CHAPTER I INTRODUCTION Pne

CHAPTER I
INTRODUCTION

Pneumonia (say: new-moan-ya) is an inflammation of one or both lungs. In people with pneumonia, air sacs in the lungs fill with fluid, preventing oxygen from reaching blood cells and nourishing the other cells of the body. When you breathe in, you pull oxygen into your lungs. That oxygen travels through breathing tubes and eventually gets into your blood through the alveoli (say: al-vee-oh-lie). ( Encarta 2006)
Pneumonia can be divided into three groups: community acquired, hospital or nursing home acquired (nosocomial), and pneumonia in an immunocompromised person.
Community-acquired Pneumonia is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an acute inflammatory condition that’s result from aspiration of oropharyngeal secretions or stomach contents in the lungs. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. Streptococcus pneumoniae remains the most commonly identified pathogen in community-acquired pneumonia. Other pathogens have been reported to cause pneumonia in the community, are Staphylococcus, Haemophilusinfluenzae, Klebsiella, Legionella. ( Johnson:2008)
Accrording to DOH,in the Philippines, there are more than 40,000 cases of CAP annually. More than 50% are admitted in the hospital. Pneumonia is considered the 3rd leading cause of death and the 4th leading cause of morbidity as of 2005. The morbidity trend decreased slightly from 1997 to 2000 but the number of cases remained high at 829 cases per 100,000 population in 2000. On the other hand, there is a decreasing trend of mortality from pneumonia in the general population from 1990 to 2000 despite the high number of cases per year. The mortality rate from pneumonia decreased from 64.7 deaths per 100,000 population in 1990 to 42.7 deaths per 100,000 in 2000 (PHS). This reflects improvement in the diagnosis and treatment of cases.
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis (National Kidney Foundation, 2002).
End-stage renal disease (ESRD) occurs when 90% of the nephrons are lost, Patients at this stage experience chronic and persistent abnormal kidney Function. The BUN and creatinine levels are always elevated. These patients may make urine but not filter out the waste products, or urine production may cease. Dialysis or a kidney transplant is required to survive. ( Medical-Surgical Nursing, Linda S. Williams, et.al. : 2003)
Nephrosclerosis refers to the changes in the nephron, specifically the afferent and the efferent arterioles and the glomerular capillary loops. The vessel walls thicken, and the vessel lumen narrows. As a result, renal blood flow is decreased and interstitial tissue changes occur. Over time, ischemia and fibrosis develop.
Nephrosclesosis is associated with benign essential hypertension or malignant hypertension and the effects of atherosclerosis. A history of diabetes mellitus is also common. The effects of essential hypertension on renal vasculature may be controlled with adequate blood pressure control. (Medical-Surgical Nursing 2nd edition, 2002: 2101).
Kidney disease is on the rise and is an important cause of death in the Philippines. Statistics show that kidney disease among the Filipinos is shooting up every year. Almost 10,000 Filipinos requiring either dialysis for life or a kidney transplant for survival. About 31% of them have the most advanced stage of the disease.
The main cause of kidney disease seems to be the increasing diabetic conditions among the Filipinos. It is seen that about 55% of Filipinos develop kidney disease when they suffer from diabetes. The Philippine Society of Nephrology (PSN) issued the statement that diabetes is the single most common cause of kidney failure among diabetes mellitus nephropathy patients.

Significance of the Study
This study aims to educate the people about the disease of the kidneys specifically chronic kidney disease. Many of us know that most of our country men like to eat food that is salty. They don’t control themselves in terms of that physiological activity. This study also aims to be their eye opener for understanding how important our body is and how important is its functions to our daily life activities. Lastly, this study aims to be the advocate of good health and wellness to those people who will read it.

CHAPTER II
PATIENT PROFILE

A. Biographic and Demographic data
The reporter names his patient “Mila,” from Alalum, San Pascual, Batangas. Mila was born on September 20, 1943 in Mindoro. She is 66 years and 10 months old, single and retired teacher. She is a devoted roman catholic who regularly attends most of the church’s programs. For her health-care financing support she uses her “Phil-health card,” “GSIS,” and her monthly retirement pension. She was admitted in the ICU department of Mary Mediatrix Medical Center on July 20, 2010 at 10:00 am. Most of the information of the patient where taken from her, through writing, chart, and her sister.
B. Health History
1. Chief complaints
Patient Mila was admitted with her chief complaints of difficulty of breathing.
2. History of present illness
3 days prior to admission, patient Mila developed productive cough and colds with series of unrecorded fever and shortness of breath. Patient Mila had chest pain due to increasing severity of cough and effort of shortness of breath, and diarrhea.
1 day prior to admission, patient was brought to the ER for consultation and ordered for admission but refused and signed consent for refusal. Patient was given Levofloxacin and Fluimucil. Few hours prior to admission; due to severe dyspnea, patient consulted and was admitted.
3. past medical history
She is hypertensive; she was diagnosed to have hypertension when she was 45 years old.She takes metroprolol only when she feels faint or pain at her nape. At same age, she was also diagnosed of having diabetes mellitus. She has no history of pulmonary tuberculosis or cancer. Her sister stated that she has no allergies to any drugs or foods. She is not taking any vitamins or supplements.
4. Family history
According to patient Mila’s sister, theirfamily have a history of hypertension from both of their parents; diabetes mellitus from their mother; and death of their cousin of renal disease 3 years ago.
5. Lifestyle
Personal habits
Patient Mila’s habits were sewing table clothes and gardening as what she wrote.
Diet
The typical diet of patient Mila was food rich in protein such as meat and fish. Vegetable dishes were served 3 times a week as written by the patient.
Activities of daily living
Patient Mila stays most of the time inside their house sewing table clothes and doing most of the household chores.
Recreation and hobbies
Besides sewing, patient Mila spends time in reading the Bible and watching television.
6. Social data
Patient Mila is the eldest among her 6 siblings; she is most attached to her 3rd younger sister who brought her to the hospital. She speaks tagalog, she resides in San Pascual, Batangas. She belongs to a senior citizen group who are also active in participating church’s activities. She is a retired elementary teacher. She stays with her sister and her sister’s family. She has no problem with her neighbours.
C. Developmental theories
Erick Erickson’s Psychosocial Theory
Integrity versus despair
Ability to adapt changes in lifestyle, functioning level, and family structure.
After the retirement of patient Mila, as what previously stated she spends time in sewing, reading the Bible and joining senior citizen group were they participate in most of the church’s activities. She stays with her sister and her sister’s family.
Sigmund Freud’s Psychosexual Theory
Genital Stage
It is the stage where full sexual maturity and function development of skills needed to cope with the environment (Kozier, et. al., 2008 p.352).
Patient Mila had reached full sexual maturity and full potential of being a woman. She never regrets her single status, her first love was teaching. Being a teacher already feels like being a mother as what she wrote.
Jean Piaget’s Cognitive theory
Formal Operations Phase
This phase manifests use of critical thinking and reasoning is deductive and futuristic (Kozier, et. al., 2008 p.357).
Patient Mila has achieved formal operational phase, with her almost 40 years of being a teacher she is able to decide on her own. As what observed, she is able to decide on her hospitalization needs, she instructs her sister by hand writing.
Lawrence Kohlberg’s Moral Evolution theory
Post- Conventional (Social Contract Legalistic Orientation)
In this stage the person lives autonomously and defines moral values and principles that are distinct from personal identification with group values. She lives according to principles that are universally agreed on and that the person considers appropriate for life, universal focus. In social contract legalistic orientation, the social rules are not the sole basis for decisions and behaviour because the person believes a higher moral principle applies such as equality, justice, or due process (Kozier,et. al., 2008 p.359).
Patient Mila has a good attitude when it comes to dealing with other people despite her present condition. She has formulated her own principle from the experience she had gone through.
Robert Havighurst’sAge periods and Developmental Tasks
Late Maturity
This stage of development showcases in adjusting to decreasing physical strength and health, retirement and reduced income, establishing an affiliation with one’s age group, adopting and adapting social roles in a flexible way, and satisfactory physical living space.
Patient knows that her present condition is part of being old as written by her. She is a member of senior citizen in their place. She has a satisfactory physical living space.
CHAPTER III
ASSESSMENT
A.Physical assessment
System Normal Findings Standard Book Picture Manifestations Actual signs and symptoms manifested by the patient Neurological The patient appears relaxed, smooth gait, and symmetrical body movements. The patient should be able to correspond to verbal orders, oriented to time, person, and place. The patient should have the ability to concentrate or maintain attention span. A conscious patient should correspond to verbal, eye, and motor orders. Weakness and Fatigue; confusion; inability to concentrate; disorientation; tremors; seizures; astrexis; restlessness of legs; burning of soles of feet; behaviour changes. July 20, 2010:
12:30pm
Weak, Restless, irritable, with GCS of 9/15, eyes open spontaneously, with symmetrical body movements.
2:30pm
Appears relaxed, GCS of 11/15, eyes open spontaneously, with symmetrical body movements.
July 21, 2010:
Alert, Relaxed, GCS of 11/15 Respiratory Chest must be symmetric, spine vertically aligned, skin must be intact, chest wall intact, uniform temperature, quiet, rhythmic, effortless respirations, full symmetric excursion. Crackles; thick, tenacious sputum; depressed cough reflex; pleuritic pain; shortness of breath; tachypnea; kussmaul-type respirations; uremic pneumonitis; “uremic lung” July 20, 2010:
(+)wheezes on both lungs, (+) crackles, RR: 28, SOB, O2 sat: 78% uniform temperature, full symmetrical excursion. On mechanical ventilator with the following settings: TV- 280, BUR- 24, FiO2- 100, PF-40

