Iloilo Doctors’ College

College of Nursing
West Avenue, Molo, Iloilo
Tel. No. (033)338-2830

“Kidney, My Love So Sweet”

CKD secondary to DM 2 (Diabetic Nephropathy); Pneumonia A case presentation of

Presented by:
BSN IV Group 2

Members:
Ceralbo, Honey Hope
Doria, Krizzel
Enicola, Patricia
Filomeno, KyllaSharice
Gales, Mar Jean
Gilio-agan, Liezel Mae
Hilado, Sheilla Mae
Ibarreta, Paola Claire
Jusa, Ma. Thea
Khan, Jaen Leilah

Clinical Instructor: Dr. Lerina T. Alabado RN, MAN

Area: Basic Care Unit
 Table of Contents
Page No.
Introduction 1
Objectives 2
Nursing Health History 3
Biographic Data 3
Chief Complaint 3
History of Present Illness 3
Past Medical History 4
Family History of Illness 4
Lifestyle 4
Social and Psychological Data 5
Physical Assessment 6
General Appearance 6
Head 6
Nervous system 6
Respiratory 7
Cardiovascular 7
Gastrointestinal 7
Genito-Urinary 7
Musculoskeletal 7
Integumentary 7
12 Cranial Nerves 8
Anatomy and Physiology 9
Pathophysiology 11
Diagnostic Test and Laboratories 12
Drug Study 23
Nursing Care Plan 42
Evaluation 45
Course in the Ward 45
Discharge Plan 47
Documentation 48
 Introduction
The kidneys make up the body’s main purification system. They remove waste products,
many of which are toxic, from the blood. The kidneys also help control the composition of blood
and blood volume. Approximately one-third of one kidney is all that’s needed to maintain
homeostasis. Even after extensive damage, the kidneys can still perform their life-sustaining
function. If the kidneys are damaged further, however, death results unless specialized medical
treatment is administered.
Chronic kidney disease includes conditions that damage your kidneys and decrease their
ability to keep you healthy by doing the jobs listed. If kidney disease gets worse, wastes can build to
high levels in your blood and make you feel sick. You may develop complications like high blood
pressure, anemia (low blood count), weak bones, poor nutritional health and nerve damage. Also,
kidney disease increases your risk of having heart and blood vessel disease. These problems may
happen slowly over a long period of time. Chronic kidney disease may be caused by diabetes, high
blood pressure and other disorders.
Chronic kidney disease, or CKD, causes more deaths than breast cancer or prostate cancer.
It is the under-recognized public health crisis. It affects an estimated 37 million people in the U.S.
(15% of the adult population; more than 1 in 7 adults) and approximately 90% of those with CKD
don’t even know they have it. 1 in 3 American adults (approximately 80 million people) is at risk for
CKD. CKD is more common in women (15%) than men (12%). CKD is the 9th leading cause of death
in the U.S. In 2016, over 500,000 patients received dialysis treatment, and over 200,000 lived with
a kidney transplant. The National Kidney Foundation (NKF) has led the way in rallying action on this
problem.
KIDNEY disease, mainly caused by diabetes and high blood pressure, is the sixth leading
cause of death in Western Visayas. On the national level, figures presented by the Philippine
Statistics Authority showed that kidney disease is the seventh cause of morbidity and eight for
mortality or death. Western Visayas, is currently among the top 10 regions with the highest cases
along with Region 4A (Calabarzon), and Region 3 (Central Luzon) comprised of Bulacan, Bataan,
Pampanga, Tarlac, and Nueva Ecija. Based on the Philippine Renal Disease Registry, there are 28,
215 Filipinos who are currently undergoing dialysis. Of the number, 941 are in Region 6 (Western
Visayas).
Patients with chronic kidney disease (CKD) are more at risk for pneumonia than the general
population due to being immunocompromised. Pneumonia in patients with CKD is associated with
increased hospitalization, cardiovascular events, and mortality.
It is important to identify factors that increase the risk for CKD, even in individuals with
normal GFR. Risk factors include small for gestation birth weight, childhood obesity, hypertension,
diabetes mellitus, autoimmune disease, advanced age, African ancestry, a family history of kidney
disease, a previous episode of acute kidney injury, and the presence of proteinuria, abnormal
urinary sediment, or structural abnormalities of the urinary tract.

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 Objectives
General Objectives:
At the end of this case presentation, the presenters and the audience will enhance
their understanding about chronic kidney disease, its nursing management and our role as
student nurses in acquiring the proper knowledge, skills and attitude in providing care to
the patient with chronic kidney disease secondary to diabetes mellitus; and pneumonia.
Specific Objectives:
KNOWLEDGE
1. Define Chronic Kidney Disease and its underlying and defining characteristics.
2. Recognize the signs and symptoms associated with Chronic Kidney Disease.
3. Identify the pathophysiology, its factors that precipitate or predispose patient’s
condition.
SKILLS
1. Perform a nursing care plan in managing client’s sign and symptoms utilizing the nursing
process.
2. Execute appropriate nursing interventions to apply with the client’s needs.
3. Record proper documentation with regards to client’s progress and condition.
ATTITUDE
1. Approach the patient and the folks nicely with confidence to earn their full trust.
2. Explain to them clearly the information that we are going to obtain from them.
3. Acknowledge client’s needs using a holistic approach.

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 Nursing Health History
A. Biographic Data:
Patient’s Name: R.G.P.B
Address: Jaro, Iloilo City
Age: 62 years old
Sex: Female
Marital Status: Widow
Occupation: Housewife
Religion: Protestant
Attending Physician: Dr. A and Dr. DC
Date of Admission: January 2, 2020
Time of Admission: 5:17pm
Educational Attainment: High School Graduate
Weight: 60 kgs
B. Chief Complaint:
“Pinot dughan ko, hindi ako kaginhawa” as verbalized by the patient.
(Shortness of breath)
Impression: Pulmonary effusion secondary to Hypoalbuminemia;
Pneumonia; Chronic Kidney Disease secondary to DM 2
C. History of Present Illness
In January 2, 2020 around 2 in the morning, patient experienced difficulty of
breathing and was rushed to WVMC admitted as OPD. Oxygen supplement was given. CBC,
ABG and blood chemistry were also taken. Patient was given EPO 4000 units SQ, Isosorbide
Mononitrate (ISMN) 60 mg/1tab, Febuxostat 40mg/tab OD then was discharged.
In the afternoon, the patient went to her private physician who requested chest x-
ray which revealed pulmonary congestion and pleural effusion. Then she was advised for
admission at IDH.
On admission, vital signs were taken with temperature of 36.2C, pulse rate of
61bpm, respiratory rate 20cpm, blood pressure of 170/80mmHg, and oxygen saturation of
95%.

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 D. Past Medical History
R.G.P.B was positive for chicken pox, measles and rubella during childhood and was
completely immunized with BCG, DPT, OPV, Hepa B and measles. Patient has no drug or
food allergies.
In 1970 at 12 years old, patient R.G.PB fell from a lumboy (Java plum) tree and
suffered from pelvic fracture and had first aid at their local health Center at Jaro, Iloilo.
In 1987, she was diagnosed of Diabetes Mellitus at age 31 and has been taking
Diamicron 60mg/tab OD and Vildagliptin (Galvus) 500mg/tab OD as maintenance
medications.
In 2010, she suffered from a mild stroke. She was prescribed Clopidogrel 75mcg/tab
OD and Isosorbide Mononitrate (ISMN) as her maintenance medications.
In 2014, she had a second attack of stroke and was diagnosed with CKD because of
her high creatinine levels and was prescribed with Ketoanalogue 600mg/1cap 2caps OD and
Sodium Bicarbonate 1tab TID as maintenance medications. In 2018, she had a third attack
of stroke.
Last December 27, 2019, she was inserted with AV fistula in her left arm at TMC as
standby access incase her creatinine continues to increase.
E. Family History of Illness
There is a history of hypertension and heart disease in the patient’s family. Her father
died due to old age and pneumonia. Her mother is still alive and is also suffering from mild
stroke.
F. Lifestyle
Patient R.G.PB lives with her seven children in their family compound. She gets her
finances from her late husband’s pension funds and has her own boarding house for rent
business. In her teenage to adulthood years, she had vices of smoking cigarettes and
drinking alcohol, she was also fond of drinking soda but later stopped when she was
diagnosed of Diabetes Mellitus (1987). In the past, she would do her own laundry but now,
her children are helping her. She was fond of doing Zumba exercise but when her husband
died 3 years ago due to liver cirrhosis she suffered from depression and was not able to
continue anymore. She had no outdoor activities since then.
On a typical day, she sleeps at 9pm and wakes up at 4am and cannot sleep anymore all
throughout the day. She takes Rivotril 0.5mg tablet for her insomnia. Usually, she would
stay in bed, sit on a couch, stroll on their garden and eat when its meal time. Her diet
consists mainly of fish, fruits and vegetables like malunggay, lettuce, apple, carrots and
grapes. In terms of grocery shopping and food preparation, she takes turns with her
daughters.

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 G. Social and Psychological Data
Patient R.G.P.B has a good relationship with her children. Her late husband was a real
estate administrator when he was still alive but died due to pneumonia complication and
old age. She is a high school graduate, and now a housewife. She would get her finances
from her late husband’s pension funds and from their Boarding House for rent business.
If she’s in stressed, she would talk to her children or go to church and stroll around. Her
hobbies include watching television, going to church, walking around their neighborhood
and chatting with friends.
She lives in a concrete type of house where houses are near to each other. She
complains that the building beside of their house is noisy due to the live band during
weekends.

