ST. PAUL UNIVERSITY DUMAGUETE COLLEGE OF NURSING SY: 2011-2012

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN RELATED LEARNING EXPERIENCE A Clinical Paper On

ESRD secondary to Diabetic Nephropathy, Hypertension And Diabetes Mellitus Submitted by: Jessaryl R. Roja, SN-SPUD

Submmited to: Mr. Ever John Laingo, RN

Submitted on: February 27, 2012

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TABLE OF CONTENTS AKNOWLEDGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . .2 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5 CHAPTER 1- CASE OVERVIEW INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . 6 OBJECTIVE . . . . . . . . . . . . . . . . . . . . . . . . . .7 SCOPE AND LIMITATION . . . . . . . . . . . . . . . . . . . . 8 CHAPTER 2- CASE DATA AND INFORMATION BIOGRAPHIC . . . . . . . . . . . . . . . . . . . . . . . . . 9 FAMILY HISTORY . . . . . . . . . . . . . . . . . . . . . . .11 GORDONS FUNCTIONAL UNIT . . . . . . . . . . . . . . . . . .13 PHYSICAL ASSESSMENT . . . . . . . . . . . . . . . . . . . . 15 LABORATORY AND DIAGNOSTIC EXAM . . . . . . . . . . . . . . .22 CHAPTER 3- LITERATURE REVIEW NORMAL ANATOMY AND PHYSIOLOGY . . . . . . . . . . . . . . . 24 THEORETICAL BACKGROUND . . . . . . . . . . . . . . . . . . .30 CHAPTER 4- CASE ANALYSIS AND INTERPRETATION PATHOPHYSIOLOGY . . . . . . . . . . . . . . . . . . . . . . 37 MEDICAL MANAGEMENT. . . . . . . . . . . . . . . . . . . . 40 51

SURGICAL MANAGEMENT. . . . . . . . . . . . . . . . . . . .

NURSING CARE MANAGEMENT . . . . . . . . . . . . . . . . . . 54 PROGRESS NOTES . . . . . . . . . . . . . . . . . . . . . . .59 DISCHARGE PLAN . . . . . . . . . . . . . . . . . . . . . . .64 CHAPTER 5- CONCLUSIONS AND RECOMMENDATION CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . 65 RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . 66 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

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ACKNOWLEDGEMENT It is an achievement for being able to finish this Related Learning Experience in Holy Child Hospital with lots of learning gained and being able to utilized and apply appropriate nursing care efficiently and effectively. Such learning and achievement would not have been possible if not because of the collaborative effort among the different health care providers in the hospital and my group mates in this rotation. With this, the researcher would like to thank the following persons who in one way or another have helped and contributed a lot in the completion and success of this paper:

To parents, love ones and group mates, for the undying love and support financially, emotionally, spiritually and physiologically.

To Sr. Mila Grace A. Silab, SPC, Dean of the College of Nursing, for giving every student the opportunity to have hands-on duty and allowing them to practice their skills and apply learned knowledge from four walls of the classroom to clinical area, specifically at Holy Child Hospital.

To the administrators, personnel, stuffs and maintenance of Holy Child Hospital, for their warm welcome and the willingness they showed of imparting their knowledge and skills to the nursing students upon working in the area.

To St. Paul University Dumaguete College of Nursing faculty and staff, for their countless efforts of teaching the students during their long hours of lectures for the enhancement of the skills, knowledge, and attitude of the students during hands-on exposure.

To our clinical instructor, Mr. Ever John Laingo, R.N., for facilitating, supervising and sparing his knowledge and skills to his students unselfishly and whole-heartedly during clinical exposure and also for motivating his students to become better and more effective, efficient and responsible student nurses.

To Ms.B.C and to her significant other, for their unwavering acceptance to the care given to them and for willingly participate in this clinical case study.

And most especially, to God, the Almighty Father, who showers all His blessings, keeps the group safe at all times, strengthens their Page | 3

minds, hearts and spirits during the entire length of exposure and for guidance, and most especially for the researchers able to come up with confidence and dignity.

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ABSTRACT This paper is a case study of a 58 year old patient at Holy Child Hospital. She was admitted last February 14, 2011 at around 3:00 am under the care of Dr. EVA and Dr. J.A. The student nurse was able to render a focus care of the patient 1 day. According to the patient, it had been 1 week since she had experienced loss of appetite, vomiting, inability to walk and do activities of daily living and generalized fatigue. She also experience dizziness. The final diagnoses of the patient are End-Stage renal failure secondary to Diabetic Nephropathy, Hypertension and Diabetes Mellitus. This clinical paper contains the biographical data, Gordons functional unit of assessment, head to toe physical assessment, pharmacologic regimen and identified nursing problems. Initial Physical assessment and interview under the students care was done last February 21, 2012, followed by obtaining information from the chart and it was the last day the student nurse could obtain necessary information such as physical assessment, history taking and patients respond to management. Pharmacologic regimen includes Glucobay and lantus to manage Diabetes Mellitus Pritor and Vasalat to manage hypertension, Provitality, Calvit, and Sorbifer as nutritional supplements, Vessel Due to prevent thrombus formation, Plasil and Omeprazole to manage GI problems such as vomiting and accumulation of acid. There was also hemodialysis via femoral venous catheter that was happened last February 12 and 24 the patient undergone as management for End-Stage Renal Failure. Patient scheduled for AV fistula creation as permanent access for hemodialysis. From the span of time being with the patient, the student nurse has identified 3 nursing problems with 3 nursing care plans were made to address such problem. With the different assessment findings and manifestations, the student nurse was able to give efficient nursing care management and treatment to effectively address the identified problems.

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CHAPTER I CASE OVERVIEW INTRODUCTION My patient is a 58 year old, residing at Bais City with the diagnoses of End-stage renal failure secondary to diabetic nephropathy, hypertention and diabetes mellitus type 2. Diabetes Mellitus Type 2 diabetes mellitus is a disorder that disrupts the way of the body uses glucose (sugar). All the cells in the body need sugar to work normally. Sugar gets into the cells with the help of a hormone called insulin. If there is not enough insulin, or if the body stops responding to insulin, sugar builds up in the blood which can cause an increase pressure of the blood due to its viscosity. Long standing type 2 diabetes mellitus will lead to Chronic renal failure and suddenly, End-stage renal failure which is irreversible. As i reviewed the history of my patient, genetic is the most prominent cause of her diseases because her father had a diabetes mellitus and her mother had a hypertention. Says she had been hospitalized before due to DM and hypertension and she claims that she didiny comply all her medication because she thought nothing will gonna happen if she discontinue her maintenance medication since she already feeling well. I personally chose this case because it will give me a lot of learnings and experiences which I can used in the future. I can apply all the knowledge that I have learned from previous learnings that I had. And it will help people who have these kind of diseases to manage and prevent the occurance of any complications that will arise if prompt treatment will not be address. Most especially, it will benefit the health care provider because, this clinical contains the progression of the patient and the flow of management.

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OBJECTIVES GENERAL OBJECTIVE: At the end of this case study, the researcher will be able to learn important knowledge, skills and gain a desirable attitude in constructing and presenting a case study for the purpose of understanding patients having End-Stage Renal Failure, Hypertension and Diabetes Mellitus and determining specific health care needs to improve their optimum level of functioning through collaborative care and treatment.

SPECIFIC OBJECTIVES: The said objectives are set that after one day of gathering pertinent facts and rendering utmost quality nursing care to the patient and her case, this clinical paper aims to: 1. identify the underlying condition of the patient, the etiology, clinical manifestations, diagnostic procedures and medical managements done. 2. trace a comprehensive pathophysiology of the provision of the patient. 3. correlate the pathophysiology to the clinical manifestations, nursing interventions, and medical managements done. 4. identify three prioritized Nursing Care Problems and their suitable interventions for the disorder. 5. implement the prioritized nursing care interventions effectively and efficiently. 6. comprehensively provide information which are facts and reliable. 7. give health teachings to improve patients health. 8. reassess patients condition in order to know the improvement of the patients health. 8. respect and uphold the confidentiality of the patients chart and medical records. 9. construct recommendations concerning patients case. 10. appreciate the importance of knowledge gained throughout the study of the clients case for the purpose of future improvement.

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SCOPE AND LIMITATIONS SCOPE This case study presents the relevant and necessary information regarding to the past and present health status and care rendered to the patient, the Biographic data, the Gordons Functional Areas Assessment, Psychosocial Nursing History and Physical assessment and other information which are seen in Patients chart such as Drug study and Laboratory Exams. As well as pathophysiology, normal anatomy and physiology of the system involved, theoretical background and three prioritized Nursing Care Plan which will address the identified problem during the patients care. LIMITATION While conducting this case study, the researcher encountered limitations as follows: 1. The researcher span of time to care for the patient which is 1 whole shift was not enough to note for the patients progression and to thourough assess patients condition. 2. The time when researcher hadle the patient is also the time when the patient is for discharge, that is why I dont have the time to gather information.

