I.

Introduction
Renal failure results when the kidneys cannot remove the bodys metabolic

wastes or perform their regulatory functions. The substances normally eliminated in the urine accumulate in the body fluids as a result of impaired renal excretion, affecting endocrine and metabolic functions as well as fluid, electrolyte, and acid-base disturbances. Renal failure is a systemic disease and is a final common pathway of many different kidney and urinary tract diseases. Each year, the number of deaths from irreversible renal failure increases (Brunner and Suddarths, 2010).

There are two types of renal failure, which is acute renal failure and chronic failure. Acute renal failure is a rapid loss of renal failure due to damage to the kidneys while chronic renal failure is a kidney damage to require renal replacement therapy on a permanent basis. In acute renal failure, there is a widely accepted criterion for ARF is a 50% or greater increase in serum creatinine above baseline (normal creatinine is less than 1.0 mg/dL). Urine volume may be normal or changes may occur. Possible changes include oliguria (less than 500 mL/day), nonoliguria (greater than 800 mL/day) or anuria (less than 50 mL/day). There are also four phases in ARF which includes initiation, oliguria, diuresis and recovery. The initiation phase begins with the initial insult and ends when oliguria develops while the oliguria phase is accompanied by an increase in the serum concentration of substances which are usually excreted by the kidneys and in this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia. In the diuresis phase, there is a marked of gradual increase in urine output which signals that glomerular filtration has started to recover and although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal due to the presence of uremic symptoms. And lastly, the recovery period signals the improvement of renal function and may take 3 to 12 months, laboratory values return to the patients normal level (Brunner and Suddarths, 2010).

This is a case of patient MF, a 38 year old female which has been diagnosed with Acute Renal Failure secondary to bilateral obstructive uropathy secondary to 1

ureteral stenosis, Distal 3rd; s/p C-section with hysterectomy. Patient MF was admitted last February 15, 2012 at NMMC with a chief complaint of difficulty voiding; oliguria. Weeks prior to admission (Feb. 8, 2012), patient MF went to her sister-in-law's house and had a small talk. When she decided to go home, theyve noticed patient MF bleeding approximately 2L of blood thus rushed to the hospital. She gave birth to her 9 th son through cesarean section following a sub-total hysterectomy due to placenta accrete at Gingoog City. Day after delivery (Feb. 9, 2012), physicians noted minute amount of urine therefore she was under observation not until referral was made to Northern Mindanao Medical Center on Feb. 14, 2012 because no improvement of urine output observed.

GENERAL OBJECTIVES At the end of one hour case presentation of Patient diagnosed with, The group will be able to present the appropriate and essential information and every detail concerning the case of the patient as well as identify and determine the effective pharmacologic and non-pharmacologic interventions. The group will also be able to attain greater understanding of the nursing practice, integrate good communication skills in interacting with the clinical instructors, classmates and to the group, impart knowledge to the students regarding the Patients diagnosis, deliver the case in a concise, accurate and a well- mannered presentation, and show collaborative relationship and active participation. Another point worthy to be noted is that we should be knowledgeable about the pathophysiology as well as the contributing and causative factors of the said condition of the patient and give further details about the said diagnosis through methodical research and teamwork. This can increase the students overall knowledge and skills for the furtherance of each students nursing practice and regard the significance of realizations which will be carried by our clinical instructors in the area that necessitates for improvement.

SPECIFIC OBJECTIVES At the end of one hour case presentation, the proponents will be able to: Present the case of the patient effectively. Provide an environment conducive to learning.

Defend the case logically and academically. Incorporate knowledge and skills that the audience can benefit of such as

nursing interventions or procedures to be rendered to the patients condition. Have a systematic discussion on the disease process. Provide the anatomy and physiology of the body systems affected by the disease

process. Properly present the appropriate nursing care plan in accordance with the

patients chief problems and its corresponding prioritization. Present the thorough drug study of the medications taken by the patient. Present the detailed lab values that were taken and its corresponding implication. Maintain confidentiality regarding the patient and focus on the presentation regarding the patients condition. Accept professionally any constructive criticism from the panel of clinical instructors. Incorporate fully the modifications of the clinical instructors with the write-up. Do after care of the area used for presentation.

SCOPE AND LIMITATIONS The SCOPE of the case study are as follows: 1. The practical scope of this case study is equivalent to the span of 32 hours 2. The anatomy and physiology of the systems that are affected by the disease condition. 3. Pathophysiology. 4. Medical and nursing management. 5. Laboratory results or different diagnostic tests. 6. Drug study of the medications prescribed by the physician. 7. Discharge planning. 8. Conclusion and recommendation. 9. Nursing care plan. 10. Prognosis 11. Nurses notes and Doctors orders. 12. The general information gathered about the condition of the patient

The LIMITATIONS which were identified are the following: 1. Unable to get the data from the previous hospitalization in Gingoog City 2. Information obtained from an interview with the patient and SO 3. Unable to obtain the U/A and cystoscopy results 4. The case presentation is limited to the information gathered during the first two days of duty & from the patients chart. Patient was not assessed beforehand because he was admitted only during the actual start of duty. 5. No data pertaining to latest laboratory results from February 29, 2012 up to present.

II.

ASSESSMENT A. Narrative

Demographic Data This is a case of Patient MF, a 38 years old female and a resident of Gingoog City, born on January 10, 1974. She is a devout Roman Catholic. She was admitted at Northern Mindanao Medical Center last February 15, 2012 at 10:30 am with chief complaints of difficulty voiding and oliguria. Reason for Hospitalization Patient NG went to her sister-in-law's house last Feb. 8, 2012 and after they had a small talk then she decided to go back home and from there she started bleeding she was rushed to the hospital. She had approximately loss 2L of blood. She gave birth to her 9 th son through cesarean section following a sub-total hysterectomy due to placenta accrete. On Feb 9, 2012, the physician noted that minute amount of urine was voided therefore she was under observation not until referral was made to Northern Mindanao Medical Center on Feb. 14, 2012 because there was no improvement of urine output. Physical Assessment The patient cant stand and walk without assistance. She appears to be conscious and responsive however there was slow response to questions raised. Her manner of dressing is appropriate for age and weather but her general appearance is untidy, has a dry scalp & hair, shiny skin and presence of dandruff. Foul odor is noted since patient MF has poor hygienic practices and also due to unchanged FBC since admission. She has a fair complexion. Edema is evident on her lower extremities as well as the upper extremities. B. Functional Assessment Vital Signs On the day of assessment, February the patients ital si ns were as ollows bp or heart rate cp or respiration or te perature or blood pressure and her oxy en saturation is %.. owe er on MFs te perature increased to 38.1C. Nutrition and Metabolic pattern Prior to ad ission Patient NBs usual diet consists o rice ish e etable dried ish and fond of eating salty foods. She is a Roman Catholic and does not have any cultural and religious restrictions in her diet. Upon admission, her diet was low salt because of the presence of bipedal pitting edema. During her admission, she has lost her appetite whenever she felt pain

and taken diuretic edication. She doesnt ha e any aller ies on ood. She reported di iculty swallowing since there was a catheter inserted in her neck. Elimination Pattern Prior to ad ission patients usual bowel pattern was once a day and the character o the stool were soft and formed, brown in color. Before the delivery, she voided many times but after the cesarean section only small amount of urine was voided. Difficulty voiding was evident. She has an indwelling catheter and was oliguric with 10 cc of urine output during our ornin shi t duty. Patient MF hasnt chan ed her oley ba catheter since ad ission. Respiration Patient MF experiences dyspnea when pain oocurs. She has cough but without phlegm. Presence of crackles on left lung field noted. Nail beds were pinkish with capillary refill which was approximately 3 seconds and clubbing of fingers was not noted. No cyanosis noted on both lower extremities. Respiration rate is 22 cycles per minute. Patient does not show nasal flaring. Ultrasound was done on Feb. 21, 2012 and it revealed Pleural Effusion on left lung. Circulation Patient MF has bipedal edema which was heavy on her part and the reason she cant move freely. Numbness was felt in both hands as well as the lower extremities which were affected by edema. Tingling was felt in both hands. There was a change in frequency and amount of urine which accounts only 10 cc and was oliguric right after the operation. Activity/ Safety/ Mobility Status Patient MF doesnt ha e enou h sleep since she only slept or hours at ni ht. She also reported difficulty in initiating activities due to feeling of heaviness on her feet and back pain that radiates in the abdomen. She prefer sitting on bedside. On Feb. 15, 2012, she was given blood transfusion. There was no ambulatory device rather than family members help and assist her in ADLs. Cognition and perception/ Sensory Reflexes Pupils are round in shape, they constrict and are reactive to light and accommodation. She does not have any ear problem and had not undergone any ear examination. Her sense of smell is not impaired and no epistaxis noted. On Feb. 21, 2012 periorbital is evident however on the 2nd week of assessment it was absent. Pt MF was oriented in terms of time, place and person. She reported difficulty swallowing due to the presence of intrajugular catheter. Her handgrip were weak in both hands and has a slouch posture. Value Belief Pattern Patient NB is a de out Ro an atholic. She belie es in hilot. She also under one hilot on her th baby so that it will be position appropriately.

Dates of Assessment: 02-21- 12 and 02-28-12

A. GENERAL INFORMATION

Name: Patient MF Age: 38 years old Civil Status: Married Religion: Roman Catholic

Birthday: January 10, 1974 Sex: Female Occupation: Housewife Address: Gingoog City, Philippines Informant: Patient MF Admission date: Feb 15, 2012

Time: 10:30 am

Chief Complaint: difficulty voiding; oliguria Attending Physician: Dr. A / Dr. B Admitting Diagnosis: Acute renal failure secondary to intra-op hemorrhage s/p hysterectomy Principal Diagnosis: Acute renal failure secondary to bilateral uropathy secondary to ureteral stenosis, distal 3rd; s/p c-section hysterectomy

Operating Diagnosis: Peritoneum nephrostomy, bilateral failed; Antegrade Nephrotography, bilateral 2/12/22; IJ catheter insertion,right 2/28/12

History of Present Illness: Weeks prior to admission (Feb. 8, 2012), patient MF went to her sister-in-law's house and had a small talk. When she decided to go home, theyve noticed patient MF bleeding approximately 2L of blood thus rushed to the hospital. She gave birth to her 9th son through cesarean section following a sub-total hysterectomy due to placenta accreta. Day after delivery (Feb. 9, 2012), physicians noted minute amount of urine therefore she was under observation not until referral was made to Northern Mindanao Medical Center on Feb. 14, 2012 because no improvement of urine output observed.

Vital Signs: HR : 98 bpm RR: 22 cpm

Temp: 37 C(02-21), 38.1 (02/23, 02/28-02/29) BP: 140/80 mm/Hg O2 Sat: 98% Weight: 56 kg

B. ACTIVITY / REST

Subjective

Usual activities / hobbies: Magbantay sa mga bata ug magtabang ug uma Leisure Time activities: Maminaw ug radio ug matulog pud usahay kung makatulog napud ang mga bata Limitations imposed by condition: Dili nako ma aregla ug tarong ako mga bata kay layo ko, labi na tong bag-ong anak nako nga gikan cesarean Number of hrs of sleep: Mga upat ka oras kung gabii, depende kay dili ko katulog kung magtukar ang sakit sa ako tiyan dapit Naps: Tunga sa oras rasad, usahay halos dili na gyud 9

Aids: Naa man mi unlan, habol. Mamay-pay nalang dayon Difficulty in sleeping: Maglisod kog katulog kung magtukar ang sakit sa ako tahi. Mukatay dayon sa ako tiyan. Musakit pud ako likod ug apil Feeling on awakening: Maayo kung makatulog tarong. Makamata pud kung magtukar ang sakit Others / Comments: Magsakit lagi ako likod unya mukatay bisan asa dapit sa ako tiyan. MF is active prior to admission. Presently, MF reports difficulty in initiating activities due to feeling of heaviness of her feet and back pain that radiates in the abdomen. She prefers sitting on bed.

Objective

Observed response to activity: MF sits on bedside more often and lies on bed during hours of sleep. Needs assistance during ambulation. Cardiovascular: BP change noted from usual (as reported by pt) 120/90 to 140/80(increased). Respiratory: No signs of dyspnea noted. RR within normal limits (22).

Mental Status: oriented, coherent and responsive however slow response to questions raised noted

Posture: MF prefers sitting on; slouch posture noted.

LOM (Limitation of Movement): Remained sitting on bedside and hesitates movement due to reported pain from post surgery incision sites (Cesarean section,nephrostomy and intrajugular catheter). 10

Others / Comments: Gait posture not assessed since no ambulation period seen. However, MF stated that assistance is provided by the SO when accessing to bathroom for defecation. MF reports difficulty in breathing when in pain but absent during assessment. Body malaise and slowed movement noted.

C . CIRCULATION

Subjective

History of Hypertension: Ako papa nga side, tag-as man to sila BP Heart trouble: Wala man Ankle/ Leg Edema: Nag hupong ako tiil, bug-atan sad ko maong dili ko makalihoklihok Slow healing: Aw dili man Claudication: not assessed; MF has not ambulated during assessment Cough / Hemoptysis: Wala. Panalagsa lang kanang uga Extremities Numbness: Kaning gapang hupong nga tiil ug kamot sad nako Tingling: Uo, kaning ako kamot Change in frequency/amount of urine: Katong pagkahuman jud nako na operahan ginagmay na dayon ko ka-ihi maong gibalhin ko dari nga hospital Objective Blood Pressure

R Lying: 140/80 mmHg

Sitting:

130/80 mmHg

Standing: not assessed; not tolerated

11

L Lying: 140/80 mmHg

Sitting:

130/80 mmHg

Standing: not assessed; not tolerated

Pulse pressure: Right: 60mmHg, Left: 50mmHg PMI: most audible at 5th intercostal space Heart rate / Sounds: 98 bpm Rhythm: regular Pulse Carotid: 90 bpm Radial: 98 bpm

Popliteal: Impalpable due to presence of edema Temporal: 82 bpm Femoral: 68 bpm

Dorsalis Pedis: Impalpable due to edema Vascular Bruit: none Breath sounds: crackles noted on left lung

Jugular vein distention: During first assessment (02/21) no distention noted. During 2nd assessment (02/28) intrajugular catheter noted. Extremities Temp: 37 (02-21), 38.1 (02-28) Capillary refill: 3 sec. Color: light brown

Homans sign: (-) negative

Others/Comments: Presence of bipedal pitting edema noted. Jugular vein distention noted on 2nd assessment due to Intrajugular catheter related to HEmodialysis treatment. UTZ abdomen(02-21) revealed Pleural effusion on left lung. MF manifested hyperthermia on the 2nd day of duty(02-23) and the 2nd week(02-28, 0301).Generalized edema also noted. D. EGO INTEGRITY

Subjective

Reports of stress factors: Karon nga naa ko dari, dili kaayo maka lihok2x. Kani pung sakit nga ako gakabati sa tahi ug likod 12

Ways of handling stress: Magpahulay nalang para dili mahuna-hunaan Financial concerns: Bayrunon sa hospital ug ang pagskwela sa mga bata Relationship status: Kasal na. Okay raman sad mi sako bana ug mga anak Lifestyle: Simple lang. Makakaon sa isa ka adlaw, okay na kaayo Recent changes: Karon, dili nako matabangan ako bana sa pag-uma. Mga bata pud dili mabantayan. Dili na kaayo ko maka trabaho labi nag ga sakit ako tahi ug likod Feeling of Helplessness: usahay Feeling of Hopelessness: aw naa man gyud na Feeling of Powerlessness: uo, naa sad

Others / Comments: MF reports of stress related to present condition;pain on incision site from cesarean section, nephrostomy procedure and intrajugular catheter.

