Public

COLLEGE OF NURSING

IN PARTIAL FULFILMENT IN
NCM 102

CASE PRESENTATION
“CHRONIC KIDNEY DISEASE”

SUBMITTED BY:

I. INTRODUCTION

Chronic Kidney Disease

"It's a silent disease" until the kidneys are severely damage, Andrew Levey, chief of nephrology at Tufts New England, Medical Center in Boston, said.

What is chronic kidney disease?

Chronic Kidney disease or CKD , is a condition that affects the function of the kidneys and that may progress over time to kidney failure. When the kidneys fail, dialysis or kidney transplant is needed to support life- and people can live in decades with dialysis and/or kidney transplant. Many disease can cause CKD . The most common are diabetes and high blood pressure. (Life options by the medical education institute, inc. if Madison Wis.)

Many people who have chronic kidney disease don’t know it, because the early signs can be very subtle. It can take many years to go from chronic kidney disease (CKD) to kidney failure. Some people with CKD live out their lives without ever reaching kidney failure.

However, for people at any stage of kidney disease, knowledge is power. Knowing the symptoms of kidney disease can help you get the treatment you need to feel your best.

Most chronic kidney disease (CKD) is not curable, but if its detected early there maybe a number of ways to slow down the disease, help the patients to feel better, and help them make better medical decisions.

Nursing Theories

Dorothea Orem's Self Care Theory

Nursing theory guides nursing practice. Dorothea Orem's self care theory is one of the general theories that can be applied to multiple settings in nursing practice. The dialysis arena is one area of nursing practice in which the application of this theory would be appropriate because it is crucial for patients to be actively involved in self care. Orem believed that people have a natural ability for self care and that nursing should focus on affecting that ability. (Orem 1995)

The goal of nursing practice is to assist patients to be adequately prepared to be engaged in their own care, thereby improving patient outcomes and quality of life. As nurses, we can do it by establishing a trusting nurse-patient relationship, providing support and education, allowing patient’s one control of their situation by participating in decision making, and encouraging patients to actively participate in the hemodialysis treatment.

Theory of Comfort: Katherine Kolcaba Kolcaba defines health care needs as needs for comfort, arising from the stressful health care situations that cannot be met by recipient’s traditional support system. These needs include physical, psycho spiritual, social and environmental needs made apparent through monitoring and verbal or non verbal reports, needs related to pathophysiological parameters needs for education and support, and needs for financial counselling and interventions.

She also described comfort as the most important nursing action in the provision of nursing care for the sick. And it id the immediate and holistic experienced of being strengthened through having the needs met for the Three types of Comfort: Relief, Ease and Transcendence.

This is very essential of taking care and providing comfort to an old woman. Through intentional assessment of comfort needs, design of comfort measures to address needs and re assessments of comfort levels after implementation compared to the previous baseline to evaluate if patient comfort needs are met. Because enhancing her comfort strengthens her to engaged in improving her health status.

II. REVIEW OF RELATED LITERATURE

Chronic kidney disease
Chronic kidney disease is when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually over time, usually months to years. Chronic kidney disease is divided into five stages of increasing severity (see Table 1 below). Stage 5 chronic kidney failure is also referred to as end-stage renal disease, wherein there is total or near-total loss of kidney function and patients need dialysis or transplantation to stay alive. The term "renal" refers to the kidney, so another name for kidney failure is "renal failure." Mild kidney disease is often called renal insufficiency.
Chronic Kidney Disease Causes
Although chronic kidney disease sometimes results from primary diseases of the kidneys themselves, the major causes are diabetes and high blood pressure. * Type 1 and type 2 diabetes mellitus cause a condition called diabetic nephropathy, which is the leading cause of kidney disease in the United States. * High blood pressure (hypertension), if not controlled, can damage the kidneys over time. * Glomerulonephritis is the inflammation and damage of the filtration system of the kidneys and can cause kidney failure. Postinfectious conditions and lupus are among the many causes of glomerulonephritis. * Polycystic kidney disease is an example of a hereditary cause of chronic kidney disease wherein both kidneys have multiple cysts. * Use of analgesics such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil) regularly over long durations of time can cause analgesic nephropathy, another cause of kidney disease. Certain other medications can also damage the kidneys. * Clogging and hardening of the arteries (atherosclerosis) leading to the kidneys causes a condition called ischemic nephropathy, which is another cause of progressive kidney damage. * Obstruction of the flow of urine by stones, an enlarged prostate, strictures (narrowings), or cancers may also cause kidney disease.
Chronic Kidney Disease Symptoms
The kidneys are remarkable in their ability to compensate for problems in their function. That is why chronic kidney disease may progress without symptoms for a long time until only very minimal kidney function is left.

Because the kidneys perform so many functions for the body, kidney disease can affect the body in a large number of different ways. Symptoms vary greatly. Several different body systems may be affected. Notably, most patients have no decrease in urine output even with very advanced chronic kidney disease. * Fatigue and weakness (from anemia or accumulation of waste products in the body) * Loss of appetite, nausea and vomiting * Need to urinate frequently, especially at night * Swelling of the legs and puffiness around the eyes (fluid retention) * Itching, easy bruising, and pale skin (from anemia) * Headaches, numbness in the feet or hands (peripheral neuropathy), disturbed sleep, altered mental status (encephalopathy from the accumulation of waste products or uremic poisons), and restless legs syndrome * High blood pressure, chest pain due to pericarditis (inflammation around the heart) * Shortness of breath from fluid in lungs * Bleeding (poor blood clotting) * Bone pain and fractures * Decreased sexual interest and erectile dysfunction
Exams and Tests
Chronic kidney disease usually causes no symptoms in its early stages. Only lab tests can detect any developing problems. Anyone at increased risk for chronic kidney disease should be routinely tested for development of this disease. * Urine, blood, and imaging tests (x-rays) are used to detect kidney disease, as well as to follow its progress. * All of these tests have limitations. They are often used together to develop a picture of the nature and extent of the kidney disease.
In general, this testing can be performed on an outpatient basis.
Urine tests
Urinalysis: Analysis of the urine affords enormous insight into the function of the kidneys. The first step in urinalysis is doing a dipstick test. The dipstick has reagents that check the urine for the presence of various normal and abnormal constituents including protein. Then, the urine is examined under a microscope to look for red and white blood cells, and the presence of casts and crystals (solids).
Only minimal quantities of albumin (protein) are present in urine normally. A positive result on a dipstick test for protein is abnormal. More sensitive than a dipstick test for protein is a laboratory estimation of the urine albumin (protein) and creatinine in the urine. The ratio of albumin (protein) and creatinine in the urine provides a good estimate of albumin (protein) excretion per day.
Twenty-four-hour urine tests: This test requires you to collect all of your urine for 24 consecutive hours. The urine may be analyzed for protein and waste products (urea, nitrogen, and creatinine). The presence of protein in the urine indicates kidney damage. The amount of creatinine and urea excreted in the urine can be used to calculate the level of kidney function and the glomerular filtration rate (GFR).
Glomerular filtration rate (GFR): The GFR is a standard means of expressing overall kidney function. As kidney disease progresses, GFR falls. The normal GFR is about 100-140 mL/min in men and 85-115 mL/min in women. It decreases in most people with age. The GFR may be calculated from the amount of waste products in the 24-hour urine or by using special markers administered intravenously. Patients are divided into five stages of chronic kidney disease based on their GFR (see Table 1 above).
Blood tests
Creatinine and urea (BUN) in the blood: Blood urea nitrogen and serum creatinine are the most commonly used blood tests to screen for, and monitor renal disease. Creatinine is a breakdown product of normal muscle breakdown. Urea is the waste product of breakdown of protein. The level of these substances rises in the blood as kidney function worsens.
Estimated GFR (eGFR): The laboratory or your physician may calculate an estimated GFR using the information from your blood work. It is important to be aware of your estimated GFR and stage of chronic kidney disease. Your physician uses your stage of kidney disease to recommend additional testing and suggestions on management.
Electrolyte levels and acid-base balance: Kidney dysfunction causes imbalances in electrolytes, especially potassium, phosphorus, and calcium. High potassium (hyperkalemia) is a particular concern. The acid-base balance of the blood is usually disrupted as well.
Decreased production of the active form of vitamin D can cause low levels of calcium in the blood. Inability to excrete phosphorus by failing kidneys causes its levels in the blood to rise. Testicular or ovarian hormone levels may also be abnormal.
Blood cell counts: Because kidney disease disrupts blood cell production and shortens the survival of red cells, the red blood cell count and hemoglobin may be low (anemia). Some patients may also have iron deficiency due to blood loss in their gastrointestinal system. Other nutritional deficiencies may also impair the production of red cells.

