NORTHEASTERN COLLEGE

COLLEGE OF NURSING

SANTIAGO CITY, PHILIPPINES

ANEMIA PROBABLY SECONDARY TO CHRONIC KIDNEY DISEASE V

SECONDARY TO HYPERTENSIVE NEPHROSCLEROSIS

CASE PRESENTED BY:

ACELOM, LILIJANE

AGANA, LOVELYN

AGUSTIN, CHARLOT

GACUSAN, LORNALYN

LOPEZ, RHEN CYRYLL G

MADAMBA, SHERYL MAE

MAGTUBO, ELIZABETH

RAMONES, PRECIOUS DIANE

TIMBANG, KEYCHELLE ANN

UAO, DIVINA GRACIA

TABLE OF CONTENTS

CASE STUDY/CASE PRESS

OVERVIEW

DEMOGRAPHICS

HISTORY OF ILLNESSES

PAST MEDICAL HISTORY

PRESENT

FAMILY

PHYSICAL ASSESSMENT (HEAD TO TOE)

11 GORDONS

COURSE IN WARD

LABORATORY

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY, BOOK

PATHOPHYSIOLOGY, PATIENT

DRUG STUDY

NCP

DISCHARGE PLANNING
OVERVIEW
This study presents the important considerations of diagnosis and treatment in view of the
ongoing study of the admitted patient. Patient Mrs. RR is a 59 year old, from Cordon Isabela.
She told us that she’s experiencing cough and generalize body weakness for days before she
decided to go to the hospital for admission and to seek medical help.

The attending physician advised the patient to go through a series of laboratory tests specifically
routine blood test, ecg,and urine testing. It was then find out that patient Mrs. RR is experiencing
anemia probably secondary to chronic kidney disease v secondary to hypertensive
nephrosclerosis and with moderate covid 19. The patient said that she was vaccinated with
Moderna for the first and second vaccine.

Anemia is a common complication in chronic kidney disease, and is associated with a reduced
quality of life, and an increased morbidity and mortality. The mechanisms involved in anemia
associated to CKD are diverse and complex. They include a decrease in endogenous
erythropoietin (EPO) production, absolute and/or functional iron deficiency, and inflammation
with increased hepcidin levels, among others.

Hypertensive arteriolar nephrosclerosis is progressive kidney damage caused by long standing,

poorly controlled high blood pressure.
Hypertensive arteriolar nephrosclerosis results when long-standing hypertension damages
tissue in the kidneys, including small blood vessels, glomeruli, renal tubules, and interstitial
tissues. As a result, progressive chronic kidney disease develops.

Hypertensive nephrosclerosis progresses to end-stage renal disease (severe chronic kidney

disease) in only a small percentage of people. However, because chronic hypertension and
nephrosclerosis are common, hypertensive nephrosclerosis is one of the most common causes
of end-stage renal disease.
Therefore, the goal of treatment is to control the symptoms of the disease effectively, to become
acquainted with the various conditions that enter into the differential diagnosis of the patients
condition, and to be able to apply the types of treatment recommended for the patient.

Demographic data:

Name: Patient Mrs. RR

Age: 59y/o

DOB: November 29, 1963

Sex: Female

Ward: Medical Surgical Ward

Address: Purok 6, Aguinaldo (Rizaluna Este), Cordon Isabela 3312

Contact Number: 09051406906

Occupation: N/A

Marital status: Married

Date of admission: February 13, 2023

Time of Admission: 7pm

Allergic to: (-) allergy

Date of discharge: N/A

PAST MEDICAL

-In August 2020 the patient was admitted to hospital and later on diagnosed with the same
illness. Anemia Probably Secondary to Chronic Kidney Disease V Secondary to Hypertensive
Nephrosclerosis.

PRESENT

History of present illness:

-Anemia Probably Secondary to Chronic Kidney Disease V Secondary to Hypertensive

Nephrosclerosis

According to the patient, she is a former OFW, but when she’s back in Philippines she does work
at the farm and also do house chores and later on diagnosed with CKD or the illness she have
right at the moment. Since the diagnosis her family ask her to stay home and not to do any type
of work.

FAMILY HISTORY

- The patient said that no one in her family has any type illnesses like diabetes, ckd,
hypertension.

-The patient does not have allergy to any food and drugs.

PHYSICAL ASSESSMENT

(HEAD TO TOE)

AREA METHOD FINDINGS INTERPRETATIONS

Head Inspection, Palpation Hair is smooth in Normal
texture, and no trace of
 infestations.

The scalp is clean, no

lumps and lesions
noted.

Facial movements are

symmetrical.

Nares are patent and

no drainage is present.