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 Physical Assessment
General Appearance
Patient R.G.PB is lying in bed, awake, conscious, coherent and oriented to three
spheres, cooperative, has good eye contact, with a positive disposition, well-groomed, on
oxygen support via nasal cannula at 2LPM, PNSS 1L infusing well at 10mL/hr, skin is intact,
moist, with a fair complexion, has an Av fistula on left arm and in cardiopulmonary distress
during the assessment.
 Head
 Hair:
o Hair is generally grayish in color, evenly distributed, oily, no signs of
infestations.
 Scalp:
o Is smooth, dry and intact without lesions or masses no dandruff noted
 Eyes:
o Patients claims to have cataract on right eye as evidenced by opacity of the lens
o Eyes move in a smooth coordinated motion in all directions,
o Pupils on left eye round, reactive to light accommodation
o (-) nystagmus
 Ears:
o No redness or swelling noted on both ears
o No foul-smelling discharges
o Able to hear clearly within 2 feet of distance
 Nose:
o Midline, symmetrical, patent
o Free of discharges, no masses or tenderness observed, free of lesions
o Able to distinguish smell, no stiffness or pain felt as claimed by the patient.
o Presence of nasal cannula
 Mouth:
o Lips are slightly pale in color, moist, free of lesions
o Oral mucosa is slightly pink and free of lesions,
o Teeth is off-white-yellowish in color, without dentures, tongue is pink, moist,
able to move freely
o Tongue is slightly pink
o Taste not properly assessed.

 Nervous system
o Alert, conscious, coherent, oriented to three spheres, no problems noted.
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 Respiratory
o Patient is on oxygen support via nasal cannula at 2LPM
o Slightly in respiratory distress (shallow breathing), respiratory rate is at 19 bpm
with regular rhythm, symmetrical chest expansion, presence of adventitious
breath sounds, crackles heard on both lungs, cough heard at times with minimal
yellow phlegm.
 Cardiovascular:
o Heart rate has regular rhythm at 69 bpm, pulse palpable bilaterally
o Present peripheral pulses
o no jugular vein distention
o normal capillary refill
 Gastrointestinal:
o Umbilicus inverted and midline
o no tenderness noted or masses palpated
o bowel sound: gurgling
o not experiencing nausea and vomiting, stool consistency: formed
 Genito-Urinary:
o Voiding freely on diaper, no urinary incontinence, a urine output of 430 cc
during our shift
 Musculoskeletal:
o Temporomandibular joint; movable, no clicking or locking.
o Neck; erect, midline, full ROM
o Bones; no deformities, masses or tenderness.
o Spinal column; midline, evenly spaced, no scoliosis, kyphosis nor lordosis noted.
o Upper and Lower extremities; full ROM, muscle grade is 5/5, non-tender, no
deformities. Left arm with AV fistula, bruit sounds heard, dressing dry and
intact. Right arm with IV line. Slight edema noted on lower extremities.
 Integumentary:
o Skin is generally fair in complexion, intact, warm to touch, good skin turgor, no
masses or nodules palpable, no edema noted.
o Finger nails are clean, well-trimmed, firmly attached to the nail beds. Left small
toenail is deformed and has ingrown.

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 12 Cranial Nerves
o CN I – Olfactory
 Normal sense of smell
o CN II – Optic
 Cataract on right eye
 Left eye normal visual fields via confrontation
o CN III – Oculomotor
 Lower edges of lids meet bottom edges of Irises; upper lids cover
approximately 2mm of irises
o CN IV – Trochlear
 Normal eye movements
o CN V – Trigeminal
 Patient can clench teeth tightly; masseter muscles when teeth are clenched.
On palpation both masseter muscles feel equal in size and strength
 Patient identifies the same sensation bilaterally, and tells when and where she
feels.
o CN VI – Abducens
 Both eye move smoothly in six cardinal fields of gaze
o CN VII – Facial
 Raised both eyebrows
 Frown
 Show both upper and lower teeth
 Smile
 Puff both cheeks
o CN VIII – Acoustic
 Equal hearing in both ears within 2 feet
o CN IX – Glossopharyngeal
 when patient speaks, her uvula and soft palate move straight up
 patient’s voice is clear
o CN X – Vagus
 Strong gag reflex
o CN XI - Spinal Accessory
 Patient lifts shoulder despite my downward pressure
o CN XII – Hypoglossal
 tongue is centered on mouth, slight tongue movement

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 AnaPhi and Pathophysiology
A. Anatomy and Physiology
 Kidneys - kidneys are bean-shaped and about the size of a tightly clenched fist. They
lie behind the peritoneum on the posterior abdominal wall on either side of the
vertebral column near the lateral borders of the psoas major muscles. The kidneys
extend from the level of the last thoracic (T12) to the third lumbar (L3) vertebrae
and the rib cage partially protects them.
 The liver is superior to the right kidney, causing the right kidney to be slightly
lower than the left.
 Each kidney measures about 11 cm long, 5 cm wide, and 3 cm thick and weighs
about 130 g.
 The renal capsule, a layer of fibrous connective tissue, surrounds each kidney.
Perirenal fat, a dense layer of adipose tissue, in turn, engulfs the renal capsule.
This perirenal fat acts as a shock absorber cushioning the kidneys against
mechanical shock. A thin layer of loose connective tissue, the renal fascia,
anchors the kidneys and surrounding adipose tissue to the abdominal wall.
 The hilum is a small area that lies on the medial side of each kidney, where the
renal artery and nerves enter and the renal vein and ureter exit the kidneys. The
hilum opens into the renal sinus, a cavity that contains fat and connective tissue.
 Pancreas- is a complex organ composed of both endocrine and exocrine tissues that
perform several functions.
 The pancreas consists of a head, located within the curvature of the duodenum,
a body, and a tail, which extends to the spleen.
 The endocrine part of the pancreas consists of pancreatic islets (islets of
Langerhans) .The islet cells produce insulin and glucagon, which are very
important in controlling the blood levels of nutrients, such as glucose and amino
acids, and somatostatin, which regulates insulin and glucagon secretion and may
inhibit growth hormone secretion.
 The exocrine part of the pancreas is a compound acinar gland. The acini produce
digestive enzymes. Clusters of acini form lobules that are separated by thin
septa. Lobules are connected by small intercalated ducts to intralobular ducts ,
which leave the lobules to join interlobular ducts between the lobules. The
interlobular ducts attach to the main pancreatic duct, which joins the common
bile duct at the hepatopancreatic ampulla. The hepatopancreatic ampulla
empties into the duodenum at the major duodenal papilla. A smooth muscle
sphincter, the hepatopancreatic ampullar sphincter (sphincter of Oddi) regulates
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 the opening of the ampulla.
 An accessory pancreatic duct, present in most people, opens at the minor
duodenal papilla. The ducts are lined with simple cuboidal epithelium, and the
epithelial cells of the acini are pyramid-shaped. A smooth muscle sphincter
surrounds the pancreatic duct where it enters the hepatopancreatic ampulla.

 Lungs - are the principal organs of respiration, and on a volume basis they are among
the largest organs of the body.
 Each lung is conical in shape, with its base resting on the diaphragm and its apex
extending superiorly to a point approximately 2.5 cm superior to the clavicle.
 The right lung is larger than the left and weighs an average of 620 g, whereas
the left lung weighs an average of 560 g.

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 Precipitating Factors
 Lifestyle History: Smoking
B. Pathophysiology of the Disease Process
& Alcohol Drinking
 Diabetes
Predisposing Factors  High blood pressure
 AGE (62 years old)
 Sex
 Family History (Hpn
and Heart Disease) Diabetes Mellitus

RETINAL BLOOD FLOW GROWTH FACTORS

(Endothelin, NO, PG12) (VEGF, TGFβ)

BASEMENT MEMBRANE
THICKENING

VASCULAR OCCLUSION
(platelet aggregation, leukocyte VASCULAR CELL DEATH
activation/adherence) (polypol pathway, AGEs, oxidative stress)

RETINAL HYPOXIA

GROWTH FACTORS
(VEGF , PIGF , PEDF )

CHRONIC KIDNEY DISEASE

Immunocompromised

Pneumonia

A set of progressive mechanisms, involving and hyperfiltration and hypertrophy of the remaining
viable nephrons, that are a common consequence following the long term reduction of renal mass,
irrespective of underlying etiology. The responses to reduction in nephron number are mediated by
vasoactive hormones, cytokines, and growth factors. Eventually, these short term adaptations of hypertrophy
and hyperfiltration become maladaptive as the increased pressure and flow within the nephron predisposes
to distortion of glomerular architecture, abnormal podocyte function, and disruption of the filtration barrier
leading to sclerosis and dropout of the remaining nephrons Increases intrarenal activity of the rennin
angiotensin system (RAS) appears to contribute to both the initial adaptive hyperfiltration and to the
subsequent maladaptive hypertrophy and sclerosis. This process explains why a reduction in renal mass from
an isolated insult may lead to a progressive decline in renal function over many years.

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 Diagnosis and Laboratory Procedures
January 2, 2020
ABG (Admission)
is used to check the function of the patient's lungs and how well they are able to move oxygen and remove
carbon dioxide
Result Units Reference Values Remarks Significance
Ph 7.35 7.35-7.45 Normal No significance
pCO2 38 mmHg 35-45 Normal No significance
pO2 60 mmHg 80-100 ↓ DOB due to
pulmonary effusion
Na+ 129 mmol/L 138-145 ↓ Hyponatremia due
to CKD
K+ 4.2 mmol/L 3.4-4.5 Normal No significance
Ca++ 0.72 mmol/L 1.15-1.35 ↓ Hypocalcemia due to
CKD
HCO3 22 mmol/L 22-26 Normal No significance
TCO2 22 mmol/L 23-27 ↓ Kidney disease and
Diabetic ketoacidosis
BE -4 mmol/L +/- 2 ↑ Disturbance is
caused by
pleural effusion
SO2 C 89 % 95-100 ↓ Due to pleural
Effusion
pH (36.2 oC) 7.36 7.35 -7.45 Normal No Significance
pCO2 (36.2 oC) 37 mmHg 35-45 Normal No significance
o
pO2 (36.8 C) 57 mmHg >79 ↓ Due to Anemia and
Pleural Effusion
pH O2 103 mmHg
paO2/pHO2 0.55 mmHg
Operator Entered
Device Used: None
FiO2 21%2 L/min
*= Result value out of range. Computer Derived
ParameterDx/Cc: Pulmonary Effusion
C= Incalculable

Overall Significance
Patient has hypoxemia secondary to pleural effusion.

