Professional Documents
Culture Documents
In Partial Fulfillment
NCM 106
PRESENTED BY:
BATCH 2018
Almario, Michelle I.
Dottie, Sophia
October, 2017
TABLE OF CONTENTS
I. Introduction
II. Objectives
V. Gordons
X. Pathophysiology
XVI. References
INTRODUCTION
This is a case study of patient M.A.V, 59 years old, female, who lives in BF
Resort Las Pias and born in South Africa on December 16, 1957. She was
admitted at University of Perpetual Help Medical Center Las Pias City with a chief
complaint of difficulty of breathing on June 19, 2017 at 3:43 AM. The admitting
Acute Renal Failure (ARF) is a condition in which the kidneys are unable to
electrolyte, and acid-base balance. It has an abrupt onset and with prompt
Acute Renal Failure has four defined stages phases: onset, oliguric or
anuric, diuretic and recovery phase. Treatment depends on stage and severity of
renal compromise. Phases of ARF: onset, initial phase of insult or injury. Oliguric,
less than 400cc/day. For older 600-700cc/day, lasts 8-14 days or 1-2 weeks,
days, diuresis of 3-5L/day, increase BUN & Creatinine level, dangers: FVD,
nephrotoxic drugs. ARF can be divided into three classifications depending on site:
(GFR). Disorder treat lead prerenal failure include cardiogenic shock, heart failure
(RF), myocardial infarction (MI), burns, trauma, hemorrhage, septic or anaphylactic
shock and renal artery obstruction. Renal or intrarenal causes for renal failure are
substances. Acute tubular necrosis (ATN) creates for 90% of cases of acute
perfusion similar to prerenal hypo perfusion aspect that correction of the causative
damage from nephrotoxins. Post renal failure occurs as the result of an obstruction
in the urinary tract anywhere from the tubules to the urethral meatus. Obstruction
most commonly occurs with stores in the ureters, bladder or urethra; however,
the hospitalization discharge diagnose for kidney disease 2005-2015, the rate of
hospitalization for kidney disease increased, particularly among adults age >60
disease. Overall incidence among hospitalized patients ranges from 13% to 22%.
The overall incidence of ARF in the ICU is higher at 20% to 50% and is associated
with mortality over 50% prediction scores have been developed for outcomes of
ARF, but have variable causes up to 7& of inpatient cases of ARF require renal
replacement therapy. In ICU mortality rate exceeds 50% in case multiorgan failure.
Minor rises in creatinine (> 0.3 mg/dl) are associated with an increased risk of
hospital mortality, an increased risk of chronic kidney disease and higher rates of
progressing to 2ns stage renal failure. The mortality of this condition remains high
(possibly as 80% in intensive care settings). Death often results from complications
The students chose this case study primarily because of interest to gain
further understanding regarding the disease condition. This will also help
approaches for the treatment of acute renal failure. To give us also an idea
on how we could give proper nursing care to our clients with this condition,
and so that we could apply them on our future exposures as student nurses
B. Objectives
2. What system, organ or part of the body are affected by the disease
process?
3. Where and how the illness was obtained, how it progressed and affected
the body?
Gender : Female
Race/Nationality : Filipino
Occupation : Housewife
medications. She was diagnosed with CKD 1 year prior to admission. Patient
The patient was apparently well when few minutes prior to admission. She
was found vomiting by her relatives. This was associated with difficulty of breathing
and headache. Patient was rushed to the ER. Upon arrival in the ER the patient
July 6, 2017 at 11 AM
July 6, 2017 at 9 AM
GENERAL APPEARANCE
SKIN
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Color Inspection Fair Light brown to Normal
complexion brown
Symmetry of Inspection Purplish Symmetrical Presence of
color discoloration hematoma/
in other parts bruise
of the body.
Edema Inspection Present Absent In hands and
arms
NAILS
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Nail Curvature Inspection Long nails, Convex 160o Normal
convex 160 o
Texture Inspection Firm Firm Normal
Nail bed color Inspection Pale Pinkish Due to
kidney
disorder
Capillary refill Palpation Prolonged Less than 4 Due to
capillary refill seconds decreased
peripheral
perfusion
HEAD
Area Assessed Technique Actual Normal Analysis
Used Findings Findings
Hair Distribution Inspection Evenly Evenly Normal
distributed distributed
Hair Thickness Inspection Thick Thick or Thin Normal
With external
ventricular drain
Texture & Palpation Kinky hair Silky at the right side
Oiliness of her head,
washing her
hair as part of
morning care is
not done.
