Name: Mrs.

MM Age: 77 years old

Nursing Diagnosis: Anxiety related to chronic illness w/ changes in roles/ body image.

Medical Diagnosis: ESRD secondary to DM Nephropathy

Short-term Goal: At the end of my shift, patient will verbalize acceptance of self in situation.

Long-term Goal: At the end of hospitalization, patient will demonstrate adaptation to changes or events that have
occurred.
Cues: Problem Scientific Rationale Nursing Rationale Evaluation
Interventions
• Body ANXIETY Anxiety is a normal experience. • Assessed • Helps Goal met.
malaise Moderate or high level of anxiety level of determi Patient
can increase alertness and fear of ne the verbalized
• Blurred in client. kind of acceptance
performance in particular
vision interven of self in
situations. However, people who situation.
tions
experience continues or recurring required
• Restlessness • Explained
fears or episodes of intense fear procedure .
can feel powerless to manage their s/ care as • Fear of
symptoms and their lives can delivered. unknow
become severely restricted. Repeated n is
explanati lessene
on’s d by
frequently informat
http:/www.panicanxietydisorder.o as ion &
rg au /index.htm needed. may
enhanc
e
accepta
nce of
perman
ence of
ESRD
• Provided and
opportunit necessit
ies for y for
client to dialysis.
ask
questions • Creates
& feeling
verbalizati of
on of openne
concern. ss &
coopera
tion &
provides
informat
ion that
will
assist in
problem
identific
Name: Mrs. MM Age: 77 years old
Medical Diagnosis: ESRD secondary to DM Nephropathy
Nursing Diagnosis: Altered Fluids & electrolytes r/t Urinary retention as evidence increase K & decrease Na.
Short term Goal: At the end of my shift, patient will be able to increase urine output at least 1500cc in 24 hrs.
Long term Goal: At the end of hospitalization, the patient will be able to have a normal urine output & voiding pattern.
 Cues Problem Scientific Nursing Intervention Rationale Evaluation
Rationale

S- No Oliguria The production of • Assess the • To be able to Goal partially

subjective an abnormally cause of apply the proper met-patient
small volume of decrease therapeutic passed out urine
Objective: urine. This may be at least 300 cc.
urinary output regimen.
• Decreased a result of copious
sweating, kidney
of urine
disease, loss of
output • Encourage • May minimize
blood
380cc client to void urinary
every 2-4 hrs & retention/overdis
• Dribbling of
when urge is tention of the
urine Reference: noted bladder
• Potassium- Nursing Care • Determine the • Serve as
7.47 Plans initial fluids and baseline for
increased
Page 89 electrolytes progress.
(3.5- 5.0 level
mg/dl)

• Monitor intake
• To determine
• Sodium- & output hourly
the progress of
134
• Percuss/palpate the disease
decreased
suprapubic
• A distended
(135-145 area.
mg/dl) bladder can be
felt in the
suprapubic
area.
• Observe Signs
and symptoms
of fluids & • To be able to
electrolytes prevent further
imbalance such complication
as dyspnea and administer
changes in proper
therapeutic
Name: Mrs. MM Age: 77 yrs. old

Medical Diagnosis: ESRD secondary to DM Nephropathy

Nursing Diagnosis: Sleep pattern disturbance r/t urinary frequency

Short-term Goal: at the end of my shift, the clients will increase the sleeping hours from 5 hrs. to 8 hrs.

Long-term Goal: At the end of the patient’s hospitalization, patient achieves optimal amount of sleep as evidenced by
rested appearance, verbalization of having a good sleep and improvement in sleep pattern.

Scientific Nursing
Cues Problem Rationale Evaluation
Rationale Interventions

Subjective: Lack of sleep The client is Goal partially

Unable to sleep met.
“Hindi ako because she • Assess the • To determine
makatulog ng cause of the proper Patient’s
frequent urge to
husto” as inability to sleeping pattern
empty urinary sleep.
verbalized by the bladder. Thus her increased from 5-
• Assist patient • To promote
patient. sleeping pattern is 7 hrs.
in observing relaxation.
Objective: disrupted. any previous
b
• restlessness Bedtime
• Dark circles ritual.
under eyes
• irritable
• Advised • To promote
Ref: urinary
daytime
elimination
 Nursing Care physical thus
Plans activities as reducing
indicated. bladder
Page 61 distention
to promote
By: klopp sleep
during
night time.