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January 2, 2020

Blood Chemistry
Is used to show how well certain organs are working and can help find abnormalities
Result Units Reference Values Remarks Significance

Serum Phosphorus: 4.30 mg/dl 2.5-4.9 Normal No significance

Ionized Ca 0.86 mmol/L 1.13-1.32 ↓ Kidneys could not filter
blood as they should

Overall Significance
Patient is at risk for hypocalcemia due to CKD

January 2, 2020

Hematology
Prothrombin Time Activity
Is a blood test that measures the time it takes for the liquid portion of the blood to clot
Result Units Reference Values Remarks Significance
Control (Stago) 89.37 % 73-106 Normal No significance
Pt 12.90 sec 11.5-15.5 Normal No significance
Act 100 % > 69.9 Normal No significance
Ratio 0.96 - <1.21 Normal No significance
Se Index 1.02
Normalized Ratio 0.95 - <1.21 Normal No significance
Bleeding Time
Duke’s Method 3’30” min 1-5 Normal No significance
Clotting Time
Lpf Whine Method 14’00’’ min 5-15 Normal No significance

January 3, 2020

Blood Chemistry
Is used to show how well certain organs are working and can help find abnormalities
Result Units Reference Values Remarks Significance
Protein 56.62 g/l 64-82 ↓ Proteinemia
Due to
Glomerulonephritis
Albumin 28.62 g/l 34-50 ↓ Albuminemia due to
Glomerulonephritis
Globulin 28.0 g/l 22-35 Normal No significance
A/G Ratio 1.0 g/l 1.1-2.4 ↓ Due to
Glomerulonephritis

Overall Significance
Patient has glomeruli damage that leads to the loss of
albumin and other proteins
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January 3, 2020
Urinalysis
Is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and
diabetes.
Remarks Significance
Microscopic Examination
Color: Pale Straw Normal No Significance
Transparency: Hazy Normal No Significance
pH level: 6.5 Normal No Significance
Reaction: Acidic Normal No Significance
Specific Gravity: 1.01 Normal No Significance
Chemical Examination
Sugar: TRACE
Bilirubin: Negative Normal No significance
Ketone: Negative Normal No significance
Blood: Negative Normal No significance
Albumin: +3 ↑ Albuminuria due to
glomerulonephritis
Urobilinogen: Negative Normal No significance
Nitrate: Negative Normal No significance
Leukocytes: 1+ ↑ Presence of infection
WBC pus cells: 5/8 HPF 1+ ↑ Presence of Infection
RBC:1-3/ HPF Occasional Normal No significance
Epithelial cell
Squamous Cells: Many Normal No significance
Crystals:
Amorphous Urates: Occasional Normal No significance

Overall Significance
Increased albumin due to kidney dysfunction; Patient also has
Urinary Tract Infection

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January 3, 2020
Occult Blood (Immunochromatographic Method)
Used to check stool samples for hidden blood
KIT: FOBT DIAQUICK Overall Significance
Result: Positive Patient is positive for bleeding in upper GIT

January 3, 2020

Crossmatching and Retyping

Pt’s Blood Type “O”
Rh Pos (+)
*Blood Bag #1
Blood Type “O +”
Serial no. 017186
Vol 319mL
Blood Preparation PRBC
Saline Phase NEG (-)
Albumin/ UTSS Phase NEG (-)
Anti-Human Globulin NEG (-)
Remarks: Compatible
*Autocontrol= Negative
*With Shled Specimen*

January 3, 2020
Routine stool Examination (RS)
Is done to help diagnose certain conditions affecting the digestive tract
Remarks Significance
Specimen Stool
Method Direct Smear
Microscopic Exam
Stool Color Brown Normal No significance
Stool Consistency Loose Due to diet
Cellular Elements
Red Blood Cells 0-1/HPF
Pus cells 0-1/HPF
Bacteria many Abnormal organism found
Yeast cell few Normal
Entamoebacilli 5cysts/slide (Few) Pathogenic amoeba
EntamoebaHistolytica 4 cysts/slide (Few) Pathogenic amoeba

Overall Significance
Patient is positive for amoebiasis

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January 4, 2020
Hematology
CBC
Is done to determine blood components needed to evaluate overall health
Result Units Reference Values Remarks Significance
Hemoglobin 104 g/L 120-150 ↓ Due to anemia
Hct 0.33 L/L 0.35-0.49 ↓ Due to anemia
RBC 3.80 10^12/L 3.8-5.2 Normal No Significance
WBC 7.08 10^9/L 4.5-11 Normal No Significance
Differential Count
Band Neut 0.02 0.02-0.05 Normal No Significance
Segmenters 0.78 0.50-0.70 ↑ Due to infection
Lymphocytes 0.08 0.22-0.40 ↓ Lymphocytopenia
due to infection
Eosinophils 0.03 0.01-0.04 Normal No Significance
Monocytes 0.09 0.03-0.08 ↑ Due to infection
Blood Indices
MCH 27.30 pg 26-34 Normal No Significance
MCV 87.30 fl 80-100 Normal No Significance
MCHC 31.30 g/dl 32-36 ↓ Due to anemia
* Platelet Count Adequate

Overall Significance
Patient’s kidneys could not produce enough EPO thus, resulting to anemia

January 4, 2020
Chemistry
Used to check how the body’s organs are working
Result Units Reference Values Remarks Significance
Examination
Serum Creatinine 561.83 mmol/L 49-90 ↑ Due to CKD
Serum Potassium 6.39 mmol/L 3.5-5.1 ↑ Kidneys could not
remove excess K due
to CKD

Overall Significance
Patient is at risk for hyperkalemia due to CKD

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January 6, 2020
Hematology
CBC
Is done to determine blood components needed to evaluate overall health
Result Units Reference Values Remarks Significance
Hemoglobin 93 g/L 120-150 ↓ Kidneys could not
produce EPO
Hct 0.28 L/L 0.35-0.49 ↓ Kidneys could not
produce EPO
RBC 3.44 10^12/L 3.8-5.2 ↓ Kidneys could not
produce EPO
WBC 7.15 10^9/L 4.5-11 ↑ Due to infection
Differential Count
Segmenters 0.74 0.50-0.70 ↑ Due to infection
Lymphocytes 0.15 0.22-0.40 ↓ Lymphocytopenia
due to infection
Eosinophils 0.03 0.01-0.04 Normal No Significance
Monocytes 0.08 0.03-0.08 Normal No Significance
Blood Indices
MCH 27.10 pg 26-34 Normal No Significance
MCV 82.20 fl 80-100 Normal No Significance
MCHC 32.90 g/dl 32-36 Normal No Significance
* Platelet Count Adequate

Overall Significance
Patient’s kidneys could not produce enough EPO thus, resulting to anemia; Being
immunocompromised resulting to developing an infection
January 6, 2020
Chemistry
Used to check how the body’s organs are working
Result Units Reference Values Remarks Significance
Examination
Serum Creatinine 561.83 mmol/L 3.5-5.1 ↑ Impaired Kidney
Function
Serum Potassium 4.39 mmol/L 3.5-5.1 Normal No Significance

Overall Significance
Poor creatinine clearance by the kidneys due to CKD

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January 6, 2020
Urinalysis
Is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and
diabetes.
Remarks Significance
Specimen: Urine
Macroscopic Examination
Color: Pale Straw Normal No significance
Transparency: Hazy Normal No significance
pH Level: 7 Normal No significance
Reaction: Acidic Normal No significance
Specific Gravity 1.015 Normal No significance
Chemical Examination
Sugar Trace Normal No significance
Bilirubin Negative Normal No significance
Ketone Negative Normal No significance
Blood Negative Normal No significance
Albumin 3+ ↑ Albuminuria due to
Glomerulonephritis
Urobilinogen Negative Normal No significance
Nitrite Negative Normal No significance
Leukocytes 1+ ↑ Presence of Infection
Microscopic Examination
Epithelial Cells
Squamous Cells: Few Normal No significance
Crystals
Amorphous Urates Few Normal No significance
Others
Mucus Threads Few Normal No significance

Overall Significance
Increased albumin due to kidney dysfunction; Patient also has
Urinary Tract Infection

January 7, 2020
Gram Stain (GS)/ KOH
Is used to detect the presence of bacteria and fungi
Specimen- Sputum
Gram Stain:
- Direct Smear shows rare Gram (+) cocci singly in pair; rare Gram (-) bacilli
- Polymorphonucleare cell: >25/ LPF Squamous epithelial cells: <10/ LPF
KOH:
No fungal elements seen on smear

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January 7, 2020
Hematology
CBC
Is done to determine blood components needed to evaluate overall health
Result Units Reference Values Remarks Significance

Hemoglobin 119 g/L 120-150 ↓ Kidneys could not

produce EPO
Hct 0.36 L/L 0.35-0.49 Normal No significance
RBC 4.25 10^12/L 3.8-5.2 Normal No significance
WBC 8.40 10^9/L 4.5-12 Normal No significance
Differential Count
Segmenters 0.84 0.50-0.70 ↑ Due to infection
Lymphocytes 0.10 0.22-0.40 ↓ Lymphocytopenia due to
infection
Eosinophils 0.03 0.01-0.04 Normal No significance
Monocytes 0.03 0.03-0.08 Normal No Significance
Blood Indices
MCH 27.90 pg 26-34 Normal No Significance
MCV 82.80 fl 80-100 Normal No Significance
MCHC 33.30 g/dl 32-36 Normal No Significance
* Platelet Count Adequate

Overall Significance
Poor kidney Function; infection still present

January 7, 2020
Chemistry
Used to check how the body’s organs are working
Result Units Reference Values Remarks Significance
Examination
Serum Creatinine 622.33 mmol/L 49-90 ↑ Impaired Kidney Function
Serum Potassium 3.84 mmol/L 3.5-5.1 Normal No Significance

Overall Significance
Poor creatinine clearance by the kidneys due to CKD

19
January 7, 2020
X-Ray
Imaging test that uses radiation to produce pictures of the organs, tissues and bones of the body. When
focused on the chest, it can help spot abnormalities or diseases of the airways, blood vessels, bones, heart
and lungs
Chest PA:
There are hazy densities seen in the lower lungs.
The trachea is midline
The cardiac silhouette is enlarged w/ CT ratio of 0.57

The aortic knob is calcified

The hemidiaphragms are intact. The costophrenic sulci are blunted
The rest of the visualized osseous structures and soft tissues are unremarkable