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CHAPTER II CASE DATA AND INFORMATION BIOGRAPHICAL DATA Name: Ms. B.C Age: 58 years old Address: Bais City, Negros Oriental Birthday: October 23, 1953 Birthplace: Bais City, Negros Oriental Marital Status: Widow Nationality: Filipino Religion: Roman Catholic Educational attainment: Grade 6th Attending Physician: Dr. Alcantara and Dr. Amante Source of Information and Reliability: Patient-----------------------50% Patients Chart---------------20% Significant other-------------30% Total 100%

CHIEF COMPLAINT nagluya ko , dli na ko kalakaw ug wlay gana mukaon, ako isuka akong gikaon as verbalized by the patient. HISTORY OF PRESENT ILLNESS One week prior to admission, patient was resting at home because she felt tired even during at rest, feel dizzy most the time and experienced loss of appetite. She tried to eat but it didnt help relieved the symptoms. She cant even stand nor do thing on her own because of tendency to fall. She states that it was more severe than before when she was first experienced the symptoms. The severities of the symptoms alarmed her family to seek for medical attention. She

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immediately brought to the emergency room of Holy Child Hospital with a high BP 180/100 mmHg. She was admitted last February 14, 2012, Monday. She says that she was admitted last year still at Holy Child hospital with same complain and with the diagnosis of hypertension and diabetes mellitus thus the patient has maintenance medication but admitted that she stop taking it because she thought nothing will happen to her after she felt better. PAST HEALTH HISTORY a) Childhood illnesses: chicken pox, mumps, fever, colds, coughs, hypertension, diabetes melitus and cataract secondary to dabetic retinopathy. b) Hospitalizations: July 2011 at Holy Child Hospital under Dr. Alcantara because of hypertension and diabetes millitus. c) Surgeries: undergone cataract removal 2 years ago. Patient did not able to remember her surgeon as well as significant others. d) Serious injuries: so far, patient claims that his serious injury she have was her cataract. e) Serious or chronic illnesses: says she have been hypertensive and diabetic for years. f) Immunization: complete immunizations. g) Allergies: no known allergy. h) Medications: says she had pritor, amlodipine/vassalat and acarbose as her maintainance medications but claims that she stop taking it after she felt better.

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FAMILY HISTORY FATHERS SIDE MOTHERS SIDE

+ DM 63

+ O.A 72

+ HTN 66

+ HTN 70

+ O.A 70

+ PNEU 61

+ DM 69

+ O.A 65

A&W 54

A&W 51

+ HTN 62

+O.A 69

+ O.A 71

+ HTN 56

+ O.A 65

HTN 64

DM, HTN 60 DM HTN 58

DM 56

HTN 54

HTN 52

A&W 50

A&W 48

HTN 45

Figure 2.1. Genogram

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LEGEND :

-

MALE

A&W

- Alive and well

PNEU Pneumonia

-

FEMALE

O.A Old Age

-

- Patient

HTN Hypertension

DM diabetes Mellitus

INTERPRETATION: According to patients family history her illness is mainly hereditary due to the fact that her mother has a hypertension and her father has a Diabetes mellitus. She claims that she is not fan of eating salty foods and sweets. She has a good lifestyle. She pointed that she had medications to be maintained but suddenly, she failed to comply after feeling better. So, family history is the most accurate evidence that really determined the main cause of the patients illness.

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PSYCHOSOCIAL HISTORY Healthcare Practices and Beliefs Patient claims that she immediately go to the hospital if she terribly not feeling well and she is not into hilots or quack doctors because she feel so confident when the one who cares for her is the one that knowledgeable enough to cure her illnesses. Typical Day Patient really wakes up early in the morning at around 6am to do household stuffs and sleeps at night at around 7pm in the evening. She rest during siesta periods. Nutritional Patterns Prior to admission, patient claims that she is fun of eating sweet deserts especially chocolates. She also claims that she love eating vegetable and meat. She not usually eats heavy meals. She drinks water most of the time because usually she lose her appetite. Activities and Exercise Patterns Patient says that she exercise through household stuffs but easily fatigue and feel so tired. Says that her muscle easily get weak thus resting periods is more than working periods. Pets and Hobbies Admits she loves spending to her garden and taking care of her plants and flowers. She having fun bond along with her grandchildren and play with them. Sleep/Rest Patterns Prior to admission, patient admits that her resting period is longer than her working time due to the fact that she easily gets tired. Socio-economic Status Patient relies on his children who have works which provide her with his necessities. Her second child receives about 10,000 php per month. Patient has own health insurance.

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Environmental Health Patterns Lives in a one story house with three bedrooms and one comfort room. House is situated in Bais City. Their house is near the church and city hall. Roles, Relationships, Self Concept Patient claims that she is a responsible mother to her children. She admits that she gave what is due to them. She gave them education and care they need. She also has a good relationship with them emotionally, socially, physically and spiritually. Cultural influences If symptoms persist, patient then refers to his doctor or the emergency department in Holy Child Hospital. Religious/Spiritual Influences Patient claims that his religion is Roman Catholic. In the past, patient and family went to church together every Sunday and sometimes attended weekly bible studies but when her other children live separately, she used to attend mass alone and sometime with her grand children, used to pray together with family. Family Roles/Relationships Claimed he was able to fulfill role as an obedient son and responsible brother. Closest relationship with a family member would be his mother. Does not often talk to his father, but still cares for him internally. Stress and Coping Patterns Able to cope with stress factors through resting and sleep. She claims that her stress usually gone when she rest and do gardening.

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System Integumentary system

Functional Assessment Patient verbalized pain at the right femoral area.

Head, face and neck

Red glow noted above the eye brow and roof of the mouth using penlight indicate that it is clear with no discharges.

Table 2.1 PHYSICAL ASSESSMENT Inspection Palpation SKIN Cold to touch. Brown in skin color. Have a poor skin Darker at expose turgor more that area. 3 seconds. Hairs are evenly Pain noted upon distributed palpation of throughout the scalp right femoral with grayish hair area. color. No lesions. Head in nonHematoma noted at tender and no the right femoral masses. area. Dry skin. NAILS NAILS Fine in texture, Pinkish in color, soft and has good convex and has 160 capillary refill degree angle of of less than 3 attachment. seconds. Head circumference Temporal pulse of 61 cm.appopriate rate is 45bpm to age. weak and easy NOSE diminshed. Nares are patent Non-tender upon upon occluded each palpation of nostrils. maxiallary and LIPS frontal sinuses. Lips are pale, moist No tenderness and and no lesions. noted upon ORAL MUCOSA palpation of the 18 teeth with dental lips

Percussion

Auscultation

Resonance maxillary and frontal sinuses upon percussion.

Thyroid gland no sound detected upon auscultation.

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caries noted upon inspection. Oral mucosa and tonsils are pink, moist and intact. Tongue is mobile, pinkish in color, moist and no lesions noted. NECK Neck positioned midline, no lumps, bulges or masses. Thyroid gland not visible. No masses or swelling. Eyes and the ears Patient verbalized that her left eye is not able to read and has difficulty reading in a far distance and also patient cannot able to read newsprint at 14 inches distance without her eye glass. Patient verbalized absence of visual field at the left side. Patient verbalized that she cant hear the words whispered and Eye muscles have coordinated movements. Eye is clear and bright. Eye lashes are curl outward, eyeball are round. Scleras are whitish in color. Iris is black. Pupil of the left eye has 3mm which is not responsive to light and at the right has 2mm, responsive to light

No bulges noted upon palpation of oral mucosa. Tougue is nontender, no masses. NECK Neck is nontender, no lumps, bulges or masses. Thyroid gland has no masses or swelling.

Eyeballs are firm, no masses, and bulges. No pain noted upon palpation. Lacrimal glands are not palpable unless it will swell. Both ear are elastics and nontender.

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cant able to hear the tick of the clok/

Respiratory system

and has good accommodation. Ears are at level of outer canthus of the eye. Skin color same with the face. With normal discharges at the external ear canal. RR- 15 cpm, regular and effortless breathing. 1:2 AP ratio Chest expansion equal for both anterior and posterior.

Trachea is midline in position. No tenderness and crepitus noted upon palpation. Symmetrical chest excursion. Vibration felt bilateral upon doing tactile fremitus.

Cardiovascular system

HR- 62 bpm weak and intermittent rhythm. Carotid pulse is visible in any position and jugular is only visible in

Resonance to second and third ICS on left and dull over the fourth to fifth ICS Resonance to fourth ICS on right with dullness noted over fifth ICS just above the coastal margin. Resonance on eight ICS. Dullness in the fourth and fifth ICS.

Bronchial area has a high-pitch sound. Bronchovesicular area has moderate sound. Vesicular area low-pitched sound with no adventitious breath sound.