Chronic Kidney Disease Treatment
Self-Care at Home
Chronic kidney disease is a disease that must be managed in close consultation with your healthcare provider. Self-treatment is not appropriate. * There are, however, several important dietary rules you can follow to help slow the progression of your kidney disease and decrease the likelihood of complications. * This is a complex process and must be individualized, generally with the help of your healthcare provider and a registered dietitian.
The following are general dietary guidelines: * Protein restriction: Decreasing protein intake may slow the progression of chronic kidney disease. A dietitian can help you determine the appropriate amount of protein for you. * Salt restriction: Limit to 4-6 grams a day to avoid fluid retention and help control high blood pressure. * Fluid intake: Excessive water intake does not help prevent kidney disease. In fact, your doctor may recommend restriction of water intake. * Potassium restriction: This is necessary in advanced kidney disease because the kidneys are unable to remove potassium. High levels of potassium can cause abnormal heart rhythms. Examples of foods high in potassium include bananas, oranges, nuts, and potatoes. * Phosphorus restriction: Decreasing phosphorus intake is recommended to protect bones. Eggs, beans, cola drinks, and dairy products are examples of foods high in phosphorus.
Other important measures that you can take include: * Carefully follow prescribed regimens to control your blood pressure and/or diabetes. * Stop smoking * Lose excess weight
In chronic kidney disease, several medications can be toxic to the kidneys and may need to be avoided or given in adjusted doses. Among over-the-counter medications, the following need to be avoided or used with caution: * Certain analgesics - Aspirin; nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen [Motrin, for example]) * Fleets or phosphosoda enemas because of their high content of phosphorus * Laxatives and antacids containing magnesium and aluminum such as Milk of Magnesia and Mylanta * Ulcer medication H2-receptor antagonists - cimetidine (Tagamet), ranitidine (Zantac), (decreased dosage with kidney disease) * Decongestants like pseudoephedrine (Sudafed) especially if you have high blood pressure * Alka Seltzer, since this contains a lot of salt * Herbal medications
If you have a condition such as diabetes, high blood pressure, or high cholesterol underlying your chronic kidney disease, take all medications as directed and see your healthcare provider as recommended for follow-up and monitoring.
Medical Treatment
There is no cure for chronic kidney disease. The four goals of therapy are as follows: 1. To slow the progression of disease 2. To treat underlying causes and contributing factors 3. To treat complications of disease 4. To replace lost kidney function
Strategies for slowing progression and treating conditions underlying chronic kidney disease include the following: * Control of blood glucose: Maintaining good control of diabetes is critical. People with diabetes who do not control their blood glucose have a much higher risk of all complications of diabetes, including chronic kidney disease. * Control of high blood pressure: This also slows progression of chronic kidney disease. It is recommended to keep your blood pressure below 130/80 mm Hg if you have kidney disease. It is often useful to monitor blood pressure at home. Blood pressure medications known as angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB) have special benefit in protecting the kidneys. * Diet: Diet control is essential to slowing progression of chronic kidney disease and should be done in close consultation with your health care provider and a dietitian. For some general guidelines, see the Self-Care at Home section of this article.
The complications of chronic kidney disease may require medical treatment. * Fluid retention can be treated with any of a number of diuretic medications, which remove excess water from the body. However, these drugs are not suitable for all patients. * Anemia can be treated with erythropoiesis stimulating agents. Erythropoiesis stimulating agents are a group of drugs that replace the deficiency of erythropoietin, which is normally produced by healthy kidneys. Often, patients treated with such drugs require either to take iron by mouth or sometimes even intravenously. * Bone disease develops in patients due to an inability to excrete phosphorus and a failure to form activated Vitamin D. In such circumstances, your physician may prescribe drugs binding phosphorus in the gut, and may prescribe active forms of vitamin D. * Acidosis may develop with kidney disease. The acidosis may cause breakdown of proteins, inflammation and bone disease. If the acidosis is significant, your doctor may use drugs such as sodium bicarbonate (baking soda) to correct the problem.
Prevention
Chronic kidney disease cannot be prevented in most situations. You may be able to protect your kidneys from damage, or slow the progression of the disease by controlling your underlying conditions. * Kidney disease is usually advanced by the time symptoms appear. If you are at high risk of developing chronic kidney disease, see your healthcare provider as recommended for screening tests. * If you have a chronic condition such as diabetes, high blood pressure, or high cholesterol, follow the treatment recommendations of your healthcare provider. See your healthcare provider regularly for monitoring. Aggressive treatment of these diseases is essential.
Avoid exposure to drugs especially NSAIDs (nonsteroidal anti-inflammatory drugs), chemicals, and other toxic substances as much as possible.

III.PATIENT’S DATA PROFILE

A. GENERAL DATA:

Name: "GEG" Age: 71years old
Address: Quezon City
Marital Status: Widow
Religion: Catholic
Admitting diagnosis: Sepsis Secondary to Diabetes Mellitus foot left
Final Diagnosis: Chronic Kidney Disease probably secondary to DM nephropathy, DM foot (left),DM II uncontrolled Date of Admission: November 18 2009 Place of Admission: Quirino Memorial Medical Center
Attending Physician: Dr. Boom

B. Chief Complaint:

Loss of consciousness

C. History of Present illness:

This is a case of a 71 year old female adult from Brgy. Butokan QC, who came to Quirino Memorial Medical Center last November 18, 2009 with complaint of loss of consciousness.

3 months prior to admission patient accidentally stepped on a thumbtacks on the left sole of the foot, there is no accompanying symptoms and no treatment or management done.

