I. PATIENT ASSESSMENT DATA BASE A.

GENERAL DATA

1. Patients name: M.O 2. Address: San Nicolas, Pangasinan 3. Age: 23 y/o 4. Sex: F 5. Birth date: November 6, 1987 6. Rank in the Family: 2nd among siblings 7. Nationality: Filipino 8. Civil Status: Single 9. Date of Admission: September 9, 2011 Time: 9:30am 10. Order of Admission: Admit to medical ward, to secure consent, monitor TPR every shift, low-salt low fat diet, CBC, U/A, BUNcreatinine, FBS, total protein, albumin, globulin, AG ratio, IVF D5LRS 1L x KVO, furosemide 60 mg IV stat then 40mg IV every 8hrs and cefuroxime 750mg IV every 8hrs ANST. 11. Attending Physician: Dr. De Vera B. CHIEF COMPLAINT: Edema 1 month and pain in the lumbar area. C. HISTORY OF PRESENT ILLNESS: Ten days prior to admission, the patient had onset of body malaise and numbness of lower extremities which resulted to difficulty in walking , Prior to admission there is a presence of edema in the lower extremities and pain in the lumbar area which she was admitted in San Carlos Hospital. D. PAST HEALTH HISTORY: 1. Childhood illness: The patient suffered from common colds during rainy and cold seasons especially during ber months. 2. Immunization: The patient has completed immunization but he cannot remember the doses given. 3. Major illness: The patient does not undergo any minor and major operations and injuries. 4. Current medications: The patient takes nifedipine, neo-black 50mg, captopril and ascorbic acid. 5. Allergies: The patient does not have allergy.

E. FAMILY ASSESSMENT: Name E.O N.O M.O M.O MJ.O Relation Father Mother Eldest 2nd Child 3rd Child Age 59 55 24 23 21 Sex M F F F F Occupation None Housewife None None None Educational attainment HS Graduate Elementary HS Graduate HS Graduate HS Graduate

F. SYSTEMS REVIEW: 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN She said that health is life because when one of their family members is ill she considers it as a problem and once they take over the counter medicine immediately without consultation to a physician. Eating nutritious food is their way to prevent illnesses. 2. NUTRITIONAL METABOLIC PATTERN: According to her she has no food preferences. Able to eat all foods such as vegetable of any kind, meat, poultry products like adobo, and she mostly eats salty food. In breakfast mostly they eat rice with eggs; in lunch and dinner mostly they prepared vegetables and rice, minimal in meat and fish. She drinks 8-10 glasses of water per day and drinks soda like sparkle and coca-cola.

3. ELIMINATION PATTERN: Bowel habits: The patient defecates 1-2 times a day. Colour: Brown Odour: Foul odor Consistency: bulky stool Laxatives use: The patient is not using any laxatives. Bladder: The patient micturates 3-5 times a day and sometimes experienced painful urination. Colour: light yellow Odour: pungent Alterations: Sometimes experienced painful urinations. 4. ACTIVITY EXERCISE PATTERN: Self care ability: 0 Feeding 0 Bathing 0 Bed mobility 0 Dressing 0 Toileting 0 Home maintenance 0 Grooming I Cooking

Legend: 0 full care

I requires use of equipment II requires assistance/supervision from others III requires assistance/supervision from others and equipment and a device IV dependent; doesnt participate

5. COGNITIVE PERCEPTUAL PATTERN: Hearing: Responds quickly every time we asked questions. She is not using any hearing aids. Vision: The patient is not using any glasses/contact lens. Sensory Perception: Upon tapping her shoulder she responded quickly. The patient can differentiate between sweet and bitter. Learning Styles: The patient read books and watches television, in this way she learns new information.

6. SLEEP REST PATTERN Sleep habits: The patient sleeps early at night and does not take nap at afternoon. She prefers to sleep with two pillows at her back Special sleeping problems: The patient cant sleep well especially when there was a presence of pain in her nape. Hours of sleep: The patient usually sleeps at 11:00 p.m. up to 6:00 a.m. Sleeping alterations: The patient doesnt have any problem alteration in his sleeping patterns.

Sleeping aids: The patient use sleeping aids such as listening to the radio.