Infestations Inspection None None Normal
Body Hair Inspection None None Normal
Facial Inspection No Facial Symmetrical Comatose with
Movements movements GCS of 3
EYES
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Eyebrows Inspection Evenly Evenly Normal
distributed distributed
Eyelashes Inspection Evenly Equally Normal
distributed distributed
Eyelids Inspection Intact skin, Intact skin and Normal
bilateral bilateral
blinking blinking
Conjunctiva Inspection Pale Pinkish Due to
Heart
Failure
Lacrimal Palpation Watery/ Teary No tenderness With
Gland eyes blockage in
tear duct or
Epiphora
Cornea Inspection Clear Clear Normal
Black, Equal in
size, Pupils are
Pupils Inspection Sluggish pupil equally round Due to
and reactive to increased
light and ICP
accommodatio
n. (PERRLA)
EARS
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Pinna Inspection Uniform in Uniform color Normal
color, with skin, and
symmetrical symmetrical
Ear canal Inspection Presence of Presence of Normal
cerumen/earw serumen/earwax
ax
Hearing Inspection Unresponsive Responds when Comatose
Acuity called patient with
GCS of 3
NOSE
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
External Nose Inspection With Symmetrical NGT noted
Contraptions at the left
nostril
Nasal Cavity Inspection With Dark pink, dry, NGT noted
Contraptions free of at the left
exudates nostril
Sinus Palpation With No tenderness NGT noted
Tenderness Contraptions at the left
nostril
Nasal Mucosa Inspection With Intact and NGT noted
Contraptions midline at the left
nostril
PHARYNX
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Uvula Inspection With In midline With
Contraptions Endotracheal
tube hooked
on MV with
set up of
__________
__
Oropharynx Inspection With Pinkish With
Contraptions Endotracheal
tube hooked
on MV with
set up of
__________
__
Gag reflex w/ the use of With Intact With
tongue Contraptions Endotracheal
depressor tube hooked
on MV with
set up of
__________
__
MOUTH
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Lips Inspection With sore, Symmetrical Due
wound Endotracheal
tube
Gums Inspection Pinkish, Pink, moist, With
moist, firm, firm, and Endotracheal
intact intact tube and
during oral
care I cannot
open her
mouth
thoroughly.
Tongue Inspection Midline and Midline, With
movable pinkish and Endotracheal
movable Tube
Palate Inspection Light pink, Light pink With
intact intact Endotracheal
Tube
NECK
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Muscles Palpation Symmetrical Symmetrical Normal
Movement Inspection Limited Coordinated Comatose with
GCS of 3 and
with ETT
Range of Inspection Limited Full Comatose with
Motion GCS of 3 and
with ETT
Muscles Inspection Limited Equal Comatose with
Strength GCS of 3 and
with ETT
Lymph nodes Palpation Palpable Not palpable Presence of
infection
HEART
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Rhythm Auscultation Irregular Regular Due to Heart
Failure
Heart Sounds Auscultation Presence of S1 louder at Due to Heart
S3 or third apex, S2 Failure
heart sound louder at base
ABDOMEN
Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Skin Integrity Inspection Dry skin Skin color is Due to ARF
uniform , no
lesions
Contour Inspection Distended Flat/Rounded Oliguric or
hypouresis
High pitched, High Pitched,
Bowel Auscultation irregular irregular Normal
Sounds gurgles, 5-35 gurgles, 5-35
times/min in times/min in all
all quadrants quadrants
Palpation Palpation Tender No tenderness Due to
urinary stasis
LABORATORY STUDY
Complete Blood Count It is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with fluid
volume (such as dehydration) or loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It
can reflect acute or chronic infection, allergies and problem with clotting.
https://www.nid
dk.nih.gov/heal
th-
information/kid
ney-
disease/chronic
-kidney-
disease-
ckd/anemia
A type of
E phagocyte
O that
S produces
I the anti-
N inflammato 0.00- 0.01 0.01 0.01 0.02 0.02 0.01 0.01 0.01 0.01 Normal
O ry protein 0.05 (N) (N) (N) (N) (N) (N) (N) (N) (N)
P histamine.
H Used to
I diagnose
L allergy,
S drug
reactions,
and
parasitic
infections.
Interpretation:
Sinus rhythm
Left Atrial Enlargement
Left Ventricular Hypertrophy
ST T wave Abnormality secondary to strain and / or ischemia
Specimen: Serum
06-19-17 07-06-17
(www.medicinenet.com)
(www.Medlineplus.gov)
(http://wap.kidneyfailureweb.com/
view.php?aid=326)
(labtestsonline.org)
Hyperuricemia can be
caused by producing too
much uric acid in the body.