Teeth and gums are in

good condition.

Uvula and tongue are

midline. No sores or
coating is present.

The patient is able to

appropriately chew
food.

The patient is able to

speak clearly with no
slurring garbled words.
Neck Inspection, Palpation No swollen lymph Normal
node in the neck noted,
Thyroid gland not
tender and not enlarge,
Neck muscles are
equal in size, Trachea
is positioned in the
 midline upon
palpation.
Skin Inspection, Palpation The skin is pale in Abnormal
color.

No skin lesions, no
edema noted.
Chest and Lungs Auscultation Shortness of breath - Abnormal
dyspnea (due to
anemia) - Wheezing
sound
Heart Inspection, The apical beat of the Normal
Auscultation heart is heard over the
apex of the heart
which is located at
fifth intercostal space
(point of maximal
impulse).

Breast and Axilla Auscultate, Breast size are equal, Normal

percussion, Palpation slightly rounded and
symmetrical. Nipples
are similar, small,
rounded and with a fair
brown color. Areoles
are round and
bilaterally the same.
Axilla is smooth
without lesions. No
enlarged is tympanic in
sound. No masses or
 pain noted upon
palpation.

Nail Inspection, Palpation Convex in curvature , Abnormal

rough with slow
capillary refill. - (5
seconds)
UPPER Inspection Decorticate Normal
EXTREMITES position ,arms are able
to abduct and adduct.

ABDOMEN Inspection, The abdomen is Normal

percussion, Palpation generally symmetrical
in configuration and
has normal growing
sound of 12. Upon
percussion, the
abdomen is tympanic
in sound. No masses or
pain noted upon
palpation.

LOWER Inspection Able to flex abduct Normal

EXTREMITES and adduct.

GENETALIA Inspection Two echogenic Normal

parallel lines in a
transverse section in
 the midtrimester.
Clitoris are seen
between the labia
directed caudally. No
ulceration ,urethral ,no
discharge and palpable
masses.

11 GORDON’S

PATTERN BEFORE DURING ANALYSIS

HOSPITALIZATION HOSPITALIZATION

HEALTH According to the According to the There is a change in

PERCEPTION patient she was a patient she is her everyday routine
PATTERN hardworking mother persistently on her before and after.
back then, she always HD 2x a week.
helps her husband in
She was not able to
their farm and also do
go to their farm to
house chores.
help her husband
She said she is strong because of her
and can do things for condition.
her family.
The patient said her
family does not allow
her to do house
chores anymore.
 She said she is
experiencing body
weakness most of the
time.

NUTRITION AND According to the The patient still takes There are changes of
METABOLIC patient she takes her meal 3x a day. her nutrition and
PATTERN regular meal 3x a metabolic pattern
day. before and during
She said that she still
She shares that most Because before the
can eat vegetables,
of the time she eat patient eats everything
meat, and fish but in
vegetables, meat, and that she like. But when
moderation especially
fish. she got sick, many
foods that the doctor
food are adviced to be
advised her not to
avoided.
take. During
hospitalization the
physician adviced her
to have a renal diet

She has no difficulty

She said she doesnt
in swallowing.
have a difficulty in
swallowing.

And according to the She eats nutritious

patient she is eating food but not the same
nutritious food anymore like before.
everytime and She is very cautious
mention of not having with the food she eats
any problem on her now.
stomach. She does
She said she does not
not experience any
have indigestion and
 indigestion back then. is completely
eliminated all the
No allergies of food.
food the doctor told
her not to take.

The patient now

consumes atleast 6
The patient consumes
glasses of water a
water of about 2 liters
day.
a day especially when
she is working in
their farm.

ELIMINATION The patient said she The patient said is

PATTERN does not have any there is a slight
Elimination pattern
problem urinating, change in her bowel
was changed.
she said she urinates movement.
atleast 4x a day in the
According to the
morning, before bed
patient she urinate 4x
and mostly during
a day but little at
daytime especially
morning and night
when she consumes a
and sometimes she
right amount of
urinate once a day or
water.
2x a day
She defecate 2x a day
She now defecate
morning and night .
once a day especially
during evening.

EXERCISE According to the The patient said she There is a changed

PATTERN patient she does not does not exercise when it comes to
have any regular even before and exercise pattern, the
exercise at all but she considered working fact that she is no
 said that working in in the farm and doing longer do house chores
their ricefield and the house chores are and cannot go also to
doing ther house her form of exercise the ricefield.
chores are considered but during
her exercise. hospitalization, due to
her condition she
cannot do any form of
exercise at all.