Impression:
*Pneumonia, lower lungs minimal pleural effusion, Bilateral
*Cardiomegaly
*Atherosclerotic Aorta
*Follow- up is suggested

January 8, 2020

Routine Stool Examination (RS)

Is done to help diagnose certain conditions affecting the digestive tract
Remarks Significance
Specimen Stool
Method Direct Smear
Microscopic Exam
Stool Color Dark Brown Normal No Significance
Stool Consistency Formed Normal No Significance
*No Parasite Seen on Smear

January 8, 2020
Occult Blood (Immunochromatographic Method)
KIT: FOBT DIAQUICK
Result: Negative

Overall Significance
Patient is negative for bleeding in upper GIT

20
January 8, 2020
Urinalysis
Is used to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and
diabetes.
Remarks Significance
Specimen: Urine
Macroscopic Examination
Color: Straw Normal No significance
Transparency: Hazy Normal No significance
pH Level: 7 Normal No significance
Reaction: Acidic Normal No significance
Specific Gravity 1.015 Normal No significance
Chemical Examination
Sugar 1+ Glycosuria due to CKD
Bilirubin Negative Normal No significance
Ketone Negative Normal No significance
Blood Negative Normal No significance
Albumin 3+ Albuminuria due to
glomerulonephritis
Urobilinogen Negative Normal No significance
Nitrite Negative Normal No significance
Leukocytes Negative Normal No significance
Microscopic Examination
WBC Pus Cells 2-4/ HPF Occasional Normal No significance
RBC 1-2/ HPF Occasional Normal No significance
Epithelial Cells
Squamous Cells: Occasional Normal No significance
Crystals
Amorphous Urates Occasional Normal No significance

Overall Significance
Increased albumin due to kidney dysfunction; Patient also has
Urinary Tract Infection

21
January 9, 2020
Hematology
CBC
Is done to determine blood components needed to evaluate overall health
Result Units Reference Values Remarks Significance
Hemoglobin 108 g/L 120-150 Kidneys could
not produce EPO
Hct 0.95 L/L 0.35-0.49 ↑
RBC 3.91 10^12/L 4.5-12 ↓ Kidneys could
not produce EPO

Differential Count
Band Neut 0.2 0.02-0.05 ↑
Segmenters 0.72 0.50-0.70 ↑ Due to infection
Lymphocytes 0.14 0.22-0.40 ↓ Lymphocytopenia
due to infection
Eosinophils 0.08 0.01-0.04 ↑
Monocytes 0.04 0.03-0.08 Normal No significance
Blood Indices
MCH 27.60 pg 26-34 Normal No significance
MCV 88.60 fl 80-100 Normal No significance
MCHC 31.10 g/dl 32-36 ↓ Due to anemia
*Platelet Count Adequate

Overall Significance
Patient’s kidneys could not produce enough EPO thus, resulting to anemia; Being
immunocompromised resulting to developing an infection

January 9, 2020
Chemistry
Used to check how the body’s organs are working
Examination
Result Units Reference Values Remarks Significance

Serum Creatinine 659.91 mmol/L 49-90 ↑ Impaired Kidney

Function
Serum Potassium 4.00 mmol/L 3.5-5.1 Normal No Significance
Albumin 28.05 mmol/L 34-50 ↓ Reduced synthesis
and increased
degradation of
albumin

Overall Significance
Poor creatinine and albumin clearance by the kidneys due to CKD

22
DRUG
STUDY

23
 Drug Classification and
mechanism of action
Generic name:
Antidiabetic
Linagliptin
Brand name:
Trajenta Mechanism of action:
Description: Linagliptin inhibits
dipeptidyl peptidase-4 (DPP-4),
Dosage:5mg/tab an enzyme which is involved in
the inactivation of the incretin
hormones GLP-1 (glucagon-like
Route: oral peptide-1) and GIP (glucose-
dependent insulinotropic
polypeptide). Both incretin
Timing: OD 1:30 hormones are involved in the
physiological regulation of
glucose homeostasis. Inhibition
of DPP-4 leads to increased and
prolonged active incretin levels
Indication and Side effects and Special Nursing responsibility
Contraindication adverse reaction precaution
Indicate as an adjunct to
diet and exercise to Hypoglycemia, severe and  Check doctors order
improve glycemic control disabling arthralgia, Patient w/ history of  Observe 12 rights in giving
in adult who have type 2 nasopharyngitis, rash, mouth pancreatitis; angioedema medication
ulcer, stomatitis, diarrhea, to other DPP-4 inhibitor.
diabetes mellitus  Right patient
cough. Rarely, Not intended in patients
 Right dose
Contraindication:
hypersensitivity reactions. w/ IDDM or for the
 Right drug
Potentially Fatal: Acute treatment of diabetic
Hypersensitivity pancreatitis ketoacidosis. Pregnancy  Right route
and lactation.  Right time
Type 1 diabetes mellitus  Right education
 right assessment
Diabetic ketoacidosis  Right evaluation
 Right to refuse
 Right documentation
 Right expiration
 Right reason
 Before taking this must told
your doctor your medical
history, especially if you have
disease in pancreas
(pancreatitis)
 You may experience blurred
vision , dizziness and
drowsiness due to extremely
low or high blood sugar. Do
not do any activities requiring
alertness or clear vision until
you can perform well
 May be taken with or without
food
24
 Drug Classification and Indication and Side effects and Special precaution Nursing responsibility
mechanism of action Contraindication adverse reaction
Generic name: prevention and therapy of  Check doctors order
Ketoanalogues an essential damages due to faulty or Hypercalcemia may Ketolog should be  Observe 12 rights in giving
Ketoanalouge
amino acid deficient problem develop taken during meals medication
metabolism in chronic to allow proper  Right patient
Mechanism of action: the renal insufficiency in absorption and  Right drug
Brand name: plasma kinetics of amino connection with limited metabolism into the  Right dose
Ketosteril acids protein food of <40g/day corresponding  Right route
and their integration in amino acids. The  Right time
metabolic serum calcium levels  Right education
pathways are well should be monitored  right assessment
Dosage: 600mg/tab established. It regularly.  Right evaluation
should nevertheless be noted contraindicated in: Ensure the sufficient  Right to refuse
that, in Hypercalcemia, supply with calories.
Route: oral  Right documentation
uremic patients, the plasma disturbed amino acid
 Right expiration
disturbances do not seem to metabolism.
 Right reason
Timing: ,TID depend In case of hereditary
8am-1pm-6pm on digested amino acid phenylketonuria, it
 Administer with food to
intake, and has to be taken into
prevent GI upset
that the post-absorptive account that
 Monitor vital signs
kinetics ketoanalogue
 Instruct patient to report
seems to be distributed very contains
immediately if symptoms of
early in phenylalanine.
 hypercalcemia occurs like
the development of the Disturbed amino
muscle weakness,
disease. acid metabolism
constipation
 Monitor calcium levels
 Monitor for signs of
hypercalcemia and
electrolyte levels.
 Monitor vital signs
especially cardiac changes

25
 Drug Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
mechanism of action Contraindication reaction
Generic Diuretics low blood
Edema due to cardiac, pressure,  Check doctors order
name: hepatic & renal disease, • dehydration Patient w/ pre diabetes or DM,  Observe 12 rights in giving
Furosemide Mechanism of action: inhibit burns; mild to moderate and electrolyte hepatic cirrhosis, gout, medication
Brand reabsorption of HTN, hypertensive depletion (for impaired micturition, at risk  Right patient
sodium and water in the crisis, acute heart failure, example, sodium, from a pronounced fall in BP.  Right drug
name: ascending limb of the loop of reduced urinary output potassium). Risk of ototoxicity w/ rapid inj.  Right route
Lasix Henle by interfering with the due to gestoses, chronic • jaundice, Renal and hepatic impairment.  Right dose
chloride binding site of the renal failure, nephrotic • ringing in the Elderly, childn. Pregnancy and  Right time
1Na+, 1K+, 2Cl- syndrome. ears (tinnitus), lactation.  Right education
cotransport system. • sensitivity to  right assessment
Loop diuretics increase the Contraindication: light  Right evaluation
Dosage:20mg rate of delivery of tubular Anuria; hepatic coma & (photophobia),  Right to refuse
fluid and electrolytes to the precoma; severe • rash,
Route: IV  Right documentation
distal sites of hydrogen and hypokalemia &/or • pancreatitis,
 Right expiration
potassium ion secretion, while hyponatremia; • nausea,
 Right reason
Timing:10pm OD plasma volume hypovolemia w/ or w/o • diarrhea,
contraction increases hypotension. • abdominal
 Assess patient’s underlying
aldosterone production. Hypersensitivity to pain, and
condition before starting
The increased delivery sulfonamides dizziness.
therapy.
and high aldosterone Increased blood
 Monitor for CNS,
levels promote sodium sugar and uric
hyperactive reflexes,
reabsorption at the distal acid levels
depressed cardiac
tubules, thus increasing
output, nausea, vomiting,
the loss of potassium
tachycardia
and hydrogen ions
 Assess fluid volume
status(urine, color, quality
and specific gravity)
 Assess patient tinnitus, or
Pain

26
 Drug Classification Indication and Side effects and Special precaution Nursing responsibility
and Contraindication adverse reaction
mechanism of
action
Generic Effectively treats GI: Diarrhea ,nausea, History of hypersensitivity to  Check doctors order
antibiotic bone and joint antibiotic- penicillin, and GI disease  Observe 12 rights in giving medication
name: infections, associated colitis. (particularly colitis). Renal  Right patient
Cefuroxime bronchitis, impairment. Pregnancy and  Right drug
meningitis, Skin: Rash , lactation  Right dose
Mechanism of pharyngitis/tonsillitis, pruritus, urticaria.  Right route
Brand action: sinusitis, lower  Right time
name: Bind to bacterial respiratory tract Urogenital:  Right education
Ceftin cell infections, skin and Increased serum  right assessment
wall membrane, soft tissue creatinine and  Right evaluation
causing cell death infections, urinary BUN, decreased  Right to refuse
tract infections, and creatinine
 Right documentation
Dosage:500mg/tab is used for surgical clearance.
 Right expiration
prophylaxis,
 Right reason
Route: oral reducing or Hematology:
eliminating Hemolytic anemia
 Determine history
infection. MISC:
Timing: BID 8am- of hypersensitivity reactions to cephalosporins,
Anaphylaxis
4pm penicillins, and history of allergies, particularly to drugs, before
therapy
Contraindication:
is initiated.
Hypersensitivity to
 Lab tests: Perform
cephalosporins
culture and sensitivity
and related antibiotics;
tests before initiation of therapy and periodically
during therapy if indicated. Therapy may be instituted pending
test results. Monitor periodically BUN and creatinine clearance.