Negative bruist upon ausculatation of carotid and jugular vein. S2 is louder than

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supine. Pulsation on the apex is visible. Right carotid pulse rate- 61 bpm Left carotid pulse rate- 72bpm equally regular in rhythm, soft and pliable. Peripheralvascular system Absence of pain in calf upon dorsiflexion. UPPER EXTREMITIES Evenly skin color. No edema, erythema or lesion. Absence of hair and wrinkled skin noted. Arm circumference of 21cm right and left Arm length of 65cm right and 63cm left. LOWER EXTREMITIES Evenly skin color. Hematoma noted at the right femoral area with catheter in placed having dry, intact dressing with no signs of bleeding Absence of hair and wrinkled skin noted. Leg circumference of Rough skin texture, dry and cold to touch. Pain noted upon palpation of right femoral area. Good capillary refill of right and left toe nails less that 3 seconds. Peripheral pulse: Brachial pulse rate- 56bpm right 52bpm left, regular in rhythm and weak bilateral Radial pulse69bpm weak right 72 bpm left, hard to locate

S1. No bruist and murmur upon auscultation of the aorta.

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53cm both right and left. Leg length 110cm at the right and 109am at the left leg. Calf circumference of 35am at the right and 33cm at the left.

bilateral. Femoral pulse rate- 64bpm left regular in rhythm. Popliteal pulse rate- 16bpm right 12bpm left, hard to locate and easily oblirated bilaterally. Dorsalis pedis pulse rate- not present. Posterior tibialis pulse rate-not present Allens testpatients color of palm return to pink 5-6 seconds after release from compression of radial and ulnar arteries. Color change test- pinkish color return in 12 seconds after elevating the

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patients leg from supine position and dangle her feet. Gastrointestinal And gastrourinary system Patient attempt to vomit every after eating. Facial grimace noted upon deep palpation of right lower quadrant and right upper quadrant. No pain noted upon assessing the kidney using kidney punch test. Pain noted at the right and left lower quadrant upon deep palpation of the abdomen. (+) rebound tenderness. (+) mc.burneys sign Patient complaint of weight lost from 56kg to 48kg. Patient complaint of fatigue and weakness. No pain upon palpation of TMJ. Patient felt no pain Patients abdomen is rounded in contour. Abdominal pulsation slightly visible at epigastric area. Bladder is not palpable. Muscle contract upon stimulating its reflexes. No masses or organs floating upon doing ballotment. (-) kehrs sign (-) ballances sign (+) rebound tenderness (+) mc.burneys sign (-) murphys sign (-) obturator muscle test. Flaccid muscle tone with muscle strent of +2 in both extremities. No crepitus upon palpation of TMJ. Liver span at midclavicular line 7cm and 4am at midsternal line. Sleen is not palpable. Bowel sounds present with 6 click/min in all quadrant. Absence of venous hums, friction rub and bruist.

Musculoskeletal system

Senile kyphosis noted. Muscle weakness which unable patient to stand on her own. Patient has coordinated movements of her

Patient felt no pain upon tapping the metacarpal area (-) tinels test. Felt no fluid upon tapping

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upon flexing both right and left wrist (-) phalens test. Patient felt no pain upon flexing the knees up to her abdomen ()thomas test. Patient felt no pain (-) straight leg raising

extremities. Can walk with assistance. Patient can perform point-to-point localization, finger to thumb opposition, toe tapping and heel down shin. Can perform passive ROM exercise.

the knee (-) bulge test.

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Laboratory Examinations Complete Blood Count is the calculation of the cellular or formed elements of blood to generally determine if there is any abnormality of their count which help health care provider to diagnose. February 14, 2012 RBC 3.9 mcL Table 2.2 Complete Blood Count February Interpretation 24, 2012 RBC 3.8 mcL A decrease in RBC will indicates that there is decrease production or increase destruction. In relation to patients diagnosis of End-stage Renal Failure, it is very evident that there is decrease production of RBC due to decrease production of erhytropoietin which is produce by the kidney. WBC 4 mcL A decrease in WBC mostly indicates that the persons immune system is compromised which will prone the patient to acquire infection. Since the patient has End-stage Renal Failure, the toxins that suppose to excret via urine are highly accumulate in the blood for a long period of time which causes the decompensation of immune system. HEMOGLOBIN A decrease in hemoglobin is related to 10 g/dl decrease RBC which really a problem because there will be decrease oxygen carying capacity of the blood which will lead to many problems along the way. Thus the patient will be weak and pale. HEMOTOCRIT A decrease in hematocrit indicates that the 35.2 % amount of space or volume take up by red blood cells in the blood is decrease which also related to the patients diagnosis which is end-stage renal failure

WBC 4.4 mcL

HEMOGLOBIN 10.4 g/dl

HEMATOCRIT 38 %

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Creatinine and Potassium test this test is realible to check for kidney function. Table 2.3 Creatinine and Potassium level February 24, 2012 Interpretation Creatinine The creatinine is a waste product thus its level should be maintain in 3.45 mg/dl a normal range. It is being regulated by the kidney through excretion via urine. But in patient with end stage renal failure, the creatine level is constantly increased due to failure of the kidney to filter it. Potassium Patient has an elevated Potassium level because kidney failed to 4.6 mmol/L excrete it. Elevated levels of potassium are one of the most dangerous symptoms of advanced kidney disease because they affect the contractility of the heart.

February 14, 2012 Creatinine 3.42mg/dl

Potassium 4.8 mmol/L

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CHAPTER III LITERATURE REVIEW ANATOMY AND PHYSIOLOGY Renal System

The urinary system consists of all the organs involved in the formation and release of urine. It includes thekidneys, ureters, bladder and urethra. The kidneys are bean-shaped organs which help the body produce urine to get rid of unwanted waste substances. When urine is formed, tubes called ureters transport it to the urinary bladder, where it is stored and excreted via the urethra. The kidneys are also important in controlling our blood pressure and producing red blood cells.

Figure 3.1: Urinary System Anatomy Components of the Urinary System Kidney and Ureters The kidneys are large, bean-shaped organs towards the back of the abdomen. They lie behind a protective sheet of tissue within the abdomen. The kidneys perform many vital functions which are important in everyday life. They help us get rid of waste products by making

urine and excreting it from the body. A special system of tubes within the kidneys allow substances such as sodium and chloride to be filtered. The kidneys regulate the amount of water in the body. Humans produce about 1.5 litres of urine a day. However, if we drink more water, we may produce more urine. On hot days, if we Page | 24

get dehydrated and sweat more, we may produce less urine. This is why it's very important to drink lots of water on hot summer days. The kidneys also produce renin (a hormone important in regulating blood pressure) and erythropoietin (helps produce red blood cells). The kidneys are reddish brown in colour and measure about 10 cm in length, 5 cm width and 2.5 cm thick. On the side of the kidney with the smaller curve is an opening called the hillum, where blood vessels, nerves, and the ureters enter the kidney. On one end of the ureters is a funnel-shaped expansion, called the renal pelvis, where urine collects. The ureters carry urine to the bladder; they are 2530 cm long tubes lined withsmooth muscle. The muscular tissue helps force urine downwards. The ureters enter the bladder at an angle, so urine doesn't flow up the wrong way. The kidney can be divided into two distinct regions. There is an outer red-brown part (cortex) and inner lighter coloured part (medulla). The cortex is made up of special units called corpuscles, nephrons, and a system of straight and curvy collecting tubules supplied by many blood vessels. In the outer part of the kidney, there are many nephrons which act as filtering units. Each nephron is supplied by a ball of small blood vessels, called glomeruli. A diagram of a single glomerulus is seen below. Blood is filtered through the small blood vessels to produce a mixture that is the precursor of urine. This mixture then passes through more tubules, where water, salt and nutrients are reabsorbed. Bladder The bladder is a pyramid-shaped organ which sits in the pelvis (the bony structure which helps form the hips. The main function of the bladder is to store urine and, under the appropriate signals, release it into a tube which carries the urine out of the body. Normally, the bladder can hold up to 500 mL of urine. The bladder has three openings: two for the ureters and one for the urethra. The bladder consists of smooth muscles. The main muscle of the bladder is called the detrusor muscle. Muscle fibres around the opening of the urethra forms a ring-like muscle that controls the passage of urine. When we want to urinate, stretch receptors in the bladder are activated, which send signals to our brain and tell us that the bladder is full. The ring-like muscle relaxes and the detrusor muscle contracts, allowing urine to flow. The blood supply of the bladder is from many blood vessels. Some of these blood vessels are named: the vesical arteries, the obturator, uterine, gluteal and vaginal arteries. In females, a venous network Page | 25

drains blood from the bladder arteries into the internal iliac vein. Nervous control of the bladder involves centres located in the brain andspinal cord.

Urethra The male urethra is 1820 cm long, running from the bladder to the tip of the penis. The male urethra is supplied by the inferior vesical and middle rectal arteries. The veins follow these blood vessels. The nerve supply is via the pudendal nerve. The female urethra is 46 cm long and 6 mm wide. It is a tube running from the bladder neck and opening into an external hole located at the top of the vaginal opening. As the female urethra is shorter than the male urethra, it is more likely to get infections from bacteria in the vagina. The female urethra is supplied by the internal pudendal and vaginal arteries.

