I.

Definition of Terms

1. Pulmonary Edema- is fluid accumulation in the lungs. It leads to impaired gas exchange and may cause respiratory failure. It is due to either failure of the heart to remove fluid from the lung circulation ("cardiogenic pulmonary edema") or a direct injury to the lung parenchyma ("noncardiogenic pulmonary edema").

2. Atherosclerosis- also known as arteriosclerotic vascular disease or ASVD) is a condition in which an artery wall thickens as the result of a build-up of fatty materials such as cholesterol. It is a syndrome affecting arterial blood vessels, a chronic inflammatory response in the walls of arteries, in large part due to the accumulation of macrophage white blood cells and promoted by lowdensity lipoproteins (plasma proteins that carry cholesterol and triglycerides) without adequate removal of fats and cholesterol from the macrophages by functional high density lipoproteins (HDL).

3. Cardiomegaly- is a medical condition wherein the heart is enlarged. It is generally categorized in the following manner: a.) Cardiomegaly due to dilation b.) Cardiomegaly due to ventricular hypertrophy ( Left ventricular hypertrophy, Right ventricular hypertrophy, Left atrial enlargement)

4. Pneumonia- is an inflammatory condition of the lung.It is often characterized as including inflammation of the parenchyma of the lung (that is, the alveoli) and abnormal alveolar filling with fluid (consolidation and exudation). The alveoli are microscopic air filled sacs in the lungs responsible for gas exchange. Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs. Its cause may also be officially described as unknown when infectious causes have been excluded.

5. Hypertension- is a chronic medical condition in which the systemic arterial blood pressure is elevated. It is the opposite of hypotension. It is classified as either primary (essential) or secondary. About 9095% of cases are termed "primary hypertension", which refers to high blood pressure for which no medical cause can be found. The remaining 510% of cases (Secondary hypertension) are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system.

6. Chronic Kidney Disease- also known as chronic renal disease, is a progressive loss in 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.

7. Diabetes mellitus, often simply referred to as diabetesis a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes: Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.) Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short, and adult-onset diabetes.) Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. 2

II. Vital Information

Name- Mr. Chuva Age- 73 y.o Gender- Male Civil status- widower Birth date- Aug. 10, 1937 Birth place- Wato, Marawi City Cultural Group- Islam Primary Language- Maranao Religion- Islam Highest educational attainment- College Graduate Occupation- Retired Agriculturist Usual Health Care Provider- Hospital (MSH) Reason for health contact- difficulty of breathing Date of confinement- Nov. 26, 2010

Source of information- 60% S.O, 30% Patients Chart, 10% pt Attending Physician- Dr. Gomez Final Diagnosis- Pneumonia, Pulmonary Congestion and Chronic Kidney Disease

III. Assessment

a. Nursing History

History of Present Illness

5 years ago, the patient was diagnosed with DM and Hypertension by Dr Gomez. Upon diagnosis, the patient was then maintaining meds such as Dopidogrel 75mg, Hydralazine 25mg, and Amiodarone 20mg. TID for Hypertension, Bumetanide 10mg, ketosteril 500mg, Sodium Bicarbonate 65mg, and Calcium carbonate 500mg, for CKD. After the diagnosis, the patient then had several admissions due to DOB and Hypertension. on March 2010 The patient was admitted due to hypertension. then he was again admitted on May due to DOB, then on June due to BOD, August due to BOD, September due to DOB and November due to DOB all managed by Dr Gomez. 2 weeks PTA, pt had progressive weakness with difficulty of ambulation. Pt. had decreased appetite and urine output. Pt. had fever, did not experience vomiting. No consultation done 1 week PTA, pt. had dyspnea with edema on both associated with difficulty in sleeping until one day PTA which persisted and prompted admission. History of Past Illness S.O verbalized that pt. had allergy on fishes from the sea and prefer fishes from lake and fishponds. S.O. did not know pts childhood illnesses. Pt had undergone surgery for the removal of kidney stones and an ear surgery and was hospitalized countless times ever since he was diagnosed with DM type 2 and hypertension 5 yrs. ago. No accidents/ injuries were recalled. Pt had not been immunized. 4

b. Genogram PATERNAL MATERNAL

73 37

59

57

55

52

51

49

45

42

40

LEGEND:

MALE FEMALE

PATIENT UNRECALLED INFORMATION

DM2 DECEASED

HYPERTENSION

PEROS: DAY 1 General Appearance: The patient is lying on the bed, Appears weak and drowsy, conscious, Coherent, with pitting edema on lower extremities and non pitting edema on left arm. The patient has cataract on both Eyes with decreased hearing ability on both ears. System/Areas Subjective findings Objectives findings Problem Identified Head/Hair/Face No history of head injury/operation with no complaints of headache, no tenderness upon palpation. Normocephalic, no changes in scalp color, hair thinly yet evenly distributed over scalp area with grayish coloration of hair. Hair strands are strong. Face is symmetrical, no lesions on the face with beard evenly distributed over the chin with grey hair. Able to do different facial expressions symmetrically. Able to identify odor Decreased visual ability able to feel sensation active corneal reflex able to smile decreased hearing ability Not wearing eyeglasses despite the decrease in visual perception. Eyes symmetrically, pupils equally round & reactive to light & accommodation, presence of cataract on both eyes , no discharges noted on nose & ears, decreased hearing ability, with O2 inhalation via nasal cannula at 3 liter per minute None

Neurologic

No history of neurologic problem

None

Eyes/Ears/Nose & sinuses

Previously diagnosed with Cataract last 2005. History of otitis media, with blurred vision.

Impaired visual perception, Impaired Auditory perception

Mouth & Pharynx

With history of several tooth extraction

Lips are cracked and dry, Dry oral mucosa, tonsils not inflamed, dental carries in all teeth, equal jaw strength Palpable thyroid, no lymph node tenderness and enlargement Equal chest expansion, Dyspneic RR 22 25/ min with O2 inhalation at 3-4 lpm. presence of crackles on both lung field upon auscultation, with occasional respiratory distress as evidenced by used of accessory muscle upon respiration with productive cough Back symmetrical with normal curvature of the spine, no crepitus upon palpation lymph node not inflamed, no discharges noted, no swelling, no injury, breast even in color, nipples symmetrical Weak thread pulse, fatigue, CRT-<2 second, BP ranges 110/80 to 130/90 with maintenance drugs. Heart rate ranges 60 80.

Impaired skin integrity

Neck Thorax/Lungs

No history of neck injury nahihirapan akong huminga as verbalized by the patient.

none Ineffective airway clearance

Back Breast/Axilla Cardiovascular/Peripheral vascular

No complaints of back pain Complaints of chest pain, no history of breast disease and surgery Family history of hypertention, diagnosed to have hypertension last 2005 and recently diagnosed with atherosclerotic aorta as seen on chest x ray with cardiomegally Loss of appetite With history of kidney stone formation masakit ang buong katawan ko lalo na ang mga paa koas verbalized by the patient No history of skin disease

none none Risk for decreased cardiac output r/t decreased pumping ability of the heart secondary to cardiomegally None Fluid Volume Excess None

Gastro-intestinal tract Genito-urinary tract Musculoskeletal

Integumentary

Extremities Endocrine

Sakit ilihok akong tiil as verbalized by the patient Diagnosed type 2 Diabetes Mellitus

With abdominal distention, no visible mass, with hypoactive bowel sounds 3 times per minute With FBC, oliguria <30 cc/hr urine output, with yellowish coloration of urine Muscle grade 2 on lower extremities, muscle grade of 3 on left arm and grade 5 on right arm, no muscular atrophy or deformity Intact, dry skin, wrinkled skin, poor skin turgor, hyperpigmented skin color, cool clammy skin, with pitting & non-pitting edema Grade 2 edema on right leg, non-pitting edema on left arm

None

Risk for impaired skin integrity None 7

PEROS: DAY 2 General Appearance: The patient is lying on the bed, Appears weak and drowsy, conscious, Coherent, with pitting edema on lower extremities and non pitting edema on left arm. The patient has cataract on both Eyes with decreased hearing ability on both ears. System/Areas Review of System ( subjective) Nistory of head injury/operation with no complaints of headache No history of neurologic problem Physical Assessment (objectives) Normocephalic, hair evenly distributed to scalp area with grayish coloration of hair; thinning of hair Able to identify odor Decreased visual ability able to feel sensation active corneal reflex able to smile decreased hearing ability Eyes symmetrically, pupils equally round & reactive to light & accommodation, presence of cataract on both eyes , no discharges noted on nose & ears, decreased hearing ability, with O2 inhalation via nasal cannula at 3 liter per minute Dry oral mucosa, tonsils not inflamed, dental carries in all teeth, equal jaw strength Palpable thyroid, no lymph node tenderness Problem Identified

Head/Hair/Face Neurologic

None None

Eyes/Ears/Nose & sinuses

History of otitis media, with blurred vision.

Impaired visual perception, Impaired Auditory perception None

Mouth & Pharynx

With history of several tooth extraction

Neck

No history of neck injury

none

Thorax/Lungs

nahihirapan akong huminga as verbalized by the patient.