Or if the kidneys are not
able to remove it from the
blood normally, the level
acid in the blood increases.
(labtestsonline.org)
www.webmd.com
July 6, 2017
(labtestsonline.org)
Specimen: Blood
06-19-17 07-04-17
Brain Plain
June 26, 2017
Clinical date: Follow - up, no neurologic improvement / deterioration
Comparison: Non-contrast cranial CT scan dated June 19, 2017
Technique: multiplanar CT scan of the Brain without IV contrast
Findings:
The previously noted right cerebellar hemorrhage increased in volume, now at 7.11 co
(previously 3.5cc)
There is interval resolution of the ventricular dilatation. A ventricolostomy tube is now seen
with tip at the right frontal skull
Impression:
Interval increase in the volume of the acute.
Brain Plain
July 4, 2017
There is no significant interval change in the size of the previously noted right cerebellar
hemorrhage.
Minimal perisimal edema is again seen. The dilated 4th ventricle remains mildly compressed
in its right side. It still appears to slightly compress/indent the right of the pons.
There is also no significant change in the intraventricular hemorrhage with residual blood in
the occipital horns.
The ventricles remain mildly symmetrical dilated. Ventriculostomy tube is again seen with tip
at the right lateral ventricle. Accompanying craniotomy defect at the right frontal bone is also
again seen.
There is also no appreciable change in the adjacent hypodensities along the tube tract.
Opacities are again seen in the frontal, ethmoid, sphenoid, and maxillary sinuses sligycitive of
sinus mucosal disease.
http://www.mayoclinic.org/
symptoms/low-
potassium/basics/causes/sy
m-20050632
PROTHROMBIN TIME
Control 13.20 Seconds
Test 15:30 Seconds
1HR 1.12
Activity 77.20%
Followed up since 6/20/2017 shows interval resolution of the pleural effusion on the right
Heart is magnified
Atheromatous aorta is again noted
Left hemi diaphragm and castropheric sulcus are still poorly defined
EDT tip at T3 - T4 level
ISV Catheter tip at the level of right atrium
NGT, Sternotomy wires and vascular clips are again seen
Rate- Atrial: PR: 0.10 Sec QRS: 0.08 sec Axis 35 deg
100bpm
Ventricular: 100bpm QTA: 0.36Sec AT
URINALYSIS
http://healthylifemed.com/turbid-urine/
https://medlineplus.gov/ency/article/003
582.htm
ELECTROENCEPHALOGRAPHY REPORT
July 3, 2017
History: Right cerebellar hemorrhage, with draining tube on the right; ARF sec to CKD; HF,
HCVD, T2 DM-MR; s/p CABG 2011
EEG Findings:
This is 21-channel digital EEG recording performed the standard international 10-20
systems. The patient has a Glasgow Coma Scale score of 6/15. duration of the recording was
1 hour.
Activation procedure: Photic stimulation (5-25 Hz) did not elicit any abnormal responses.
Hyperventilation was not performed.
Nonepileptiform abnormalities: None
Epileptiform abnormalities: No epileptiform discharges were seen. No EEG seizures were
recorded.
Interpretation:
This is an abnormal EEG recording due to findings supportive of a moderate, diffuse
encephalopathy of non-specific etiology. No electrographic seizures were recorded.
CLINICAL FINDINGS
blood pressure (BP)- 138/68 mmHg, Pulse rate - 72 beats per minute, Respiratory rate of 29
cycle per minute, Temperature of 37.9 degree Celsius and with oxygen saturation of 100%.
Patient is with NGT noted at the left side of the nostril, with ventricolostomy tube seen at the
right frontal skull and with a mechanical ventilator with a set-up of Tidal Volume (volume of
gas delivered during each ventilator breath) 400, FIO2 (Fractional Inspired Oxygen, amountof
oxygen delivered by ventilator to patient) 35%, I:E ratio (length of inspiration compared to
The CBC (Complete Blood Count) on June 29, 2017 , the result of Red blood cells,
haematocrit and haemoglobin are low maybe due to the kidneys are diseased or damaged.
produced by the body and released into the blood to help trigger or regulate particular body
functions. EPO prompts the bone marrow to make red blood cells, which then RBCs circulate
in the blood and carry oxygen throughout the body. So, when kidneys are damaged they do not
make enough erythropoietin (EPO). As a result, the bone marrow makes fewer red blood cells.