27
 Drug Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
mechanism of action Contraindication reaction
Generic name: proton pump Short-term treatment Diarrhea, nausea, Patient with reduced
inhibitors of active duodenal fatigue, body store or risk  Check doctors order
Omeprazole ulcer; First- constipation, factors for reduced  Observe 12 rights in giving medication
line therapy in vomiting, vitamin B12 absorption;  Right patient
Mechanism of treatment flatulence, acid risk of osteoporosis.  Right drug
Brand name: action: Gastric acid- of heartburn or regurgitation, taste Hepatic impairment.  Right dose
Prilosec pump inhibitor: symptoms perversion, Ultra rapid  Right route
Suppresses gastric of gastro esophageal arthralgia, metabolizers  Right time
acid secretion by reflux disease myalgia, urticaria,  Right education
specific inhibition (GERD); Short- dry mouth,  right assessment
Dosage:40mg of the hydrogen- term treatment of dizziness,  Right evaluation
potassium ATP as active benign gastric headache,  Right to refuse
Route:IV enzyme system at ulcer; GERD, paresthesia,
 Right documentation
the secretory severe erosive abdominal pain,
 Right expiration
surface of the esophagitis, skin rashes,
 Right reason
Timing:4:25 gastric parietal poorly responsive weakness, back
 Caution patient to swallow capsules whole—not to
pm cells; blocks the symptomatic pain, upper
open, chew, or crush them.
final step of acid GERD; Long-term respiratory
 Arrange for further evaluation of patient after 8
production. therapy: infection, cough.
weeks of therapy for gastro reflux disorders; not
intended for maintenance therapy.
Contraindication: Potentially
 Administer antacids with omeprazole, if needed.
Contraindicated with Fatal: Anaphylaxis.
 Take the drug before meals. Swallow the capsules
hypersensitivity to
whole; do not chew, open, or crush them. This drug
omeprazole or its
will need to be taken for up to 8wk (short-term
components;
therapy) or for a prolonged period

28
 Drug Classification and Indication and Side effects and adverse reaction Special Nursing responsibility
mechanism of Contraindication precaution
action
Generic  Significant: Myopathy, myalgia, diabetes .  Check doctors order
Dyslipidaemic agents Atorvastatin is used to mellitus, persistent serum transaminase Patients with diabetes  Observe 12 rights in
name: treat high cholesterol, and elevations. Rarely, immune-mediated mellitus, giving medication
Atorvastatin to lower the risk of necrotising myopathy (IMNM), interstitial hypothyroidism,  Right patient
stroke, heart attack, or lung disease. hereditary muscular  Right drug
Mechanism of action: other heart complications  Blood and lymphatic system disorders, recent  Right dose
Brand in people with type 2 disorders: Thrombocytopenia. stroke, transient  Right route
Atorvastatin selectively diabetes, coronary heart  Eye disorders: Blurred vision. ischaemic attack,  Right time
name: and competitively inhibits disease, or other risk  Gastrointestinal disorders: Diarrhea, severe acute infection,  Right education
Itorvaz HMG-CoA reductase, the factors. Atorvastatin is hypotension, major
constipation, nausea, dyspepsia, flatulence.  right assessment
enzyme that catalyses the used in adults and children  .Metabolism and nutrition surgery, severe  Right evaluation
conversion of HMG-CoA to who are at least 10 years disorders: Hyperglycemia. metabolic disorder  Right to refuse
produce mevalonate. The old  and uncontrolled
Dosage:40mg/tab
Musculoskeletal and connective tissue  Right
reduction of mevalonate disorders: Muscle spasms, joint swelling, seizures. Not indicated
documentation
production results to a Contraindication: musculoskeletal and extremity pain. for elevated
Route:oral  Right expiration
compensatory increase in  Nervous system disorders: Headache, chylomicrons as the
 Right reason
the expression of LDL Active liver disease, dizziness, paresthesia, amnesia. primary lipid
 Monitor liver function
Timing: OD 1pm receptors and stimulation unexplained persistent  Psychiatric disorders: Insomnia, nightmares. abnormality. Patients tests prior to initiation
of LDL catabolism, serum transaminase  Renal and urinary disorders: UTI. who consume large of therapy and as
consequently lowering elevation. quantities of alcoholic
 Respiratory, thoracic and mediastinal clinically indicated
LDL-cholesterol levels beverages. Renal  Advise patient that this
disorders: Nasopharyngitis,
impairment. medication should be
pharyngolaryngeal pain.
used in conjunction with
diet restrictions (fat,
 Potentially Fatal: Severe rhabdomyolysis cholesterol,
with acute renal failure, hepatitis, hepatic carbohydrates, alcohol),
failure. Rarely, Stevens-Johnson syndrome, exercise, and cessation
anaphylaxis, toxic epidermal necrolysis. of smoking. Atorvastatin
does not assist with
weight loss.

29
 Drug Classification and Indication and
mechanism of action Contraindication
Generic Atenolol is used with or
beta-blockers. without other
name: medications to treat high
Atenolol blood
Mechanism of action: pressure (hypertension).
Lowering high blood
Brand Atenolol selectively and pressure helps prevent
competitively blocks β1- strokes, heart attacks,
name: adrenergic receptors but and kidney problems.
has little or no effect on β2- This medication is also
Tenormin receptors except at high used to treat chest pain
doses. It has negative (angina) and to improve
inotropic effects without survival after a heart
100mg/tab OD
8pm intrinsic attack
Contraindication:
Dosage: Patients with
100mg/tab bradycardia, cardiogenic
shock, hypotension,
Route:oral metabolic acidosis, 2nd
or 3rd degree heart
block, severe peripheral
Timing:
arterial disease, sick sinus
OD 8pm
syndrome (without
pacemaker),
uncompensated cardiac
failure, and untreated
phaeochromocytoma
Side effects and adverse reaction Special precaution Nursing responsibility
 Blood and lymphatic system Patients with  Check doctors order
disorders: Thrombocytopenia. bronchospasm or  Observe 12 rights in giving
 Cardiac disorders: Bradycardia. reversible obstructive medication
Eye disorders: Dry eyes, visual airways disease,  Right patient
disturbances. diabetes mellitus,  Right drug
 Gastrointestinal disorders: Nausea, peripheral vascular  Right dose
diarrhea, dry mouth. disease, Raynaud’s  Right route
 General disorders and administration disease, Prinzmetal’s  Right time
site conditions: Fatigue. angina, myasthenia  Right education
 Musculoskeletal and connective gravis, psoriasis and  right assessment
tissue disorders: Lupus-like thyroid diseases. Avoid  Right evaluation
syndrome. abrupt withdrawal.  Right to refuse
 Renal impairment.
Nervous system disorders: Dizziness,  Right documentation
headache. Elderly. Pregnancy and
 Right expiration
 Psychiatric disorders: Hallucinations, lactation
 Right reason
depression, nightmare, psychoses.
 Reproductive system and breast  Take drug with meals if GI
disorders: Impotence. upset occurs
 Skin and subcutaneous tissue  Do not stop taking this drug
disorders: Psoriasiform skin unless told to do so by a
reactions, purpura, alopecia. health care provider.
 Vascular disorders: Postural  Avoid driving or dangerous
hypotension, cold extremities, activities if dizziness or
Raynaud’s phenomenon weakness occurs.
 Report difficulty breathing,
night cough, swelling of
extremities, slow pulse,
confusion, depression, rash,
fever, sore throat.
30
 Drug Classification and
mechanism of action
Generic
angiotensin receptor blockers
name:
Telmisartan
Mechanism of action:
Brand Telmisartan, a nonpeptide
tetrazole derivative, is an
name: angiotensin II type 1 (AT1)
Micardis receptor antagonist producing its
BP lowering effects by selectively
blocking the binding of
Dosage:40mg/tab angiotensin II to AT1 receptors,
thereby reducing angiotensin II-
Route:
induced vasoconstriction
oral
aldosterone-secretion and Na
Timing:OD 1pm reabsorption.
Indication and Side effects and adverse reaction Special precaution Nursing
Contraindication responsibility
This medication is used  Significant: Hypotension, orthostatic Patient with aortic or  Check doctors
hypotension, hyperkalemia, bradycardia, angina
to treat high blood mitral stenosis, order
pressure (hypertension). pectoris, tachycardia, hypertension, peripheral obstructive hypertrophic  Observe 12
Lowering high blood edema, intermittent claudication, increased cardiomyopathy, rights in giving
serum creatinine. Rarely, hypoglycemia,
pressure helps prevent ischemic cardiopathy, medication
interstitial lung disease.
strokes, heart attacks, unstented unilateral or  Right patient
 Blood and lymphatic system disorders: Anemia,
and kidney problems.  Cardiac disorders: Chest pain, palpitation,
bilateral renal artery  Right drug
dyspnea. stenosis; ascites due to  Right dose
Contraindication:  Endocrine disorders: Tinnitus, vertigo. cirrhosis, refractory  Right route
Biliary obstructive  Eye disorders: Visual disturbance, ascites, Patients  Right time
disorders. Concomitant  conjunctivitis. undergoing major  Right education
use with aliskiren in Gastrointestinal disorders: Diarrhea, abdominal surgery or during  right
patient with diabetes pain, dyspepsia, flatulence, nausea, vomiting. anesthesia. Black race. assessment
mellitus or renal  Musculoskeletal and connective tissue Mild to moderate
 Right evaluation
impairment (GFR<60 disorders: Back pain, myalgia, hepatic and renal
 Nervous system disorders: Dizziness, headache,
 Right to refuse
mL/min/1.73 m2). Severe impairment. Lactation.
 Psychiatric disorders: Insomnia, depression,  Right
hepatic impairment.
anxiety. documentation
Pregnancy.
 Renal and urinary disorders: UTI, cystitis.  Right expiration
 Respiratory, thoracic and mediastinal  Right reason
disorders: Upper respiratory tract infection,  Take drug with
sinusitis, pharyngitis, cough. meals if GI
 Skin and subcutaneous tissue disorders: Rash, upset occurs
pruritus, dermatitis.  Report difficulty
 Potentially Fatal: Hyperkalemia, renal function breathing, night
deterioration characterized by oliguria,
cough, swelling
progressive azotemia, and acute renal failure.
Rarely, angioedema, toxic skin eruption, sepsis
of extremities,
slow pulse,
confusion,
depression, rash
31
 Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
Drug mechanism of action Contraindication reaction
Generic Headache, dizziness, drowsiness, Patient w/  Check doctors order
Anti hypertensive Clonidine is used to treat dry mouth, constipation, cerebrovascular disease,  Observe 12 rights in giving
name: high blood depression, anxiety, nausea, ischemic heart disease medication
pressure, attention deficit fatigue, anorexia, parotid pain, including MI, occlusive  Right patient
Clonidine Mechanism of action: hyperactivity paresthesia, delusional peripheral vascular  Right drug
disorder (ADHD), drug perception, sleep disturbances, disorders (e.g.  Right dose
Brand Clonidine stimulates α2- withdrawal (alcohol, vivid dreams, impotence and loss Raynaud's disease), or  Right route
adrenoceptors in the brain stem opioids, or smoking), of libido, urinary retention or those w/ history of  Right time
name: which results in reduced menopausal flushing, incontinence, orthostatic depression. Avoid  Right education
sympathetic outflow from the diarrhea, and certain pain hypotension, itching or burning abrupt withdrawal.  right assessment
Catapres CNS, and a decrease in peripheral conditions. sensations in the eye, Renal impairment.  Right evaluation
resistance, heart rate, BP and accommodation disorder, Pregnancy and  Right to refuse
renal vascular resistance. Contraindication: decreased lacrimation, fluid lactation.
 Right documentation
Dosage:150 Severe bradyarrhythmia retention, pruritus and rashes
 Right expiration
mcg/tab secondary to 2nd- or 3rd- (transdermal), bradycardia
 Right reason
degree AV block or sick (including sinus bradycardia w/ AV
 Assess blood pressure
Route:oral sinus syndrome block), other ECG disturbances,
periodically and compare to
heart failure, hallucinations,
normal values
cramp, Raynaud's syndrome,
Timing: BID 9am-
9pm

