CHRONIC KIDNEY DISEASE

SECONDARY TO
DIABETIC NEPHROPATHY
I. CLIENT’S DATA
Name: Mrs. L
Age: 55 years Old
Sex: Female
Address: Mobo, Masbate City
Admitting Diagnosis: CKD/Anemia
Date of Admission: July 15,2019
Final Diagnosis: CKD Secondary to Diabetic
Nephropathy
Date of Discharge: July 25, 2019
Chief Complaint: Body Weakened
Days of hospital: 11 days
II.
INTRODUCTIO
N
 WHAT IS DIABETIC NEPHROPATHY?
Diabetic nephropathy Kidney disease from long-standing diabetes. Diabetes affects the tiny blood
vessels in the glomerulus, a key structure in the kidney composed of capillary blood vessels. This structure
is critical for blood filtration. Features of diabetic nephrotic syndrome, which is characterized by excessive
protein in the urine, high blood pressure, and progressively impaired kidney function. With severe diabetic
nephropathy, kidney failure, end-stage renal disease requiring kidney dialysis or a kidney transplant may
result. Also known as intercapillary glomerulonephritis, Kimmelstiel-Wilson disease, and Kimmelstiel
Wilson syndrome.
Diabetic nephropathy is also called Diabetic kidney disease, Chronic Kidney Disease, or Kidney disease or
Diabetes.
Diabetes results in high blood sugar levels. Overtime, these high glucose levels can damage various areas of
the body, including the cardiovascular system and kidneys.
Diabetic nephropathy is a major cause of long-term kidney disease and end-stage renal disease (ESDR).
When a person has diabetes, whether type 1 or type 2 or gestational diabetes, their body cannot use or
produce insulin as it should.
 CAUSES:
Damage to the kidneys puts stress on these vital organs & prevents them
from working properly.
When this happens:
The body starts to lose protein through the urine.
The kidneys cannot remove waste products from the blood.
The kidneys cannot maintain healthy fluid levels in the body.
 RISK FACTORS:

• Diabetes type 1 or type 2.

• Hyperglycemia.
• Hypertension.
• Family history.
• High blood cholesterol.

Other risk factors:

• Smoking
• Age
• Sex
• Races
SYMPTOMS AND STAGES
Stages:
Stage 1:
Kidney damage present but normal kidney function and a GFR of 90% or above.
No Symptoms

Stage 2:
Kidney damage with some loss of function and a GFR of 60-89%.
Usually No Symptoms

Stage 3:
Mild to severe loss of function and a GFR of 30-59%.
Symptoms: Fatigue, Swelling, Frequent urination
 Stage 4:

Severe loss of the function and GFR of 15-29%.

Symptoms: Fatigue,fluid retention, swelling, shortness of breath

Stage 5:

Kidney failure and GFR of under 15%.

Symptoms: Itching, Trouble Sleeping, Metallic taste, vomiting, Muscle Cramps
SYMPTOMS:

• Swollen ankles, feet, lower legs, or hands due to water

retention.
• Darker urine due to blood in the urine.
• Shortness of breath.
• Fatigue due to lack of oxygen in the blood.
• Nausea and vomiting.
• A metallic taste in the mouth.
• Muscle weakness
 Diagnostic Test:
To determine whether you have diabetic kidney disease, you may need certain tests and procedures, such as;

 Blood test. If you have diabetes, you will need blood tests to monitor your
condition & determine how well your kidneys are working.
 Urine test. Urine samples provide information about your kidney functions and
whether you have too much protein in the urine. High levels of protein called
microalbumin may indicate your kidneys are being affected by disease.
 Imaging test. Your doctor may use X-rays and Ultrasound to assess your
kidneys structure and size.
 Renal function testing. Assess your kidneys filtering capacity using renal dialysis
testing.
 Kidney biopsy. Your doctor may recommend a kidney biopsy to remove a
sample of the kidney tissue.
Treatment:
Medication:

Control high blood pressure. Medications called angiotensin-converting enzyme (ACE) inhibitors
and angiotensin II receptor blockers (ARBS) are used to treat high blood pressure.

Manage high blood sugar. Several medications have been shown to help control high blood sugar
in people with diabetic nephropathy.

Foster bone health. Medications can often or help manage your calcium phosphate balance.

Control protein in urine. Medications can often reduce the level of the protein albumin in the
urine and improve kidney function.
 Late stage treatment option:

1. Kidney dialysis. Is a procedure that typically uses a machine to separate waste products from the
blood and remove them from the body.
Types of dialysis
 Hemodialysis: A medical procedure to remove fluid and waste products from the
blood and to correct electrolyte imbalances.
This is accomplished using a machine and a dialyzer, also referred to as an “artificial kidney”
Hemodialysis is used to treat both acute (temporary) and chronic (permanent) kidney
failure.
 Peritoneal dialysis. Is a treatment that uses the lining of your abdomen (belly area),
called your peritoneum, and a cleaning solution called dialysate to clean your blood.
Dialysate absorbs waste and fluid from your blood, using your peritoneum as a
filter.
2. Kidney transplant. A kidney transplant if diabetic nephropathy reaches the final stage and if a
suitable donor can provide a kidney.
PREVENTION:

Life changes that can help with this include:

