I.

INTRODUCTION

a) IMPORTANCE OF THE CASE STUDY

Knowing the different kinds of diseases in our community, it is important for us to know how to prevent
these kinds of diseases and what is the management we are going to use if we encountered one of these
sicknesses. According to our source, disease management has been defined as a system of coordinated care
interventions in which patient’s self care efforts are significant. For this case study, our purpose in doing this
is to provide an overview of Acute Renal Failure and impart ways on how to prevent and manage this disease.

b) OBJECTIVES

 Introduce what Acute Renal Failure is.

 Differentiate between Acute Renal Failure and Chronic Renal Failure.
 Discuss the Anatomy and Physiology of systems which can be damaged by Acute Renal Failure.
 Explain the Pathophysiology of the disease.
 Discuss the predisposing and precipitating factors of the disease.
 Discuss the signs and symptoms of the disease.
 Discuss the possible complications of Acute Renal Failure.
 Present diagnostic and laboratory procedures in detecting Acute Renal Failure.
 State management goals for a patient with Acute Renal Failure.
  List the types of oral and IV medications for Acute Renal Failure and their mechanisms of action.
 Impart the role of Renal Failure self-management education in assisting patients with Acute Renal
Failure to make required attitude changes to manage their disease.
Acute Renal Failure
Acute renal failure (ARF) is the rapid breakdown of renal (kidney) function that occurs when high levels
of uremic toxins (waste products of the body’s metabolism) accumulate in the blood. ARF occurs when the
kidneys are unable to excrete (discharge) the daily load of toxins in the urine.
Based on the amount of urine that is excreted over a 24-hour period, patients with ARF are
separated into two groups:
 Oliguric: patients who excrete less than 500 milliliters per day (< 16 oz/day)
 Nonoliguric: patients who excrete more than 500 milliliters per day (> 16 oz/day)

In Nonoliguric patients, the urine is of poor quality (i.e., contains little waste) because the
blood is not well filtered, despite the fact that an adequate volume of urine is excreted. Both
kidneys are failing when ARF occurs. One normally functioning kidney can maintain adequate
blood filtering.

Chronic Renal Failure

Chronic, or irreversible, renal failure is a progressive reduction of functioning renal tissue such that the
remaining kidney mass can no longer maintain the body’s internal environment. CRF can develop insidiously
over many years, or it may result from an episode of ARF from which the client has not recovered.

Precipitating Factors of ARF:

  Diet (Eating salty and fatty foods)
 Lifestyle (Smoking And drinking)

Predisposing Factors:
 Age
 Heredity
Signs and Symptoms of ARF
The patient may manifest the following:
 Oliguria
 Tachycardia and hypotension
 Dry mucous membranes and flat neck veins
 Lethargy
 Cool, clammy skin
 Azotemia
 Electrolyte imbalances
 Nausea and vomiting
 Constipation
 Irritability and Fatigue

Complications of Acute Renal Failure

 Ischemic acute tubular necrosis can lead to renal shutdown. Electrolyte imbalance, metabolic acidosis,
and other severe effects follow as the patient becomes increasingly uremic, and renal dysfunction disrupts
other body systems. If left untreated, the elderly patient is particularly susceptible to volume overload,
precipitating acute pulmonary edema, hypertensive crisis and infection.

Diagnostic and Laboratory Tests to Detect Acute Renal Failure

 Blood studies: BUN, serum creatinine, potassium, bicarbonate, hematocrit, and hemoglobin, pH,
serum osmolality
 Urinalysis, protein, osmolality, sodium
 Creatinine clearance
 Electrocardiogram
 Ultrasonography
 X-ray of abdomen, kidney-ureter-bladder radiography
 Excretory urography, retrograde pyelography
 Renal scan, CT scan and nephrotomography
II. NURSING ASSESSMENT

A.PERSONAL HISTORY
 Mr. R resides at Sta. Lucia Sasmuan Pampanga, and he is 57 years old. His wife is elementary teacher
and he has a son who is in college at present. Due to financial difficulties of the family of Mr. R in his times,
he is not able to finish his elementary course and finished grade four. Their religion is Catholic.
Mr. R lives a sedentary lifestyle. He likes to eat salty and fatty foods such as chicken, pork and instant
noodles. He also states that everyday, his day is not complete if he is not able to eat his favorite food which is
noodles. He smokes and drinks alcoholic beverages whenever there is occasion but it’s neither a vice nor a
habit. More often, he sleeps around 7:30pm and wakes at 5:00am. He usually stays at home and prepare
their meal everyday, sometimes he play cards with his neighbors. Mr. R does not exert effort on having
exercise. His wife supports them financially.

B.HISTORY OF PAST ILLNESS

Mr. R doesn’t remember if he had mumps or chickenpox before nor completed his immunization. He
had never been hospitalized before. He has an allergic in penicillin. Their family doesn’t have history of renal
failure or any hereditary diseases. They believed on traditional beliefs and seek for albularyo when their sick.

C.HISTORY OF PRESSENT ILLNESS

Mr. R condition started a week before he was admitted to the hospital. He had fever and chills then took
biogesic. On the second day he had hypogastric pain and vomited that’s why they sought consultation to a
nearby hospital (Diosdado Macapagal Hospital).
 He was admitted with the impression of Acute Renal Failure. Because his condition becomes worst,
they decided to transfer him to JBLMRH last December 11, 2005 at 4:30 pm. He was brought to Medicine
Ward. His vital signs upon admission are as follows: BP: 120/80, CR: 89, RR: 22. His blood type is B. His
doctor suggested submitting himself for dialysis but he refused due to their financial status. December 13,
2005, he was subjected for blood transfusion. Because of his anxiety and fear of pain made by needle prick,
he refused to subject himself for CBC and withdraws for any kind of care give to him; he even refuses to take
his vital signs. Mr. R is suffering from oliguria, uremia and anemia.
Usually the family argues about Mr. R diet. His wife stated that Mr. R is hard headed but they can’t do
anything because he is the one who usually prepare their meal.

D.PHYSICAL ASSESSMENT

A. General Appearance
Mr. Romeo Velasco is 57 year old. He was brought to JBLMRH last December 11, 2005 with a chief
complaint of general body weakness. Appears to be untidy (uncombed hair).Vital signs are as follows: BP:
120/80, CR: 90, RR: 22.

B. Review of Systems
SKIN: fair complexion, dry skin, no jaundice, cold to touch and patient is pale
HEAD: head is proportional to the body, no tenderness observed, and no inflammation
EYES: (+) Perrla, eyebrows are well-distributed, no cataract observed, eyelids are able to blink
 EARS: are symmetrical, no tinnitus, no discharges, no lesion
NOSE AND SINUSES: no epistaxis, no discharges, and no tenderness observed
MOUTH AND THROAT: dry lips, hoarseness of voice, tongue can be protruded, and no inflammation
observed
NECK: able of full neck motion without pain, there is no inflammation upon palpation, no lump and no
swollen lymph node
RESPIRATORY: no sputum and no asthma
CARDIAC: hypertensive
GASTROINTESTINAL: low appetite, allergic to penicillin
URINARY: has oliguria (with average urine output of 10mL/hour)
GENITAL: not assessed
PERIPHERAL VASCULAR: nail beds are pale, with an impaired capillary refill time
MUSKULOSKELETAL: with impaired mobility
NEUROLOGIC: general body weakness
HEMATOLOGIC: redness, pain in areas where transfusion was done, has a decrease hgb count upon
laboratory results
PSYCHIATRIC: patient is nervous and anxious
 NO HISTORY OF FAMILIAL DISEASES