COGNITIVE – She is normal in The patient said The patient cognitive

PERCEPTUAL terms of her cognitive sometimes she forgot perceptual has slightly
ability. She has good something, but she change when it comes
memory and remembers to her memory
reasoning. afterwards and said because of her age.
that it is normal at her
age

The taste, smell,

The taste ,smell, vision, hearing and
vision, hearing and decision making are
decision making are still the same as
normal and on point. before.

SLEEP- REST The patient said she The patient have a The patient sleep-rest
PATTERN have a normal sleep- hard time getting her pattern has changed.
rest pattern before. sleep as she said that
sometimes her
She sleeps 6-7 hours.
condition bothers her
 She is not using from overthinking.
phone when in bed as
She sleeps 5 hours,
it will ruin her
but not steady,
sleeping pattern.
sometimes she
suddenly wakes up in
the middle of the
night.

She said she is using

phone watching
videos when she cant
get her sleep.

SELF She has positive She said that she still The self-perception-
PERCEPTION- outlook in life. She believe that she will self conception does
SELF said that problems be fine . She is not not change. The
CONCEPTION may come and go and discourage because of patient has positive
that is normal. her situation or outlook in life.
condition. She said
She said that she has
she took strength
a cheerful
from her family
personality.
The patient told us
that sometimes she
gets upset and sad
because of her
condition but also
thinks that everything
happens for a reason.

ROLE- The patient is married She still guides her There is a change in
RELATIONSHIP with 3 children. She children, but when it role-relationship
PATTERN is a former Ofw, and comes to helping her
 when she’s back in husband in providing pattern.
Philippines she helps their needs she can no
her husband do the longer do it because
farming as well as of her condition.
doing the house
keeping. As well as
guiding their children
in every aspect of
life.

SEXUALITY- The patient said that The patient said they The patient is not that
REPRODUCTIVE both her and husband seldom do coitus. active anymore.
PATTERN are sexually active.

COPPING – She always tell and She always share her Nothing changed to
STRESS share problems to her problems to her coping-stress tolerance
TOLERANCE husband and children husband and children pattern. The patient is
PATTERN and together they especially when they always open to sharing
solved most of those found out about her her problem to her
problems they illness. family.
encounter.

The patient said they

have a strong bond as
a family and help
each other whenever
problems come their
way.

VALUE Religion – Roman There is no changes There are no changes

Catholic in her religion
 The patient is a
Roman catholic but
said she seldom go to
church.

She is not taking

herbal medicine

COURSE IN THE WARD

Date Time Doctor's order Rationale

02- 7pm Please admit the patient to prevent the transmission of microorganisms
13- to isolation ward from infected or colonized patients to other
23 patients, hospital visitors, and health care workers,

Secure consent for Informed consent is a process of communication

admission and between you and your health care provider that
management often leads to agreement or permission for care,
treatment, or services. Every patient has the right
to get information and ask questions before
procedures and treatments.

Heplock to keep IV catheters open and flowing freely.

Renal diet to keep the levels of electrolytes, minerals, and

fluid in your body balanced when you have CKD
or are on dialysis.

Diagnostics:
CBC
Na
K
Bun
Createnine
Chest x-ray
12LECG
Blood typing
Feretenine
DTIBC
RBS
Reticulocyte count

Therapeutics:
-Sodium by carbonate
tablet TID

Calcium by carbonate Calcium carbonate is a dietary supplement used

tablet TID when the amount of calcium taken in the diet is not
enough.

Ferrous sulfate tab to treat or prevent anemia (a lower than normal

TID number of red blood cells) when the amount of
iron taken in from the diet is not enough

Betahistine 16mg 1tab q8

prn for dizziness

Secure 5units PRBC to detect the presence of antibodies in the recipient

properly cross match against the red blood cells of the donor.
 Transfuse 1 unit PRBC
properly cross match

To run for 4 hours the

transfuse 2 units PRBC
during hemodialysis
repeat CBC 6 hours post
Bt

Hook 0²support at 3-4pm

via nasal cannula

Monitor vs and record helps to identify when a patient has an elevated

heart rate or blood pressure, which could indicate
dehydration or shock; rapid breathing, which could
indicate respiratory distress; or low blood pressure,
which could indicate shock

Monitor INO every shift

and record

Watch out for dyspnea,

chest pain, difficulty of
breathing .

Refer In order for the patient to be assess and evaluate

properly

7:30pm Referral service for Hemodialysis can help your body control blood
hemodialysis pressure and maintain the proper balance of fluid
and various minerals — such as potassium and
sodium — in your body

ht setting duration 4
 hours

IVF 2L + 2units PRBC to prevent or treat dehydration.

