Patient’s Initials: M. N. M Age: 41 years old Sex: Male Civil Status: Married Medical Diagnosis: CKD Secondary to Uremic Encephalopathy, Hypertensive Nephrosclerosis vs. Gouty Neuropathy Attending Physician: Dr. Valdez, Dr. Manzon, Dr. Ocampo, Dr. Concepcion I. CHIEF COMPLAINT – General body weakness – Drowsiness – Pain on knees II. NURSING HISTORY The patient, MNM, has hypertension for 21 years, he’s not taking any medications until year 2008 when he was prescribed Nifedipine and Carvedilol. He also has gouty attacks for 14 years now and he is taking Allopurinol. Four days PTC, patient verbalizes pain on his knees.
He was then also noticed by his wife to be drowsy at all time and has melena in which they sought consult at a nearby hospital. Three days PTC during the stay in the hospital patient was noted to have episodes of epistaxis on which he was given a dose of tranexamic acid. One day PTC, patient’s hemoglobin decreased and was advised to have a transfusion of 2 ‘U’ of PRBC then they decided to transfer the patient in this institution. III. PATHOPHYSIOLOGY Modifiable Factors – Lifestyle – Diet – Alcohol – Smoking – Chronic NSAID use – Hypertension Non Modifiable Factors – Hereditary – Age – Sex
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Renal tissue loses function Renal function adaptation Kidneys lose ability to maintain fluid and electrolyte homeostasis Decrease in Glomelular Filtration Rate Decrease ability to concentrate urine Decrease ability to excrete toxins Further decrease of GFR Increase plasma concentration of creatinine and urea CHRONIC KIDNEY DISEASE -Uremia -Azotemia Oliguria Serum Creatinine: 624 Decrease GFR IV. LABORATORY AND DIAGNOSTIC CT Scan (April 27, 2010) Plain CT scan of brain was performed. Exam was studied with 1. 25 mm thick section at 1. 25mm intervals. All these are parallel to orbito-meatal line.
No evidence of abnormal high or low density lesions throughout the brain. The brainstem as well as cerebellum are unremarkable. No evidence of hemorrhage noted. The ventricular system are well visualized and show no evidence of dilatation nor displacement. There is no shift of midline sutures nor is there evidence of subdural or epidural hematoma formation. The cerebellopontine angle, sella, orbits and bony calvarium are unremarkable. There are no hazy densities seen in ethmoid and sphenoid sinuses. IMPRESSION: Unremarkable plain CT scan of brain. Follow-up study recommended poly sinusitis described.
Chest X-ray (April 27, 2010) A right side CTT is seen in place with tip seen at level of the 3rd posterior rib. Tip of the subclavian catheter seen at level of the 7th posterior rib. No other significant changes noted. Hematology | Normal Val. | April 27, 2010| April 28, 2010| April 29, 2010| April 30, 2010| Hemoglobin| 140-175| 82| 76| 84| 73| Hematocrit| 0. 41-0. 50| 0. 24| 0. 23| 0. 25| 0. 22| WBC| | 8. 2| 9. 1| 16. 7| | Segmenters| | 0. 90| 0. 86| 0. 90| | Lymphocytes| | 0. 06| 0. 13| 0. 05| | Eosinophils| | 0. 01| | | | Monocytes| | 0. 03| | 0. 01| | Stab Cells| | | | 0. 03| |
Platelet Count| 150-450×109| 140| 140| 112| 116| Bleeding Time | | | 2 mins30 secs| | | Blood Chemistry (April 29, 2010) | Normal Values| Result| BUN| 2. 50-7. 10 mmol/L| 18. 30| Serum Creatinine| 58-110 umol/L| 624| Na| 137-145 mmol/L| 143| Ca| 2. 10-2. 55 mmol/L| 1. 82| K| 3. 50-5. 10 mmol/L| 3. 10| Albumin| 35-50 g/L| 22| Urinalysis (April 26, 2010) | Normal Values| Result| Color| | Yellow| Character| | Slightly cloudy| Specific Gravity| | 1. 020| pH| | 6. 0| Albumin| | +2| Sugar| | (-)| WBC| | 6-10/HPF| RBC| | 8-12/HPF| Bacteria| | +1| Epithelial Cells| | Few| PT/PTT (April 25, 2010) | Control| Result| Reference Value|
Prothrombin Time| 11. 6 secs| 12. 2| 10-14| % Activity| | 92. 1%| 70-120%| INR| | 1. 05| ; or = 1. 15| PTT| 30. 5 secs| 36. 7| Ratio: 1. 16 ; or = 1. 2| PT/PTT (April 28, 2010) | Control| Result| Reference Value| Prothrombin Time| 11. 77 secs| 11. 9| 10-14| % Activity| | 97. 5%| 70-120%| INR| | 1. 01| ; or = 1. 15| PTT| 30. 5 secs| 35. 5| Ratio: 1. 16 ; or = 1. 2| V. MEDICATIONS AND TREATMENT Brand Name/ Generic Name| Dosage, Frequency, Route| Indication, Contraindication| Side Effects and Adverse Reaction| Nursing Responsibilities| Zyloprim (Allopurinol)| D: 100mg/tabF: ODPCR: PO| I:
Prevention of gouty arthritis and nephropathyCI: Hypersensitivity| CV: hypotension, flushing, hypertension, bradycardia, heart failureCNS: drowsinessGI: diarrhea, hepatitis, nausea, vomiting| -Monitor intake and output ratios. -Monitor for joint pain or swelling. -Emphasize the importance of follow-up checkups to monitor effectiveness. | Zynapse(Citicoline)| D: 1 gmF: q12R: IV| I: Cerebrovascular accident in acute and recovery phase, symptoms and signs of cerebral insufficiency such as dizziness, memory loss, poor concentration, disorientation, etc. and recent cranial traumatism and their sequelae.