2 months and 3 weeks prior to admission the patient's granddaughter saw changes on the left sole. She noticed redness on the surrounding tissue on the puncture site. They went to the Quack doctor for treatment, the Quack doctor advised to washed the puncture site with boiled Guava leaves and apply oil on the puncture site. They do the advised treatment for one week.

2 months and 2 weeks prior to admission the patient's daughter noticed blister formation. The patient continuously applied oil and washed it with boiled Guava leaves.

2 months prior to admission the daughter noticed an open wound on the puncture site the patient decided to went back to the Quack doctor. The Quack doctor, advised to put penicillin powder on the wound and continue to wash it with boiled Guava leaves.

1 month and 3 weeks prior to admission the patient's daughter noticed that the wound was rapidly increasing in size from the sole, It's size increased in 1and 1/2 inches to the left side of the left foot. They continue applying penicillin powder and boiled Guava leaves. They continue the advised treatment for 1 month and 2 weeks.

1 week prior to admission the patient experienced sudden weakness. No consultation and no medication taken.

Few hours prior to admission patient experienced generalized weakness with accompanying dizziness resulting in loss of consciousness. The patient seek for consultation at QMMC hence, admitted.

D. Past medical history

The patient was hospitalized last year 2005 because of anemia and was diagnosed with Diabetes Mellitus and the patient has also undergone blood transfusion on the said hospitalization.

E. Family History

(+) Hypertension. Both mother and father side
(+) diabetes mellitus, both mother and father side
(+) PTB, mother side

F. Personal and Social History

The patient is the youngest of the two siblings in their family. She is not an alcohol drinker but she has been a tobacco smoker for ten years, smoking 1 pack per. day.

IV.ASSESSMENT

A.REVIEW OF SYSTEM

General

(+) weakness
(+) fatigue (-) fever
(-) Lumps

Cardio vascular System

(-) chest pain
(-) orthopnea
(-) cyanosis
(-) palpitation
(+) pallor

Gastrointestinal System

(-) nausea and vomiting
(+) abdominal pain RLQ
(-) anorexia
(-) flatulence
(-) difficulty in swallowing

Respiratory System
(+) DOB

Urinary System

(+) oliguria

Nervous System

(-) headache
(-) tremor

Genital System

(-) discharge
(-) unusual bleeding

Musculoskeletal System

(+) body weakness
(-) deformities
(-) swelling
(-) pain (muscle, bone and joint)

Neurologic system

(+) sleep disturbance

B.PHYSICAL ASSESSMENT

* Initial Vital signs * Temp - 37 * Bp – 130/90 * RR – 33cpm * PR – 70bpm * General Appearance * Body built - medium frame * Posture - Upright * Dress, grooming hygiene - Appropriately dressed * Mental status * Level of consciousness - Conscious * Orientation - oriented (about the time, place and person * Language and communication - use of simple word * Skin * Color - (+) pallor * Temperature - warm to touch * Moist - dry * Texture - rough * Turgor - wrinkle loss of elasticity * Lesions - (-) lesions * Hair distribution - fairly distributed gray, free from lice * Nails * Nail plate shape - convex * Nail condition - smooth * Nail bed color - pale * Capillary refill - 4 sec. * Head * Skull - (-) lumps, (-) tenderness * Scalp - (-) redness, (-) scaling * Hair condition - evenly distributed * Face mass - symmetrical, normal contours, (-) edema Facial movement - symmetrical * Eyes * Eye condition - straight normal * Eye brows - thick, evenly distributed * Blink response - bilateral * Eyeballs - symmetric * Conjunctiva - pale * Sclera - white * Pupils - equal size, round, symmetrical * Reaction to light accommodation - reactive to light * Visual acuity unable to recognize 12-14 inches away * Ears * Color - normal racial tone * Symmetry and size position - symmetric * Texture and elasticity - elastic * Pina - recoils when folded * External canal - some serumen * Hearing acuity - respond to whispered voice (2 ft. Away) * Nose * External - normal racial tone * Septum - midline * Mucosa - pale * Patency - both patent * Nasal cavity - moist * Sinuses - non-tender * Mouth * Lips - pale * Mucosa - slightly pale * Tongue - midline
Pink
Movable and rough * Teeth - (-) oral cavity * Gums - slightly pink * Pharynx * Uvula - midline * Mucosa - pink * Tonsil - not inflamed * Posterior pharynx - normal * Gag reflex - present * Neck * Neck muscle - freely movable, (-) lymph nodes * Lymph nodes - not palpable * Trachea - midline * Thyroid gland - not palpable * Breast and axillary * Symmetry - symmetrical * Contour - sagging * Skin characteristic - wrinkled loss of elasticity * Lymph nodes - not palpable * Chest * Shape - pigeon * Lung expansion - no lagging * Breathing pattern - normal * Breath sound - bronchovisicular * Percussion - resonance * Heart sound - normal with regular rhythm * Lungs - unable to perform * Abdomen * Skin integrity - normal racial tone * Contour and symmetry - rounded * Bowel sound - normal 25/min. * Palpation - tender to touch * Bladder - palpable distended * Liver - not palpable * Upper extremities * Motor strength - weak 4/5 * Muscle tone - pale * Lesions - none * Deformity - none * Peripheral pulse - palpable * Lymph nodes - not palpable * * Lower extremities * Muscle tone - pale * Lesions - none * Deformity - none * Peripheral pulse - normal,palpable * Lymph nodes - not palpable * Wound - non healing wound on left foot

C. LABORATORY TESTS AND EXAMINATIONS

CHEST X-RAY RESULT
Date: 11/19/09

Result >Examination shows a nodular like opacity measuring 2.5 cm by 2.5 cm in the right upper lung with associated apical pleural thickening.
>The rest of the lung fields are clear
>The lungs are Hyper aerated
>Heart is of normal size and configuration
>Aorta id tortuous and calcified
>Other chest structures are unremarkable.

Impression

>Nodular like opacity in the right upper lung with associated apical pleural thickening suggest CT scan for further evaluation.
>Bilateral Pulmonary Hyper aeration
>Atheromatous Aorta

X-RAY RESULT (FOOT X-RAY)
Date: 11/19/09

Result

>Examination of the left foot shows minimal lytic destruction the base of the 5th metatarsal with surrounding cutaneous emphysema. >no other significant findings

Impression

> Above findings consistent with ostoemyelitis.