• To prevent
• Limit fluids
urinary
before
bladder
bedtime.
retention
causing
dribbling of
urine.

Patient’s Name: Mrs. M.M. Age: 77 years old

Medical Diagnosis:ESRD secondary to DM Nephropathy

Nursing Diagnosis:Decreased tissue perfusion related to peripheral vasoconstriction as manifested by high blood
pressure.

Short – Term Goal:At the end of my shift, patient will decrease blood pressure from 160/90 to 130/90

Long - Term Goal: At the end of the patient’s hospitalization, will maintain adequate tissue perfusion as evidenced by BP
declining toward normal range for client.

CUES PROBLEM SCIENTIFIC NURSING INTERVENTION RATIONALE EVALUATION

RATIONALE

Subjective: Decreased Constriction of • . Measure and recorded • Provides Goal not met.
Tissue the peripheral blood pressure as objective data Patient’s blood
No subjective Perfusion blood vessels for pressure
indicated
will alter the monitoring. remained
flow of blood to 160/90.
Objective: perfuse the
• Observed skin color, • Presence of
different cells of moisture, temperature, pallor: cool,
• Oliguria
the body. and capillary refill time. moist skin;
• Hyperten and delays
Reference: capillary refill
sive
time may be
www.elsevier.co
due to
• Restless m peripheral
ness vasoconstricti
on.
• Cold and • May
clammy indicate
skin heart or
renal
• Noted failure
dependent/general
edema

• Helps
reduce
sympatheti
c
stimulation
; promotes
relaxation.
• Reduces
• Provided calm, restful physical
surroundings, stress and
minimize tension
environmental that affect
activity/noise. Limit blood
the number of visitors pressure
and length of stay. and the
course of
• Maintain activity hypertensi
on.
restrictions; such as
• Decreases
bed rest/chair rest;
schedule periods of discomfort
uninterrupted rest; and may
assisted client with reduce
self-care activities as sympatheti
needed. c
stimulation

• Provided comfort
 measure such back
massage, elevation of
head.

• Administered
antihypertensive • Antihypert
medications as ensive
prescribed medication
s play a
key role in
treatment
of
hypertensi
on
associated
with
chronic
renal
failure.
• Encouraged
compliance with • Adherence
dietary and fluid to diet and
restriction therapy. fluid
restrictions
and
dialysis
schedule
prevents
excess
fluid and
sodium
accumulati
 on.

Patient's Name:Mrs. MM Age: 77 years. Old

Medical Diagnosis: ESRD secondary to DM nephropathy

Nursing Diagnosis: Risk for systemic infection related to hemodialysis procedure as manifested by fatigue,
weakness and low Hb., Hct.level

Short term goal: At the end of the shift, patient will experience no signs/symptoms of infection.

Long – term goal: At the end of hospitalization, patient will maintain/demonstrate improvement in laboratory values

Cues Problem Scientific Nursing Rationale Evaluation

Rationale Intervention
Systemic Infection Frequent IV • Promoted good • Reduces risk of Goal met- Patient
cannnula will hand washing cross- had experienced no
introduce by client and contamination signs of infection.
Objective: microorganism in staff.
• BP 160/90 the blood circulation • Use aseptic • Reduces
mmHg that would trigger technique when bacterial
• Restlessness systemic infection. manipulating colonization
• Oliguria IV/invasive and risk of
• Hct.level lines. ascending
0.25 UTI.
• Na level 134 • Encouraged • Prevents
Reference: deep breathing, atelectasis and
• Hb. 0.83gm/l Medical Surgical 1st coughing, mobilizes
edition by Udan frequent secretions to
position redue risk of
changes. pulmonary
infections.

• Assessed skin • Excoriations

 integrity from scratching
may become
secondarily
infected.