Dyspneic, presence of crackles on both lung field upon auscultation, with occasional respiratory distress as evidenced by used of accessory muscle upon respiration with productive cough Back symmetrical, lymph node not inflamed, no discharges noted, no swelling, no injury, breast even in color, nipples symmetrical Weak thread pulse, fatigue, CRT-<2 second With abdominal distention, no visible mass, with hypoactive bowel sounds 3 times per minute With FBC, oliguria <30 cc/hr urine output, with yellowish coloration of urine Muscle grade 2 on lower extremities, muscle grade of 3 on left arm and grade 5 on right arm, no muscular atrophy or deformity Intact, dry skin, wrinkled skin, poor skin turgor, hyperpigmented skin color, cool clammy skin, with pitting & non-pitting edema Grade 2 edema on right leg, non-pitting edema on left arm

Ineffective airway clearance

Back Breast/Axilla Cardiovascular/Peripheral vascular Gastro-intestinal tract Genito-urinary tract Musculoskeletal

No complaints of back pain Complaints of chest pain, no history of breast disease and surgery Family history of hypertention Loss of appetite With history of kidney stone formation masakit ang buong katawan ko lalo na ang mga paa koas verbalized by the patient No history of skin disease

none none None None Fluid Volume Excess None

Integumentary

none

Extremities Endocrine

Sakit ilihok akong tiil as verbalized by the patient Diagnosed type 2 Diabetes Mellitus

Risk for impaired skin intgerity none

c. Gordons Assessment of Functional Health Patterns Health Perception/Management Pattern

Patients reason for admission is dyspnea and he has been hospitalized thrice for the last 3 months due to the same complaints.

Nutritional/Metabolic Pattern

Currently, patients appetite is poor since whenever he eats, he vomits. However, before he was diagnosed with DM, his diet was mainly rice, vegetables and lots of chocolates. Patients daughter emphasized on the love of his father for extra sweetness by recalling moments when his father added more sugar on their already sweet meals. His father used to have chocolates or any sweet food every after meal as his dessert. His father also liked his food to the salty side. Since the diagnosis, his father had already minimized eating sweets and carbohydrates since the patient is also obese. Obviously, patient is a Muslim therefore he does not eat pork. Currently, patient stated that he has difficulty in swallowing. Patient also has dental carries. Patients fluid intake is approximately less than 1L daily as his daughter stated.

10

Elimination Pattern Before admission, patients usual BM was thrice a day but since admission, patient have not eliminated his bowel. Patient is experiencing oliguria amb less than 400cc every day. Patient has poor skin turgor and dryness and Grade 2 pitting edema on lower extremities and a non pitting edema on upper left extremity. Exercise and Activity Pattern Patients lifestyle is sedentary and his usual activity is watching TV. Patient does not have an exercise pattern since his weakness overcomes his initiatives to exercise. Furthermore, patient experiences dyspnea with or without exertion.

Sleep and Rest Pattern Patients daughter stated that his father has an unusual sleeping pattern. According to her, his father does not sleep at night and sleeps only during the day for at most 2 hours.

Cognitive/Perceptual Pattern

According to patients daughter, his fathers last eye examination resulted to his diagnosis of cataract. This was last 2005. In fact, patient is partially blind and partially deaf. His both eyes are affected by the cataract and he is considered partially deaf because he could not hear if the speaker is speaking at a normal level of voice. One must speak closer to his ear for him to hear. His eardrum was operated on in PGH due to otitis media. When asked about pain, patient stated that his whole body is in pain. Self-Perception Pattern Patient cannot express himself clearly. Role-Relationship Pattern 11

Patient lived his children and grandchildren. Therefore, patients family structure is extended.

Sexuality and Reproductive Pattern

Patient is a widower. His wife died last 2008.

Coping Stress Management Pattern The death of his wife was a major stressor to the patient. Patient stated that he just keeps on praying to Allah for the soul of his wife. Value and Belief Pattern

According to the patient, his grandchildren are the most important thing to him right now and he always prays to Allah for their happiness.

d. Diagnostic Tests Diagnostic Test Complete Blood Count RBC 3.02 Result Normal Values 4-6 x 10 12/L Interpretation Decreased Significance Indicates anemia, fluid retention, Nursing Implication 1.) Explain to the patient and SO that 12

(ordered upon admission ) 0.40-0.54 Hematocrit 0.24 Decreased

overhydration Indicates anemia , fluid retention, overhydration Indicates anemia, fluid retention, overhydration

blood sample is needed for the test. 2.) Explain to the patient and SO that blood sample is needed to diagnose certain abnormalities. 3.) Assess for bleeding disorder. 4.) Client may feel uncomfortable during the test due to torniquet pressure and puncture. 5.) Apply pressure after venipuncture.

130-160 x 10 9/L Hemoglobin 88 5-10 x 10 9/L WBC 7.0 0.25-0.35 Lymphocytes 0.15 Monocytes 0 0 - 0.03 0 - 0.01 Eosinophils Basophils 0 0 0.03-0.07

Decreased

Normal

Decreased Decreased

Indicates immunosuppresion Indicates immunosuppresion. A low number of this indicates vulnerability to infection

Normal Normal

Serum Creatinine

Albumin

- 27.18

35-54 g/L

Decreased

May indicate

1.)

Explain

the 13

(ordered upon admission) Creatinine 613.18 53-106 Osmol/L Increased

cirrhosis, acute liver failure, malnutrition Indicate renal disease that has seriously damaged 50% or more nephrons

Whole Blood

Potassium - 5.39 Sodium - 133.3

3.5-5 mmol/L 135-148 mmol/L

Increased Decreased

May indicate renal failure. This is due to abnormal exchange of potassium and sodium. Renal failure can decrease excretion of potassium thus, hyperkalemia and hyponatremia occur.

procedure to the patient and SO. 2.) Apply direct pressure to the venipuncture site until bleeding stops. 3.) Assess for hematoma on the site. 4.) Instruct patient and SO to resume his medications discontinued before the test. 1.) Explain the procedure to the patient and SO. 2.) Apply direct pressure to the venipuncture site until bleeding stops. 3.) Assess for hematoma on the site. 4.) Instruct patient and SO to resume his medications discontinued before the test.

Chest X-Ray

Atherosclerotic Aorta

Abnormal

14

IV. Anatomy and Physiology RESPIRATORY SYSTEM Upper Respiratory Tract

The upper respiratory tract consists of the parts outside the chest cavity: The air passages of the nose, nasal cavities, pharynx, larynx, and upper trachea. Air enters and leaves the respiratory system through the nose which is made of bone and cartilage covered with skin. Just inside the nostrils are hairs which help block the entry of dust. Then the two nasal cavities are within the skull, separated by the nasal septum, which is a bony plate made of the ethmoid bone and vomer. The nasal mucosa is ciliated epithelium with goblet cells that produce mucus. Just as shelves in a cabinet provide more flat space for storage, the conchae increase the surface area of the nasal mucosa. As air passes though the nasal cavities it is warm and humidified, so that air that reaches the lung s warm and moist. The bacteria and cilia continuously sweep the mucus toward the pharynx. Most of this mucus is eventually swallowed, and most bacteria present will be destroyed by the HCl acid in the gastric juiceThen the perinasal sinuses are air cavities in the maxillae, frontal, sphenoid, and ethmoid bones. These sinuses are lined with ciliated epithelium, and the mucus produced drains into the nasal cavities. The functions of the paranasal sinuses are to lighten the skull and provide resonance (more vibrating air) for the voice.The pharynx is a muscular tub posterior to the nasal and oral cavities and anterior to the cervical vertebrae. Pharynx is divided into three parts the uppermost portion is nasopharynx, which is behind the nasal cavities. The soft palate is elevated during swallowing to block the nasopharynx and prevent food or saliva from going up rather than down. The nasopharynx is a passageway for air only, but the remainder of the pharynx serves as both an air and food passageway, although not for both at the same time. The oropharynx s behind the mouth; its mucosa is stratified squamous epithelium, continuous with that of the oral cavity. On its lateral walls are the palatine tonsils also the lymph nodules. Together with the adenoid and the lingual tonsils on the base of the tongue, they form a ring of lymphatic tissue around the pharynx to destroy the pathogens that penetrate the mucosa. The laryngopharnx is the most inferior portion of the pharynx. It opens anteriorly into the larnynx and posteriorly into the esophagus. Contraction of the muscular wall of the oropharynx and laryngopharynx is part of the swallowing reflex.The Larynx is often called the voice box, name that indicates one of its functions, which is speaking. The other function of the larynx is the is to be an air passageway between the pharynx and the trachea. The largest cartilage of the larynx is the thyroid cartilage which you can feel on the anterior surface of your neck. The epiglottis is the upper most cartilage. During swallowing, the larynx is elevated, and the epiglottis closes over the top, rather like trap door or hinged lid, to prevent the entry of the saliva or food. Lower Respiratory Tract 15

The trachea is about 4-5 inches long and extends from the larynx to the primary bronchi. The wall of the trachea contains 16-20 C-shaped pieces of cartilage, which keep the trachea open. The mucosa of the trachea is ciliated epithelium with goblet cells. As in the larynx, the cilias sweep upward toward the pharynx. The right and the left bronchi are the branches of the trachea that enters the lungs. Their structure is just like that of the trachea, with c-shaped cartilages and ciliated epithelium. The further branching of the bronchial tubes is often called the bronchial tree. Imagine the trachea as the trunk o an upside-down tree with extensive branches that become smaller and smaller, these smaller branches are called the bronchioles. The lungs are located on either side of the heart in the chest cavity and are encircled and protected by the rib cage. The base of each lung rests on the diaphragm below the apex (superior trip) is at the level of the clavicle. The alveoli are the basic functional units of the lungs they are also called as air sacs. The flat and alveolar type 1 cells that form most of the alveolar sacs walls are simple squamous epithelium. In the spaces between the clusters of alveoli is elastic connective tissue, which is important for exhalation. Cardiovascular System The heart provides the major force that causes blood to circulate, and the peripheral circulation functinns to carry blood, exchange nutrients, waste products, and gases, transport hormones, components of the immune system, molecules required for coagulatiOn, enzymes, nutrients, gases, waste products, and other substances are transported in tha blood to all areas of the body, regulate blood pressure, and direct bhood f,ow. Blood flows from the heart thrOugh elastic arteries, muscular arteries, and arterioles to the capillaries. Blood returns to the heart from the capillaries through venules, small veins, and large vein. Layers of blood vessels The tunica intima consists of endothelium, a delicate connective tissue basement membrane, a thin layer of connective tissue called the lamina propia, and a fenestrated layer of elastic fibers call the internal elastic membrane. The internal elastic membrane separates the tunica intima from the next layer, the tunica media. The tunica media, or middle layer, consists of smooth muscle cells arranged circularly around the blood vessel. The amount of blood flowing through a blood vessel can be regulated by contraction or relaxation of the smooth muscle in the tunica media. A decrease in blood flow results from vasoconstriction, an increase in blood vessel diameter because of smooth muscle relaxation. The tunica adventitia is composed of connective tissue, which varies from the dense connective tissue near the tunica media to loose connective tissue that merges with the connective tissue surrounding the blood vessels.The main components of the human cardiovascular system are the heart and the blood vessels.It includes: the pulmonary circulation, a "loop" through the lungs where blood is oxygenated; and the systemic circulation, a "loop" through the rest of the body to provide oxygenated blood. An average adult contains five to six quarts (roughly 4.7 to 5.7 liters) of blood, which consists of plasma, red blood cells, white blood cells, and platelets. Also, the digestive system works with the circulatory system to provide the nutrients the system needs to keep the heart pumping. Renal system 16