BFR 250

DFR 500

Repeat heparin To prevent blood clots.

2- 3pm -for transfer to 606 once

14- RTPCR negative
23

inform once at ward

transfuse another 1 unit

PRBC to run for 4 hours

-Secure 2 more units

PRBC properly typed
and crossmatched

-continue maintenance
HD 2x a week

revise HD Setting to no
heparin

Refer In order for the patient to be assess and evaluate

properly

2- 12:30am Heplock to keep IV catheters open and flowing freely.

15-
23

Renal diet to keep the levels of electrolytes, minerals, and

fluid in your body balanced when you have CKD
or are on dialysis.

diagnosis:
repeat CBC 6h post BT
Na,K,Mg in AM

NaHCO3 Tab TID

CaCO tab TID

Ferrous sulfate tab TID to treat or prevent anemia (a lower than normal
number of red blood cells) when the amount of
iron taken in from the diet is not enough

butamirate citrate tab, 1 reduces the resistance in the airways by inhibiting

tab TID pm for dry bronchospasm and anti-inflammatory effect
cough

send HD once hgb is

atleast 7mg/dl

Monitor vs q4 and record helps to identify when a patient has an elevated

heart rate or blood pressure, which could indicate
dehydration or shock; rapid breathing, which could
indicate respiratory distress; or low blood pressure,
 which could indicate shock

I and O every shift indicate the fluid balance for a patient.

watch out for : DOB, To better manage the health status of the patient
hypotension and prevent it from having hypotension

Refer In order for the patient to be assess and evaluate

properly

2- 1:35pm >Please send For the patient treatment of her illness,

15- hemodialysis notification hemodialysis helps control blood pressure and
23 and schedule for hd, balance the important minerals, such as potassium,
Suggest possible time. sodium, and calcium in the blood.

>repeat CBC, Na, K, Mg In order that waste products and fluid that build up
6h post HD in the body will be treated. To effectively filter out
unwanted substances and fluids from the blood.

>Refer In order for the patient to be assess and evaluate

properly.

2- 1:40pm >HD settings

15-
23

Duration:4H

>UF:2L + unit pack RBC This is to help replace blood due to anemia.

>BFR:250 ml/min

>DFR:500 ml/min
 >Regular heparin To maintain the production of blood.

>Nst flashing by
carbonate

LABORATORY AND DIAGNOSTICS

HEMATOLOGY RESULT FORM I 02/13/2023

PARAMETERS RESULT REF. RANGE PARAMETERS RESULT REF. RANGE

WBC N:4.00-20.0 10^9/L HEMOGLOBIN 4.9 N: 17.0-20.0
6.28 C:4.00-12.0 10^9/L C:12.0-16.0
A:5.0-10.0 10^9/L AM:13.0-18.0
AF:11.0-16.0
Neutrophils 70.00 N:40.0-80.0% HEMATOCRIT 13.9 N: 38.0-68.0
C:50.0-70.0% C:35.0-49.0
A:50.0-65.0% AM:40.0-54.0
AF:37.0-54.0
Lymphocytes 16.10 N:10.0-60.0% RBC 3.5 N: 3.5-7.0
C:20.0-60.0% C:3.5-5.2
A:25.0-35.0% AM:3.5-5.0
AF:4.0-5.5
Monocytes 6.60 N: 3.00-13.0% MCV 59.9 N: 95.0-125
C:3.00-12.0% C:80.0-100
A:3.00-7.00% A:80.0-97.0
Eosinophils 6.40 N:0.50-5.00 % MCH 21.1 N: 30.0-42.0
C: 0.50-5.00 % C:27.0-34.0
A:1.00-3.00% A:26.0-32.0
Basophils 0.90 0.00-1.00% MCHC 35.1 N: 30.0-34.0
C:31.0-37.0
A:31.0-36.0
PLATELET 201 150-450 10^9/L

CLINICAL CHEMISTRY RESULT FORM II 02.13.2023

TEST TEST PRINCIPLE RESULT NORMAL

VALUES
THYROID
FUNCTION TEST
TSH3 CHEMILUMINISCENCE - 0.4001-4.049
FT3 CHEMILUMINISCENCE - 4.26-8.10
FT4 CHEMILUMINISCENCE - 10.0-28.2
TT3 CHEMILUMINISCENCE - 0.970-1.69
TT4 CHEMILUMINISCENCE - 71.2-141.0
TUMOR MARKERS
AFP CHEMILUMINISCENCE - <7.22 IU/mL
BHCG CHEMILUMINISCENCE - <6.15 mIU/Ml
CA 125 CHEMILUMINISCENCE - <30 U/mL
CA 15-3 CHEMILUMINISCENCE - <30 U/mL
CA 19-9 CHEMILUMINISCENCE - <37 U/mL
CEA CHEMILUMINISCENCE - <3.0 ng mL
PSA-TOTAL CHEMILUMINISCENCE - <4 ng /mL
PSA-FREE CHEMILUMINISCENCE - 0.015-50 ng / mL
OTHERS