• Monitored vital • Fever with

signs increased pulse
and a
respiration is
typical of
increase
metabolic rate
resulting from
inflammatory
process,
although sepsis
can occur
without a febrile
response.
 DRUG CLASSIFICATION MECHANISM OF INDICATION/ SIDE EFFECTS NURSING
NAME ACTION CONTRAINDICATION CONSIDERATIONS

BRAND: Sympathomimetic Exogenously Indications: Nausea, 1.]Monitor vital

administered, it vomiting, signs and ECG
Docard produces direct Correction of tachycardia, during infusion. If
hemodynamic BP drops
stimulation of anginal pain,
imbalances present in 30mmHg stop
beta-1 receptors palpitation, infusion and
GENERIC: and variable renal failure. dysnea, report to
stimulations. Contraindications: headache, physician.
Dopamine
hypotension,
HCL Uncorrected 2.]Assess for
hypertension,
tachyarrythmias or vasoconstriction, oxygenation and
ventricular fibrillation. perfusion deficit:
decrease urine
DOSAGE: dyspnea,
output, dyspnea. cyanosis,
2 amp in decrease BP,
D5W 250cc chest pain,
dizziness.
@ 10
mgtts/min 3.]Assess
titrate by patient’s GI
increment of complaints:
3 mgtts/ min nausea and
vomiting.

4.]Monitor BP
closely for
sudden drop
after drug is
stopped.
 DRUG CLASSIFICATION MECHANISM OF INDICATION/ SIDE EFFECTS NURSING
NAME ACTION CONTRAINDICATION CONSIDERATIONS

BRAND: Alkalinizing agent, Increases plasma Indications: Metabolic 1.]Assess

Antacid, Electrolyte bicarbonate, alkalosis respiratory and
which excess Treatment of metabolic (dizziness, pulse rate.
buffers H ion acidosis. cramps, thirst,
2.]Monitor fluid
concentration; anorexia, N & V, balance.
GENERIC:
DRUG CLASSIFICATIONreverses MECHANISM OF INDICATION/ tetany, seizures).
SIDE NURSING
NAME metabolicACTION Contraindications:
CONTRAINDICATION Paravenous
EFFECTS CONSIDERATIONS
3.]Assess for the
Sodium
acidosis. administration symptoms of
bicarbonate Edema, hypertension, alkalosis.
may lead to tissue
BRAND: Insulin product, anti- Increases glucose severe kidney
Indications: Hypoglycemia, 1. ]Assess V/S.
necrosis.
diabetic agent transport across insufficiency, insulin 4.]Teach patient
Humulin R Moderate
hypoventilation.
muscle and fat cell to severe resistance, 2. ]Use
about a tuberculin
sodium
DOSAGE:
diabetic ketoacidosis or or
restricted diet.
membranes to local and
650mg 1tab hyperosmolar insulin syringe for
reduce glucose generalized accuracy of
TIDGENERIC: level. hyperglycemia regular allergic measurement.
insulin. Mild diabetic reaction.
Insulin ketoacidosis. Newly 3. ]Keep in cold
injection diagnosed diabetes. location,
preferably a
(Regular
refrigerator.
insulin)
Contraindications:
4. Do not freeze.
Hypoglycemia.
DOSAGE: 5. ]Observe closely
Hypersensitivity to
for
insulin. S&S of hyper- or
6 “u” IV now
hypoglycemia
until
dosage
established.

6.] Monitor BP, BS,

LDL,
cholesterol and
HbA1c.
 DRUG CLASSIFICATION MECHANISM OF INDICATION/ SIDE EFFECTS NURSING
NAME ACTION CONTRAINDICATIO CONSIDERATIONS
N

BRAND: Rapid-acting Facilitates the Indications: Hypersensitivity 1. ]Document

insulin, Anti diabetic transport of to insulin. disease
Humalog agent glucose into Diabetes mellitus. In onset, level of
mix 25 combination with control previous
cardiac and
sulfonylureas to treat agents trialed, and
skeletal muscle the outcome.
and adipose high blood glucose n
GENERIC: tissue. It also adults over 65 years
2.] Monitor VS,
increases of age. CBC,
Insulin lispro HbA1c, U/A;
synthesis of
injection microalbumin and
glycogen in the
Contraindications: renal function
liver.
studies.
DOSAGE: Use during episodes
of hypoglycemia. 3. ]Review signs
25 ‘u’ SQ 10 and
Hypersensitivity to
symptoms of
mins BB, 12 insulin lispro. hypoglycemia and
‘u” SQ 10 appropriate
mins BS management.

