Case Study

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Presented to: Elizabeth Ladroma, RN

In Partial Fulfillment of the Requirements In Related Learning Experience (RLE)

By Mia Charisse F. Lamparero Morris Antiporta Janice Idiong Stephen Anthony Navarro Catherine Ardina Neko Nebres BSN 4

January 11, 2011


I. INTRODUCTION A Objectives II. ASSESSMENT A. Biographical Data B. Chief Complaint C. History of Present Illness D. Past Medical and Nursing History E. Personal, Family and Socio-Economic History F. Developmental History G. Patient Need Assessment Physical Assessment         General survey Vital signs Nutritional status Integumentary System HEENT Pulmonary System Cardiovascular System Gastrointestinal System

  

Musculoskeletal System Genito-urinary System Course in the Ward



As nurses, we could help our patients by having a deep understanding of the disease, that we may learn the proper interventions for the acute kidney disease patients. In this way, we could render quality care for them. We could as well lead them to the proper treatment to lessen their sufferings brought by the kidney failure, in anyhow. By having a wide understanding of the disease, we could impart teachings on how we could prevent the worsening of the condition. As nurses, it is our responsibility to render information and impart health teachings to improve the condition of our patients to the best of our abilities. One of the characteristics that we, nurses, should have is to be informative and only through a keen study of disease such as this way for us to gain all the information that we need to learn. OBJECTIVES The research for this case study, its data and substantial facts could not be attained without the improvised objectives that are needed to be followed and observed that will guide us in planning, preparing and arranging the information systematically. The objectives are devised within the day of our clinical exposure. The objectives would serve us guiding principles for us to arrive to our goals and aims. A. General Objective: Within the time-span of duty, the student nurse will complete the chosen case to be studied with factual pertinent data gathered. As well as to know and familiarize other

related information connected to it and apply the nursing skills that had learned and practice not only or the call of this study but also for the future reference. B. Specific Objectives:    To obtain sufficient and relevant information regarding patient’s condition. To present personal data of the patient. To trace the present history of the patient’s health and illness and define the diagnosis of the patient having Acute renal failure.    To conduct a thorough head-to-toe assessment serving as baseline data. To present the pathophysiology of the patient’s diagnosis. To identify the different drugs ordered and to know their action, indication, adverse effects and nursing responsibilities.  To impart suitable and realistic health teachings to the watcher for the patient’s welfare.  To evaluate the outcome of the condition of the patient.



Name Age Sex Civil Status Birthdate Birthplace Address:

: Mrs. Banana : 46 years old : Female : Married : November 13, 1964 : Bohol : Prk 19, Pag-asa, Mesaoy, New Corella, Davao del Norte

Nationality Religion Occupation Attending Physician Admitting Diagnosis Final Diagnosis

: Filipino : Roman Catholic : Banana Plantation Worker : Dr. Cyrus Asis MD : Polyneuropathy; T/C UTI : Acute Renal Failure 2 Severe Dehydration 2 AGE


The patient was admitted at Bishop Joseph Reagan Memorial Hospital last December 12, 2010 at 8:53 in the morning due to the complaint of generalized body malaise She was attended at the Emergency department and had taken a clinical history and physical assessment. She was immediately transferred at St. Joseph Right Wing room 319-6. He was attended by Dr. Asis, a resident physician of the said hospital.

C. HISTORY OF PRESENT ILLNESS Three days prior to admission, patient had loose bowel movement of about five times associated with vomiting more than ten times and abdominal pain, fever, dysphasia and body malaise. Four hours prior to admission had severe generalize body malaise with five episodes of loose watery stool, non- mucoid, non blood streaked. No consultation done, no medications taken two days prior. D. PAST MEDICAL AND NURSING HISTORY Mrs. Banana was known for being hypertensive for 5 years now. She was hospitalized in Davao Regional Hospital because of the said health problem. According to her, her chief complain that time was only hypertension. She was discharged from the hospital after six days of confinement. On December 12, 2010 she was then experiencing loose bowel movement and body malaise that cannot be tolerated anymore which led them to admission.


Aka Mrs. Banana is a 46 year old banana plantation worker. She was separated from her husband who led her to work in order to sustain their needs. The family of Mrs. Banana belongs to a marginalized socio-economic status. In order to provide and sustain the daily needs of their family, she works as a banana plantation worker. She have 2 daughters: one is 9 year old and the other is 11 year old. She doesn’t have a history for hypertension and DM F. DEVELOPMENTAL TASK  Robert J. Havighurst Developmental Task Theory According to Havighurst developmental theory, Mrs. Banana, 46 years of age, belongs to a period of late adulthood which was achieving mainly located in family, work, and social life. Family-related developmental tasks are described as finding a mate, learning to live with a marriage partner, having and rearing children, and managing the family home. Mrs Drain was working at heavy workload just to have money to help for their everyday expenses. She doesn’t have time to care for her own needs because she always attended her children first. G. PATIENT NEED ASSESSMENT Date: December 13, 2010 Name of Patient: Mrs. Banana Age: 46 years old Admission Date/Time: December 12, 2010 8:53 am Admitting Medical Diagnosis: Polyneuropathy; T/C UTI Arrived on Unit by: per stretcher Accompanied by: accompanied by her sister AdmittingWeight /VS: 48kgs BP- 80/50 RR-26 PR-123 Temp- 36.7 From: Emergency Room Sex:Female Status: Married

