I.

DATABASE AND HISTORY:

A case of Mrs. X, 40 years old, married and recently residing at Lamac,Consolacion

Cebu. She’s a government worker and at the same time a food vendor. She loves to eat foods that
is raw and has vinegar; and fun of drinking soft drinks. She was admitted a year ago for a
cesarean section surgery ectopic pregnancy. Her menarche starts at 14. years old with occasional
dymenorrhea, blood light in color; 31 days cycle with 3-4 days duration.
3 days PTA, Mrs. X sought consultation for difficulty in breathing; she was prescribed
medications and was relieved. 2 days PTA, she complained for a flank pain and sought
consultation again. Upon consultation, some laboratory examinations have been done. Mrs. X is
by then diagnosed with a T/C chronic renal failure secondary problem to chronic
glomerulonephritis and thus admitted.

PHYSICAL ASSESMENT:

EENT:
 No lesions noted
 Conjunctiva is pink in color
 Reported no difficulty in swallowing

RESPIRATORY:
 22 cpm
 reported difficulty in breathing after doing such activities

CARDIOVASCULAR:
 fatigue
 dizziness

GASTROINTESTIONAL:
 no problem

GENITO-URINARY:
 flank pain
 urine light yellow in color
 urinates 5 times/day with at least 20 cc

NERVOUS:
 lethargic

SKIN:
 non-pitting edema on the extremities
II. LABORATORY RESULTS:

EXAMINATIONS NORMAL RANGE RESULTS SIGNIFICANCE

SGPT 0.0-32.0 28.7
URINE ANALYSIS
Color Straw
Transparency Cloudy
Reaction 5.5
Specific gravity 1.010
Sugar traced
Protein (-)
AM urates few
Bacteria few
Uric acid F: 24-57 6.8
potasium 3.6-5.5 8.0

III. ANATOMY AND PHYSIOLOGY:

Kidney
Approximately one million nephrons (right) compose each bean-shaped kidney (left). The
filtration unit of the nephron, called the glomerulus, regulates the concentration within the body
of important substances such as potassium, calcium, and hydrogen, and removes substances not
produced by the body such as drugs and food additives. The filtrate, urine, leaves the nephron
through a long tubule and collecting duct. Chemical signals triggered by the body’s need for
water and salt cause the walls of the tubule to become more or less permeable to these
substances, which are reabsorbed accordingly from the urine.
URINE FORMATION:

Blood enters the kidney through the renal artery. The artery divides into smaller and
smaller blood vessels, called arterioles, eventually ending in the tiny capillaries of the
glomerulus. The capillary walls here are quite thin, and the blood pressure within the capillaries
is high. The result is that water, along with any substances that may be dissolved in it—typically
salts, glucose or sugar, amino acids, and the waste products urea and uric acid—are pushed out
through the thin capillary walls, where they are collected in Bowman's capsule. Larger particles
in the blood, such as red blood cells and protein molecules, are too bulky to pass through the
capillary walls and they remain in the bloodstream. The blood, which is now filtered, leaves the
glomerulus through another arteriole, which branches into the meshlike network of blood vessels
around the renal tubule. The blood then exits the kidney through the renal vein. Approximately
180 liters (about 50 gallons) of blood moves through the two kidneys every day.

Urine production begins with the substances that the blood leaves behind during its
passage through the kidney—the water, salts, and other substances collected from the glomerulus
in Bowman’s capsule. This liquid, called glomerular filtrate, moves from Bowman’s capsule
through the renal tubule. As the filtrate flows through the renal tubule, the network of blood
vessels surrounding the tubule reabsorbs much of the water, salt, and virtually all of the nutrients,
especially glucose and amino acids, that were removed in the glomerulus. This important
process, called tubular reabsorption, enables the body to selectively keep the substances it needs
while ridding itself of wastes. Eventually, about 99 percent of the water, salt, and other nutrients
is reabsorbed.

At the same time that the kidney reabsorbs valuable nutrients from the glomerular filtrate,
it carries out an opposing task, called tubular secretion. In this process, unwanted substances
from the capillaries surrounding the nephron are added to the glomerular filtrate. These
substances include various charged particles called ions, including ammonium, hydrogen, and
potassium ions.

