medication and preparing it but to

know the essential classification of the drugs and its effectiveness that

soon will help to the patient for their fast recovery.


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REFERENCES


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MOSBYS Clinical Nursing (4th edition)

Saunders manual of Nursing Carehttp://www.Creativehealthinstitute.com

Kozier, B.,et al. (2007) Kozier & Erbs Fundamentals of Nursing: Concepts,

Process & Practice. (8th Edition, Vol. 1). Philippines.Pearson Education South

Asia PTE. LTD.

Marieb, E. (2006). Essentials of Human Anatomy and Physiology. (8th

Edition) Philippines. Pearson Education Inc., Prentice Hall Smeltzer, Suzanne C., et.al (2010). Medical-Surgical Nursing.(12th Edition).

Philadelphia. Wolters Kluwer Health & Lippincott Williams &Wilkins

Doenges, Marilynn, Moorhouse, M.F, & Alice Murr. (2008) Nurses Pocket

Guide:Diagnoses, Prioritized Interventions and Rationales. (11th Edition).

Taiwan.F.A.Davis CompanyBrunner and Suddharts, et al. (2008) Textbook of Medical-Surgical Nursing

(11th Edition) PhiladelpiaWolters Kluwer, Lippin Colt Williams and Wilkins.

MIMS.com (2010) Philippines Index of Medical Specialties (123rd Edition

2010)
http://www.scribd.com/


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