Objective

Emotional Status: calm Others / Comments: MF is mostly responsive.

E. ELIMINATION

Subjective 13

Usual Bowel pattern: Kas-a sa isa ka adlaw. Usahay dili ko makalibang, sakit man gud muutong Character of stool: Dili basa dili pud tubol. Brown ang color Last BM: On 02-21 assesment, Ganiha buntag Laxative use: Wala man History of bleeding: Wala pud Hemorrhoids: Wala

Constipation: Dili man. Makalibang man sad ko Diarrhea: wala sad Usual voiding Pattern: Ikadaghan katong wala pako nanganak. Pero pagkahuman sa cesarean, ginagmay na lang ako ihi. Dili pud nako gina-ihap Incontinence: Ambot lang, naka catheter man ko Urgency: MF is in FBC since admission Retention: Dili man, gagmay ra ako inihian Frequency: MF is in FBC Pain/burning/difficulty in voiding: Wala may sakit pero galisod lang kog ihi lagi. Gagmay ra mugawas gikan adtong na operahan ko. Gi catheter nalang dayon ko History of kidney/bladder disease: Wala man Others / Comments: MF has unchanged foley bag catheter since 02-16-12. Oliguria noted: 10cc during AM shift (7-3am)

Objective

Abdomen Tender: positive Soft/Firm: slightly bloated, firm 14

Palpable mass: none ascites Bladder palpable: none Distended: none Abdominal Girth: 49in

Bowel sounds: absent; possible due to moderate

Others/Comments: Bloated firm abdomen noted with presence of moderate ascites. Soiled dressing noted Wala pa nailisan ug dressing sukad opera

F. FOOD / FLUID

Subjective

Usual diet (type): Bisag unsa ra ako ginakaon. Luto, isda, mga utan, bulad, kanang mga parat nga pagkaon, ganahan kaayo ko ana Number of meals daily: Ika tulo sa isa ka adlaw Last meal/intake: 02/21 Ganiha buntag (Breakfast) Loss of appetite: Usahay labi nag magtukar ang sakit, di ko ganahag kaon Nausea/Vomiting: wala man nuon Dentures: wala Allergy/Food Intolerance: Wala Heartburn/Indigestion: Wala sad Mastication/swallowing problems: Uo, galisod kog tulon tungod aning catheter sa ako liog Usual weight: 50kg katong wala pako naburos Changes in weight: Wala ko kabalo pero uo nidako gyud kay buros man gikan. Karon murag nisamot man 15

Diuretic use: Uo naa koy tambal nga in-ana Others / Comments: MF is in Low salt diet related to presence of bipedal pitting edema, pleural effusion and ascites. Objective

Current weight: 56kg Height: 5 Body Build: Small body frame Skin turgor: poor Mucous membranes: moist/pinkish Hernia/masses: none Edema General: none Dependent: bipedal pitting edema noted

Periorbital: noted on 02-21-12 but absent one the 2nd week of assessment Ascites: moderate ascites noted on ultrasound (02/28/12)

Thyroid enlarged: none Halitosis: present Condition of teeth/gums: no gum hypertrophy and lesions;moist, cavities noted Appearance of tongue: pink, moist Others/Comments: MF has small body frame however abnormal body appearance noted due to presence of bipedal pitting edema and ascites. Katong buros pako, himarat ko. Nidako pud ako tiyan, murag tubig ra ang sulod

16

G. HYGIENE

Subjective

Activities of Daily Living Mobility: independent independent Feeding: independent Hygiene: independent Dressing: independent Toileting:

Equipment/presence of devices required: wala man Assistance provided by: Ako anak, bana ug igsuon sa ako bana. Depende kung kinsay naa dari Others / Comments: MF is dependent on ADL. However, she hesitates on moving because of fear of possible sudden pain.Slowed movement is noted.MF shows poor hygienic practices.

Objective General Appearance: hair uncombed with dry and shiny skin (bipedal edema). Appears weak and is sits on bedside. Manner of Dress: Appropriate Habits: Most of the time, sits on bedside. Only lies to bed during hours of sleep. No mannerisms noted Body odor: present (foul) Condition of scalp: Presence of vermin: dry scalp and dandruff noted none

Others / Comments: Foul odor noted, maybe related to poor hygienic practice and presence of unchanged foley bag catheter since admission.

17

H. NEUROSENSORY

Subjective

Fainting spells/Dizziness: Wala man Headache: Wala sad Tingling/numbness/weakness (location): ako tiil ug kamot Seizures: Dili man

Eyes /Vision loss Right/Left: wala Cataract: wala Glaucoma: wala Last examination: wala

Sense of smell: Wala may problema Epistaxis: Wala Other/Comments: On 02-21-12 assessment, periorbital edema noted. However on the 2nd week, it was absent.

Objective

Mental status

Oriented/Disoriented : Oriented to time,place and person Affect: appropriate Delusions: none Hallucinations: none

Memory: Recent and remote memory good and intact Speech pattern: Spontaneous 18

Congruence: congruent Glasses: none Contacts: none Hearing aids: none Pupil size/reaction: PERRLA on both eyes Facial drooping: none swallowing:MF reported problem on swallowing due to presence of intrajugular catheter Handgrip/release: Right: weak Left: weak

Posturing: slouch posture noted Paralysis: none Others / Comments: MF responds to questioned raised slowly. Usually about 5 sec

I.

PAIN/ COMFORT

Subjective Onset: Mukalit lang lagi ang sakit Duration: Dugay2x pud lagi. Mga pila pud ka minuto 19

Location: Sa ako tahi, mukatay dayon sa tiyan pati sa ako likod Pain Scale: mga 9 Precipitating Factor: Presence of incision site from cesarean section, puncture from nephrostomy surgery. Aggravating Factor: Kung maglihok ko How relieved: Dili ko maglihuka, magingkod nalang pud ko kaysa maghigda kay masakit man gud Associated symptoms: Mawad-an kog gana magkaon, maluyahan kog samot Others/Comments: Facial grimacing, guarding behavior, slowed movement noted. Flank pain, radiating noted.

J. RESPIRATION

Subjective

Dyspnea related to: Kung magtukar ang sakit Cough/Sputum: Usahay rako mag ubo pero wala man plema Oxygen: Nag oxygen ko pagkahuman sa ako opera Others / Comments: Pain felt my MF is related to incision site from post cesarean section that radiates to the abdomen. Post nephrostomy surgery may possibly contribute to pain. O2 administered 02-23 at 2L perminute. O2 inhalation noted on 02/21/12 Objective

RR: 22cpm Depth: labored when in pain. During assessment, MF was not into labored breathing. Symmetry: symmetrical Use of accessory muscles: none 20

Nasal flaring: none Breath sounds: Crackles noted on left lung Cyanosis: none Clubbing of Fingers: Sputum characteristics: Restlessness: none none none

Others / Comments: Ultrasound(02-21-12) revealed Pleural Effusion on left lung.

K. SAFETY

Subjective

Allergies/sensitivity: Wala man History of STD (date/type): wala pud Blood Transfusion/number: Katong pagka admit nako dinhi (02-15-12) History of accidental injuries: Wala, kaluoy sa Dyos Fractures/dislocations: Wala Arthritis/unstable joints: Wala Back problems: Uo, kung muapil siyag sakit Changes in moles: wala man Prosthesis: wala gatabangan lang ko nila dari Enlarged nodes: wala Ambulatory devices: Wala,

Expression of ideation of violence (self/others): wala man sad Others / Comments: Another blood transfusion; Feb.26,2011

21

Objective Temperature: 37 C Diaphoresis: none

Skin Integrity: intact, shiny in appearance on lower extremities, warm to touch. Presence of moderate ascites and bipedal pitting edema noted Scars: none Rashes: none Ulcerations: none Burns (degree/ %): none Drainage (note location): none Gait: not assessed; client is not ambulating Paresthesia/paralysis: none Others/Comments: Init kaayo ako paminaw o2/23/12 Laceration: none Blisters: none

Ecchymosis: none

L. SEXUALITY Sexually active: Uo Sexual concerns/difficulties: Dili nako maka-anak utro

Subjective

Age of menarche: Adtong 12 pako LMP: Adtong Mayo niaging tuig Pregnancy History: G9 T8 P0 A1 L 8

Length of cycle: 28 ka adlaw

Episiotomy: Ambot kalimot naman ko unsa klase nga tahi Complication of Pregnancy: Wala ko nagbati, natingala nalang ko nga daghan na dugo nawala sa ako. Gioperahan sad ko pagkahuman cesarean 22

Surgery: Gi cesarean ko karon tapos gi operahan napud ug lain, ambot unsa tawag ato

Others / Comments: MF underwent cesarean section following a hysterectomy due to placenta accrete on February 8,2012. MF doesnt perform self breast examination. M. SOCIAL INTERACTIONS

Subjective Marital status: Kasal na Living with: Kami tibuok pamilya Extended family: Wala Other support person: Ako igsuon ug igsuon pud sa ako bana Role within family structure: Ako gabantay sa mga bata N. TEACHING / LEARNING Years in relationship: 20 na ka tuig

Subjective Dominant language (specify): bisaya ra Literate: uo Educational level: wala nako natapos ang highschool Health Beliefs/Practices: Gatuo ko anang hilot2x. Nagpahilot ko atong ika 9 nako nga anak para maplastar ang position sa bata sa sulo Familial Risk factors: High Blood Pressure (Paternal) 23

Use of Alcohol (amount/frequency): none Others / Comments: MF is non-alcoholic/non smoker. Prescribed drugs / medications: Drug NaHCO3 CaCO3 Amlodipine Nifedipine Dose, Frequency, Route 1 tab, TID, PO 1 tab, TID, PO 10mg 1 tab, OD 5mg 1 tab, OD every 6 hours, Hold if BP 140/90 60mg IV, every 8 hours 500mg 1 tab, every 6 hours, PRN for pain 1 tab TID PO Indication Systemic alkalinizer to correct metabolic acidosis Used as calcium supplement when calcium intake may be inadequate Treatment of Hypertension Treatment of Hypertension

Furosemide Paracetamol Ketosteril

Treatment of edema associated with renal disease For pain and fever Promotes healing and prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure

24

Laboratory Results:

Laboratory Results Date: 2/21/12 Ultrasound Report:

Interpretation Diagnosis:

Findings: Liver and spleen are in normal in size and echo pattern. No focal mass seen or biliary ectasia noted. Gallbladder is physiologically distended. No intraluminal echoes seen. Right and left kidneys measure 11.23 cm x 5.5 cm and 10.8 cm, with parenchymal thickness of 2.0 cm and 1.9 cm, respectively. Central echo complexes are intact. There is mild to moderate dilatation of pelvocalyceal systems. Urinary bladder is empty with inflated Foley balloon catheter seen within. Uterus is surgically absent. Free fluid collection is seen within the abdomen Free fluid Is also seen in the left thorax Bilateral mild-moderate pelvocaliectasia Surgically absent uterus Ascites, moderate Pleural effusion, left Foley bag catheter in situ Non-remarkable ultrasound findings of liver, spleen, gallbladder and pancreas

Date: 2/15/2012 Hematology Report 25

WBC- 10.7 10^u3/Ul (4.5-10.5 10^u3/Ul) RBC- 3.17 10^u3/Ul (3.6-5.0 10^u3/Ul) Hemoglobin- 9.5 g/dL (12-16 g/dL) Hematocrit- 27.1 % (36-48 %) MPV- 7.3 fL (8-12 fL) High: indicates infections Low: indicates anemia and acute or chronic hemorrhage. Low: indicates anemia as well as with liver and kidney diseases. Low: it means that the patient is moderately to severely anemic Low: due to septic thrombocytopenia

Differential Count Lymphocytes- 6.5 % (17.4-84.2 %) Neutrophil- 88 % (43.4-76.2 %) Eosinophil- 0.4 % (1-3 %) Low: due to acute allergic reaction. High: early indication of sepsis. Low: due to radiation treatment.

Date: 2/17/2012 Hematology Report: RBC 2.62 10^u3/Ul (3.6-5.0 10^u3/Ul) Hemoglobin 7.6 g/dL (12-16 g/dL) Hematocrit 22.6 % (36-48 %)

Low: indicates anemia and acute or chronic hemorrhage. Low: indicates anemia as well as with liver and kidney diseases. Low: it means that the patient is moderately to severely anemic.

Differential Count: Eosinophils - 4.2 % (1-3 %) High: caused by allergies. 26

Date: 2/23/2012 Hematology Report: RBC 1.96 10^u3/Ul (3.6-5.0 10^u3/Ul) Hemoglobin 5.8 g/dL (12-16 g/dL) Hematocrit 16.6 % (36-48 %)

Low: indicates anemia and acute or chronic hemorrhage. Low: indicates anemia as well as with liver and kidney diseases. Low: it means that the patient is moderately to severely anemic.

Differential Count: Monocyte 2.6 % (4.5-10.5 %) Low: are not usually identified by specific diseases but are found in cases of overwhelming infection.

Date: 2/25/2012 Hematology Report: Red Blood Cells 1.68 10^u3/uL (3.6-5.0 10^u3/Ul) Hemoglobin 4.7 g/dL (12-16 g/dL) Hematocrit 14.8 % (36-48 %)

Low: indicates anemia and acute or chronic hemorrhage. Low: indicates anemia as well as with liver and kidney diseases. Low: it means that the patient is moderately to severely anemic.

Date: 2/29/2012 Hematology Report: WBC 2.7 10^u3/uL (4.5-10.5 10^u3/Ul) 27

Low: indicates risk for infection

Hematocrit 35.5 % (36-48 %) MPV 7.8 fL (8-12 fL)

Low: it indicates anemia.

Low: due to septic thrombocytopenia.

Differential count: Neutrophil 43.0 % (43.4-76.2 %) Monocyte 19.9 % (4.5-10.5 %) Eosinophils 4.9 % (1-3 %) Low: due to viral infections or a deficiency in B12 or folate. High: due to bacterial disorders and recovering state of acute infections. High: caused by allergies.

Date: 02/15/2012 Blood Gas Report: pH 7.29 (7.35-7.45) pCO2 20.8 mmHg (35-45 mm Hg) pO2 101.5 mmHg (80-100 mm Hg) HCO3 act 10.0 mmol/L (22-26 mmol/L) High: due to hyperbaric oxygenation and hyperventilation. Low: due to metabolic acidosis. Low: due to hyperventilation.

Low: indicates acidosis.