Dtibc CHEMILUMINISCENCE 141 261-497 ug/dL

TROPONIN I CHEMILUMINISCENCE - 0.120ng/mL
COMPLEMENT C3 CHEMILUMINISCENCE - 40-380 mg/’dL
 HEMATOLOGY REPORT I
02/09/2023

Para Result Unit Ref. ranges Para. Result Unit Ref. Ranges
WBC 6.11 10^9/L 4.00-10.00 MCH 21.0 pg 27.0-34.0
Neu% 71.0% 50.0-70.0 MCHC 31.7 g/Dl 32.0-36.0
Lym% 17.6% 20.0-40.0 PLT 86 10^9/L 150-450
Mon% 5.6% 3.0-12.0 RDW-CV 22.9% 11.0-16.0
Eos% 5.1% 0.5-5.0 RDW-SD 55.9Fl 35.0-56.0
Bas% 0.7% 0.0-1.0 MPV 9.1Fl 6.5-12.0
RBC 2.52 10^12/L 3.50-5.00 PDW 14.2 15.0-17.0
HGB 5.3 g/dL 11.0-15.0 PCT 0.078% 0.108-0.282
HCT 16.7% 37.0-47.0 NRBC% 0.59% 0.00-9999.99
MCV 66.2 fL 80.0-100.0

CLINICAL CHEMISTRY REPORT 02/09/2023

HEMOLYSIS (H) : <15 ICTERUS (I) : 2 TURBIDITY

(T) : <20

ASSAY RESULT HIT RANGES

Potassium 4.71 mmol/L 3.50-5.10

Creatinine HI 936.1 umol/L 46.0-92.0

Urea Nitrogen HI 62.6 mg/Dl 7.0-17.0

Calcium LO 1.95 mmol/L 2.10-2.55

02/13/2023

HEMOLYSIS (H) : <24 ICTERUS (I) : 2 TURBIDITY

(T) : <20

ASSAY RESULT HIT RANGES

Potassium 4.55 mmol/L 3.50-5.10

Sodium LO 133.1 umol/L 135.0-145.0

Creatinine HI 973.8 umol/L 46.0-92.0

Urea nitrogen HI 76.4mg/Dl 7.0-17.0

02/14/2023

Para Result Unit Ref. ranges Para. Result Unit Ref. Ranges
WBC 6.01 10^9/L 4.00-10.00 MCH 21.1 pg 27.0-34.0
Neu% 75.5% 50.0-70.0 MCHC 31.3 g/dL 32.0-36.0
Lym% 11.3% 20.0-40.0 PLT 151 10^9/L 150-450
Mon% 7.4% 3.0-12.0 RDW-CV 21.6% 11.0-16.0
Eos% 5.1% 0.5-5.0 RDW-SD 54.1 fL 35.0-56.0
Bas% 0.7% 0.0-1.0 MPV 9.7 fL 6.5-12.0
RBC 3.10 10^12/L 3.50-5.00 PDW 14.6 15.0-17.0
HGB 6.6g/dL 11.0-15.0 PCT 0.124% 0.108-0.282
HCT 20.9% 37.0-47.0 NRBC% 0.00% 0.00-9999.99
MCV 67.5 fT 80.0-100.0

HEMATOLOGY REPORT I 02/15/2023

Para Result Unit Ref. ranges Para. Result Unit Ref. Ranges
WBC 5.85 4.00-10.00 MCH 22.8 pg 27.0-34.0
Neu% 70.4% 50.0-70.0 MCHC 31.6 g/dL 32.0-36.0
Lym% 15.0% 20.0-40.0 PLT 139 10^9/L 150-450
Mon% 7.9% 3.0-12.0 RDW-CV 23.9% 11.0-16.0
Eos% 5.8% 0.5-5.0 RDW-SD 64.6 fL 35.0-56.0
Bas% 0.9% 0.0-1.0 MPV 9.6 fL 6.5-12.0
RBC 3.99 10^12/L 3.50-5.00 PDW 14.6 15.0-17.0
HGB 9.1g/dL 11.0-15.0 PCT 0.125% 0.108-0.282
HCT 28.8% 37.0-47.0 NRBC% 0.00% 0.00-9999.99
MCV 72.3 fT 80.0-100.0