Eating a nutritious diet that is high in fiber and low in sugar, processed
carbohydrates and salt.
Exercising regularly
Limiting alcohol intake
Avoiding tobacco
Checking blood glucose levels regularly
Following any treatment plan their doctor suggests.
Limiting stress where possible
III. THEORETICAL FRAMEWORK
 THEORITICAL FRAMEWORK
VIRGINIA HENDERSON
14 BASIC NEEDS
The theory focuses on the importance of increasing the patient’s
independence to hasten their progress in the hospital.
Henderson’s theory emphasize on the basic human needs and
how nurses can assist in meeting those needs.
The 14 components of the need theory show a holistic approach
to nursing that covers the physiological, psychological, spiritual
and social needs.
• Breath normally
• Eat and drink adequately
• Eliminate body wastes
• Move and maintain desirable postures
• Sleep and rest
• Select suitable clothes-dress and undress
• Maintain body temperature within normal range by adjusting, clothing and modifying environment.
• Keep the body clean and well- groomed and protect the integumentary (skin).
• Avoid dangers in the environment and avoid injuring others.
• Comminuting with others in expressing emotions, needs, fears, or opinions
• Worshipping according to one’s faith
• Working in such a way that one feels a sense of accomplishment
• Playing or participating in various forms of reactions
We choose this theory of Virginia Henderson a theory of “14 basic human needs”, because
based of our patient’s condition, we need to emphasize the need of our patient Mrs. L, so as a
nurse we need to able to meet the need of our client to support system especially on
emotional needs, which in many cases provided by the family.
Our patient has a body weakness and inability to stand / move on her own, as a nurse or
nursing student we give her courage to fight or boost her self-esteem for her fast recovery. We
told her the outcome if she will follow the treatment and proper medications.
One, of Henderson human need means is to promote and protect the integumentary. The
important teaching to our client is to protect her because she’s prone for impaired skin due to
high glucose level. According to Henderson the nurse as a substitute, a helper, and partner with
the patient. In short, we need to promote health, maintaining the health and the balance of
nutrition so that the client is able to meet the optimum level of health. We teach and explain to
the client based on her educational level.
IV. DEVELOPMENTAL TASK
ERIK ERIKSON
STAGES OF PSYCHOSOCIAL DEVELOPMENT
The premise of Erikson’s stages of psychosocial development is that a
person’s psychosocial development, from infant to elderly, depends on how
certain psychosocial crisis are resolved.
Erik Erikson (1902-1994) proposed that we all encounter certain crises
that can contribute to our psychosocial growth throughout our lifespan. He
presented this crisis as eight stages of psychosocial conflicts, often kwon as
Erik Erikson’ stages of psychosocial development.
ERIK ERIKSON’ STAGES OF PSYCHOSOCIAL
DEVELOPMENT.

Trust vs. Mistrust

(Infant – 18 months)
Autonomy vs. Shame/Doubt
(18 months – 3 years)
Initiative vs. Guilt
(3 – 5 years)
Industry vs. Inferiority
(5 – 13 years)
Intimacy vs. Isolation
(21 – 39 years)

 Generativityvs. Stagnation
(40-65 years)

 Integrityvs. Despair
(65 – To Death)
Generativity vs. Stagnation
(40-65 years)

Generativity vs stagnation is the seventh of eight stages of Erik Erikson’s theory.

This stage takes place during middle adulthood between the ages of approximately 40
and 65.
During this time, adults strive to create or nurture things that will outlast them; often
by parenting changes that benefit other people. Contributing to society and doing
things to benefit future generations are important needs, as well as creating and
accomplishing things that make the world a better place, Generativity.

While in Stagnation refers to the failure to find a way to contribute. These

individuals may feel disconnected or uninvolved with their community and with
society as a whole.
Our patients belong to this Stages, a Generativity. According to Mrs.L, even though
she was not able to graduate, it does not matter now because what is important is
that she was able to support their kids with their dreams in education. Seeing them
content in life makes her feel having had a good purpose and a significant contribution
to this world.
In some event, she would join the neighbor to go to church. Sometimes, she would
gladly participate in a community outreach program. Consistent with her stories, this
make her feel so pleased and delighted every after activity she joins. In addition, she
feels she has achieved and fulfilled a mission in life even after death.
Upon admission Mrs. L didn’t Participate any community outreach program because
of her disease, she can’t stand on her own because of body weakness.
V. PHYSIOLOGIC MEASUREMENT
PHYSIOLOGIC MEASUREMENT

DURING ADMISSION DURING ASSESSMENT

Temperature 35.6°C 37.2°C

Blood pressure 80/50 mmHg 90/70 mm Hg

Respiratory rate 22 cpm 26 cpm

Pulse rate 105 bpm 87 bpm

Weight 47 kgs 50 kgs

PRESENT HISTORY
Patient was scheduled last July 13, 2019 diagnosed of Chronic Kidney Disease. On July 15, 2019, the
client was admitted a Final Diagnosis of Chronic Kidney Disease Secondary to Diabetic
Nephropathy

PAST HISTORY
The client was admitted in the first month of 2019 diagnosed of diabetes milletus.

FAMILY HISTORY
Our patient stated “Diabetes man an ginkamatayan san akon Papa”.
The family History of our patient is Diabetes.

LIFESTYLE
Our client doesn’t have any vices.
VI. 13 AREAS OF ASSESSMENT
 13 AREAS OF ASSESSMENT

I. Social Status
Mrs. L is a 55 years old female client, born on July 7, 1964 and is currently residing at Mobo,
Masbate. She lives her husband and she have five (5) children; two (2) sons, and three (3) daughters.
During our assessment her husband and daughter accompanied her in the hospital. Her husband is
approachable and friendly whenever we asked his attention.

