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A Case Study for a Patient with Acute Renal Failure

In Partial Fulfillment

of the Requirement for the Course

NCM 106

PRESENTED BY:

BSN IV-A GROUP 1

BATCH 2018

Almario, Michelle I.

Aragon, John Cedric

Dalusag, Raven Samantha M.

Decena, Kimberly Jo-Ann

Diocareza, Angelica Jane V.

Dottie, Sophia

October, 2017
TABLE OF CONTENTS

I. Introduction

II. Objectives

III. Patients Profile

IV. History of Present Illness

V. Gordons

VI. Physical Assessment

VII. Laboratory Study

VIII. Clinical Findings

IX. Anatomy & Physiology

X. Pathophysiology

XI. Complication & Treatments

XII. Problem Prioritization

XIII. Nursing Care Plan

XIV. Drug Study

XV. Discharge Planning

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

diagnosis is ARF I PROB 2 CKD HF HCVD T2DM S/P CABG (2011).

Acute Renal Failure (ARF) is a condition in which the kidneys are unable to

remove accumulated metabolites from the blood, leading to altered fluid,

electrolyte, and acid-base balance. It has an abrupt onset and with prompt

intervention is often reversible.

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,

decrease Potassium, increase sodium, decrease magnesium. Diuretic, last 10

days, diuresis of 3-5L/day, increase BUN & Creatinine level, dangers: FVD,

hyponatremia, hypotension, shock. Recovery, lasts from 6-12 months, avoid

nephrotoxic drugs. ARF can be divided into three classifications depending on site:

Prerenal is caused by interference with renal perfusion (e.g., blood volume

depletion, volume shifts [third-space sequestration of fluid], or excessive /too

rapid volume expansion), manifested by decreased glomerular filtration rate

(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

associated with parenchymal changes caused by ischemic or nephrotoxic

substances. Acute tubular necrosis (ATN) creates for 90% of cases of acute

oliguria. Destruction of tubular epithelial cells results from (1) ischemia/hypo

perfusion similar to prerenal hypo perfusion aspect that correction of the causative

factor may be followed by continued oliguria up to 30 days) and/or (2) direct

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,

trauma, edema associated with infection, prostate, enlargement and structures

that cause post-renal failure.

The reported incidences of AKI vary and are cofounded by differences in

diagnosis, definition criteria or hospital discharge coding. In the United States, in

the hospitalization discharge diagnose for kidney disease 2005-2015, the rate of

hospitalization for kidney disease increased, particularly among adults age >60

years, & primarily because of hospitalizations with diagnosis of acute kidney

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

such as infection or gastrointestinal bleeding.


OBJECTIVES

A. Importance of the Case Study

The students chose this case study primarily because of interest to gain

further understanding regarding the disease condition. This will also help

in providing current and accurate information concerning the latest

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

and eventually as nurses.

B. Objectives

This also specifically attempts to answer the following questions:

1. What is Acute Renal Failure?

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?

4. What are the possible complications of Acute Renal Failure?

5. What interventions are needed to manage such condition?


PATIENTS PROFILE

Clients Name or Initials : M.A.V

Age : 59 Years Old

Birthdate and Place : December 16, 1957 / South Africa

Gender : Female

Address : BF Resort Las Pias City

Civil Status : Married

Religion : Born Again Christian

Race/Nationality : Filipino

Occupation : Housewife

Chief Complaint : Difficulty of Breathing

Attending Physician : Dr. E.F

Admitting Date and Time : June 19, 2017 at 3:43 AM

Admitting Diagnosis : ARF I PROB 2 CKD HF HCVD

T2DM S/P CABG (2011)


HISTORY OF PRESENT ILLNESS

The patient is known Hypertensive and Diabetic with poor compliance to

medications. She was diagnosed with CKD 1 year prior to admission. Patient

previously advised AVF for HD but refused.

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

was noted to have an O2 sat of 80% and was intubated.