Rufina Aguilar Domingo Velasco Purificacion Sanchez Virgilio Roman

Antonio Velasco Virginia Velasco Cecilia Roman Laura Roman

Romeo Velasco (allergic

in penicillin, has ARF) Julia Velasco Narcisa Roman

Aries Velasco
III. ANATOMY AND PHYSIOLOGY

KIDNEYS

The kidneys are bean shaped organs, each about the size of a
tightly clenched fist. They lie on the posterior abdominal wall, behind
the peritoneum, with one kidney on either side of the vertebral column.
Structures that are behind the peritoneum are said to be retroperitoneal.
A connective tissue renal capsule surrounds each kidney. Around a
renal capsule is a thick layer of fat, which protects the kidney from
mechanical shock. On the medial side of each kidney is the hilum,
where the renal artery and nerves enter and where the renal vein and
ureter exit the kidney. The hilum opens into cavity called the renal
sinus, which contains blood vessels, part of the system for collecting
urine and fat
The kidney is divided into an outer cortex and an inner medulla,
which surround the renal sinus. The bases of several cone- shaped renal
pyramids are located at the boundary between the cortex and the
medulla, and the tips of the renal pyramids project towards the center of
the kidney. A funnel shaped structure called a calyx surrounds the tip of
each renal pyramid. The calyces from all the renal pyramids join to form
a larger funnel called the renal pelvis. The renal pelvis then narrows to
form a small tube, the ureter, which exits the kidney and connects to the
urinary bladder. Urine passes from the kidney and connects to the
urinary bladder. Urine passes from the tips of the renal pyramids into
the calyces. From the calyses urine collects in the renal pelvis and exits
the kidney through the ureter.
The functional unit of the kidney is the nephron and there are
approximately 1.3 million of them in each kidney. Each nephron
consists of a renal corpuscle, a proximal tubule, a loop of Henle, or
nephronic loop and a distal tubule. Fluid enters the renal corpuscles
and then flows into the proximal tubule. From there it flows into the
loop of Henle, each loop of Henle has a descending limb, which extends
towards the renal sinus and an ascending limb. Which extends back
toward the cortex. The fluid flows through the ascending limbs of the
loop of Henle to the distal tubule. Many distal tubules empty into a
collecting duct, which carries the fluid from the cortex, through the
medulla. Many collecting ducts empty intro a papillary duct and the
papillary ducts empty their contents into a calyx.
The renal corpuscles and both convoluted tubules are in the renal
cortex. The collecting duct and loop of Henle enter the medulla.
Approximately 15 % of the nephrons called juxtamedullary nephrons
have loop of Henle that extends deep into the medulla of the kidney. The
other nephrons called cortical nephrons have loop of Henle that do not
extend deep into the medulla.
The renal corpuscles of the nephrons consist of Bowman’s capsule
and the glomerulus. Bowman’s capsule consist of the enlarge end of the
nephron, which is extended to form a double walled chamber. The
indention is occupied by a tuft of capillaries called glomerulus, which
resembles a ball of yarn. The cavity of Bowman’s capsule opens into the
proximal tubule, which carries fluid away from the capsule. The inner
layer of Bowman’s capsule surrounds the glomerulus and consists of
specialized cells called podocytes. The outer layer of the Bowman’s
capsule consists of simple squamous epithelial cells.
The glomerular capillaries have pores in their walls, and the
podocytes have cell processes with gaps between them. The endothelium
of the glomerular capillaries, the podocytes and the basement membrane
between them form a filtration membrane. In the first step of urine
formation, fluid called filtrate is filtered from the glomerular capillaries
into Bowman’s capsule through the filtration membrane.
Most of the nephron and collecting duct are made up of simple
cuboidal epithelium. However, the thin segments of the descending and
ascending limbs of Henle’s loop have very thin walls up of simple
squamous epithelium. The cells of proximal, thick segment of the
ascending limb of Henle’s loop, distal tubules and collecting ducts have
microvilli and many mitochondria. The proximal tubule, thick segment
of the ascending limb of Henle’s loop and the collecting duct actively
transport molecules and ions across the wall of the nephron. The thin
segment of the descending limb of the Henle’s loop is very permeable to
water and solutes and the thin segment of the ascending limb is
permeable to solutes but not to water.

URETERS, URINARY BLADDER, and URETHRA

The ureters are small tubes that carry urine from the renal pelvis
of the kidney to the posterior inferior portion of the urinary bladder. The
urinary bladder is a hallow muscular container that lies in the pelvic
cavity just posterior to the symphysis. Its function to store urine and its
size depends on the quantity of urine present. The urinary bladder can
hold from a few millimeters to a maximum of about 1000 ml of urine.
When the urinary bladder reaches a volume of a few hundred ml, a reflex
is activated, which causes the smooth muscle of the urinary bladder to
contract and most of the urine flows out of the urinary bladder through
the urethra
The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle shaped portion of the urinary bladder located
between the opening of the ureters and the opening of the urethra is
called tragone. The urethra carries from the urinary bladder to the
outside of the body.
The ureters and the urinary bladder are lined with transitional
epithelium, which is specialized to stretch. As the volume of the urinary
bladder increases the epithelial cells, and the number of epithelial cell
layers decreases. As the volume of the urinary bladder decreases,
transitional epithelial cells assume their columnar shape and form a
greater number of cell layers.
The walls of the ureter and urinary bladder are composed of layer
of smooth muscle and connective tissue. Regular waves of smooth
muscle contractions in the ureters produce the force that causes urine to
follow from the kidneys to the urinary bladder. Contractions of smooth
muscle in the urinary bladder force urine to flow from the bladder
through the urethra.
At the junction of the urinary bladder and urethra, the smooth
muscle of the bladder wall forms the internal urinary sphincter in males.
No well defined internal urinary is found in females. Elastic fibers at the
junction of the urinary bladder and urethra keep urine from passing
through the urethra until the urinary bladder pressure increases. The
internal urinary sphincter of males is under involuntary control.
Contraction of the internal urinary sphincter during ejaculation prevents
semen from entering the urinary bladder and keeps urine from flowing
through the urethra. The external urinary sphincter is formed of skeletal
muscle that surrounds the urethra as the urethra extends through the
pelvic floor. The external urinary sphincter is under involuntary and
voluntary control. It controls the flow of urine through the urethra.
In male, the urethra extends to the end of the penis, where it
opens to the outside. The female urethra is much shorter (approximately
4 cm) than the male urethra (approximately 20 cm) and opens into the
vestibule anterior to the vaginal opening.

IV. PATIENT AND HIS ILLNESS

A. PATHOPHYSIOLOGY (book based)

The driving force for glomerular filtration is the pressure gradient

from the glomerulus to the Bowman space. Glomerular pressure is
primarily dependent on renal blood flow (RBF) and is controlled by
combined resistances of renal afferent and efferent arterioles. Regardless
of the cause of ARF, reductions in RBF represent a common pathologic
pathway for decreasing GFR. The etiology of ARF comprises 3 main
mechanisms.
Pre-renal failure is brought about by diminished blood flow to the
kidneys. GFR is depressed by compromised renal perfusion. Such
decreased flow may result fro hypovolemia, shock, embolism, blood loss,
sepsis, pooling of fluid in ascites or burns, and cardiovascular disorders,
such as congestive heart failure, arrhythmias and tamponade.
Intrinsic renal failure results from damage to the kidneys
themselves, usually resulting from acute tubular necrosis. Such damage
may also result from acute poststreptococcal glomerulonephritis,
systemic lupus erythematosus, periarteris nodosa, vasculitis, sickle-cell
disease, bilateral renal vein thrombosis, nephrotoxins, ischemia, renal
myeloma and acute pyelonephritis.
Post obstructive renal failure initially causes an increase in tubular
pressure, decreasing the filtration driving force. This pressure gradient
soon equalizes, and maintenance of a depressed GFR is then dependent
upon renal afferent vasoconstriction. Post-renal failure is a bilateral
obstruction of urinary out-flow results. Its multiple causes include
kidney stones, blood clots, papillae from papillary necrosis, tumors,
benign prostatic hyperplasia, strictures and urethral edema from
catheterization.
Patients with chronic renal failure also may present with
superimposed ARF from any of the aforementioned etiologies.
Depressed RBF eventually leads to ischemia and cell death. This
initial ischemic insult triggers production of oxygen free radicals and
enzymes that continue to cause cell injury even after restoration of RBF.
Tubular cellular damage results in disruption of tight junctions between
cells, allowing back leak of glomerular filtrate and further depressing
effective GFR. In addition, dying cells slough off into the tubules, forming
obstructing casts, which further decrease GFR and lead to oliguria.