Vascular System The blood vessels are the part of the circulatory system that transports blood throughout the body. There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and the tissues; and the veins, which carry blood from the capillaries back toward the heart. The arteries and veins have different structures, veins having two layers and arteries having three: Tunica intima (the thinnest layer): a single layer of simple squamous endothelial cells glued by a polysaccharide intercellular matrix, surrounded by a thin layer of subendothelial connective tissue interlaced with a number of circularly arranged elastic bands called the internal elastic lamina. Tunica media (the thickest layer): circularly arranged elastic fiber, connective tissue, polysaccharide substances, the second and third layer are separated by another thick elastic band called external elastic lamina. The tunica media may (especially in arteries) be rich in vascular smooth muscle, which controls the caliber of the vessel.

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Tunica adventitia: entirely made of connective tissue. It also contains nerves that supply the vessel as well as nutrient capillaries (vasa vasorum) in the larger blood vessels.

Figure 3.2 Cardiovascular System Capillaries consist of little more than a layer of endothelium and occasional connective tissue. When blood vessels connect to form a region of diffuse vascular supply it is called an anastomosis. Anastomoses provide critical alternative routes for blood to flow in case of blockages. Blood vessels do not actively engage in the transport of blood (they have no appreciable peristalsis), but arteriesand veins to a degree can regulate their inner diameter by contraction of the muscular layer. This changes the blood flow to downstream organs, and is determined by the autonomic nervous system. Vasodilation and vasoconstriction are also used antagonistically as methods of thermoregulation. Oxygen is the most critical nutrient carried by the blood. In all arteries apart from the pulmonary artery, hemoglobin is highly saturated with oxygen. In all veins apart from the pulmonary vein, the hemoglobin is desaturated at about 75%. The blood pressure in blood vessels is traditionally expressed in millimetres of mercury In the arterial system, this is usually around 120 mmHg systolic and 80

mmHg diastolic . In contrast, pressures in the venous system are constant and rarely exceed 10 mmHg. Page | 27

Vasoconstriction is the constriction of blood vessels by contracting the vascular smooth muscle in the vessel walls. It is regulated by vasoconstrictors (agents that cause vasoconstriction). These include paracrine factors, a number of hormones and neurotransmitters from the nervous system. Vasodilation is a similar process mediated by antagonistically acting mediators. The most prominent vasodilator is nitric oxide (termed endothelium-derived relaxing factor for this reason). Permeability of the endothelium is pivotal in the release of nutrients to the tissue. It is also increased in inflammation in response to histamine, prostaglandins and interleukins, which leads to most of the symptoms of inflammation Pancreas The pancreas is an elongated, tapered organ located across the back of the abdomen, behind the stomach. The right side of the organ is the widest part of the organ and lies in the curve of the duodenum. The tapered left side extends slightly upward and ends near the spleen. The pancreas is made up of two types of glands: Exocrine the exocrine gland secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas. Endocrine The endocrine gland, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Figure 3.3 Anatomy of the Pancreas Page | 28

Functions of the pancreas: The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine gland in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine gland in the pancreas are insulin and glucagon, and somatostatin.

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THEORETICAL BACKGROUND DIABETES MELLITUS Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) andpolyphagia (increased hunger). There are three main types of diabetes: Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.) Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. Type 2 DM Type 2 diabetes mellitus is characterized by insulin resistance which may be combined with relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus due to a known defect are classified separately. Type 2 diabetes is the most common type. In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity. At this stage hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver. Causes Here are some causes of Diabetes Mellitus Type 2 Genetic defects of B-cell Function

Page | 30

-Maturity onset Diabetes of the young -Mithochondrial DNA mutations Genetic defect in insulin processing or insulin action -Insulin gene mutations -Insulin receptor mutation Exocrine Pancreatic Defects -Chronic pancreatitis -pancreatomy -Pancreatic neoplasia -Cystic fibrosis -Hemochromatosis Infections -Cytomegalovirus infection -Coxsackievirus B Drugs -Glucocorticoids -Thyroid Hormone -Bete adrenergic agonist

Sign and Symptoms The classical symptoms of diabetes are polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). Symptoms may develop rapidly (weeks or months) in type 1 diabetes while in type 2 diabetes they usually develop much more slowly and may be subtle or absent. Prolonged high blood glucose can cause glucose absorption in the lens of the eye, which leads to changes in its shape, resulting in vision changes. Blurred vision is a common complaint leading to a diabetes diagnosis; type 1 should always be suspected in cases of rapid vision change, whereas with type 2 change is generally more gradual, but should still be suspected. Page | 31

Management Lifestyle There are roles for patient education, dietetic support, sensible exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure. Medications Oral medications Metformin is generally recommended as a first line treatment for type 2 diabetes as there is good evidence that it decreases mortality. Routine use of aspirin however has not been found to improve outcomes in uncomplicated diabetes. Insulin Type 1 diabetes is typically treated with a combinations of regular and NPH insulin, or synthetic insulin analogs. When insulin is used in type 2 diabetes, a long-acting formulation is usually added initially, while continuing oral medications. Doses of insulin are then increased to effect. Support In countries using a general practitioner system, care may take place mainly outside hospitals, with hospital-based specialist care used only in case of complications, difficult blood sugar control, or research projects. In other circumstances, general practitioners and specialists share care of a patient in a team aproach. Optometrists, podiatrists/chiropodists, dietitians, physiotherapists, nursing specialists, nurse practitioners, or certified diabetes educators, may jointly provide multidisciplinary expertise.

End-stage kidney disease End-stage kidney disease is the complete or almost complete failure of the kidneys to work. The kidneys remove waste and excess water from the body. End-stage kidney disease (ESRD) is when the kidneys are no longer able to work at a level needed for day-to-day life.

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Causes The most common causes of ESRD are diabetes and high blood pressure. These conditions can affect your kidneys. ESRD almost always comes after chronic kidney disease. The kidneys may slowly stop working over 10 - 20 years before end-stage disease results. Symptoms Symptoms may include: General ill feeling and fatigue Itching (pruritus) and dry skin Headaches Weight loss without trying Loss of appetite Nausea

y y y y y y

Other symptoms may include: Abnormally dark or light skin Nail changes Bone pain Drowsiness and confusion Problems concentrating or thinking Numbness in the hands, feet, or other areas Muscle twitching or cramps Breath odor Easy bruising, nosebleeds, or blood in the stool Excessive thirst Frequent hiccups Low level of sexual interest and impotence Menstrual periods stop (amenorrhea) Sleep problems, such as insomnia, restless leg syndrome, or obstructive sleep apneay y

y y y y y y y y y y y y y y

Swelling of the feet and hands (edema) Vomiting, especially in the morning

Treatment Dialysis or kidney transplantation is the only treatment for this condition. Page | 33

For more information on these treatments, see: Dialysis Dialysis is a procedure that is a substitute for many of the normal duties of the kidneys. The kidneys are responsible for filtering waste products from the blood. Kidney transplant

y

y

Your doctor may also put you on medicine to control your blood pressure and manage the diabetes mellitus. You may need to make changes in your diet. Eat a low-protein diet Get enough calories if you are losing weight Limit fluids Limit salt, potassium, phosphorous, and other electrolytes

y y y y

Other treatment depends on your symptoms but may include: Extra calcium and vitamin D (always talk to your doctor before taking)y

y

Medicines called phosphate binders, to help prevent phosphorous levels from becoming too high

y

Treatment for anemia, such as extra iron in the diet, iron pills or shots, shots of a medicine called erythropoietin, and blood transfusions.

Hypertension High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body.. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is considered high. Causes Two forms of high blood pressure have been described: essential (or primary) hypertension and secondary hypertension. Essential hypertension is a far more common condition and accounts for 95% of Page | 34

hypertension. The cause of essential hypertension is multifactorial, that is, there are several factors whose combined effects produce hypertension. In secondary hypertension, which accounts for 5% of hypertension, the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. Signs and symptoms: Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so hypertension has been labeled "the silent killer." Some people with uncomplicated hypertension, however, may experience symptoms such as headache, dizziness, shortness of breath, and blurred vision Treatment Lifestyle Changes to Treat High Blood Pressure A critical step in preventing and treating high blood pressure is a healthy lifestyle. You can lower your blood pressure with the following lifestyle changes:y y y y

y y

Losing weight if you are overweight or obese. Quitting smoking. Eating a healthy diet, including the DASH diet (eating more fruits, vegetables, and low fat dairy products, less saturated and total fat). Reducing the amount of sodium in your diet to less than 1,500 milligrams a day if you have high blood pressure. Healthy adults need to limit their sodium intake to no more 2,300 milligrams a day (about 1 teaspoon of salt). Getting regular aerobic exercise (such as brisk walking at least 30 minutes a day, several days a week). Limiting alcohol to two drinks a day for men, one drink a day for women. In addition to lowering blood pressure, these measures enhance the effectiveness of high blood pressure drugs.