32
 Classification and
Drug mechanism of action
Generic
calcium channel blockers
name:
Mechanism of action:
Felodipine Felodipine, a dihydropyridine Ca-
channel blocker, produces
Brand coronary vascular smooth muscle
relaxation and coronary
name: vasodilation by inhibiting the
Plendil entry of Ca ions in select voltage-
sensitive areas of vascular smooth
muscle and myocardium during
depolarisation. It also increases
Dosage:10mg/tab
myocardial oxygen delivery in
cases of vasospastic angina
Route:
oral
Timing:
OD 8pm
Indication and
Contraindication
Felodipine is used to treat
high blood
pressure (hypertension).
Lowering high blood
pressure helps prevent
strokes, heart attacks, and
kidney problems.
Felodipine is known as
a calcium channel blocker.
By blocking calcium, this
medication relaxes and
widens blood vessels so
blood can flow more
easily.
Contraindication:
Decompensated heart
failure, acute myocardial
infarction, unstable angina
pectoris, significant cardiac
valvular obstruction,
cardiac outflow
obstruction. Pregnancy.
Side effects and adverse
reaction
 Significant: Tachycardia,
myocardial ischemia,
peripheral edema, angina,
rarely, hypotension with or
without syncope.
 Cardiac
disorders: Palpitations.
 Gastrointestinal
disorders: Nausea,
abdominal pain, vomiting,
mild gingival hyperplasia.
 General disorders and admin
site conditions: Fatigue.
 Nervous system
disorders: Headache,
dizziness.
 Vascular disorders: Flushing.
Special precaution Nursing responsibility
Patient with  Check doctors order
pronounced  Observe 12 rights in giving
gingivitis/periodontitis, medication
severe aortic stenosis,  Right patient
heart failure,  Right drug
hypertrophic  Right dose
cardiomyopathy with  Right route
outflow tract  Right time
obstruction. Hepatic  Right education
impairment. Elderly.
 right assessment
 Right evaluation
 Right to refuse
 Right documentation
 Right expiration
 Right reason
 Tell patient to take the drugs
without food or a light meal
 Tell patient to swallow tablet
whole and not crush or chew
them
33
 Drug Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
mechanism of action Contraindication reaction
Generic  Significant: Movement Moderate renal  Check doctors order
Anti anginal Trimetazidine is used for disorders (e.g. Parkinsonian impairment. Elderly.  Observe 12 rights in giving
name: long term treatment symptoms, restless leg Pregnancy. Not medication
Mechanism of action: of angina. Angina is chest syndrome, tremors, gait indicated for initial  Right patient
Trimetazidine Trimetazidine inhibits β-oxidation pain arising from instability). treatment of unstable  Right drug
of fatty acids by blocking long- the heart muscle when it angina, myocardial  Right dose
Brand chain 3-ketoacyl-CoA thiolase, does not receive enough  Gastrointestinal infarction nor in the  Right route
thereby enhancing glucose oxygen disorders: Abdominal pain, pre-hospital phase or  Right time
name: oxidation. By preserving energy dyspepsia, diarrhea, nausea during the first days of  Right education
Angimet metabolism in cells exposed to and vomiting. hospitalization.  right assessment
ischemia or hypoxia, it prevents Contraindication:  Right evaluation
decrease in intracellular ATP  General disorders and admin  Right to refuse
levels and ensures proper Parkinson's disease, site conditions: Asthenia.
35mg/tab 1 tab  Right documentation
functioning of ionic pumps and parkinsonian symptoms,
BID 8am- 6pm  Right expiration
transmembrane Na-K flow tremors, restless leg  Skin and subcutaneous  Right reason
syndrome and other tissue disorders: Rash,
Dosage: 35mg/tab  Use cautiously in patient with
movement related pruritus, heart failure and hypertension
disorders. Severe renal
Route: oral and in elderly patient
impairment (CrCl <30  Vascular disorders: Rarely,
mL/min). Lactation. arterial hypotension,
Timing: BID 8am- orthostatic hypotension
6pm

34
 Drug Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
mechanism of action Contraindication reaction
Generic Hypotension, tachycardia, Severe renal or severe  Check doctors order
Nitrates. Prevention of angina flushing, headache, dizziness, hepatic impairment,  Observe 12 rights in giving
name: pectoris due to coronary palpitation, syncope, confusion. hypothyroidism, medication
Isosorbide Mechanism of action: artery disease. The onset Nausea, vomiting, abdominal pain. malnutrition, or  Right patient
Mononitrate Isosorbide mononitrate relaxes of action of oral isosorbide Restlessness, weakness and hypothermia. Caution in  Right drug
vascular smooth muscles by mononitrate is not vertigo. Dry mouth, chest pain, patients who are  Right dose
Brand stimulating cyclic-GMP. It sufficiently rapid for this back pain, oedema, fatigue, already hypotensive.  Right route
decreases left ventricular product to be useful in abdominal pain, constipation, May aggravate angina  Right time
name: pressure (preload) and arterial aborting an acute anginal diarrhoea, dyspepsia and caused by hypertrophic  Right education
Imdur resistance (afterload). episode. flatulence. cardiomyopathy.  right assessment
Onset: 20 min (oral as Potentially Fatal: Severe Tolerance may develop  Right evaluation
conventional tab). Contraindication: hypotension and cardiac failure after long-term  Right to refuse
Severe hypotension or treatment. Lactation.
Dosage: 35mg/tab  Right documentation
anaemia, hypovolaemia,
 Right expiration
heart failure due to
Route:oral  Right reason
obstruction, or raised
 Caution patient to make
intracranial pressure due
position change slowly to
Timing: OD 11am to head trauma or cerebral
minimize orthostatic
haemorrhage
hypertension

35
 Drug Classification and Indication and Side effects and Special precaution Nursing responsibility
mechanism of action Contraindication adverse reaction
Generic Rapid-acting Hypoglycemia. Local Transferring to another type or  Check doctors order
human insulin analog Patients w/ DM who allergy, redness, swelling brand, changes in strength,  Observe 12 rights in giving
name: require insulin for the & itching at inj site. species &/or method of medication
Mechanism of action: maintenance of normal manufacture of insulin.  Right patient
Insulin glucose homeostasis. Uncorrected hypoglycemic or  Right drug
(humanlog mix The primary activity of insulin, Initial stabilization of DM hyperglycemic reactions. Usage  Right dose
25) including HUMALOG Mix75/25, is w/ inadequate dosages or  Right route
the regulation of glucose discontinuation of treatment.  Right time
Brand metabolism. Insulins lower blood Renal & hepatic impairment.  Right education
glucose by stimulating peripheral Presence of illness or emotional  right assessment
name: glucose uptake by skeletal muscle Contraindication: disturbances. Patients who  Right evaluation
and fat, and by inhibiting hepatic Hypersensitivity to insulin undertake increased physical  Right to refuse
glucose production lispro or any of the activity or change in the usual
Dosage:10-15  Right documentation
excipients of Humalog. diet. Concomitant w/
units  Right expiration
Hypoglycemia. pioglitazone especially in
 Right reason
patients w/ risk factors for
Route:  Monitor patient’s glycosylated
subcutaneous
cardiac heart failure. Discontinue
hemoglobin level regularly
if any deterioration in cardiac
 Monitor urine ketone level
symptoms occurs.
when glucose level is elevated.
Timing: BID 5:30
 Be alert for adverse reaction
AM
and drug interactions.
6:30 PM
 Monitor injection sites for
local reactions
 Assess patient and family’s
knowledge of drug therapy