GORDONS FUNCTIONAL PATTERN OF ASSESSMENT

July 6, 2017 at 11 AM

FUCTIONAL PATTERN BEFORE/DURING


Chief complaint or reason for visit Difficulty of breathing
Childhood illness According to the significant others, they
cannot remember their mother telling them
about her childhood illness.
Childhood immunization Significant others stated that as far as they
knew, their mother has complete
immunization.
History of allergies According to the significant others, their
mother doesnt have any allergies to foods,
medications, or dust.
Accidents and injuries According to the significant others, the patient
had no history of accident or injury.
History of hospitalization The significant others stated that when their
mother give birth to their youngest brother
she almost died due to bleeding. She was
also hospitalized to undergo CABGS last
2011.
Medications Significant others stated that patient have
maintenance but she is not compliance.
Every time she was told to take her
medications, she got mad and said that she
knows what she is doing.
Family history of illness According to the significant others, they do
not remember her mother telling them about
their families illnesses, and the family lives in
South Africa.
Health perception and health For the significant others perception, they
management pattern knew that their mother know about her health
issues but despite of that she is not
compliance with the medication.
Nutritional metabolic pattern Before Hospitalization
Prior to admission, the significant others
said that their mother eat regularly, thats
why they did not expect that her illness is
already severe.
During Hospitalization
The patient is on osterized feeding
through NGT noted at left of nostril.

DIET: Diabetic of 1800 kcal/day divide to 6


equal feeding (EF) at 150 cc every 4 hours
with pre and post flushing.

Elimination pattern Before Hospitalization


According to the significant others, their
mothers elimination pattern is regular as
what they knew, because their mother
doesnt tell them any problem about it.
During Hospitalization
During hospitalization, the patient
elimination pattern is not normal; produces
urine 20 or less cc/hour and on our last
duty on July 7, 2017, no more urine
produced for several hours.
Activity exercise pattern Before Hospitalization
According to the significant others, she
is not fond of exercising. Her household
chores serves as her exercise regimen.
She is fond of watching Korean drama.
She has a collection of CDs of Korean
dramas.
During Hospitalization
The patient is comatose with GCS of 3.
Sleep rest pattern Before Hospitalization
According to the significant others, they
were not able to monitor their mothers
sleep pattern (what time she sleeps and
what time she wakes up because they are
working).
During Hospitalization
The patient is comatose with GCS of 3.
Cognitive /perceptual pattern Before Hospitalization
According to the significant others, they
did not see anything wrong about her. She
has a strong sense of sight, smell and
hearing. The patient had also a very good
memory according to them.
During Hospitalization
The patient is comatose with GCS of 3.
Self-conception and self-concept During Hospitalization
pattern Patient is comatose with GCS of 3.

Role-relationship pattern Before Hospitalization


The significant others said that their
mother is a responsible and a loving
mother and wife. She loves our father very
much, thats why despite of not having a
family in the Philippines, she still agreed to
live in the Philippines with their father.
Shes a brave woman.
During Hospitalization
Ive witnessed how the family loves the
patient so much. Every time they visit, they
always pray and sing a song to her. The
patient family provided a cassette in her
room as a music therapy to promote
relaxation.
Sexuality reproductive pattern The group decided not to ask her children
about this.
Coping and stress tolerance Before Hospitalization
pattern According to the significant others, they
noticed that when their mother had a
problem, she just keep it on herself. She
doesnt want her family to worry.
Value belief pattern Before Hospitalization
The patient is a Born Again Christian.
According to the significant others their
mother attended worship every Sunday.
They believe that their mother is a God
fearing woman.
During Hospitalization
The family is prayerful. They do prayer
meeting every time they visit the patient.
The husband read a prayer to her
solemnly. The significant others said that
they do not lose hope because they
believe in miracle. Theres a lot of
struggles and challenges that their mother
has already surpassed miraculously and
they believe that another miracle will
happen on her.
PHYSICAL ASSESSMENT

July 6, 2017 at 9 AM

GENERAL APPEARANCE

Area Techniqu Actual Findings Normal Analysis


Assessed e Used Findings
Body Built Inspection Not Proportionate Presence of
proportionate edema
Posture and Inspection Comatose Coordinated Decorticate
Gait and Erect
Body Odor Inspection No body odor No body odor Normal
Speech Inspection Uncommunicativ Coherent Comatose
e with GCS of
3.