Drugs to Treat High Blood Pressure There are several types of drugs used to treat high blood pressure, including:y y y y y

Angiotensin-converting enzyme (ACE) inhibitors Angiotensin II receptor blockers (ARBs) Diuretics Beta-blockers Calcium channel blockers

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y y y y

Alpha-blockers Alpha-agonists Renin inhibitors Combination medications Diuretics are often recommended as the first line of therapy for most people who have high blood pressure. However, your doctor may start a medicine other than a diuretic as the first line of therapy if you have certain medical problems. For example, ACE inhibitors are often a choice for a people with diabetes. If one drug doesn't work or is disagreeable, other types of drugs are available. If your blood pressure is more than 20/10 points higher than it should be, your doctor may consider starting you on two drugs or placing you on a combination drug. High Blood Pressure Treatment Follow-Up After starting high blood pressure drug therapy, you should see your doctor at least once a month until the blood pressure goal is reached. Once or twice a year, your doctor will check the level of potassium in your blood (diuretics can lower this, and ACE inhibitors and ARBs may increase this) and other electrolytes and BUN/creatinine levels (to check the health of the kidneys). After the blood pressure goal is reached, you should continue to see your doctor every three to six months, depending on whether you have other diseases such as heart failure.

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CHAPTER IV CASE ANALYSIS AND INTERVENTION

Precipitating Factor 1.eating too much sweets 2.diet 3.sedentary lifestyle

Insulin Resistance

Predisposing factors: 1.family history of DM 2. Obesity 3. Age above 40

Exhaustion of the Beta cells

Decrease insulin production

Decrease amino acid in the circulation

Degradation of proteins

Decrease absorption of glucose by the cell

Breakdown of fat

Decreased urinary nitrogen

Cell starvation Activity intolerance related to generalized weakness.

Stimulation of hunger mechanism via hypothalamus Further ion loss Potassium retention Cardiac arrythmias POLYPHAGIA

Hunger

Dehydration Page | 37

Risk for injury related to Risk for Injury related to generalized body weakness.

Lantus Increase CBS Glucobay HYPERGLYCEMIA Increase viscosity of the blood Increase Blood Pressure 180/100

Decrease oxygen going to the cell

Muscle weakness (+)

Capillary basement membrane thickening Increase viscosity of the blood Diffuse glomerular sclerosis

Renal hypoperfusion

Pritor, Vasalat, POLYDYPSIA Lasix STAT

Decrease circulating blood volume

POLYURIA & ALBUMINURIA

NEPHROPATHY

RENAL FAILURE

Hypovolemia Dizziness, lightheadednes

hemodialysis

ESRD

Hypotension & Tachycardia

Impaired function of the kidney

Page | 38

Pain rated as 6 due to Venous Catheter temporary accesses hemodialysis

Provitality Calvit

Excrete important nutrients and

Decrease erhytropoietin production

Acute pain related to Insertion of venous catheter at the femoral area as a temporary access for hemodialysis

Omeprazole Plasil

Gastric irritation, loss of appetite, nausea, vomiting

Hydrogen retention (metabolic acidosis)

Decrease production of RBC

RBC 3.8 mcL, Hgb 10 g/dl,

Potassium retention

Uremia

sorbifer

Cadiac arrythmias

Accumulation of toxins

Creatinine 3.42mg/dl Figure 4.1 Pathophysiology Legend etiology Signs and symptoms

medication

Laboratory

Disease process

NCP

Medical management

Page | 39

MEDICAL MANAGEMENT PHARMACOLOGIC MANAGEMENT Generic name: Telmisartan Brand Name: Pritor Classification: Anti-Hypertensive Angiotensin II receptor antagonist Indication: manage hypertension and treat diabetic nephropathy of

patient with diabetes mellitus type 2. Dosage: 40mg 1 tablet once daily. Drug Action: block the vasoconstrictor and aldosterone-producing effects of angiotensin II at the receptor sites including vascular smooth muscles and adrenal glands thus decreasing the blood pressure and slow the progression of diabetic nephropathy. Side/adverse effects: dizziness, hypotension, tachycardia, edema, chest pain, abdominal pain, diarrhea, nausea and vomiting. Nursing Responsibilities: y Teach the family of techiniques on how to monitor blood pressure and pulse rate. y y y Administer with meals Advice patient to take medication as directed even feeling well. Take missed dose as soon as remembered. Do not double dose. Do not discontinue until physician say so. y y Inform patient to avoid food containg salts and potassium. Caution the patient to avoid sudden change in movements and

activities that requires alertness. y y Provide safety. Inform patient that this medication does not cure but just manage the hypertension. Generic name: Sulodexide Brand Name: Vessel Due F Page | 40

Classification: Anti-thrombotic Indication: Vascular pathologies with thrombotic risk. Dosage: 250 SLU 1 capsule once daily 12noon. Drug Action: Vessel Due-F contains sulodexide, a glycosaminoglycan featuring a marked antithrombotic also capable action of either on arterial altered or venous

systems

and

normalizing in

viscosimetry vascular

parameters

generally

present

patients

with

pathologies with thrombotic risk. Side/adverse effects: Hemorrhage, nausea, vomiting and abdominal pain Nursing Responsibilities: y y y y hemocoagulative parameters should be monitored. Taken with meals. Do not discontinue unless directed by physician. Watch for any signs of bleeding or hemorrhage.

Generic name: Acarbose Brand Name: Glucobay Classification: Antidiabetic Alpha-glucosidase inhibitor Indication: Management of type 2 diabetes mellitus. Dosage: 50mg 1 tablet once daily 8am after breakfast. Drug Action: Lowers blood glucose by inhibiting the enzyme alpha-glucosidase in the GI tract, delay and reduce glucose absorption. Side/adverse effects: Abdominal pain, diarrhea and flatulence.

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Nursing Responsibilities: y Monitor for hypoglycemia and serum glucose level prior to

administration. y y Administer after breakfast. Inform the patient not to take medication if she/he missed the dose. Do not double dose. y Inform patient about the action of the drug and its effects.

Generic Name: Calvit-C Brand Name: Dehlvi Classification: Anti-fatigue Indication: Generalized fatigue. Dosage: 500mg 1 tab trice daily. Drug Action: Contains natural calcium and Vitamin C. Calcium is essential for the growth and development of healthy bones and strong teeth. It is also useful in osteoporosis and helps control blood

cholesterol levels, assists nerve, muscle and digestive function, regulates heart muscle function and sleep. Vitamin C also helps prevent atherosclerosis by strenghtening the artery walls through its participation in the synthesis of collagen, and by preventing the undesirable adhesion of white blood cells to damaged

arteries. An adequate intake of the vitamin is highly protective against stroke and heart attack. Side/adverse effects: none. Nursing Responsibilities: y Encourage patient to consume more of sardines, dairy products and soya milk which are rich in calcium and citrus fruits, green vegetables, tomatoes and strawberries which are rich in vit.C y Avoid carbonated drinks, alcohol, caffeine and increase intake of salts.

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Generic Name: Amlodipine Brand Name: Vasalat Classification: anti-hypertensive Calcium channel blocker Indication: Management for hypertension. Dosage: 5g 1 tablet once daily 12 noon. Drug Action: Inhibit the transport of calcium into myocardial and vascular smooth muscles cells resulting in inhibition of contraction,

systemic vasodilation thus decreasing the blood pressure. Side/adverse effects: Headache, dizziness, edema, hypotension, bradycardia, mausea. Nursing Responsibilities: y Advise patient to take it as directed even if feeling well.take missed dose as soon as possible. Do not double dose. Taper the dose. y Teach the family of techiniques on how to monitor blood pressure and pulse rate. y y Inform patient to avoid food containg salts and potassium. Caution the patient to avoid sudden change in movements and

activities that requires alertness. y y Provide safety. Inform patien that this medication does not cure but just manage the hypertension. Generic Name: Ferros Sulfate Brand Name: Sorbifer Classification: antianemics Iron supplements Indication:

Page | 43

Treat

iron

deficiency

in

patient

having

kidney

disease

who

undergoing hemodialysis or not. Dosage: 300mg 1 tablet once daily before lunch. Drug Action: Iron is an essential mineral found in hemoglobin, myoglobin and many enymes, enters to blood streams and tranported to organs of the reticuloendothelial system (liver, bone marrow, spleen) where it is separate out and becomes part of iron stores. Side/adverse effects: Hypotension, nausea, constipation, dark stools, diarrhea,

epigastric pain, vomiting, dyspnea and cough. Nursing Responsibilities: y y y y Assess nutritional status and dietary history. Assess any signs of allergic reaction. take it as directed. Report immedietly to physician if stomach pain, fever, nausea and vomiting and diarrhea occured.

Pro Vitality Dietary Supplements Indication: nutrient supplement for patient having chronic disases such as heart disease, cancer, and diabetes. Dosage: 3 capsule after breakfast. Drug Action: TRE-EN-EN GRAIN CONCENTRATES Feed your cells--energize your life. Good nutrition begins at the cellular level. Tre-en-en is the world's first and only whole grain lipids and sterols supplement proven to enhance energy and vitality by optimizing cell membrane function. It energizes your entire body by helping your cells function more efficiently.

CAROTENOID COMPLEX Page | 44

Carotenoid Complex is the world's first and only whole food supplement clinically proven by USDA researchers to protect your heart, defend your cells, and boost your ommune power.