B. PATHOPHYSIOLOGY (CLIENT CENTERED) WITH DIAGRAM

The patient’s condition that leads to acute renal failure is related to

nephrotoxins (diet, lifestyle). There is an increase in BUN and creatinine

that indicates impaired renal function .There is also an increase in WBC,

neutrophils, and lymphoctes that indicates of infection /inflammation.

The doctor’s order is to check the CBC, RBC, BUN, CREATININE, Na, K

Cl, and for Urinalysis. The patient was advice to submit himself for

dialysis because he is anemic and to take Furosemide as diuretics. The

doctor prescribed CaCo3 because of hypocalcemia and Kalium Durule

because of hypokalemia.

While there is decrease in renal blood flow the symphathetic

response is to increase the production of Renin and Angiotensin II that

cause hypertension, thus the doctor order manidipine for the patient.
 PATHOPHYSIOLOGY OF ACUTE RENAL FAILURE (Client Center )

Nephrotoxins

Increase WBC,
Neutrohils, Lymphocytes Circulatory Inadequacy

Symphatetic Response
Uremia /Severe Increase BUN and
Anemia Creatinine

Med’s given Increase Renin and

Angiotensin II

Decrease K, Na Hypokalcemia
Hypertension
 C. DIAGNOSTIC AND LABORATORY PROCEDURES

DATE ORDERED: DECEMBER 11, 2005

HEMATOLOGY

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
MCH 32.4 27-33 pg Normal
MCV 90.1 82-92 fl Normal
MCHC 36 31-36g / dL Normal
reticulocyte 2.5 1- 5 % Normal
count

DATE ORDERED: DECEMBER 11, 2005

DIAGNOSTIC RESUL NORMAL INTERPRETATION NURSING

PROCEDURE T VALUES REPONSIBILITIES
Hgb 77 M:125-175g/L > Indication of >Notify the
F:115-155g /L severe anemia physician
>Continue monitor
the laboratory
results
>Advise the patient
to eat foods rich
and iron
>Encourage the
patient to take iron
supplements
 Hct 0.23 M 0.40 – 0.52 > Indication of >Notify physician
F 0.38 – 0.48 anemia from >Monitor lab
dietary deficiency, results
malnutrition and
kidney diseases.
WBC 12.0 > Indication of > Notify physician
infection or
inflammation.
Neutrophils 0.90 0.20- 0.35 > Indication of > Notify physician
infection
Lymphocytes 0.08 0.02 – 0.05 > Indication of > Notify physician
infection
Stab 0.02 0.02 – 0.05 Normal
Platelet 163 Normal

DATE ORDERED: DECEMBER 11, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
FBS 6.64 3.85 – 9.0 Normal
mmol / L
BUN 13.1 1.7 – 8.3 > Indication of
mmol / L renal failure or
glomerulonephritis.
Creatinine 273 M = 60 – 120 > Indication of
mmol / L urinary tract
F = 58 – 100 failure or high
mmol / L protein diet
Sodium 137 136 – 145 Normal
mmol / L
Potassium 2.3 3.5 – 5.0 > Indication of >Notify Resident on
mmol / L hypokalemia or Duty
loss of potassium >Encourage to take
in the body potassium
because of severe supplements and
vomiting. foods rich in
potassium such as
banana etc.
Chloride 109 101 – 111 Normal
mmol / L
Calcium 1.71 2.05 – 2.60
mmol / L
Phosphorus 1.1 0.81 – 1.62 Normal
mmol / L

DATE ORDERED: DECEMBER 11, 2005

URINALYSIS

COLOR Light yellow

REACTION Acidic
SPECIFIC GRAVITY 1.020
COARSE GRANULAR 2.4 / LPF
PUS CELLS 8.10 / HPF
RC 3.5 / HPF
EPITHELIAL CELLS Few
 DATE ORDERED: DECEMBER 12, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
FBS 95.9 70 – 105 Normal
mg / dL

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
Potassium 3.0 3.5 – 5.0 > Indication of mild >Notify resident on
mmol / L hypokalemia or duty
mild loss of >Encourage the
potassium in the patient to take
body because of potassium
vomiting. supplements and
foods rich in
potassium such as
banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
Sodium 135 136 – 145 > Indication of
mmol / L mild hyponatremia,
renal insufficiency
and uremia.
Potassium 3.1 3.5 – 5.0 > Indication of mild >Notify resident on
mmol / L hypokalemia or duty
mild loss of >Encourage the
 potassium in the patient to take
body because of potassium
vomiting. supplements and
foods rich in
potassium such as
banana, etc.

DATE ORDERED: DECEMBER 13, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
Hgb 73 M =125- > Indication of >Notify the
175g/L severe anemia physician
F = 115 – >Continue monitor
155g/L the laboratory
results
>Advise the patient
to eat foods rich
and iron
>Encourage the
patient to take iron
supplements
Hct .20 M =.40-.52 > Indication of >Notify physician
F = .38 -.48 anemia from >Monitor lab
dietary deficiency, results
malnutrition and
kidney diseases.
 DATE ORDERED: DECEMBER 14, 2005

DIAGNOSTIC RESULT NORMAL INTERPRETATION NURSING

PROCEDURE VALUES REPONSIBILITIES
Hgb 83 M = 125 – > Indication of >Notify the physician
175 g / L severe anemia >Continue monitor
the laboratory
results
>Advise the patient
to eat foods rich and
iron
>Encourage the
patient to take iron
supplements
Hct 0.25 M =.40-.52 > Indication of >Notify physician
F =.38-.48 anemia from >Monitor lab results
dietary deficiency,
malnutrition and
kidney diseases.
Potassium 3.0 3.5 – 5.0 > Indication of >Notify resident on
mmol / L mild hypokalemia duty
>Encourage the
patient to take
potassium
supplements and
foods rich in
potassium such as
banana, etc.
 V. PATIENT AND HIS CARE

A. PLANNING (NURSING CARE PLAN)

NCP#1

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective: >Fatigue >A decrease in >After 4 hours >Establish rapport >to facilitate >After 4
Objective: related to Hgb count of nursing client and hours of
>Patient is decreased Hgb would be a intervention, student nurse nursing
conscious and count. factor in the patient interaction intervention,
coherent having fatigue will goal was met
>with ongoing because RBC demonstrate as evidenced
IV of D5 0.3 plays an an improve >Discuss with the >education by:
NaCl 500cc X important role ability to patient the need may provide *clients
KVO in our cells participate in for activity. Plan motivation to verbalization
>Vital signs: and muscle to desired schedule with the increase of feeling of
BP: 110/80 function activities and patient and activity level less fatigue
PR: 79 normally. he will identify the through and weakness
RR: 20 Patient with verbalize an activities that patient may *patient
Temp: 37.6 ARF may suffer increase leads to fatigue. feel too weak participates
>Patient to anemia energy level. initially in some
manifest because our activities as
generalized body kidney is one much as he
weakness of the >Monitor vital >indicates could
>Patient is producers of signs physiological *patient is
pale erythropoietin level of awake
 >Patient is that is one tolerance
dizzy component for
>with poor RBC
muscle tone production and >Encourage the >to gain
>the patient RBC are the patient to eat energy
has a decreased one who
Hgb count of 83. carries oxygen >Administer >for the body
(Normal Value is and nutrients medications such to have
123-175g/L for to other cells as ferrous sulfate enough RBC
males) and muscles as prescribed to supply the
for them to muscles and
function. A cells enough
decrease in nutrients to
erythropoietin function
production will properly
tend to
produce a >Encourage/advise >to increase
small amount the patient to the patients
of RBC that perform ROM activity level
would lead to a exercise in a step-by-
decreased step manner
supply of
oxygen to >Encourage the >restoration of
different cells patient to rest energy
and muscles in
the body. >Promote overall >to correct the
Therefore, health measures need of supply
leading to poor such as proper of RBC and to
muscle tone nutrition, adequate reduce fatigue
and a problem fluid intake and by gaining
with muscle appropriate energy
contractility vitamin/iron
that could supplement.
make the client
feel that he is >Maintain >to improve
weak. strenuous activity activity
restrictions. tolerance,
avoid
activities that
requires too
much energy
 NCP #2