July 21, 2010:
Still with wheezes but minimal, RR: 22, O2 sat: 99%, still with mechanical ventilator.
Cardiovascular BP: 100-120/60-90
mmHg

Heart rate:
60-100 beats per minute
ECG:
Normal Sinus Rhythm without dysrrhytmia

Hypertension; pitting edema (feet, hands, sacrum); periorbitaledema; pericardial friction rub; engorged neck veins; pericarditis; pericardial effusion; pericardial tamponade; July 20, 2010:
12:50pm
BP: 200/140mmhg, +1 bipedal edema, engorged neck veins. HR: 63 bpm, bounding pulse
ECG:

July 21, 2010
BP: 150/100, (-) edema, (-) neck vein engorgement, HR: 65
ECG: Normal Sinus Rhythm without dysrrhytmia
Digestive Audible bowel sounds. Tympany over the stomach and gas-filled bowels; dullness especially on the liver and spleen, or a full bladder.
Ammonia odor to breath (“uremic fetor”); metallic taste; mouth ulcerations and bleeding, anorexia, nausea, and vomiting; hiccups; constipation or diarrhea; bleeding of GI tract. July 20, 2010
With Nasogastric Tube through Left nasal opening, Audible bowel sounds

July 21, 2010
Still with NGT through left nasal opening Integumentary Skin varies from light to deep brown.
Skin color must be uniform except in area exposed to the sun. Moisture must be present in skin folds and axillae. No edema must be present. No abrasions and lesions
must be present Gray-bronze skin color; dry, flaky skin; pruritus; ecchymosis; purpura; thin, brittle nails; coarse, thinning hair Dry lips; dry and flaky skin; coarse, thinning hair; +1 bipedal edema,

Musculoskeletal Muscles should be of equal size on both sides of the body. Muscles should be firm. Movement of the muscles should be smooth and coordinated. Each muscle should have equal strength on both sides. Muscle cramps, loss of muscle strength; renal osteodystrophy; bone pain; bone fracture; foot drop July 20, 2010
Loss of muscle strength; (+) 7/10 joint pain;

July 21, 2010
Increase muscle strength; absence of joint pain Lymphatic System Lymph nodes in the neck and axillary area should not be palpable. May have palpable lymph node due to infection No Lymph nodes palpated Genitourinary Urination: continent voiding of amber colored urine in sufficient quantity; no dysuria
Bladder Distention: not visible
Initially, salt-wasting and consequent hyponatremia produce hypotension, dry mouth, loss of skin turgor, listlessness, fatigue, and nausea; later, somnolence and confusion develop. As the number of functioning nephrons decreases, so does the kidneys’capacity to excrete sodium, resulting in salt retention and overload. Accumulation of potassium causes muscle irritability, then muscle weakness as the potassium level continues to rise. Fluid overload and metabolic acidosis also occur. Urinary output decreases; urine is very dilute and contains casts and crystals. July 20,2010
ABG study shows metabolic acidosis, Output: 80cc
July 21, 2010
Input: 600 cc
Output 200cc