The excretory system consists of the kidneys, the ureters, the urinary bladders, and the urethra. The kidneys are the major excretory organs of the body. The Urinary system eliminates waste, regulates blood volume, ion concentration and pH; and it is involve with red blood cell production. Filtering the blood The kidneys remove wastes and excess water (fluid) collected by, and carried in, the blood as it flows through the body. About 190 liters (335 pints) of bloodenter the kidneys every day via the renal arteries. Millions of tiny filters, called glomeruli, in side the kidneys separate wastes and water from the blood. Most of these unwanted substances come from what we eat and drink. The kidneys automatically remove the right amount of salt and other minerals from the blood to leave just the quantities the body needs. The cleansed blood returns to the heart and recirculates through the body. Excess wastes and fluid leave the kidneys in the form of urine. Urine is stored in the bladder until it is full and then leaves the body via the urethra. Most people pass about 2 liters (4 pints) of urine every day. Balancing fluid levels By removing just the right amount of excess fluid, healthy kidneys maintain what is called the body's fluid balance. In women, fluid content stays at about 55% of total weight. In men, it stays at about 60% of total weight. The kidneys maintain these proportions by balancing the amount of fluid that leaves the body against the amount entering the body. Fluid comes into our bodies from what we drink, and from high-liquid foods such as soup. If we drink a lot, healthy kidneys remove the excess fluid and we pass a lot of urine. If we don't drink much, the kidneys retain fluid and we don't pass much urine. Fluid also leaves the body through sweat, breath, and feces. If the weather is hot and we lose a lot of fluid by sweating, then the kidneys will not pass so much urine. As your kidneys fail, maintaining this balance becomes more difficult. You may suffer symptoms of too much fluid. You may need to watch your diet and what you drink to maintain fluid balance. Helping control blood pressure One of the important functions of the kidneys is to regulate blood pressure. Healthy kidneys make hormones such as renin and angiotensin. These hormones regulate how much sodium (salt) and fluid the body keeps, and how well the blood vessels can expand and contract. This, in turn, helps control blood pressure. They do this by regulating: The amount of water in the body. If there is too much water in the body (fluid overload) blood pressure will go up. If there is too little water in the body (dehydration) the blood pressure will drop. The width of the arteries. The arteries constantly change in width as blood flows through them. The narrower the arteries, the higher the blood pressure. Renin helps control narrowing of the arteries. Failing kidneys often make too much renin. This raises blood pressure. If your blood pressure is high, your heart is working harder than normal to pump blood

17

through your body. High blood pressure (also called hypertension) caused by a breakdown in these functions is common in people with kidney failure. It is also a complication, a secondary condition caused by kidney failure. Helping make red blood cells Healthy kidneys produce a hormone known as erythropoeitin (EPO), which is carried in the blood to the bone marrow where it stimulates the production of red blood cells. These cells carry oxygen throughout the body. Without enough healthy red blood cells you develop anemia, a condition which makes you feel weak, cold, tired, and short of breath. Urine Formation Filtration The first step in formation of urine is filtration. Filtration is the process by which the blood that passes through the glomerulus is filtered out, so that only certain structures pass through into the proximal convoluted tubule. The rate at which the blood is filtered is known as the glomerular filtration rate, which is normally 125 ml/minute or 180 liters/day! The glomerulus lining is such that it only allows small molecules to filter through, like glucose, plasma, ions like sodium and potassium, urea, etc. The larger molecules, like blood cells and protein cannot pass through the glomerulus. This is the reason that when there are kidney diseases, the glomerulus lining is affected, due to which the protein molecules also pass through, leading to blood and protein in urine. Selective Reabsorption As mentioned above, in filtration step of urine formation, there is only crude and elementary separation of waste products and a lot of water, glucose and other important materials also pass through. Thus, there is need for reabsorption of these important elements back into the body, which is where the second step, that is reabsorptions, comes in. This step is known as selective reabsorption because only some elements are reabsorbed back into the body. Reabsorption occurs in two steps, which is active reabsorption (which requires energy) and passive reabsorption (which does not require energy). Due to the difference in concentration of the fluid inside and outside the tubules, 99% of the water returns into circulation and thus, is passively absorbed, which is important for urine formation and flow. Provided the glucose levels are normal, almost all of the glucose is reabsorbed back into the blood from the proximal tubules. This glucose is actively transported into the peritubular capillaries. However, when there is a very large amount of glucose in the blood, then some of it passes into the urine, which is one of the signs of diabetes. Sodium ions are the only ions that are partially absorbed from the renal tubules back into the blood. Tubular Secretion

18

The last step in urine formation is tubular secretion. This is the step where the urine is made concentrated by increasing the concentration of waste elements. Thus, in this stage, substances move into the distal and collecting tubules from blood in the capillaries around these tubules. These substances are secreted by the mechanism of active transport. The substances secreted include hydrogen ions, potassium ions, ammonia, and certain drugs or metabolic end products. Thus, the kidney tubules play a crucial role in maintaining the body's acid-base balance and maintaining the electrolyte balance in the body. The distal convoluted tubules then drain the urine into the collecting tubules. Then, several collecting tubules join together to drain their contents into the collecting duct, which finally, after urine formation, flows into the ducts of Bellini. This then eventually reaches the renal pelvis, from where the urine flows into the ureter to reach the urinary bladder. Thus, these were the various urine formation steps that take place right from the time when blood flows into the kidneys, till urine is passed into the ureters. The various urinary system diseases occur when there are problems with the functioning of the kidneys, which reflects in the final urine color, odor and concentration. The Endocrine System The endocrine system is made up of hormones regulate the bodys growth, body), and sexual development and bloodstream and may affect one or several Essentials of Anatomy and Physiology 5th The role of the endocrine system is hormones which transfer information and different hormones move through the affect only certain cells. Hormones are chemical messengers set of cells to another to coordinate the act on some specific cells because they through binding with a receptor (part of like a key into a lock - that causes a chain cell does not have a receptor for a different receptors for the same hormone, different cells. (Rod R. Seeley et. al, McGraw-Hill Int. NY 10020 2005) glands that produce and secrete hormones. These metabolism (the physical and chemical processes of the function. The hormones are released into the organs throughout the body. (Rod R. Seeley et. al, edition, McGraw-Hill Int. NY 10020 2005) to maintain the body in balance through the release of instructions from one set of cells to another. Many bloodstream, but each type of hormone is designed to created by the body. They transfer information from one functions of different parts of the body. Hormones can themselves do not actually cause an effect. It is only the cell specifically designed to recognize the hormone) reaction to occur, changing the activity of the cells. If a hormone then there will be no effect. Also, there can be and so the same hormone can have different effects on Essentials of Anatomy and Physiology 5th edition,

19

The major glands of the endocrine system are the pituitary, thyroid, parathyroids, adrenals, pineal body, thymus, and the reproductive organs (ovaries and testes). The pancreas is also a part of this system; it has a role in hormone production as well as in digestion. A gland is a group of cells that produces and secretes chemicals. A gland selects and removes materials from the blood, processes them, and secretes the finished chemical product for use somewhere in the body. The endocrine gland cells release a hormone into the blood stream for distribution throughout the entire body. These hormones act as chemical messengers and can alter the activity of many organs at once. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The hypothalamus controls all the processes undergone by the anterior and posterior pituitary glands. It initiates the production of hormones by the APG. The APG is controlled by releasing hormones which are chemical signals produced by the nerve cells of the hypothalamus, causing either stimulation or inhibition of hormone production. Secretion of hormones by the PPG is controlled by nervous system stimulation of nerve cells in the hypothalamus. Parathyroid glands secrete parathyroid hormone which is essential for the regulation of blood calcium levels. Adrenal glands produce epinephrine and norepinephrine which are fight-or-flight hormones that prepare the body for vigorous physical activity. Testes and ovaries produce hormones that are responsible for secondary sex characteristics, spermatogenesis, and oogenesis. The thymus gland secretes thymosin which aids in the synthesis of WBC for fighting infection. This gland decreases in size in some older adults. The pineal body releases melatonin that is thought to decrease the secretion of LSH & FSH by decreasing the release of hypothalamic-releasing hormones. The thyroid gland, located on either side of the trachea, is controlled by the thyroid stimulating hormone releases by the anterior pituitary gland, which was initially stimulated by the TSH releasing hormone from the hypothalamus. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The pancreas is also part of the body's hormone-secreting system, even though it is also associated with the digestive system because it produces and secretes digestive enzymes. The pancreas produces two important hormones, insulin and glucagon. They work together to maintain a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain stores of energy. The pancreas completes the job of breaking down protein, carbohydrates, and fats using digestive juices of pancreas combined with juices from the intestines, secretes hormones that affect the level of sugar in the blood, and produces chemicals that neutralize stomach acids that pass from the stomach into the small intestine by using substances in pancreatic juice. It contains Islets of Langerhans, which are tiny groups of specialized cells that are scattered throughout the organ. In humans, the pancreas is a 15-25 cm (6-10 inch) elongated organ in the abdomen adjacent to the small intestine and lies toward the back. It has three regions: a head (abuts a part of the duodenum), body (at the level of L2 of the spine) and tail (extends toward the spleen). (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005) The pancreatic duct (also called the duct of Wirsung) runs the length of the pancreas and empties into the second part of the duodenum at the ampulla of Vater. The common bile duct usually joins the pancreatic duct at or near this point. Many people also have a small accessory 20