4. ]Continue BP
control,
diet and exercise
for
disease control.
 DRUG MECHANISM INDICATION/ NURSING
CLASSIFICATION SIDE EFFECTS
NAME OF ACTION CONTRAINDICATION CONSIDERATIONS

BRAND: Vitamins & Minerals Hematinic. Indications: Hypotension, chest 1. ]Watch for
Iron sucrose is pain, hypertension, serious
Encifer dissociated by Treatment of iron hypervolemia, CHF, hypersensitivity
the deficiency anemia in cramps, reactions of iron
reticuloendoth the following patients: musculoskeletal sucrose.
GENERIC: elial system Hemodialysis pain, diarrhea,
into iron and Dependent Chronic nausea, vomiting, 2. ]Medication is
Iron sucrose. Kidney Disease (HDD- abdominal pain, administered 1 to
sucrose Encifer iron CKD) patients receiving elevated liver 3
component an erythropoietin. enzymes, skin times/wk. Do not
appears to irritation, pruritis, administer more
distribute Contraindications: application site than
DOSAGE: mainly in the reaction, dizziness, 3 times/wk.
blood and to Patients with evidence dyspnea,
Amp 20 some extent in of iron overload, in pneumonia, cough, 3. ]For IV
mg/mL the patients with known headache, fever, administration
(brown, extravascular hypersensitivity to iron asthenia, malaise. only.
sterile, fluid. sucrose or any of its
aqueous inactive components .
soln) x 5's. and in patients with
anemia not caused by
iron deficiency.
 DRUG MECHANISM INDICATION/ NURSING
CLASSIFICATION SIDE EFFECTS
NAME OF ACTION CONTRAINDICATION CONSIDERATIONS

BRAND: Hypnotics & Depresses the Indication: Amnesic 1]. Monitor blood
Sedatives limbic system episodes pressure, heart rate
Dormicum and reticular Disturbances of sleep and rhythm,
formation respiration, airway
(subcortical integrity,arterial
GENERIC: level of CNS) oxygen, saturation,.
by increasing Contraindication: Emergency
or facilitating equipment
Midazolam the inhibitory Hypersensitivity shoud be nearby.
neurotransmitt .
er activity of 2.] Its onset of action is
DOSAGE: GABA. 1
hour.The action
15mg ½ lasts for
tab OD 2-6 hours.

3. ]Dormicum is given
may
be slower in the
elderly
than in younger
adults.

4. ]Inform patient that

drug
may cause amnesia.
 DRUG CLASSIFICATION MECHANISM INDICATION/ SIDE EFFECTS NURSING
NAME OF ACTION CONTRAINDICATIO CONSIDERATIONS
N

BRAND: Vitamins and Component of Indications: Nausea, 1.] Document

minerals hemoglobin for constipation, indication for therapy.
Iberet oxygen Supplement for diet. diarrhea or
folate 2. ]Assess metabolic
transport; . stomach pain.
panel
enzymes for and vitamin levels as
energy Contraindications: indicated.
metabolism.
Thalassemia,
3. ]List agents prescribes
GENERIC: sideroblastic anemia, to
hemochromatosis & ensure none interact or
Multivitami hemosiderosis. impact vitamin
n with iron Children. absorption.

4. ]Take with food for best

DOSAGE: absorption.

1 tab OD
 INDICATION/
DRUG CLASSIFICATIO MECHANISM NURSING
CONTRAINDICA SIDE EFFECTS
NAME N OF ACTION CONTRAINDICATIONS
TION
BRAND: anti angina Reduces Indications: Orthostatic 1.] Assess location,
cardiac oxygen hypotension, duration,
Minitran demand by Prophylaxis of tachycardia, intensity,and
decreasing left angina, palpitation, precipitating
ventricular end hypertension rash. factors of the patient’s
GENERIC: diastolic angina pain.
pressure (pre Contraindication
Nitroglyceri -load) and to s: 2.]Evaluate therapeutic
n patch lesser extent effectiveness (cardiac
systemic Severe anemia, status) and adverse
vascular increase response
resistance (after intracranial (hypotension,
DOSAGE: load). Also pressure, allergy arrhythmias)
increases blood to adhesives,
5 mg flow through the hypersensitivity to 3.]Dosed should be
OACW x collateral nitrates and reduced
16 h coronary orthostatic gradually when
vessels. hypotension. discontinuing after long-
term
therapy.