II. Mental Status

During our assessment the patient is able to state correctly the place and time. We asked her if
where she is, “ Adi man ako sa provincial yana”, as verbalized by the patient. The patient is able to
read words shown to him.
Upon our assessment, Mrs. L is oriented to time and place and able to deliver concrete messages.
We asked anexplain anything regarding to her disease based or matched on her educational level.
Mrs. L was able to respond in questions asked to her.
III. Emotional Status
During our assessment, we asked her if she is aware about her ailment “ oo kay dugay ko na
ini gina batyag pero sugad ko la naaraman na igwa ako sin diabetes”, as verbalized by the
client. We asked her also what she feels about her condition “naga pangluya lang ang akon
lawas”, as stated by the client.
Upon our assessment, Mrs. L is aware regarding her condition.

IV. Sensory Perception

Sense of Sight
The client is asked to read a printed letter at the distance of 1 meter occluding the other
eye. The client had read the letters without difficulty on the right eye but blurry on the left
eye. Patient’s eye is symmetrical in moving.
Upon our assessment with the given data, Mrs. L can read, extraocular movement, and
papillary response is normal.
 Sense of Taste
During our assessment Mrs. L was examined using variety of food which taste salty, bitter,
sweet, and sour. Mrs. L was able to differentiate each taste.
Upon our assessment, the client’s sense of taste is normal.
Sense of Hearing
For the auditory assessment, every word that we whispered the patient was instructed to
repeat it.
Upon our assessment based on the given data, patient’s auditory is normal.
Sense of Smell
The patient’s nose is in the midline of the face and is symmetrical, there was no any
obstructions or secretions. We provided alcohol to test it.
 Tactile Sensitivity
During our assessment in the examination of the touch sensation of the
patient, she was instructed to tell what she feels when she was going to be
pricked on her arm. Mrs. L responded and stated that the pricking was felt.
Upon our assessment, Mrs. L’s sensory transmission, functions well as
manifested by the data presented.
V. Motor Stability and Gait
During our assessment Mrs. L gait was assessed. We asked her if she can stand on ger own
balance by herself, “makatindog ako pero kailangan ko san alalay kay natutumba ako”, “ may igwa
man manas an akon mga tiel” as verbalized by the client.
Assessment of the range of motion of the patient was done through instructions which include
the ability of the patient to bend her shoulder apart. She can also move her shoulder laterally
and medially as well as rotate his shoulder in the same manner. She can also bend her elbow
and can lift her both hands.
The patient has difficulty in flexing and extending his left knee of her ankle and foot. Tilting her
foot inward and moving it toward and away the midline of her body is also a difficult thing to
do. Her neck is systematical with her head in central position.
Mrs. L gait is hindered due to her physical position. Muscle weekend and Edema is present on
lower extremities which results in gait difficulty.
VI. Body Temperature

Date Assessed Time Temperature

July 23, 2019 2:30 pm 37.2°C

July 24, 2019 3:00 pm 36.9°C

July 25, 2019 2:10 pm 36.0°C

Upon assessing Mrs. L temperature, the given

above indicates that she had a normal body
temperature during our assessment.
VII. Respiratory Status
.

Date Assessed Time Respiratory Rate

July 23, 2019 2:30 pm 26 cpm

July 24, 2019 3:00 pm 31 cpm

July 25, 2019 2:10 pm 31 cpm

Mrs. L had above normal range interpretation of

tachypnea.
VIII. Circulatory Status

Date Assessed Time Pulse Rate Blood Pressure

July 23, 2019 2:30 pm 87 bpm 90/70 mm Hg

July 24, 2019 3:00 pm 78 bpm 120/60 mm Hg

July 25, 2019 2:10 pm 85 bpm 130/90 mm Hg

During our assessment of her capillary refill, her nail beds returned to its
original color after four (3) seconds.

Upon our assessment the data given above shows that Mrs. L’s pulse rate is in
normal range. On July 23 and 24 the blood pressure of our client is below normal an
interpretation of below normal while on July 25 her blood pressure is above normal
an interpretation of hypertension. Her capillary refill is not normal.
IX. Nutritional Status
Before hospitalization, Mrs. L usually prefer to eat fish, meat and sometimes vegetable. She eats two
(2) whole meals per day (skip either breakfast or dinner). During admission, Mrs. L eats three (3)
meals “lugaw kag sabaw”. Patients verbalized “permi ako ginagutom”. She drinks six (6) to seven (7)
glasses a day.

X. Elimination Status
Before hospitalization, Mrs. L usually defecate three times (3x) a week and she said, “itom
an akon udo”. During admission and during our assessment she did not defecate since she
admit.
The clients had a catheter with six hundred (600) cc per hr and the color of the urine is
dark yellow.
XI. Reproductive Status
Mrs. L verbalized “45 years old nag udong an akon regla”.

XII. Sleep-Rest-Pattern
Mrs L before her hospitalization stated that she sleeps almost 6-7 hours a day. But during
hospitalization her sleeping pattern has been change she stated due to environmental
factor.