Date: 02/23/2012 Blood Chemistry Report Creatinine 22.5ng/dl (0.7-1.2) Increased; indicates kidney/renal problem

28

02 inhalation @ 2L/min 02/22/12 Dandruff Body Map: Periorbital edema (02/21/12) Intrajugular catheter (2/28) Median cesarean incision Radiating pain; 9/10 scale Absent bowel sounds UTZ whole abdomen (02/21): Pleural Effusion on left Lung
Punture from nephrostomy procedure Flank pain; radiating

Facial Grimacing

BP: 140/80mmHg

IVF of PNSS 1L @ KVO rate Bipedal pitting edema Shiny/glossy Capillary refill: 3 secs Poor skin turgor Warm to touch

Oliguria: 10cc / 8hrs shift Foleybag catheter F16 noted

Small body frame Weak Slouch posture Slowed movement Moaning noted Hyperthermi a: 38.1 (02/23, 02/29-03-01) Tingling and numbness on upper and lower extremities Body Malaise Generalized edema

Tender Slightly bloated Moderate ascites Girth: 49in Guarding behavior Soiled dressing

III. Anatomy and Physiology

The Female Reproductive System

The female reproductive organs are the ovaries, the uterine tubes, the uterus, the vagina, the external genital organs, and the mammary glands. The internal reproductive organs are within the pelvis between the urinary bladder and the rectum. The uterus and the vagina are in the midline, with the ovaries to each side of the uterus. A group of ligaments holds the internal reproductive organs in place. The most conspicuous is the broad ligaments, an extension of the peritoneum that spreads out on both sides of the uterus and attaches to the ovaries and uterine tubes. The Uterus The uterus is the size and shape of a mediumsized pear- about 7.5 cm long and 5 cm wide. It is slightly flattened anteroposteriorly and is oriented in the pelvic cavity with the larger, rounded part, the fundus, directed superiorly and the narrower part, the cervix, directed inferiorly. The main part of the uterus, the body, is between the fundus and the cervix. A slight constriction called the isthmus marks the junction of the cervix and the body. Internally, the uterine cavity continues as the cervical canal, which opens through the ostium into the vagina. The uterus is supported by the broad ligament, a peritoneal fold extending from the lateral margins of the uterus to the wall of the pelvis on either side; the round ligaments, extend from the uterus through the inguinal canals to the labia majora of the external genitalia; and the uterosacral ligaments, attach the lateral wall of the uterus to the sacrum. Normally, the uterus is anteverted, meaning the body of the uterus is tipped slightly anteriorly. In addition to ligaments, skeletal muscles of the pelvic floor support the uterus inferiorly. The uterine wall is composed of three layers. First, the peritoneum or serous layer is the one which covers the uterus. The next layer is the myometrium or muscular layer, composed of a thick layer of smooth muscles and accounts for the bulk of the uterine wall. It is also the thickest layer of smooth muscle in the body. The innermost layer of the uterus is the endometrium or mucous membrane, which consist of a simple columnar epithelial lining and a connective tissue layer called lamina propria. Simple tubular glands, called spiral glands, are scattered about the lamina propria and open through the epithelium into the uterine cavity. The endometrium consists of two layers: a thin and basal layer and the thick, superficial functional layer that lines the cavity itself. Small spiral arteries of the lamina propria supply blood to the functional layer of endometrium. These blood vessels play important role in the cyclic changes in the endometrium.

30

Uterine Cycle The term uterine cycle refers to the changes that occur primarily in the endometrium of the uterus during the menstrual cycle. Cyclic secretions of estrogen and progesterone are the primary cause of these changes. The endometrium of the uterus begins to proliferate after menses. The remaining epithelial cells rapidly divide and replace the cells of the functional layer that were sloughed during the last menses. A relatively uniform layer of low cuboidal endometrial cells is produced. The cells later become columnar, and the layer of the cells folds to form tubular spiral glands. Blood vessels called spiral arteries project through the delicate connective tissue that separates the individual spiral glands to supply nutrients to the endometrial cells. After ovulation, the endometrium becomes thicker, and the spiral glands develop to a greater extent and begin to secrete small amounts of a fluid rich in glycogen. Approximately 7 days after ovulation, or about 21 days of menstrual cycle, the endometrium is prepared to receive a developing embryonic mass, if fertilization has occurred. Formation of the Placenta The placenta is a highly vascular disk, 15 to 20 centimeters in diameter and 2.5 centimeters thick, that develops from both embryonic and maternal tissue. It is usually formed and fully functioning by the end of the embryonic period. After the infant is born, the placenta is expelled from the uterus as the afterbirth. The placenta develops as chorionic villi from the embryo penetarate the endometrium of the uterus. As this occurs, the villi become highly vascular and these vessels extend to the umbilical arteries and umbilical vein. The spaces in the endometrium surrounding the villi are filled with maternal blood. Oxyg en and nutrients diffuse from the mothers blood into the fetal blood, and metabolic wastes, including carbon dioxide, diffuse from the fetal blood into the maternal blood. The membranes of the fetal capillaries and chorionic villi normally keep the featl and maternal blood from actually mixing. By the diffusion of the substances across the membranes, the placenta functions as a nutritive, respiratory, and excretory organ, it also secretes hormones and thus functions as a temporary endocrine gland. The human chorionic gonadotropin hormone is similar to luteinizing hormone from anterior pituitary and maintains mothers corpus luteum for first two months of pregnancy. The estrogen helps maintain endometrium, stimulates mammary gland development, inhibits follicle-stimulating hormone, and increases uterine sensitivity to oxytocin. And lastly, the progesterone hormone that is responsible for the inhibition prolactin and follicle stimulating hormone.

31

The Urinary System

The urinary system consists of all the organs involved in the formation and release of urine. It includes the kidneys, ureters, bladder and urethra. One quarter to one fifth of cardiac output passes through the kidneys at all times. This means that the kidneys filter approximately 1.2 liters of blood every minute. It is therefore not surprising that even slight abnormalities of renal function quickly lead to electrolyte disturbances. The kidneys are located near the vertebral column at the small of the back; the left kidney lying a little higher than the right. Each is identical in structure and function. They are bean-shaped, about 10 cm long and 6.5 cm wide. Each kidney comprises an outer cortex and an inner medulla. The kidney is supplied with oxygenated blood via the renal artery and drained of deoxygenated blood by the renal vein. In addition, urine produced by the kidney as part of its excretory function, drains out via narrow tubules and the ureter, in turn connected to the bladder. The main functional unit of the kidney is the nephron. There are approximately one million nephrons per kidney. The role of nephrons is to make urine by: filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large macromolecules like proteins are untouched; recycling the required quantities of useful solutes which then re-enter the bloodstream. The ureters are tubes that are 25-30cm long and lined with smooth muscle. These tubes help carry urine to the bladder. The muscular tissue helps force urine downwards. They enter the bladder at an angle, so urine doesnt flow up the wrong way. Any proteins that are roughly 30 kilodaltons or under can pass freely through the membrane. Although, there is some extra hindrance for negatively charged molecules due to the negative charge of the basement membrane and the podocytes. Any small molecules such as water, glucose, salt (NaCl), amino acids, and urea pass freely into Bowman's space, but cells, platelets and large proteins do not. As a result, the filtrate leaving the Bowman's capsule is very similar to blood plasma in composition as it passes into the proximal convoluted tubule. Together, the glomerulus and Bowman's capsule are called the renal corpuscle. The loop of Henle (sometimes known as the nephron loop) is a U-shaped tube that consists of a descending limb and ascending limb. It begins in the cortex, receiving filtrate from the proximal convoluted tubule, extends into the medulla, and then returns to the cortex to empty into the distal convoluted tubule. Its primary role is to concentrate the salt in the interstitium, the tissue surrounding the loop.

32

Urine leaves the medullary collecting ducts through the renal papilla, emptying into the renal calyces, the renal pelvis, and finally into the bladder via the ureter. Because it has a different embryonic origin than the rest of the nephron (the collecting duct is from endoderm whereas the nephron is from mesoderm), the collecting duct is usually not considered a part of the nephron proper.

Formation of Urine Urine is formed in three steps: Filtration, Reabsorption, and Secretion. Filtration Blood enters the afferent arteriole and flows into the glomerulus. Blood in the glomerulus has both filterable blood components and non-filterable blood components. Filterable blood components move toward the inside of the glomerulus while non-filterable blood components bypass the filtration process by exiting through the efferent arteriole.

Reabsorption This reabsorption process allows water (H2O) to pass from the glomerular filtrate back into the circulatory system. Glucose and various amino acids also are reabsorbed into the circulatory system. These nutrients have carrier molecules that claim the glomerular molecule and release it back into the circulatory system. If all of the carrier molecules are used up, excess glucose or amino acids are set free into the urine Secretion Some substances are removed from blood through the peritubular capillary network into the distal convoluted tubule or collecting duct. These substances are Hydrogen ions, creatinine, and drugs. Urine is a collection of substances that have not been reabsorbed during glomerular filtration or tubular reabsorbtion. Water Regulation by the Kidneys Most of the control of water conservation takes place in the distal and collecting tubules of the nephrons under control of anti-diuretic hormone, (ADH), sometimes called vasopressin. This hormone is released by the posterior pituitary under control of the hypothalamus in the midbrain area. The hypothalamus monitors the water content of the blood. If the blood contains too little water (indicating dehydration) then more ADH is released. If the blood contains too much water (indicating over-hydration) then less ADH is released into the blood stream.

33

Renin-Angiotensin-Aldosterone System The long-term control of blood pressure is via the renin-angiotensin-aldosterone (RAA) system. This system is also one of the body's compensatory mechanisms to a fall in blood pressure. The kidneys release renin into the bloodstream and this converts angiotensinogen to angiotensin I which in turn is converted to angiotensin II by angiotensin converting enzyme in the capillaries of the lungs. Under the influence of Angiotensin II, aldosterone levels increase. This increases blood sodium levels by decreasing the amount of salt excreted by the kidneys. Retaining salt instead of excreting it into urine increases the osmolarity of the blood and so the blood volume. As the volume increases, so does the blood pressure. Angiotensin II is also a potent vasoconstrictor which raises blood pressure by increasing vascular resistance.

The Circulatory System

The human circulatory system is responsible for delivering food, oxygen, and other needed substances to all cells in all parts of the body while taking away waste products. As blood circulates around the body, it picks up oxygen from the lungs, nutrients from the small intestine, and hormones from the endocrine glands, and delivers these to the cells. Blood then picks up carbon dioxide and cellular wastes from cells and delivers these to the lungs and kidneys, where they are excreted. Systemic Circulation Systemic blood circulation is a part of cardiovascular system or circulatory system. Circulatory system is divided in two parts systemic circulation and pulmonary circulation. The blood vessels (arteries, veins, and capillaries) are responsible for the delivery of oxygen and nutrients to the tissue. Oxygen-rich blood enters the blood vessels through the heart's main artery called the aorta. The forceful contraction of the heart's left ventricle forces the blood into the aorta which then branches into many smaller arteries which run throughout the body.

34

IV. Pathophysiology Narrative

For the actual pathophysiology of Acute renal failure of patient MF, factors that predisposed the client to such disease are her age (38 y/o): increasing age is a risk factor (Brunner & Suddarths 2010), gender (female) and maternal record: G9 T8 P0 A1 L 8 the record indicates multparity, a factor that contributed to placenta accreta (Pilliteri, 2010); the factors that precipitated the disease are diet: himarat ko, puts patient at high risk of fluid retention, the unexpected bleeding and absence of labor pain (February 8, 2012), presence placenta accreta and health belief gatuo ko anang pahilot2x,a possible contributing factor for location deviation of placenta. Patient MF undergone median cesarean incision due to the unexpected bleeding and absence of labor pains, and during the said operation it was discovered that the patient had placenta accreta thus, she had an emergency hysterectomy, and one complication of the operation is possible trauma and compression of the neighbouring structures due to the initial suturing of the uterosacral cardinal ligaments after the removal of uterus. It is believed that during the course of the said suturing, both ureters are traumatized and compressed, as manifested by oliguria the day after surgery: sign positive of ureteral stenosis, a condition where the ureteral lumen narrows, that then eventually resulted to bilateral obstructive uropathy. The said event lead to congestion of urine in the urinary tract specifically on the major and minor calyces which lead to dilatation of the structures, termed as caliectasia, leading to compression of arteries and veins surrounding the calyces. The blood flow on said structures are impeded thus causing hypoperfusion, resulting to decreased glomerular filtration rate and impairing the kidneys function, termed as Acute Renal Failure. Moreover, with the compression of the ureters there is fluid retention; hypervolemia occurs resulting to fluid accumulation in the peritoneum, thorax and fluid shifting from intravascular to intracellular space is also evident. On the other hand, it is believed that the patients acute renal failure is an exacerbation/due to the possible hemorrhage per patients report and intra-operative hemorrhage during two successive operation patient had. With the hemorrhage there is decreased blood volume, resulting to hypoperfusion of the kidneys and decrease glomerular filtration, then impairment of kidney function occurs.

35

Pathophysiology of Acute Renal Failure secondary to Bilateral Obstructive Uropathy secondary to Ureteral Stenosis, Distal third: Status post C/S Hysterectomy Predisposing Factor:
Age: 38 years old (increasing age)- Brunner and Suddarths Gender: Female (pregnancy) Maternal record: G9 T8 P0 A1 L 8 (multiparous: contributed to placenta accreta)- Pilliteri, 2010 History of Abortion- 6th child Unexpected bleeding and absence of labor pain

Precipitating Factor:
- Diet hi arat ko- high risk for fluid retention - Unexpected bleeding and absence of labor pain - Placenta accrete finding - Health Belief: atuo ko anan pahilot x- possible contributing factor for location deviation of placenta

Caesarean section (2/8/12)

ura liters an pa du o nako adto Possible hemorrhage

Placenta accreta Median caesarean incision noted on the abdomen with Radiating pain; 9/10 scale Removal of whole uterus (hysterectomy) Admitting diagnosis: intra-op hemorrhage CBC (2/15/12): RBC-3.17 10^6/uL, Hgb-9.5 g/dL, Hct- 27.1%

- Paracetamol 500mg 1tab, every 8 hour, PRN for pain

Ureteral compression and trauma due to initial suture on the uterosacral cardinal ligaments Stricturing of both ureters that lead to ureteral stenosis, distal third

Decrease circulating blood volume Metabolic Acidosis, partially compensated ABG (2/15/12) pH- 7.29 pCO2- 20.8 mmHg pO2- 101.5 mmHg HCO3- 10.0 mmol/L

8 \ \

36

2/22/12 Percutaneous Tube Nephrostomy, bilateral: failed - Punture from nephrostomy procedure - Flank pain; radiating Oliguria 10cc (2/21/12) UTZ whole abdomen (2/21/12): Bilateral mildmoderate pelvocaliectasia Urine congestion in the calyces Bilateral obstructive Uropathy

Fluid accumulation on the peritoneum

- Tender, slightly bloated and firm abdomen - Crackles noted on the left lung - Abdominal girth- 49in (221-12); 45 in (2-28-12) - Absent bowel sounds

Free fluid collection seen within the left thorax UTZ whole abdomen (2/21/12) result: - ascites, moderate - pleural effusion, left - Generalized edema (2/21&22/12) - Periorbital edema (2/21/12) - Bi-pedal edema pitting edema (2/21&28/12) - Skin turgor is poor - Shiny/glossy and warm-to-touch skin - Capillary refill- 3 secs - BP- 140/80 mmHg - (+) numbness on lower extremities - (+) tin lin on sa ako ka ot

Compression of arteries and veins around the calyces

hypervolemia

Hypoperfusion Decreased glomerular filtration rate

Blood Chemistry (2/23/12)Creatinine22.5 mg/dl

Fluid shifts from intravascular to intracellular compartment

Impaired Kidney Function

Acute renal failure

Hemodialysis (2/28/12)

- Ketosteril 1tab, TID, PO - Amlodipine 10mg, 1tab, OD - Nifedipine 5mg 1 tab, OD every 6 hours, Hold if BP 140/90 - Furosemide 60mg IV, every 8 hours

- NaHCO3 1tab, TID, PO - CaCo3 1tab, TID, PO

- Blood Transfusion 2 units of PRBC (2/28/12)

37

1 - Dx: Excess fluid volume related to intravascular fluid shifting secondary to acute renal failure - Ix: 1. Monitor intake and output 2. Proper positioning of edematous extremity; elevate by use of small pillow 3. Monitor v/s 4. Auscultate lung and heart sounds. 5. Provide for scheduled rest periods. 6. Assist client to ambulate 7. Assist to perform active ROM exercises - Dependent: Hemodialysis

2 - Dx: Altered body temperature r/t immune system defense mechanism - Ix: 1. Perform tepid sponge bath. 2. Promote bed rest 3. Provide cool circulating air using a fan. 4. Measure input and output. 5. Control environment al temperature. Move victim to cooler area out of direct sunlight. 6. Remove excess clothing and covers. 7. Turn to sides every 2hours

3 - Dx: Acute abdominal pain related to presence of incision median site on lower abdomen secondary to cesarean section operation - Ix: 1. Instruct to do deep breathing exercises 2. Provide a calm and quiet environment. 3. Provide diversion activities such as chatting, reading newspaper, guided imagery 4. Place the client according to her desired position of comfort. 5. Proper splinting of incision sight when there is an urge to cough 6. Provide rest periods.