4.]Apply transdermal
(TD)
patches to area without
hair: press hard to
adhere if
patch becomes
dislodged,
apply a new one.

5.Do not discontinue

abruptly.

6.]Closely monitor vital

signs.

7.] Use caution when

near a
microwave oven,
leaking
radiation may heat
 DRUG CLASSIFICATION MECHANISM INDICATION/ SIDE EFFECTS NURSING
NAME OF ACTION CONTRAINDICATION CONTRAINDICATIONS
BRAND: Anti-infectives Inhibits Indications: Nausea, diarrhea, 1.]Assess renal function
(Quinolones) bacterial DNA abdominal pain, before and during
Ciprobay gyrase thus Infection of the anorexia, dizziness, therapy: urine output,
preventing kidneys, and urinary headache, very rarely, BUN and creatinine.
replication in tract, genital organs, insomnia, peripheral,
susceptible abdomen, and skin. sweating, convulsion. 2.]Assess for possible
GENERIC: bacteria adverse reactions:
Contraindications: G.U: interstitial
DRUG
Ciprofloxacin CLASSIFICATION MECHANISM INDICATION/ SIDE EFFECTS NURSING
nephritis.
NAME OF ACTION CONTRAINDICATION
Hypersensitivity to CONTRAINDICATIONS
BRAND: Loop diuretics Acts in the Indications: on other
ciprofloxacin Electrolyte & fluid 1.] Monitor electrolytes,
3. ]Document indication
thick quinolones changes: Excess liver and renal function
for therapy, type,
Burinex
DOSAGE: ascending Hypertension. water loss, studies:onset,
causes for low
limb of the dehydration potassiumand characteristic of
500 mg 1 loop of Henle, electrolyte symptoms
tab OD where it depletion 2.] Monitor VS. Repeat
GENERIC: inhibits the Contraindications: including duiresis4.may cause
]Assess patient for
co-transport hypokalemia dehydration and
s/sx’s
Bumetanide of sodium, Anuria. Hepatic coma hyponatremia, circulatoryof collapse
infection before and
potassium, or severe electrolyte hypovolemia, (especially in the
during treatment
and chloride depletion. thromboembolism elderly.)fever,
DOSAGE: from the , circulation characteristic of
luminal collapse. 3.]Assessurine
BP before
1 mg tab filtrate. and during therapy with
OD Increases patient lying, standing,
excretion of and sitting as
water, appropriate; orthostatic
sodium, hypotension can occur
potassium, rapidly.
calcium and
chloride; 4.]Advise the patient to
decreases take the medication in
DRUG CLASSIFICATION uric acid
MECHANISM INDICATION/ SIDE EFFECTS the morning. NURSING
NAME secretion;
OF ACTION and CONTRAINDICATION CONTRAINDICATIONS
cause no
BRAND: Calcium Channel Possiblein
change Indication: Headache, fatigue, 1.]Teach patient to use
Blocker slight pH.
urinary Hypertension lethargy, dizziness, as directed even if
Norvasc decrease in depression, feeling better.
myocardial Contraindication: paresthesia,hallucination,
contractility. Sick sinus syndrome; malaise, anxiety, tremor, 2.]Monitor Vs , ECG,
GENERIC: CO is second-third degree vertigo, migraine, CBC
increased; atrio ventricular (AV) amnesia, nausea,
 DRUG CLASSIFICAT MECHANISM INDICATION/ SIDE EFFECTS NURSING
NAME ION OF ACTION CONTRAINDICAT CONTRAINDICATIONS
ION

BRAND: Antihypertensi Stimulates Indications: Drowsiness, sedation, 1.] Perform eenal

ve centrally alpha confusion, dizziness, studies:protein, BUN,
Catapres (centrally- adrenergic Management of all headache, fatigue, creatinine: watch for
active drug) receptors, to grades of malaise, increased levels that may
inhibit hypertension. nightmares,nervousen indicate nephritic
sympathetic ess, restlessness, syndrome: polyuria,
GENERIC: cadio anxiety, mental oliguria, frequency.
accelerator and Contraindications: depression,dry mouth,
Clonidine vaso constrictor severe hypotension. 2.]Monitor input and
hydrochlorid centers. Hypersensitivity to output.
e clonidine
3.]Advise patient to use
caution when changing
DOSAGE: position.