XIII. State of Skin and appendages

As we assessed the client, the IV site at her left hand. There is absence of infiltration. Her
skin is warm to touch and dry. Mrs L has a black with gray color.
Mrs. L has a smooth skin turgor. He has a normal hair texture, distribution, color and
absence of any skin wounds.
VII. LABORATORY RESULTS
HEMATOLOGY
Parameter Result Ref. Range Interpretation
HGB 9.4 11.0-16.0 Anemia
HCT 25.7 37.0-54.0 Decrease
WBC 21.59 4.00-10.00 Leukocytosis
Nue% 89.8 50.0-70.0 Neutrophilia
Lym% 5.7 20.0-40.0 Lymphocytopenia

Mon% 4.2 3.0-12.0 Normal

Eos% 0.1 0.5-5.0 Eosinophilia
Bas% 0.2 0.0-1.0 Normal
RBC 3.57 3.50-5.50 Normal
PLT 397 150-450 Normal
MCV 71.9 80.0-100.0 Microcytic anemia
MCH 26.4 27.0-34.0 Normal
MCHC 36.7 32.0-36.0 Normal
RDW-CV 13.8 11.0-16.0 Normal
RDW-SD 40.7 35.0-56.0 Normal
MPV 8.1 6.5-12.0 Normal
PDW 10.0 9.0-17.0 Normal
PCT 0.323 0.108-0.282
URINALYSIS

Analysis Result Range Interpretation

CHOLESTEROL 2.79 mmol/L 0.000-5.200 Normal

TRIGLYCERIDES 2.56 mmol/L 0.500-1.570 High cholesterol

HDL DIRECT 0.22 mmol/L 1.380-6.000 Low cholesterol

URIC ACID 581.27 mmol/L 149.0-479.0 Hyperuricemia

BUN 17.95 mmol/L 2.990-8.820 Elevated BUN

CREATININE 146.44 umol/L 35.40-123.8 High Creatinine

LDLC 1.401 mmol/L 0.000-2.700 Normal

SERUM ELECTROLYTES

Test Result Nomal value Interpretation

Potassium 4.32 mmol/L 3.6-5.4 mmol/L Normal

Sodium 130.3 mmol/L 134-148 mmol/L Hyponatremia
Chloride 93.0 mmol/L 99-108 mmol/L Hypochloremia
Total Chloride 2.13 mmol/L 2.0-2.6 mmol/L Hyperchloremia
Ionized Calcium 1.09 1.0-1.3 mmol/L Hyperparathyroid
ism
pH
 Analysis Result Range Interpretation

SGPT 32.46 U/L 5.00-34.00 Normal

SGOT 29.41 U/L 5.00-34.00 Normal

RANDOM BLOOD SUGAR

Date/Time Result Range Interpretation
July 16 2019 431 mg/dL 70-180 mg/dL Hyperglycemia
July 18 2019 408 mg/dL 70-180 mg/dL Hyperglycemia
July 19 2019 405 mg/dL 70-180 mg/dL Hyperglycemia
July 23 2019 475 mg/dL 70-180 mg/dL Hyperglycemia
July 25 2019 131 mg/dL 70-180 mg/dL Normal
VIII. ANATOMY
ANATOMY OF THE KIDNEY

The kidneys are a pair of bean-shaped, brown organs about the

size of your fist. They are covered by the renal capsule, which is a
tough capsule of fibrous connective tissue. Adhering to the
surface of each kidney are two layers of fat to help cushion
them.
 The kidneys are the primary functional organ of the renal system. They are
essential in homeostatic functions such as the regulation of electrolytes,
maintenance of acid–base balance, and the regulation of blood pressure (by
maintaining salt and water balance). They serve the body as a natural filter of
the blood and remove wastes that are excreted through the urine.
They are also responsible for the reabsorption of water,
glucose, and amino acids, and will maintain the balance of
these molecules in the body. In addition, the kidneys
produce hormones including calcitriol,
erythropoietin, and the enzyme renin, which are
involved in renal and hematological physiological
processes.
There are three major regions of the kidney:
1. Renal cortex
The cortex provides a space for arterioles and venules from the renal artery and vein, as well as the
glomerular capillaries, to perfuse the nephrons of the kidney. Erythropoietin, a hormone necessary
for the synthesis of new red blood cells, is also produced in the renal cortex.
2. Renal medulla
The inner-most region of the kidney, contains the majority of the length of nephrons, the main
functional component of the kidney that filters fluid from blood.
3. Renal pelvis
The renal pelvis contains the helium. The hilum is the concave part of the bean-shape where blood
vessels and nerves enter and exit the kidney; it is also the point of exit for the ureters—the urine-
bearing tubes that exit the kidney and empty into the urinary bladder. The renal pelvis connects the
kidney to the rest of the body.

The cortex and medulla make up two of the internal layers of a kidney and are composed of
individual filtering units known as nephrons.
Supply of Blood and Nerves to the Kidneys
The renal veins drain the kidney and the renal arteries supply blood to the kidney.
Because the kidney filters blood, its network of blood vessels is an important component of its
structure and function. The arteries, veins, and nerves that supply the kidney enter and exit at the
renal hilum.
Renal Artery
These arise off the side of the abdominal aorta, immediately below the superior mesenteric artery,
and supply the kidneys with blood. The renal arteries split into several segmental arteries upon
entering the kidneys, which then split into several arterioles.
These afferent arterioles branch into the glomerular capillaries, which facilitate fluid transfer to
the nephrons inside the Bowman’s capsule, while efferent arterioles take blood away from the
glomerulus, and into the interlobular capillaries, which provide tissue oxygenation to the
parenchyma of the kidney.
Renal Vein
The renal veins are the veins that drain the kidneys and connect them to the inferior vena cava.
The renal vein drains blood from venules that arise from the interlobular capillaries inside the
parenchyma of the kidney.
Renal Plexus
The renal plexus is the source of nervous tissue innervation within the kidney, which
surround and primarily alter the size of the arterioles within the renal cortex. Input from
the sympathetic nervous system triggers vasoconstriction of the arterioles in the kidney,
thereby reducing renal blood flow into the glomerulus.
The kidney also receives input from the parasympathetic nervous system, by way of the
renal branches of the vagus nerve (cranial nerve X), which causes vasodilation and
increased blood flow of the afferent arterioles. Due to this mechanism, sympathetic
nervous stimulation will decrease urine production, while parasympathetic nervous
stimulation will increase urine production.
A Nephron
A nephron is the basic structural and functional unit of the kidneys that regulates water
and soluble substances in the blood by filtering the blood, reabsorbing what is needed, and
excreting the rest as urine. Its function is vital for homeostasis of blood volume, blood
pressure, and plasma osmolarity. It is regulated by the neuroendocrine system by
hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.