7. SELF PERCEPTION AND SELF CONCEPT PATTERN: Feeling about current state: The patient stated that she has difficulty in moving. She also stated that she feels irritated because of IV Fluid attached at her right arm. Description of self: The patient described herself as a kind and loving person. Known capabilities and weakness: The patient can do household chores well, knows how to sing and dance but sometimes she is shy to show it. Self Worth: The patient stated that she is very worthy and important.

8. ROLE RELATIONSHIP PATTERN: Perception of major roles and responsibilities in the family: For her, every member of the family should do their responsibilities in order for them to have a comfortable life and she knows that she was doing her part and responsibility in their family. Perception of major roles and responsibility at work: The patient stated that it is important to have a work in order to earn money but she still looking for a job. Perception of major social roles and responsibility: The patient stated that she is not active in their barangay and she is not joining any organization.

9. SEXUALITY REPRODUCTIVE PATTERN: Menstrual History: Age of onset of menarche: 12 years old Number of menstrual days: 5 days Number of pads every menstruation: 2 pads per day Presence of PMS, dysmenorrhoeal and other menstrual problems: The patient stated that during her menstruation she was experiencing dysmenorrhoeal and pre menstrual syndrome. For both sexes Contraception: She stated that shes not using contraceptives. Sexual Activities: The patient stated that shes not yet experience sexual activities. Special health reproductive problems: The patient has no health reproductive problems. History of sex abuse: The patient stated that she has no history of sex abuse.

10. COPING STRESS TOLERANCE PATTERN: Perceptions of stress and problems in life: The patient said that problems and stress in life is normal. It makes us better and well-grown individual. Coping methods and support systems used: In order for her to cope in any problems she thinks on possible solution immediately. He also asks an advice to her mother and she prays to god to help her in solving her problems.

11. Values-Belief Pattern Values, goals, and philosophical beliefs: The patient stated that she wants to become rich; she wants to help his relatives financially and emotionally. She also stated that she believes that it is important to have a good heart and values.

Religious and spiritual belief: The family of the patient is belong to a Roman Catholic group. They go to the church when they have time. She said that it doesnt matter even if you are not a church goer , what important is you know how to apply the teachings of god.

G. Heredo-Familial Illness Maternal: Hypertension Paternal: Anemia and Colon Cancer

Development History THEORIST Erick Erickson Generativity vs. Self absorption or stagnation AGE Early Adulthood (20-35 yrs old) SEX Female PATIENT DESCRIPTION The patient stated that the major source of her strength is love and support of her family, but somehow she was regretful because she doesnt have a job.

II. PHYSICAL ASSESMENT A. GENERAL SURVEY: The patient has a medium body build. The patient is well groom, clean no foul body smell. Her Height is 152 cm. and weight is 77kg. No signs of distress noted upon assessment, able to smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show calmness during the examination. B. VITAL SIGNS ON THE PHYSICAL EXAMINATIONS: Blood Pressure: 140/190 Temperature: 37.4 C RR: 23cpm PR: 88bpm C. REGIONAL EXAMINATIONS (using IPPA technique) Hair: short and slightly curly hair, thick, no flakes, shiny and soft and with normal hair distribution and no parasite infestation noted. Head and Face: Normocephalic, spherical, proportionate to body size, symmetrical, no evidence of masses or with slightly moist scalp, pale cheeks, no rashes and lesions noted. Eyes: Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids no discharges and bilaterally blink. Nose: Nose has uniform color and symmetrical in shape. Nasal hairs are evident when light is flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration. Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in color with the skin, has no discharges and no lesions. No tenderness of sinuses noted. Ears: Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye. Pinnas are symmetrical, mobile, and able to recoil, with no lesions noted. She has wet cerumen noted on both ears when puleed down and back for better visualization. She is able to hear on both ears. Her ears lobules have holes for jewelry. Mouth: Lips are pale in color, dry and has cracks. Her teeth are a little yellow in color with few plaques. Neck and Lymph Nodes: Upon inspection, neck is symmetrical and no distention or bulging noted. Upon palpation, there is no enlargement or tenderness in her neck. Nails: Nails are long and untrimmed, pale in color.