OMEGA-III SALMON OIL PLUS

The world's first complete fish oil supplement with guaranteed potency of all eight members of the omega-3 family. Recent human clinical trails proved its bioavailability to support heart and cardiovascular health, as presented at Experimental Biology 2008. Side effects: None. Nursing Responsibility: y y Encourage patient to still eat nutrional foods. Educate the patient regarding the supplement, its benefits and it is being given to her. y Inform her that she shold not be reliant of the supplement and she should encourage to enhance her lifestyle.

Generic name: Insulin Glargine Brand Name: Lantus Classification: antidiabetics, hormone, pancreatics Indication: Control hyperglycemia in patients with type 2 DM. Dosage: 10 units Subcutaneous once daily. Drug Action: Lowers blood glucose level by stimulating glucose uptake in

skeletal muscle and fat, inhibiting hepatic glucose production. Side/adverse effects: Hypoglycemia, sweeling, pruritus and allergic reaction.

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Nursing Responsibilities: y y y Assess for signs of hypoglycemia. Monitor blood glucose level. Educate the family or the patient how to administer the

medication, route and dosage. y Inform the patient this medication can manage hyperglycemia not treatment for diabetes. y y Emphasize the compliance of this medication. Educate the family of the patient about the drug, its side

effects and why is it given to the patient.

Generic name: Omeprazole Brand Name: Losec Classification: Anti-ulces agent Proton-pump inhibitor. Indication: Reduction of risk of GI bleeding Dosage: 20mg 1 capsule once daily. Drug Action: Binds to an enzyme or gastrict parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into gastric lumen thus diminished accumulation of acid. Side/adverse effects: Dizziness, abdominal pain, fatigue, headache, checst pain, nausea and vomiting.

Nursing Responsibilities: y y y y Assess for epigastric pain. Administer before meals. Do not chew or crust. Instruct the patient to cautiously take the medication as

ordered. Do not discontinue. Do not double dose. y Inform patient ot avoid activity that requires alertness.

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y

Advice the patient to report any signs of bleeding.

Generic name: metoclopramide Brand Name: Plasil Classification: Antiemetics Indication: Prevent or treat nausea and vomiting Dosage: 40mg 1 tablet once daily. Drug Action: Blocks dopamine receptors in chemoreceptor trigger zone of the CNS. Stimulates motility of the upper GI tract and accelerates gastric emptying. Side/adverse effects: Restlessness, drowsiness, fatigue & lassitude. Less frequent

insomnia, headache, dizziness, nausea, galactorrhea, gynecomastia or bowel disturbances. Nursing Responsibilities: y assess patient for nausea, vomiting, abdominal distention, and bowel sounds before and after administration. y y May cause drowsiness. Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication. y Advise patient to notify health care professional immediately if involuntary movement of eyes, face or limbs occurs.

Generic name: furosemide Band name: Lasix Classification: lood diuretics Indication: Renal disease and hypertention. Dosage: 40mg IVTT stat.

Page | 47

Drug Action: Inhibits the reabsorption of sodium and chloride from the loop of Henle and distal Renal Tubule. Increase renal excretion of water, sodium, chloride, magnesium, potassium and calcium. Effectiveness persists in impaired renal function. Side/adverse effects: Dehydration, hypocalcemia, hypokalemia, hypomagnesemia, hypochloremia, hyponatremia, hypovolemia, blurred vision,

dizziness, headache, anorexia, dry mouth, nausea and vomiting, paresthesia. Nursing Responsibilities: y y y y y y Assess fluid status Monitor blood pressure. Assess side/adveres effects. Report immedietly to health care provider if there is any. Caution the patient about sudden change and position and should avoid activities that required alertness. Advice the patient to continue additional management of hypertension. Emphasize the need for check ups.

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Hemodialysis Healthy kidneys clean your blood by removing excess fluid,

minerals, and wastes. They also make hormones that keep your bones strong and your blood healthy. When your kidneys fail, harmful wastes build up in your body, your blood pressure may rise, and your body may retain excess fluid and not make enough red blood cells. When this happens, kidneys. Hemodialysis removal of certain elements from the blood by virtue of the difference in rates of their diffusion through a semipermeable membrane while being circulated outside the body; the process involves both diffusion and ultrafiltration. It is the most common method used to treat advanced and permanent kidney failure. Hemodialysis requires five things before the procedure. 1. Access to patients circulation (usually via fistula) 2. Access to a dialysis machine and dialyzer with a semipermeable membrane 3. The appropriate solution (dialysate bath) 4. Time: 12 hours each week, divided in 3 equal segments 5. Place: home (if feasible) or a dialysis center you need treatment to replace the work of your failed

Figure 4.2. Hemodialysis PROCEDURE1. Patients circulation is accessed 2. Unless contraindicated, heparin is administered 3. Heparinized (heparin: natural clot preventer) blood flows

through a semipermeable membrane in one direction. Page | 49

4. Dialysis solution surrounds the membranes and flows in the

opposite direction5. Dialysis solution is:

a. Highly purified water b. Sodium, potassium, calcium, magnesium, chloride and dextrose c. Either bicarbonate or acetate, to maintain a proper pH6. Via the process of diffusion, wastes are removed in the form

of solutes (metabolic wastes, acid-base components and electrolytes)7. Solute wastes can then be discarded or added to the blood 8. Ultrafiltration removes excess water from the blood. 9. After cleansing, the blood returns to the client via the

access. Complications related to vascular access in Hemodialysis

1. Infection 2. Catheter clotting 3. Central venous thrombosis 4. Stenosis or thrombosis 5. Ischemia of the affected limb 6. Development of an aneurysm Nursing interventions for Hemodialysis

1. Explain procedure to client 2. Monitor hemodynamic status continuously 3. Monitor acid-base balance 4. Monitor electrolytes 5. Insure sterility of system 6. Maintain a closed system 7. Discuss diet and restrictions on: a. Protein intake b. Sodium intake c. Potassium intake d. Fluid intake 8. Reinforce adjustment to prescribed medications that may be affected by the process of hemodialysis 9. Monitor for complications of dialysis

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SURGICAL MANAGEMENT Arteriovenous fistula Creation An arteriovenous fistula (AV fistula) is the connection of a vein and an artery, usually in the forearm, to allow access to the vascular system for hemodialysis, a procedure that performs the functions of the kidneys in people whose kidneys have failed. Connecting the vein and artery is a surgical procedure. The fistula develops over a period of months after the surgery. AV fistula provides a long-lasting site through which blood can be removed and returned during hemodialysis. The fistula, which allows the person to be connected to a dialysis machine, must be prepared by a surgeon weeks or months before dialysis is started.

Placement of new access should be initiated several months before the anticipated need for hemodialysis to allow time for fistula maturation and troubleshooting, as well as to avoid catheter placement and the associated risk of central vein stenosis. PREOPERATIVE CONSIDERATIONS/ NURSING RESPONSIBILITIES: y Physical examination for compressible veins in the forearm and arm should be performed, as well as Allen's test for palmar arch patency. Any history of congestive heart failure, diabetes, intravenous drug use, or chemotherapy should be elicited. y In most patients, preoperative vein mapping should be obtained to maximize the creation of arteriovenous fistulae over graft placement. Target veins should have a diameter larger than 3 mm, although smaller distendable veins may be used. y Access creation should occur in the nondominant forearm first, starting at the most distal site possible. Strategic placement of access is important to maximize the number of sites available over the life of the patient

PROCEDURE INCISION y The patient is placed supine, with the arm placed on an arm board.

Page | 51

y

The radial artery and the target cephalic vein are located. Intraoperative ultrasound can help the surgeon localize the vein and reassess patency of the vessel.

y

A longitudinal incision is made between the target vein and the radial artery

y

All of the operations to create a fistula require some sort of anaesthetic. Commonly, a local anaesthetic is used for a fistula at the wrist. This requires the injection of an anaesthetic

under the skin which then numbs or freezes the area where the operation will be performed. DISSECTION y A small flap is made to allow mobilization of the cephalic vein. The vein is mobilized for a short distance and assessed for adequacy. y The fascia over the radial artery is incised, and proximal and distal control of the vessel is obtained. y The cephalic vein is divided as distally as possible, flushed with heparinized saline, and dilated manually. y The patient is heparinized, and proximal and distal arterial clamps are placed. y y An end-to-side anastomosis is performed with 6-0 Prolene suture. The clamps are removed, with the distal arterial clamp removed last. The cephalic vein is palpated for a thrill. Revision may be necessary if a thrill is not readily palpable. If the fistula is pulsatile without a thrill, a distal obstruction may be present. If the obstruction is not from inadequate vein mobilization, a venogram may need to be performed. CLOSURE y The wound is closed in two layers with interrupted 3-0 Vicryl subcutaneous sutures and a running 4-0 Monocryl subcuticular layer. POST-OPERATION CONSIDERATIONS: y y y y y y Making sure the access is checked before each treatment. Not allowing blood pressure to be taken on the access arm. Checking the pulse in the access every day. Keeping the access clean at all times. Using the access site only for dialysis. Being careful not to bump or cut the access.