B. Diagnostic Test
Diagnostics and Laboratory tests
Chest X-ray
* Significance to patient
Evaluate known or suspected pulmonary and cardiovascular disorder.
Evaluate placement and position of an endotracheal tube.
Monitor effectiveness of treatment regimen.
* Result:
Shows bilateral pulmonary congestion and edema; bilateral minimal pulmonary effusions are also seen
* Nursing considerations/responsibilities
Before
* Positively identify the patient using at least two unique identifiers before providing care, treatment, or services
* Inform the patient that the procedure assesses cardiopulmonary status.
* Obtain a history of patient’s symptoms and complaints, including a list of known allergens
* Record the date of last menstrual period .
* Review the procedure with the patient. Address concerns about pain and explain that no pain will be experience during the test.
Intra-test
* Ensure that the patient has removed all external metallic objects from the area to be examined.
* Instruct the patient to remain still throughout the procedure, because movements result unreliable results.
* Observed standard precautions
Post-test
* The report will be sent to the requesting HCP, who will discuss the result with the patient.
* Recognized anxiety related to the test results and be supportive of impaired activity related to respiratory capacity and perceive loss of physical activity.
Complete Blood Count
* Significance to patient
Detect haematological disorder, neoplasm, or immunological abnormality
Monitor fluid imbalances
Monitor the progression of non-hematological disorders such as COPD, and renal disease
Provide screening as part of CBC count in a general physical exam, especially upon admission.
* Significant result
Norma Values July 19,2010 July 20,2010 BUN 2.50-6.07mmol/L 14.28 Creatinine 61.88-106.08mmol/L 928.20 Blood uric acid 0.15-0.35mmol/L 0.30 WBC 5-11 10^3/uL 20.91 RBC 4.2-5.4 10^6/uL 3.53 HGB 12.0-16.0 mg/dL 10.2 HCT 38-47% 32.9 Neutrophil 0.55-0.77% 0.88 Serum Na 135-148mmol/L 129 Serum K 3.5-5.3mmol/L 3.8 Serum Ca 8.2-10.2mg/dL 6.8
* Nursing considerations/responsibilities
Before
* There is no preparation necessary for a full blood count. It can be done at any time of the day. However, if the blood test will be used not only for a blood count but for other reasons (e.g., glucose or cholesterol monitoring), you will be required to fast before hand. Therefore, this test is better in morning.
During
* Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false decrease in the values of some test.
After
* Assess the puncture site for signs of bleeding or bruising of the skin. If the platelet count or other clotting measures are decreased, clotting will be slow to occur. To promote clotting, the nurse can use sterile gauze to apply pressure to the site or raise the arm above the head while maintaining pressure on the site.
* Arrange for prompt transport of the specimen. If there is an anticipated delay, refrigerate the specimen.

12-lead ECG
* Significance to patient
* To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac hypertrophy, electrolyte imbalnces.
* Significant result
Normal Sinus Rhythm without dysrrhytmia

* Nursing responsibilities
Before
* Explain the procedure to the patient
* Tell patient that she doesn’t need to restrict fluid or food
* Describe the test including who will perform it, where it will be done, and how long it will last
* Tell patient that an electrodes will be attach in her arms, legs, and chest and the procedure is painless
* Advise patient not to talk during the test
* Check patients medication history for use of cardiac drugs, and note the use for such drugs on the test form
During and after test
* Confirm patient’s identity using two identifiers according to facility policy
* Place patient on supine position
* Have the patient expose her chest and ankles, provide chest drapes
* Turn on the machine and check the paper supply
* When the machine finishes the tracing, remove the electrodes and reposition the patient’s gown and bed cover
* Label each ECG strips with patient’s name
* Disconnect the equipment.
* Report any abnormal ECG findings to practitioner

Arterial Blood Gas analysis
* Significance to patient
* To evaluate the efficiency of pulmonary gas exchange
* To assess the integrity of the ventilator system
* To determine the acid-base level of the blood
* To monitory respiratory therapy
* Significant result
Normal Value July 20,2010 July 21,2010 pH 7.35-7.45 7.32 pCO2 35-45 33 pO2 80-90 74 HCO3 22-26 20.1 O2 sat 96-100% 78 99%
* Nursing responsibilities
Before
* There is no preparation necessary for a full blood count. It can be done at any time of the day. However, if the blood test will be used not only for a blood count but for other reasons (e.g., glucose or cholesterol monitoring), you will be required to fast before hand. Therefore, this test is better in morning.

During
* Ensure that the blood is not taken from the hand or arm that has intravenous line. Hemodilution with intravenous fluids causes a false decrease in the values of some test.
After
* Assess the puncture site for signs of bleeding or bruising of the skin. If the platelet count or other clotting measures are decreased, clotting will be slow to occur. To promote clotting, the nurse can use sterile gauze to apply pressure to the site or raise the arm above the head while maintaining pressure on the site.
* Arrange for prompt transport of the specimen. If there is an anticipated delay, refrigerate the specimen.

CHAPTER IV
Nursing Care Plan
Problem #1:
Difficulty of Breathing
July 20, 2010
Cues:
Subjective:
Obejective:

(+)wheezes on both lungs
(+) crackles
RR: 28
Shortness of breath
ABG’s: ABG’s: pH- 7.32, pCO2- 33, pO2- 74, HCO3-20.1, O2 sat- 78%

Weakness
Capillary refill: 4 seconds
Cyanosis

Tachycardia
Chest X-ray: Shows bilateral pulmonary congestion and edema; bilateral minimal pulmonary effusions are also seen;
Nursing Diagnoses
– Ineffective airway clearance related to tracheal bronchial obstruction secondary to edema formation as manifested by CXR result: Shows bilateral pulmonary congestion and edema; bilateral minimal pulmonary effusions, RR: 28bpm, wheezes, and crackles
-Impaired gas exchange related to altered oxygen and CO2 exchange secondary to alveolar inflammation and presence of secretions as manifested by capillary refill of 4 sec, ABG’s: pH- 7.32, pCO2- 33, pO2- 74, HCO3-20.1, O2 sat- 78%

Rationale:
Planning
NOC: Respiratory status: airway patency and Gas exchange
Short term goal:
After 30 min of nursing intervention patient will display patent airway with breath sounds clearing, absence of dyspnea, decrease RR from 28 to 12-20bpm
Demonstrate improved ventilation as manifested by capillary refill: 2-3sec, O2 sat and ABGs within normal limit.
Long term goal:
After 1 day of nursing intervention patient will maintain patent airway and improved ventilation.
Nursing Intervention
NIC: Respiratory monitoring and airway managemeny
Independent nursing intervetion:

1. Assessed rate/depth of respirations and chest movement.Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. (Doenges: 2007)
2. Auscultated lung fields, crackles and wheezes.Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction
3. Elevated head of bed, change position frequently. Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions.
4. Assisted patient with frequent deep-breathing exercises. Demonstrate/help patient learn to perform activity, e.g., splinting chest and effective coughing while in upright position.Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.(Gulanick and Myers: 2007)
5. Suction as indicated. Stimulates cough or mechanically clears airway.
6. Monitor pulse oximetry readings.Follows progress and effects of disease process/therapeutic regimen, and facilitates necessary alterations in therapy.(Doenges: 2006)

7. Perform chest physiotherapy such as Percussion.To help clear excessive bronchial secretion from airways by shaking mucus from the walls of the airways and draining them from the lungs. (Balita, 2006:71)
Dependent
8. Administered Duavent neb every shows, Performed treatments between meals and limited fluids as appropriate.Facilitates liquefaction and removal of secretions. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing, expectorations.
9. Administered Fluimucil 200mg/ sachet 1 sachet TID. Mucolytic that reduces the viscosity of pulmonary secretions by splitting disulphide linkages between mucoprotein molecular complexes.
Collaborative
10. Assistedwith intubation, institution/maintenance of mechanical ventilation. Development of/impending respiratory failure requires prompt life-saving measures.
Evaluation
Short term: Goal partially met
After 30 min of nursing intervention has displayed absence of difficulty in breathing but still have minimal wheezes, RR: 24, O2 sat 98%.
Long term: Goal met
After 1 day of nursing intervention patient had maintained patent airway and improved ventilation as evidenced by: RR: 22, O2 sat: 99%, but still with minimal wheezes.
Problem #2: Hypertension
July 20, 2010
Cues
Subjective:
Objective:

* Weak
* Restless
* BP: 200/140mmhg
* +1 bipedal edema
* engorged neck veins
* HR: 63 bpm
* bounding pulse
* Serum Sodium: 129mmol/L
Nursing Diagnosis
Decreased cardiac output related to increase vascular resistance as manifested by BP of 200/140.
Rationale: Hypertension or High Blood Pressure, medical condition in which constricted blood vessels increase the resistance to blood flow, causing an increase in blood pressure against vessel walls. The heart must work harder to pump blood through the narrowed arteries. As a result, blood flow to vital organs such as heart, brain decreases (Microsoft (r) Encarta (r) 2006).