36
 Drug Classification and
mechanism of action
Generic Antihistamine
name:
Mechanism of action:
Levocetirizine
Levocetirizine, an
Brand antihistamine and is an
active enantiomer of
name: cetirizine. Its binding affinity
to H1-receptor is twice than
cetirizine. It selectively
Xyzal
competes for H1-receptor
sites on effector cells in the
gastrointestinal tract, blood
Dosage:5mg/tab vessels and respiratory tract.
Route:oral
Timing: OD 8pm
Indication and Side effects and
Contraindication adverse reaction
 Significant: CNS depression,
Levocetirizine is an rebound pruritus.
antihistamine used to  Ear and labyrinth
relieve allergy symptoms disorders: Otitis media.
such as watery eyes,  Gastrointestinal
runny nose, itching disorders: Dry mouth,
eyes/nose, and diarrhea, vomiting,
sneezing. It is also used constipation, abdominal
to relieve itching and
pain.
hives. It works by  General disorders and
blocking a certain administration site
natural substance conditions: Fatigue, asthenia,
(histamine) that your pyrexia.
body makes during an  Nervous system
allergic reaction disorders: Headache.
 Psychiatric disorders: Sleep
Contraindication: disorder, somnolence.
 Respiratory, thoracic and
ESRD (CrCl < 10 mL/min) mediastinal
or undergoing
disorders: Nasopharyngitis,
haemodialysis
pharyngitis, cough.
 Vascular disorders: Epistaxis
Special precaution Nursing responsibility
 Check doctors order
Patient with increased  Observe 12 rights in giving medication
risk of urinary  Right patient
retention (e.g. spinal  Right drug
cord lesion, prostatic  Right dose
hyperplasia), epileptic  Right route
patients and at risk of  Right time
 Right education
convulsion. Children.
Mild to moderate renal  right assessment
 Right evaluation
impairment. Pregnancy
 Right to refuse
and lactation
 Right documentation
 Right expiration
 Right reason
 Assess respiratory status, such as wheeze
or tightness of the chest.
 If allergy-testing is planned, medication
should be stopped 48 hours before testing.
 Ensure patients are aware that this
medication may make them drowsy. If affected
they should not drive or operate machinery.
 Alcohol can increase any drowsiness.
 Patients who have missed a dose should
take it as soon as they remember. If it is almost
time for the next dose, patients should skip the
missed dose. Double doses should not be
taken.
 Health education advice should be given
regarding limiting exposure to allergens.
37
 Drug Classification and Indication and Side effects and adverse Special precaution
mechanism of action Contraindication reaction Nursing responsibility
Generic Hematopoetic agent Treatment of anemia, Headache, low fever, fatigue. Skin Check hematocrit  Check doctors order
especially renal anemia rash/urticaria. HTN, exacerbation regularly (, once a wk at  Observe 12 rights in giving
name: Mechanism of action: from renal function of existing HTN & hypertensive the early stage & once medication
EPOETIN ALFA - Erythropoietin (EPO) is a insufficiency including encephalopathy. Increased blood every 2 wk during  Right patient
INJECTION (e- glycoprotein that regulates the hemodialysis & non- viscosity, hepatic impairment, maintenance). Maintain  Right drug
POE-tin AL-fa) production of red blood cells by hemodialysis of chronic increased GOP & GPT. Nausea, hematocrit at 30 vol%.  Right dose
stimulating the division and renal failure vomiting, anorexia & diarrhea Adjust diet to avoid  Right route
differentiation of committed hyperkalemia. Patients  Right time
Brand erythroid progenitor cells in the w/ MI or pulmonary  Right education
bone marrow. Contraindication: infarction. Monitor BP  right assessment
name: regularly. Adopt daily  Right evaluation
Eposino ferrotherapy if serum  Right to refuse
Uncontrollable, severe ferric conc is <100
4000 units SQ 2x  Right documentation
HTN. Combined infections mg/mL or if transfer in
per week  Right expiration
saturation is <20%.
 Right reason
Childn, pregnancy &
Dosage:4000  Monitor patient blood pressure
lactation.
UNITS before therapy
 Monitor blood count, hematocrite
Route: may cause excessive clotting
subcutaneous  Patient need additional heparin for
prevent blood clotting during
dialysis
Timing:2x per
week

38
 Drug Classification and Indication and Side effects and adverse Special precaution Nursing responsibility
mechanism of action Contraindication reaction
Generic The main medical use for Increased appetite, nausea, wt. Patient w/ angle-closure  Check doctors order
antamines pizotifen is for the gain, drowsiness, dizziness, dry glaucoma, urinary  Observe 12 rights in giving
name: prevention of migraine and mouth, fatigue, muscle pain or retention, epilepsy. medication
cluster headache. Pizotifen cramps, heavy or restless legs, Avoid abrupt  Right patient
PIZOTIFEN is one of a range of fluid retention, facial flushing, withdrawal. Renal and  Right drug
Brand medications used for this reduced libido, exacerbation of hepatic impairment.  Right dose
Mechanism of action: purpose, other options epilepsy, dreaming, hepatic injury  Right route
name: include propranolol,  Right time
Mosegor vita Pizotifen is a sedating topiramate, valproic acid,  Right education
antihistamine which is known to cyproheptadine and  right assessment
1 cap OD 8pm inhibit the reuptake of serotonin amitriptyline  Right evaluation
by blood platelets, thereby  Right to refuse
preventing loss of tone of
Dosage:1 cap  Right documentation
intracranial vessels. It has weak Contraindication:
 Right expiration
antimuscarinic properties and it Pizotifen is contraindicated
Route:oral  Right reason
also antagonises the action of in patients who suffer
tryptamine from hypersensitivity to
 Avoid activities required
Timing: OD 8pm any of its components, also
concentration
Pizotifen is contraindicated
 Administer with meals to avoid
in gastric outlet
GI irritation
obstruction, pregnancy,
angle-
closure glaucoma and
difficulty urinating

39
 Drug Classification and
mechanism of action
Generic name:
CaCo3 +Vit D3
Mechanism of action:
Brand name: Calcium carbonate is a
calcium supplement that
is used in deficiency states
Dosage: I tab and as an adjunct in the
prevention and treatment
Route: oral of osteoporosis. Vitamin
D3 is a fat-soluble sterol,
it aids in the regulation of
Timing: OD 8am calcium and phosphate
homeostasis and bone
mineralisation.
Indication and
Contraindication
It may be used to treat
conditions caused by
low calcium levels such as
bone loss (osteoporosis),
weak bones
(osteomalacia/rickets),
decreased activity of the
parathyroid gland
(hypoparathyroidism), and
a certain muscle disease
(latent tetany). ... Vitamin
D helps your body
absorb calcium and
phosphorus.
Contraindication:
Patients with
hypercalcaemia and/or
hypercalciuria.
Nephrolithiasis,
hypervitaminosis D,
hypophosphataemia
Side effects and adverse Nursing responsibility
reaction Special precaution
 Check doctors order
Constipation, flatulence, Impaired calcium  Observe 12 rights in giving medication
nausea, abdominal pain absorption in achlorhydria  Right patient
and diarrhea. Pruritus, which is common in  Right dose
rash and urticaria. elderly. Increased risk of  Right drug
hypercalcaemia and  Right route
hypercalciuria in  Right time
hypoparathyroid patients  Right education
receiving high doses of  right assessment
vitamin D. Caution when  Right evaluation
using in patients with  Right to refuse
history of kidney stones.
 Right documentation
Renal impairment;
 Right expiration
frequent monitoring of
 Right reason
serum calcium and
 Do not continue this medication beyond 1–2 wk,
phosphorus is
since it may cause acid rebound, which generally
recommended
occurs after repeated use for 1 or 2 wk and leads
to chronic use. It is potentially dangerous to self-
medicate. Do not take antacids longer than 2 wk
without medical supervision.
 Avoid taking calcium carbonate with cereals or
other foods high in oxalates. Oxalates combine
with calcium carbonate to form insoluble,
nonabsorbable compounds.
 Do not use calcium carbonate repeatedly with
foods high in vitamin
40
 Drug Classification and Indication and
mechanism of action Contraindication
Generic name:
Vit B + folic acid Vit B complex Treatment & prevention of
folate, vit B1, B6,
B12 deficiencies. For
Brand name: Mechanism of action: Each capsule supplementation where
contains: Thiamine mononitrate folate & vit B12 are reduced
Folicard-B Plus (Vit. B1) 200 mg, Pyridoxine HCl (Vit. due to intake of certain
B6) 50 mg, Cyanocobalamin (Vit. B12) medicines eg, fenofibrate,
500 mcg, Folic acid 5 mg. metformin, & methotrexate.
Folic acid, Thiamine (B1), Pyridoxine Lowers homocysteine levels
(B6) and Cyanocobalamin (B12) are to reduce risk of CV diseases,
Dosage: 1 cap members of the Vitamin B Group MI, stroke, peripheral arterial
Folic acid and Vitamin B12 help cells vascular disease &
Route: oral to multiply and are important co- endothelial dysfunction
factors for the remethylation of
homocysteine to methionine, hence Contraindication:
Timing: OD 8am in lowering plasma homocysteine Hypersensitivity to Folicard B-
levels Plus Capsule is a
contraindication. In
addition, Folicard B-Plus
Capsule should not be used if
you have the following
conditions:
 Intolerance to the
drug
 hypersensitivity
Side effects and adverse Special precaution Nursing responsibility
reaction
 Diarrhea Patients w/ folate-  Check doctors order
dependent tumors.  Observe 12 rights in giving
 Peripheral vascular medication
thrombosis  Right patient
 Itching ransitory exanthema  Right drug
 Feeling of swelling of entire  Right dose
body  Right route
 Allergic reactions  Right time
 Anorexia  Right education
 Nausea  right assessment
 Abdominal distention  Right evaluation
 Flatulence  Right to refuse
 Right documentation
 Right expiration
 Right reason
 Do not breast feed while taking
this drug without consulting
physician.
 Rich food sources of B12 are
nutrient-added breakfast cereals,
vitamin B12-fortified soy milk,
organ meats, clams, oysters, egg
yolk, crab, salmon, sardines,
muscle meat, milk, and dairy
products
41
 Nursing
Care Plan