duct, the duct of Santorini, which extends from the main duct more upstream (towards the tail) to the duodenum, joining it more proximal than the ampulla of Vater. The pancreas is supplied arterially by the Pancreaticoduodenal arteries and the splenic artery: the splenic artery supplies the neck, body, and tail of the pancreas; the superior mesenteric artery provides the inferior pancreaticoduodenal artery; and the gastroduodenal artery provides the superior pancreaticoduodenal artery. Venous drainage is via the pancreaticoduodenal veins which end up in the portal vein. The splenic vein passes posterior to the pancreas but is said to not drain the pancreas itself. The portal vein is formed by the union of the superior mesenteric vein and splenic vein posterior to the neck of the pancreas. In some people (some books say 40% of people); the inferior mesenteric vein also joins with the splenic vein behind the pancreas (in others it simply joins with the superior mesenteric vein instead). (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5 th edition, McGraw-Hill Int. NY 10020 2005) The pancreas is a compound gland in the sense that it is composed of both exocrine and endocrine tissues. The exocrine function of the pancreas involves the synthesis and secretion of pancreatic juices. The endocrine function resides in the million or so cellular islands (the islets of Langerhans) embedded between the exocrine units of the pancreas. Beta cells of the islands secrete insulin, which helps control carbohydrate metabolism. Alpha cells of the islets secrete glucagon that counters the action of insulin. There are four main types of cells in the islets of Langerhans. They are relatively difficult to distinguish using standard staining techniques, but they can be classified by their secretion: Beta cells secretes Insulin and Amylin lower blood sugar, Alpha Cells secretes Glucagon raise blood sugar, Delta Cells secretes Somastotatin inhibit endocrine pancreas, PP Cells secretes pancreatic polypeptide which inhibits exocrine pancreas The islets are a compact collection of endocrine cells arranged in clusters and cords and are crisscrossed by a dense network of capillaries. The capillaries of the islets are lined by layers of endocrine cells in direct contact with vessels, and most endocrine cells are in direct contact with blood vessels, by either cytoplasmic processes or by direct apposition. There are two main types of exocrine pancreatic cells, responsible for two main classes of secretions: Centroacinar cells secretes bicarbonate ions, Basophilic cells secretes digestive enzymes such as pancreatic amylase, pancreatic lipase. (Rod R. Seeley et. al, Essentials of Anatomy and Physiology 5th edition, McGraw-Hill Int. NY 10020 2005)

V. Risk Factors and Pathophysiology

21

See attached concept map.

VI. Nursing Management

a. NCPs

Problem Identified: dyspnea Nursing Diagnosis: Impaired Gas Exchange related to accumulation of fluid in the pleural space secondary to CKD Cause Analysis: Pleural effusion is usually secondary to other diseases such as CKD. In CKD, areas of the lung are not adequately ventilated because of mucosal edema that cause partial occlusion of the bronchial/alveoli with a resultant decrease in alveolar oxygen tension (Smeltzer, 2010). Cues Subjective: Masakit ang paghinga ko, as verbalized by the patient. Objective: -shallow inhalation -dyspnea -pallor -crackles -stridor -RR 22 -Chest X-ray showed bilateral pulmonary congestion Objectives STO: After 30 minutes of nursing interventions, patient will have normal inhalation, relief of dyspnea, decreased adventitious breath sounds. LTO: After 3 days of nursing interventions, patient will demonstrate improved ventilation and oxygenation of tissues within client acceptable range and absence of symptoms of respiratory distress. Nursing Interventions
Independent: 1. Rate/depth of respirations and chest movement was assessed. Manifestations of respiratory distress are dependent on the degree of lung involvement and underlying disease condition. Cyanosis of nail beds may represent vasoconstriction or the bodys response to fever/chills.

Rationale

Evaluation STO: After 30 minutes of nursing interventions, patient will have normal inhalation, relief of dyspnea, decreased adventitious breath sounds.

2. Color of skin, mucous membranes and nail of beds were assessed, noting for peripheral cyanosis. 3. Mental assessed. status was

Restlessness, confusion and may reflect hypoxemia/decreased cerebral oxygenation.

LTO: After 2 days of nursing interventions, patient did not demonstrate improved irritation, ventilation and somnolence oxygenation of tissues.

22

4. Heart rate and rhythm were monitored. 5. Body temperature monitored as indicated. was

Tachycardia is usually present as a result of fever/dehydration but may represent a response to hypoxemia. High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. Keeping the head elevated lowers diaphragm, promoting chest expansion and mobilization and expectoration of secretions to keep airway clear. Shock and pulmonary edema are the most common causes of death in pneumonia and require immediate medical intervention.

6. Head of bed was elevated and patients position was changed frequently.

7. Deterioration of condition was assessed, noting hypotension, pallor, change in level of LOC, severe dyspnea and restlessness. Collaborative: 8. Pulse monitored. oximetry was

9. Oxygen therapy was administered through nasal cannula, 3Lpm.

Identifies problems and facilitates alterations in pulmonary therapy. The purpose of oxygen therapy is to maintain partial oxygen level above 60 mmHg.

Problem Identified: dyspnea Nursing Diagnosis: Ineffective Airway Clearance related to increased sputum production secondary to Pneumonia

23

Cause Analysis: Pneumonia affects both ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon dioxide (Smeltzer, 2010, p 559). Cues Subjective: Masakit ang paghinga ko, as verbalized by the patient. Objective: -shallow inhalation -dyspnea -pallor -cough with sputum production -RR 22 Objectives STO: After 8 hours of nursing interventions, patients inhalation will improve amb relief of dyspnea. LTO: After 3 days of nursing interventions, patient will display patent airway with breath sounds clearing, absence of dyspnea. Evaluation STO: After 8 hours of nursing interventions, 1. Rate/depth of respirations Tachypnea, shallow patients inhalation will and chest movement was respirations and asymmetric improve amb relief of assessed. chest movement are dyspnea.
Independent: frequently present due to discomfort of moving chest wall and fluid in the lung. Keeping the head elevated lowers diaphragm, promoting chest expansion and mobilization and expectoration of secretions to keep airway clear. Deep breathing facilitates maximum expansion of the lungs/smaller airways. Warm fluids aid in mobilization and expectoration of secretions. Facilitates liquefaction removal of secretions. and

Nursing Interventions

Rationale

2. Head of bed was elevated and patients position was changed frequently.

LTO: After 2 days of nursing interventions, patient did not l display patent airway with breath sounds clearing, absence of dyspnea.

3. Client was assisted with frequent deep-breathing exercise. 4. Warm water was offered. Collaborative: 5. Patient was assisted to nebulization- Salbutamol q 4h. 6. Expectorants administered. 7. D5NSS and were provided. were

Aids in reduction of bronchospasm and mobilization of secretions. Fluids are requires to replace losses and aid in mobilization of secretions.

humidified

24

Problem Identified: dyspnea Nursing Diagnosis: Ineffective Breathing Pattern related to decreased lung expansion secondary to pulmonary congestion tertiary to CKD Cause Analysis: Altered lung expansion decreases the ability of normal respiration thus affecting breathing (Smeltzer, 2010). Cues Subjective: Nahihirapan akong huminga, as verbalized by the patient. Objective: -shallow inhalation -dyspnea -pallor -crackles -stridor -RR 22 -Chest X-ray showed bilateral pulmonary congestion Objectives STO: After 30 minutes of nursing interventions, patient will have normal inhalation, relief of dyspnea, decreased adventitious breath sounds. LTO: After 3 days of nursing interventions, patient will demonstrate improved ventilation and oxygenation of tissues within client acceptable range and absence of symptoms of respiratory distress. Nursing Interventions
Independent: 1. Evaluated respiratory function, noting rapid/shallow respirations, dyspnea and changes in v/s. Respiratory distress and changes in v/s occur as a result of physiologic stress and pain, or may indicate development of shock due to hypoxia. Breath sounds may be diminished or absent in a lobe, lung segment or entire lung field.

Rationale

Evaluation STO: After 30 minutes of nursing interventions, patient will have normal inhalation, relief of dyspnea, decreased adventitious breath sounds.

2. Auscultated sounds.

breath

3. Assisted client with splinting painful area when coughing and deep breathing. 4. Maintained comfort, usually bed elevated. affected side. client to sit up possible. position of with head of Turn to Encouraged as much as

Supporting chest abdominal muscles makes coughing more effective/less traumatic. .

LTO: After 2 days of nursing interventions, patient did not demonstrate improved ventilation and and oxygenation of tissues.

Promoted maximal inspiration; enhances lung expansion and ventilation in unaffected side. Assist client to deal with the physiologic effects of hypoxia, which may be manifested as anxiety and or fear.