150 mg /tab 4.]Teach patient not to

1 tab BID skip or discontinue
medication without
consulting physician.
 DRUG CLASSIFICAT MECHANISM INDICATION/ SIDE EFFECTS NURSING
NAME ION OF ACTION CONTRAINDICATION CONTRAINDICATIONS

BRAND: Calcium Salt Essential for Indications: Venous irritation, 1.]If a precipitate is
maintaining tingling sensation, noted in the syringe do
Kalcinate normal Management of feeling of oppression not use.
function of hypocalcemia, or heat, chalky taste,
nerves, hypocalcemic tetany, fatigue, GI symptoms 2.]IV rate should not
GENERIC: muscles, the hyperkalemia with (anorexia, IV, nausea exceed 0.5-2 ml / min.
Calcium skeletal cardiac toxicity. and vomiting, 3.]Monitor calcium
Gluconate system, and abdominal pain, dry levels and renal
permeability mouth, thirst) function.
of cell Contraindications:
membranes
Digitalized clients,
and
DOSAGE: sarcoidosis, renal or
capillaries.
cardiac disease,
1amp SIVP ventricular fibrillation.
Cancer clients with
bone metastases,
renal calculi,
hypophosphatemia,
hypercalcemia
DRUG NAME

CLASSIFICATION MECHANISM INDICATION/ SIDE EFFECTS NURSING

OF ACTION CONTRAINDICATION CONSIDERATION

BRAND: Antiplatelet drug Blocks ADP Indication: GI bleeding, 1.]Assess for

receptors, bruising, symptoms of
Plavix (anticoagulant which prevent Reduction of hematoma, stroke, MI during
thrombolytic) fibrinogen atherosclerotic events epistaxis, treatment
binding at in patients with hematuria, eye
GENERIC: that site and atherosclerosis. bleeding, 2.]Monitor signs of
thereby Treatment of patients intracranial bleeding; hemoglobin
Clopidogrel reduce the suffering from non-ST bleeding, GI and hematocrit
possibility of segment elevation. disturbances, periodically

DOSAGE: platelet Contraindication: diarrhea, rush. 3.]Monitor liver

adhesion and function studies: AST,
75mg/tab ½ aggregation. Hypersensitivity. ALT, bilirubin,
tab only Severe liver creatinine if patients
impairment. is on long-term
therapy;
thrombocytopenia,
neutropenia may
occour.
DRUG NAME MECHANISM OF INDICATION / SIDE EFFECTS NURSING
ACTION CONTRAINDICATION CONSIDERATION

Brand Name: Decreases blood Indication: Insulin resistance; 1. Obtain patient

glucose by transport allergic reactions that history, including drug
Humulin-N of glucose into cells Management of type1 include redness, pain, history and any know
and the conversion of DM or insulin itching, swelling or allergies.
glucose to glycogen dependent diabetis inflammation.
Generic Name: indirectly increases mellitus and type 2 Hypoglycemia, 2. Monitor fasting
blood pyruvate and diabetis mellitus which temporary visual blood glucose, 2 hours
lactate, decreases cannot be controlled impairment. Insulin after meals; also
phosphate and by diet, exercise or administration may glycosylated Hgb may
potassium. weight reduction cause insulin be measured to
alone. antibodies to form. identify treatment
effectiveness.
Contraindication:
3. Monitor urine
Hypoglecemia , ketones during illness;
hypersensitivity insulin requirements
reactions.IV may increase during
administration of stress, illness.
insulin suspension,
diabetic coma. 4. Monitor body weight
periodically; changes
in weight may
necessitate changes
in insulin dose.
5. Assess for
hypoglycemic reaction
that can occur during
peak time.