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective: >Excess fluid >Kidneys are >After four >Establish >to facilitate >After four
Objective: volume responsible for hours of rapport client and hours, goal
>Patient is related to the elimination nursing student nurse met as
conscious and inability of the of waste interventions; interaction evidenced by:
coherent kidney to excrete products in our *there would *an increase
>with ongoing waste products body. If there be a stabilized >Monitor vital >to be able to in urine
IV of D5 0.3 is an alteration fluid volume signs monitor the output from
NaCl 500cc X on the normal by increasing changes in the 10mL to
KVO functioning of the urine condition of 30mL/hour
>Vital signs: the kidney, output of the the client *the client
BP: 110/80 there would be patient verbalized
PR: 79 a problem in *the client >to monitor understanding
RR: 20 the excretion of verbalize an >Monitor I and O the normality of fluid
Temp: 37.2 waste understanding of urine restriction in
>patient is products. of individual output his diet and
oliguric average Making the dietary/fluid began to
of 10mL/hour waste to stay restriction >Assess appetite >to be able to implement it
>Hgb: 73 in the and note for know other *patient is
Hct: 0.20 circulation and nausea or reason which awake
(Normal Values: excessive fluid vomiting contributes to *patient
Hgb is 125- may be the his condition always stay on
175g/L and Hct result because bed
I 0.40-0.52 for there are only >Restrict Na and >to avoid
male) intake but a fluid intake as further excess
 >patient is limited amount indicated fluid
restless of output accumulation
because of the >Administer
damaged of medications such >to promote
malfunctioning as diuretics as elimination of
kidney. ordered waste
products

>Evaluate >to reduce

edematous tissue
extremities, pressure and
change position risk of skin
frequently breakdown

>Discuss >for better

importance of understanding
fluid restriction on why the
and “hidden client needs t
sources” of intake restrict his
such as foods fluid
high in water consumption
content

>Identify “danger” >to ensure

signs requiring timely
notification of evaluation
healthcare
provider.
 NCP #3

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective: >Risks for >Risk for >After 5 hours >Establish > To gain the >Goal met
Objective: infection infection is the of patient and rapport cooperation of because the
>Patient is related to state in which student nurse the patient
patient as well
conscious and environmental an individual is interaction the during the
as the SO
coherent condition at risks for patient will interaction practicing the
>with being invaded verbalize interventions
ongoing IV of by pathogenic understanding >Encourage the > To reduce or given
D5 0.3 NaCl organisms / and identify pt. and the S.O to minimize the
500cc X KVO microorganisms intervention to practice proper transfer of
>Vital signs: due to poor reduce risk for hand washing microorganism
BP: 110/80 environmental infection techniques s
PR: 79 sanitation to its
RR: 20 surroundings >Encourage the
Temp: 37.2 patient and the > To prevent
 = poor SO to practice the spread of
sanitation environmental microorganism
 = unable to sanitation s in the
meet surroundings
patients >Encourage the
demands patient to throw > To avoid
for personal the garbage or insects and
care trash properly other
 = poor microorganism
hygiene s that carries
 = presence viruses
of insects in >Instruct the
the patient to eat > To increase
surroundin foods rich in Vit. body resistance
gs C like guava,
oranges,
calamansi etc…

>Encourage
compliance to > For protection
drug regimen against
infection
 NCP #4

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective: >Ineffective >Ineffective >After 5 >Establish >To gain the >Goal was
Objective: therapeutic therapeutic hours of rapport cooperation partially met
>Patient is regimen regimen is the nursing of the patient
as evidence by
conscious and management state in which intervention during the
the patient
coherent related to the patient was the patient interaction cooperation in
>with ongoing IV financial unable to meet and the SO some of the
of D5 0.3 NaCl status the demands in will >Provide >To know the intervention
500cc X KVO prevention and understand information about importance of given.
>Vital signs: curing of illness the the patients therapeutic
BP: 110/80 because of importance condition regimen and
PR: 79 financial in the the value of
RR: 20 problem compliance treatment
Temp: 37.2 of drugs and program
 = refuse to take other
the medication therapeutic >Encourage to >To identify
given regimen. identify the causative
 = limited social patients and factor
interaction significant others
 = lack of perception and
interest expectation of
 =uncooperative treatment
regimen
 NCP #5

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective: >Knowledge >Knowledge >After 5 hours >Establish >To gain the >Goal met
“ Bisa deficit deficit is the of nursing rapport cooperation because the
kung mangan related to state in which intervention of the patient patient
babi” disease the patient lack the patient during the participates in
condition of information verbalize interaction learning
Objective : about his understanding process.
>Patient is condition about his >To evaluate
conscious and condition >Assess for the if the patient
coherent patient’s is ready to
>with ongoing readiness to learn the
IV of D5 0.3 learn concept of
NaCl 500cc X wound
KVO cleaning
>Vital signs:
BP: 110/80 >Determine >To assess
PR: 79 client’s ability to what level of
RR: 20 learn. teaching we
Temp: 37.2 are going to
 =uncoopera- impose.
tive
 = lack of >Determine >To identify
interest blocks to possible
 = the pt. learning. (Like hindrances
frequently language that would
ask about barriers, physical affect in the
his condition factors and teaching and
 = eating food physical stability) learning
which are process
restricted on
his diet >Provide >To
information understand
about the patient the condition
condition of the patient

>Encourage the >To avoid

patient to follow secondary
the right diet problem and
complication
 NCP # 6

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective : Imbalanced Imbalanced After 4 hours >ascertain >to determine Goal was met
nutrition nutrition related of client and understanding of what as evidenced
Objective : less than to therapeutic student nurse individual information toby the clients
>Patient is body dietary interaction the nutritional needs be provide theverbalization of
conscious and requirement restrictions; as client will be client/SO understanding
coherent s related to evidenced by able to of the
>with disease lack of interest verbalize >discuss eating >to appeal to therapeutic
ongoing IV of condition in food/eating understanding habits, including clients likes & dietary
D5 0.3 NaCl of the food preferences desires restrictions
500cc X KVO therapeutic
>Vital signs: dietary >assess drug >these factors
BP: 110/80 restriction interactions and may be
PR: 79 use of diuretics affecting
RR: 20 appetite, food
Temp: 37.2 intake, or
>body absorption
weakness
-numbness in >assist in >to correct
the lower developing underlying
extremities individualized causative
-dizziness diet regimen factors
-fatigue
-dry skin >explain to the >in order to
-pale client the facilitate
prescribed diet understanding
and gain the
clients
participation
to the diet
regimen

>provide oral >these will

liquid preparation help in
providing
nutrients to
the client

>provide frequent >to prevent

mouth care stomatitis,
remove bad
taste, increase
patients
comfort

>provide atleast >to minimize

30-35 kcal/kg metabolism of
body weight/day body protein
and maintain
body weight