Planning
NOC: Circulation status
Short term Goal
After 4 hours of nursing intervention, patient will manifest reduction of blood pressure to 130-140/90-100.
Long term Goal
After 2 days of nursing intervention patient will have no elevation of blood pressure above normal limits and will maintain blood pressure within acceptable limits.
Nursing Intervention
NIC: Hemodynamic regulation
Independent Nursing intervention
1. Monitor blood pressure every 1 hour. When possible obtain pressures lying, sitting, and standing. Changes in blood pressure may indicate changes in patient status requiring prompt attention. Comparing pressures in both sides provides information as to amount of vascular involvement. Blood pressure may vary depending on body position and postural hypotension may result in syncope (Comer:73).
2. Note presence, quality of central and peripheral pulses. Bounding carotid, jugular, radial, and femoral pulses may be observed/ palpated. Pulses in the legs/ feet may be diminished, reflecting effects of vasoconstriction (increased in systemic vascular resistance) and venous congestion.
3. Observe skin color, moisture, temperature, and capillary refill time. Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to vasoconstriction or reflect cardiac decompensation/ decreased output
4. Note dependent / general edema. May indicate heart failure, renal or vascular impairment.
5. Provide calm, restful surroundings, minimize activity. Helps reduce sympathetic stimulation, promotes relaxation.
6. Monitor response to medications to control blood pressure.Response to drug therapy is dependent on both individual as well as the synergistic effects of the drugs.
Dependent Nursing Intervention
Administer medications as ordered:
7. Adalat 60 mg/tab 1 tab once-a-day. May be necessary to treat severe hypertension when a combination of a diuretic and a sympathetic inhibitor does not sufficiently control BP. Vasodilation of healthy cardiac vasculature and increased coronary blood flow are secondary benefits of vasodilator therapy.
8. Catapres 75mg/tab 1 tab sublingually as needed for bp> 160/100. Decreases blood pressure by stimulating alpha-adrenergic receptors to inhibit sympathetic cardioaccelerator and vasoconstrictor centers.
9. Prepare for Hemodialysis. Reduction or uremic toxins and correction of electrolyte imbalances and fluid overload may limit/ prevent cardiac manifestations such as hypertension.
Evaluation
Short term
Goal partially met:
After 4 hours of nursing intervention, patients blood pressure has decreased to 160/130mmhg but still above expected outcome.
Long term
Goal partially met:
After 2 days of nursing intervention, patient’s blood pressure is 150/100 mmhg still above normal limit but no elevations noted.

Problem
#3: Joint Pain
July 20, 2010
Cues:
Subjective
Patient wrote 7/10 pain scale
Patient localizes pain on the joints
Objective:

Serum Ca: 6.8mg/dL
Serum K: 3.8 N
Grimace
BP: 200/140
Blood uric acid 0.30mmol/L
BUN: 14.

Nursing Diagnosis
Acute pain related to accumulation of uric acid to bones secondary to renal failure
Rationale:
Planning
NOC: Pain control
Short term:
After 2 hour of nursing intervention, patient will demonstrate relief from pain as evidence by absence of facial grimace and reduce pain scale.
Long term:
After 1 day of nursing intervention, patient will maintain relief from joint pain.
Nursing intervention
NIC: Pain management
Independent nursing intervention
1. Assessed pain, noting location, characteristics, intensity. Assessing the pain helps evaluate severity and intensity (Gulanick et. al, 1998)

2. Explained cause of pain and importance of notifying caregivers of changes in pain occurrence and characteristics. Explanation provides opportunity for timely administration of analgesics and alert caregivers to possibility of passing stone or developing complications (Gulanick et. al, 1998)

3. Provided comfortable and restful environment. Comfortable and restful environment promotes relaxation, reducing of muscle tension and enhancement of coping (Gulanick et. al, 1998)

4. Encouraged use of diversionalactivites and non-pharmacological interventions to alleviate pain. Diversional activities redirects patients attention and aidsin muscle relaxation (Gulanick et. al, 1998)

Dependent nursing intervention
5. Administered Caltrate plus 1 tab TID with meals. Calcium is an essential mineral that is necessary for strong bones, normal functioning of nerves and muscle and also plays a role in the formation of blood clots
6. Administer medication as indicated, e.g., analgesics. Relieves pain and enhances comfort
7. Provide sitz bath. Relieves local discomfort.
8. Apply/ monitor effects of transcutaneous electrical nerve stimulator (TENS). Used to block transmission of pain stimulus.
9. Prepare for hemodialysis. Reduction or uremic toxins and correction of electrolyte imbalances
Evaluation
Short term: Goal partially met
After 2 hours of nursing intervention patient demonstrated less pain as evidenced by writing “medyomasakitparinperohindiganunkasakitkanina,” and 5/10 pain scale, with the absence of facial grimace.
Long term: Goal met
After 1 day of nursing intervention patient maintained relief from pain as evidenced by absence of complaints from pain.

Problem #4
+1 Bipedal edema
July 20,2010
Cues
Subjective:
Objective:

* +1 bipedal edema
* Capillary refill: 3 seconds
* BP: 200/140mmhg
* Creatinine: 928.20 ?
* HCT: 32.9?
* HGB 10.2?
* K: 3.9?
* Output: 80cc

Nursing Diagnosis
Fluid volume excess r/t compromised kidney functions secondary to chronic kidney disease
Rationale:
The kidney cannot concentrate or dilute the urine normally in end stage renal diseases. Appropriate responses by the kidney to changes in the daily intake of water and electrolytes, therefore, do not occur. Some patients retain sodium and water, increasing the risk for edema, heart failure and hypertension(Smeltzer et.al, 2008 p. 1529)
Planning
NOC: Fluid Balance
Short term goal:
After 4 hours of nursing intervention, patient will display appropriate urine output and vital sign with normal limits
Long term goal:
After 2 days hours of nursing intervention the patient will experience no rapid progression of the edema.
Nursing intervention
NIC: Fluid/ electrolyte management
Independent Nursing Intervention
1. Monitor strictly intake and output every 1 hour. Low output less than 400 cc/ml may be first indicator of acute failure, especially in high-risk patient (Doenges,2002)
2. Assess skin, face and dependent areas for edema. Edema occurs primarily in dependent tissues of the body (Doenges,2002)
3. Monitor blood pressure every 1 hour. Hypertension can occur because of failure of the kidneys to excrete urine (Doenges,2002)
4. Assess level of consciousness. May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia (Doenges,2002)
5. Monitor laboratory (BUN, Creatinine, Na, K). Assesses progression and management of renal dysfunction or failure (Doenges,2002)
Dependent Nursing intervention
6. Restrict fluids as indicated. Fluid management is usually calculated to replace output from all sources plus estimated insensible losses is treated with volume replacers and/ or vasopressors (Doenges,2002)
7. Prepare for hemodialysis as indicated. Done to correct volume overload, electrolyte and acid-base imbalances and to remove toxins. (Doenges,2002)
Evaluation
Short term:
Goal not met:
After 4 hours of nursing intervention, patient has still no urine output.
Long term:
Goal met:
After 2 days of nursing intervention, patient manifest absence of edema and urine output of 200cc.