Anatomy and Physiology:

A kidney contains over 1 million functioning units called nephrons. Each nephron is composed
of a glomerulus and tubule. The glomerulus acts to filter the blood free of cells and large
proteins, producing an ultrafiltrate composed of the other smaller circulating elements. The
ultrafiltrate enters the tubule, which is highly specialized at various segments, to produce the
final urine by removing substances from the tubular fluid (reabsorption) or adding substances to
the tubular fluid (secretion). Filtration, reabsorption, and secretion keep the organism in balance
in terms of water, minerals, electrolytes, and hydrogen ion concentration and eliminate the toxic
substances produced by the body. The major known hormonal functions of the kidney influence
blood pressure, calcium metabolism, and red blood cell production.

The main functions of kidneys are Excretion of wastes- kidneys excrete urea and uric acid into
the urine, which are products of metabolism. Reabsorption of vital nutrients, which includes:
glucose (at normal plasma level), amino acids, water, sodium, chloride, potassium, magnesium,
calcium, bicarbonate and phosphate.
Kidneys work to remove waste products from the body, remove drugs from the body, balance the
body's fluids, release hormones that regulate blood pressure, produce an active form of vitamin D
that promotes strong, healthy bones, control the production of red blood cells.
The kidneys are located on either side of the spine, in the retroperitoneal space. The left kidney is situated a
little higher than the right one, because of the liver on the right side of the abdominal cavity, above the right
kidney.

PATHO: PATIENT

NURSING CARE PLAN

ASSESSMEN DIAGNOS PLANNING INTERVENTION RATIONALE EVALUATION

T IS
Goal met

Subjective: -ineffective -after 3 days -Auscultate breath -To check for the -After 3 days of
airway of nursing sounds and assess presence of nursing
“Nahihirapan
clearance as intervention airway pattern adventitious intervention the
ako
a the patient breath sound patient was able
huminga”as
manifested will to demonstrate
verbalized by
by demonstrate behaviors to
the patient.
difficulty of behaviors to improved airway
-Changes in the
breathing. improve Monitor V/S clearance
vital sign will
airway
show the client
-Administered -Demonstrate
Objective: clearance
progress
salbutamol +IPRA behaviours of
-shortness of nebulization improved airway
-To prevent
breath Q30mins then clearance
irritation of
Q6hours
bronchial walls
-dyspnea

-Instructed SO to do
-To increase
chest physiotheraphy
oxygen of the
after every
patient
nebulization

-Assisted patient to
position of comfort.

- keep environment
 free of allergen, such
as dust, smoke,
powder

-Administer oxygen
as needed

ASSESSMEN DIAG PLANNING INTERVENTION RATIONALE EVALUATION

T NOSI
S
Subjective:”hi - - following a 1 -Assess sleep pattern -High percentage -After a 1 days of
ndi ako sleepi day of nursing disturbances that are of sleep nursing
makatulog ng intervention the associated with disturbances can intervention the
kagabi kase distur patient will environment like affect the recovery patient was able
nahihirapan bance achieve optimal putting light off or of the patient. to display
akong amount of sleep dim light. improvement in
-To determine
huminga”as as evidenced by: sleeping pattern
usual sleeping
verbalized by as evidenced by:
pattern and to
the patient.
compare if there -The patient
Objective
are any verbalized:
improvements on “Medyo
-verbalized of
Objective:
the sleeping pattern nakatulog na ako
feeling rested
of the patient. ng maayos
Presence of eye
kumpara dati”
bags

-decreased the
- Relaxant
presence of eye
-The patient does
Weakness bag
not look weak and
Restlessness
restlessness
Irritability compare to the
past
-Administered
diazepam tablet once -The presence of
a day at bedtime eye bags have
-To avoid
been minimized
disturbances during
or have gone
sleep, and also to
-Observe and obtain
maximize the sleep
feedbacks regarding
and rest of the
on the usual sleeping
client
pattern ,bedtime
 routine and the usual
number of hours of
sleep and rest.

-Do as much care as

possible without
waking up the client
and do as much care
as possible while the
client is still awake.