4 -Dx: Impaired tissue integrity related to presence of median incision site on lower abdomen secondary to caesarean section delivery - Ix: 1. Instruct patient to keep site clean and dry 2. Remove any sharp objects within patients environment 3. Instruct patient to splint when coughing 4. Elevate head of bed to at least 30 degree 5. Teach the patient about the importance of eating protein-rich foods such as fish, meat, beans and legumes 6. Instruct the patient to avoid straining when defecating 7. Teach patient about proper wound care such as changing of dressings when saturated and at least once every 3 days 8. Encourage splinting of wound when coughing

38

5 - Dx: Impaired skin integrity related to bilateral edema secondary to acute renal failure - Ix: 1. Change dressings frequently 2. Use appropriate barrier dressings or wound coverings 3. Maintain/ instruct in overall skin hygiene (e.g. wash thoroughly, pat dry, gently massage with lotion or moisturizer) 4. Apply simultaneou s warm and cold compress

6 - Dx: Risk for Infection related to inadequate primary and secondary defences - Ix: 1. Encourage patient to promote proper hygiene such as hand washing 2. Assist in changing the dressing aseptically. 3. Encourage patient to perform active ROM exercises such as rotation of feet and ankle for at least 10 mins. 4. Encourage patient to eat foods high in protein such as fish, and red meat.

7 - Dx: Impaired physical mobility related to pain and discomfort - Ix: 1. Assist or have client reposition self on a regular schedule. 2. Schedule activities with adequate rest periods. 3. Do active ROM exercises like flexion and extension of wrist and lower extremities. 4. Turn to sides every 2 hours. 5. Support body parts or joints using pillows, towel roll. 8 \ \ - Dx: Self-care deficit; bathing and dressing related to acute abdominal pain and discomfort secondary to presence of incision site - Ix: 1. Involve client in formulation of plan of care at level of ability. 2. Assist client in bathing. Allow the client to sit while bathing. provide and Promote privacy. 3. Assist client in shampooing. Provide rationale of hair care. 4. Assist client in dressing. Maintain privacy of the client. 5. Instruct the client to combed hair.

39

Legend: Disease process Signs and symptoms Laboratory results Surgical interventions Medical interventions Medications Cause Present disease condition

Nursing Care Plan

40

V. Medical Management
Ideal Management Treatment for acute kidney failure typically requires a hospital stay. Most people with acute kidney failure are already hospitalized. How long you'll stay in the hospital depends on the reason for your acute kidney failure and how quickly your kidneys recover. A. Treating the underlying cause of your kidney failure Treatment for acute kidney failure involves identifying the illness or injury that originally damaged your kidneys. Your treatment options will depend on what's causing your kidney failure. B. Treating complications until your kidneys recover Your doctor will also work to prevent complications and allow your kidneys time to heal. Treatments that help prevent complications include:

C. Treatments to balance the amount of fluids in your blood. Acute kidney failure is sometimes caused by a lack of fluids in your blood. In this case, your doctor may recommend intravenous fluids. In other cases, acute kidney failure may cause you to have too much body fluid, leading to swelling in your arms and legs. In these cases, your doctor may recommend medications (diuretics) to cause your body to expel extra fluids. D. Medications to control blood potassium. If your kidneys aren't properly filtering potassium from your blood, your doctor may prescribe calcium, glucose or sodium polystyrene sulfonate (Kayexalate) to prevent the accumulation of high levels of potassium in your blood. Too much potassium in the blood can cause dangerous irregular heartbeats (arrhythmias).

E. Medications to restore blood calcium levels. If the levels of calcium in your blood drop too low, your doctor may recommend an infusion of calcium.

41

F. Dialysis to remove toxins from your blood. If toxins build up in your blood, you may need to undergo temporary hemodialysis often referred to simply as dialysis to help remove toxins and excess fluids from your body while your kidneys heal. Dialysis may also help remove excess potassium from your body. During dialysis, a machine pumps blood out of your body through an artificial kidney (dialyzer) that filters out waste. The blood is then returned to your body. G. Management Acute renal failure often is preventable. Risk factors for this condition include diabetes mellitus, chronic renal insufficiency, heart failure, and advanced age. Many medications can injure the kidneys. Dosing schedules can help prevent acute renal failure. For example, acute renal failure is less likely to develop with a oncedaily dose of an aminoglycoside than with multiple daily doses. 14 When acute renal failure is diagnosed, the cause(s) must be identified and treated. Critical measures include maintaining adequate intravascular volume and mean arterial pressure, discontinuing all nephrotoxic drugs, and eliminating exposure to any other nephrotoxins Electrolyte abnormalities must be corrected, and urine output should be monitored closely. Pigment or uric acid exposure can be treated with alkaline diuresis. Ethylene glycol or methanol poisoning should be treated with an alcohol drip or with fomepizole (Antizol).

42

Actual Management Date 02/18/12 02/29/12 Order Venoclysis of PNSS1L to run at KVO rate. Rationale NSS is a solution of common salt in distilled water, of strength of 0.9%. It is called normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. It is an isotonic solution. It is less irritating for the body cells. It is used to patients with salt and water deprivation. KVO rate is ordered for prophylactic access.

02/18/12

Diet as Tolerated (DAT) Low sodium diet

To attain optimal growth, tissue repair and normal functioning of the organs. For maintenance of nutrition & for promotion of wellness through food intake via regular diet per orem. Low sodium diet prevents further accumulation and fluid shifting in the intravascular space thus reduces progression of fluid retention.

2/18/12

I & O q shift and VS q 4

This measures how much fluids are taken and how much has been excreted. This also indicates possible problem in the kidneys especially when output is significantly reduced when intake is of large amount. Monitoring the vital signs in significant to evaluate the 43

clients well being. It serves as a baseline data for comparison if abnormalities is likely to be determined such as that of hyperthermia which may indicate infection and high BP that may result to more complications.

2/18/12

Fluid Restriction 500cc/day

In between dialysis sessions, fluid can build up in the body. Too much fluid will lead to shortness of breath, an emergency that needs immediate medical attention. This would also reduce progression of ascites and edema associated with acute renal failure. Indicated for: 1.) Central venous access for infusion of vasoactive drugs, TPN, high dose KCl, etc. 2.) Hemorrhagic disorder where large volumes blood/blood products needed 3.) Measurement of central venous pressure 4.) Need for frequent blood draws where peripheral access limited. 5.) Lack of peripheral venous access For extracorporeal removing waste products such 44

2/29/12

Intrajugular Vein Catheter Insertion

2/28/12

Hemodialysis

as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure.

02-15-12

Drugs: NaHCO3 1 tab, TID, PO Systemic alkalinizer to correct metabolic acidosis

CaCO3 1 tab, TID, PO

Relief of symptoms of hyperactivity and used as calcium supplement when calcium intake may be inadequate Hypertension Hypertension

Amlodipine 10mg 1 tab, OD Nifedipine 5mg 1 tab, OD every 6 hours, Hold it BP 140/90 Furosemide 60g IV, every 8 hours Paracetamol 500mg itab, every 6 hours, PRN for pain Ketosteril 1 tab TID PO

Treatment of edema associated with renal disease For pain and fever Prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure

45

VI. Drug Study

Generic Name (Brand Name) NaHCO3 Dosage, Frequency , Route 1 tab, TID, PO Classification Indication Mechanism of action Side effects Nursing considerations Instruct to avoid milk when administering the drug Monitor electrolyte levels Monitor ABG status Do not take longer than 2 weeks except under advice and supervision of a physician Provide adequate fluid intake based on the modified diet

Antacid

Systemic alkalinizer to correct metabolic acidosis

Short acting, potent systemic antacid. Rapidly neutralizes gastric acid to form NaCl, CO and HO. After absorption, plasma alkali reserve is increased and excess Na and bicarbonate ions are excreted in urine, thus rendering urine less acid

Belching Gastric distention Hypokalemia Hypocalcemi a Dehydration

46

CaCO3

1 tab, TID, PO

Fluid and electrolyte replacement; Antacid

Relief of symptoms of hyperactivit y Used as calcium supplement when calcium intake may be inadequate

Rapid acting antacid with high neutralizing capacity and relatively prolonged duration of action. Decreases gastric acidity, thereby inhibiting proteolytic action of pepsin on gastric mucosa.

Mood and mental changes Hypercalcem ia Nausea and vomiting Flatulence

Avoid taking CaCO3 with cereals or other foods high in oxalates Do not take vitamin D or Sodium CO3 when taking CaCO3 Do not continue this medication beyond 1-2 week, since it may cause acid rebound Monitor serum and urine calcium weekly Note number and consistency Take drug prescribed, do not double or skip dose Avoid hazardous activities until stabilized on drug Avoid OTC drugs, grapefruit juice unless directed by prescriber 47

Amlodipine

10mg 1 tab, OD

Antianginal; Antihypertensi ve

Hypertension Inhibits calcium ion influx across cell membrane during cardiac depolarization; Produces relaxation of coronary vascular smooth muscle, peripheral vascular smooth muscle

Gastric upset Fatigue Headache Dizziness Palpitation Nausea and vomiting Diarrhea

 Change positions slowly to prevent orthostatic hypotension Continue with good oral hygiene to prevent gingival disease Provide safety measures such as raising of side rails Access to nearest Comfort room or bedside commode Provide adequate rest periods Monitor v/s Nifedipine 5mg 1 tab, OD every 6 hours, Hold if BP 140/90 Calcium channel blocker Hypertension Dilates coronary arteries; relaxes coronary vascular smooth muscle; dilates peripheral arteries Palpitations Headache Dizziness Drowsiness Fatigue Tachycardia Light headedness Avoid hazardous activities until stabilized on drug, dizziness is no longer a problem Limit caffeine consumption; Take no alcohol Avoid OTC drugs unless directed by a prescriber Increase fluid intake to prevent dehydration Change position 48

slowly to avoid orthostatic hypotension Provide safety measures such as raising of side rails Provide adequate rest periods Monitor v/s

Furosemide

60g IV, every 8 hours

Loop Diurertic

For edema associated with renal disease

Inhibits the reabsorption of sodium and chloride from the ascending limb of the loop of Henle, leading to a sodium-rich dieresis

Dizziness Headache Drowsiness Fatigue Blurred vision Orthostatic hypotension Thrombophle bitis Rash n/v anorexia constipation diarrhea

Administer with food or milk to prevent GI upset Reduce dosage if given with other antihypertensive; readjust dosage gradually as BP responds. Monitor v/s Monitor intake and output Give early in the day so that increased urination will not disturb sleep Measure and weight to monitor fluid change, on 49

the same day, with the same clothes and the same measuring scale Provide safety measures such as raising of side rails Provide adequate rest periods Access to the nearest comfort room or bedside commode Provide adequate food intake that is based on the modified diet

Paracetamol

500mg itab, every 6 hours, PRN for pain

Antipyretic Analgesic (non-opiod)

For pain and fever.

Antipyretic: reduces fever by acting directly on the hypothalamic heatregulating center to cause vasodilation and sweating, which helps dissipate heat. Analgesic: site and mechanism of action unclear.

Headache Give drug with food if GI upset occurs Chest pain D/c drug if Dyspnea hypersensitivity Acute kidney reactions occur. failure Report rash, Hypersensitivi unusual bleeding ty: rash, fever or bruising, yellowing of skin or eyes, changing in voiding patterns. Monitor v/s Elevate the head of the bed Provide adequate 50

rest periods Provide tepid sponge bath Provide adequate fluid intake

Ketosteril

1 tab TID PO

Ketoanalogs; Essential amino acids

Prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure

Normalizes metabolic process, promotes recycling product exchange. Reduces ion concentration of potassium, magnesium and phosphate.

Hypercalcemi a

Evaluate for any contraindications Take drug as prescribed Warn the patient about possible side effects and how to recognize them Give with food if GI upset occurs Frequently assess for hypercalcemia

51

VII. Nursing Care Plans

Nursing Care Plan #1

Asessment Subjective Cues: Gahupong ako tiil, bug-atan sad ko maong di ko ganahan mulihok as verbalized by patient.

Diagnosis Excess fluid volume related to intravascular fluid shifting secondary to acute renal failure

Planning Short term: At the end of 1 hour, the patient will be able to: 1. Demonstrate behavior change on diet modification to reduce progression of fluid retention 2. Participate on medical and nursing interventions that reduces risk of further fluid retention

Interventions Independent 1. Monitor intake and output

Rationale

Evaluation

Low urine output less than 400ml/day may be first indicator of acute failure. Accurate I&O is necessary for determining fluid replacement needs and reducing risk for fluid overload.

Objective Cues: Periorbital edema noted Bipedal pitting edema noted Oliguria(10cc) noted Weight gain from 50kg- 56kg

At the end of 1hour nursing interventions, goals were partially met; client adhered to diet modification (low sodium diet), performed active ROM. However, client still hesitates to ambulate.

2. Proper positioning of edematous extremity; elevate by use of small pillow

Promotes backflow and return of proper circulation

Long term: At the end of 32 hours,

3. Monitor v/s

Serves as baseline data for comparison to detect abnormalities

At the end of 16hours 52

 V/S: BP = 140/80mmHg Lab results: 02/21/12 Ultrasound; Whole abdomen : Moderate Ascites revealed Pleural Effusion on left lung 02/23/12 Blood Chemistry Report: Creatinine = 22.5mg/dl (increased)

the patient will be able to: 1. Improve status as evidenced by decreased BP(130/80mmHg, creatinine level within normal limits, reduced/absent bipedal pitting edema, weight loss to usual weight.

for immediate referral. This prevents further complication of the clients condition

nursing interventions, goals were partially met. BP reduced to 120/80mmHg but edema is still present.