VITAL SIGNS during the assessment

Area Technique Actual Normal Analysis


Assessed Used Findings Findings
Temperature Measured 37.9 degree 36-37.5 With fever
using a Celsius degree
thermometer Celsius
through
axillary
Pulse Rate Measured 98 beats per 60-100 beats Normal
using a Pulse minute per minute
Oximeter
Respiratory Inspection 29 cycles per 12-20 cycles Tachypnea
Rate minute per minute
Blood Not 130/70 mmHg 90/60 Normal
Pressure Applicable 120/80 mmHg

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

Moisture Inspection Dry skin Moist Oliguric or


hypouresis
Temperature Palpation Flushing or Warm to touch Fever with
hot skin temperature
of 37.9
Skin Turgor Palpation Difficulty to Good skin With edema
pinch up skin. turgor

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

CHEST AND LUNGS


Area Technique Actual Normal Analysis
Assessed Used Findings Findings
Breathing Inspection Tachypneic Regular Increase RR
Pattern with 29
cycles per
minute
Symmetry Inspection Symmetrical Symmetrical Normal
Smooth, no Smooth, no Normal
Skin Inspection tenderness tenderness and
and lesions lesions
Breath Auscultation Presence of Clear Due to heart
Sounds crackles failure

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

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.

Note: Patient was given Fe So4 (Ferrous sulfate).


Exami Indication/ Normal Results Interpretation
nation Purpose Values
It is the When kidneys
count of the 06- 19- 17 06-20-17 06-23-17 06- 26- 17 06-27-17 06-29-17 07-3-17 07-4-17 07-6-17 are diseased or
actual damaged, they
Red number of 4.0- do not make
red blood 6.0x10^ 2.5 (L) enough
Blood cells per 12 3.31 (L) erythropoietin
volume of 3.07 (L) (EPO). As a
3.04 (L)
Cell blood. Cells 3.03 (L)
result, the bone
that deliver 3.46 (L) marrow makes
oxygen 3.18 (L) fewer red blood
2.91 (L)
throughout 2.80 (L) cells, causing
the body anaemia. Other
and make common
blood look causes of
red. anemia in
people with
kidney disease
include blood
loss from
haemodialysis

https://www.nid
dk.nih.gov/heal
th-
information/kid
ney-
disease/chronic
-kidney-
disease-
ckd/anemia

H 0.25 (L) Because renal


E It is 0.31 (L) disease can
M traditionally 0.28 (L) cause low level
A defined as 0.37 - 0.29 (L) s of
0.31 (L)
T the 0.57 erythropoietin
0.33 (L)
O percentage 0.31(L) and/or iron in
C of RBCs 0.28(L) the body.
R per volume 0.26(L)
I of whole https://labtests
T blood. online.org/unde
rstanding/analy
tes/hematocrit/t
ab/test/
H It is a 75 (L)
E protein used 107 (L)
M by red 97 (L) Due to kidney
O blood cells 120 - 96 (L) disease.
G to distribute 160 g
L oxygen to 89 (L)
O other 103 (L)
B tissues and 96 (L)
I cells in the 87 (L)
N body. 79 (L)
These If a person has
immune 19.00 a high white
White cells form (H) blood cell
in the bone 14.40 count, it may
Blood marrow to 4.8- (H) 13.80 indicate that
help fight 10.8x10 (H) 12.70 they have an
Cell infection. ^9 g (H) infection and
High levels 14.30 that the
(Leuko may (H) 18.80 immune system
cytes) indicate (H) 19.40 is working to
infection. (H) 22.20 destroy it.
Low levels (H) 22
may result (H) http://www.me
from dicalnewstoday
treatment or .com/articles/3
disease. 15133.php
S Used to
E determine if 0.40 - 0.87 Due to
G there is 0.74 (H) 0.89 infection and
M infection. (H) 0.88 acute kidney
E (H) failure.
N 0.80
T (H) 0.81 http://www.me
E (H) 0.85 d-
R (H) 0.89 health.net/high
S (H) 3.88 -
(H) 0.83 neutrophils.htm
(H) l

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.