Client’s Perception of reason for Admission:” Luya man gud kayo akong lawas ma’am murag dili nako malihok” as verbalized How has problem been managed by client at home: NONE Allergies: No allergies was being experience according to the patient Medication (at home): NONE, (at the hospital): See Drug Study Physiological Needs: I. Oxygenation  BP : 50/60 PR 96 bpm RR 25 cycles/min CR_________  Lungs (per auscultation: character: lung sound; symmetry of chest expansion; breathing character and pattern.) fine, short, interrupted crackling sound was being heard upon auscultation, symmetry chest expansion was being observe during breathing.

 Cardiac status (per auscultation

sounds character; chest pain?

Dull, low pitched and longer followed by a silent then higher pitch: no chest pain noted  Capillary Refill: Within 2 – 3 seconds using the blanched test  Skin Character and Color: dry, pale, dark brown in color  Life-supporting Apparatus: O2 @ 2 LPM  Other Observations (related): Patient cannot be able to stand alone and experiencing dizziness II. Temperature Maintenance:

 Temperature: 36.7º C  Skin Character: dry, pale, dark brown in color; with good skin turgor  Other Observations (related): N-O-N-E III. Nutritional Fluid:  Height: 5’ 4’’/ 48kg. consumed  Prescribed Diet:  Eating Pattern: 3x a day; can only consume ¼ of served meal  Skin Character: dry, rough skin; with good skin turgor  Intake (IVF: Fluid/Water):  Other Observations (related):slightly obese and vomits all food eaten IV. Elimination:  Last Bowel Movement (frequency; amount, character): 5-7 times, yellow to amber in color, watery and plenty.  Normal Pattern: 2x a day  Urination (frequency, amount, character, sensation): twice, with yellow ambered colored urine, about 200 cc.  Other Observations (related): experiencing watery stool and defecated 7x during the shift. V. Rest-Sleep:  Bed Time: 6: 00PM Waking Up Time: 6:00 AM Amount of food consumed: ¼ of meal served

 Sleep (amount of sleep): 4-5 hours

 Problems (as verbalized): “Wala ko katulog kagabii og luya kayo akoang paminaw”  Other Observations (related): N-O-N-E VIII. Stimulation-Activity:  Work: Banana Plantation Worker  Reaction/Past time: Watching TV  Hobbies/Vices: None Safety-Security Need  Neuro V/S: 15/15  Mental Status (coherent, responsive, conscious, unconscious): Coherent, Responsive and consciuos  Emotional Problem (diaphoretic, trembling, restless) Irritable, diaphoretic and fatigue. Love-Belonging Need  Children (living with?) Living with 2 daughters and raise them alone.  Husband (living with?) NONE

Self – Esteem Need -Need to accept to be independent but still needs assistance to people around him. Appreciate the care and love of family. Need to discuss feelings and concerns. Interact effectively to people. Self- Actualization Need

- Control one’s emotions and discipline self particularly in taking care of health. Need to learn to listen and follow what is advised for easy recovery.


Patient received lying on bed, awake, responsive, coherent to verbal communication, dry lips, with normal capillary refill (less than 3 sec) ; fatigue and weakness noted and verbalized on lower extremeties and unable to stand alone.

Vital Signs Date/Shift Time 12/12/10 9am 11am 12nn 4pm 7:15pm 8pm 12/13/10 12mn 4am 8am 12nn 4pm 8pm 9:25pm 12/14/10 12mn 2am 3:30am 4am 5am 6am 8am 10am 12nn Temp 36.2 36 37 38 39.8 38 36.8 36.8 36.8 37 36.8 36.4 37 36.7 36.3 BP 80/50 80/60 90/60 100/70 110/80 120/80 100/60 90/60 100/60 80/60 110/80 70/50 80/60 80/60 80/60 80/60 80/60 90/60 80/60 90/60 90/60 90/60 PR 123 103 98 96 85 90 86 88 90 94 89 60 93 109 86 110 RR 26 21 22 21 24 30 24 22 38 43 31 30 24 26 28 41 93% 96% O2 SAT OUTPUT OUTPUT



Nutritional Status

Upon admission, patient was on DAT. Normally takes meal 3 times a day but vomited after. Depending on varied conditions, he consumes moderate amount of food per meal. No known hypersensitivity to food allergens and other problems related to food consumption.  Integumentary System