4. Auscultate lung and heart sounds.

Fluid overload may lead to pulmonary edema and HF hypoxia.

5. Provide for scheduled rest periods.

Bed rest can induce dieresis related to diminished peripheral venous pooling resulting in increase intravascular volume and GFR Ambulation promotes circulation to the peripheries.

6. Assist client to ambulate

7. Assist to perform active ROM exercises

This promotes circulation

53

Dependent: Administer as ordered: Nifedipine 5mg 1 tab, OD every 6 hours, Hold if BP 140/90 Amiodipine10mg 1 tab, OD Treatment of Hypertension

Treatment of hypertension

Hemodialysis

For extracorporeal removing waste products such as creatinine and urea, as well as free water from the blood when the kidneys are in renal failure.

54

Nursing Care Plan #2 Assessment Subjective cues: Init kaayo akong paminaw as verbalized by MF Diagnosis Altered body temperature r/t immune system defense mechanism Planning Short term: At the end of 30 mins, MFs temperature will lower down from 38.1C to 36.547.5C Perform tepid sponge bath. Enhances loss by oration conduction Intervention Independent: Rationale Evaluation Short term: heat The objective was evapmet: The patients and temperature lowered down from 38.1C to 36.8C.

Promote bed rest .

Reduces body heat production Long term:

Objective cues: Skin warm to touch at 38.1C temperature Weakness noted Body malaise noted Provide circulating using a fan. Measure and output. cool air The objectives were Dissipates heat by met. MF maintained convection. body temperature within normal limits Fluid resuscitation may be necessary to correct dehydration. The patient who is significantly dehydrated is no longer able to sweat, which allow 55

Long term: At the end of 8hrs, MFs temperature will maintain within normal limits.

input

Lab result: WBC 2.7 10^u3/uL (decreased) Monocytes 19.9 % (increased) Eosinophils 4.9 %(increased) Control environmental temperature. Move victim to cooler area out of direct sunlight. Remove clothing covers. excess and -

for evaporative cooling hyperthermia.

Removing resources of heat can begin cooling process and reduce core necrosis.

This decreases warmth and increases evaporative cooling.

Turn to sides every 2hours

Promotes ventilation

56

Dependent: Administer oxygen at 2L/min as ordered Paracetamol 500mg 1tab, every 6 hours, PRN for pain Hyperthermia increases metabolic demand for oxygen.

To lower down fever and relieve pain

57

Nursing Care Plan #3

Assessment Subjective Cues: Magtukar ang sakit sa ako tahi. Mukatay dayon sa ako tiyan. Musakit pud ako likod ug apil as verbalized by the pt Onset: Mukalit lang lagi ang sakit Duration: Dugay2x pud lagi. Mga pila pud ka minuto Location: Sa ako tahi,

Diagnosis Acute abdominal pain related to presence of incision median site on lower abdomen secondary to cesarean section operation

Planning Short Term: At the end of 30 mins. of giving nursing interventions, the patient will be able to: Be informed regarding methods that provide relief of condition. Verbalize understanding about the condition and therapy regimen. Participate in interventions that lessens pain Long Term:

Intervention Independent: Instruct to do deep breathing exercises Provide a calm and quiet environment. Provide diversion activities such as chatting, reading newspaper, guided imagery Place the client according to

Rationale

Evaluation Short Term: After 30 mins. of giving nursing interventions, goals met; MF participated in independent interventions to relieve pain.

Promotes relaxation and decrease of pain Decrease stimuli that causes pain

Long Term: After 8 hours of giving nursing interventions, goals were met as evidence by; Adherence to pharmacologic intervention Verbalization of lowered pain scale of 5/10 from 9/10. Other symptoms were no longer 58

Distracts and diverts attention of pain

relieves the pain felt and

mukatay dayon sa tiyan pati sa ako likod Pain Scale: mga 9 Aggravating Factor: Kung maglihok ko How relieved: Dili ko maglihuka, magingkod nalang pud ko kaysa maghigda kay masakit man gud Associated symptoms: Mawad-an kog gana magkaon, maluyahan kog samot

At the end of 8 hours of giving nursing interventions, the patient will be able to: Verbalize significant reduction of pain scale from 9 to 5/10 Demonstrate independence in continuing demonstration of techniques and activities that reduces pain.

her desired position of comfort Proper splinting of incision sight when there is an urge to cough Provide rest periods

promotes comfort

evident such as that of facial grimacing, moaning ang guarding behavior

Prevents precipitatio n of pain on the area

Facilitates reduction of pain

Dependent: Administer as ordered: 500mg 1tab, every 6 hours, PRN for pain Helps relieve and alleviate pain

59

Objective Cues: Guardin g behavior noted; incision site Moaning Facial grimacin g noted Slowed moveme nt noted

60

NURSING CARE PLAN #4 Assessment Subjective Cues: Gi caesarean ko gikan naghupong akong duha ka tiil as verbalized by MF Diagnosis Impaired tissue integrity related to presence of median incision site on lower abdomen secondary to caesarean section delivery Planning Short term: At the end of 30 minutes of nursing interventions the patient will be able to: Demonstrate practices that would prevent complications of wound such as wound care and proper hygiene Interventions Independent: Instruct patient to keep site clean and dry To prevent moisture that would promote the growth of bacteria To prevent further damage to tissue integrity At the end of 30 minutes of nursing interventions, the following goal was completely met. MF complied to interventions to improve tissue integrity Rationale Evaluation

Remove any sharp objects within patients environment

Objective Cues: Presence of median incision site on lower abdomen Soiled dressing noted

Long term: At the end of 8 hours of nursing interventions patient will be able to: Display timely healing of wound as evidenced by: tissue healing Instruct patient to splint when coughing To prevent abrasion and further breakage of tissue integrity At the end of 8 hours of nursing interventions, the following goal were partially met; temperature reduced to 36.5C, dressing promote lung was not changed expansion and breathing

Elevate head of bed to at least 30 degrees

61

 Weight: 56kg

V/S: BP= 140/80m mHg T= 38.1C

Maintain a complicationfree wound as evidenced by absence of pus around surgical wound area

Teach the patient about the importance of eating protein-rich foods such as fish, meat, beans and legumes Instruct the patient to avoid straining when defecating

Protein is an essential component that facilitates wound healing

Increased abdominal pressure can contribute to the disintegratio n of the suture. To prevent further complication s of wound such as infection of wound.

Teach patient about proper wound care such as changing of dressings when saturated and at least once every 3 days Encourage splinting of wound when

To reduce pain

62

coughing

Dependent: Administer as ordered: Ketosteril 1 tab TID PO Promotes healing and prevention and treatment of conditions caused by modified or insufficient protein metabolism in chronic renal failure

63

NURSING CARE PLAN #5 Assessment Subjective Cues: naghupong akong duha ka tiil as verbalized by MF nidako pud ako tiyan, murag tubig ra ang sulod as verbalized by MF gi-cesarean ko gikan as verbalized by MF Diagnosis Impaired skin integrity related to bilateral edema secondary to acute renal failure Planning Short term: At the end of 2 hours of nursing interventions and health teachings the patient will be able to: Participate in prevention measures and treatment program Verbalize feelings of increased selfesteem and ability to manage situations Maintain optimal nutrition/ physical wellbeing Interventions Independent: Rationale Evaluation Short term: At the end of 2 hours of nursing intervention Goals are met: MF complied with interventions to improve skin integrity. Long term: At the end of 8hours nursing intervention, goals were partially met; there was decrease of abdominal girth from 49in to 44in. However, bipedal edema is still present

Change dressings frequently

To reduce the risk for complication and minimize the risk for infection To protect wound and surrounding tissue from excoriating secretions/ drainage and to promote wound healing To provide barrier to infection, reduce risk of dermal trauma, , and enhance comfort

Use appropriate barrier dressings or wound coverings

Objective Cues: Presence of median incision site on lower

Maintain/ instruct in overall skin hygiene (e.g. wash thoroughly, pat dry, gently massage with

64

abdomen Long term: Soiled dressing noted Shiny, bipedal pitting edema on lower extremitie s noted Moderate ascites noted Weight: 56kg V/S: BP= 140/80m mHg T= 38.1C At the end of 8 hours of nursing interventions and health teachings, the patient will be able to: Display timely healing of wound without complications Promote lifestyle changes to promote health and well-being

lotion or moisturizer) Apply simultaneous warm and cold compress To increase feeling of comfort

Dependent: Administer Furosemide 60mg IV every 8 hours Treatment of edema associated with renal disease

65

NURSING CARE PLAN #6 Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective cues: wala pay ilis akong dressing sa akong tahi sa caesarean sukad sa operasyon, as verbalized by the patient

Risk for Infection related to inadequate primary and secondary defences

Short- term: At the end of 8 hours of giving nursing interventions, the patient will: Verbalize ways to prevent possible occurrence of infection. Demonstrate ways on proper wound dressing. Long- term: At the end of 2 days of giving nursing interventions, the patient will: Manifest no signs of infection such

Independent: Encourage patient to promote proper hygiene such as hand washing Assist in changing the dressing aseptically. Encourage patient to perform active ROM exercises such as rotation of feet and ankle for at least 10 mins. Encourage patient to eat foods high in protein such as -To prevent the spread of infection.

Short Term: At the end of 8hours nursing intervention, goals were partially met; MF demonstrated active ROM exercises however, wound dressing was not changed. Long Term: -To promote blood circulation especially on the lower extremities and to promote faster healing. At the end 2days nursing intervention, goals were partially met; clients temp decreased from 38.1 to 36.5C but wound healing was still not achieved.

-To prevent infection.

Objective cues: Lab results (02-23-12) Monocyte 2.6 % (4.5-10.5 %) (02-29-12) WBC: 2.7 10^u3/uL (4.5-10.5

-Protein rich foods aids in healing.

66

10^u3/Ul) Monocyte 19.9 % presence of FBC since admission (02-15-12) presence of median incision on lower abdomen soiled dressing on the median incision on the abdomen V/S T= 38.1C

as increase body temperature and pain on the incision site.

fish, and red meat. Dependent:

Administer as ordered: 0. NaHCO3 1 tab TID PO Systemic alkalinizer to correct metabolic acidosis Promotes healing and prevention and treatment of conditions caused by modified or insufficient protein metabolis m in chronic renal failure.

1. Ketosteril 1 tab TID PO

67

NURSING CARE PLAN # 7 Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective cues: Bug-atan ko sa akong tiil mao dili ko gusto mo lihok, as verbalized by the patient

Impaired physical mobility related to pain and discomfort

Short- term: At the end of 2 hours of giving nursing interventions, the patient will: Verbalize of understanding of situation and individual treatment, regimen and safety measures. Participate in ADLs and desired activities. Long- term: At the end of 8 hours of giving nursing interventions, the patient will:

Independent:

Short Term: At the end of 2 hours nursing intervention, goals were partially met; MF demonstrated active ROM exercises.

2. Assist or have client reposition self on a regular schedule. 3. Schedule activities with adequate rest periods.

To promote optimal level of function. To prevent fatigue.

Objective cues: Slowed movement noted Guarding behaviour on incision site Sits on bedside oftentimes Facial

Long Term: 4. Do active ROM exercises like flexion and extension of wrist and lower extremities. To prevent muscle atrophy and systemic circulation . To prevent complicati ons like 68 At the end 8 hours nursing intervention, goals were partially met; MF still showed slowed movement and no ambulation.

5. Turn to sides every 2 hours.

grimacing noted

Maintain or increase strength and function.

pressure ulcers. 6. Support body parts or joints using pillows, towel roll. To maintain position of function and reduce risk of pressure ulcers.

Dependent: Administer as ordered: Paracetamol 500mg PRN Treatmen nt of pain

69

NURSING CARE PLAN #8 Assessment Subjective Cues: Bug-atan ko sa akong tiil mao ng di ko ganahan molihok, as verbalized by the patient mahadlok ko magtukar ang sakit sa ako tiyan kung maglihok ko, as verbalized by the patient Objective Cues: Presence of dandruff Foul body odor noted Uncombe d hair noted Slowed movement Unchange d clothes Diagnosis Self-care deficit; bathing and dressing related to acute abdominal pain and discomfort secondary to presence of incision site Planning Interventions Rationale Evaluation Short Term Enhances sense of control and aids in cooperation and maintenance of independence. Sitting while bathing will conserve energy and lessens discomfort. Modesty may lead to reluctance to participate in care. Proper hair care promotes removal of dirt and dandruff that may cause itchiness that may lead to excoriation of the scalp. Providing the client with At the end of 1 hour nursing intervention, the goals were partially met because the patient is still hesitant to move, thus only sponge bath, changing of clothes, and combing of hair were the only activities done by the patient with assistance.

Short- term Independent At the end of 1 hour 1. Involve client in nursing intervention, formulation of the client will be able plan of care at to: level of ability. Demonstrate techniques to meet own needs 2. Assist client in Perform selfbathing. Allow care activities the client to sit such as bathing while bathing. and dressing provide and within own level Promote of ability privacy. Fully bathe self with assistance Demonstrate activities that promote removal 3. Assist client in of dandruff such shampooing. as shampooing Provide Dressed self rationale of hair with assistance care. Combed hair independently Long-term At the end of 16 hours nursing intervention,

Long Term At the end of i6 hours nursing intervention, the goals were partially met. The client still does not want to take 70

(for two days)

the client will be able to: Perform selfcare activities such as bathing and dressing independently Remain free of body odor Have a healthy and dandrufffree scalp

rationale will encourage the patient to continue hair care. 4. Assist client in dressing. Maintain privacy of the client. 5. Instruct the client to combed hair. To facilitate in performing the hygienic practice.

a bath, thus presence of dandruff was still evident.

Combing of hair does not require much energy consumption. Instructing the client to comb her hair promotes independence of performing selfcare activities.

Dependent 1. Administer PCM 500 mg, PRN for pain before bathing and dressing.