ASSESSMEN DIAGNOSI PLANNIN INTERVENTIO RATIONAL EVALUATIO

T S G N E N
SUBJECTIV Deficient After the - Demonstrate Knowledge After the
E: knowledge nursing health teachings of how to nursing
 related to intervention as appropriate. handle care intervention,
“Hindi ko po
lack of the patient can save
alam gagawin Goal partially
information will time.
ko pag met as
and verbalize
-Assess the
inaatake ako evidenced by
education understandin
client’s
ng asthma” as response of the
about g of
knowledge of -Identifying
verbalized by patient to
asthma as condition
asthma triggers the asthma
patient learning plan
evidenced disease
and asthma triggers will
and actions
by frequent process and
medication. make the
performed.
questioning treatment
client know
how to
control them.
OBJECTIVE:

Inaccurate -Instruct the

follow-through client how to
-
of instruction avoid asthma
Environment
or performance triggers.
al trigger
on test or
control can
procedures
lessen the
frequency of
asthma
attacks.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective After 7 hours Independent; -to have -after 7 hours
The patient Tissue of nursing
baseline data of nursing
verbalized, Perfusion intervention:
-monitor and
“Nanghihina related to The patient intervention
po ang buong anemia will not record vital -restricted
there was an
katawan ko” demonstrate
Objective: restlessness improvement
Hgb- 6.6 gldl Long term sign specially activity
on the patient
Capillary goal: Hgb
blood reduces
refill- >3 levels will condition as
seconds BP- return to saturation. oxygen
evidenced by;
140/80 Use of normal level
demands of
accessory Normal
-maintain bed
muscles when capillary refill the heart and -patient
breathing rest
other organs. verbalized,
Restlessness
”di na ako
Dependent;
-blood
masyadong
transfusion
-administer nanghihina”
increases the
blood
patient blood -improved
component as
volume and breathing.
ordered.
raises the hgb
-gives fluids level.
medicine as
-maintaining
prescribed by
circulating
the doctor
volume
maximizes
tissue
perfusion

DRUG STUDY
DRUG DOS MECHA INDICATION SIDE EFFECT AND NURSING
NAME AGE NISM OF AND ADVERSE EFFECT RESPONSIBI
ACTION CONTRAINDIC LITIES
 ATION
BRAN 500m Replaces Indicated for low -Slowed heart rate,upset -monitor
D g tab calcium calcium stomach,vomiting,belching,c hemodynamic
NAME: in condition such onstipation,dry s,it may
1 tab deficienc as mouth,increased urination causes hypo
Calcium 3x a y states osteoporosis,oste and loss of appetite tension,brady
Carbona day omalacia ,hypoth cardia and
te -Acts by yroidism and arrhythmia.
neutralizi kidney
ng dysfunction. -check if right
hydrochl mediation and
oric acid dose
BRAN gastric
D secretion. Contraindication - do not
NAME : administer
: oral drugs
-hypersensitivity within 1-3hr
High calcium of antacid
levels in the administration
CALTR
ATE urine - give calcium
Kidney stones carbonate
(renal calculi) antacid 1 and
3 hr after
Low phosphate meals and at
levels bedtime

High calcium =warning

level avoid
extravasation
Suspected
digoxin toxicity

DRUG DOSAGE MECHA INDICATION SIDE EFFECTS AND NURSING

NAME , ROUTE NISM OF AND ADVERSE EFFECT RESPONSIBI
 & ACTION CONTRAINDIC LITIES
FREQUE ATION
NCY

FEROUS 35mg tab - provides Indication: -nausea,epigastric -assess

SULFAT element pain,vomiting,constip nutritional
E 1 tab 3 x a iron,an - Prevention and ation,black status, bowel
day essential treatment of iron stools,diarrhea and function
componen deficiency anorexia.
t in the anemias -monitor
BRAND hemoglobin,
NAME: formation -dietary
of hematocrit,
supplement for iron levels.
FERRIC hemoglob iron.
ORR in. Instruct patient
not to crush or
Contraindication chew extended
: release forms

-hypersensitivity Advise patient

to report
-severe constipation
hypertension and changes in
stool or
consistency.

DRUG DOSAGE, MECHANI INDICATION SIDE NURSING

NAME ROUTE & SM OF AND EFFECT RESPONSIBILI
FREQUEN ACTION CONTRAINDICA S AND TIES
CY TION ADVER
SE
EFFECT

BETAHISTI 16mg/tab - Act as Indication: Skin rash -drug should be

NE both partial that may taken with food
1tab every histamine - reduction of include
BRAND 8hours as H1 receptor recurrent vertigo itchy,red -advise relatives
NAME: needed for agonist and episodes associated swollen to support
SERC dizziness H3 receptor with Meniere’s blistered patient’s
antagonist disease . or ambulation
in neuronal peeling
 tissue. skin -protect
medication from
- moisture.
headache