Thorax and Lungs: clear breath sounds upon auscultation and no reports of pain during inhalation and exhalation. Cardiovascular: with regular rate and normal rhythm upon ausculatation. Breast and axilla: not performed Abdomen: Her abdomens color is same with the rest of the part of the body. Upon palpation, no pain verbalized, no changes in facial expression, no pulsations felt, relaxed abdominal muscles that normally accompany exhalation. Extremities: A. Upper Extremities (ARMS) Upon inspection, hands and arms are symmetrical, absence of muscle wasting, and no tenderness and redness. Upon palpation, arms and hands have symmetrical muscle tone. There is equal or symmetrical muscle strength.

B. Lower Extremities (LEGS) Upon palpation, no pain noted, cool to touch. There is a presence of pitting edema graded as +2 (moderate pittind edema) No inflammation. Genitals: not performed Rectum and Anus: not performed Neurological/Cranial Nerves: Cranial Nerves: (CN1) able to identify aromas by smelling with eyes close; (CN2) able to see objects; (CN3)Both eyes coordinated, moves in unison; (CN4&6) able to move eyeball downward and laterally; (CN5) able to blink eyes; (CN7) able to smile, raise eyebrows, puff cheeks and close eyes; (CN8) able to respond to questions being heard; (CN10) has rough and vibrating sound; (CN11) able to shrug shoulders, elevate and flex arms and legs against resistance;(CN12) able to protrude tongue and move it side to side.

III.

PERSONAL/SOCIAL HISTORY A. Habits/Vices Caffeine: The patient drinks one cup of coffee a day. Smoking: The patient said that she is a chain smoker wherein she consumes 2 packs of cigarette in just 1 day. She smokes Malboro and Fortune. Alcohol: The patient said she drinks alcohol 4 times a week together with her peers. They usually drink Emperador Lights and Red Horse. Tea: She does not drink tea. Drugs: The patient did not take any drugs like shabu and marijuana.

B. Lifestyle: According to the patient, she prefers to be with her peers and she often stays at their house. She helps her mother and sisters in doing household chores. She doesnt want to do nothing because she is an active person. C. Social Affiliation: She stated that she has lots of friends in their school and barangay because she is very approachable and nice to be with. D. Rank in the Family: 2nd among the 3 siblings. E. Educational Attainment: The patient said that she finish high school. IV. ENVIRONMENTAL HISTORY The patient is living together with her parents and sisters. Their environment is free from pollution because they are far from the street. They have garden at the side of their house. They have a clean, nice and green environment. They make a compost pit where they can put their garbage, and sometimes they burn their garbage too. There are many neighbourhoods and distance of the house is slightly near.

VI.

Anatomy and Physiology

Function of the Urinary System: The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism and because of this, it is sometimes referred to as the excretory system. Although the urinary system has a major role in excretion, other organs contribute to the excretory function. The lungs in the respiratory system excrete some waste products, such as carbon dioxide and water. The skin is another excretory organ that rids the body of wastes through the

sweat glands. The liver and intestines excrete bile pigments that result from the destruction of hemoglobin. The major task of excretion still belongs to the urinary system. If it fails the other organs cannot take over and compensate adequately. The urinary system maintains an appropriate fluid volume by regulating the amount of water that is excreted in the urine. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. Components of the Urinary System: The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside.

KIDNEYS The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult, each kidney is approximately 3 cm thick, 6 cm wide and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney.

The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule. The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop.

Parts of the Kidney:

Renal Vein -This has a large diameter and a thin wall. It carries blood away from the kidney and back to the right hand side of the heart. Blood in the kidney has had all its urea removed. Urea is produced by your liver to get rid of excess amino-acids.