Page | 52

y

Not wearing tight jewelry or clothing near or over the access site.

y y

Not lifting heavy objects or putting pressure on the access arm. Sleeping with the access arm free, not under the head or body.

Temporary venous catheter creation If your kidney disease has progressed quickly, you may not have time to get a permanent vascular access before you start hemodialysis treatments. You may need to use a venous catheter as a temporary access. PROCEDURE: A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin. It has two chambers to allow a two-way flow of blood. Once a catheter is placed, needle insertion is not necessary. Catheters are not ideal for permanent access. They can clog, become infected, and cause narrowing of the veins in which they are placed. But if you need to start hemodialysis immediately, a catheter will work for several weeks or months while your permanent access develops.

POST-OPERATION CONSIDERATION:y y y y y y y y

Keep your access clean at all times. Use your access site only for dialysis. Be careful not to bump or cut your access. Dont let anyone put a blood pressure cuff on your access arm. Dont wear jewelry or tight clothes over your access site. Dont sleep with your access arm under your head or body. Dont lift heavy objects or put pressure on your access arm. Check the pulse in your access every day.

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SUBJECTIV E Sakit ang gibutang the hose samot na kung maduot. As verbalized by the patient.

OBJECTIVE S -facial grimace noted upon palpation on the surrounding site. -position to unaffected side to avoid pain. -protective gestures noted. -pain rated as 6 with pain scale of 0-10 -disturbance in sleep -restlessness.

NURSING DIAGNOSIS Acute pain related to Insertion of venous catheter at the femoral area as a temporary access for hemodialysis DEFINITION: Acute pain -unpleasant sensory and emotional experience arising from actual or potential tissue damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end a duration less than 6 months.

SCIENTIFIC ANALYSIS If the kidney disease has progressed quickly, surgeon may not have time to get a permanent vascular access before he start hemodialysis treatments. He may need to use a venous catheter as a temporary access. A catheter is a tube inserted into a vein in your neck, chest, or leg near the groin or femoral area. It has two chambers to allow a two-way flow of blood. Once a catheter is placed, needle insertion is not necessary.Catheters are not ideal for permanent access. They can clog, become infected, and cause narrowing of the veins in which they are placed. But if you need to start

PLANNING

IMPLEMENTATION

RATIONALE

That after 5 hours of nursing care, the patient will be able to: -report pain is relieved or lessen. -verbalizes her own plan of care to manage pain. -show willingness to participate in diversional activities. -demonstrate use of different relaxational techniques in releiving pain. -verbalize that such pain management provide relief. -follow prescribe pharmacologic management.

INDEPENDENT -assess the nature, quantity, intensity or severity of pain and its underlying cause.

-to provide appopriate nursing management of underlying cause of pain. -to render immediate care for such changes in response to pain. -to enhance client independence and participation.

EXPECTED OUTCOME/ EVALUATION That after 5 hours of nursing care, the patient was able to:

-check vital signs and skin condition.

-identify and plan with the client of her preferable diversional activities. -provide dim and calm enviroment.

-to promote patient rest which is conducive for her health. -to improve patients knowledge on how to lessen the pain.

-teach patient how to do deep breaathing exercise when pain is not on its peak.

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SUBJECTIV E

OBJECTIVE S -

NURSING DIAGNOSIS Sources: Doenges, M., et al. Nurses packet guide, Acute pain. Edition 12 pages 586.

SCIENTIFIC ANALYSIS hemodialysis immediately, a catheter will work for several weeks or months while your permanent access develops. Source:Medicinenet.com (2011). Hemodialysis manage Renal Failure. Retrieved on February 22, 2012 from http://www.medicin enet.com/hemodialy sis/article.htm

PLANNING

IMPLEMENTATION

RATIONALE

That after 5 hours of nursing care, the patient will be able to: -

DEPENDENT -administer analgesic as ordered. (monitor side and adverse effects

-to promote relief of pain.

EXPECTED OUTCOME/ EVALUATION That after 5 hours of nursing care, the patient was able to:

Page | 55

SUBJECTIV E kapoy kung maglihoklihok as verbalized by the clent

OBJECTIVE S -pale lips -dry skin -cold skin -muscle weakness (muscle strength of +2) -inability to stand or sit on her own. -needs assistance in activities.

NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

PLANNING

IMPLEMENTATION

RATIONALE

Activity In relation to patients intolerance case which is related to diabetes mellitus, it is generalized possible that the cells weakness. are depriving from DEFINITION: glucose which only Activity stays at vascular intolerancecompartment and the insuffecient viscosity of the blood physiologic or makes the movement psychological slow thus the patient energy to appear pale and the endure or muscles are weak. complete Source: required or Lewis S., MD.,et desired daily al.Medical Surgical activities. nursing. Diabetes Sources: mellitus. Edition Doenges, M., seven. V et al. Nurses Volume 2 page 1253 packet guide. Activity intolerance Edition 12 pages 73.

That after 5 hours of nursing care, the patient will be able to: -identify factors affecting activity intolerance and eliminate or reduce their effects as possible. -use techniques to enhance activity intolerance. -participate willingly to activities.

INDEPENDENT -Note presence of factors contributing to fatigue. -evaluate clients actual and perceived limitations, and severity of deficit in light of usual status. -adjust/plan activities.

-fatigue may affect activity intolerance -Provide comparatve baseline information

-to prevent overexertion.

-assist with activities -to prevent injury Give client information that provides evidence of daily/weekly progress. -encourage client ot -To enhance have positive attitudes sence of welltowards reaching his being goals

EXPECTED OUTCOME/ EVALUATION That after 5 hours of nursing care, the patient was able to: -shows understanding about the possible cause of her intolerance in activity. -shows willingness to participate in activities. -use of her own techniques in enhancing her intolerance to activity.

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SUBJECTIV E

OBJECTIVE S -tissue hypoxia -flaccid muscle tone with musle weakness (muscke strenght of 2+) -presence of fatigue - inability to stand or sit on her own. -needs assistance in activities -pain noted upon palpation of right femoral area

NURSING DIAGNOSIS Risk for Injury related to generalized body weakness. DEFINITION: At risk for injury as a result of environmental conditions interacting with the individuals adaptive and defnsive resources. Sources: Sources: Doenges, M., et al. Nurses packet guide. Activity intolerance Edition 12 pages 73.

SCIENTIFIC ANALYSIS In relation to patients case which is diabetes mellitus, it is possible that the cells are depriving from glucose which only stays at vascular compartment and the viscosity of the blood makes the movement slow thus the patient appear pale and the muscles are weak. With this due to lack of oxygen supply to different organs, muscles, and tissues the patient will be experiencing difficulty in performing some activity of daily living like; standing or even sitting on a chair, which put the patient in a high risk for falls and even injury.

PLANNING

IMPLEMENTATION

RATIONALE

That after 5 hours of nursing care, the patient will be able to: -identify factors that would put his/her condition high risk for injury or falls. -utilize some nonpharmacological techniques thatwould enable patient to lessen the possibilities for falls. -develop or demonstrate changes in behavior towards lifestyle

INDEPENDENT -Ascertain knowledge of safety needs or injury prevention and motivation -Assesss the mood,coping abilities and personality styles

-tonprevent injury in home and community

EXPECTED OUTCOME/ EVALUATION That after 5 hours of nursing care, the patient was able to: -verbalize understanding of factors that would put her condition at high risk for injury or falls. -demonstrate proper way of using nonpharmacologic regimen. -change her behavior towards caring herself.

-that may result to carelessness or increased risk taking without consideration of consequences -to identify risk for falls

-Assess clients muscle strenght,gross and fine motor coordination -Side rails up or do not allow the patient to stay or sit near the edge of the bed without assistance

-to promote safety and prevent injury or falls to happen.

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SUBJECTIV E

OBJECTIVE S

NURSING DIAGNOSIS

SCIENTIFIC ANALYSIS

PLANNING

IMPLEMENTATION

RATIONALE

EXPECTED OUTCOME/ EVALUATION

Source: Lewis S., MD.,et al.Medical Surgical nursing. Diabetes mellitus. Edition seven. Volume 2 page 1253

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Table 4.4 PROGRESS NOTES

Date

Problem

Medical Intervention

Nursing Intervention

Outcome

February 14, 2012

Patient is vomiting

-Heplock inserted @ right metacarpal vein for administrati on Of medication. -NOD administered Plasil 10mg IVTT as ordered.

-check the attachment and placement, assessed bleeding.

-patent and well attached.

-assessed and monitored any signs of side/adverse effects of the medication -check the attachment and placement, assessed bleeding.

-taken and well tolerated.