The Glomerulus
The glomerulus is a capillary tuft that receives its blood supply from an afferent arteriole
of the renal circulation. Here, fluid and solutes are filtered out of the blood and into the
space made by Bowman’s capsule.
IX. PATHOPHYSIOLOGY
 Chronic Kidney Disease
(Diabetic Nephropathy)

PREDISPOSING FACTORS: PRECIPATING FACTORS:

(Non-modifiable) (Modifiable Risk Factor)
>Race >Diabetes
>Family history of kidney disease

>Decreased renal blood flow

Hypertension
>Urine outflow obstruction

↑BUN Decreased Glomerular Filtration ↑Serum

Creatinine

Hypertrophy of remaining Loss of

nephrons Sodium in Hyponatremia
Urine

Inability to concentrate urine

 Further loss of nephron function

Loss of non-excretory Loss of excretory renal

renal function function

↑Calcium Failure to Immune Excretion of Decreased

↑Productio nitrogenous sodium
absorption produce Disturbance
n of Lipids reabsorption
erythropoietin waste
in tubule

Uremia Water
Anemia Infection
Retention

↑BUN
Impaired insulin ↑Creatinine Edema
production ↑Uric Acid
X. NURSING CARE PLAN
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Ineffective tissue Within 1-2days of nursing 1. Monitor BP changes. 1. Hypovolemia is Goal met. After 1-2 days
Subjective cues: perfusion related to interventions the patient manifested by of nursing interventions.
“Maluya lang an akon decreased hemoglobin will be able to demonstrate hypotension along with The patient shall have
lawas” as verbalized by concentration in blood increased perfusion as tachycardia and demonstrated increased
the client. secondary to Chronic individually appropriate tachypnea estimates of perfusion as individually
Kidney Disease as (e.g. fatigue, weakness the severity the appropriate
Objective cues: evidenced by fatigue, and pallor must absence) hypovolemia may be (e.g. fatigue, weakness
 Fatigue weakness, and pallor. and BUN,Cr within normal made when BP drops and pallor must
 Weakness range. more than 10mmHg. absence) and BUN,Cr
 Pallor within normal range.
 Anemia 2. Monitor and record RBC 2. Provide assessment of
*Hgb results:9.4g/dl count, hgb & hematocrit levels degree of anemia.
*Normal:11.0-16.0 dl as indicated.
3. Note characteristics of urine
3. To assess for hematuria &
 Elevated lab results: specific gravity. proteinuria and renal
*BUN results: 17.95 L impairment.
Normal: 2.99-8.820L 4. Review laboratory studies 4. Increase BUN & Creatinine
*Creatinine: 146.44L (e.g. BUN & creatinine levels) levels may alter mentation.
*Normal: 35.40- and note mentation status.
123.8L 5. Measure urine output on a 5.To assess renal perfusion
regular schedule. and function.
 Hypertension
130/90mmHg 6. Provide for protein diet 6. Calories help to meet the
restrictions, as indicated, body’s needs; eating large
while providing adequate amounts of protein can
calories. increase levels of BUN &
creatinine.
7. Encourage patient 7. reductions in
to eat more fiber. creatinine/BUN levels in
(fruits, people with chronic
vegetables and kidney disease who
whole grains) increased their fiber
intake

8. RBC need iron folic

8. Administer acid & multivitamins,
medications as epogen stimulates the
prescribed, including bone marrow to
iron & folic acid such produce RBC.
as supplements, &
multivitamins.
 Multivitamins +
iron (hemarate)
1tab once a day,
after breakfast.
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective cues: Hyperglycemia related to Within 1.- 3hours of 1. Blood sugar monitoring. 1. Assess blood glucose Goal met. After 1.- 3hours of
decrease insulin nursing interventions the Normal range 70-180 level before meals and nursing interventions the patient
production Secondary to patient will be able to mg/dL. at bedtime. will be able to Maintain blood
Objective cues: Type II Diabetes as Maintain blood glucose 2. Monitor feet and educate 2. Decreased blood flow glucose levels within normal
evidenced by high glucose levels within normal limits patient of importance for to the feet and limits of 131 mg/dl and prevent
 RBS RESULTS: level . of 70-180 mg/dl and foot monitoring. Monitor neuropathy cause the complications and
431 mg/dL prevent complications and foot care. reduction in sensation. progression of disease.
(7/16/19) progression of disease.
408 mg/dL 3. Monitor vitals/blood 3. Diabetic patients are at
(7/18/19) pressure. higher risk of hypertension.
405 mg/dL Vascular strain can affect
(7/19/19) 4. Educate patient on how to vision, kidney function or
475 mg/dL self-administer insulin at lead to stroke and heart
(7/23/19) home. attack.