Fine and thin yet dry hair was noted. His nails were in convex shape, smooth in texture, capillary refill of less than 3 seconds with pale nail beds. With good skin turgor, dry, and brown in color.  HEENT

The size of head was in proportion with the body. The eyes were symmetrical with the ears (pinna); pupils react spontaneously to light, with pale conjunctiva. Eyebrows symmetrically aligned, eyelashes equally distributed, lids closed symmetrically. With approximately 15 to 20 blinks per minute. No discharges noted on ears. Nasal septum was intact and in the midline, no discharges or flaring, air moves freely through the nares. Non-pitting edema noted at both feet.  Pulmonary System

With symmetrical chest expansion; crackles sound heard upon auscultation; RR: 30 cpm

Cardiovascular System

Cardiac sound from dull, low pitched (“lub”) to higher pitch (“dub”) sound , with irregular cardiac rhythm ; 60 beats per minute abnormal. Capillary refill time takes less than 3 seconds .  Gastrointestinal System

Watery stool plenty , non-mucoid and non-blood streaked.  Musculoskeletal System

Weakness and fatigue noted as manifestation of the disease process, marked reluctant to move. With limited range of motion.  Genito-urinary System Patient voided after meal in our shift. Urine appears amber in color, moderate in amount. Client’s normal voiding pattern is 4 times a day. Palpation on kidneys reveals no evidence of tenderness and distention. H. COURSE IN THE WARD



CLINICAL FINDINGS PRE-RENAL -volume depletion Reduced or There is decrease (Structurally intact hypotension deprived perfusion in GFR so causes nephrons) (systemic of kidney-renal oliguria, azotemia,





RENAL (with -acute tubular structural and necrosis due to functional damage) ischemia nephrotoxin -disease of slomeruli

POST-RENAL (Obstruction of urine flow in anywhere along urinary tract

-obstruction lumen -compression lumen

of of

ischemiafunctional disorder or depression of GFR or both The necrotic debris, cellular blebs block the filteration barrier + macula densa is also activated due to chloride load hence causes prerenal vasodilation Urine outflow is obstructed so further filtration is declined.

possible retention edema

fluid and

Blocking of filteration barrier also causes oliguria and if oliguria nitrogenous compounds and creatinine is obviously increased in blood. There is decrease in GFR so causes oliguria, azotemia, possible fluid retention and edema.

B. Discharge Plan To the patient who is diagnose of having acute renal failure, it is deemed necessary that after the hospital stay, compliance of the following action must be strictly observed for rehabilitation.

Medications -

Advise the client to take the medications on time to preserve the

efficacy of the drug. Instruct the client to take the medication with food to avoid GI irritation.

Exercise/Economic Factor -

Encourage to do a routine ambulation as a light

exercise. Advise not to engage in strenuous activities. Encourage to take rest every after activity. Treatment Encourage to ask proper explanation before starting a procedure to

properly understand what is going to happen. Instruct client to ask and properly understand before signing the consent. Health Teaching - Encourage patient to take a bath and do ADL’s within limits if

her safety. Tell the patient to notify the physician immediately if there are unusualities. Follow all instructions including medications, diet regimen and do’s and don’ts that was instructed to her by the physician.. Out patient Follow-up discharge. Diet - Instruct patient to eat nutritious, high protein diet to promote healing and eat smaller, more frequent meals to decrease feeling of fullness and bloating. Spiritual/Sexual Activities - Encourage to reflect on her life situations and properly understand these situations. To pray every day to help in coping up ones spirituality. IX. PHARMACOLOGICAL MANAGEMENT - Advise to have a follow up check up any time after


A. Textbooks Douges, M.E., (2002). Nurse’s pocket guide: diagnosis, interventions & rationales. (8th Edition). Philadelphia: F.A. Davis Company.

Douges, M.E., (2002). Nursing care plan: guidelines for individualizing patient care (6th Edition) Philadelphia: F.A. Davis Company. Gulandick, M., Nursing care plan. (3rd Edition) Ignatavicius, D.D. & Workman, M.L. (2006). Medical-surgical nursing: critical thinking for collaborative care. (5th Edition). St. Louis, Missouri: Elsevier Saunders. Kozier, B., (2004). Fundamentals of nursing: concepts, process & practice. (7th Edition). Philippines: Pearson Education South Asia PTE Ltd. Smeltzer, S.C. & Bare, B.G. (2004).Textbook of medical-surgical nursing(10th Edition, Volume 2). Philadelphia: Lippincott Williams and Wilkins. pp 553-538. Spratto, G.R. & Woods, A.L. (1994). Nurse’s drug reference. USA: Delmar Publishers Incorporated. Ulrich & Canale. (2005). Nursing care planning guides. (6th Edition). B. Internet Downloads

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