L Include T- 0.09 (L)


Y cells, B- 0.20 - 0.04 May be due to
M cells and 0.40 (L) 0.08 infection.
P NK cells. (L) 0.09
O Viral (L) 0.07
C infections (L)
Y may 0.05
T increase (L) 0.05
E their (L) 0.04
S number. (L) 0.06
(L)
It is a type
of WBC
M that is
O produced
N by the bone
O marrow and 0.03 - 0.03 (N) 0.06 0.06 0.09 0.10 0.05 0.05 0.07 0.10 May be due to
C helps to 0.09 (N) (N) (N) (H) (N) (N) (N) (H) infection.
Y protect the
T body from
E foreign
S invaders,
such as
harmful
bacteria and
viruses.
Helps to
Platelet determine 150- 240 (N) 185 219 218 (N) 219 217 (N) 222 190 150 Normal
the 450x10 (N) (N) (N) (N) (N) (N)
Count presence of ^9g
bleeding.
Morphology
June 19, 2017
P Wave: Upright
QRS Complex Narrow
ST Segment Isoelectric
T Wave Upright, Inverted in I, Acl
Other

Interpretation:
Sinus rhythm
Left Atrial Enlargement
Left Ventricular Hypertrophy
ST T wave Abnormality secondary to strain and / or ischemia

SPECIMEN: WHOLE BLOOD


June 19,2017
Test Result Normal Values
HBA1c 7.0% 4.3-6.4

High HbA1c levels indicate


poorer control of diabetes
than levels in the normal
range. The patient may not
restrict sugar intake. She
lack of exercise and not
adhere to medication
instructions.
http://www.emedicinehealth
.com/hemoglobin_a1c_hba1
c/article_em.htm

Specimen: Serum

Examination Result Normal values

06-19-17 07-06-17

Creatinine 1020.87 669.55 49-90 mmol/L

Elevated creatinine level


signifies impaired kidney
function or kidney disease.
As the kidneys become
impaired for any reason, the
creatinine level in the blood
will rise due to poor
clearance of creatinine by the
kidneys. Abnormally high
levels of creatinine thus warn
of possible malfunction or
failure of the kidneys.

(www.medicinenet.com)

Sodium 139.00 131 137-145 mmol/L

June 19, 2017


Examination Result Normal values

Blood Urea Nitrogen 34.40 1.8-6.4 mmol/L

Higher than normal BUN


levels is a sign that the
kidneys aren't working
efficiently. Other factors
may affect BUN, too.
Bleeding in the gut, heart
failure and some medicines
may cause the BUN to go
up.
https://lifeoptions.org/learn-about-
kidney-disease/blood-and-urine-
tests/)

(www.Medlineplus.gov)

Ionized Calcium 0.72 1.05-1.25 mmol/L

Kidney disease, because


low calcium is especially
common in those with renal
failure wherein the
absorption of calcium in the
gastrointestinal tract will
decrease. Also renal failure
patients often have acidosis
which can promote the
discharge of calcium from
the kidneys

(http://wap.kidneyfailureweb.com/
view.php?aid=326)
(labtestsonline.org)

Magnesium 1.01 0.80-100 mmol/L

June 19, 2017

Test Result Normal Value

Phosphorus 1.70 0.81-1.58

The kidneys help to control


the amount of phosphate in
the blood. Extra phosphate
is filtered by the kidneys
and passes out of the body
in the urine. A higher level
phosphate in the blood is
usually caused by a kidney
problem.
www.webmd.com

Blood Uric Acid 419 155-357

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

June 19, 2017


Test Result Normal Value

Reticulocyte count 2.5% 0.5-1.5%

A high reticulocyte count


with low RBCs, low
haemoglobin, low
haematocrit (anemia). A
low reticulocyte count may
be seen with severe kidney
disease; this may cause a
low level of erythropoietin.
www.labtestsonline.org