Together, glomerular filtration, tubular reabsorption, and tubular secretion produce urine,
which flows into collecting ducts, which guide it into the microtubules of the pyramids. The
urine is then stored in the renal cavity and eventually drained into the ureters, which are long,
narrow tubes leading to the bladder. From the roughly 180 liters (about 50 gallons) of blood that
the kidneys filter each day, about 1.5 liters (1.3 qt) of urine are produced.
 IV. PATHOPHYSIOLOGY:

PREDISPOSING FACTOR/S:
• Age

KIDNEY PRECIPITATING FACTOR/S:

• Diabetes mellitus
• Hypertension
STAGES OF PROGRESSION:
o Increase • Sickle-cell anemia
blood  Deterioration of
• Chronic
urea glomerular filtration rate
gomerulonephritis
nitrogen (GFR)
o Increase  Tubular reabsorption
serum  Endocrine function
creatinine

STAGE 1: DIMINISHED
RENAL RESERVE
 Decreased GFR by 50% of
normal (120-130 ml/min)

HYPERTHROPHY OF
THE REMAINING
NEPHRONS
 STAGE 2: RENAL Loss of
Dilute polyuria
Failure toINSUFFICIENCY
convert calcium sodium in
 Inability to concentrate
(inactive form) urine
urine
 GFR reduction 20% to
50% of nitrogen
hyponatremia
Decreased calcium absorption

STAGE 3: RENAL FAILURE

 Further loss of nephron
function LOSS OF EXCRETORY
 GFR lest than 20% of RENAL FUNCTION:
nitrogen o Decrease hydrogen
excretion
o Decrease phosphate
excretion
o Decreased potassium
excretion
V. MEDICAL-SURGICAL
STAGE 4: END MANAGEMENT:
STAGE OF o Decreased excretion of
RENAL DISEASE nitrogenous waste
IDEAL
 GFR less than 5% ACTUAL
 urinalysis  Loss of non-excretory  Decreased
Urinalysissodium
 X-ray reabsorption
 IV therapy
renal function
 IV urography  Modification of diet
 Sonography  Medication provided uremia
 Computed Tomography
Water retention
 Renal biopsy
 Dialysis
 Disturbance in
 Kidney transplantreproduction
 Change in diet Immune disturbance
 Medication  Increase production of
 Hemodialysis lipids
 Protein, Fluidand Sodiuminsulin
Impaired restriction
action
 Failure to produce
erythropoietin
VI. IDEAL NURSING MANAGEMENT:

A. Maintaining/demonstrate improvement in laboratory values.

a) Note reports of increasing fatigue and weakness.
b) Monitor level of consciousness.
c) Evaluate response to activity, ability to perform task.

B. Regain/maintain level of mentation.

 a) Assess extent of impairment in thinking ability, memory and orientation.
b) Provide quiet/calm environment.
c) Communicate information/instructions in simple short sentence.
d) Promote adequate rest and undisturbed sleep.

C. Demonstrate techniques/behaviors to maintain the prevention of skin breakdown/injury.

a) Inspect skin for changes in color, turgor and vascularity.
b) Inspect areas of edema.
c) Change position frequently; move patient carefully.
d) Investigate reports of itching.
e) Suggest wearing loose-fitting cotton garments.

D. Maintaining cardiac output as evidenced by BP and heart rate within patient’s normal
range.
a) Assess degree of hypertension: monitor BP in postural positions (lying, sitting and
standing).
b) Assess activity level, response to activity.
c) Evaluate presence of peripheral edema.