Increase blood creatinine and potassium level

Hemodialysis started via Temporary venous catheter @ femoral area -w/hold vasalat and pritor prior to hemodialysis

- Explained procedure to patient -monitored electrolytes -health teaching given regarding the BP and

-patient verbalized understanding of the procedure and health teaching given.

restrictions on: Protein intake, Sodium intake, Potassium

intake, Fluid intake -Reinforced adjustment to prescribed medications that may be affected by the process of hemodialysis -Monitored for complications -signed inform consent

Administered

-assessed for

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Vessel Due 1 capsule as ordered.

side/adverse effects

Increase in BP 180/100 mmHg

Given Lasix 20mg IVTT stat. Ordered Vasalat 5g 1 tablet once daily at 6pm.

-Monitored any signs of adverse/side effect. -Monitored the BP every 2 hours -Health education given regarding factors that may contribute to increase in BP.

-BP ranging from 150-160 mmHg. -verbalized understanding of the health teaching given.

RBS 240mg/dl

Given Lantus 10u as ordered Ordered Glucobay 50mg 1 tab once daily after breakfast.

-monitored RBS every 6 hours. -monitored for signs of hypoglycemia

-RBS ranging from 104-190 mg/dl -no signs of hypoglycemia noted.

Patient February 15, 2012 complaint of fatigue and muscle weakness And inability to walk.

Ordered nutritional supplements such as ProVitality 3capsule once daily, Sorbifer 300 mg 1 tablet once daily after breakfast and Calvit 1 tablet as trice daily every after eating as ordered -ordered 40 grams

-monitored and checked of patients compliance. -assessed patients level of muscle weakness -passive ROM exercise given. -assisted patient in bowel and bladder activity. -provided patient activity-rest pattern. -provided safety; side rails up and utilized other safety devices.

-After 3-5 days patient verbalized less complaint of fatigability and weakness. -medication taken and well tolerated.

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carbohydrate s, low salt, diabetic diet February 17, 2012 Patient felt intense pain rated as 9 in a scale of 0-10 due to femoral catheter. February 18, 2012 Patient complaint of dizziness -demonstrated deep breathing exercise. -provided calm environment which is conducive for resting. -let patient be on her comfortable position. -thing that can trigger pain were avoided. -assessed level of consciousness. -provided safety. -patient verbalized of feeling well, less dizzy. -no injury happened throughout the shift. -patient still report tolerable pain rates as 6 in a scale of 0-10.

February 21,2012

-patient still report tolerable pain rates as 6 in a scale of 0-10.

-encouraged patient to do diversional activities. -health teaching given regarding relaxation techniques such as deep breathing exercise and position. -given patient time to rest. -avoid disturbances. -patient was given discharge plan and may go home as ordered. -health teaching given to significant others regarding medication compliance and diet regimen, exercise and activities to be perform at home and scheduled check ups.

-patient still report tolerable pain rates as 6 in a scale of 0-10.

-questions are answered -confusion was address. -verbalized understanding regarding health teaching given.

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DISCHARGE PLAN Maintenance medications:Discharge instructions should be given to significant others and to the patient before discharge. The compliance the following medications at home is a must. Table 4.5: Maintenance medications Medication Amlodipine (Vasalat) Telmisartan (Pritor) Lantus Acarbose (Glucobay) ProVitality Calvit FerroeSulfate (sorbifer) Dosage 5g 1 tab 40mg 1 tab 10 u 50mg 1tab 3 capsules 500mg 1 tab 300mg 1 tab Time of administration Once daily 12 noon Once daily 8am after breakfast Once daily Once daily 8am after breakfast Once daily 8am after breakfast Three times daily 8am-12noon-8pm Once daily 12noon before lunch

Health teaching: y Educate patient and and what the are family the about the indication of of

medications

side/advese

effect

these

medication if not follow the right prescription well. y Teach the patient and significant others on how to administer medication especially injectable once. Make sure that they

understant it well and encourage them to ask questions if there is any. y Inform the family and the patient that the compliance of the following medication listed above is needed and shoukd not be discontinued. y Following the prescribed time, dosage and route is needed inorder not to have any problems due to side/adverse effects. Do not double dose. y Encourage the family and the patient to contact emmidietly the physician for any unusual manifestation the patient has.

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Exercise and activities: The client should be encouraged to perform regular exercises such as walking, body stretching or ROM exercises at the level of his tolerance in order for her to enhance or maintain physical fitness and overall health and wellness. It also improves circulation and prevents occurrence of bone-related diseases. Significant others assistance is highly needed during exercises for safety reasons that is why health education of family or significant others is a must. Inform the family to support the patient and make her feel that she is not alone carrying her own problems and over exhaustion because these may cause stress which will contribute to increase level of blood glucose in the body. Inform the family and the patient to be careful in activities that would lead to wounds or break the integrity of the skin because it will be heal slowly due to the patients condition which is diabetes mellitus Treatment: The client should be instructed and encouraged to take

medications as maintenance to manage her diseases. She should need to undergo hemodialysis twice in a week as ordered by her doctor. Health teaching to family regarding how to take blood pressure and how to monitor blood sugar level is a must. Out-Patient Check Up: Client should inform the need for return check up on the date scheduled by the physician once every month to evaluate clients

condition, to know the progression of clients state of health and to determine the need for any medical interventions. Before patient will go for check up make sure that she has request slip and she already went for required laboratory examinations such as CBC and urinalysis to check for creatinine and potassium. Diet: The client should follow the prescribe diet ordered by her physician such as 40 grams carbohydrates, low salt diet, diabetic diet. Patient should limit her fluid into 1000ml daily as prescribed by her

physician.

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Spiritual Care: The client should be encouraged to continue enhancing his

relationship with God through prayer, reading and reflecting on bible passages. Allowing the client to reflect will give him a sense of awareness and may be able to review his values and beliefs through prayer.

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CHAPTER V CONCLUSION AND RECOMMENDATION

CONCLUSION After taking care of Patient in NS2 Holy Child Hospital and studying her case and medications, Student Nurse learned a lot. Before starting this paper, Student Nurse has set objectives that help in meeting goals. And now, in the end of this clinical paper, Student Nurse proudly says that objectives are met.

Student Nurse has learned to appreciate the type of disorder the patient have, most especially the evident manifestations the

causes and how it progress and develop. But most of all how learning and knowledge be apply in taking care of the said

Patient and learned to anticipate weather the management given are efficient and effective. Indeed, no one can destroy persons health. Extraneous and internal factors have a big role to play. Indeed, the exposure help a lot in identifying cause of the disease, how to manage it and how learned knowledge is apply in order to efficiently and effectively formulate and render appropriate care. And all

levels of prevention are very important in addressing any kind of disease and complications.

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RECOMMENDATIONS To the patient: She is advised to take part in complying with the

treatment; the medication and therapeutic regimen designed for her rehabilitation. She should realize the importance of

complying with her medication and the benefits this practice would bring to the improvement of her well-being and proper care of ones self. To the patients family: The patients family plays an important role in the

patients state of health and recovery. The family should be physically present so that the patient would feel their support and concern. They are encouraged to take part in managing

patients disease at home such as administration of medication, reminding the patient of the things she needs to avoid and to encourage her to have positive outlook in life. is of prime importance that they are In addition, it and educated

oriented

regarding the patients disease so that they can also enhance the patients state of health by collaborating with the health care team especially in rehabilitative period. Holy child hospital NS2 The researcher recommends that they should continue their good facilities in treating the ill patients, because it really helps patients recovery. The patient should receive what is due to them in congruent of the services they pay. The patients must be kept clean, well-fed, and have mattresses to sleep on. The hospital must continue to provide a safe and clean environment which is conducive to health for the patients and staff. They should continue to render efficient nursing care for the

effective outcome. The proponents recommend that the health care team would continue their good work in order to provide health care service that promotes health and prevent diseases. they are encouraged to know and apply the latest Also of

trends

management in improving patients state of health.

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To the student nurses: Even if nursing students find it difficult to establish rapport and good nurse-patient relationship because of the

relatively short time spent in the clinical area, still we have to render amounts of effort, time and trust to our patients; apply all learning that we have and improve our knowledge and skill in caring for our patients; we were expected to continue learning new management and improve them and we must play a part in the promoting optimum level of health and preventing the occurrence of the disease.

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Bibliography:

Aggarwal, R., et.al.(2009). The Bantan Medical Dictionary. Definition of Caffeine. NY: Market House Book Ltd. Deglin, J., et.al (2011). Daviss Drug Guide for Nurses. USA: F.A Davis Company. Doenges, M., et al.(2010). Nurses packet guide Edition 12.

USA: F.A Davis Company. English, L. (2008). English-Tagalog Dictionary. Definition Of alertness. Glenview, Illinois: Scott, Foresman and Company. Lewis, S., et.al (2008) Medical-Surgical Nursing. Diabetes Mellitus, Hypertension and Renal Failure. Phil: Elsevier, Inc. Medicinenet.com (2011). Hemodialysis manage Renal Failure. Retrieved on February 22, 2012 from http://www.medicinenet.com/hemodialysis/article.htm Thibodeau, G.A., et.al (2003) Anatomy and physiology. Pancreas, Cardiovascular and urinary system. Missouri, St.Louis: Mosby, Inc. Venes, D. (2005). Tabers Cyclopedic Medical Dictionary. USA: F.A Davis Company

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