24
42
ASSESSMENT NURSING GOAL/OBEJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
SUBJECTIVE: Ineffective airway clearance LONG TERM: Independent:
r/t decrease lung expansion After nursing interventions the
“nabudlayan ako mag ginhawa’’ secondary to pleural effusion patient will maintain a patent 1.Establish rapport to patient To gain patient trust and Goals partially met as evidenced
as verbalized by the patient. and infection airway cooperation. by:
2.Monitor V/S especially RR
OBJECTIVES: every 4 hours To obtain baseline data and note a) RR ranges from 18-20cpm
RATIONALE: SHORT TERM: for changes.
V/S: Pleural effusion and infection after 9 hours of nursing b) Able to sleep longer (30min-
T-36.1‫ﹾ‬C damage the lungs and the intervention the patient will be 1H)
RR-24cpm chest wall resulting to able to: 3.Maintain calm attitude To limit level of anxiety
PR-71bpm secretion and accumulation of while dealing with client c) Able to expectorate small to
BP-130/80mmhg fluid causing blocking of 1.improve respiration within moderate phlegm.
airway normal range (16-20 cpm) To note for respiratory
1.Trouble sleeping abnormalities that may indicate
2.O2 at 2L/min Reference: 2.Establish a normal effective 4.Monitor breath sound early respiratory compromise and
3.Chest x-ray result: Nurses Pocket’s Guide by respiratory pattern as evidenced hypoxia.
Minimal pleural effusion bilateral Marilynn G. Doenges by absence of sign/symptoms of
4.Presence of crackles on both hypoxia with ABGs within client’s 5.Place the client in a high To promote physiological/ ease of
lung fields upon auscultation normal/Acceptable range fowler’s position maximal inspiration
5.Productive cough with yellowish
phlegm 3. Sleep at longer time
6.Orthopneic DEPENDENT:
7. Always in high fowlers position 4. Expectorate phlegm
9. PAI with salbutamol; 1.Administer oxygen (2L/m) To improve oxygen supply
2x a day. via nasal cannula as ordered
8am and 6pm To maintain intravenous line in
10.Impression: pneumonia 2.Maintain IV rate PNSS 1L x case of emergency and a route of
10 cc/h as ordered medication

3. Administer Pulmo-aide Relaxes bronchial and smooth

inhalation with salbutamol muscle by acting on beta2 –
(salbutamol 1neb. BID) as adrenergic receptors.
ordered

43
ASSESSMENT
SUBJECTIVE:
“sakit ang wala ko na kamot”
as verbalized by the patient.
OBJECTIVES:
Pain scale of 8 out of 10
Presence of AV Fistula
Swelling of left forearm
Warm to touch
Redness
Creatinine –level 622.33
Impression: CKD
NURSING GOAL/OBEJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Altered comfort related LONG TERM:
to pain at left forearm 1. Establish rapport to patient. 1. To gain trust and cooperation.
(Presence of AV fistula) After nursing interventions, the
secondary to surgery patient will be relieved from 2. For baseline data
pain/discomfort. 2.Monitor vital signs
3. Indicates the need for
Demonstrate use of relaxation 3. Perform an assessment of pain to evaluation of effectiveness of
include location, characteristics,
skills and diversional activities. intervention and may signal
onset/duration, frequency,
development of complication.
quality, severity and grimacing
SHORT TERM: (0-10 scale).
4. Promotes non-pharmacologic
After 9 hours of nursing 4. Provide comfort measures, quiet pain management.
RATIONALE: interventions, the patient will be environment and calm activities.
able to: 5. Distracts attention and reduce
Surgery causes damage 5. Encourage diversional activities tension. Goals partially met as evidenced
to the nerve endings 1.Pain scale will reduce from and relaxation techniques such as by
and inflammatory 8/10 to 5/10 listening to music, 6. This helps the extra fluid move .
process resulting to pain Texting/chatting. back towards the heart for 1. Patient’s Pain scale reduced
and discomfort. 2. Will not develop circulation to the rest of the body from 8/10 to 5/10.
complications. 6. Elevate Left arm on 1 pillow while and to help reduce swelling. 2. Swelling still noted.
Reference: on bed 3. Able to mobilize left arm with
Nurses Pocket’s Guide 3. Mobilize her left forearm. 1. Pressure can lead to support.
by Marilynn G. Doenges thrombosis and induces a
Dependent:
compression of the blood vessels.
1.Observe AVF precaution
2. Bind to bacterial cell
 no BP taking at left arm
wall membrane,
 No blood extraction
causing cell death (antibiotic)
 No IV insertion
2.cefuroxime 500mg/tab BID 3. To maintain intravenous line in
8am and 4pm as ordered case of emergency and a route of
3. Maintain IV rate PNSS 1L x 10 medication
cc/h as ordered
44
 Evaluation
Patient R.G.PB is very eager to be discharged out of the hospital. She has a great
support system from her children, and relatives that gives her a great joy despite her
condition. Upon our assessment, it is noted that the patient needs assistance with regards
to her activities of daily living such us standing up, transferring from bed to chair/ couch,
walking to the bathroom and the like due to pain on her hip and being in bed for quite a
while.
The physician ordered “may go home” last January 12, 2020, one week of
hospitalization.
The general and specific objectives were met and we have understood the
underlying principles of CKD secondary to DM 2. In a way, this will make us more
knowledgeable about illustrating theories that can help show how different aspects of a
person’s life are related to each other and use it as basis for our future cases.

Course of Stay in the Ward

January 2, 2020
Patient was admitted around 5:17pm to BCU per stretcher, vital signs were taken
with temperature of 36.2oC, pulse rate of 61bpm, respiratory rate 20cpm, blood pressure of
170/80mmHg, and oxygen saturation of 95%. Mio strictly monitored. PNSS IV line started at
right arm with infusion rate of 1L x 10cc/hr. Limited oral fluid intake to 800cc/day.
Prothrombin time and blood chemistry test requested. ABG result had an overall
significance of hypoxemia secondary to pleural effusion. Blood chemistry result had an
overall significance of risk for hypocalcemia due to CKD.
January 3, 2020
The following labs were taken: Urinalysis, Occult Blood, and a Routine Stool exam
and had an overall significance of poor kidney function due to glomeruli damage that leads
to the loss of albumin and other proteins, presence of bleeding in her upper GI and routine
stool exam shows that patient is positive for amoebiasis. Cross matching and retyping was
also requested for blood transfusion. Patient was given 1 bag of packed RBC.
January 4, 2020
Request for CBC, serum creatinine, serum potassium tests and had an overall
significance of patients’ kidneys could not produce enough EPO thus resulting to anemia
and shows patient is at risk for hyperkalemia due to CKD.
January 5, 2020
Doctor ordered to continue medication and continue strict monitoring of intake and
output of the patient.

45
January 6, 2020
Doctor requested for repeat laboratory test: CBC, serum creatinine, serum
potassium, and urinalysis had an overall significance of patients’ kidneys could not produce
enough EPO thus resulting to anemia, patient being immunocompromised developed
infection and poor creatinine clearance by the kidneys due to CKD.
January 7, 2020
Request for Gramstain/KOH, Xray, CBC, serum creatinine, serum potassium and
urinalysis had an overall significance of poor creatinine clearance by the kidneys due to CKD
and infection is still present. X-ray result showed diagnosis of pneumonia lower lungs,
minimal pleural effusion bilateral, cardiomegaly, atherosclerotic aorta, and follow up is
suggested.
January 8, 2020
Routine stool exam, urinalysis and occult blood test had an overall result of patient
is negative for upper GI bleeding, increased albumin due to kidney dysfunction and patient
still has UTI.
January 9, 2020
Repeat CBC, serum creatinine and serum potassium test had an overall significance
of poor creatinine and albumin clearance by the kidneys due to CKD.

46
Discharge Plan
Patient R.G.PB 62 years old came in due to pulmonary effusion related to
hypoalbuminemia; chronic kidney disease. She was discharged on January 12, 2020 with
may go home medications of the following:
Medications Frequency Timing
Ketoanalogue 600mg/tab 1tab, TID 8am-1pm-6pm
Vit B + Folic Acid 1cap, OD 8am
CaCo3 + Vit D3 1tab, OD 8am
To consume remaining stock of BID x 5days more 8am-6pm
PiperacilinTazobactam IV then shift to Cefexime
200mg/tab,

Mosegor Vita 1cap, OD 8pm

Eposino 400 units subcutaneous 2x per week
Levoceterizine 5mg/tab 1tab, OD at bedtime 8pm
Insulin (Humalog Mix 25) 15 units SQ pre breakfast
10 units SQ pre supper
Clonidine (Catapres) 150mcg/tab 1tab, BID 9am-9pm
Atenolol 100mg/tab OD 8pm
Telmisartan 40mg/tab. 1tab, OD 1pm
Atorvastatin (Itorvaz) 40mg/tab 1tab, OD at bed time 8pm
Linagliptin (Trajenta) 5mg/tab ½tab, OD after lunch
Felodipine 10mg/tab 1tab, OD 8am
Trimetazidine MR 35mg/tab 1tab, BID 8am-6pm
IsosorbideMononitrate 35mg/tab 1tab, OD 11am

OTHERS: (Home care, Physical activity, Special precautions)

1. Advice BP monitoring and CBG monitoring at home
2. Clinic follow-up on January 16, 2020 with repeat CBC, Creatinine, Potassium result
of follow up

Provide client teachings.

1. Instruct patient to moisturize the feet and ankles with lotion or petroleum jelly. Do not put
oils or creams between toes — the extra moisture can lead to infection.
2. Instruct to check the feet daily for calluses, blisters, sores, redness or swelling.
3. Instruct patient to rotate sites when giving Insulin medication.
4. Instruct to give medications at the right route, dose and time.
5. Encourage to have a good sleeping time and adequate nutrition.
6. Advise the patient to comply with her dietary instructions.
7. Teach the patient to avoid foods high in sodium.
8. Encourage patient to move around and bend legs to avoid getting blood clots when resting
for a long period of time.
9. Advise the patient to do walking exercises.
10. Advise the patient to comply with her follow up check-up.
11. Teach how to take care of AV Fistula

47
Documentation

48