IX. DISCHARGE PLANNING:

MEDICATION • Instruct patient to continue taking her medications as

prescribed by the physician.
• Advise patient not to stop taking the drug abruptly.
EXERCISE • Encourage patient to do light exercises like walking a short
distance walk.
• Advise also to do deep breathing exercises.
TREATMENT • Stress the importance of follow-up examinations and
treatment of the patient for a faster recovery.
HEALTH TEACHING • Teach patient on how to prevent the reoccurrence of the
disease.
• Demonstrate to the patient on how to do deep breathing
exercises.
• Discuss different home care management regarding the
disease.
OUT-PATIENT • Advise patient to have a regular check-up at the nearest
health center.
• Instruct patient to report to the physician immediately if any
unusualities have occurred.
DIET • Encourage patient to have adequate caloric intake and
vitamin supplementation must be ensured.
• Restrict protein and fluid allowance in 500-600 ml.
• Instruct patient to follow carefully the diet provided by the
 dietician.
SPIRITUAL • Encourage patient to have a strong faith in God and always
ask for His guidance.
• Encourage patient to have a positive outlook regarding the
situation.
VII. DRUG SUMMARY:
Name of Date Classification Dose, Mechanism of Specific Side effects Nursing
Drug ordered frequency, action indications interventions
route
Allopurinol 3-2-08 Antigout drug 100mg 1 Reduces uric Gout or CNS: fever, BEFORE:
tab, TID acid production hyperurecemia. drowsiness, - instruct patient to
PO by inhibiting Hyperurecenia headache, take the drug with
xanthine caused by paresthesia, or immediately
oxidase. malignancies. peripheral edema, after meals to avoid
To prevent gout neuropathy, gastric irritation.
attacks. neuritis.
To prevent uric EENT: epistaxis DURING:
acid G.I. - encourage patient
nephropathy Nausea, vomiting, to drink adequate
during cancer diarrhea, fluid while taking
chemotheraphy. abdomimal pain, the drug.
Recurrent gastritis, taste loss
calcium calculi. of perversion,
dyspepsia. AFTER:
G.U. - tell patient to stop
Renal failure, the drug at first sign
uremia of rash which may
HEMA: precede severe
agrunulocytosis hypertension or
anemia, aplastic other adverse
anemia, reaction.
thrombocytopenia,
leukopenia,
leukocutosis.
HEPATIC:
hepatitis,
hepatomegaly,
hepatic necrosis
 Name of Date Classification Dose, Mechanism of Specific Side effects Nursing
Drug ordered frequency, action indications interventions
route
Cefuroxime 3-2-08 Cephalosporins 750 mg Second Infection of CV: phlebitis, BEFORE:
axetil IVF q 6 generation urinary and thrombophlebitis - ask patient if
hrs. cephalosporins lower GI: he/she is allergic
that inhibits respiratory pseudomembranous to penicillins or
cell-wall tracts. colitis, nausea, cephalosporins.
synthesis Serious lower vomiting, anorexia,
promoting respiratory diarrhea DURING:
osmotic tract infection SKIN: - instruct patient to
instability and UTI. maculopapular, take oral form
usually Uncomplicated erythematous, with food and if
bacteriacidal. UTI. urticaria, rashes suspension is
Skin and skin OTHER: given, tell patient
structure hypersensitivity to shake container
infection. reaction, serum well.
sickness
anaphylaxis AFTER:
- instruct patient to
notify prescriber
about rash or
evidence of
superinfection.
 Name of Date Classification Dose, Mechanism of Specific Side effects Nursing
Drug ordered frequency, action indications interventions
route
Paracetamol 3-2-08 Non-opioids 500mg Thought to Mild fever, HEMA: BEFORE:
analgesics, IVTT q 6 produce analgesia pain hemolytic - tell patient or SO’s
Antipyretics hrs. by blocking pain anemia, that the drug is only
impulses by neutropenia, for short-term use
inhibiting leukopenia, only, if fever and pain
synthesis of pancytopenia, is unrelieved; consult
prostaglandin in HEPATIC: the physician.
the CNS or of jaundice
other substances METABOLIC: DURING:
that sensitize pain hypoglycemia - warn patient that
receptor to SKIN: rash, high doses or
stimulation. urticaria unsupervised long-
term use can cause
liver damage.

AFTER:
- advise patient to
report to the prescriber
immediately if
unusual side-effects
occurs.
VIII. NURSING CARE PLAN:
ASSESSMENT NURSING NURSING GOAL NURSING RATIONALE OUTCOME
DIAGNOSIS INTERVENTIONS CRITERIA