Blood in the renal vein also has exactly the right amount of water and salts. This is because the kidney gets rid of excess water and salts. The kidney is controlled by the brain. A hormone in our blood called Anti-Diuretic Hormone (ADH for short) is used to control exactly how much water is excreted. Renal Artery - This blood vessel supplies blood to the kidney from the left hand side of the heart. This blood must contain glucose and oxygen because the kidney has to work hard producing urine. Blood in the renal artery must have sufficient pressure or the kidney will not be able to filter the blood. Medulla - The medulla is the inside part of the kidney. This is where the amount of salt and water in your urine is controlled. It consists of billions of loops of Henle. These work very hard pumping sodium ions. ADH makes the loops work harder to pump more sodium ions. The result of this is that very concentrated urine is produced. Cortex - The cortex is the outer part of the kidney. This is where blood is filtered. We call this process "ultra-filtration" or "high pressure filtration" because it only works if the blood entering the kidney in the renal artery is at high pressure. Billions of glomeruli are found in the cortex. A glomerulus is a tiny ball of capillaries. Each glomerulus is surrounded by a "Bowman's Capsule". Glomeruli leak. Things like red blood cells, white blood cells, platelets and fibrinogen stay in the blood vessels. Most of the plasma leaks out into the Bowman's capsules. This is about 160 litres of liquid every 24 hours. Most of this liquid, which we call "ultra-filtrate" is re-absorbed in the medulla and put back into the blood. Blood supplied to the kidney contains a toxic product called urea which must be removed from the blood. It may have too much salt and too much water. The kidney removes these excess materials. Glomerulus and Bowman's Capsule - This is where ultra-filtration takes place. Blood from the renal artery is forced into the glomerulus under high pressure. Most of the liquid is forced out of the glomerulus into the Bowman's capsule which surrounds it. Proximal Convoluted Tubules - Proximal means "near to" and convoluted means "coiled up" so this is the coiled up tube near to the Bowman's capsule. This is the place where all that useful glucose is re-absorbed from the ultra-filtrate and put back into the blood. If the glucose was not absorbed it would end up in your urine. Loop of Henle - This part of the nephron is where water is reabsorbed. Kidney cells in this region spend all their time pumping sodium ions. This makes the medulla very salty; you could say that this is a region of very low water concentration. If you remember the definition of osmosis, you will realize that water will pass from a region of high water concentration (the ultra-filtrate and urine) into a region of low water concentration (the medulla) through cell membranes which are semi-permeable. Distal Convoluted Tubules - Distal means "distant" so it is at the other end of the nephron from the Bowman's capsule. This is where most of the salts in the ultra-filtrate are re-absorbed.

Collecting Duct - Collecting ducts run through the medulla and are surrounded by loops of Henle. The liquid in the collecting ducts (ultra-filtrate) is turned into urine as water and salts are removed from it. Although our kidneys make about 160 litres of urine every 24 hours, we only produce about . litre of urine. It is called a collecting duct because it collects the liquid produced by lots of nephrons.

URETERS Each ureter is a small tube, about 25 cm long that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface. The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells.

URINARY BLADDER The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue.

URETHRA The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina. In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis.

VII. Pathophysiology

Antigen (group A beta-hemolytic streptococcus) Antigen-antibody product Scarring and loss of glomerular filtration membrane Decrease glomerular filtration rate Impaired blood flow Decrease Glomerular filtration rate Proteinuria Diminished Renal Reserved GFR (50%) Renal insufficiency BUN, creatinine levels begin to rise Remaining nephrons undergo changes to compensate for those damage nephrons Hypertrophy of nephrons Renal failure

 Impaired kidney function and uremia

Sodium and water retention Excess fluid goes to extremities Peripheral edema

Build up of waste in the blood Uremia Uremic frost Itchiness

Hydrogen retention Decrease production of erythropoeitin Nausea/Vomiting Decrease production of RBC by the bone marrow Decrease RBC that carry oxygen in the muscles and tissues Fatigue and weakness

VIII. Laboratory and Diagnostic Examination CLINICAL LABORATORY TEST Age: 23

Name: Olipas, Maribel Address: San Nicolas, Pangasinan Requesting M.D: Dr. Devera

Test HEMOGLOBIN: F:(123-153g/L)

Result 118

Interpretation -indicates anemia. If RBC is decreased, the hemoglobin decreases also. This means that exchange of gases between the alveoli, and the capillary beds are affected, and there will be less oxygenated blood circulating the body, and hypoxia results. This is caused by impaired production of erythropoietin by the kidney. Eythropoietin stimulates the bone marrow to produce blood products especially RBC. -Hemodilution or there is decreased concentration of RBC in the blood. Plasma volume is increased because of fluid shifting. -Normal -It indicates infection -Patient is prone to immunosupression since his lymphocytes are small in number. Lymphocytes play an important role in immune response (B and T lymphocytes).

HEMATOCRIT: F :( 0.359-0.446vol %) RBC (3-4x1O/l) WBC(4.5-11x10/L) LYMPHO (20-45%)

.34 3.48 13.6 15.8

San Carlos City Pangasinan Department of Laboratory Vitros Clinical Chemistry Report Patient Name: Olipas, Maribel Sample ID: 023913

Test Urea

Reference 36.8mmol/L

Result HI

Albumin A/G Ratio

22.1g/L .7

HI LO

Globulin

32

LO

Significance High levels of urea mean your kidneys are not getting rid of waste and it remains in the body Indicate kidney damage. A low A/G ratio reflects overproduction of globulins, due to chronic infections and kidney disease. Indicates kidney problem.