Problem #5:
Irritability
July 20,2010
Cues:
Subjective:

Objective
Shortness of breath
Weak
Restless
Irritable
Withdraws to touch
GCS: 9/15
ABG’s: pH- 7.32, pCO2- 33, pO2- 74, HCO3-20.1, O sat- 78%
Serum Sodium: 129mmol/L
Creatinine: 928.20 ?
HCT: 32.9?
HGB 10.2?

Nursing Diagnosis
Disturbed thought processes related to accumulation of toxins, metabolic acidosis, hypoxia, and electrolyte imbalances in the brain.
Rationale:
With advance renal disease, metabolic acidosis occurs because the kidney cannot excrete increased loads of acid. As glomerular filtration decreases, the serum creatinine and BUN levels increase. In renal failure, erythropoietin production decreases and profound anemia results, producing fatigue, angina, and shortness of breath. (Smeltzer, et.al., 2004)
Planning
NOC: Cognition- Ability to execute complex mental processes

Short term Goal

After 4 hours of nursing intervention, patient will appear relax.

Long term goal
After 1 day of nursing intervention, patient will maintain relax state.

Nursing intervention

NIC: Reality Orientation- Promotion of patient’s awareness of personal identity, time, and environment
1. Assess extent of impairment in thinking ability, memory, and orientation. Uremic syndrome’s effect begins with minor confusion/ irritability and progress to altered personality or inability to assimilate information and participate in care.
2. Ascertain from SO patient’s usual level of mentation. Provides comparison to evaluate progression/resolution of impairment.
3. Provide SO with information about patient’s status. Some improvement in mentation may be expected with restoration of more normal levels of BUN, electrolytes, and serum pH.
4. Provide quiet/calm environment. Minimizes environmental stimuli to reduce sensory overload/confusion while preventing sensory deprivation.
5. Reorient the surroundings, person, and so forth. Provide calendars and clock. Provides clues in recognition of reality.
6. Communicate information/ instructions in simple, short sentences.Ask direct yes/no questions. Repeat explanations as necessary. May aid in reducing confusion, and increases possibility that communications will be understood/remembered.
7. Establish a regular schedule for expected activities. Aids in maintaining reality orientation and may reduce fear/confusion.
8. Promote adequate rest and undisturbed periods for sleep. Sleep deprivation may further impair cognitive abilities.
Dependent nursing intervention
9. Monitor laboratory studies, e.g., BUN/Cr, serum electrolytes, glucose level, and ABGs. Correction of elevations/imbalances can have profound effects on cognition/mentation.
10. Provide supplemental 02 as indicated. Correction of hypoxia alone can improve cognition.
11. Avoid use of barbiturate and opiates. Drugs normally detoxified in the kidneys will have increased half-life/cumulative effects, worsening confusion.
12. Prepare dialysis. Marked deterioration of thought processes may indicate worsening of azotemia and general condition, requiring prompt intervention to regain homeostasis.

Evaluation
Short term
Goal met:After 4 hours of nursing intervention, patient manifested improved condition as evidenced by relaxed appearance.
Long term
Goal met:
After 1 day of nursing intervention patient maintained calm and relaxed state.
Problem #6: Dry Skin
July 20,2010
Cues
Subjective:
Objective:
Dry lips;
Dry and flaky skin;
coarse, thinning hair;
+1 bipedal edema,
Decreased mobility
Nursing Diagnosis:
Risk for impaired skin integrity r/t alteration in skin turgor secondary to kidney disease
Rationale
Some degree of edema and hypertension is present in most patients with CKD. Increased permeability of the glomerular membrane may also occur, with associated pitting edema, hypoalbuminemia, hyperlipidemia, and fatty cast in the urine (Smeltzer, et.al., 2008 p. 1517)

Planning
NOC: Tissue Integrity: Skin & Mucous Membranes
Short term goal:
After 2 hours of nursing intervention, patient will demonstrate intact skin without lesions or scratches.
Long term Goal:
After 1 day of nursing intervention, patient will still maintain intact skin in the absence of lesions, scratches, or abrasions.
Nursing Intervention
NIC: Skin surveillance
Independent Nursing intervention
1. Inspect skin for changes in color, turgor, or vascularity. Indicates areas of poor circulation/breakdown that may lead to decubitus formation/infection.
2. Monitor fluid intake and hydration of skin and mucous membranes. Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level.
3. Inspect dependent areas for edema. Elevate legs as indicated. Edematous tissues are more prone to skin breakdown. Elevation promotes venous return, limiting venous stasis/ edema formation.
4. Change position frequently; move patient carefully ;pad bony prominences with sheepskin, elbow/elbow heel protectors. Decreases pressure on edematous, poorly perfused tissues to reduce schemia.
5. Provide soothing skin care. Avoid use of soaps. Apply ointments or creams .Lotions and ointments may be desired to relieve dry, cracked skin..
6. Keep linens dry and wrinkle-free. Reduces dermal irritation and risk for skin breakdown.
7. Encourage patient to report itching.Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products

DEPENDENT
8. Provide foam/ floatation mattress.Reduces prolonged pressure on tissues, which can limit cellular perfusion, potentiating ischemia/ necrosis
Evaluation
Short term: Goal met
After 2 hours of nursing intervention, patient manifested intact skin as evidenced by absence of lesions and scratches
Long term: Goal met
After 1 day of nursing intervention, patient maintained intact skin as evidenced by absence of skin breakdown.