July 6, 2017

Examination Result Normal values

Albumin Low albumin levels can 34.50 g/L (L)


reflect diseases in which the
kidneys cannot prevent
albumin from leaking from
the blood into the urine and
being lost

(labtestsonline.org)

Specimen: Blood

Test Result Normal Values

06-19-17 07-04-17

Procalcitonin Level 2.66 mg/ml 59.65 mg/ml Less than 0.50

High levels indicate a high


probability of sepsis and
also suggest a higher risk of
progression to severe sepsis
and septic shock. High
levels may seen in people
with serious bacterial
infections.
www.labtestsonline.org

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

There is minimal in the intra ventricular haemorrhage.


There is resolution of the periventricular.

Midline structures are still in place.

Rest of findings are unchanged

Impression:
Interval increase in the volume of the acute.
Brain Plain
July 4, 2017

Clinical Data: Follow-up; GCS 8 previously GCS 6


Comparison: non-contrast cranial CT scan dated 07/03/2017
Non-contrast cranial CT scan reveals the following impression/findings:

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.

There is also fullness of the nasopharyngeal region.


The rest of the findings are unchanged.
NOTE: Patient was given KLYTE
Examination Normal Results Interpretation
Values
06-19-17 06-27-17 07-06-17 Due to kidney disease,
diabetes, high blood
pressure and heart disease.
P
O The most common cause is
T excessive potassium loss in
A 3.5 - 5.1 urine due to prescription
S mmol/L 5.60 3.10 4.10 medications that increase
S urination. Also known as
I water pills or diuretics,
U| these types of medications
M are often prescribed for
people who have high
blood pressure or heart
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%

(Normal value lesser than or equal to 1.2)


(Normal value 70 - 130%)

PARTIAL THROMBOPLASTIN TIME


Test 29-90 Seconds
Control 31-90 seconds
Chest X-Ray
June 27, 2017

Examination Chest AP (portable)

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

June 28, 2017 1:37PM

Examination Normal Values Results Interpretation

Color Pale, Dark Yellow Normal


yellow
May due to proteinuria. It is also one of
Transparency Clear Turbid the common causes of turbid urine.

http://healthylifemed.com/turbid-urine/

Reaction 4.65 - 8.0 7.0 Normal


Diabetes and kidney disease may cause
Protein Negative Positive elevated levels of protein in urine.
1
http://www.mayoclinic.org/symptoms/pr
otein-in-urine/basics/causes/sym-
20050656

Glucose Negative Negative Normal

Specific 1.10 - 1.25 1.010 Normal


Gravity

RBC 0.4/ HPF Loaded / A higher than normal number of RBC in


HPF the urine may be due to kidney disease.

https://medlineplus.gov/ency/article/003
582.htm

Pus Cells 0.4 / HPF 1-3 Indication of some type of infection

Epithelial cell Negative Occasio If present condition are infection,


nal inflammation and malignancies
Bacteria Negative Rare There are only few bacteria or it is rare
to find
Test Result Normal Values
06-20-17 07-04-17
Bleeding Time 3 minutes 2 minutes 1-3 minutes
Clotting Time 6 minutes and 6 minutes 3-7 minutes
30 seconds

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

Medications: Leviteracetam (Keppra)

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.

Background: Background activity consists of diffuse, 1.5-2.0 Hz arrhythmic, polymorphic


delta maximum over the bifrontal region, and mixed with medium voltage, 4.0-5.0 Hz activity.
There was no posterior dominant rhythm.

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

The patient lying on bed, unconscious, unresponsive, comatose with GCS of 3,

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

length of expiration) 1:2.

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.

Healthy kidneys produce a hormone called erythropoietin (EPO). A hormone is a chemical

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

working to destroy it.

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.