5. Maintained a calm attitude, assisting client to take control by using slower/deeper respirations. Collaborative:

25

6. Oxygen therapy was administered through nasal cannula, 3Lpm.

Aids in reducing work of breathing; promotes relief of respiratory distress and cyanosis associated with hypoxemia.

Problem Identified: oliguria Nursing Diagnosis: Fluid volume excess related to decreased urine excretion secondary to CKD Cause Analysis: The kidney cannot concentrate or dilute the urine normally in ESRD. Appropriate responses by the kidney to changes in the daily intake of fluids, thus, do not occur (Smeltzer, 2010, p. 1325). Cues Subjective: Hindi ako masyado nakararamdam ng pagiihi, as verbalized by the patient. Objective: -urine output < 400cc daily - 1.080 specific gravity of urine - 130/80 mmHg BP -generalized tissue edema -pulmonary congestion on X-ray -intake of approximately 500 cc daily Objectives STO: After 8 hours of nursing interventions, patient will feel increased sensation of urination. LTO: After 3 days of nursing interventions, patient will display improved urinary output with specific gravity near normal and lessened edema. Nursing Interventions
Independent: 1. Fluid status assessed: a. I an O b. Skin turgor and edema c. BP d. RR and effort

Evaluation STO: After 8 hours of nursing interventions, Assessment provides patient did not feel baseline and ongoing increased sensation of database for monitoring urination.
changes and interventions. evaluating

Rationale

LTO: After 2 days of nursing interventions, 2. Fluid intake was limited to prescribed amount. Fluid restriction will patient did not display determine on basis of urine improved urinary output output and response to with specific gravity near 3. Potential sources of fluid therapy. normal and lessened were identified: edema.
a. Medications and fluid used to take or administer medications; oral and IV. b. Foods Unrecognized sources fluids may be identified. of

4. Rationale for fluid restriction was explained to the patient and family. 5. Patient was assisted to cope with the discomforts resulting from fluid restrictions.

Understanding promotes patient and family cooperation with fluid restriction. Increasing patient comfort

26

6. Frequent oral hygiene was encouraged. Collaborative: 7. Furosemide was administrated as indicated. 8. Patient was prepared for dialysis.

promotes compliance dietary restrictions.

with

Oral hygiene minimizes dryness of oral mucous membranes.

Promote volume. Done to overload.

increased

urine

correct

volume

Problem Identified: facial grimace when moved Nursing Diagnosis: Pain related to accumulation of uremic waste products in the peripheries secondary to CKD Cause Analysis: As renal function declines, the end products of protein metabolism accumulate in the blood adversely affecting every system in the body (Smeltzer, 2010, p. 1325).

Cues Subjective: Masakit pag gumalaw ako, as verbalized by the patient. p- when moved or moves q- prolonged crushing r- whole body s- 8/10 t- everyday, especially in the morning

Objectives STO: After 3 hours of nursing interventions, patient will report that pain is alleviated. LTO: After 3 days of nursing interventions, patient will display relaxed manner and be able to sleep and engage in desired activity.

Nursing Interventions
Independent: 1. Assessed degree characteristic of pain.

Evaluation STO: After 8 hours of nursing interventions, and Degree of pain is directly patient reported that pain related to extent of is alleviated.
circulatory deficit, inflammation and extent of edema.

Rationale

LTO: After 2 days of nursing interventions, Reduces discomfort patient did not display 3. Encouraged client to associated with muscle relaxed manner and was not able to sleep and change position every 2 contraction and movement. hours. engage in desired activity.
2. Maintained bed rest during acute phase.

27

Objective: -facial grimace -pain scale 8 -generalized tissue edema Grade 2 -Creatinine level of 613.18 -Na-K level of K= 5.39 & Na= 133.3

4. Monitored v/s noting elevated temperature. Collaborative: 5. Administered paracetamol as indicated.

Decreases/prevents muscle fatigue, helps minimize muscle spasm, and maximizes circulation to tissues. Elevations in HR may indicate increased pain/discomfort or occur in response to fever and inflammatory process. Relieves pain and decreases muscle tension and reduces fever and inflammation, respectively.

Problem Identified: edema Nursing Diagnosis: Risk for Impaired skin integrity related to peripheral edema. Cause Analysis: CKD patients retain sodium and water, increasing the risk for edema (Smeltzer, 2010, p. 1068) Cues

28

Objectives Subjective: Lumaki ang katawan ko, as verbalized by the patient. Objective: - urine output of <400 cc daily -1.080 pecific gravity of urine -130/80 BP -generalized tissue edema Grade 2 -pulmonary congestion on X-ray - decreased ability to grasp ideas

Nursing Interventions STO: After 8 hours of nursing interventions, patient will demonstrate behaviors/techniques to prevent skin breakdown/injury. LTO: After 3 days of nursing interventions, patient will maintain intact skin.

Rationale
Independent: 1. Inspected skin for changes in color, turgor, vascularity. Noted redness, excoriation. Observed for ecchymosis, purpura. 2. Monitored fluid intake and hydration of skin and mucous membranes. 3. Inspected areas for edema. dependent

Evaluation STO: After 8 hours of nursing interventions, Indicates areas of poor patient demonstrated circulation/breakdown that behaviors/techniques to may lead to decubitus prevent skin formation/infection. breakdown/injury.
Detects presence of dehydration or overhydration that affects circulation and tissue integrity at the cellular level. Edematous tissues are more prone to breakdown. Decreases pressure on edematous, poorly perfused tissues to reduce ischemia. Baking soda, cornstarch baths decrease itching and are less drying than soaps. Lotions and ointments may be desired to relieve dry, cracked skin. Reduces dermal irritation and risk of skin breakdown. Although dialysis has largely eliminated skin problems associated with uremic frost, itching can occur because the skin is an excretory route for waste products, e.g., phosphate crystals (associated with hyperparathyroidism in ESRD). Alleviates discomfort and reduces risk of dermal injury

LTO: After 2 days of nursing interventions, patient maintained intact skin.

4. Changed position q 2; moved patient carefully; pad bony prominences with sheepskin, elbow/heel protectors. 5. Provided soothing skin care. Restricted use of soaps. Applied ointments or creams (e.g., lanolin, Aquaphor). 6. Kept linens dry, wrinklefree. 7. Investigated itching. reports of

29

8. Recommended to patient to use cool, moist compresses to apply

scratch) pruritic areas. Keep fingernails short; encourage use of gloves during sleep if needed. 9. Suggested wearing loosefitting cotton garments.

Cues Risk Factors: Endogenous chemical alteration (glucose/ insulin and/or electrolyte imbalance)

Objectives

STO: Within 30 minutes of Encouraged use of providing health teaching, foam/flotation mattress by the patient will verbalize Address client awareness of sensory needs name; reorient as and presence of overload needed to place, and/or deprivation and person, time, and identify/modify extend factors situation. Give short that contribute to alterations explanations, speaking in sensory/perceptual slowly and enunciating abilities. clearly. Schedule nursing time to provide for uninterrupted rest periods. LTO: After 30 days of effective nursing interventions, the patient will be free from injury and use resources effectively and appropriately. Keep clients routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. Protect client from injury (avoid/ limit of restraints as able, place bed in low position) when cognition is impaired. Pad bed rails if client is prone to seizures. Evaluate visual acuity as indicated.

Nursing Intervention Collaborative: vital signs Monitor and mental status.

Prevents direct dermal irritation and promotes evaporation of moisture on Rationale the skin.

Evaluation

STO: Provides a The patient verbalized baseline from which to Reduces prolonged pressure awareness of sensory needs compare abnormal on tissues,e.g., fever limit and presence of overload findings; which can cellular perfusion, and/or deprivation and may affect mentation. potentiating identified/modified extend Decreases ischemia/necrosis. factors that contribute to confusion and helps alterations in maintain contact with sensory/perceptual abilities. reality.

Promotes restful sleep, reduces fatigue, and may improve cognition. Helps keep client in touch with reality and maintain orientation to the environment. Disoriented client is prone to injury, especially at night, and precautions need to be taken as indicated. Seizures precautions reduce risk of physical injury. Retinal edema/ detachment, hemorrhage, presence

LTO: The patient was free from injury and use resources effectively and appropriately.

30

Investigate reports of hyperesthesia, pain, or sensory loss in the fee/ legs. Look for ulcers, reddened areas, pressure points, loss of pedal pulses.

Provide bed cradles. Keep hands/ feet warm, avoiding exposure to cool drafts/ hot water or use of heating pad.

Assist with ambulation/ position changes. Collaborative: Carry out prescribed regimen for correcting DKA as indicated.

of cataracts or temporary paralysis of extraocular muscles may impaire vision, requiring corrective therapy and/ or supportive care. Peripheral neuropathies may result in severe discomfort, lack of/ distortion of tactile sensation, potentiating risk of dermal injury and impaired balance. Note: Mononeuropathy affects a single nerve (most often femoral or cranial), causing sudden pain and loss of motor/ sensory function along affected nerve path. Reduces discomfort and potential for dermal injury. Note: Sudden development of cold hands/ feet may reflect hypoglycemia, suggesting need to evaluate serum glucose level. Promotes client safety, especially when sense of balance 31

Monitor laboratory values; e.g., blood glucose, serum osmolality, Hb/ Hct, BUN/ Cr.

is affected. Alteration in thought process/ potential for seizure activity is usually alleviated once hyperosmolar state is corrected. Imbalances can impair mentation. Note: If fluid is replaced to quickl, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication).