>restrict protein >to improve

and maintain taste and
body weight increase
 carbohydrate/
calorie intake

>restrict protein >to decrease

and phosphate at the metabolic
prescribed end products
amount of urea,
potassium,
phosphate
and hydrogen
 NCP # 7

ASSESSMENT NURSING SCIENTIFIC OBJECTIVE NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective Impaired Usually occurs After 4 hours >assess clients >to be able to Goal was met
urinary with urinary of client and understanding of provide as evidenced
Objective: - elimination tract obstruction student nurse condition appropriate by the clients
>Patient is related to that affects the interaction the information verbalization of
conscious and disease kidneys client will be that are understanding
coherent condition bilaterally such able able to needed by the of condition
>with as prostatic verbalize client
ongoing IV of hyperplasia understanding
D5 0.3 NaCl of condition >provide time for >provide hard
500cc X KVO the client to have candy or gum
>Vital signs: question and >in order to
BP: 110/80 answer them in facilitate
PR: 79 the simplest understanding
RR: 20 understandable
Temp: 37.2 form
>oliguria
>irritability > Determine >in order to
>decreased clients previous assess
urine output elimination deviation
pattern of
elimination and
compare with
current situation

>palpate bladder >to assess

retention

>Emphasize >to reduce

importance of risk of
keeping the area infection
clean and dry and/or skin
breakdown
NCP # 8

ASSESSMENT NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION INTERVENTION

Subjective: Social Aloneness After 4o of >Established >To improve Goal met.

o
Isolation experienced by nursing rapport client’s After 4 of
Objective: related to the individual intervention perception ofnursing
>Patient is traumatic and perceived the patient self as aintervention
conscious and incidents as imposed by will be able to worthwhile the patient
coherent causing others as a demonstrate person was able to
>with ongoing physical negative or willingness or demonstrate
IV of D5 0.3 pain. threatening desire to >Encouraged >to enhance willingness or
NaCl 500cc X state. socialize with the patient to client’s desire to
KVO other. express his feelings of socialize with
>Vital signs: feelings self worth other.
BP: 110/80
PR: 79 >Identify >to maintain
RR: 20 support system involvement
Temp: 37.2 available to the with others
>the patient patient
manifest >to
restlessness, >Provide encourage
incommunicable positive continuation
, reinforcement of efforts
projects hostility when client
in behavior, poor make moves
eye contact. toward others

>Be honest and >honesty

keep all and
promises dependability
promote a
trusting
relationship

>Be cautious >a

with touch until suspicious
trust has client may
established. perceive
touch as a
threatening
gesture.

>Introduce >provide role

client to those models,
with similar / encourage
shared interest problem
and other solving.
supportive
people
NCP #9

Cues Nursing Scientific Desired Interventions Rationale Expected

Diagnosis Explanation Outcome Outcomes

Subjective: Anxiety Anxiety often After 30 Create an > Trust is an After 30

Ø related to accompanies minutes of atmosphere that essential first minutes of
pain. pain. The threat nursing facilitates trust. step in the nursing
Objective: of the unknown intervention, therapeutic intervention,
>Patient is and the inability the patient relationship the patient
conscious
to control the will appear Seek to appears
and
coherent pain or the relaxed and understand > To facilitate relaxed and
>with
events report anxiety client’s planning for reported
ongoing IV
of D5 0.3 surrounding it is reduced to perspective of a the best anxiety is
NaCl 500cc
often augment a manageable stressful approach to reduced to a
X KVO
>Vital the pain level. situation. anxiety manageable
signs:
perception. A reduction. level.
BP: 110/80
PR: 79 perception of Encourage > To identify
RR: 20 lacking control verbalization of specific
Temp: 37.2
or a sense of feelings, emotions such
helplessness perceptions, as anger or
> poor eye
tends to and fears. helplessness,
contact
increase pain distorted
>restless-
perception. perceptions
ness
and
>irritable
unrealistic
> increase
fears.
tension
Identify > These will
> facial
situations that enable the
tension
precipitate client to
> facial
anxiety prevent or
grimace
(describe what recognize his
the person anxiety in
experienced order to
immediately initiate
prior to feeling problem
anxious and solving.
identify
associated
events).
B. IMPLEMENTATION
1. MEDICAL / SURGICAL MANAGEMENT

INTRAVENOUS FLUID

Date Ordered: Date IVF (type of Fluid Description Nursing

Started/discontinued fluid and Responsibility
regulation)
Date Started: December > D5 0.3 > It is a solution of sodium > Watch out for
11, 2005 and December NaCl 500 cc chloride in sterile water but in emptying of the
15, 2005 X KVO much higher concentration. solution. Replace
Discontinue: December solution whenever
16, 2005 necessary.
>Check for the
Date Started: December >PNSS 500cc >In medicine saline is a patency of IV lines.
12, 2005 and December X KVO solution of sodium chloride in
14, 2005 sterile water, used commonly
Discontinue: Discontinue for intravenous infusion,
after BT, replace previous cleaning contact lenses, and
IVF nasal irrigation or jala neti.
Sodium chloride (NaCl) is
ordinary salt.
MEDICATION AND DRUG STUDY

DRUG DATE ACTION INDICATION DOSAGE: ROUTE SIDE NURSING

ORDERED OF EFFECTS RESPONSIBILITIES
ADMINISTRATION,
FREQUENCY

Generic December Antipyretic Analgesic- 300 mg IV 30 min CNS: Monitor

Name: 11, 2005 Antipyretic in prior to BT Headache Temperature
Paracetamol Analgesic patients with GI:
aspirin Hepatic Assess for history of
allergy, toxicity allergy to
haemostatic and Paracetamol,
disturbances failure, impaired hepatic
and bleeding. jaundice function, chronic
CV: Chest alcoholism.
pain,
dyspnea Physical
assessment, skin
color, lesions, liver
evaluation; CBC,
liver and renal
function test.

Give drug with food

if upset is noted.

Discontinue drug if
hypersensitivity
reactions occur.
Report skin rash,
unusual bleeding or
bruising, following of
skin or eyes,
changes, in voiding
patterns.
 DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIES

Generic Name: December Competitively Relief of 1 amp IV - Dizziness Assess history of

Diphenhydramin 11, 2005 blocks the symptoms 30 min -Sedation allergy to
e effects of associated prior to - antihistamines.
Hydrochloride histamine at with allergic BT Drowsiness
H1 receptor reactions to -Dry mouth Physical
Brand Name: sites, has blood or assessment, skin
Benadryl atropine- like plasma. color, lesions,
an texture, reflexes,
antipruritic, PR, RR, BP,
and sedative adventitious
effects. sounds; bowel
sounds; prostate
palpation; CBC with
differential.

Inform patient
about the following
side effects that may
occur.

Monitor for difficulty

breathing,
hallucinations,
tremors, loss of
coordination,
unusual
disturbances, and
irregular heartbeat.
 DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIES

Generic December Essential Dietary 1 tab TID -constipation Assess history o

Name: 11, 2005 element of supplement -nausea allergy to calcium;
Calcium the body; when -GI upset renal calculi;
Carbonate helps calcium -loss of hypercalcemia
maintain the intake is appetite ventricular
Brand Name: functional inadequate. fibrillation; digitalis
Caltrate integrity of toxicity.
the nervous
and Physical
muscular assessment, BP,
systems, peripheral
helps perfusion, ECG;
maintain abdominal exam,
blood bowel sounds,
coagulation. mucous
membranes; serum
electrolytes,
urinalysis.

Monitor serum
phosphorus levels
periodically during
long-term oral
therapy.

Advice client to take

drug between meals
and at bedtime.
Chew tablets
thoroughly before
swallowing, and
follow with a glass
of water or milk.

Advice client about

following side effects
that may occur.