Problem #7
Difficulty expressing needs verbally
July 20, 2010
Cues
Subjective:
Objective:
Inability to speak
Presence of mechanical ventilator
Irritable
Nursing Diagnosis:
Impaired verbal communication related to presence of endotracheal tube
Rationale:
Endotracheal tube passes between the vocal cords making the patient unable to speak. (Williams: 2003)
Planning
NOC: Communication: expressive ability
Short term goal
After 1 hour of nursing intervention, patient will establish method in which needs can be understood, e.g., writing and demonstrate satisfaction in the method of communication made.
Long term goal
After 1 day of will maintain satisfaction on the chosen method of communication like writing.
Nursing Intervention
NIC: Communication enhancement- Speech deficit
Independent Nursing Intervention
1. Assessed patient’s ability to communicate by alternative means. Method of communicating with patient is therefore highly individualized.
2. Established means of communication: Maintained eye contact; asked yes/no questions; provide pen and paper. Eye contact assures patient of interest in communicating, a great deal can be done with yes/no questions, and writing provides the best way to communicate with patient.
3. Considered form of communication upon placing IV. IV positioned in hand/wrist may limit ability to write or sign.
4. Placed call bell within reach. Makes the patient be able to relax, feel safe, and breathe with the ventilator knowing that the nurse is vigilant and needs will be met.
5. Place note at central call station informing staff that patient is unable to speak. Alerts all staff members to respond to patient at the bedside instead of over the intercom
6. Encourage family/SO to talk with patient, providing information about family and daily happenings. Maintains contact with reality and enabling the patient feel part of family unit can reduce feeling of awkwardness.
7. Reorient the surroundings, person, and so forth. Provide calendars and clock. Provides clues in recognition of reality.
Evaluation
Short term: Goal met
After 1 hour of nursing intervention, patient was able to establish method of writing in which needs are understood and demonstrated satisfaction on the method of communication made as evidenced by writing “yes” when asked if she’s satisfied with the way she communicates.
Long term: Goal met
After 1 day of nursing intervention, patient was able to maintain satisfying method of communication through writing.
Drugs Ordered
1.Duavent neb every shows
Generic name: Ipratropium/salbutamol (Albuterol)
Classification
Pharmacologic Class: Symphathomimetic (beta2-adrenergic agonist)
Therapeutic class: Bronchodilator, anti-asthmatic
Indication:
To prevent or treat bronchospasm in patients with reversible obstructive airway disease
Mechanism of Action: relaxes smooth muscles by stimulating beta2-receptors, thereby causing bronchodilation and vasodilation.
Contraindication: Hypersensitivity to ketotifen or any other component of the formulations.
Adverse reactions: Sedation, dry mouth, dizziness, weight gain. Occasionally, CNS stimulation, visual acuity changes, dry eyes, headache, fatigue. Rarely, cystitis; very rarely, increase in liver enzyme and hepatitis.
Nursing Resposibilities:
-Stay alert hypersensitivity reactions and paradoxical bronchospasm. Stop the drug immediately if these occur.
-Monitor serum electrolyte levels.
-Teach patient s/sx of hypersensitivity and paradoxical bronchospasm. Tell her to stop taking drug immediately and contact prescriber if these occur.
-Instruct patient to notify the prescriber if prescribed dosage fails to provide relief

2. Hydrocortisone 100mg IV every show
Brand name: Cortizan
Classification: Corticosteroid
Indication: Severe inflammation, adrenal insufficiency
Mechanism of action: Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism
Contraindication: Systemic fungal infection, IM use in ITP, administration of live virus vaccines in patients receiving immunosuppressive corticoid doses; psychosis; acute glomerulonephritis; amoebiasis; nonasthmatic bronchial disease.
Adverse effects: depression, flushing, sweating, headache, mood changes, hypertension, circulatory collapse, thrombophlebitis, embolism, tachycardia, edema, fungal infection, increase intra-ocular pressure, blurred vision, diarrhea, nausea and vomiting.
Nursing responsibilities:
– Determine whether patient is sensitive to other corticosteroids
– Monitor patient’s weight , blood pressure, and electrolyte level
– Watch out for adverse effects
– Elderly patients may be more susceptible to osteoporosis for prolonged use
– Teach patient signs and symptoms of adrenal insufficiency: fatigue, muscle weakness, joint pain, fever anorexia, nausea, SOB, dizziness.

3. Fluimucil 200mg/ sachet 1 sachet TID
Generic name: Acetylcysteine
Classification: Mucolytic type of respiratory drug
Indication: adjunct therapy for abnormal viscid or inspissated mucous secretions in patients with pneumonia.
Action: Mucolytic that reduces the viscosity of pulmonary secretions by splitting disulphide linkages between mucoprotein molecular complexes.
Contraindication: patient hypersensitive to drug, use cautiously in elderly or debilitated patients with severe respiratory insufficiency
Adverse reactions: Nausea, vomiting and other GI symptoms, generalized urticarial, accompanied by mild fever, hypotension, wheezing, dyspnea, and stomatitis.
Nursing Responsibility:
– Inform patient that drug may have foul smell or taste, the unpleasant odour will decrease after repeated use, the discoloration of solution after bottle is opened does not impair its effectiveness.
4. Dilatrend 25mg/tab 1/2 tab OD
Generic name: Carvedilol
Classification: Antihypertensive
Indication: Hypertension
Action: Has a mixture of both alpha and beta adrenergic blocking activity. It causes vasodilation and decreased peripheral resistance; reduces exercise-induce tachycardia and reflex orthostatic hypotension.
Contraindication: Bronchial asthma, chronic bronchitis, pulmonary emphysema, allergic rhinitis, swelling of laryngeal mucosa, sinus node syndrome, SA block, 2nd and 3rd degree AV block, severe liver dysfunction, metabolic acidosis
Adverse effect: dizziness, headaches, and tiredness. Slowed pulse rate or GI upset or flu-like symptoms, breathing problem.
Nursing responsibility:
– Alert: patient receiving this therapy who have a history of severe anaphylactic reaction to several allergens may be more reactive to repeated challenge ( accidental, diagnostic, or therapeutic)
– Mild hepatocellular injury may occur during therapy. At first sign of hepatic dysfunction, perform test for hepatic injury or jaundice; if present stop drug
– If drug must be stop, do so gradually over 1 to 2 weeks
– Monitor patient with heart failure for worsened condition, renal dysfunction, fluid retention; diuretics may need to be increase
– Monitor diabetic patient closely; drug may mask hypoglycaemia, or hyperglycemia may be worsened
– Observe patient for dizziness or light-headedness for 1 hour after giving each new dose
– Monitor elderly patients carefully; drug levels are about 50% higher in elderly patients than in younger patients
– Monitor blood glucose level

5. Adalat 60mg/tab itab OD
Generic name: Nifedipine
Classification: Anti-anginals
Indication: Hypertension
Action: Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces relaxation of coronary vascular smooth muscle and peripheral vascular smooth muscle, dilates coronary vascular arteries.
Contraindication: Hypersensitive to drug, used cautiously in patients with HPON and elderly patient
Adverse effects: dizziness, flushing, headache, hypotension, peripheral edema, tachycardia, and palpitations.
Nursing Responsibilities:
– Advise patient to report chest pain immediately.
– Monitor blood pressure frequently