32

33

Problem Identified: Muscle weakness Nursing Diagnosis: FATIGUE r/t decreased metabolic energy production, altered body chemistry: insufficient insulin, and increased energy demands: hypermatabolic state/ infection Cause Analysis (with ref.): Lowered plasma volume produces weakness and fatigue (Pathophysiology Concepts of Altered Health States7th ed. By Porth, Carl Mattson). Cues Objectives Nursing Intervention Rationale Evaluation SUBJECTIVE: STO: STO: Discuss with client Education Verbalization of an Within 30 minutes of the need for activity. Plan may provide motivation The patient identified basis unremitting/ overwhelming providing health of fatigue and individual schedule with client and to increase activity lack of energy, inability to teachings, the patient will identify activities that level even though client areas of control and report maintain usual routines/ identify basis of fatigue sense of energy. lead to fatigue. may feel too weak level of physical activity. and individual areas of initially. Alternate activity Tired; Inability to restore control and report sense of with rest periods of rest/ Prevents energy even after sleep energy. uninterrupted sleep. excessive fatigue. Monitor pulse, LTO: respiratory rate, and BP Indicates The patient still did not before/ after activity. physiologic levels of perform ADLs and did not tolerance. Discuss ways of OBJECTIVE: participated in desired conserving energy while Client will be Inability to maintain usual LTO: activities at level of ability bathing, transferring, and able to accomplish routines After 30 days of effective and did not participate in so on. more with a decreased Decreased performance nursing interventions, the recommended treatment expenditure of energy. Increase client Accident-prone patient will perform ADLs program. participation in ADLs as Increases Impaired ability to and participate in desired tolerated. confidence level/ selfconcentrate activities at level of ability esteem and tolerance Restlessness and participate in level. Note: Elderly Less interest in recommended treatment clients may experience surroundings program. a lag effect in which exercise may precipitate hypoglycemia as late as 24 hr after exercising, leading to extensive fatigue and muscle tremors. 34

b. Discharge Plan Medications Sodium Bicarbonate Dosage/Frequency 650mg(56 tab) 3x a day (8-1-6) Nursing Instructions Chew oral tablets thoroughly and follow with a full glass of water. Do not take within 1-2 hours of any other drugs to decrease risk of drug interactions Have periodic blood tests and medical evaluations. Report irritability, headache, tremors, confusion, swelling of extremities, difficulty of breathing, black or tarry stools. Do not take with other oral drugs. Absorption of these medications can be blocked; take other oral meds. At least 1-2 hours after Calcium Carbonate May experience these side effects: constipation, nausea, GI upset, loss of appetite(special dietary consultation may be necessary) Report loss of appetite nausea, vomiting, abdominal pain, constipation, dry mouth, thirst, and increased voiding. Take drug with food or milk. Complete the full course 35

Calcium Carbonate

300mg(56tab) 3x a day (8-1-6)

Nitro Furantoin (Macrodantin)

100mg (7cap.) once a day (8pm)

Bumetanide (Bumex)

1mg (21 tab) 3x a day (8-1-6)

of drug therapy to ensure a resolution of the infection. Take this drug at regular intervals around-the-clock; consult nurse or pharmacist to setup a convenient schedule. May experience these side effects: nausea, vomiting, abdominal pain (eat frequent small meals), diarrhea, drowsiness, blurring of vision, dizziness (observe caution driving or using dangerous equipments); brown or yellow-rust urine. Report fever, chills, cough, and chest pain, difficulty of breathing, rash, numbness or tingling of the fingers or toes. Record alternate day or intermittent therapy on a calendar or dated envelopes Take the drug early in the day so increased urination will not disturb sleep; take with food or meals to prevent GI upset. Weigh yourself on a regular basis, at the same time and in the same clothing; record the weight on your calendar. You may experience these side effects: increased volume and frequency of urination; dizziness, feeling faint on arising, drowsiness (avoid rapid position changes; hazardous activities, such as driving; and alcohol consumption); sensitivity to sunlight; loss of body potassium. Report weight change of more than 3 pounds in 1 day; swelling in ankles or fingers; unusual bleeding or bruising; nausea; dizziness, trembling, numbness, fatigue; muscle weakness or cramps. Take oral drug without regard to meals. If an antacid is needed, do not take it within 2 hours of levofloxacin dose. 36

Levofloxacin

50mg (12 tab.) once a day 10 a.m.

Ferrous Sulfate (Imefen)

1 tab. B.I.D (6am-6pm)

Drink plenty of liquids while you are using this drug. You may experience thes side effects : nausea, vomiting, abdominal pain (eat small frequent meals); diarrhea or constipation(consult your health care provider) ; drowsiness, blurred vision; sensitivity to sunlight. Report rash, visual changes, severe GI problems, weakness, tremors. Take drug on an empty stomach with water. Take after meals if GI upset is severe(avoid milk, eggs, coffee, and tea). Take liquid preparations diluted in water or juice, and sip them through a straw to prevent staining of the teeth. Treatment may not be necessary if cause of anemia can be corrected. It may be needed for several months to reverse anemia. Have periodic blood tests during therapy to determine the appropriate dosage. Do not take this preparation with antacids or tetracyclines. If these drugs are needed, they will be prescribed. You may experience these side effects: GI upset, nausea, vomiting (take drug with meals); diarrhea or constipation; dark or green stools. Keep this drug out of reach of children. Report severe GI upset, lethargy, rapid respirations, constipation.

EXERCISE

Promote passive exercises. Deep Breathing & Coughing exercises. 37

THERAPY Insulin therapy clients with type 2 diabetes are not dependent on exogenous insulin administration for survival. They may need supplemental insulin for adequate glucose control, especially in times of stress of illness. Insulin Pump therapy small portable pumps for the continuous administration of regular insulin are sometimes used. The small pump, worn externally, injects insulin subcutaneously into the abdomen through an indwelling needle site that is usually changed daily. Intensive Diabetes therapy clients in the intensive treatment group learned to adjust their insulin doses to keep their blood glucose levels as close to normal as possible. Combination therapy is defined as the use of two or more oral anti-diabetes agents or an oral agent combined with insulin. The advantage is that because the various groups of oral agents have different sights and mechanisms of action, they can complement and even augment each other. Early referral for initiation of renal replacement therapies as indicated by patients renal status HEALTH TEACHINGS Foot Care People with neuropathy need to take special care of their feet. The nerves to the feet are the longest in the body and are the ones most often affected by neuropathy. Loss of sensation in the feet means that sores or injuries may not be noticed and may become ulcerated or infected. Circulation problems also increase the risk of foot ulcers. Doctors estimate that nearly half of the amputations caused by neuropathy and poor circulation could have been prevented by careful foot care. Here are the steps to follow: Clean your feet daily, using warmnot hotwater and a mild soap. Avoid soaking your feet. Dry them with a soft towel; dry carefully between your toes. Inspect your feet and toes every day for cuts, blisters, redness, swelling, calluses, or other problems. Use a mirror (laying a mirror on the floor works well) or get help from someone else if you cannot see the bottoms of your feet. Notify your health care provider of any problems. Moisturize your feet with lotion, but avoid getting it between your toes. Each week or when needed, cut your toenails to the shape of your toes and file the edges with an emery board. Always wear shoes or slippers to protect your feet from injuries. Prevent skin irritation by wearing thick, soft, seamless socks. Wear shoes that fit well and allow your toes to move. Break in new shoes gradually by wearing them for only an hour at a time at first. Before putting your shoes on, look them over carefully and feel the insides with your hand to make sure they have no tears, sharp edges, or objects in them that might injure your feet. 38

If you need help taking care of your feet, make an appointment to see a foot doctor, also called a podiatrist.

*Teach them to maintain good nutrition and adequate fluid intake. Instruct them not to smoke, cross their legs, or restrictive clothing. *Teach them to inspect all areas of their feet daily. , Looking for open areas, warmth, redness, discharge, formation of calluses or corns, or anything unusual. *Encourage clients to use productive measures, such as (1) always wearing good-fitting, high quality shoes. (2) Avoiding temperature extremes, and (3) seeking immediate medical attention for any injury or problem. Explain that all cuts and blisters need to be cleaned and treated with an antiseptic preparation. If a cut or blister begins to appear infected (warmth, pain, and swelling) or has drainage, encourage the patient to notify the primary healthcare provider immediately. Teach the patient to avoid constricting clothing such as constricting stockings, garters, girdles, or elastic slippers. If the patient needs to be on bed rest, encourage her or him to keep bed linens loose over the feet and legs. Instruct the patient to avoid very hot baths if peripheral neuropathy causes decreased temperature sensation. If the patient is a child or teenager, recognize that a diagnosis of DM changes a family permanently. Parents usually expect their child to be healthy and often react with shock and disbelief. The impact on the child depends on the childs age. School-age children may be impressed with the new condition and may be challenged by the new skills it involves. Adolescents, in comparison, may feel unfairly victimized and respond by becoming depressed, resistant, uncooperative, or insecure. Work with the entire family to support their adaptation to the illness. Introduce the family to other families with the same problem. If the problems are abnormal, make a referral to a counselor. Explain that treatment of hypertension, anemia, and hyperglycemia and detection of proteinuria all help to slow disease progression and improve patient outcomes. Promote frequent oral hygiene. Encourage reduced alcohol intake. Encourage frequent handwashing.

OPD VISITS/ REFERRALS Instruct patient to have a regular check-up of his/her glucose level Emphasize the importance of the follow up exams according to scheduled visits by her doctor to monitor progress. Regular clinical and laboratory assessment to keep BP below 130/80 mm Hg.

DIET 39

Nutrition, diet and weight control are the foundation of diabetes management. The most important objective in the dietary and nutritional management of diabetes is to control. Avoid adding sugar to foods such as coffee and cereal Avoid foods that are sweetened with sugar or honey, such as jellies, jams, cakes and ice cream. Be consistent about the amount, distribution, and timing nutrients. Increase amount of carbohydrates in a meal eaten before sustained exercise. Limit intake of saturated fat and cholesterol.