Pain relief and client participation reduces discomfort, preserves dignity, &gives a sense of control. 71

VIII. Discharge Plan

RATIONALE OR NURSING CONSIDERATIONS MEDICATION NaHCO3- 1tab, tid, po CaCO3-1tab, tid, po Ketosteril- 1tab, tid, po Amlodipine- 10mg 1 tab, OD -treatment for metabolic acidosis - treat electrolyte imbalance -supply essential proteins in the body -for hypertension

EXERCISE Deep breathing exercises Encouraged bed strenuous activities Active ROM extension of extremities and coughing -promote pulmonary function and prevent atelectasis limit -to reduce exertion and metabolic rate

rest;

exercises; flexion- -Promotes mobility and prevents joint upper and lower stiffness

TREATMENT Hemodialysis twice a week -to remove waste products and excess fluid -to repair ureter stenosis

Ureteroplasty

HEALTH TEACHINGS Medication compliance

-to receive optimum effectiveness for the pharmacologic management of condition -to monitor fluid status -to prevent infection 72

Take BP and weight daily Care on intrajugular vein catheter

Take a bath daily with cold water

-deposition of irritating toxins to skin my cause itchiness; to promote comfort and prevent skin breakdown -promotes faster healing and prevents infection -facilitates pharmacologic treatment and fasten improvement of condition

Wound care; regular dressing

Compliance to diet medication

Importance of hygiene practice

keeping

good -promote well being, increases comfort

Importance of ambulation Compliance to medication

-promotes mobility and proper circulation -for continuous management in treating condition

OUT PATIENT FOLLOW-UP Report to physician after 2 weeks or -evaluate effectiveness of pharmacologic immediately if signs and symptoms and health teachings and to monitor improvement of condition thus preventing worsens complications. Return after hemodialysis a week for -facilitates continuity of treatment

DIET Fluid restriction- <500cc

Facilitate easy ingestion because dysphagia (difficulty swallowing). -it spares protein breakdown

of

High-carbohydrate intake

Avoid potassium and phosphorus- -to aid in electrolyte balance rich foods such as apple, banana, citrus fruits and juices and coffee

73

Reduce intake of salty foods

-to decrease fluid retention and prevent further edema -facilitate in timely wound healing

High protein diet

SPIRITUALITY Promote socialization to family and -to promote expression of anxiety and fear and offer emotional support friends Have time for silence and prayer -to aid in spiritual and emotional health

74

IX. Prognosis
CRITERIA: Good Fair Poor Criteria Interpretation

A. Response of the patient Patient gradually regarding the presence of regained strength. However, retention of the conditions manifestation edema still persists. after its management B. Physiologic response of MF showed the body to disease process improvement of disease condition from medical and nursing interventions given but some clinical manifestations are evident C. symptoms Patient showed associated with the disease improvement from admission, these are condition manifested by the disappearance of the periorbital edema and the decrease of abdominal size; from 49in to 44in D. Performance of the daily Activities were living of the patient during impaired due to pain felt on incision site confinement (e.g. eating, from caesarean toileting, dressing, etc.) section, puncture site from nephrostomy that radiates on abdominal area. E. Compliance of the patient MF is compliant to medical and nursing 75 Relief of

to the medication and/ or interventions. therapy F. Adequacy of rest periods MF reports difficulty of sleeping due to and sleep sudden pain but still reports long hours of sleep G. Consumption of the Pt adheres to diet modification; low sodium diet

patient with nutrition H. Patients

significant SO follows health others behaviour regarding teachings instructed that is beneficiary to the health teaching given by the clients healing the health caregiver and the course. physician

I. Attitude

Shows calmness and complies all procedures and medications given

J. Duration of Illness and MF was admitted for a long period of recovery time(2wks) due to presence of multiple complications K. Precipitating Factors MF was unable to identify factors that precipitated her current admission SO(husband,child, sister-in-law) supports MF through the course of treatment and adheres to fasten 76

M. Family Support

healing process by following instructed health teachings. N. Level of Consciousness MF is fully awake and oriented to the surroundings and to environmental stimulis

CALCULATIONS: Formula: amount # of (good/fair/poor) x 100 = % (Percentile) 13 Amount of: Good = 7 Fair = 3 Poor = 3 Percentile 54% 23% 23%

INTERPRETATION: With a percentage result of 54%, the patient will more likely to have a good prognosis because the nature of the problem is modifiable and is likely to cause complications due to the support system of the client such as the healthcare team and her family. As for the patients response regarding the presence of the conditions manifestations after its management, we gave the criterion a fair mark since some manifestations showed improvement such that of the abdominal girth(49in to 44in). physiologic response of the patient to the disease process was graded fair because she was able to prevent worsening of the disease condition from her present situation, that is, after provision of therapeutic regimen and medication only specific vital signs remain abnormal; blood pressure of 180/100mmHg and respiration rate of 26cpm. The relief of symptoms associated with the disease condition was marked good because the patient had eliminated manifestations of hypertension which includes headache and nausea, and improved her respiratory cycle from 30cpm to 26cpm. In his daily living 77

performances during confinement, the patient displayed poorness. MF is independent on ADL however showed poor compliance related to fear that pain will occur. Moreover, for the compliance of medications and therapy, we gave the criterion a good mark because he was able to adhere to his medications with the proper supervision of the health care staff and the student nurses. For the next criterion, the patients adequacy of rest periods and sleep was also fair because she was able to rest and have long sleeping hours during the hospital stay regardless of the condition of the vicinity but reports difficulty when pain occurs. The consumption of the patient with nutrition was, likewise, good since the patient adheres to diet modification; low sodium diet. For the following criteria, we gave a good mark regarding the patients attitude and his significant others behaviour regarding the health teaching given by the health caregiver and the physician. For the duration of illness and recovery, we rated it as poor. MF is confined for 2weeks already and improvement of condition is still on the process. Poor mark was given to precipitating factors of the patient as she was unable to identify the factors that precipitated the condition and current admission. And lastly for the family support and level of consciousness, we gave both criteria a good mark. Significant others showed support to MF. MFs level of consciousness is that she was responsive, cooperative and coherent and when asked about recent and remote memories she was able to effectively and congruently answer the raised questions.

78

X. Conclusion
This case study motivated and enabled the proponents to acquire information regarding patients with Acute Renal Failure secondary to Bilateral Obstructive Uropathy secondary to Ureteral Stenosis, Distal 3rd ; Status Post Cesarean Section with Hysterectomy and how this disease condition affects the treatment plan on such cases. This condition requires medical attention and management. Nursing care plan were prioritized based on clinical manifestation along with the limitation of the patient resulting from this condition. Based from our patients case, we conclude that acute renal failure is manageable for as long as it is diagnosed early and is given immediate attention before severe complications occur. The patient also plays the most vital role in the prevention and treatment of her disease condition because she has to actively cooperate in her treatment regimen. Her compliance to all medicines, diagnostic procedures and medical instructions must be further accomplished.

In the case of our patient with efficient teamwork, health teachings and compliance to the necessary interventions and medication regimen, risk for complications was reduced. It is our responsibility to monitor them closely so that we could refer for any abnormal changes immediately thus preventing further harm considering the health of our patient. So far in the current status of our patient is still in her current medications and at the same time in the active stage of her disease condition. We were able to provide further details about the said diagnosis through methodical research and teamwork, we were able to establish and at the same time expand our overall knowledge and skills in nursing practice and the importance which will were conveyed by our clinical instructors.

In conclusion, this case can be means of awareness to everyone and will be utilized by the nurses as means of improving ones knowledge and skills in managing such disease.

79

XI. Recommendation
This case study is recommended to the academic community, health care team members, and to the public. This will significantly help nurses, students, and the other health care givers to be equipped with the knowledge and skills in giving healthcare to patients with this type of disease. For the academic community, it would be a beneficial source for the future researchers for further study regarding Acute Renal Failure secondary to bilateral obstructive uropathy, secondary to ureteral stenosis, distal 3rd status post CS hysterectomy including the cause and management of the complications. The members of the health care team is also recommended to have a thorough assessment in order to come up with the best pharmacologic and non-pharmacologic interventions that they could give to the patients with this disease condition and be prepared in proper management for the future abnormalities that could happen to patients with this complication. This will serve as a future reference for the student nurses in order to have an organization of thought for their case presentations. Significant others are affected with the patients condition emotionally, socially and financially. It is important to provide health education about the disease process for better understanding. Health teaching must be focused on compliance to medication as well as the strict adherence to activity and rest patterns. Student nurses and other health care providers should have numerous books regarding urinary system, be updated about the disease and incorporate it with the desired care plan. Through this, they can prevent patients with Acute Renal Failure secondary to bilateral obstructive uropathy, secondary to ureteral stenosis, distal 3rd status post CS hysterectomy from developing severe complications, preserve patients health and promote wellness. It is advised to collaborate with the other health care providers and the significant others as well. It is recommended that further evaluation will be done to effectively evaluate the patient due to patients non-compliance of medication interventions. Patients also need to be evaluated on compliance to outpatient treatment regimen. Finally, it is also 80

recommended to the public, to gain information and knowledge from this case study. This case study would help the public gain some facts regarding the complications, its signs and symptoms, and its treatment.

81

XII. Bibliography

TEXTBOOKS
Black, J. & Jane H. Hawks (2009). Medical-Surgical Nursing: Clinical Management for Positive Outcomes th (8 Ed.). Saunders Elsevier. Singapore: 499-500. Smeltzer, S., Bare, B. et al.. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (12th Ed.). Lippincott Williams & Wilkins. Philadelphia. Karch, Amy M. RN, MS (2010). Lippincotts Nursing Drug Guide. Lippincott Williams & Wilkins, New York Schrock(1994). Handbook of Surgery (10 Edition). USA: Jones Medical Publication, pg 665 Pathophysiology.USA: Lippincott Williams & Wilkins, pg 231 Corbett(1987). Laboratory tests and diagnostic Edition).Connecticute: Prentice Hall Publishing, pg81 procedures with Nursing diagnosis(2
nd th

Doengers, et al., (2010). Nurses pocket guide. Philidelphia: Lippincott Williams and Wilkins VanPutte, R. & Russo, A. (2011). Seeleys anatomy and physiology(9 Edition). New YorkL The McGrawHill Companies, Inc. Applegate, E. (2006). The anatomy and physiology learning system(3 Edition). USA: Elsevier Inc. Ameerally, P. (2000). Anatomy. UK: Harcourt Publisherss Ltd. Marieb, E. (2006). Essentials of Human anatomy and physiology (8 Ed.) Elsevier(Singapore) Pte Ltd. Singapore
th rd th

82

XIII. Appendices A. Doctors Order

DATE 2/15/2012 TIME 11:30 AM PHYSICIANS ORDERS Patient seen and examined. UTZ Bilateral 1. For cystoscopy, retrograde pyelography possible DJ stention operation once with CP clearance 2. For nephrostomy bilateral once with CP clearance 3. For hemodialysis Endorsed patient to Dr. D 2/16/2012 10:35 AM Still for Hemodyalisis Give Nifedipine 5mg OD 12nn then q6 PRN Follow up UDRL etc Start Amlodipine 10g 1tab OD Continue Meds Repeat Crea, CBC with pH, K FF-up URDL, Hep B and HIV for Dialysis Continue Medication Will refer to Nephro Refer accordingly Pls follow up labs Advise Percutaneous tube Nephrostomy Bilateral - Not decided yet Still for Dialysis Continue medication To Start NaHCO3 1tab TID CaCO3 tab OD Give NaHCO3 50Meq slow IV To insert NaHCO3 drip (100mEq + 250 cc D5W) WITH 20cc/hr Will refer to Dr. Casino Refer accordingly Urosurgery Management FA Percutaneous Tube Nephrostomy Bilateral Hysterectomy LA Secure consent Will refer to Dr. Vallejo Admit to P1F3 Secure consent to cure 83

2/16/2012

6:30 PM

7:50 PM 8:15 PM

2/17/2012

1:30 PM

3:30 pm

2/18/2012

11 AM

DAT Fluid restriction < 500 cc/day Heplock Diagnostics: - CBC with pH - U/A - Na,K,Ca,Mg - Crea,BUN, RBs - ABG Therapeutics: - Furosemide 60g IV - NaHCO3 1tab TID - CaCO3 1tab TID - Ketosteril 1tab TID I&O q shift Monitor v/s q 4 and refer - BP < 90/60 or > 160/90 - HR < 60 or > 110 - RR < 12 or > 30 For Hemodialysis Secure consent for the procedure Repeat serum Crea Post Dialysis Refer to Nephro 11:20 Am 1:15 PM Refer to surgery Repeat Crea, repeat ABG Give Furosemide 80mg IVT now Continue other medications Refer accordingly Rpt Crea Continue meds Refer accordingly

2/19/2012 12NN S (-) fever (-) SOB I: 600 O: 80 O- BP 130/90 Still no consent for Hemodialysis 11 AM Crea 12.2

84

URO Notes Pt withdrew consent for nephrostomy Gets hemodialysis 2/20/2012 10 AM For E of 412 of UA For rpt ABG Rpt Crea, Na, K Continue medications Refer to surgery for possible Percutaneous Nephropathy Refer accordingly Refer to OROSURGERY for possible stent insertion/ retrograde pyelography Refer for surgery (Uro subspe Dr. Eduave)- done Requested for lop 100mg Continue medications Refer accordingly

2/21/2012 11AM S: (-) urine output (+) (-) SOB I: 180 O: 0 BP: 150/100 Clear ECE, (+) bipedal edema Crea: 15.4 2/22/2012 11AM

4PM S: (-) SOB (-) fever U/O: 0 BP: 150/100 Clear ECE, CW (+) bipedal edema

For Percutaneous tube nephropathy bilateral under local anesthesia Secure consent Please refer Continue medications Refer accordingly

85

10:30PM

10:35PM

URO NOTES - Attempted Percutaneous tube nephropathy bilateral - Maximize management - Hemodialysis is suggested - For CBC, - Back to ward Surgical Plasma ONCE CP observed 1. Cystoscopy, retrograde pyelography, stenting Exlap Refer to surgery- Urosurgery for re-evaluation BP monitoring q 1hour Repeat CBC, Repeat APTT, protime, clotting time, bleeding time Close watch Repeat ECG 12 leads O2 inhalation at 2-3L/minvia nasal cannula Refer for onset of chest pain or discomfort Repeat ECG 12 leads at 6AM CBR w/o TP For repeat CBC Repeat ECG 12 leads Cleared for Cystoscopy,Retrograde Pyelography, Uretral Stenosis

2/23/2012 12:15 AM Referred to bleeding for post OR Awake, coherent

1:05 AM BP: 130/90 ECG: (-) chest pain 9:30AM Rounds with Dr.Casino

9:40 AM Refer to Dr. Carprio OR for cystoscopy Pt cleared by Dr. Carpio

1:00 PM BP: 130/90

O2 at 2-3 L/min via nasal cannula Repeat ECG 12 leads at 6AM CBR with TP 86

(-) ghost pain For hemodialysis once with consent 2/24/2012 11:00 AM Hemodialysis settings UFR 2 liters Duration 2 hours Refer to Dr. Sangkowa for insulin Still to IJ catheter Pls inform undersigned Surgery informed 5PM 2/25/2012 9 AM Decrease Furosemide to 40g q8 Repeat CBC with pH, CXR, Crea,Na,K,Mg Repeat ABG Shift IVF to heplock Continue medication Refer accordingly Pls facilitate CXR Continue medications Give Furosemide 40mg IVT post BT Still to secure 2 u pRBC for HD use URO notes For cystoscopy, with urethroscopy possible open Still to secure consent If ok with medicine Schedule to emergency once ok with medicine Inform once cleared 2/27/2012 9 AM For ECG Follow up CSR-PA For CP clearance/evaluation For E Hemodialysis Hemodialysis Setting: BFR 200 mL UFR 2L Duration 2 hour Bicarbonate bath For IJ catheter insertion Transfer 2u of blood Refer crea post HD For catheter insertion Right side Paracetamol 500 mg 1 tab q6 Thankyou very much for the referral Seen at HDU 87