Potassium is low may be because of excessive potassium loss in urine due to


prescription medications that increase urination. Also known as water pills or diuretics, these
types of medications are often prescribed for people who have high blood pressure or heart
disease.
ANATOMY AND PHYSIOLOGY

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,

blood pressure, calcium and red blood cells.

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

valves prevent urine from flowing back towards the kidneys.

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 body through the penis.

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

may be held closed to delay urination.

Urinary System Physiology

Maintenance of Homeostasis

The kidneys maintain the homeostasis of several important internal conditions by controlling

the excretion of substances out of the body.

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

during filtration. (See more about ions.)

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

conserve bicarbonate ions, which act as important pH buffers in the blood.

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

antidiuretic hormone (ADH). ADH is produced in the hypothalamus and released by

the posterior pituitary gland to help the body retain water.

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

remain in the blood.


PATHOPHYSIOLOGY

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

for decreasing GFR. The etiology of ARF comprises 3 main mechanisms.

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

cardiovascular disorders, such as congestive heart failure, arrhythmias and tamponade.

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

glomerulonephritis, systemic lupus erythematosus, periartesis rotosa, vasculitis, sickle cell

disease, bilateral renal vein thrombosis, nephrotoxins, ischemia, renal myeloma and acute

pyelonephritis.

Post-obstructive renal failure initially causes an increase in tubular pressure, decreasing

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

and urethral edema from catheterization.

Patients with chronic renal failure also may present with superimposed ARF from any

of the aforementioned etiologies.

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

decrease GRF and used to oliguria.


PREDISPOSING FACTORS PRECIPITATING FACTORS

Age ACUTE RENAL Lifestyle


Diet
Sex
FAILURE Diabetes Mellitus
Race Hypertension
Cardiovascular disease

Decreased blood flow to renal arteries

Release of Renin by the iuxtaglomerular

Renin enters the blood stream

Collection of angiotensin in the liver to Angiotensin I

Angiotensin I passes through the lung capillaries

ACE in the lung capillaries converts angiotensin I to angiotensin II (potent vasoconstrictor

Vasoconstriction Release of aldosterone from adrenal gland

Sodium Retention

Increase plasma

Increase blood pressure

Decrease tissue perfusion Signs and Symptoms

Decreased Urine Output


Unable to excrete metabolic waste Increase BUN
Increase Creatinine
If TREATED: Edema
If not TREATED
Dialysis
Recurrent ARF
Antihypertensive meds
DM meds
Diuretics Further damage to glomeruli

Good Prognosis/Poor
Prognosis Hypertrophy of the remaining healthy glomeruli
(depends on the
persons. A number of hypertrophied glomeruli dies

Renal impairment (40 -50 % remaining GFR)

Signs and Symptoms


Further stimulation of RAAS (Renin Angiotensin
Nocturia Aldosterone System)
Fatigue
Lassitude Further damage occurs

Renal Insufficiency (20-40 % remaining GFR)

Renal Failure (10-20 % remaining GFR)

ESRD (End Stage Renal Disease)

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

experience chest pain.

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.

PERMANENT KIDNEY DAMAGE

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

kidney transplant to survive.

HYPERKALEMIA

Serum K rises by 0.5 mmol/L per day is oliguric and anuric patients due to impaired

excretion of ingested or infused k and k released from the injured tissue.

ANEMIA

Is due to impaired erythropoesis, homolysis, bleeding, hemodilution, and reduced red

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

of death is higher in people who had kidney problems.


TREATMENT

Prevention:

No specific therapy for ischemic or nephrotic ARF except preventing the etiologic

factors.

Preventing hypotension by aggressive volume replacement.

Judicious of nephrotic drugs.

Adjusting dosage of the nephrotic drugs.

Specific Therapies:

PRERENAL

Correction of hypokalemia depends upon the etiology that caused it.

Corrected with blood if it is due to hemorrhage.

Serum K and acid have status should be corrected.

Cardiac failure needs aggressive management with positive 10 isotopes , preload and

afterload reducing agents and antiarrhythmic agents IABP

INTRINSIC RENAL ARF

ANP Therapy; low dose dopamine; loop diuretic; calcium channel blockers; alpha

adreno-receptor blocker; prostaglandin analogous.