Advice client to
report loss of
appetite; nausea,
vomiting, abdominal
pain, constipation,
dry mouth, thirst,
increased voiding.
 DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIES

Generic December Inhibits the -Edema 80 mg IV -Increased Assess history:

Name: 11, 2005 reabsorption associated post BT volume and Allergy to
Furosemide of sodium with renal frequency of furesemide,
and chloride disease. urination; sulfonamides;
Brand name: from the - drowsiness tartazine; electrolyte
Lasix proximal -dizziness depletion anuria,
and distal -feeling faint severe renal failure.
renal tubule on arising
and the loop -sensitivity Physical
of henle, to sunlight assessment: skin
leading to -loss of body color, lesions,
sodium, rich potassium edema, orientation,
diuretics. reflexes, hearing,
pulses, baseline
ECG, BP,
orthostatic BP,
perfusion; RR, liver
evaluation, bowel
sounds; urinary
output patterns;
CBC, serum
electrolytes, blood
sugar, liver and
renal function tests,
uric acid, urinalysis.

Administer with
food or milk to
prevent GI upset.

Inform client about

the side effects that
may occur.

Report loss or gain

of more than 3 lbs.
in one day, swelling
in ankles or fingers,
unusual bleeding or
bruising, dizziness,
trembling,
numbness, fatigue,
muscle weakness or
cramps.
 DRUG DATE ACTION INDICATION DOSAGE SIDE NURSING
ORDERED EFFECTS RESPONSIBILITIES

Generic December Competively -Hypertension, 50 mg 1 -Dizziness Assess history of

Name: 15, 2005 blocks beta- alone or with tab BID -Drowsiness sinus bradycardia
Metoprolol adrenergic other drugs, -Light (HR < 45 beats/min)
Brand receptors in the especially headedness Second or third-
Name: heart and diuretics. -blurred degree heart block
Toprol XL juxtaglomerular -prevention of vision (PR interval > 0.24
apparatus, reinfarction in -nightmares sec), cardiogenic
decreasing the the MI pts who -depression shock CHF, systolic
influence of the are -sexual BP < 100 mg Hg;
sympathetic hemodymacally impotence diabetes or
nervous system stable or thyroxicosis;
on these within 3-lod of asthma or COPD.
tissues and the acute MI
excitability of -treatment of Physical
the heart, angina Assessment: weight,
decreasing pectoris. skin condition,
cardiac output neurologic status,
and the release PR, BP, ECG,
of rennin, and respiratory status,
lowering BP; kidney and thyroid
acts in the CNS function, blood and
to reduce urine glucose.
sympathetic
outflow and Inform clients
vasoconstrictor regarding side
tone. effects that may
occur.

Monitor difficulty
breathing, night
cough, swelling of
extremities, slow
pulse, confusion,
depression, rash,
fever and sore
throat.
 Name of Mechanism Indication Dosage, Route Contraindication Side Nursing
Drug of Action of Effects/Adverse Implication
administration Effects
and Frequency
(Date
Oredered)

Generic Long-acting For patients Manidipine It should not be Cardiovascular: Blood

Name: calcium with 20mg/tab OD taken by the Facial hot Pressure
Manidipine antagonist, hypertension patient who is flushes, feeling of should
dilating pregnant or warmth, always be
Brand blood > December 14, suspected of conjunctival monitored.
Name: vessels, 2005 being pregnant. congestion,
Caldine mainly by palpitation or Watch out
calcium tachycardia. for excessive
channel GI: Nausea, drop of
blockade vomiting, blood
stomach pressure so
discomfort, that
enlarged feeling appropriate
of abdomen, measures
constipation or such as
oral dryness. dosage
Psychoneurologic restriction
: Dizziness, and
dizziness on cessation
standing up, should be
headache, dull done.
headache,
sleepiness or Caution the
numbness. patient that
Blood: such
Leukopenia. symptoms
Liver: Elevation of like
GOT, GPT, g- dizziness
GPT, LDH and may occur.
alkaline
phosphatase. Advise the
Kidney: Elevation patient to
of BUN and avoid
serum creatinine. hazardous
Hypersensitivity: activities
Rash or pruritus. requiring
Others: General the
malaise, alertness of
weakness, the patient.
edema,
pollakiuria and Watch out
elevation of total for adverse
serum reactions.
Cholesterol, uric
acid and
triglycerides.
Name of Drug Mechanism of Indication Dosage, Route Contraindication Side
Action of Effects/Adverse
administration Effects
and Frequency
(Date Orederd)

Generic Recombinant Symptomatic 5000 iu / SC / -uncontrolled Increased blood

Name: human or transfusion once a week hypertension pressure and
Erythropoietin erythropoietin (r- requiring -known hypertensive
Brand Name: HuEPO) is a anaemia hypersensitivity to encephalopathy
Eprex purified associated >December 16, mammalian-cell -Flu-like
glycoprotein with chronic 2005 derived products symptoms, bone
which stimulates renal failure. -known pain and chills
erythropoiesis. hypersensitivity to following
any of the injections
components of this -Seizures
product -Headache
-Pain in the
subcutaneous
area
Name of Mechanism Indication Dosage, Route Contraindication Side Nursing
Drug of Action of Effects/Adverse Implication
administration Effects
and Frequency
(Date Ordered)

Generic Replaces For patients Kalium Durule 1 Contraindicated Hyperkalemia, Frequently

Name: potassium with tab TID for patients with arrhythmias, monitor the
KCl and hypokalemia hyperkalemia and weakness, potassium
Brand maintain >December 13, renal confusion and levels of the
Name: potassium 2005 insufficiency hypotension. patient
Kalium levels
Durule Use the drug
with caution
for patients
with cardiac
disease.

The drug is
commonly
used orally
with
potassium
wasting
diuretics to
maintain
potassium
levels.

Watch out
for adverse
reactions.
SPECIAL PROCEDURES
 DATE
ORDERED / PROCEDURE RESULT PROCEDURE NURSING
DATE DESCRIPTION RESPONSIBILITIES
PERFORMED
December 11, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusion reactions transfusion is reactions
(1 “u”) performed to > Watch for signs of
supply any shock
blood loss or
any deficiency
in RBC.

December 12, > Blood > No allergic > Blood > Watch for allergic
2005 Transfusin reactions transfusion is reactions
(1 “u”) performed to > Watch for signs of
supply any shock
blood loss or
any deficiency
in RBC

December 14, > Blood > No allergic > Blood

> Watch for allergic
2005 Transfusion reactions transfusion is
reactions
(1 “u”) performed to
supply any > Watch for signs of
blood loss or shock
any deficiency
in RBC
VI. PATIENTS DAILY PROGRESS

Doctor’s Order
Name: Romeo Velasco Age: 57 Male Civil Status: M
Address: Sasmuan, Pampanga Ward: Med
Hospital #: 130290

Date: December 11, 2005

 Please admit to as under ORANGE
 Secure consent for admission and NGT
 TPR on shift
 NPO temporarily except meds
 # uremia
CBC 12 LEKG
RBC CXR PAV
BUN / Creatinine Renal UTZ
Na K CL Urinalysis
.Uremia / anemia 2° to ESRD prob. To CBN
BP = 130/80mmHg CR = 76 bpm Cra. = 3.1
 IVF D5 0.3 NaCl 500cc x KVO, start KCL drip 10meqs + 90cc
PNSS x 1° x 4 doses then for serum K 1 hour after the last dose.
 CaCO3 500mg/tab 1 tab TID
 Advise dialysis
# Anemia
Place MCV MCH MCHC PBC Retic G
 prepare 3 “u” PRBC properly typed and matched
 PNSS 500cc while on BT, replace previous IVF after each unit
  Transfuse 1st unit once available
Paracetamol 300mg / IV and Diphenhydramine 50g /IV 30
minutes prior to BT
Furosemide 80mg/ IV / post BT
 Insert Folley Catheter and do I & O q 1° and record pls.
 Monitor vital signs q 1°.
# Glucoserum
FBS in AM
HBAC
 CBC q 12° and record pls.
 Inform service residence.
 Complete Hx / pls.
 Refer accordingly.