2/26/2012

11:00 AM

2/28/2012

3:50 PM

6:30 PM

B. Nurses Notes
DATE 2/15/2012 SHIFT 7-3 am ER NOTES Admitted a case of 38 years old female from Gingoog, awake, afebrile, not in respiratory distress with chief complaint of oliguria BP: 140/90mmHg, PR: 85bpm, RR:20cpm Placed on stretcher comfortably Seen and examined by Dr. Valleja with orders carried out DAT Consent to care signed Instructed Inserted heplock aspetically CBC with platelet count, Na, K, Ca, Mg, Urinalysis, Crea, BUN, RBS, ABG, HIV HBsAg, Anti HCV requested Chest Xray done ECG 12 leads done Medications prescribed For insertion of IJ shunt Consent for procedure signed For repeat serum creatinine post hemodialysis For hemodialysis Observed for any unusualities Needs attended Transported to ward with latest vital signs of BP: 140/80mmHg; PR: 80bpm, RR:20cpm, T:37C 2/15/2012 4:80 pm 88 ER WARD NOTES NURSES NOTES

 Received from ER extension per wheelchair With heplock at left arm For intrajugular insertion & hemodialysis Ushered to bed comfortably Kept back dry Ate with good appetite Kept watched for unusualitites endorsed 2/15/2012 11-7 am Received asleep on bed With heplock at left arm in place Kept watch for unusualities Kept well rested Needs attended Kept safe and comfortable Endorsed 2/16/2012 7-3 pm Received awake on bed With heplock in placed With foley bag catheter attached to urobag Consumed share with fair appetite Above heplock changed to IVF of Visited by Dr. Valleja with orders carried out Calls attended Brought to ward for further management and care 2/16/2012 7-3 pm 2:00 pm WARD NOTES Received awake per wheelchair from emergency room Conscious and coherent With foley catheter attached to urobag With ongoing PNSS @ 950 cc level @ KVO rate 89

DAT

Ushered to ward and placed to bed safely and comfortably Instructed Still for CP clearance Needs attended Kept watch for any unusualities Endorsed

2/16/2012

3-11 pm

Received awake on bed with onfoing venoclysis of PNSS @ 980 cc regulated @ KVO rate Not in any form of respiratory distress With foley bag catheter attached to urobag Vital signs taken and recorded Adequate rest provided Seen and examined by Dr. Laguindab with new orders carried out Consumed share with fair appetite Needs attended Kept watch for any unusualities endorsed

2/16/2012

11-7 am

Received on bed With ongoing PNSS 1L @800cc level @KVO rate With foley catheter attached to urobag Not in any form of distress Provided adequate rest Kept comfortable on bed Ate fairly Needs attended Endorsed

2/17/2012

7-3 pm

Received awake, conscious, coherent with PNSS 1L

90

@850cc with foley catheter to urobag Back kept dry, turned to sides For IJ catheter insertion and for hemodialysis Fluid restricted to <500cc /day Kept watched for unusualities Well rested 2/17/2012 3-11 pm Received awake sitting on bed Conscious and coherent With ongoing intravenous fluid of bottle #1 PNSS1L @840cc level @KVO rate infusing well at left arm With foley catheter attached to urobag with yellowish in color @ 10cc level With generalized edema noted Complained of pain at operative site with pain scale of 5/10 Afternoon care done Vital signs taken and recorded Fluid restricted to <500cc/day, patient and watcher informed Consumed half share with fair appetite Health teachings with emphasis on: a. Compliance to medication b. Avoid strenuous activities c. Encourage to avoid fatty and salty foods d. Encourage to eat 1 banana per meal I & O measured and recorded Still for U/A Still for dialysis Endorsed with a pain scale of 3/5 with latest vital signs: BP:150/90mmHg, T:36C, PR:83bpm

91

2/17/2012

11-7 am

Received awake lying on bed with PNSS1L @680cc level regulated at KVO rate With foley catheter attached to urobag Bedside care done Placed on moderate high back rest Ate fairly Still for intrajugular catheter insertion consent signed Kept monitored endorsed

2/18/2012

7-3 pm

Received on bed With ongoing IVF of PNSS regulated at KVO rate With foley catheter Vital signs taken Placed on comfortable position Ate fairly Due medications given Still for intrajugular Cared for Well rested

2/18/2012

3-11 pm

Received awake on bed With ongoing PNSS1L @600cc level With foley catheter attached to urobag Vital signs taken and recorded Placed on moderate high back rest Consumed share with fair appetite Still for intrajugular catheter For percutaneous tube nephrostomy

92

 Local anesthesia consent signed On intake and output monitoring Kept watch for any unusualities Well rested 2/18/2012 11-7 am Received awake lying on bed with PNSS IL @ 500cc level regulated @ KVO rate With foley catheter attached to urobag Placed on moderate high back rest Ate fairly Morning care done Ate fairly Kept monitored endorsed 2/19/2012 7-3pm Received on bed With ongoing PNSS 1L @KVO rate With FBC attached to urobag Vital signs taken and recorded Ate fairly; fluid restricted up to 500cc/day Due meds given Kept watched Endorsed 2/19/2012 3-11 pm Received awake on bed With foley catheter attached to urobag With ongoing PNSS1L @450cc level @KVO rate Vital signs taken and recorded Placed on moderate high back rest Needs attended Consumed share with fair appetite Instructed to decrease fluid intake up to 500cc/day

93

 Kept watched for any unusualities Due medications given as ordered Endorsed 2/19/2012 11-7 am Received awake lying on bed Conscious and responsive With PNSS1L @400cc level regulated at KVO rate With foley catheter attached to urobag Placed on moderate high back rest Ate fairly Morning care done Kept monitored Endorsed 2/20/2012 7-3 pm Received awake on bed With ongoing PNSS1L @200cc level regulated @KVO rate With foley bag catheter attached to urobag Vital signs taken and recorded Bedside care done Ate fairly Seen and examined by Dr. Laguindab with new orders carried out Adequate rest provided Kept comfortable Well rested 2/20/2012 3-11 pm Received awake on bed With ongoing PNSS1L @100cc level @ KVO rate With foley catheter attached to urobag Vital signs taken and recorded For emergency ultrasound of whole abdomen done

94

 Brought back to ward and placed on bed safely and comfortably Ate fairly Needs attended Kept watched for any unusualities Endorsed 2/20/2012 11-7 am Received asleep on bed With PNSS1L @950cc level regulated @KVO rate With foley bag catheter attached to urobag Vital signs taken and recorded Ate fairly Kept comfortable Well rested 2/21/2012 7-3 pm Received on bed With ongoing PNSS regulated at KVO rate Conscious and coherent Vital signs taken and recorded Placed on comfortable position Ate fairly Due medications given Kept watched Cared for Well rested 2/21/2012 3-11 pm Received awake on bed with foley catheter attached to urobag Conscious and coherent With ongoing PNSS 1L @ 900cc level @ KVO rate Vital signs taken and recorded Placed on moderate high back rest

95

 Consumed share with fair appetite Needs attended Kept watch for any unusualities Endorsed 2/21/2012 11-7 am Received awake on bed With PNSS @ 850cc level regulated at KVO rate With foley bag catheter attached to urobag Vital signs taken and recorded Ate fairly Kept comfortable Well rested 2/22/2012 7-3 am Received awake on bed With ongoing PNSS 1L @950cc regulated at KVO rate With foley bag catheter attached to urobag Bedside care done Due medication given Ate fairly Seen and examined by Dr. Laguindab with orders carried out Adequate rest provided Kept watched for any unusualities Well rested 2/22/2012 3-11 pm Received awake on bed with ongoing venoclysis of PNSS 1L @ 780 cc level regulated at KVO rate With foley bag catheter attached to urobag Not in any form of respiratory distress Vital signs taken and recorded Adequate rest provided

96

 Placed on a moderate high back rest position Consumed share with fair appetite Seen and examined by Dr. Laguindab with new orders carried out Needs attached Kept watched for any unusualitites Brought to operating room per wheelchair with ongoing IVF of PNSS 1L regulated @ KVO rate accompanied by relatives 2/22/2012 7:45 pm OR NOTES Received from P1F3 per wheelchair awake, conscious and coherent; with no repiratory distress With ongoing IVF of PNSS1L @ 500cc level regulated at KVO rate infusing well at right hand With foley catheter French 14 attached to urobag in place and draining well With consent signed for percutaneous tube nephrostomy bilateral Ushered to OR bed safely and comfortably Attached to monitor with initial vital signs of BP 164/110mmHg, PR: 79bpm, RR: 20cpm, O2sat:99% Surgical skin preparation done aseptically Draped accordingly Initial counting of sponges and instruments done and recorded 8:55 pm 8:57 pm 10 mL anesthesia inducted by Dr. Valleja Operation started Percutaneous tube nephrostomy bilateral performed by Dr. Vallejos and assisted by Dr. Eduave failed. Autograde Nephrostomy performed 97

10:20 pm 10:40 pm

Final counting of sponges, instruments and sharps done and recorded complete with surgeons informed Operation ended Wound dressing applied Post-operative care rendered Transported to P1F3 per stretcher awake, conscious , and coherent With same IVF going on With foley catheter attached to urobag in place and draining well Endorsed to ward NOD with latest vital signs of BP: 160/100mmHg; PR:79bpm, RR:20cpm, O2sat:99%

2/22/2012 11-7 am 11:15 pm

WARD NOTES Received from OR per stretcher Conscious and coherent With PNSS 1L at 500 cc level regulated at KVO rate With foley bag catheter attached to urobag Vital signs taken and recorded Bleeding at post operative site Referred to Dr. Pajares BP monitoring increased to 1 hour For CBC with platelet, APTT, pro time, clotting time, and bleeding time determination done ECG 12 leads taken and referred to Dr. Pajares Started O2 inhalation @2LPM via nasal cannula as ordered For repeat ECG 12 leads at 6am done On complete bed rest without toilet privilege Closely monitored

12:15 am

98

 Well rested Addendum Referred to Dr. Eduave for bleeding of post-op site With order sent, CBC, APTT, PTPA, Crea done 2/23/2012 7-3 am Received awake with post-operative wound clean and dry, dressing kept intake with PNSS at KVO rate at 800cc With foley balloon catheter to urobag For O2 support at 3LPM via nasal cannula Encouraged binder use Followed up consent of post operative laboratory diagnostics Limit fluid intake to less than 500cc/day Visited by Dr. C and cleared patient for cystoscopy, retrograde pyelography 2/23/2012 3-11 pm Received awake sitting on chair with an ongoing intravenous fluid of #2 PNSS 1L @630cc level regulated @ KVO rate infusing well at right dorsal With O2 inhalation via nasal cannula regulated at 3L/min With foley bag catheter connected to urobag draining with yellow colored urine Conscious and coherent Periorbital edema noted on both eyes With dry dressings at the incision site noted @ lower back Pitting bipedal edema noted Verbalized pain @ lower back with a pain scale of 6 out of 10, where 10 is the highest 99

 Initial vital signs taken and recorded as follows: T:38.1C, HR:86bpm, RR:22cpm, BP:120/80mmHg, O2sat:99% Febrile, T:38.1C Tepid sponge bath done Temperature rechecked, T:37.7C Afternoon care provided such as changing of bed linens, clothing, and hair care Lower extremities elevated with pillows Instructed to limit fluids to <500cc/day Consumed half of share with fair appetite Health teachings given with emphasis on: a. Proper hygiene to facilitate wellness b. Deep breathing exercises to promote relaxation c. Proper nutrition, low sodium foods d. Proper wound dressing Verbalized understanding on health teachings given Pain scale decreases to 4 from 6 out of 10 where 10 is the highest Endorsed with latest vital signs of T:36.8C, HR:89bpm, RR: 21cpm, BP:120/80mmHg, O2sat:99% 2/23/2012 11-7 am Received asleep on bed With PNSS1L @300cc level regulated @ KVO rate With foley catheter attached to urobag Vital signs taken and recorded Ate fairly Kept comfortable Well rested

100

2/24/2012 7-3 am

Received awake sitting on chair With ongoing PNSS @300cc level regulated at KVO rate With foley bag catheter attached to urobag Bedside care done Due medication given Ate fairly Seen and examined by Dr. Laguindab Adequate rest provided Well rested

2/24/2012

3-11 pm

Conscious and coherent With ongoing intravenous fluid of #2 PNSS @ 280cc level @ KVO rate infusing well @ left arm With Post operative wound @ posterior noted with dry and intact With foley catheter attached to urobag draining yellow urine output in 5cc Complaint of pain @ the operative site, pain scale of 5/10 Febrile, T:37.9 With capillary refill time of 2 seconds Maintained high back rest Performed deep breathing exercises Continuous tepid sponge bath rendered to promote cooling surface Provided comfort measures such as repositioning Served with low appetite Rechecked temperature 37.6 Health teachings given with emphasis on: a. Importance of non pharmacologic pain

101

management b. Proper wound care c. Compliance to dietary regimen Intake and output measured With no signs of active bleeding Able to understand health teachings 2/24/2012 11-7 am Received asleep on bed With ongoing IVF of PNSS @ 180cc level regulated @ KVO rate With post operative would at posterior noted dry and intact With foley catheter attached to urobag With complaint of pain with a pain scale of 4 out of 10 Vital signs taken and recoreded Placed on moderate high back rest Back kept dry Instructed on deep breathing exercises Adequate rest provided Ate fairly Kept watched for any unusualities Endorsed, well rested 2/25/2012 7-3 pm Received awake on bed with venoclysis @ left arm @ KVO rate With foley bag catheter in place attached to urobag Edema on the lower extremities noted Assisted with activities of daily living Placed on moderate high back rest Seen and examined by Dr. Laguindab with new orders carried out Above intravenous fluid terminated and changed 102

 Ate share with fair appetite Reminded client to limit fluid to less than 500cc/day Endorsed with no unusualities 2/25/2012 3-11 pm Received conscious on bed With heparin lock at left arm With foley bag catheter attached to urobag Edema at lower extremities noted Placed on moderated high back rest Provided a calm and safe environment Served and ate share Kept watch for unusualities Still for IJ insertion consent signed Adequate rest provided Endorsed 2/25/2012 11-7 am Received asleep on bed With heplock at right arm With foley catheter attached to urobag Vital signs taken and recorded Placed on moderate high back rest Kept back dry Adequate rest provided Ate fairly Kept watch for any unusualities Endorsed 2/26/2012 7-3 pm Received awake, conscious, pallor noted, with lethargy noted, with foley catheter to urobag, with heplock attached to patient Needs assistance rendered, O2 support on standby Fluid restricted to <500cc/day