HEMATOLOGY
DATE: 11/19/09

Test/Parameters | Result | Unit | Normal Values | Significance | Nursing Implications | RBC count | 1.87 L | X10^112/L | 4.20-5.20 | Not normal values may decrease in anemia and chronic renal failure | Assess for the cause of a decrease RBC count. Check for blood loss and obtain a history of anemias, renal insufficiency, chronic infection or leukemia. | Hemoglobin | 57 L | g/L | 120.0-160.0 | Not normal values may decrease in Anemia | Observe the client for signs and symptoms of anemia. Check the hematocrit if the haemoglobin level is low. | Hematocrit | 0.18 L | | 0.36-0.47 | Not normal values may decrease in Anemia | Assess for signs and symptoms of anemia, changes in vital signs for schock. | MCV | 94.7 | f/L | 80.0-96.0 | | | MCH | 30.5 | Pg | 27-31 | | | MCHC | 32.2 | | 32.0-36.0 | | | Platelet count | 587 H | X10^12/L | 150-450 | Not normal, elevated platelet count may indicate presence of infection, acute blood loss. | | WBC count | 19.1H | X10^12/L | 5.0-10.3 | Not normal elevated WBC may indicate presence of infection | Check the vital signs and signs and symptoms of inflammation and infection. |

DIFFERENTIAL COUNT

Parameters | Result | Reference range | Significance | Nursing implication | Neutrophils | 0.925H | 0.500-0.700 | Not normal values may increase in acute bacterial infection | | Lymphocytes | 0.059L | 0.200-0.700 | Low lymphocyte count is an elevation of granulocytes increase in many circumstances bacterial infection at the top of the list | | Eosinophils | 0.000 | 0.000-0.060 | | | Monocytes | 0.015 L | 0.020-0.090 | Not normal, decrease value may indicate aplastic anemia | | Basophils | 0.001 | 0.000-0.020 | | |

HEMATOLOGY-II COAGULATION PANEL

Parameter | Result | Unit | Reference | Prothrombin | 11.1 | Secs. | 10—14 | PT INR | 0.93 | INR | | PT& Activity | 118.1 | | | PT normal control | 12.0 | Secs. | 10—14 | APTT | 36.7 | Secs. | 28-44 | APTT normal control | 31.5 | Secs. | 28-44 | Clotting time | | | | Bleeding time | | | |

HEMATOLOGY
Date: 11/23/2009

Parameters | Result | Unit | Normal values | Significance | Nursing implication | RBC count | 2.56 L | X10^12/L | 4.20-5.40 | Not normal values may decrease in anemia | Assess for the cause of a decrease RBC count. Check for blood loss and obtain a history of anemias, renal insufficiency, chronic infection or leukemia. | Hemoglobin | 77 L | g/L | 120.0-160.0 | Not normal values may decrease in anemia | Observe the client for signs and symptoms of anemia. Check the hematocrit if the haemoglobin level is low. | Hematocrit | 0.23 L | | 0.36-0.47 | Not normal values may decrease in anemia | Assess for signs and symptoms of anemia, changes in vital signs for schock. | MCV | 91.4 | f/L | 80.0-96.0 | | | MCH | 30.1 | Pg | 27-31 | | | MCHC | 32.9 | | 32.0-36.0 | | | Platelet | 355 | X10^12/L | 150-450 | | | WBC count | 14.1 H | X10^12/L | 5.0-10.0 | Not normal elevated WBC may indicate presence of infection. | Check the vital signs and signs and symptoms of inflammation and infection. |

DIFFERENTIAL COUNT

Parameters | Result | Reference range | Significance | Nursing implications | Neutrophils | 0.748 H | 0.500-0.700 | Not normal values may increase in acute bacterial infection | Assess for signs and symptoms of infection | Lymphocytes | 0.106 L | 0.200-0.700 | Low lymphocyte count is an elevation of granulocytes increase in many circumstances bacterial infection at the top of the list | Assess for signs and symptoms of viral infection. | Eosinophils | 0.067 H | 0.000-0.060 | Not normal, elevated eosinophils may indicate allergies, parasitic disease, phlebitis, | Asses the patient for sign and symptoms of allergies. | Monocytes | 0.078 | 0.020-0.090 | | | Basophils | 0.001 | 0.000-0.020 | | | Blood type with Rh | A+ | | | |

HEMATOLOGY
Date: 11/26/09

Parameters | Result | Unit | Normal values | Significance | Nursing implication | RBC count | 2.57 L | X10^12/L | 4.20-5.40 | Not normal values may decrease in anemia | Assess for the cause of a decrease RBC count. Check for blood loss and obtain a history of anemias, renal insufficiency, chronic infection or leukemia. | Hemoglobin | 78 L | g/L | 120.0-160 | Not normal values may decrease in anemia | Observe the client for signs and symptoms of anemia. Check the hematocrit if the haemoglobin level is low. | Hemtocrit | 0.24 L | | 0.36-0.47 | Not normal values may decrease in anemia | Assess for signs and symptoms of anemia, changes in vital signs for shock. | MCV | 87.3 | f/L | 80.0-96.0 | | | MCH | 28.4 | Pg | 27-31 | | | MCHC | 32.5 | | 32.0-36.0 | | | Platelet | 391 | X10^12/L | 150-450 | | | WBC count | 12.0 H | X10^12/L | 5.0-10.0 | Not normal elevated WBC may indicate infection | Check the vital signs and signs and symptoms of inflammation and infection. |

DIFFERENTIAL COUNT

Parameters | Result | Reference range | Significance | Nursing Implications | Neutrophils | 0.592 | 0.500-0.700 | | | Lymphocytes | 0.203 | 0.200-0.700 | | | Eosinophils | 0.099 H | 0.000-0.060 | Not normal, elevated eosinophils may indicate allergies, parasitic disease, phlebitis, | Asses the patient for sign and symptoms of allergies. | Monocytes | 0.103 H | 0.020-0.090 | Not normal, elevated monocytes may indicate Viral disease, parasitic disease. | Check the WBC count. Elevated monocytes occur during infection. | Basophils | 0.003 | 0.000-0.020 | | |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/19/09

Test | Result | Unit | Range | Significance | Nursing implication | CREA | 451.28 H | Umol/L | (44.0-80.0) | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours. Limit beef and poultry if the serum creatinine level is very high. | UREA | 34.60 H | | 2.14-7.14 | Not normal, elevated BUN may indicate presence of dehydration, renal failure, kidney diseases, DM. | Check vital signs every 8hours and urinary output in 8 and 24 hours for decrease urinary output. Assess clients dietary intake. | Sodium | 136.5 | mmol/L | 135-148 | | | Potassium | 8.09 H | mmol/L | 3.5-5.3 | Not normal, elevated potassium level may indicate hyperkalemia. | Assess urine output to determine renal function. Observe for signs and symptoms of hyperkalemia, such as abdominal crumps,oliguria. | Chloride | 107.9 H | mmol/L | 98-107 | Not normal, elevated chloride level may indicate dehydration, kidney dysfunctions, metabolic acidosis. | Assess for signs and symptoms of hyper chloremia such as weakness, lethargy. Monitor daily weights and intake and output. |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: Nov.21,2009

Test | Result | Unit | Ranges | Significance | Nursing implications | CREA | 342.65 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Potassium | 5.16 H | mmol/l | 3.5-5.3 | Not normal, elevated potassium level may indicate hyperkalemia. | Assess urine output to determine renal function. Observe for signs and symptoms of hyperkalemia, such as abdominal crumps,oliguria |

Test | | | | | | CREA | 301.93 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Test | | | | | | CREA | 301.93 H | Umol/l | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: Nov. 22,2009

Test | Result | Unit | Range | Significance | Nursing implication | CREA | 357.55 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Test | | | | | | CREA | 386.61 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Test | | | | | | CREA | 386.61 | Umol/L | 44.0-80.0 | | |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: Nov. 23,2009

Test | Result | Unit | Range | Significance | Nursing implication | CREA | 132.32 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Test | | | | | | CREA | 112.16 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/24/09

Test | Result | unit | Ranges | Significance | Nursing implications | Crea | 265.69 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/25/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 280.46 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. |