December 12, 2005

BP = 110/ 70mmHg (+) body weakness (-) N / V
 Repeat serum K after 4th dose KC
 Low salt, low protein diet.
 Transfuse 1 unit PRBC properly typed and matched to run for 4
hours.
 Furosemide 80mg / post BT.
 For renal UTZ
 Repeat with in 6 hours post BT.
 Continue meds.
December 13, 2005 7:30am
(-) pallor
 For repeat H & H.
Romeo Velasco – refused dialysis.
8:00am
BP = 120/80mmHg; T = 35.8 °C; RR = 21; PR = 79bpm
(+) nausea (+) vomiting of coffee
 Transfuse 1 “u” PRBC properly typed and matched to run for 6
hours.
 Furosemide 80mg / IV.
 Insert NGT.
 Fecalysis with occult blood
 Still for dialysis.
 Monitor VS, I & O q 1°
 Continue meds.
 Consent for blood transfusion.
 Meds:
1. Furosemide 80mg TID
2. CaCO3 TID

4:20pm
 Start Kalium Durules 1 tab. TID

December 14, 2005

BP = 180/ 100mmHg: CR = 94bpm; (+) anorexia
 Manidipine 200mg / tab OD
  For H/H.
 For removal of NGT.
 Start tube feeding at 1600 kcal in 6 divided doses.
 Continue meds.
 VS q 4°

12.14.5 6:50pm
BP = 140/90 mmHg CR = 82bpm T = 37.2 °C
(+) upper arm twitching (-) DOB (-) chest pain
 May remove NGT.
 For K and Albumin
 Prepare and transfuse 1 “u” of PRBC properly typed and
matched.
 H/H 6° prior to BT
 Furosemide 80mg / post BT, watch for transfusion reaction.
 VS q 1°

December 15, 2005 4:00pm
BP = 170/90mmHg
 start metoprolol 50mg / tab BID
 H/H prior to BT
 Continue meds.
 VS q 1°
Refused medications, VS q 1° and BT.
December 16, 2005
BP = 110/80mmHg
MGH
 home meds
1. Erythropoietin 5,000 u/ sc once a week
2. CaCO3 / tab TID.
3. Manidipine 20mg /tab OD

Follow up check up:: January 11, 2006

Discharged @ 4:30pm 12/16/05

 Daily Progress Table

12-11-2005 12-12-2005 12-13- 12-14-2005 12-15-2005 12-16-2005

2005
Vital Signs T: 37 T: 36.7 T: 35.8 T: 37.2 T: 37 T: 37.2
at 12PM PR: 90 PR: 76 PR: 79 PR: 82 PR: 83 PR: 79
RR: 22 RR: 20 RR: 21 RR: 22 RR: 20 RR: 21
BP: 120/80 BP: 110/70 BP: 120/80 BP: 140/90 BP: 170/90 BP: 110/80
Lab *Blood *Blood *Blood *Blood REFUSED REFUSED
Procedure Chemistry* Chemistry* Chemistry* Chemistry*
>MCH – 32.4 >FBS – 95.9 >K – 3.0 >Hgb – 83
>MCV – 90.1 >K – 3.0 >Hgb – 73 >Hct – 0.25
>MCHC – 36 >Hgb – 73 >Hct – 0.20 >K – 3.0
>Reticulocyte >Hct – 0.20
count– 2.5%
>Hgb – 77
>Hct – 0.23
>WBC – 12.0
>Neutrophils –
0.90
>Lymphocytes –
0.08
>Stab – 0.02
>Platelet – 163
>RBS – 6.64
>BUN – 13.1
>Crea – 1939
>Na – 137
>K – 2.3
>Chloride – 109
>Ca – 1.71
>Phosphorus – 1.1

*Urinalysis*
>Color: Light
Yellow
>Reaction – Acidic
>Specific Gravity –
1.020
>Coarse Granular
– 2.4/LPF
>Puss Cells –
8.1/HPF
>RC – 3.5/HPF
>Epithelial cells –
few
Medications >CaCO3 Continue meds: New Meds: New Meds: New Meds: MGH
500mg/tab TID >CaCO3 >Kalium >Manidipine >Metoprolol Home meds:
>Paracetamol 300 500mg/tab TID Durule 200mg/tab OD 50mg/tab >Erythropoietin
mg IV BT meds: 1tab TID Continue meds: TID 5,000 u/ sc
>Diphenhydramide >Diphenhydramide Continue >CaCO3 Continue once a week
50mg IV 30 mins 50mg IV 30 mins meds: 500mg/tab TID meds: >CaCO3 / tab
prior to BT prior to BT >CaCO3 >Kalium Durule >Manidipine TID.
>Furosemide 80mg >Furosemide 80mg 500mg/ tab 1tab TID 200mg/tab >Manidipine
IV Post BT IV Post BT TID BT meds: OD
20mg /tab OD
>Diphenhydramide >CaCO3
50mg IV 30 mins 500mg/tab
prior to BT TID
>Furosemide 80mg >Kalium
IV Post BT Durule 1tab
TID

IVF >D5 0.3 NaCl >PNSS 500cc X >PNSS 500cc X >D5 0.3
500cc X KVO KVO KVO NaCl X KVO
>PNSS 500cc X
KVO
Special >1st unit BT >2nd unit BT >3rd unit BT
Procedures 9:40PM 11:30AM 9:00PM
NORMAL VALUES:

* Normal Values
Hgb M: 125 – 175g/L
F: 115 – 155g/L
Hct M: 0.40 – 0.52
F: 0.38 – 0.48
WBC
Neutrophils 0.45 – 0.65
Lymphocyte 0.20 – 0.35
Stab 0.02 – 0.05
Platelet
RBS 3.85-9.0mmol/L
BUN 1.7-8.3
Creatinine M: 60 – 120
F: 58 – 100
Sodium 135 – 145
Potassium 3.5 – 5.0
Calcium 2.02 – 2.60
Phosphorus 0.81 – 1.62
Chloride 101 – 111
FBS 4.1 – 6.1 mmol/L
MCH 27 – 33 pg
MCV 82 – 92 fl
MCHC 31 – 36 g/dL
Reticulocyte count 1 – 5%
PATIENTS DAILY PROGRESS

12-11-05

The patient was transferred from Diosdado Macapagal Hospital at Lubao,

Pampanga, and was admitted to JBLMRH under orange service.
The vital signs taken were BP 130/80, PR 76. The ongoing diagnosis is
Uremia/Anemia 2 to ESRD prob. 2 to CBN.

He was hooked with an IVF of D5 0.3 NaCl 500cc x KVO, started KCl drip 10
meqs + 90 cc PNSS x 1x 4 doses then for serum K 1 after the last dose.

CaCO3 500 mg 1 tad TID was ordered as meds

Patient is refusing dialysis, that’s why dialysis was advised

# Anemia
1st unit of 3 U pack RBC was transfused. Pre BT meds are given and they are as
follows: Paracetamol 300 mg IV, Diphenhydramine 50 g IV 30 mins prior to BT
and furosimide 80 g IV was given post BT.

Foley catheter was inserted

# Glucoserum

FBS in AM was taken

HBAC

CBG was ordered to be done q 12.

12-12-05

The patient BP was 110/70. There was (+) body weakness and (-) N/V. Serum K
after 4th dose KCl was repeated. Low salt, low protein diet was prescribed.

1 unit of packed RBC was transfused, consumed within 4 hours, furosemide 80

mg was given post BT.

For renal UTZ, H/H was repeated within 6 hours post BT.