CI: Must not be administered to patients with hypertonia of the parasympatetic| GI: gastrointestinal disorders| -Must not be administered along with medications containing medophenoxate. | Iseptin(Sucralfate)| D: 1 gmF: q8R: PO| I: Short term management of duodenal ulcers. Management of gastric ulcer or GERD. Prevention of gastric mucosal injury caused by high dose aspirin or other NSAIDs. CI: Hypersensitivity. Use cautiously in renal failure. | CNS: dizziness, drowsinessGI: constipation, diarrhea, dry mouth, gastric discomfort, indigestion, nausea| -Assess patient routinely for abdominal pain and frank or occult blood in the stool. Dulcolax(Bisacodyl)| D: 10 mgF: ODHSR: PO| I: Treatment of constipation. Evacuation of the bowel before radiologic studies or surgery. CI: Hypersensitivity. Abdominal pain; obstruction; nausea and vomiting| GI: abdominal cramps, nausea, diarrhea, rectal burningF: hypokalemiaMS: muscle weakness| -Assess patient for abdominal distention, presence of bowel sounds and usual pattern of bowel function. -Encourage patient to use other forms of bowel regulation. | Biogesic (Paracetamol)Medamol(Paracetamol)| D: 500 mgF: q4 ? 37. 8? CR: POD: 300 mgF: q4 ? 38. 5? CR: IV| I: Mild pain and fever. CI: Previous hypersensitivity.
Products containing alcohol, aspartame, sugar, saccharin or tartrazine should be avoided in patients who have hypersensitivity or intolerance to these compounds. | GI: hepatic failure, hepatotoxicityGU: renal failureHemat: neutropenia, pancytopenia, leukopenia| -May alter blood glucose monitoring. -if overdose occurs, acetylcysteine (Acetadote) is the antidote. | Tazicef(Ceftazidime)| D: 1 gmF: q12R: IV| I: Treatment of infections. Febrile NeutropeniaCI: Hypersensitivity to cephalosporin| CNS: seizures, headacheGI: pseudomembranous colitis, diarrhea, nausea, vomiting, cholelithiasis| -Assess for infection-Dilute cephalosporins in at least g/10 ml. | Nexium(Esomeprazole)| D: 40 mg, 1 vialF: ODAMR: IV| I:GERD including erosive esophagitis. Decrease risk of gastric ulcer during continuous NSAID therapy. CI: Hypersensitivity, lactation. | CNS: headacheGI: abdominal pain, constipation, diarrhea, dry mouth, flatulence, nausea| -Assess patient routinely for epigastric or abdominal and frank or occult blood in the stool, emesis or gastric aspirate-Administer at least 1 hour before meals. Plasil(Metoclopromide)| D: 1 ampF: PRN x hiccupsR: IV| I: Prevention of chemotherapy ??? induced emesis. Treatment and prevention of post operative nausea and vomiting. Treatment of hiccups. CI: Hypersensitivity, possible GI obstruction or hemorhhage| CNS: drowsiness, extrapyramidal reactions, restlessness, anxiety, depressionCV: arrhythmias, hypertension, hypotensionGI: constipation, diarrhea, dry mouth, nausea| -Assess patient for nausea, vomiting, abdominal distention and bowel sounds before administration. Assess patient for signs of depression periodically through therapy. | Dilantin(Phenytoin)| D: 4 mlF: q8R: PO| I: Treatment and prevention od tonic clonic seizures and complex partial seizures. CI: Hypersensitivity, sinus bradycardia| CNS: ataxia, agitation, confusion, dizziness, drowsinessCV: hypotension, tachycardiaGI: nausea, constipation, vomiting, gingival hyperplasia| -Assess oral hygiene. Vigorous cleaning may help control gingival hyperplasia. Implement seizure precaution. | Isoptin(Verapamil)| D: 40 mgF: TIDR: PO| I: Management of hypertension, angina pectoris. CI: Hypersensitivity, BP ? 90 mmHG| CNS: abnormal dreams, anxiety, confusion, dizziness, headacheResp: cough, dyspnea, shortness of breathGI: abnormal liver function studies, anorexia, constipation, diarrhea| -Monitor blood pressure and pulse before therapy, during dosage titration and periodically throughout therapy. -Monitor intake and output ratios daily. Calvit(Calcium Carbonate + Vitamin D)| D: 650 mgF: q6 with mealsR: PO| I: Antacid, Calcium supplementCI: Hypercalcemia, bone tremors, severe renal failure, hypersensitivity| GI: constipation, flatulence, diarrheaGU: renal dysfunction, acid rebound| -Assess hepatic status-Avoid alcohol while taking the drug| VI. NURSING PRIORITIES 1. Ineffective breathing pattern related to decrease lung expansion secondary to pneumothorax. 2. Impaired skin integrity related to effects of pressure and mobility. VIII. DISCHARGE PLAN | Content| Strategy| 1. Compliance Medication Diet2.
Follow up/Check up| – Importance of compliance to medication. – The prescribed time, frequency and dosage of medication. – Discuss in layman’s term the indication, contraindication and side effects of the medications. – Importance in change of diet. – Advice to avoid intake of foods high in fat and salt. – Emphasize to the patient the importance of follow up check ups. | Health teachingProvide verbal and written instructions on the dosage and frequency of taking the medications. Health teachingInform the relative and the patient on the prescribed diet. |