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 275.20 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Urea | 11.80 H | | 2.14-7.14 | Not normal, elevated BUN may indicate presence of dehydration, renal failure, kidney diseases, DM. | Check vital signs every 8hours and urinary output in 8 and 24 hours for decrease urinary output. Assess clients dietary intake. |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/26/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 261.67 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. |

Test | Result | Unit | Ranges | Significance | Nursing implications | Potassium | 3.17 | mmol/L | 3.5-5.3 | | |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/27/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 65.94 | Umol/L | 44.0-80.0 | | | Sodium | 140.0 | mmol/L | 135-148 | | | Potassium | 3.19 H | mmol/L | 3.5-5.3 | Not normal, elevated potassium level may indicate hyperkalemia. | Assess urine output to determine renal function. Observe for signs and symptoms of hyperkalemia, such as abdominal crumps,oliguria | Chloride | 105.2 | mmol/L | 98-107 | | |

BUN,CREA DETERMINATION ( SODIUM, POTASSIUM, CHLORIDE)
Date: 11/28/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 238.28 | Umol/L | 44.0-80.0 | | |

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 259.21 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Sodium | 139.7 | mmol/L | 135-148 | | | Potassium | 3.22 | mmol/L | 3.5-5.3 | | | Chloride | 108.6 H | mmol/L | 98-107 | Not normal, elevated chloride level may indicate dehydration, kidney dysfunctions, metabolic acidosis. | Assess for signs and symptoms of hyper chloremia such as weakness, lethargy. Monitor daily weights and intake and output. |

BUN,CREA Determination (sodium, potassium, chloride)
Date: 11/29/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 247.55 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Sodium | 138.3 | mmol/L | 135-148 | | | Potassium | 3.02 | mmol/L | 3.5-5.3 | | | Chloride | 107.3 H | mmol/L | 98-107 | Not normal, elevated chloride level may indicate dehydration, kidney dysfunctions, metabolic acidosis. | Assess for signs and symptoms of hyper chloremia such as weakness, lethargy. Monitor daily weights and intake and output. |

BUN,CREA Determination (sodium, potassium, chloride)
Date: 11/30/09

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 235.63 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Sodium | 140.3 | mmol/L | 135-148 | | | Potassium | 2.80 | mmol/L | 3.5-5.3 | | | Chloride | 112.7 H | mmol/L | 98-107 | Not normal, elevated chloride level may indicate dehydration, kidney dysfunctions, metabolic acidosis. | Assess for signs and symptoms of hyper chloremia such as weakness, lethargy. Monitor daily weights and intake and output. |

Test | Result | Unit | Ranges | Significance | Nursing implications | Crea | 229.28 H | Umol/L | 44.0-80.0 | Not normal, elevated crea level may indicate acute and chronic renal failure. | Check the amount of urine output in 24 hours.Limit beef and poultry if the serum creatinine level is very high. | Sodium | 138.5 | mmol/L | 135-148 | | | Potassium | 3.15 | mmol/L | 3.5-5.3 | | | Chloride | 106.0 | mmol/L | 98-107 | | |

CLINICAL CHEMISTRY
Date: 12/01/09

| Normal Range | Unit | | Result | Normal Range | FBS | 3.05-5.77 | mmol/L | 24 hour urine volume | | | RBS | 2.5-7.2 | mmol/L | 24 hour urine protein | | 28-141mg/day | HBAIC | 4.5-5.7 | | Crea clearance | | >50 | Total Cholesterol | 0-5.2 | mmol/L | BUN | | 2.14-7.14 mmol/L | HDL | M= 0.71-1.21F= 0.78-2.21 | mmol/L | Crea | | M= 53-97 umol/LF= 44.0-80.0 umol/L | LDL | 1.69-4.55 | mmol/L | LIPASE | | 13.60 U/L | VLDL | 0.5-1.0 | mmol/L | Amylase | | 28-100 U/L | Triglycerides | 0-2.3 | mmol/L | K-MB | | 0-25 U/L | Ast/SGOT | M= up to 25F= up t021 | U/L | Total CK | | M= 0-180 U/LF= 0-165 U/L | Alt/SGPT | M= up to 30F= up to 23 | U/L | Uric Acid | | M=202.3-416.5 ummol/LF=142.8-339.2 ummol/L | Alka Phosphate | 25-90 | U/L | Sodium | 141.8 | 135-148 mmol/L | Total Protein | 67-87 | g/dl | Potassium | 3.54 | 3.5-5.3 mmol/L | Albumin | 38-50 | g/dl | Chloride | 110.7 H | 98-107 mmol/L | Globulin | 23-35 | g/dl | | | | Total biliburin | Up to 18.8 | Umol/L | | | | Direct biliburin | Up to 4.3 | Umol/L | | | | Indirect biliburin | Up to 14.5 | Umol/L | | | |

ARTERIAL BLOOD GAS REPORT (ABG)
Date: 11/19/09

Measured | Result | Reference Ranges | Interpretation | pH | 7.273 Low | 7.350-7.450 | Metabolic Acidosis | pCO2 | 31.5 Low | 35.0-45.0 | | pO2 | 140.3 High | 80.0-100.0 | |

Calculated Data | | Unit | HCO3 act | 14.3 | mmol/L | BE (ecf) | -12.6 | mmol/L | BE (B) | -11.13 | mmol/L | O2 CT | | ml/dl | O2 sat. | 98.5 | % | ct CO2 | 15.2 | mmol/L | Entered Data FIO2 | 28.0 | % |

CBG MONITORING
RAi Given

Date: 11/22/09 Time | Result | Insulin Given | 6:00 am | 106 mg/dl | | 12:00 nn | 147 mg/dl | | 6:00 pm | 139 mg/dl | 2 units |

Date: 11/23/09 Time | Result | Insulin Given | 12:00 mn | shifted | | 6:00 am | | | 12:00 nn | 126 mg/dl | | 6:00 pm | 176 mg/dl | 2 units |

Date: 11/24/09 (TID-Pre meals) Time | Result | Insulin Given | 6:00 am | 113 mg/dl | | 1:00 pm | 136 mg/dl | | 5:00 pm | 139 mg/dl | |
Date: 11/25/09 Time | Result | Insulin given | 6:00 am | 370 mg/dl | 10 "units' | 11:00 am | 111 mg/dl | | Date: 11/26/09 Time | Result | Insulin Given | 6:00 am | 138 mg/dl | | 1:00 pm | 163 mg/dl | 2 "units" | 5:00 pm | 147 mg/dl | |

Date: 11/27/09 Time | Result | Insulin Given | 12:00 nn | 137 mg/dl | | 6:00 pm | 156 mg/dl | |

Date: 11/28/09 Time | Result | Insulin given | 6:00 am | 143 mg/dl | | 1:00 pm | no strips | | 6:00 pm | 176 mg/dl | 2 "units" | Date: 11/29/09 Time | Result | Insulin given | 6:00 pm | 136 mg/dl | |

Date: 11/30/09 Time | Result | Insulin given | 6:00 am | 110 mg/dl | | 12:00 nn | 159 mg/dl | 2 "units" | 6:00 pm | 121 mg/dl | |