12-13-05

7:30 am
There was (-) pallor. The patient was for H/H

The patient refused dialysis

8:00 am
The patients vital signs were as follows: BP: 120/80, T: 35.8C, RR: 21, PR: 79.
The patient has (+) nausea and vomiting.

He was transfused with 1 U PRBC consumed for 6 hours; furosemide 80 mg IV

was given. He was inserted with NGT. For fecalysis with occult blood.
The patient was for dialysis but still he is still refusing.

4:20 pm

Kalium Durule TID was started.

12-14-05

The patients vital signs are as follows; BP: 180/100, CR: 94. Manidipine 200 mg
1 tab OD was started. For H/H. Tube feeding was 1600 kcal in 6 divided doses.
The NGT was removed due to the anxiety of the patient.

12-14-05

6:50 pm

The patients vital signs were as follows BP: 140/90, CR: 82, T: 37.2°C. There was
positive arm twitching, negative DOB, negative chest pain. He was for K,
Ca, and Albumin count.

12-15-05

The patient BP was 170/90. Metropolol 50 mg 1 tab BID was started. For H/H
post BT.

The patient was lying on bed and not talking and would not open his eyes. He
refused H/H, and all his oral meds.

12-16-05

The patient BP was 110/80. The he was sitting on bed, and verbalizes that he
does not remember that he had refused all to take all his medications. There was
(+) dizziness and loss of appetite due to therapeutic diet prescribed. He is still
refusing dialysis.
May go home. Home meds were as follows: Erythropoietin 5,000 IU SC once a
week, CaCO3 1 tab TID, and Manidipine 20 mg 1 tab OD.

He was scheduled to have his checked up on Jan.11, 2006. The patient was
discharged at 4:30 pm.
VII. DISCHARGE PLANNING

Medications:
 Erythropoietin 5000 IU, SC once a week
 CaCO3 1 tab TID
 Manidipine 20mg 1 tab OD

Exercise:
 Encouraged to perform ROM exercise
 Limit activities that requires too much movement
 May perform ADL in a limited range

Treatment:
 Medication as prescribed by ROD
 Low salt – low fat diet and Uremic diet

Health Teaching:
 Advised patient to eat nutritious food like fruits, fish and
vegetables.
 Advised to limit salt and fat intake
 Advised patient to monitor intake and output.
 Advised patient to perform light exercises

Out-Patient Visit
 Instructed patient to be back on January 11, 2006 for
follow up check-up.

Diet:
 Low fat – low salt diet, Uremic diet
VIII: Conclusion and Recommendation

Acute Renal Failure is a kind of disease that is suddenly

manifested by people who are not aware of what they are eating. People
who manifest ARF have same manifestations and these are high in
creatinine, hyperkalemia, oliguria, anemia and the worst is uremia.
Uremia is a toxic manifestation of this disease in which a person has
urine in its blood because of inability of the kidney to excrete the waste
from the body because of its damage. Having uremia in a person with
ARF can lead to its worst condition and if cannot be prevented, it can
lead to death of the person. However, there is still hope in treating Acute
Renal Failure in compare with Chronic Renal Failure. There are different
prevention strategies, diagnostic screening methods and treatments that
can be applied in patients with Acute Renal Failure.
Renal Failure can be acute or chronic. Chronic Renal Failure
affects patients for a long period of time and can only be treated by
kidney transplant. Unlike Acute Renal Failure, the normal functioning of
the kidney can be achieved by spontaneous treatment and hemodialysis
if advised by the doctor. Though, hemodialysis can be performed for
persons with CRF, however, the normal functioning of the kidney could
not be achieved. To manage the patient with this kind of condition (ARF),
it should be done with complete cooperation of the patient and its family.
The client with ARF must be endowed to accept self-management and
learn how to control himself in times of temptation of doing wrong things
that could affect his condition. Clients with ARF should have a
consistent check-up, updating and monitoring his own condition.
Proper education should be imparted in clients with ARF. They
should be educated on what are the things that they should be aware of.
This includes his diet, his activities of daily living and his medications.
Proper monitoring of his urine output should also be included in
educating them. In addition to the diet of the client, we should also
present substitutes for foods that the patient wants that could not affect
his condition. A uremic and a low-salt low-fat diet should be imposed on
patients with ARF. We should also include that they should abide the
orders of the physician in order for him to be treated in his condition. As
nurses, we should also take in consideration the financial stability and
the degree of knowledge our client has so that we can come out with
nursing interventions that is appropriate to his level of understanding.
Health care providers should be aware of the risk and
complications of acute renal failure to patients. We should always
monitor their fluid and electrolyte balance and other laboratory results
for us to be updated of the patient’s progress in the hospital.
Acute Renal Failure is a major disease condition. We should be
careful of what we are eating and doing. We can avoid having this
disease by following a healthy diet and regular exercise. As a famous
saying from the medical field, “Prevention is better than cure”.

Current Trends on Acute Renal Failure

Taken from: RenaMed Biologics and Genzyme Announce Worldwide

Collaboration to Advance Investigational Treatment for Acute Renal
Failure
-- Data from Phase II study, completed by RenaMed, to be presented at
ASN in November –

Sep 28, 2005

LINCOLN, R.I., and CAMBRIDGE, Mass., Sept. 28 – RenaMed Biologics,

Inc. (RenaMed™), formerly Nephros Therapeutics, Inc., and Genzyme
Corporation
(NASDAQ = GENZ ) announced today that they have entered into a
strategic collaboration to jointly develop and commercialize RenaMed’s
Bio-Replacement Therapy™ for the treatment of acute renal failure. The
product utilizes physiologically active renal epithelial cells, administered
ex vivo in a hollow-fiber cartridge, intended to treat a sudden loss of
kidney function with the ultimate goal of improving survival rate.
Genzyme and RenaMed will undertake a collaborative effort to advance
the product through clinical development, manufacturing, and
commercialization on a worldwide basis.

The joint development and commercialization agreement calls for a

50/50 sharing of costs and profits. Genzyme will contribute funding of
approximately $23 million through the third quarter of 2006 to support
the next stage of clinical development, and may make additional
payments to RenaMed upon completion of certain developmental
milestones. These additional payments could total $20 million.
Thereafter, the agreement calls for shared program funding, and for
potential additional milestone payments by Genzyme at approval.
Genzyme also made an equity investment in a recent private financing
completed by RenaMed in June 2005.

Reaction:

It is a fact that acute renal failure is one of the major diseases that
occur in this world. There are lots of treatments that are being presented
today to treat acute renal failure. These include hemodialysis,
medications and many more. But recently, corporations which are the
RenaMed and the Genzyme joined forces to develop and commercialize a
new product to treat Acute Renal Failure; the Bio-Replacement therapy
which utilizes epithelial cells and so on to treat the sudden loss of
function of our kidney and improve the survival rate of the patient who
possess this kind of disease.
This latest trend in medicine will contribute a lot in treating this
kind of disease. As individuals here in this society, we should support
this kind of breakthroughs because this will not just benefit the elite
people in our society but also to indigent people who cannot afford the
expensive therapies that should be done in treating acute renal failure.
Even though this kind of treatment was discovered and developed, we
should always be careful on what we are doing so that the probability of
having the disease will decrease. But the most important is, early
prevention and detection of the disease is one of the main goal to avoid
renal failure such as limit intake of salty and fatty foods.

IX. BIBLIOGRAPHY / REFERENCES

 Laboratory Procedures and Results/ Reference unit HAU Library

 www.yahoo.com
 Medical-surgical book by Black
 Angeles City Library (Nursing Books specifically Pathophysiology
Book)
 Anatomy and Physiology (Official book of CON-HAU)
 JBLMRH (Patient’s Records)
 Holy Angel University
College of Nursing

In Partial Fulfillment of the requirement in

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