6. Caltrate plus 1 tab TID with meals
Generic name: Calcium, elemental (as carbonate) 600mg, Vit. D 200IU, magnesium 40mg, zinc 7.5mg, copper 1mg, manganese 1.8mg, boron 250mcg; tabs (sugar-free); assorted fruit-flavor chewable tabs (contain sugar).
Classification: Calcium (different salts in combination) ; Belongs to the class of calcium-containing preparations. Used as dietary supplements.
Indication: Supplement for Ca deficiency & conditions that require increased Ca intake; may reduce the risk of osteoporosis later in life
Action: Calcium is an essential mineral that is necessary for strong bones, normal functioning of nerves and muscle and also plays a role in the formation of blood clots
Contraintication: Hypercalcemia and hypercalciuria (e.g., hyperparathyroidism, vitamin D overdosage, decalcifying tumors such as plasmocytoma; bone metastases); severe renal disease; and in calcium loss due to immobilization.
Adverse effects: GI discomfort, hypercalcemia, hypercalciuria.
Nursing responsibilities:
– Record amount and consistency of stools. Manage constipation with laxative or stool softener
– Monitor calcium level, especially in patient with renal impairment
– Watch for evidence of hypercalcemia (nausea, vomiting, headache, confusion, and anorexia)

7. Piptaz 2.25mg IV every 12 hours
Generic name: Piperacillin Na
Classification: Piperacillin and enzyme inhibitor ; Belongs to the class of penicillin combinations, including beta-lactamase inhibitors. Used in the systemic treatment of infections.
Indication: Treatment of infections in the lower resp tract eg severe community-aquired pneumonia & healthcare pneumonia; uncomplicated & complicated skin & skin structure infections
Action: Piperacillin, an extended-spectrum penicillin, exerts its antimicrobial action in growing and dividing bacteria by interfering with septum formation and cell wall synthesis of susceptible bacteria. It binds to penicillin-binding proteins on the bacterial cell wall and blocks peptidoglycan synthesis. Peptidoglycan is a heteropolymeric structure that gives the cell wall its mechanical stability. The final stage of the peptidoglycan synthesis involves the completion of the cross-linking with the terminal glycine residue of the pentaglycine bridge linking to the fourth residue of the pentapeptide. The transpeptidase that performs this step is inhibited by piperacillin. The bacterial cell wall weakens leading to swelling and rupture of the microorganism
Contraindication: Hypersensitivity to penicillins, cephalosporins& ß-lactam inhibitors.
Adverse reaction: Rash, pruritus, fever; diarrhea, nausea, constipation, vomiting, dyspepsia, stool changes, abdominal pain, transient leucopenia, neutropenia, thrombocytopenia; hepatic & renal effects; headache, insomnia, agitation, dizziness, anxiety; HTN, chest pain, edema, moniliasis, rhinitis, dyspnea, hypotension, ileus, syncope, rigors, phlebitis, pain, inflammation, thrombophlebitis.
Nursing Responsibilities:
-Assess CBC and kidney and liver function test results.
-Monitor for s/sx of superinfection and other serious adverse reactions.
-Be aware that cross-sensitivity to penicillins may occur.
-Instruct patient to take drug with food or milk to reduce the GI distress and enhance absorption.
-Advise to patient not to take antacids within 2hours of drug.
-Tell patient to continue to take full amount prescribed even when he feels better.
-Instruct patient to report s/sx of allergic response and other adverse reactions, such as rash, easy bruising, bleeding, severe GI problems, or difficulty breathing.

8. Asmavent neb every 12hours
Generic name: Budesonide
Classification: Belongs to the class of other inhalants used in the treatment of obstructive airway diseases, glucocorticoids.
Indication: Use for the management of bronchial asthma
Action: Anti-inflammatory corticosteroid that exhibits potent glucocorteroid activity and weak mineralocorticoid activity, have a wide-range of inhibitory activities against such cell types as mast cells and macrophages and mediators involved in all allergic and nonallergic inflammation.
Contraindication: hypersensitive to drugand in those with status asthmaticus or other acute asthmatic episodes; use cautiously, if at all, in patients with active or quiescent TB of the respiratory tract, ocular herpes simplex, or untreated systemic fungal, bacterial, viral, or parasitic infections.

Adverse reaction: Neck pain; cough, resp infection, rhinitis, sinusitis, stridor. Gastroenteritis, oral candidiasis, abdominal pain, dry mouth, nausea, vomiting, dyspepsia. Wt gain.Fracture, myalgia, arthralgia.Hypertonia, migraine, asthenia, dystonia, hyperkinesia.Ecchymosis, epistaxis, emotional liability.Contact dermatitis, rash. Taste perversion
Nursing Responsibilities:
– When transferring from systemic corticosteroid to budesonide, use caution and gradually decrease corticosteroid dose to prevent adrenal insufficiency
– Drug doesn’t remove the need for systemic corticosteroid therapy in some situations.
– If bronchospasm occurs after using this drug, stop therapy and treat with bronchodilators
– Improved lung function has been observed within 24 hours of starting budesonide treatment, although maximum benefit may not be achieved for 1 to 2 weeks or longer.

9. Floxel 500mg/tab every 48 hours
Generic name: Levofloxacin
Classification: Fluoroquinolone
Therapeutic class: anti infective
Indication: Community-acquired pneumonia
-Acute bacterial exacerbation of chronic bronchitis
Action: Inhibits the enzyme DNA gyrase in susceptible gram-negative and gram-positive aerobic and anaerobic bacteria, interfering with bacterial DNA synthesis.
Contraindication: Epilepsy, history of tendon disorders related to fluoroquinolone therapy, children or adolescent, pregnancy and lactation, hypersensitive to drug.
Adverse reaction: Nausea, diarrhea, headache, dizziness, insomnia, musculoskeletal effects, pain, reddening of the infusion site, phlebitis, increase in liver enzyme, eosinophilia, leukopenia, asthenia, superinfection, eye irritation, urticaria
Nursing responsibilities:
-Check vital signs especially BP. Too rapid infusion can cause hypotension.
-Assess for severe diarrhea which may indicate pseudomembranous colitis.
-Watch for hypersensitivity reaction. Discontinue drug immediately if rash or other s/sx occur.
-Tell patient to stop taking drug and contact prescriber if he experiences the s/sx of hypersensitivity reactions or severe diarrhea.
-Instruct patient not to take with milk yogurt, multivitamins containing zinc or iron, or antacids containing aluminium or magnesium.
-Caution patient to avoid driving and other activities that require mental alertness until CNS effects of drugs are known.