Normal Value: 5. Nutrition and Lifestyle 4. Glucose vales are used

70-180 mg/dl education. to adjust insulin doses.
 Exercise (brisk walking,
 Hyperglycemia water aerobics,
 Polyphagia swimming, or jogging) 5. To Increase circulation
 Make healthy diet, a fiber and lead to reduced blood
diet (Beans, carrots, sugar levels
whole grains or brown
Rice and cereals)
 6. Administered 6. Adherence to the
insulin therapy and therapeutic regimen
antidiabetic regularly, promotes tissue
as ordered perfusion, keeping
• Insulin glargine glucose in the normal
(Apidra) 10 units range slows
subcutaneous
• (Toujeo) 20 units
subcutaneous
once a day.
• Linagliptin 5
mg/tab, 3x a day
 Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation
Subjective cues: Excess fluid volume Within 1-2 days of 1. Note amount/rate of 1. To monitor fluid Goal met. After 1-2 days
“may igwa manas an akon related to sodium nursing interventions the fluid intake from all retention & evaluate of nursing interventions
mga tiel” as verbalized by sources (PO, IV,). degree excess.
retention. client’s will be able to the client’s will be able to
the client. 2. Compare current 2. Provides
stabilized fluid volume weight with admission comparative baseline. stabilized fluid volume as
as evidenced by and/or previously evidenced by balanced
Objective cues: balanced I/O, stable stated weight. I/O, stable weight, and
 Pitting edema weight, and free of signs free of signs of edema.
(lower extremities) 3. That may indicate
of edema. 3. Note presence of
 Catheter is present increase in fluid
Edema.
 Oliguria retention.
5. Results: 600cc per
24hr
4. Review laboratory 4. Monitoring of
6. Normal: 800-2000ml
per 24hr data changes & evaluating
(e.g. BUN/Cr, serum, effectiveness of
 Weight gain electrolytes and urine interventions.
47 kls (Before)
specific gravity).
50 kls. During
hospitalization 5.To prevent
5. Set an appropriate
rate of fluid peaks/valley in fluid
intake/infusion level
throughout 24-hour
period.
(D5W IVF of 700 cc).
6. Evaluate edematous 6. To reduce tissue
extremities, change pressure and risk of
position frequently. skin breakdown.
• Lying with your bed
with your legs
elevated is the best
position.