Date: 12/01/09 Time | Result | Insulin given | 6:00 am | 97 mg/dl | | 11:00 am | 209 mg/dl | 4 units |

V. ANATOMY AND PHYSIOLOGY

THE URINARY SYSTEM

How does the urinary system work?
Your body takes nutrients from food and uses them to maintain all bodily functions including energy and self-repair. After your body has taken what it needs from the food, waste products are left behind in the blood and in the bowel. The urinary system works with the lungs, skin, and intestines—all of which also excrete wastes—to keep the chemicals and water in your body balanced. Adults eliminate about a quart and a half of urine each day. The amount depends on many factors, especially the amounts of fluid and food a person consumes and how much fluid is lost through sweat and breathing. Certain types of medications can also affect the amount of urine eliminated.
The urinary system removes a type of waste called urea from your blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.
The kidneys are bean-shaped organs about the size of your fists. They are near the middle of the back, just below the rib cage. The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus, and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.
From the kidneys, urine travels down two thin tubes called ureters to the bladder. The ureters are about 8 to 10 inches long. Muscles in the ureter walls constantly tighten and relax to force urine downward away from the kidneys. If urine is allowed to stand still, or back up, a kidney infection can develop. Small amounts of urine are emptied into the bladder from the ureters about every 10 to 15 seconds.
The bladder is a hollow muscular organ shaped like a balloon. It sits in your pelvis and is held in place by ligaments attached to other organs and the pelvic bones. The bladder stores urine until you are ready to go to the bathroom to empty it. It swells into a round shape when it is full and gets smaller when empty. If the urinary system is healthy, the bladder can hold up to 16 ounces (2 cups) of urine comfortably for 2 to 5 hours.
Circular muscles called sphincters help keep urine from leaking. The sphincter muscles close tightly like a rubber band around the opening of the bladder into the urethra, the tube that allows urine to pass outside the body.
Nerves in the bladder tell you when it is time to urinate, or empty your bladder. As the bladder first fills with urine, you may notice a feeling that you need to urinate. The sensation to urinate becomes stronger as the bladder continues to fill and reaches its limit. At that point, nerves from the bladder send a message to the brain that the bladder is full, and your urge to empty your bladder intensifies.
When you urinate, the brain signals the bladder muscles to tighten, squeezing urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax. As these muscles relax, urine exits the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.
What causes problems in the urinary system?
`Problems in the urinary system can be caused by aging, illness, or injury. As you get older, changes in the kidneys’ structure cause them to lose some of their ability to remove wastes from the blood. Also, the muscles in your ureters, bladder, and urethra tend to lose some of their strength. You may have more urinary infections because the bladder muscles do not tighten enough to empty your bladder completely. A decrease in strength of muscles of the sphincters and the pelvis can also cause incontinence, the unwanted leakage of urine. Illness or injury can also prevent the kidneys from filtering the blood completely or block the passage of urine.
What are some disorders of the urinary system?
Proteinuria is the presence of abnormal amounts of protein in the urine. Healthy kidneys take wastes out of the blood but leave in protein. Protein in the urine does not cause a problem by itself. But it may be a sign that your kidneys are not working properly.
Renal (kidney) failure results when the kidneys are not able to regulate water and chemicals in the body or remove waste products from your blood. Acute renal failure (ARF) is the sudden onset of kidney failure. This condition can be caused by an accident that injures the kidneys, loss of a lot of blood, or some drugs or poisons. ARF may lead to permanent loss of kidney function. But if the kidneys are not seriously damaged, they may recover. Chronic kidney disease (CKD) is the gradual reduction of kidney function that may lead to permanent kidney failure, or end-stage renal disease (ESRD). You may go several years without knowing you have CKD.
Urinary retention, or bladder-emptying problems, is a common urological problem with many possible causes. Normally, urination can be initiated voluntarily and the bladder empties completely. Urinary retention is the abnormal holding of urine in the bladder. Acute urinary retention is the sudden inability to urinate, causing pain and discomfort. Causes can include an obstruction in the urinary system, stress, or neurologic problems. Chronic urinary retention refers to the persistent presence of urine left in the bladder after incomplete emptying. Common causes of chronic urinary retention are bladder muscle failure, nerve damage, or obstructions in the urinary tract. Treatment for urinary retention depends on the cause.

PARTS OF THE KIDNEY

Capsule- the renal capsule is the membranous covering of the kidney. it directly covers the renal cortex, which forms the outer stratum.

Cortex- the cortex of the kidney is the outer section which covers the internal medulla. the cotrtex is visible near the outer edge of the cross sectioned kidney. it is composed of blood vesels and urine tubes and is supported by a fibrous matrix.

Calyx- the calyces (plural of calyx) are the recesses in the internal medulla of the kidney which encloses the pyramids. they are use to subdivide the sections of the kidney anatomically,with distinction being made between major calyces and minor calyces.

Renal Column- the renal columns are lines of the kidney matrix which supports the cortex of the kidney. They are composed of lines of blood vessels and a fibrous, cortical material.

Pyramid- the renal pyramids are conical segmentswithin the internal medulla of the kidney. the pyramids contain the secreting apparatus and tubules and are also known as the malphighian pyramids.

Renal Sinus- the renal sinus is the cavity wtihin the kidney which houses the renal pyramid. nerves and blood vessels pass into the renal sinus through the hilus.

Hilus- the hilus is the slit like opening in the middle of the concave medial border of the kidney. nerves and blood vessels pass through the hilus into the renal sinus within.

Renal Artery- one quarter of the total blood output from the heart comes to the kidneys along the renal atery. Two renal arteries arise from the abdominal section of the aorta.,each artery supplies a lobe of the kidney. the incoming artery devides into four or five branches, eventually forming arterioles, each of which leads to the compact ball of capillaries called the glomerulus.

Renal vein- cell waste is discharged in the veins for excretion through the kidneys. the body circulates about 425 gallons of blood through the kidneys on a daily basis but only about a thousandth of this is coverted into urine. the remainder goes back into circulation through the renal arteries. from the Bowman's capsule, the blood is carried through the compact network of capillaries that forms the glomerulus within the capsule. the capillaries eventually reconverge into small venules which lead to the larger renal veins. there are two renal veins. one extending from each lobe of the kidney and opening into the vena cava.

Renal papilla- is the location where the Medullary pyramids empty urine into the renal pelvis. Histologically it is marked by medullary collecting ducts converging to channel the fluid. Transitional epithelium begins to be seen.

Role in disease: Some chemicals toxic to the kidney, called nephrotoxins, exert their damage at the renal papillae. Damage to the renal papillae may result in death to cells in this region of the kidney, called renal papillary necrosis

Renal medulla is the innermost part of the kidney. The renal medulla is split up into a number of sections, known as the renal pyramids. Blood enters into the kidney via the renal artery, which then splits up to form the arcuate arterioles. The arcuate arterioles each in turn branch into interlobular arterioles, which finally reach the glomeruli. At the glomerulus the blood reaches a highly disfavourable pressure gradient and a large exchange surface area, which forces the serum portion of the blood out of the vessel into the renal tubules. Flow continues through the renal tubules, including the proximal tubule, the Loop of Henle, and finally leaves the kidney by means of the collecting duct, leading to the renal ureter.
The renal medulla (latin renes medulla = kidney middle) contains the structures of the nephrons responsible for maintaining the salt and water balance of the blood. The renal medulla is hypertonic to the filtrate in the nephron and aids in the reabsorption of water.