10. Catapres 75mg/tab SL PRN for blood pressure >160/100
Generic name: Clonidine
Classification: antihypertensive
Indication: Essential and renal hypertension
Action: Stimulates alpha-adrenergic receptors to inhibit sympathetic cardioaccelerator and vasoconstrictor centers.
Contraindication: hypersensitive to drug; transdermal form is contraindicated in patients hypersensitive to any component of the adhesive layer of transdermal center; epidural form is contraindicated in patients receiving anticoagulant therapy, in those with bleeding diathesis, in those with an injection site infection, and those who are hemodynamically unstable or have severe CV disease; use cautiously in patient with chronic renal failure.
Adverse Reaction: drowsiness, dry mouth, dizziness, headache, constipation, depression, anxiety, fatigue, nausea, anorexia, parotid pain, sleep disturbances, vivid dream, urinary retention, slight orthostatic hypotension, burning and itching sensation.
Nursing Responsibilities:
– Drug may be given to lower blood pressure rapidly in some hypertensive emergencies
– Monitor blood pressure frequently. Dosage is usually adjust in patient’s blood pressure and tolerance
– Elderly patients may be more sensitive than younger ones to drug’s hypotensive effect
– Observe patient tolerance to drug’s therapeutic effects, which may require increase dosage
– Advise patient that stopping drug abruptly may cause severe rebound high blood pressure. Tell her dosage must be reduced gradually over 2 to 4 days as instructed by prescriber

11. Prevacid FDT 30mg/tab OD-AM
Generic name: Lansoprazole
Classification: proton pump inhibitors (PPI)
Indication: used for treating ulcers of the stomach and duodenum, gastroesophageal reflux disease (GERD) and Zollinger-Ellison Syndrome.
Action: block the production of acid by the stomach
Contraindication: patients with known hypersensitivity to any component of the formulation of PREVACID. Amoxicillin is contraindicated in patients with a known hypersensitivity to any penicillin. Clarithromycin is contraindicated in patients with a known hypersensitivity to clarithromycin, erythromycin, and any of the macrolide antibiotics. Concomitantadministration of clarithromycin with cisapride, pimozide, astemizole, or terfenadine is contraindicated.

Adverse reaction: diarrhea, nausea, vomiting, constipation, rash and headaches. Dizziness, nervousness, abnormal heartbeat, muscle pain, weakness, leg cramps and water retention rarely occur.
Nursing Responsibilities:
Assessment
· History: Hypersensitivity to lansoprazole or any of its components; pregnancy; lactation
· Physical: Skin lesions; body T; reflexes, affect; urinary output, abdominal examination; respiratory auscultation
Interventions
· Administer before meals. Caution patient to swallow capsules whole, not to open, chew, or crush. If patient has difficulty swallowing, open capsule and sprinkle granules on apple sauce, Ensure,yogurt, cottage cheese, or strained pears; for NG tube, mix granules from capsule with 40 mL apple juice and inject through tube, flush tube with additional apple juice; or granules for oral suspension can be added to 30 mL water, stir well, and have patient drink immediately.
· WARNING: Arrange for further evaluation of patient after 4 wk of therapy for acute gastroreflux disorders if symptomatic improvement does not rule out gastric cancer, which did occur in preclinical studies.
· Switch to oral drug from IV as soon as patient is able to take oral drugs. Use of IV drug for > 7 days is not approved.
Teaching points
· Take the drug before meals. Swallow the capsules whole-do not chew, open, or crush. If you are unable to swallow capsule, open and sprinkle granules on apple sauce, or use granules, which can be added to 30 mL water, stirred, and drunk immediately.
· Arrange to have regular medical follow-up care while you are taking this drug.
· You may experience these side effects: Dizziness (avoid driving a car or performing hazardous tasks); headache (medications may be available to help); nausea, vomiting, diarrhea (proper nutrition is important, consult with your dietitian to maintain nutrition); symptoms of URI, cough (reversible; do not self-medicate, consult with your health care provider if this becomes uncomfortable).
· Report severe headache, worsening of symptoms, fever, chills.
CHAPTER V
CONCLUSION
End-stage renal disease (ESRD) is the most feared consequence of kidney disease. ESRD results when kidney function has deteriorated and is no longer adequate to sustain life, and renal replacement therapy– dialysis or transplantation — becomes necessary to maintain life. Conditions that may lead to ESRD include hypertension, diabetes, and fluid in the kidneys. Efforts should be directed at improving quality of life, providing patient education, and preventing progression to ESRD
The patient has been undergoing dialysis to maintain life. On the second day of her admission in the ICU, she showed improvement after undergoing dialysis. She was admitted with a blood pressure of 200/140mmhg, appropriate treatment was than but still her blood pressure is above her normal limit.

CHAPTER VI
RECOMMENDATION
Whenever there is, the onset of a certain disease it implies one to contribute hercooperation and willingness to be responsible for her own health. The patient must submitherself to palliative care for her to reducing the severity of her disease. The goal is to prevent andrelieve suffering and to improve quality of life for people facing serious, complex illness. Thepatient must be sensitive of her own needs and be able to expect liability for her actions. She isalso encouraged to verbalize her own thoughts and feelings concerning how she perceives hercondition affect her life and her acceptance of her disease. She is advised to take part incomplying with the treatment designed for her. She should realize the importance of complyingwith her medication and the benefits this practice would bring to her and her family’s well-being.Moreover, she must not hesitate on seeking medical assistance whenever she feels anyun-usualities in her body
This case study must be a pattern that other individuals must follow. The Nursing Education circle must be involved in sharing the different facets of diseases especially the diseases common to our country. Also, we must educate the people through seminars, immersions and case studies so that the people might be able to benefit from nursing education.
This case study must be the basis of succeeding batches of clinical nurses who are also going to make this kind of reports. This case study might not be efficient but important data gathering and research was done to make this research possible.

BIBLIOGRAPHY
BOOKS
Catagnus, J. M. & Hager, L.(Eds.).(2008). Deciphering Diagnostic Tests. Hong Kong: Wolters Kluwer, Lipincott Williams and Wilkins.

Daniels, R.(2006). Delmar’s Manual of Laboratory and Diagnostic Tests.Singapore: Thomson Learning Asia.

Deglin, J. H. &Vallerand, A. H.(2005). Davis’s Drug Guide for Nurses (9thed). Thailand: F. A. Davis Company.

Doenges, M., et. al. (2002).Nursing Care Plans: Guideline for Individualizing Patient Care. (6thed). Thailand: F. A. Davis Company.

Gulanick, M., et. al. (1998).Nursing Care Plans: Nursing Diagnosis and Intervention. (4thed). Missouri, USA.

Handbook of Medical-Surgical Nursing.(4THed). (2005). Tokyo: Lippincott, Williams and Wilkins: Wolters Kluwer Health.

Kozier, B., et.al.(2008). Fundamentals of Nursing (8thed). Singapore: Pearson Education South Asia Pte Ltd.

Smeltzer, S & Bare, Brenda. (1992). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (7thed). USA: J. B. Lippincott Company

Smeltzer, S et.al. (2008). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (11thed). USA: Lippincott Williams and Wilkins.
Williams, L et. Al. (2003). Medical-Surgical Nursing ( second edition).USA: F.A. Davis company
INTERNET
Kidney diseases and their complications, an alarming scenario in the Philippines.Bio-medicine. Retrieved on August 11, 2009 from
http://www.bio-medicine.org/medicine-news/Kidney-diseases-and-their-complications–an-alarming-scenario-in-the-Philippines-8303-1/.

MIMS Hong Kong.Gascon tab. Retrieved August 11, 2009, from
http://www.mimsonline.com/Page.aspx?menuid=mng&name=Gascon+tab&h=gascon,tab&CTRY=HK.

National Kidney Foundation.”K/DOQI Clinical Practice Guides for Chronic Kidney Disease”. Retrieved August 24, 2009, from
http://www.kidney.org/professionals/KDOQI/guidelines_CKD.
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