7. Administer Diuretics, as 7. To excrete excess

prescribed fluid
• Metolazone 5mg 1tab
once a day after
lunch
XI. DRUGS STUDY
 DRUG NAME CLASSIFICATI ACTION INDICATION CONTRA SIDE EFFECT NURSING
ON INDICATION CONSIDERATION
Generic name; Anticoagulant, Used for the Vascular Hypersensitivity to GI disorders: - Assess patients for signs
Anti prophylaxis and pathologies with soludexide, heparin - Nausea of bleeding and hemorrhage
Soludexide thrombotics treatment of thrombotic risk, and heparin like - Vomiting unusual bruising, black tarry
fibrinolytic thromboembolic transient products. - Epigastragia at the stools. Notify physician if
Brand name; disease however ischemic attacks side of injection. these occur.
Vessel due recent research and - Diaresis and - Chills
has also cerebrovascular hemorrhagic - Fever - Monitor patient for
demonstrated the disease, diseases. - Urticaria hypersensitivity reactions
beneficial effect peripheral - Pain (chills, fever, urticarial.)
of sulodexide in vascular Report signs to physicians
 1 ampule, animal models or insufficiency,
slow IV, reperfusion injury diabetic - Monitor platelet count
once a day. and the treatment retinopathy, MI, every 2-3 days throughout
of diabetic retinal vassal therapy. May cause mild
nephropathy. thrombosis. thrombocytopenia w/c
appears on the 4th day and
resolves despite continued
heparin therapy.
 DRUG CLASSIFICAT ACTION CONTRA SIDE EFFECT NURSE
NAME ION INDICATIO INDICATION CONSIDERATION
N
Generic Xanthine Decreases Atenurix is a Coadministration - Dizziness - Instruct patients to
name: oxidase serum uric acid xanthine with - Skin rash contact health care
inhibitor by inhibiting oxidase (XO) azathioprine, - Nausea provider if they experience
Febuxostat xanthine inhibitor mercaptopurine, - joint pain/ swelling/ chest pain, rash,
oxidase. indicated for or theophylline. stiffness shortness of breath, or
Brand name: the chronic neurologic symptoms
Atenurix management suggesting a stroke.
of
hyperuricemia - Advise patient that
in patients product may be taken
 40mg/tab, with gout.. without regard to meals.
1tab
 once a - Advice that concomitant
day prophylaxis with an
 after NSAID or colchicine for
lunch. gout flares may be used.
 CONTRA SIDE EFFECT NURSE CONSIDERATION
DRUG NAME CLASSIFICATION ACTION INDICATION INDICATION
Generic name: Therapeutics: In normal individuals, Supplements -Hypercalcemia, Hypercalcemia Before:
Ketoanalogue supplements there is an increase indicated for disturbed amino acid May develop. 1.Assess electrolyte levels
in the plasma level of patients having metabolism. 2.Explain therapeutic value of drugs
Trade name: ketoanalogues, 10 urologic problems 3.Assess allergy to the drug
Ketosterile min. after oral like chronic kidney - In case of heredity 4.Caution patient of the different
ingestion. These level disease. phenylketonuria, it has side effects
reach values that are to be taken into 5.Assess vital sign
approximately 5 account that 6.Proper preparation of the drug.
 1tab, times higher than the ketoanalogue contains During
 3x a day initial level. Peak phenylalanine. 1. Verify patient ‘s identity
 after lunch. levels are reaches 2. Administered with food to prevent
within 20-60 min and - Disturb amino acid GI upset.
normal levels are metabolism 3. Administer drug at right time,
reached again after route, and dosage.
90 min. 4. Advice to swallow the tablet
gastrointestinal whole.
absorption is thus 5. Monitor vital sign.
very rapid. Due to the After
natural pathways of 1. Document administration of drug.
disposal of a-ketonic 2. Instruct patient to report
acids in the immediately if symptoms of
organism, it is hypercalcemia. Occurs like muscle
probable that weakness, constipation.
exogenous intakes 3. Monitor calcium levels.
are very rapidly 4. Monitor for signs of
integrated hypercalcemia and electrolyte
Intometabolic cycles. levels.
5. Monitor vital signs especially
cardiac changes.
DRUG CLASSIFICATI ACTION INDICATION CONTRA SIDE EFFECT NURSE CONSIDERATION
NAME ON INDICATION
Generic Proton pump Gastric acid Short term Contraindicated Diarrhea, nausea,  Caution patient to swallow
name: inhibitors (PPI) pump inhibitor; treatment of with fatigue, constipation, capsules whole not to open,
suppresses activeduodenal hypersensitivity to vomiting, flatulence, chew, or crush them.
Omeprazole gastric acid ulcer; first omeprazole or its acid regurgitation, Arrange for further
secretion by linetherapy in components; use taste perversion, evaluation of patient after
specific inhibition treatment of cautiously with arthralgia, myalgia, weeks of therapy for gastro
Brand name: of the hydrogen heartburn or pregnancy, urticarial, dry mouth, reflux disorders; not
Prilosec potassium ATP symptoms of lactation. dizziness, headache, intended for maintenance
as enzyme gastroesophaged par aesthesia, therapy.
system at the refluxdisease abdominal pain, skin  Administer antacids with
gastric parietal (GERD rashes, weakness, omeprazole, if needed.
 40 mg. cells; blocks the back pain, upper
IV every final step of acid respiratory infection,
24 production. cough.
hours.
 Name of Drug Dosage, Mechanism of Indication Contraindication Side-Effects Nursing Responsibilities
Route & Action
Frequency
Generic Name: 1 tab once a  To prevent
day after vitamin &  Prevention &  Hypersensitivity  Nausea and vomiting  Advise patient to take
MV + Iron breakfast. iron- treatment of iron to any of the  Bloating medicine as prescribed.
deficiency deficiency component of  Upper abdominal  Advised patient to take iron
anemia. anemia, folate the product, discomfort for high Fe supplements an hour before
Brand Name: deficiency & for patients with doses, meals for maximum
the lowering of primary  Diarrhea or absorption.
Hemarate plasma hemochromatos constipation  Advised patient to take liquid
homocysyeteine. is, peptic ulcer  Staining of teeth forms of iron using a straw to
or ulcerative  Stools may appear prevent teeth staining.
colitis. darker in color.  Treat underlying case of iron
deficiency anemia through
diet and iron
supplementation.
 Educate about foods high in
iron which includes organ and
other meats, leafy vegetables,
raisins, and beans.
 Encourage client to have diet
rich in vitamin C to enhance
absorption of iron in iron-rich
foods.
 DRUG DOSAGE Actions INDICATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

 Orthostatic hypotension
Classification : 5mg 1tab,  To get rid of  Treatment of salt  Anuria  Excessive volume  Assess fluid status throughout
Diuretics once a day, excess of and water  Allergy or depletion, therapy
after lunch water. retention . hypersensitivity to  Palpitations  Monitor daily weight, intake and
 for the treatment metolazone output, amount and location of
Brand Name:  Joint pain
of hypertension. edema and skin turgor.
 Electrolyte imbalance:
- Hypokalemia  Monitor electrolytes before and
Metolazone - Hyponatremia periodically throughout of therapy.
- Hypomagnesemia  Monitor BP before and during
administration.
 Instruct patient to take medication
exactly as directed.
 DRUG DOSAGE Action INDICATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

Classification : 5 mg tab, helps to lower high Indicated as an  Hypersensitivity  Hyperlipidemia  Before taking linagliptin,
3 times a day blood glucose adjunct to diet and  Type 1 diabetes  Cough assess if the client has allergy
Antidiabetic exercise to improve mellitus  Hypertriglyceridemia in medication.
glycemic control in  Diabetic  Weight gain  Before using this medication,
adults with type 2 ketoacidosis  Hypoglycemia tell your doctor or pharmacist
Brand Name: diabetes mellitus. your medical history,
especially of: disease of the
Linagliptin pancreas (pancreatitis).

 You may experience blurred

vision, dizziness, or
drowsiness due to extremely
low or high blood sugar
levels. Do not drive, use
machinery, or do any activity
that requires alertness or
clear vision until you are sure
you can perform such
activities safely.

 Limit alcohol while taking this

medication because it can
increase your risk of
developing low blood sugar.