Other common causes of anemia in people with kidney disease include blood loss from
haemodialysis. Patient had dialysis every Tuesday, Thursday and Saturday. For the White
Blood Cells and Segmenters, the results are high and Lymphocytes the result is low thats
maybe because of the infection. The white blood cells are vital components of the blood and
have a very important function in protecting the body from attack. This can be from bacteria,
viruses, or other foreign substances that the body sees as some kind of threat. Their role is to
fight infection, and they are essential for health and well-being. If a person has a high white
blood cell count, it may indicate that they have an infection and that the immune system is
For the urinalysis last June 28, 2017, patients protein is positive 1, thats maybe
because of the kidney disease and diabetes that the patient have. These diseases may cause
elevated levels of protein and resulted also of having a turbid transparency of urine.
The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The
kidneys filter the blood to remove wastes and produce urine. The ureters, urinary bladder, and
urethra together form the urinary tract, which acts as a plumbing system to drain urine from
the kidneys, store it, and then release it during urination. Besides filtering and eliminating
wastes from the body, the urinary system also maintains the homeostasis of water, ions, pH,
Kidneys
The kidneys are a pair of bean-shaped organs found along the posterior wall of the abdominal
cavity. The left kidney is located slightly higher than the right kidney because the right side of
the liver is much larger than the left side. The kidneys, unlike the other organs of the abdominal
cavity, are located posterior to the peritoneum and touch the muscles of the back. The kidneys
are surrounded by a layer of adipose that holds them in place and protects them from physical
damage. The kidneys filter metabolic wastes, excess ions, and chemicals from the blood to
form urine.
Ureters
The ureters are a pair of tubes that carry urine from the kidneys to the urinary bladder. The
ureters are about 10 to 12 inches long and run on the left and right sides of the body parallel to
the vertebral column. Gravity and peristalsis of smooth muscle tissue in the walls of the ureters
move urine toward the urinary bladder. The ends of the ureters extend slightly into the urinary
bladder and are sealed at the point of entry to the bladder by the ureterovesical valves. These
Urinary Bladder
The urinary bladder is a sac-like hollow organ used for the storage of urine. The urinary bladder
is located along the bodys midline at the inferior end of the pelvis. Urine entering the urinary
bladder from the ureters slowly fills the hollow space of the bladder and stretches its elastic
walls. The walls of the bladder allow it to stretch to hold anywhere from 600 to 800 milliliters
of urine.
Urethra
The urethra is the tube through which urine passes from the bladder to the exterior of the body.
The female urethra is around 2 inches long and ends inferior to the clitoris and superior to the
vaginal opening. In males, the urethra is around 8 to 10 inches long and ends at the tip of the
penis. The urethra is also an organ of the male reproductive system as it carries sperm out of
The flow of urine through the urethra is controlled by the internal and external urethral
sphincter muscles. The internal urethral sphincter is made of smooth muscle and opens
involuntarily when the bladder reaches a certain set level of distention. The opening of the
internal sphincter results in the sensation of needing to urinate. The external urethral sphincter
is made of skeletal muscle and may be opened to allow urine to pass through the urethra or
Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important internal conditions by controlling
Ions.
The kidney can control the excretion of potassium, sodium, calcium, magnesium,
phosphate, and chloride ions into urine. In cases where these ions reach a higher than
normal concentration, the kidneys can increase their excretion out of the body to return
them to a normal level. Conversely, the kidneys can conserve these ions when they are
present in lower than normal levels by allowing the ions to be reabsorbed into the blood
pH.
The kidneys monitor and regulate the levels of hydrogen ions (H+) and bicarbonate
ions in the blood to control blood pH. H+ ions are produced as a natural byproduct of
the metabolism of dietary proteins and accumulate in the blood over time. The kidneys
excrete excess H+ ions into urine for elimination from the body. The kidneys also
Osmolarity.
The cells of the body need to grow in an isotonic environment in order to maintain their
fluid and electrolyte balance. The kidneys maintain the bodys osmotic balance by
controlling the amount of water that is filtered out of the blood and excreted into urine.
When a person consumes a large amount of water, the kidneys reduce their reabsorption
of water to allow the excess water to be excreted in urine. This results in the production
of dilute, watery urine. In the case of the body being dehydrated, the kidneys reabsorb
as much water as possible back into the blood to produce highly concentrated urine full
of excreted ions and wastes. The changes in excretion of water are controlled by
Blood Pressure.