CLINICAL LABORATORY TEST Name: Olipas, Maribel Address: San Nicolas, Pangasinan Requesting M.D: Age: 23

CLINICAL MICROSCOPY (URINALYSIS) Physical and Chemical Properties Color: _ Yellow_______ Transparency: ____Turbid_________ Ph/Reaction: ____(6.0)_acidic______ Specific Gravity: ___1.010__________ Protein: ____(++++)______ Sugar: ____negative______

Microscopic Procedure Puss Cells: __TNTC/hpf__ Red Cells: __3.5/hpf__ Epithelial Cells: __moderate__ Mucous Threads: __few__ Amorphous Urates: __many__

*Total protein levels are often elevated in persons with serious infections because of abnormally increased production of antibody.

Name: Olipas, Maribel Address: San Nicolas, Pangasinan Requesting M.D:

CLINICAL LABORATORY TEST Age: 23

Test FBS BUA BUN CREATININE

Reference 70-99 mg/dl 3.4-5.20 mg/dl 7-23mg/dl 0.50-1.70 mg/dl

Result 91.6 5.19 37.54 9.82

Significance -Normal -Normal High blood urea nitrogen indicates insufficient filtration in the kidneys. -Increased creatinine levels in the blood suggest diseases or conditions that affect kidney function. Creatinine reflects glomeruli filtration rate. -Normal -Normal -Normal

TRIGLYCERIDE HDL-CHOLESTEROL LDL- CHOLESTEROL

36-165mg/dl 30-85mg/dl 66-178mg/dl

140.6 49.2 125.38

IX. Drug Study

Generic Name: Cefuroxime ( axetil ) Brand Name: ceftin Classification: anti - infective

Dosage: 750 mg IV every 8 hours

Indication: serious infection of urinary tract s

Mechanism of action A second generation cephalosporin that inhibits cell wall synthesis, promoting osmotic instability, usually bactericidal

Side effects Diarrhea

Contraindication Contraindicated in patients hypersensitive to drug or other cephalosporins.

Adverse reaction GI:nausea,anorexia, vomiting,

Nursing consideration Obtain specimen for culture and sensitivity test before giving first dose. Use cautiously in patients hypersensitive to penicillin because of possibility of cross. Sensitivity of other beta lactam antibiotics. Monitor vital signs Monitor for dehydration

Generic Name: Furosemide Brand Name: Lasix Classification: Loop Diuretic Dosage: 40 mg IV q 8

Indication: -Edema associated with renal disease

Mechanism of action A potent loop diuretic that inhibits sodium and chloride reabsorption at the proximal and distal tributes and the ascending loop of henle Side effects Anemia , azotemia, headache, drowsiness Contraindication Contraindicated with allergy to furosemide, sulfonamides, anemia, severe renal failure; hepatic coma; pregnancy; lactation. Use cautiously which SLE, gout, and diabetes mellitus. Adverse reaction Nausea, anorexia, vomiting, dizziness, vertigo, rash, pruritus. Nursing consideration Use cautiously in patients with hepatic cirrhosis and in those allergic to sulfonamides. If oliguria or azotemia develops or increases, drug away may need to be discontinued. Monitor fluid intake and out and electrolyte, BUN, and carbon dioxide levels frequently

Generic Name: Amlodipine besylate Brand Name: Novasc Classification: antihypertensive Dosage: 10 mg tablet OD

Indication: Hypertension Mechanism of action

Inhibits calcium ion influx across cardiac and smooth muscle cells, thus decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles.

Side effects
Headache, edema

Contraindication
Contraindicated in patients hypersensitive to drug. Use cautiously in patient taking other peripheral vasodilators / especially those of severe aortic stenosis) and in those of heart failure.