SPIRITUAL CARE Encourage patient to verbalize feelings. Encouraged patient and family to adopt a realistic attitude, but dont discouraged hope. You may also provide devotional or religion books as appropriate. Tell the patient that God is the greatest physician and only the one who knows and owns everything. Remind the patient that his disease is not a barrier to his relationship with God.

VII.

Medical-Surgical Management Hospital Admission Medications

Medicatio n

Generic Name

Classificati on

Indication

Mechanism of action

Adverse Effects

Drug interaction

Route/Frequen cy/Dosage

Nursing Considerations

40

Prilosec

Omeprazole

Antacids, Antireflux Agents

Peptic ulcer, Gastroesophagea l reflux disease, Esophagitis, Acidrelated gastric irritation

Omeprazole supresses gastric acid secretion by specific inhibition of the hydrogen-potassium adenosinetriphosphatas e enzyme system found at the secretory surface of parietal cells. It inhibits the final transport of hydrogen ions into the gastric lumen.

Diarrhea, Nausea and Vomiting, flatulence, dry mouth, dizziness, abdominal pain, skin rashes, cough.

Omeprazole potentially can increase the concentratio ns in blood of diazepam (Valium), warfarin (Coumadin), and phenytoin (Dilantin) by decreasing the elimination of these drugs by the liver.

IVTT, OD, 40 mg Oral, OD, 20 mg

1. Administer before meals. Caution patient to swallow (oral) the capsule-not to crush, chew. 2.Assess for patient allergies. 3. Teach patient the possible side effects after taking this drug. 4. Report severe headache and worsening of symptoms.

Lasix

Furosemide

Loop Diuretic

Edema associated with heart failure, cirrhosis, renal disease, Acute pulmonary edema, Hypertension

Inhibits reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium-rich diuresis.

Dizziness, vertigo, paresthesia, weakness, Orthostatic hypotension, cardiac arrythmias, Nausea and vomiting, gastric irritation

Zosyn

Piperacillin/ Tazobacta m

Antibiotic: penicillin

Pneumonia, Severe bacterial infection

Inhibits bacterial cell wall mucopeptide synthesis.

Hypotension, back pain, malaise, tachycardia, vertigo, flatulence,

1. Increased risk of cardiac arrhythmias with cardiac glycosides due to electrolyte imbalance. 2. Increased risk of ototoxicity with aminoglycosi de antibiotics Probenecid prolongs half lives of piperacillin and tazobactam.

IVTT, 40mg, q6H

1. Administer with food to prevent GI upset. 2. Give early in the day so that increased urination cannot disturb sleep. 3. Measure and record weight to monitor fluid changes

IVTT, 2.25 mg, q8h

1. Observe patient for signs of anaphylaxis (rash, itching, etc.). D/C if these occur. 2. Monitor vital signs always.

41

hypersensitivi ty

Increased risk of methotrexat e toxicity when used together. Potentially Fatal: Interacts with heparin and other oral anticoagulan ts. Prolongs the neuromuscul ar blockade of vecuronium and nondepolarizing muscle relaxants. Reduced diuretic and natriuretic actions by probenecid. Indometacin blunts action of bumetanide; concurrent usage with antihyperten sives may increase risk of orthostatic hypotension. Potentially Fatal: Avoid concurrent usage with Oral, 1mg, TID

3. teach patient to report any episodes of diarrhea and fever.

Burinex

Bumetanid e

high-ceiling (up to 20% excretion) Diuretics

Cardiac, renal, hepatic, and pulmonary edema, fluid retention, hypertension

Bumetanide induces diuresis by inhibiting reabsorption of water and electrolytes (sodium and chloride) in the ascending loop of Henle and proximal renal tubule.

Muscle cramps, dizziness, hypotension, headache, nausea, impaired hearing, pruritus, ECG changes, musculoskele tal pain, rash, chest discomfort, renal failure, premature ejaculation, thrombocytop enia, hypokalaemia

1. Give with food or milk to prevent GI upset 2. Give it during day so that frequent urination cannot disturb sleep. 3. Monitor weight changes. Report weight change of more than 3 pounds in 1 day. 4.Monitor V/S often esp. the BP to prevent hypotension.

42

Macrodanti n

Nitrofurant oin

Antibiotic

Prophylaxis and treatment for Urinary tract infection.

Nitrofurantoin interferes with cell metabolism and cell wall synthesis by inhibiting several enzyme systems including acetyl coenzyme A. It is bactericidal to most gram-positive and gramnegative urinary tract pathogens.

, hypomagnesa emia, hyponatraemi a, hyperuricaem ia, hyperglycae mia, hypocalcaemi a. Nausea and vomiting, abdominal pain, diarrhea, drowsiness, blurring of vision, dizziness, brown/yellowrust urine, Pulmonary hypersensitivi ty, hepatotoxocit y. Potentially Fatal: StevensJohnson Syndrome Headache, dizziness, lightheadedn ess, dizziness,dro wsiness, Potentially Fatal: Sudden Hypotension

ototoxic drugs such as aminoglycoid es and nephrotoxic drugs.

Reduced excretion with probenecid or sulfinpyrazon e. Absorption reduced by magnesium trisilicate. Antagonistic effects with quinolone antibacterial s. Reduced effects with carbonic anhydrase inhibitors or urinary alkalinisers. Concurrent intake of drugs with blood pressure lowering properties eg, blockers, calcium channel

Oral, BID

100

mg,

1. Take drug with food or milk. Complete full course of drug therapy to ensure a resolution of the infection. 2. Instruct client the possible side effects after taking this drug. 3. Report Fever, chills, coug, chest pain, difficulty breathing, rash, numbness or tingling sensations of the periphery

Deponit patch

Nitroglyceri n

Antianginals

Prophylaxis of angina pectoris

Nitroglycerin causes a relaxation of vascular smooth muscle thereby inducing a vasodilatation. Both peripheral arteries and veins are relaxed by nitroglycerin. The latter effect promotes venous pooling of blood and decreases venous return

Transdermal Patch(chest), mg, OD

1. Shave an area for application. 2. Use care if changing brands for trasdermal patch, each system has a different concentration. 3. Monitor vital 43

to the heart, thereby reducing ventricular end-diastolic pressure and volume (preload).

antagonists, vasodilators and/or alcohol may potentiate the hypotensive effect of Deponit NT. This might also occur with neuroleptics and tricyclic antidepressa nts.

signs esp. the BP to prevent sudden hypotension 4. Notify physician if chest pain prevails

Maintenance Medication Medicatio ns Plavix Generic Name Clopidogrel Bisulfate Classificati on Anticoagulan ts, Antiplatelet Indication Mechanism of Action Inhibits platelet aggregation by blocking ADP receptors on platelets, preventing clumping of platelets. Adverse reaction / Side effects CNS: Headache, dizziness, weakness, syncope, flushing. CV: Hypertension, edema Dermatologic: Rash, pruritus GI: Nausea, GI distress, constipation, diarrhea, GI bleed Other: Inc. bleeding risk Drug Interaction - Inc. risk of GI bleeding with NSAIDs, monitor pt. carefully. - Inc. risk of bleeding with warfarin; monitor carefully. Route / Frequenc y/ Dosage Adults: Oral: Recent MI, CVA, or establishe d peripheral disease: 75mg PO daily Acute coronary syndrome : 300mg Nursing Considerati ons - Taken daily as prescribed. May be taken with meals. - You may experience these side effects: Dizziness, headache, nausea, gastric distress. - Report skin 44

- Treatment of pts at risk for ischemic events recent MI, recent ischemic CVA, peripheral artery disease. - Treatment of pts with acute coronary

Medicatio ns Bumex, Burinex

Generic Name Bumetanid e

Classificati on Diuretics

syndrome. - Unlabeled use: As loading dose with aspirin to prevent adverse cardiac events in coronary stent implantation Indication

PO loading dose; then 75mg/day PO with aspirin, given at a dose from 75-325mg once daily. Mechanism of Action Inhibits the reabsorption of sodium and chloride from the proximal and distal renal tubules and the loop of Henle, leading to a natriuretic dieresis. Adverse reaction / Side effects CNS: Dizziness, confusion, fatigue, weakness, headache, drowsiness, blurred vision, irreversible hearing loss. CV: Thrombophlebitis, cardia arrththmias. GI: Nausea, anorexia, vomiting, diarrhea, gastric irritation and pain, dry mouth. GI: Polyuria, nocturia, Drug Interaction - Dec. dieresis and natriuresis with NSAIDs. - Inc. risk of cardiac glycoside toxicity. Inc. risk of ototoxicity if taken with aminoglycoside antibiotics, cisplatin. Route / Frequenc y/ Dosage Adults Oral: 0.5-1 mg/day PO in a single dose.

rash, chest pain, fainting, severe headache, abnormal bleeding

Nursing Considerati ons - Record alternate day or intermittent therapy on a calendar or dated envelopes. - Tke the drug early in the day so inc. urination will not disturb sleep; take with food or meals to prevent GI upset. - Weigh yourself on a 45

- Edema associated with heart failure, hepatic and renal disease (including nephritic syndrome).

glycosuria, renal failure. Hematologic: Hypokalemia, leukopenia, anemia, thrombocytopenia. Other: Muscle cramps and muscle spasms, weakness, fatigue, ash, sweating. Medicatio ns Amiodaron e Generic Name Amiodaron e Hydrochlori de Classificati on Adrenergic blocker; Antiarrhythm ic Indication Mechanism of Action Type III antiarrhythmic: Acts directly on cardiac cell membrane; prolongs repolarization and refractory period; inc. ventricular fibrillation threshold; acts on peripheral smooth muscle to dec. peripheral resistance. . Adverse reaction / Side effects CNS: Malaise, fatigue, dizziness. CV: arrhythmias Endocrine: hyperthyroidism GI: nausea, vomiting, anorexia, constipation. Drug Interaction - Inc. digitalis toxicity with digoxin. - Inc. quinidine toxicity with quinidine. - Inc. risk of arrhythmias with azole antifungals, fluoroquinolones , macrolide antibiotics, trazodone, cisapride, thioridazine, vardenafil, ziprasidone. - Inc. bleeding Route / Frequenc y/ Dosage Adults Oral: 20mg TID

regular basis, at the same time and in the same clothing; record the weight on your calendar.