The Nephron

Nephron (from Greek νεφρός - nephros, meaning "kidney") is the basic structural and functional unit of the kidney. Its chief function is to regulate the concentration of water and soluble substances like sodium salts by filtering the blood, reabsorbing what is needed and excreting the rest as urine. A nephron eliminates wastes from the body, regulates blood volume and blood pressure, controls levels of electrolytes and metabolites, and regulates blood pH. Its functions are vital to life and are regulated by the endocrine system by hormones such as antidiuretic hormone, aldosterone, and parathyroid hormone.[1] In humans, a normal kidney contains 800,000 to one million nephrons.[2

The Glomerulus

A glomerulus is a capillary tuft surrounded by Bowman's capsule in nephrons of the vertebrate kidney. It receives its blood supply from an afferent arteriole of the renal circulation. Unlike most other capillary beds, the glomerulus drains into an efferent arteriole rather than a venule. The resistance of the arterioles results in high pressure in the glomerulus aiding the process of ultrafiltration where fluids and soluble materials in the blood are forced out of the capillaries and into Bowman's capsule.
A glomerulus and its surrounding Bowman's capsule constitute a renal corpuscle, the basic filtration unit of the kidney. The rate at which blood is filtered through all of the glomeruli, and thus the measure of the overall renal function, is the glomerular filtration rate (GFR).

VII. COURSE IN THE WARD

DOCTOR’S ORDER

FIRST DAY OF HOSPITALIZATION

Patient was admitted under the service of Dr. Tan/ Vitan. Consent was secured. Patient has received intravenous fluid of Plain Normal Saline Solution of 1 liter running fast drip at 200cc, regulated for 8hours.Patient was placed for nothing per orem temporarily. Laboratory exams were ordered such as:

CBG with APC, Sodium, Potassium, Chloride, BUN, CREA, FBS, TLP, Blood CS, 12 LECG, Chest X-ray w/ AP, X-ray of lateral foot, and UA with ketones.

Medicines prescribed by the doctor such as:

1. Tazobactam 4.5g now then 2.25 every hour 2. Ciprofloxacin 500mg 1tab BID 3. Omeprazole 40mg OD through IV PUSH

Capillary blood glucose to be monitored every 4hours with a sliding scale starting from less than 150 mg/dl means no administration of insulin.

Rapid Acting Insulin TIV

150-200 2 units
201-250 4 units
251-300 6 units
301-350 8 units 351-400 10 units

-if more than 400 mg/dl refer to the doctor Then vital signs to be monitored every hour with persistent hypotension being watched out for. Patient referred to orthosurgery for co-management, Then patient also referred to general surgery for central venous insertion. Partial Thromboplastin and Pro Thrombin Time with oxygen inhalation of 2-3 liters via nasal canula was ordered, then 2 units of Pack Red Blood Cells properly typed and cross matched to be prepared for possible blood transfusion.

SECOND DAY OF HOSPITALIZATION

The patient was ordered to be administered with calciumgluconate intravenously 1vial now, then to be given with D5050 plus ten units of RAI now, then every 6hours.The doctor also ordered determination of serial potassium every 12hours. To be checked by the MROD for congestion every 12hours.Then monitoring of Central Venous Pressure every 2hours. To be referred if result is more than 100. Crea determination to be done in the morning, oxygen inhalation 2-3liters per minute. Patient to be transferred in MICU once with consent. Oral fluid intake to be limited to less than 2liters. Decrease intravenous fluid to 40cc per hour. The patient is for laboratory such as:

Hepa profile, ABG Calcium, Phosphate, Albumin, KUB UTZ with CT scan, Echogenesity.

Ciprofloxacin was decreased from 500 mg/tab BID to 500 mg/tab OD.12 LECG to be done in the morning. Blood transfusion to be facilitated once 2 Pack Red Blood Cell is available. Furosemide 40 mg was ordered through IV to be administered before and after blood transfusion with BP precaution. Indwelling Foley catheter to be inserted and hook to urine bag. Orthonephro referral to be followed up, and X-Ray follow up as well.

THIRD DAY OF HOSPITALIZATION

Plain Normal Saline Solution of 1liter was ordered, regulated @ 10 gtts/min. Oral fluid intake was limited to less than 1 liter per day. Oxygen 2-3 litters per minute to be given via nasal cannula. Order of 2 units of Pack Red Blood Cells to facilitate blood transfusion. Serial potassium monitoring is continued. Daily wound care to be done three times a day was ordered. The patient is still for ortho and nephro referral. Central Venous Pressure monitoring for every 2 hours. Order of KUB UTZ with CT scan and echogenesity to be facilitated. Vital signs monitoring every 2 hours. Monitor for intake and output. Also monitor total 24 hour output during night shift 10-2. Nephro notes. DM diet with SAP to be started. Fast drip of Plain Normal Saline Solution to be started now. The patient has submitted waver of refusal to transfer to MICU was noted and respected. Refusal to possible RRT was noted and respected. Follow up result of repeat potassium determination was done today. Official Chest X-Ray result in ideally for Chest CT scan with contrast. However Crea is still elevated. Follow up repeat Crea done today. ABG result in way give NAHCO3 50 mEqs slow intravenous push now. NAHCO3 1tab three times a day to be started.

FOURTH DAY OF HOSPITALIZATION

Intravenous fluid was regulated at 40cc/min. Patient is on low salt DM diet. Continue exam of serial potassium to include Crea on the next blood extraction. 3 units of Pack Red Blood Cells was ordered properly typed and cross matched. CBG monitoring for every 6 hours before meals with RAI. To insert indwelling foley catheter and hook to urine bag. Patient was on strict intake and output monitoring.
FIFTH DAY OF HOSPITALIZATION

IV out. Order for reinsertion. Patient still on DM diet and for blood transfusion with BT reaction being watched out for. Patient is for CBC with AP after blood transfusion. Daily wound care is ordered. CBG monitoring is decreased to three times a day before meals. Patient was on strict intake and output monitoring quantitatively.

SIXTH DAY OF HOSPITALIZATION

Patient is still for blood transfusion, with vital sign every 2 hours and record.

SEVENTH DAY OF HOSPITALIZATION

Order for surgery notes. The patient has been seen and examined, history and physical assessment done, to consider DM foot, osteomyelitis left foot for with below knee amputation. Will inform ortho service, secure Pack Red Blood Cell. CP endoclearance seen.

EIGHT DAY OF HOSPITALIZATION

Surgery note was seen and appreciated. Patient to be referred to cardio facility, CP clearance medication to be continued. Then refer.

NINTH DAY OF HOSPITALIZATION

Patient decreasing trend in Crea noted. 2units of Pack Red Blood Cell properly type and cross match to be transfused. Blood Transfusion reaction to be watch out for. Order for Complete Blood Count with APC after BT. Morning diet of Sodium, Potassium, Chloride. patient to be transfered to DM ward once with available bed. Continue medication. Refer.