Adverse reaction
Fatigue, dizziness, palpitations, nausea, dyspnea

Nursing consideration
Use cautiously in patients receiving other peripheral vasodilators, especially those of severe aortic stenosis, and in those of heart failure. Because drug is metabolized by the liver, use cautiously and in reduced dosages in patients with severe hepatic disease. Monitor blood pressure frequently during initiation of therapy. Monitor input and output Monitor vital signs Assess general status

X. LISTS OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY Fluid volume excess related to urinary output as manifested by edema and weight gain Activity intolerance related to lumbar pain. Imbalance nutrition less than body requirement related to anorexia, nausea, vomiting, dietary restrictions and altered mucous membranes. Deficient knowledge regarding condition and treatment

Impaired skin integrity related to alteration in skin turgor.

XI. Nursing Care Plan

Assessment S: Minamanas ang paa ,ko as verbalized. O: Pitting edema on the lower extremities graded as +2 Cold clammy skin in the lower extremities. Skin, nailbed, and lips pallor. Shiny skin noted Decrease urine output noted (350ml/24 hour) Weight:Previous:62kgs New: 77kgs. V/s: BP: 140/90 T: 37.4 PR:102 RR:31 Diagnosis Fluid volume excess related to decrease urine output as manifested by pitting edema, weight gain. Planning After 8 hours of rendering nursing care the patient display appropriate urinary output. Interventions Monitor vital sign Rationale Serves as baseline data. Tachycardia And hypertension can occur because of failure of the kidneys to excrete urine. Accurate intake and output is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload. Evaluation After 8 hours of rendering nursing intervention the patient had display appropriate urinary output.

Record accurate intake and output.

 Monitor urine specific gravity.

Measures the kidneys ability to concentrate urine. Daily body weight is best monitor of fluid status. A weight gain of more than 0.5 kilogram per day suggests fluid retention. Edema occurs primarily in dependent tissues of the body.

Weigh daily at same time of day, on same scale, with same equipment and type of clothing.

Assess skin, face, and dependent areas for edema.Evaluat e degree of edema(on scale of (+)1 to(+)4.

Monitor heart rate and BP.

Tachycardia and hypertension can occur

because of failure of the kidney to excrete urine. Auscultate lung and heart sound. Fluid overload may lead to pulmonary edema and heart failure. Evidence by development of adventitious breath sounds, extra heart sounds.

Assess level of consciousness : presence of restlessness.

May reflect fluid shift ,accumulation of toxins, acidosis, electrolyte imbalances, or developing hypoxia.

Plan oral fluid replacement with client, within

Helps avoid. Without fluids, minimizes boredom of

multiple restriction

limited sources and reduces sence of deprivation and thirst. Fluid management is usually calculated to replace ouput from all sources plus estimated insensible losses.

Administer or restrict fluids As indicated

Administer medications as indicated: Diuretics

Given early in oligoric phase of ARF in an effort to convert to nonoligoric phase, flush the tubular lumen of debris, reduce hyperkalemia, and promote adequate urine volume.

Assessment Subjective: hindi ako maysadong makagalaw kasi masakit yung may parte sa balakang ko. As verbalized by the patient. Objective: Easy fatigability noted Weak in appearance Has difficulty of doing using usual routines Moves slowly Unable to tolerate long walks

Diagnosis Activity intolerance r/t lumbar pain.

Planning After 8 hours of nursing interventions the patients will be able to demonstrate a decrease in physiologic signs of intolerance.

Intervention Assess the clients response to activity.

Rationale The stated parameters are helpful in assessing physiologic responses to the stress of activity. Tolerance varies greatly depending on the stage of the disease process and reaction to treatment specimen. Rest between activities provides time for energy conservation and recovery.

evaluation After 8 hours of nursing intervention the patient demonstrated decrease in physiologic signs of intolerance.

Monitor changes and vital signs in response to activity.

Encourage adequate rest periods, especially before meals, other ADLs, exercise session and ambulation.

 Refrain from reforming nonessential procedures.

Patients with limited activity tolerance need to prioritize task. Assisting the patient with ADLs allows for conservation of energy, caregivers need to balance proving assistance with facilitating progressive endurance that will ultimately enhance the patients activity tolerance and self esteem.

Assist with ADLs as indicated, however avoid doing for patient what he or she can do for self.

 Assist patient to plan activities for time when he has the most energy.

Not all self care and hygiene activities need to be completed in the morning. Likewise, not all house cleaning needs to be completed in one day. Adequate intake or use of nutrients is necessary to meet energy needs and build energy reserve for activity.