 Before having surgery, tell

your doctor or dentist about
all the products you use
(including prescription drugs,
nonprescription drugs, and
herbal products).
 Name of Drug Classification Dose/Freq/Route Mechanism of Action Indication Side effect Nursing Implication

Brand Name: Anti-Diabetic  10 units Insulins lower blood Type 1 diabetes (in  Hypoglycemia  Assess patient for signs and
subcutaneous glucose by stimulating adults and children)  Insulin resistance symptoms of hypoglycemia
Apidra  14 units peripheral glucose and type 2 diabetes  Lipodystrophy (anxiety; restlessness; tingling
 Lipohypertrophy
subcutaneous uptake by skeletal (in adults). in hands, feet, lips, or tongue;
 Local allergic rxn
 16 unit muscle and fat, and by  Hypokalemia chills; cold sweats; confusion;
subcutaneous inhibiting hepatic cool, pale skin; difficulty in
 Repeat RBS 2 glucose production concentration; drowsiness;
hours after nightmares or trouble
sleeping; excessive hunger;
headache; irritability; nausea;
nervousness; tachycardia;
tremor; weakness; unsteady
gait)
 Monitor body weight
periodically. Changes in
weight may necessitate
changes in insulin dose
 Assess patient for signs of
allergic reactions (rash,
shortness of breath,
wheezing, rapid pulse,
sweating, low BP) during
therapy
 Name of Drug Classification Dose/Freq/Route Mechanism of Indication Side effect Nursing Responsibilities
Action
Brand Name: Anti-Diabetic  20 units  Insulins lower  Is indicated  Respiratory  insulin is only intended
subcutaneous, blood glucose to improve infections such for the subcutaneous
Toujeo Once a day by stimulating glycemic as the common route, which is the layer
peripheral control in cold, flu, and of skin below the dermis
glucose uptake adults and bronchitis and epidermis.
by skeletal pediatric  Insulin should not be
 low blood sugar
muscle and fat, patients with mixed with any other
(hypoglycemia)
and by type 1 insulin solutions.
inhibiting diabetes  fluid retention  The rate at which insulin
hepatic mellitus and with swelling of is absorbed, the oriset, &
glucose in adults the arms or legs duration is affected y the
production with type 2  weight gain amount of exercise,
diabetes illness, food, and
mellitus.  pain, rash, amount of stress one is
swelling, and experiencing.
itchiness at the
injection sites
 skin thickening or
pits at the
injection sites
 Name of Drug Dosage, Mechanism of Indication Contraindication Side-Effects Nursing Responsibilities
Route & Action
Frequency

Classification: 1.5 gram. Bactericidal: Lowers respiratory Contraindicated with CNS: Headache, dizziness, BEFORE:
Inhibits infections caused by allergy to lethargy Do Skin Testing into the intradermal
Antibiotic synthesis of Streptococcus cephalosporins or area
Cephalosporin bacterial cell pneumonia, penicillins. GI: Nausea, vomiting,
wall causing Staphylococcus Use cautiously with diarrhea, anorexia, Protect Drug from light
cell death. aureus, Haemophilus renal failure. pseudomembranous colitis
Generic Name: influenza, E. coli, Do not mix ceftriaxone with other
Enterobacter HEMATOLOGIC: bone antimicrobial drug
aerogenes. marrow depression – dec.
Ceftriaxone WBC, platelets, Hct DURING:
Intra-abdominal Use a separate syringe when giving
infections caused by LOCAL: pain, inflammation of this drug
E.coli, Klebsiella IV Site
pneumoniae Have Vitamin K available in case of
OTHER: superinfections, hypoprothrombinemia occurs
disulfiram-like reaction with
alcohol AFTER:
Discontinue if hypersensitivity
occurs

Monitor Blood levels in patients

taking this drug
 XII. DISCHARGE PLAN
 M – ethods
 E - xercise
 T – reatment
 H – ealth Teaching
 O – utpatient
 D - iet
 S - pirituality
 MEDICATIONS
• HOME MEDS:
INSULIN TOUJEO
20-30 unit’s insulin injection
• Instruct patient to take prescribed medications regularly and comply with the
treatment regimen prescribed by the physician.

 EXERCISE
• Explain to patient the significance of regular exercise like walking and stretching.
If unable to mobilize alone, instruct the watcher to give assistance all the time.
Stretching upper extremities also promote healthy living.
• Exercise (brisk walking, swimming, or jogging).
 TREATMENT
• Instruct patient to comply with her medication treatment like the
continuous use Insulin for diabetes mellitus.
• Advise to have a family member take your blood pressure to check if
you’re maintaining a stable blood pressure.
• Since the client has her own glucose monitor, tell client to continue
monitoring blood glucose level, and immediately seek for medical help if
level is abnormally high.
• Tell the patient when and how to take blood glucose-lowering
medications, including method of administration.
 HEALTH TEACHING
• Instruct patient to practice foot care to prevent ulceration and formation of gangrenous
tissues to the lower extremities.
• Soak your feet in warm soapy water for 10 minutes before cutting your nails. Trim your
toenails straight across to prevent ingrown toenails.You may also file down your toenails.
Do not cut your nails into the corners or close.
• Educate the client on proper use and disposal of needles and syringes.

 OUTPATIENT
• Advise to have follow up check-ups after discharge.
• Advise to have regular laboratory exams for creatinine, albumin, sodium, potassium and
calcium.
DIET
• Encourage patient to eat fibrous foods like fruits and vegetables. But do
not eat too much as it can irritate the GI tract and causes bleeding.
Other examples of sources of fiber are: Beans, carrots, whole
grains or brown Rice and cereals
• Instruct patient’s family to prepare foods low in fat and cholesterol. Also
have moderate amount of sodium in the diet.

SPIRITUALITY
• Encourage patients that despite the challenges be encountering in life,
God has not yet forgotten.