ARF due to glomerulonephritis, and pleura pheresis

Hypertension and ARF due to scheroderma is sensitive to ACE inhibitors

POST RENAL ARF


Can be detected by collaboration of nephrologists, urologists, and radiologist.

Obstruction of the urethra and bladder neck is managed initially by catheterization.

SUPPORTIVE MEASURES

Salt water intake is tolerated as required; diuretics to correct by hypovolemia.

Hyperphosphatemia is corrected by Aluminum Hydroxide, calcium carbonate.

Blood transfusion if anemia, and dialysis.


PROBLEM PRIORITIZATION

PROBLEM RANK JUSTTIFICATION


Medical management of the client with stroke is
directed at early diagnosis and early identification
of the client who can benefit from thrombolytic
treatment
Ineffective Airway Emergency care of the client with stroke includes
Clearance related to maintaining a patent airway. The client should be
1
presence of secretions turned on the affected side if she/he is
unconscious to promote drainage of saliva from
the airway. Clients with stroke are at high risk for
aspirations pneumonia, which is a direct cause of
health in 6% of clients with stroke. Aspiration is
the most common in the early period and is related
to loss of pharyngeal sensation, loss of
oropharyngeal motor.
Kidneys are responsible for the elimination of
Fluid volume deficit waste products in our body. If there is an alteration
related to inability of on the normal functioning of the kidney, there
kidney to excrete waste would be a problem in the secretion of waste
2
product as evidenced by products. Making the waste to stay in the
urine output of 20cc/hour circulation and excessive fluid would result
because there is only an intake but a limited
amount of output because of the damaged or
malfunctioned kidney.
Altered body temperature Hypothalamus is the thermoregulation center of
related to disease process the human body. Presence of infection
3
as evidence by body trigger of fever called pyrogen release of
temperature of 37.8oC prostaglandin T2 (PGE2). PGE2 then in turn acts
on the hypothalamus causing heat creating effect
increase servation or production resulting
increase body temperature (hyperthermia)
Stimulation of the vasomotor center located in
Hypertension related to medulla sends impulses to the CNS
elevated blood pressure as acetylcholine released by prosta preganglionic
manifested by the effect of 4 neurons preganglionic fiber release
medication administered norepinephrine (constriction of blood vessel)
such as Nicardipine, there by increasing blood pressure Adrenal
amlodipine and Cauidilol medulla secrets epinephrine increased blood
pressure causing it to increase blood supply in the
brain causing occipital headache.
Skin is the primary defense of the body, it protects
Risk for impaired skin the body against infections a diseases brought
integrity related to 5 about by the invasion of microbes in the body. A
immobility. norm al skin is moist and intact: dryness of the
skin is more prone to friction which may result to
impairment of the skin integrity.
DISCHARGE PLANNING

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

route, dosage, frequency and time.

Advised to report unusual side effects of drugs to the physician.

Exercise

Gradual back to basic daily routines.

Maintain rest periods between activities.

Treatment

Discuss the purpose of the treatment to be done and continued at home.

Advised patient and relatives to comply the treatment

Encouraged to eat nutritious food and adequate rest and sleep.

Discussed the importance of strict adherence to medication regimen to ensure

complete healing

Health Teaching

Discuss the patient family the importance of:

Bed rest
Maintaining proper personal hygiene

Promote safety and comfort

Outpatient

Instructed to comply continuity of follow up schedule to monitor health status by

coming back with the outpatient department one week after discharge

Reminded the patient that frequent check-ups are important to improve patients

condition and improve optimum level of wellness.

Informed significant others to report any abnormalities as soon as possible to prevent

further complications

Instructed patient to notify physician if there is any undesired feeling about disease

Diet

Advised to eat nutritious food

Advised to avoid eating salty and fatty foods

Avoid eating sweets.

Spiritual Counselling

Instructed patient to continue believing in God and she should always remember that

God work in mysterious ways like what he did to her now.


REFERENCES:

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

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