103

 Back kept dry, turned to sides at intervals With fair appetite Well rested Transported to hemodialysis unit 2/26/2012 3-11 pm Received awake on bed; with foley catheter in placed With heparin lock at left arm in placed Sat on bed at times Served with fluid restriction, less than 500cc a day Still for IJ insertion and dialysis Seen and examined by Dr. Andutan and Dr. Naval with orders made and carried out Still for cystoscopy and urethroscopy, possible open with consent signed Still for blood transfusion ongoing cross matching Slept at intervals 2/26/2012 11-7 am Received awake on bed With heplock at left arm in placed With PNSS1L at side drip for blood transfusion Vital signs taken and recorded Consumed share with fair appetite Adequate rest provided Due meds given Morning care done Needs attended Endorsed with no unusualities Addendum: Blood transfusion started with 1 u PRBC with serial # 2K12-02-1504 segment # of 446C6644, Blood type B, Rh + regulated at 15gtts/min the first 15 minutes 104

then increased at 30gtts/min for 30 minutes 2/27/2012 7-3 pm Received awake, conscious, coherent with post operative dressing clean and dry with ongoing blood transfusion of PRBC B(+) S#2K12-02-1505 piggyback to PNSS mainline Kept observed for any transfusion reaction Above transfusion consumed and terminated aseptically Still for cystoscopy with ureteroscopy Visited by Dr. L with orders carried out For emergency hemodialysis Electrocardiogram 12 lead taken 2/27/2012 3-11 pm Received awake on bed With intravenous fluid of PNSS1L 900cc level regulated @KVO rate Not in respiratory distress Vital signs checked and recorded Kept comfortable Served with fair appetite For emergency hemodialysis tomorrow Monitored, well rested 2/27/2012 11-7 am Received asleep on bed With PNSS1L @ 880 cc level regulated at KVO rate With foley catheter attached to urobag in place Vital signs taken and recorded Placed on moderate high back rest Kept back dry Ate fairly Kept watched for any unusualities

105

 Endorsed; well rested 2/28/2012 7-3 pm Received on bed With ongoing IVF PNSS1L @700cc level regulated @ KVO rate With foley catheter attached to urobag Vital signs taken and recorded Placed on comfortable position Ate fairly; oral intake limited to 500cc/day For intrajugular catheter insertion and hemodialysis Kept monitored for unusualities Cared for Well rested Addendum: Transported to hemodialysis unit for intrajugular catheter insertion per wheelchair with latest vital signs of BP: 100/70mmHg, T:37.2C, PR:86bpm, RR:24cpm. 2/28/2012 TRANSPLANT CLINIC NURSES NOTES Came in per wheelchair accompanied by relative with chief complaint of difficulty breathing Seen and examined by Dr. Jayson S. with orders carried out For intrajugular vein catheter insertion Consent signed by patient Patient maintained in sitting position with head slightly bent facing left Final skin preparation done aseptically Local anesthesia inducted at right posterior area

3:25 pm

106

3:30 pm

Trache inserted @ right intrajugular area Quidemine inserted thru trochlear Dual lumen catheter inserted through quidemine Internal jugular catheter anchored skin using silk Insertion of intrajugular vein catheter ended Dressing applied aseptically Post operative care rendered Patient instructed not to wear tight clothing to prevent obstruction of the area Transported to hemodialysis unit and endorsed to nurse on duty

3:45 pm

2/28/2012 3-11 pm

HEMODIALYSIS NOTES Received from P1F3, per wheelchair accompanied by watcher. Conscious and coherent, not in respiratory distress Bipedal edema noted With urinary catheter, draining well With right intrajugular access With venoclysis of PNSS 1L @ KVO rate hooked at right dorsal metacarpal vein HD settings order: LFR: 2 liters RFR: 200 cc/hr Duration 2 hr Placed to hemodialysis chair comfortably Consent for treatment secured Initial vital signs taken: BP: 100/70mmHg, T: 36.4C, O2sat: 98%, HR: 103 bpm Vascular abscess dressed aseptically Routine Heparinization Bicarbonate Bath

107

 Treatment started 4:05 pm Transfused 1 unit of PRBC, blood type B+ S# 2K1202-1510 Transfused second unit of blood, blood type BT s# 4:55 pm 2K12-02-1511 Monitored for transfusion reaction Post-dialysis creatinine and CBC taken sent to laboratory c/o watcher. Treatment done and completed without any unusualities Transported back to ward per wheelchair with latest BP 120/80 mmHg 2/28/2012 3-11 pm WARD NOTES Received from hemodialysis unit per wheelchair, conscious and coherent With intravenous fluid of PlainNSS1L @ 200cc level regulated @KVO rate With intrajugular catheter in placed Ushered and placed to bed safely Vital signs checked and recorded Kept comfortable Monitored for unusualities Well rested 2/28/2012 11-7 am Received on bed With ongoing IVF of PNSS1L @ 100cc level @ KVO rate With foley catheter attached to urobag draining well With IJ catheter @ right neck Placed on moderate high back rest Kept comfortable on bed 108

 Ate fairly Needs attended Well rested 2/29/2012 7-3 pm Received awake conscious coherent, with pallor noted with PNSS1L@ KVO rate at 150 cc level With intrajugular catheter to right side of neck, with foley catheter to urobag O2 support placed on standby Back kept dry, turned to sides at intervals Still for cystoscopy with ureteroscopy with consent to procedure along signed Well rested 2/29/2012 3:00 pm Received awake sitting on chair with an ongoing intravenous 1L at 1000 cc level regulated at KVO rate infusing well at left dorsal With intrajugular catheter in place With folley bag catheter connected to urobag with yellow colored urine With dry dressings at lower back Bipedal pitting edema noted Conscious and coherent Verbalized pain when swallowing with a scale of 5/10, where 10 is the highest Initial vital signs taken and recorded as follows: t: 38.1C, HR: 96 bpm, RR: 22 cpm: BP: 120/80mmHg, O2 sat: 97%

109

 Febrile 38.1C nurse on duty informed Tepid sponge bath done Temperature rechecked after 30 minutes, T: 38.0C Afternoon care provided such as hair care Lower extremities elevated with pillows Deep breathing exercises done Instructed to limit fluid intake to 1500 cc/day Health teachings given with emphasis on: a. Proper hygiene b. Proper wound dressing Verbalized understanding on the health teachings given Transported to hemodialysis unit per wheelchair with latest vital signs of T: 38C, HR: 94bpm, RR:20cpm, BP:120/80mmHg, O2sat: 98%. DIALYSIS NOTES Received from P1F3 per wheelchair accompanied by watcher with PNSS1L at KVO rate (+) edema , weak and pale looking Initial vital signs of BP 120/80mmHg, PR: 92bpm, O2sat of: 97% IJ dressed aseptically Hooked to hemodialysis machine and treatment started Seen by Dr. L with orders carried Watched for any unusualities 110

 Transported back to ward per wheelchair with latest vital signs of BP:140/90mmHg, PR:90bpm, O2sat:97% 2/29/2012 3-11 pm 8:15 pm Received from hemodialysis unit per wheelchair with an ongoing intravenous fluid of #2PNSS1L @830cc level regulated at KVO rate infusing well at right arm Transferred to bed safely Conscious and coherent Verbalized pain at abdominal area with a scale of 5/10, 10 as the highest nurse on duty informed Vital signs taken as follows: T: 37.1C, HR: 92bpm, RR:21cpm, BP:130/90mmHg, O2sat:98% Placed on semi-fowlers position Deep breathing exercises done Consumed half of share with fair appetite Reported decreased with a scale of 3/10, 10 as highest Endorsed with latest vital signs of T:37.0C, HR:90bpm, RR:20cpm, BP:120/80mmHg, O2sat:98%

111

C. Intake and Output

Input 2/15/2012 7-3 3-11 11-7 Oral 150 240 Parenteral 100 100 Total 250 340 590 Urine 0 0

Output Total 0 0 0

Input 2/16/2012 7-3 3-11 11-7 Oral 180 175 100 Parenteral 200 80 100 Total 380 255 200 835 Urine 0 10 0

Output Total 0 10 0 10

Input 2/17/2012 7-3 3-11 11-7 Oral 100 120 100 Parenteral 100 80 100 Total 200 200 200 600 Urine 50 20 10

Output Total 50 20 10 80

Input 2/18/2012 7-3 3-11 11-7 Oral 150 240 240 Parenteral 100 150 100 Total 250 390 340 960 Urine 40 20 0

Output Total 40 20 0 60

Input 2/20/2012 Oral Parenteral Total Urine

Output Total

112

7-3 3-11 11-7

150 480 300

100 100 100

250 580 400 1180

0 0 0

0 0 0 0

Input 2/21/2012 7-3 3-11 11-7 Oral 150 420 300 Parenteral 150 100 100 Total 300 5200 400 1200 Urine 0 0 0

Output Total 0 0 0 0

113

Input 2/22/2012 7-3 3-11 11-7 Oral 100 0 Parenteral 100 0 Total 200 0 200 Urine 0 0 0

Output Total 0 0 0 0

Input 2/23/2012 7-3 3-11 11-7 Oral 400 350 300 Parenteral 100 50 100 Total 500 330 400 1230 Urine 400 0 0

Output Total 400 0 0 400

Input 2/24/2012 7-3 3-11 11-7 Oral 240 100 200 Parenteral 100 112 100 Total 340 212 350 852 Urine 0 0 0

Output Total 0 0 0 0

Input 2/25/2012 7-3 3-11 11-7 Oral 250 250 250 Parenteral HL HL HL Total 350 250 250 850 Urine 5 0 0

Output Total 5 0 0 5

Input 2/26/2012 7-3 3-11 11-7 Oral 300 200 500 Parenteral HL HL HL Total 300 200 500 1000 Urine 0 0 0

Output Total 0 0 0 0

114

Input 2/27/2012 7-3 3-11 11-7 Oral 450 400 510 Parenteral HL HL HL Total 300 100 200 Urine 0 0 0

Output Total 0 0 0 0

Input 2/28/2012 7-3 3-11 11-7 Oral 400 200 300 Parenteral HL HL 100 Total 400 200 400 1000 Urine 0 0 0

Output Total 0 0 0 0

Input 2/29/2012 7-3 3-11 11-7 Oral 300 250 Parenteral HL 310 Total 300 560 860 Urine 0 10 -

Output Total 0 10 10

115

IV. Vital Signs Monitoring

February 16, 2012 7-3 170/120- 80- 20- 36.1 C 3-11 4- 160/110- 85- 22- 38.5 10- 160/90- 84- 22- 38.0 11-7 12- 160/110- 84- 21- 36.4 4- 160/90- 81- 20- 36.7

February 18, 2012 7-3 8- 140/100-80-20-36.2 12- 150/90-84-20-36.1 3-11 4- 130/90- 92- 24- 36.0 6- 150/90- 72- 23- 36.1 8- 140/90- 83- 24-36.0 11-7 12- 140/90- 82- 21- 36.3

February 17, 2012 7-3 8- 130/80- 84- 21- 36.4 12- 180/110- 80- 21- 36.8 3-11 4- 140/90- 93- 25- 36.5 6- 140/90- 90- 25- 36.5 8- 150/90- 83- 22- 36 10- 150/90- 83- 22- 36 11-7 12- 170/110- 81- 21- 35.3 4- 150/100- 82- 23- 36.9

4- 130/90- 80- 20- 36.9

February 19, 2012 7-3 8- 130/70- 86- 20- 37.2 12- 130/90- 80- 24- 37.6 3-11 4- 130/90- 82- 21- 36.7 8- 130/70- 85- 20- 36.5 11-7 12- 140/110-84- 20-3 6.6 4- 160/100- 81- 21- 36.4

116

February 20, 2012 7-3 8- 140/90- 88- 29- 37.4 12- 130/90- 84- 20- 37 3-11 4- at ultrasound 811-7 12- 160/110- 81- 22- 35.9 4- 150/100- 80- 19- 36.5

3-11 4- 130/90- 86- 24- 37.1 811-7 11-130/90- 84- 21- 36.9 12- 140/90- 86- 20- 36.7 1- 140/90- 84- 21- 36.4 2- 140/90- 82- 21- 36.4 3- 140/90- 80- 21- 36.4 4-140/90- 84- 20- 36.4

February 21, 2012 7-3 8- 150/90- 82- 24- 36.5 12- 140/80- 85- 21- 36.9 3-11 4- 150/90- 83- 22- 36.8 8- 140/80-82- 21- 36.9 11-7 12- 150/90- 78- 19- 36.3 4- 140/90- 82- 20- 36.9

February 23, 2012 7-3 8- 150/90- 82- 24- 36.9 10-140/90- 80- 20- 36.1 12- 140/90- 82- 24- 36.8 2- 140/90- 84- 20- 36.2 3-11 3-120/80- 86- 22- 38.1- 99% 4-110/80- 97- 22- 37.7- 98% 5- 100/70- 100- 22- 37.5- 98% 6- 110/70- 96- 21- 36.5- 98%

February 22, 2012 7-3 8- 140/90- 80- 24- 37.2 12- 150/90- 86- 28- 37.0

7- 120/80- 98- 22- 36.7- 99% 8- 110/70- 87- 20- 35.5- 99% 9- 110/70- 91- 21- 36.4- 99% 10-120- 80- 81- 21- 36.8- 99%

117

11-7 12- 120/80- 81- 21- 36.3 4- 110/80- 80- 20- 37.1

February 26, 2012 7-3 8- 130/80- 82- 22- 36.9 12- 110/80- 80- 20- 36.1

February 24, 2012 7-3 8- 140/70- 86- 21- 36.9 12- 140/90- 80- 24- 37.2 3-11 4- 120/80- 75- 24- 37.9 8- 120/70- 79- 26- 37.1 11-7 12- 130/80- 81- 24- 36.5 4- 130/70- 82- 22- 36.9

3-11 4- 120/80- 84- 24- 37.8 8- 110/70- 85- 22- 36.9 11-7 12- 110/80- 82- 24- 37.1 4- 100/80- 84- 21- 36.9

February 27, 2012 7-3 8- 120/70- 80- 21- 36.9 12- 130/90- 84- 24- 37.2

February 25, 2012 7-3 8- 140/90-80-22-36.1 12- 140/80- 80- 22- 36.4 3-11 4- 110/70- 81- 20- 36.1 8- 110- 90- 88- 21- 36.4 11-7 12- 110/80- 80- 20- 36.6 4- 110/70- 81- 21- 36.4

3-11 4- 130/90- 88- 21- 37.1 8- 120/80- 84- 20- 36.8 11-7 12- 130- 90- 80- 19- 36.6 4- 120/80- 82- 20- 37.1

118

February 28, 2012

4- 100/80- 84- 22- 36.9 February 29, 2012

7-3 8- 120/70- 90- 23- 36.9 12-100/70- 86- 25- 37.2 3-11 4- 130/70- 88- 22- 37.1 10- 120/70- 86- 21- 37.0 11-7 12- 110/90- 82- 23- 36.5

7-3 8- 120/80- 74- 22- 36.1 12- 110/70- 80- 20- 36.1 3-11 4- 120/80- 94- 20- 38- 98% 8- 130/90- 92 -21- 37.1 -98% 9- 130/80- 90- 20- 37.3 -98% 10- 120/80- 90- 20- 37.0- 98%

119

IV. Intravenous Fluids and Blood transfusion

Date Time Started Bottle Number Type of solution incorporated/ serial number of blood With heplock #1 #2 PNSS 1L / 30 gtts/min PNSS 1L @ KVO rate -HeplockFeb. 27, 2012 5:00 am #1 PRB u serial # : 2k12-12-1505; segment # : 446C6647; Blood type: B, RH + PRB u serial # : 2k12-02- 1510 , B+ PRB u serial # : 2k12-02- 1511 , B+ PNSS 1L @ KVO rate

Feb. 15, 2012 Feb. 16, 2012 Feb. 20, 2012

11:00 am c/o 6:00 pm

Feb. 28, 2012

4:05 pm

#1

4:55 pm

#2

Feb. 29, 2012

3 pm

#2

120