TENTH DAY OF HOSPITALIZATION

Order to remove Central Venous Pressure line. Patient is still for 2units of Pack Red Blood Cell properly type and cross match for blood transfusion. Blood Transfusion reaction being watch out for, order of Capillary Blood Glucose with APC after BT. With follow-up referral to ortho. Patient to be transferred to DM ward once with available bed. Continue medication. Then refer.

ELEVENTH DAY OF HOSPITALIZATION

Patient is to be transferred to DM ward once with available bed.
TWELVETH DAY OF HOSPITALIZATION

Intravenous out, and order to reinsert hook. Patient was back to previous IVF still for BT of 2units Pack Red Blood Cell properly typed and cross matched. Continue medication. Vital Sign monitoring every 4 hours. Watch out for hypoglycemia. Order of daily ward care for TID.

11:00am > Still to secure and transfuse of 2 units Pack Red Blood Cell properly type and cross match. With BT reaction being watch for. Order of Complete Blood Count with APC after blood transfusion. Blood Urea Nitrogen, Creatinine, Sodium, potassium, Chloride in the morning. Bed sore precaution. Patient refer back to ortho. Continue medication. Refer .

12:20pm > Patient for debridement once CP is cleared. Then seal for CP clearance. 1unit of Pack Red Blood Cell properly typed and cross matched. Then inform AM service once CP cleared with available blood. Then refer.

THIRTEENTH DAY OF HOSPITALIZATION

Order to transfused 2units of Pack Red Blood Cell properly typed and cross matched. Then secure 1units Pack Red Blood Cell properly typed and cross matched. Secure CP endo-clearance for wound debridement. Order of daily wound care with 3rd solution. Then patient refer back to our service once CP endo-clearance is cleared. Then refer.

FIFITEENTH DAY OF HOSPITLIZATION

The patient is still for transfusion of 2 units of pack red blood cells properly typed and cross matched. Then continue meds. Then refer.

SIXTEENTH DAY OF HOSPITALIZATION

The patient is still for blood transfusion of 2 units of pack red blood cells properly typed and cross matched. Then continue meds. Then refer. 6:00 PM> order for maintenance of present IV. Then order to secure 2 units of pack red blood cells properly typed and cross matched. To facilitate blood transfusion once unit is available. Continue present meals. Vital signs to be monitored every hour then record while ongoing blood transfusion then every 4 hours then record transfusion. Then refer.

SEVENTEENTH DY OF HOSPITLIZATION Order to facilitate blood transfusion of 2 units of pack red blood cells, with BT reaction being watched out for. Complete blood count with APC after blood transfusion. Continue meds then refer.

EIGHTEENTH DAY OF HOSPITALIZATION The patient is still for transfusion of 2 units of pack red blood cells. Order for Complete Blood count with APCafter blood transfusion. To give Clonidine HCL 75 mg/ tab Sub Lingual now. Then continue meds. Then refer.

NINETEENTH DAY OF HOSPITLIZATION To insert IV catheter gauge 18 prior to blood transfusion. Order to facilitate blood transfusion on 2 units of pack red blood cells properly typed and cross matched. Blood is already available. Once anemia is corrected for CP endo clearance. Once cleared refer back to ortho for scheduling of contemplated procedure. Then repeat CBC, APC and UA now. Then refer Order for Blood Urea and Nitrogen to be done in the morning. Follow up results of labs done today. Ongoing blood transfusion of 1 units pack red blood cells with BT reactions being watched out for. Complete Blood Count in the morning. Continue meds then refer.

TWENTIETH DAY OF HOSPITALIZATION To Facilitate blood transfusion if 1 unit of pack red blood cells is available. Complete blood count with APC in the morning. With BT reactions being watch out for. Continue meds then refer.

TWENTY FIRST DAY OF HOSPITLIZATION Order to maintain present Intravenous fluid. The patient is still for transfusion of 1 unit of pack red blood cells. Continue meds. Then vital signs every 4hours. Then record. 6:00pm> S/P blood transfusion of 1 unit of pack red blood cells. Order to facilitate blood transfusion of 1 unit of pack red blood cells tonight. With BT reactions being watched out for. Facilitate complete blood count with APC after blood transfusion. Determination of BUN, Crea, Sodium, potassium, and chloride to be done in the morning. Continue meds then refer.

TWENTY SECOND DAY OF HOSPITLIZATION Decrese of Intravenous fluid to Keep vein open. Patient is for ultrasound of kidney, ureter and bladder. To incorporate potassium chloride 60 mEqs to present IVF

X. PROGNOSIS/DISCHARGE TEACHING

Objective: This plan aims to continue treatment and care for clients by involving the significant others to participate in the plan of care.
Medication:
* Instruct the patient and the daughter to continue taking her medicines for easily recovery especially the antibiotic to prevent further infections.
Diet:
* Instruct the patient and the significant others to have a diet of low salt and low fat.
Environment
* Instruct the patient and the daughter to keep the environment clean and free from irritants. For easy recovery, encourage a good personal hygiene.
Treatment
* Instruct the patient and the daughter to have an alternate rest and activity which is important to maintain progress towards full recovery.
Out Patient * Instruct the patient and the significant others to make all scheduled medical visits for follow up care.
Socio Cultural/ Spiritual * Encourage the significant others to understand the patient and support any activity that she will be doing.
Health Teachings * Instruct the patient and the significant others to wash hands thoroughly. * Instruct the patient and significant others to always and properly clean the wound and proper dressing to prevent infection.

BIBLIOGRAPHY * Doenges M., Moorhouse MF., Murr A., Nurses Pocket Guide Diagnosis, Prioritized interventions, and Rationales, 11th edition, F.A Davis Company Publisher, Philadelphia, USA

* Hogan M.A, Hill K., Pathophysiology , Reviews and Rationales, Prentice Hall Publishing, Upper saddle river NJ

* Lippincot Williams and Wilkins, Pathophysiology, Lippincot Manual of nursing practice,

* Potter and Perry, Fundamentals of Nursing 5th Edition Volume 1, Published in the Philippines by ELSEVIER SCIENCE (Singapore) PTE LTD.

* Kee, Joyce LeFever. Prentice Hall Hand Book Of Laboratory and Diagnostics Tests with Nursing Implications 6th Edition. Publisher: Upper Saddle River, NJ,USA * Meds.com

* Google.com

* Nursingcrib.com

* Youtube.com

VI. PATHOPHYSIOLOGY Risk factor DM II modifiable >smoking >Diet: increase CHO >No exercise
Non modifiable >Genetics (+) >Age 71 years old

Decrease urine output
↓↓↓↓↓↓↓↓Hyperkalemia
Electrolyte imbalance
Hypertension
Increase release of renin angiotensinogenase
Proteinuria
Increase BUN/Creatinine
Glomeruli filtration no longer work
Diabetic foot
Delayed wound healing
Decrease blood circulation on the peripheral part of the body
Pallor
Decrease RBC production
Decrease hemetopoiesis
Damaged of nephrons
Hypertrophy of glomerulus
Increase pressure on work load of glomeruli
Difficulty of blood to pass into small blood vessels
Increase viscosity in blood
Increase glucose in blood
Little insulin/ insensitive insulin receptors