The kidneys monitor the bodys blood pressure to help maintain homeostasis. When
blood pressure is elevated, the kidneys can help to reduce blood pressure by reducing
the volume of blood in the body. The kidneys are able to reduce blood volume by
reducing the reabsorption of water into the blood and producing watery, dilute urine.
When blood pressure becomes too low, the kidneys can produce the enzyme renin to
constrict blood vessels and produce concentrated urine, which allows more water to
A. Book Based
The driving forces for glomerular filtration are the pressure gradient from the
glomerulus to the Bowman space. Glomerular pressure is primarily dependent on rural blood
flow (RBL) and is controlled by combined resistance of rural efferent and afferent arterioles.
Regardless of the cause of ARF, productions in RBF represent a common pathologic pathway
Pre-renal failure is brought about by diminished blood flow to the kidneys. GFR is
depressed by compromised renal perfusion. Such decreased flow may result from
hypovolemia, shock, embolism, blood loss, sepsis, pooling of fluid in ascites or burns, and
Intrinsic renal failure results from damage to the kidneys themselves, usually resulting
from acute tubular necrosis. Such damage may also result from acute post streptococcal
disease, bilateral renal vein thrombosis, nephrotoxins, ischemia, renal myeloma and acute
pyelonephritis.
the filtration driving force. This pressure gradient soon equalizes, and maintenance of
depressed GFR is then dependent upon renal afferent vasoconstriction. Post-renal failure is a
bilateral obstruction of urinary out-flow results. Its multiple causes include kidney stones,
blood clots, papillae from papillary necrosis, tumours, benign prostatic hyperplasia, strictures
Patients with chronic renal failure also may present with superimposed ARF from any
Depressed RBF eventually leads to ischemia and cell death. This initial ischemic
triggers production of oxygen free radicals and enzymes that continue to causes cell injury
even after restoration of RBF. Tubular cellular damage results in disruption of tight junctions
between cells, allowing back leak of glomerular filtrate and further depressing effective GRF.
In addition, dying cells slough off into the tubules, forming obstructing casts, which further
Sodium Retention
Increase plasma
Death
COMPLICATIONS TO PATIENT
FLUID BUILD UP
Acute kidney failure lead to a build-up of fluid in your lungs which can cause shortness
of breath.
CHEST PAIN
If the lining that covers your heart (pericardium) becomes inflamed, you may
MUSCLE WEAKNESS
When your bodys fluid and electrolytes- your bodies blood chemistry - are out of
balance, muscle weakness result. Elevated levels of potassium in your blood are
particularly dangerous.
Occasionally, acute kidney failure causes permanent loss of kidney reaction, or end-
stage renal disease. People with end-stage renal disease repair either permanent
dialysis- a mechanical filtration used to remove toxins and wastes from the body- or a
HYPERKALEMIA
Serum K rises by 0.5 mmol/L per day is oliguric and anuric patients due to impaired
ANEMIA
cell survival time. Infection. Cardio pulmonary complication and uremic syndrome.
DEATH
Acute kidney failure can lead to loss of kidney function and ultimately, death. The risk
Prevention:
No specific therapy for ischemic or nephrotic ARF except preventing the etiologic
factors.
Specific Therapies:
PRERENAL
Cardiac failure needs aggressive management with positive 10 isotopes , preload and
ANP Therapy; low dose dopamine; loop diuretic; calcium channel blockers; alpha
SUPPORTIVE MEASURES
Medication
Advised the patient to take medication at home as prescribed. The patient and
relatives must make sure that they fully understand the importance of taking the
medication.
Instructed the patient on how the prescribed drug will be taken including the right
Exercise
Treatment
complete healing
Health Teaching
Bed rest
Maintaining proper personal hygiene
Outpatient
coming back with the outpatient department one week after discharge
Reminded the patient that frequent check-ups are important to improve patients
further complications
Instructed patient to notify physician if there is any undesired feeling about disease
Diet
Spiritual Counselling
Instructed patient to continue believing in God and she should always remember that
https://www.scribd.com/document/97582/Acute_Renal_Failure
https://www.scribd.com/doc/19097977/NCB_Ineffective_Airway_Clearance
https://www.scribd.com/doc/23169793/Acute_Renal_Failure_ppt
www.webmd.boots.com/9_tom_guides/polycythermia
www.google.com.ph
www.scribd.com/doc/65247625/FeSo4
www.webmd.com/drugs
www.scribd.com/doc/34356938/Acute_Renal_Failure
www.document/179135318/fever_nursing_care_plan