DRUG DOSAGE, MECHANI INDICATION SIDE NURSING

NAME ROUTE & SM OF AND EFFECT RESPONSIBILI
FREQUEN ACTION CONTRAINDICA S and TIES
CY TION ADVER
SE
EFFECT

Generic 50mg - cough It is used for the -assess cough

name: suppressant treatment of dry type and
1 tab 3x a and is [Link] cough is -nausea frequency.
BUTAMIRA day commonly a typical symptom
TE - -monitor the
-intervals 8 available in the common viral drowsine
CITRATE over the infection of the adverse reaction.
or 12 hours. ss
counter. upper airways are -assess patient
the most common -dry vital signs.
Brand name: -it is also cause of acute mouth
works by cough. -instruct patient
SINECOD lessening vertigo to cough
FORTE the airway -contraindicated to effectively, sit
resistance. hypersensitivity to upright and take
drug. several deep
breaths before
attempting

-advice patient to
minimize cough
to prevent
irritants

-caution patient
to avoid any
activities
requiring
alertness until
response to
medication is
 known.

DRUG DOSAGE, MECHANI INDICATION SIDE NURSING

NAME ROUTE & SM OF AND EFFECTS RESPONSIBILI
FREQUEN ACTION CONTRAINDICAT TIES
CY ION And
ADVERSE
EFFECT

Sodium 22mEq/L -Improves Indicated in the Sodium -monitor vital

bicarbon the renal treatment of mediated signs,laboratory
ate function of metabolic retention result and level of
patients. acidosis,which may resulting in consciousness
occur in several weight frequently.
-oral renal gain,periphe
sodium disease,uncontrolled ral -watch out for the
bicarbonate diabetes. edema,eleva signs of
is more ted blood decreasing level
likely to Contraindicated to pressure and of consciousness.
correct acid- patient with even heart
base -record intake
failure.
disturbance. -hypersensitivity and output
accurately to
monitor renal
function.

-used to
alkalinize urine
and promote
excretion of
certain drugs in
over dosage
situation.
DRUG DOSAGE MECHAN INDICATION SIDE EFFECTS AND NURSING
NAME , ROUTE ISM OF AND ADVERSE EFFECT RESPONSIBI
& ACTION CONTRAINDIC LITIES
FREQUE ATION
NCY

CALCIFES 600mg -acts by -supplement to -an irregular - assessment

APH directly prevent heartbeat,weakness,dro and drug
1 tab 3x a increasing osteoporosis, wsiness& headache effects
day calcium osteoarthritis and
stores osteomalacia. -dry mouth and muscle -advise patient
within the or bone pain. to take these
BRAND body. supplement
NAME; with food.
-It is
NELPA contraindicated
to patient with
hypersensitivity
to any
component of the
formulation.

Name of Dosage MEHANI INDICATION ADVERSE NURSING

drug and SM OF CONTRAINDICAT EFFECT RESPONSIBILI
frequen ACTION IONS TIES
cy
AMLODIPI 10mg Inhibits Lower blood pressure Hightheaded Monitor patients
NE Tab Calcium ness swelling BP very
Done with other
ion influx ankles/feet carefully,if
1 tab agents in the
across cell or flushing patients is also on
once a management of
membrane may occur. nitrates,
day hypertension angina
with a
pectoralis and Monitor rhythm
greater
8AM
vasospastic angina. regularly during
affection
stabilization of
vascular
 smooth
dosage and
muscle
periodically
cell.
during long term
therapy.

DISCHARGE PLANNING

PATIENT: Patient RR

AGE: 59

SEX: F

DATE OF ADMISSION: February 13, 2023

DATE OF DISCHARGE:

DIAGNOSIS: ANEMIA PROBABLY SECONDARY TO CHRONIC KIDNEY DISEASE V

SECONDARY TO HYPERTENSIVE NEPHROSCLEROSIS

A. OBJECTIVES

1. Understand the disease process and their therapeutic regimen to promote proper knowledge of
long term management.

2. Promote self care and family member’s engagement to client treatment.

3. Modify lifestyle patterns to prevent or minimize complication.

4. Strengthen coping mechanism based upon client belief and values.

B. HOME MANAGEMENT

METHODS RATIONALE

HEALTH TEACHING

Explain to the patient the about her These will help the patients knowledge
condition. about her condition and for her to avoid
what is forbidden to her.

HYGIENE

Encourage her to maintain proper To protect her self from getting any
hygiene . infectious diseases.

DIET

Renal Diet To keep the levels of electrolytes,

minerals, and fluid in the body balanced
when you have CKD or are on dialysis.

SPIRTUAL CARE

Encourage patient to have faith and Prayer can bring a sense of a spiritual,
always pray to God. loving presence and alignment with God.

OUT PATIENT

Instruct the patient to visit her doctor for Prayer can bring a sense of a spiritual,
follow up check-up at given time. loving presence and alignment with God.