Nursing Considerati on
- Drug dosage will be changed in relation to response of arrhythmias, you will need to be hospitalized during initation of drug therapy; you will be closely monitored when dosage is changed. - Avoid grapefruit juice while on this drug. - Report

- Only for treatment of the ff. documented lifethreatening recurrent ventricular, arrhythmias that do not respond to documented adequate doses of other antiarrhythmics or when alternative agents are not tolerated: Recurrent

46

ventricular fibrillation, recurrent hemodynamic ally unstable ventricular tachycardia. Serious and even fatal toxicity has been reported with this drug; use alternative agents first; very closely monitor pt. receiving this drug.

tendencies with warfarin. - Potential sinus arrest and heart block with betablockers, calcium channel blockers.

unusual bleeding or bruising; fever, chills; intolerance to heat or cold; shortness of breath, difficulty breathing, cough; swelling of ankles or fingers; palpitations; difficulty with vision.

Medication s Hydralazine

Generic Name Hydralazine Chloride

Classificatio n Antihypertens ive; Vasodilator

Indication

Mechanism of Action Acts directly on vascular smooth muscle to cause vasodilation, primarily arteriolar, decreasing peripheral resistance: maintans or increases renal and cerebral

Adverse reaction / Side effects CNS: Headache, dizziness. CV: Palpitations, tachycardia, angina pectoris. GI: Anorexia, nausea, vomiting, diarrhea, constipation. Hypersensitivity : Rash, pruritus; fever, chills. Other: Flushing. Edema, muscle

Drug Interaction Drug-drug: - Inc. pharmacologic effects of betaadrenergic blockers and hydralazine when given concomitantly; doasage of beta blocker may need adjustment. Drug-food:

Essential hypertension alone or in combination with other drugs.

Route / Frequency / Dosage Adults Oral: 25mg QID PO

Nursing Considerati on - Take this drug exactly as prescribed. Take with food. Do not discontinue or reduce dosage without consulting your health care provider. - Report persistent or 47

blood flow.

cramps, dyspnea.

- Inc. bioavailability of oral hydralazine given with food.

Medication s Neut

Generic Name Sodium Bicarbonate

Classificatio n Antacids, Electrolyte, Systemic alkalinizer, Urinary alkalinizer

Indication

Mechanism of Action Inc. plasma bicarbonate; buffers excess hydrogen ion concentratio n; raises blood pH; reverses the clinical manifestatio ns of acidosis; increases the excretion of free base in the urine, effectively raising the urinary pH,

Adverse reaction / Side effects GI: Gastric rupture ff. ingestion. Hematologic: systemic alkalosis (headache, nausea, irritability, weakness)

Drug Interaction Drug-drug: - Inc. pharmacologic effects of anorexiants, flecainide, mecanylamine, quinidine, sympathomime tics with oral sodium bicarbonate. - Inc. half-lives and duration of effects of amphetamines, ephedrine, pseudoephedri ne due to alkalinization of urine.

- Treatment of metabolic acidosis with measures to control the cause of the acidosis. - Adjunctive treatment in severe diarrhea with accompanyin g loss of bicarbonate. - Oral: Prophylaxis of GI bleeding, stress ulcers, aspiration pneumonia.

sever constipation; unexplained fever or malaise, muscle or joint aching, chest pain, rash, numbness, tingling. Route / Nursing Frequency Considerati / on Dosage Adults - Chew oral Oral: tablet 650mg QID sthoroughly, PO and follow with a full glass of water. Do not take within 12 hours of any other drugs to decr. Risk off drug interactions. - Have periodic blood tests and medical evaluations. - Report irritability, headache, 48

Medications

Generic Name Calcium Salts

Classificatio n Antacid; Electrolyte

neutralizes or reduces gastric acidity, resulting in an inc. in the gastric pH, which inhibits the proteolytic activity of pepsin. Indication Mechanism of Action - Dietary supplement when calcium intake is inadequate. - Prevention of hypocalcemia during exchange transfusions. - Improves weak or ineffective myocardial contractions when epinephrine fails in cardiac Essential element of the body; helps maintain the functional integrity of the nervous and muscular systems; helps maintain cardiac function, blood coagulation; is an enzyme cofactor and affects the secretory

- Dec. pharmacologic effects of lithium, salcylates, sulfonylereas, methotrexate, docycline, and other tetracyclines. Adverse reaction / Side effects CV: Slowed heart rate. Local: Local irriation, severe necrosis, sloughing and abscess formation. Metabolic: Hypercalcemi a Drug Interaction Drug-drug: - Dec. serum levels of oral tetracyclines, salicylates, iron salts with oral calcium salts; give these drugs at least 1 hr apart. - Dec. effect of thyroid hormones replacement; space doses 2 hr apart if this combination is used. Route / Frequency / Dosage Oral: 300mg TID OD

confusion, swelling of extremities, difficulty of breathing, black or tarry stools.

Nursing Consideratio ns Oral: - Take drug between meals and at bedtime. Ulcer pts must take drug as prescribed. Chew tablets thoroughly before swallowing, and follow with a glass of water or milk. - Do not take with other oral drugs. Absorption of those 49

Calcium Carbonate

resuscitation, particularly after open heart sugery. Calcium carbonate: Symptomatic relief of upset stomach associated with hyperacidity; hyperacidity associated with peptic ulcer, gastritis, peptic esophaigits, gastric hyperacidity.

activity of endocrine and exocrine glands, neutralizes or reduces gastric acidity (oral use)

Drug-food: - Dec. absorption of oral calcium when taken concurrently with oxalic acid (found in rhubarb and spinach), phtic acid (bran and whole cereals), phosphorus (milk and dairy products)

Medications

Generic Name

Classificatio n

Indication

Mechanism of Action

Adverse reaction /

Drug Interaction

Route / Frequency

medications can be blocked; take other oral medications at least 1-2 hours after calcium carbonate. - You may experience these side effects: Constipation (can be medicated), nausea, GI upset, loss of appetite (special dietary consultation may be necessary). - Report loss of appetite, nausea, vomiting, abdominal pain, constipation, dry mouth, thirst, inc. voiding. Nursing Consideratio 50

Side effects Ketosteril Essential Amino Acids Essential amino acids - Protein energy malnutrition - Prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure. Essential and nonessential amino acids provided in various combinations to supply calories and proteins and provide a proteinbuilding and a proteinsparing effect for the body (a positive nitrogen balance). CNS: Headache, dizziness, mental confusion, loss of consciousnes s. CV: Hypertension, heart failure, pulmonary edema, tachycardia, generalized flushing. Endocrine: Hypoglycemia , hyperglycemi a, fatty acid deficiency. GI: Nausea, vomiting, abdominal pain, liver impairment, fatty liver. Hypersensitivi ty: Fever, chills, rash. Local: Pain, infection, venous Drug-Drug: - Reduced proteinsparing effects of amino acids if taken with tetracyclines.

/ Dosage Adults: Oral 500mg TID

ns - Evaluate for any contraindicati ons. - Take drug as prescribed. - Warn the patient about possible side effects and how to recognize them. - Give with food if GI upset occurs. - Frequently assess for hypercalcemia .

51

thrombosis.

VIII.

Prognosis

Patient manifested no signs of improvement on discharge. Moreover, patient denied treatment, specifically, hemodialysis. Patient was discharged even with no improvement of his condition due to his insistence of refusing treatment and going home against medical advice. His conditions are severe and complicated and eventually, these may lead to death.

IX. Bibliography

Joyce M. Black et al (2005) Medical Surgical Nursing 7th edition Elsevier Suanders Smeltzer, S. et. al. (2008). Brunner and Suddarths Textbook of Medical-Surgical Nursing 11th edition. Philadelphia: LippincottWilliams & Wilkins Spratto, G. and Woods, A. (2008). 2008 Edition PDR Nurses Drug Handbook. New York: Thomson Delmar Learning. 52

Berman, A. et. al. (2008). Kozier & Erbs Fundamentals of Nursing: Concepts, Process and Practice 8 th edition Jurong, Singapore: Pearson Education South Asia Seely, R., Stephens, T., Tate, P. (2007). Essentials of Human Anatomy & Physiology 6th edition. New York: McGraw-Hill. Van Leeuwen, A., Kranpitz, T., Smith, L., (2006) Daviss Comprehensive Handbook of Laboratory and Diagnostic Test with Nursing Implication 2nd edition, U.S.A, F.A Davis Company Nurses Quick Check - Signs and Symptoms (2006) Philadelphia, Lippincott Williams & Wilkins Nurses 5- minute Clinical Consult Diseases, (2007) Philadelphia, Lippincott Williams & Wilkins Hansel, D., Dintzis, R. (2006) Lippincotts Pocket Pathology, Philadelphia, Lippincott Williams & Wilkins Stewart, Joseph (1989) Clinical Anatomy and Pathophysiology for the Health Professional, Miami, MedMasters Inc. Pathophysiology Concepts of Altered Health States7th ed. By Porth, Carl Mattson.

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