Instruct patient to increase nutritional intake.

assessment Objective: pale cold clammy skin Edema in lower extremities Irritability

Diagnosis Impaired skin integrity related to alteration in skin turgor.

Planning After 6 hours of rendering nursing intervention, the patient demonstrates behaviours or techniques to prevent skin breakdown

Intervention establish rapport

Rationale to gain trust

evaluation After 6 hours hours of rendering nursing intervention, the patient demonstrated behaviours or techniques to prevent skin breakdown

Inspect skin for changes in color turgor, vascularity. Note redness, excoriation. Observe for ecchymosis purpura. Monitor fluid intake and hydration of skin and mucus membranes.

Indicates areas of poor circulation/breakd own that may lead to decubitus formation/infectio n.

Detects presence of dehydration or over hydration that affects circulation and tissue integrity at the cellular level. Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis/edema formation.

Inspect dependent areas for edema. Elevate legs as indicated.

 Change position frequently and move client carefully.

Decreases pressures on edematous, poorly perfuse tissue to reduce schemia. Baking soda and cornstarch baths decreases itching and are less drying than soaps. Lotions maybe desired to relieve dry skin. Reduces dermal irritation and risk of skin breakdown. Alleviates discomfort and reduces risk of dermal injury.

Provide soothing care, restrict use of soap.

Keep linens dry and wrinkle free

Recommend client use cool, moist compresses to apply pressure keep finger nails short.

 Suggest wearing loose fitting cotton garments.

Prevents direct dermal irritation and promotes evaporation of moisture in the skin

XII ONGOING APPRAISAL The patient shows progressive recovery and responding well to both medical and nursing interventions. XII. Discharge Planning Categories Plan - Instruct patient to take prescribed medications regularly and comply with the treatment regimen prescribed by the physician. Rationale -Compliance to appropriate medication and treatment prevents further complications and resistance to antibiotics and promote continuous recovery of optimal health. -The patient has the right to know his drugs therapeutic effects as well as its adverse effects. He also has the right to gain awareness about why is it given to him. -Drug interactions may occur which may be fatal to patients current situation.

Medication

- Teach patient regarding the names of the drug, its dosage, time of administration, its contraindication and side effects.

-Inform patient and significant others not to take drugs not prescribed by the physician, especially OTC drugs.

-Do not administer any other drug with same action without the physicians prescription.

-Non-prescription drug may have antagonistic or synergistic effects if taken with other drugs.

Treatment

- Instruct the significant others to report any remarkable adverse reactions or any appearance of side effects noted. - Instruct patient to comply with his medication treatment like the continuous use of beta blocker Metoprolol for control of hypertension. -Instruct client to seek medical help if any unusualties are felt such as tingling sensation or paresthesia, fatigue and body malaise, dizziness, headaches, irritability, tremors, diaphoresis, etc. -Advise to have a family member take your blood pressure to check if youre maintaining a stable blood pressure.

-For immediate remedial action response and to prevent any complicated reactions. -Maintenance meds should not be forgotten to achieve highest therapeutic effect.

-These unusualties may be indicative of worsening condition.

-Monitor of blood pressure is significant for evaluating the medications effectiveness.

- Instruct patient to practice foot care to -Proper foot care prevents injury to feet prevent ulceration and formation of and toes. gangrenous tissues to the lower extremities. Hygiene - Check and carefully wash your feet every day. -Do not wear shoes that are too small or socks that do not fit right inside your shoes. -Soak your feet in warm soapy water for 10 minutes before cutting your

nails. Trim your toenails straight across to prevent ingrown toenails. You may also file down your toenails. Do not cut your nails into the corners or close to the skin. You should not dig under or around the nail. -Emphasize the importance of bathing every day. Wash genitals with mild soap. -Proper bathing eliminates proliferation of germs and bacteria in the body. Mild soap does not irritate the skin and the genitals.

Diet - Instruct patients family to prepare foods low in fat and cholesterol. -Cholesterol build up can cause atherosclerosis. Since elder people have weakened blood vessel walls, cholesterol or atherosclerotic plaques (atheromas) can lodge in the blood vessels and obstruct blood flow. If the atheroma is dislodged, it might become an emboli and travel through the pulmonary circulation. -too much sodium can result to fluid shifting and edema. -Water replenishes the cells and decreases the chance of crystalluria.

- Also have Low-salt diet.

- Maintain good oral hydration.