.........NCP Case

Name: Mrs. MM Age: 77 years old

Nursing Diagnosis: Anxiety related to chronic illness w/ changes in roles/ body image.

Medical Diagnosis: ESRD secondary to DM Nephropathy

Short-term Goal: At the end of my shift, patient will verbalize acceptance of self in situation.

Long-term Goal: At the end of hospitalization, patient will demonstrate adaptation to changes or events that have occurred.

Cues: Problem Scientific Rationale Nursing Interventions

Rationale Evaluation

Body malaise

Blurred in vision

Restlessness

ANXIETY Anxiety is a normal experience. Moderate or high level of anxiety can increase alertness and performance in particular situations. However, people who experience continues or recurring fears or episodes of intense fear can feel powerless to manage their symptoms and their lives can become severely restricted.

http:/www.panicanxietydisorder.org au /index.htm

Assessed level of fear of client.

Explained procedures/ care as delivered. Repeated explanation’s frequently as needed.

Helps determine the kind of interventions required.

Fear of unknown is lessened by information & may enhance acceptance of permanence of

Goal met. Patient verbalized acceptance of self in situation.

Provided opportunities for client to ask questions & verbalization of concern.

ESRD and necessity for dialysis.

Creates feeling of openness & cooperation & provides information that will assist in problem identification/ solving.

Name: Mrs. MM Age: 77 years old

Medical Diagnosis: ESRD secondary to DM Nephropathy

Nursing Diagnosis: Altered Fluids & electrolytes r/t Urinary retention as evidence increase K & decrease Na.

Short term Goal: At the end of my shift, patient will be able to increase urine output at least 1500cc in 24 hrs.

Long term Goal: At the end of hospitalization, the patient will be able to have a normal urine output & voiding pattern.

EvaluationRationaleNursing InterventionScientific Rationale

ProblemCues

Goal partially met-patient passed out urine at least 300 cc.

To be able to apply the proper therapeutic regimen.

May minimize urinary retention/overdistention of the bladder

Serve as baseline for progress.

Assess the cause of decrease urinary output

Encourage client to void every 2-4 hrs & when urge is noted

Determine the initial fluids and electrolytes level

Monitor intake

The production of an abnormally small volume of urine. This may be a result of copious sweating, kidney disease, loss of blood

Reference:

Nursing Care Plans

Page 89

OliguriaS- No subjective

Objective:

Decreased of urine output 380cc

Dribbling of urine

Potassium- 7.47 increased

(3.5- 5.0 mg/dl)

To determine the progress of the disease

A distended bladder can be felt in the suprapubic area.

To be able to prevent further complication and administer proper therapeutic agents as prescribed.

To promote continuous elimination of fluids and waste products.

& output hourly

Percuss/palpate suprapubic area.

Observe Signs and symptoms of fluids & electrolytes imbalance such as dyspnea changes in ECG and restlessness.

Ensure clients compliance on hemodialysis procedure

Sodium- 134 decreased

(135-145 mg/dl)

Name: Mrs. MM Age: 77 yrs. old

Medical Diagnosis: ESRD secondary to DM Nephropathy

Nursing Diagnosis: Sleep pattern disturbance r/t urinary frequency

Short-term Goal: at the end of my shift, the clients will increase the sleeping hours from 5 hrs. to 8 hrs.

Long-term Goal: At the end of the patient’s hospitalization, patient achieves optimal amount of sleep as evidenced by rested appearance, verbalization of having a good sleep and improvement in sleep pattern.

Cues ProblemScientific Rationale

Nursing Interventions

Rationale Evaluation

Subjective:

“Hindi ako makatulog ng husto” as verbalized by the patient.

Objective:

restlessness Dark circles

under eyes irritable

Lack of sleep The client is Unable to sleep because she frequent urge to empty urinary bladder. Thus her sleeping pattern is disrupted.

Ref:

Assess the cause of inability to sleep.

Assist patient in observing any previous b

Bedtime ritual.

Advised daytime

To determine the proper

To promote relaxation.

To promote urinary

Goal partially met.

Patient’s sleeping pattern increased from 5-7 hrs.

Nursing Care Plans

Page 61

By: klopp

physical activities as indicated.

Limit fluids before bedtime.

elimination thus reducing bladder distention to promote sleep during night time.

To prevent urinary bladder retention causing dribbling of urine.

Patient’s Name: Mrs. M.M. Age: 77 years old

Medical Diagnosis:ESRD secondary to DM Nephropathy

Nursing Diagnosis:Decreased tissue perfusion related to peripheral vasoconstriction as manifested by high blood pressure.

Short – Term Goal:At the end of my shift, patient will decrease blood pressure from 160/90 to 130/90

Long - Term Goal: At the end of the patient’s hospitalization, will maintain adequate tissue perfusion as evidenced by BP declining toward normal range for client.

CUES PROBLEM SCIENTIFIC RATIONALE

NURSING INTERVENTION RATIONALE EVALUATION

Subjective:

No subjective

Objective:

Oliguria

Hypertensive

Restlessness

Cold and clammy skin

Decreased Tissue Perfusion

Constriction of the peripheral blood vessels will alter the flow of blood to perfuse the different cells of the body.

Reference:

www.elsevier.com

. Measure and recorded blood pressure as indicated

Observed skin color, moisture, temperature, and capillary refill time.

Provides objective data for monitoring.

Presence of pallor: cool, moist skin; and delays capillary refill time may be due to peripheral vasoconstriction. May

indicate heart or renal

Goal not met. Patient’s blood pressure remained 160/90.

Noted dependent/general edema

Provided calm, restful surroundings, minimize environmental activity/noise. Limit the number of visitors and length of stay.

Maintain activity restrictions; such as bed rest/chair rest; schedule periods of uninterrupted rest; assisted client with self-care activities as needed.

Provided comfort

failure

Helps reduce sympathetic stimulation; promotes relaxation.

Reduces physical stress and tension that affect blood pressure and the course of hypertension.

Decreases discomfort and may reduce sympathetic stimulation

measure such back massage, elevation of head.

Administered antihypertensive medications as prescribed

Encouraged compliance with dietary and fluid restriction therapy.

Antihypertensive medications play a key role in treatment of hypertension associated with chronic renal failure.

Adherence to diet and fluid restrictions and dialysis schedule prevents excess fluid and sodium accumulati

on.

Patient's Name:Mrs. MM Age: 77 years. Old

Medical Diagnosis: ESRD secondary to DM nephropathy

Nursing Diagnosis: Risk for systemic infection related to hemodialysis procedure as manifested by fatigue, weakness and low Hb., Hct.level

Short term goal: At the end of the shift, patient will experience no signs/symptoms of infection.

Long – term goal: At the end of hospitalization, patient will maintain/demonstrate improvement in laboratory values

Cues Problem Scientific Rationale

Nursing Intervention

Rationale Evaluation

Objective: BP 160/90

mmHg Restlessness Oliguria Hct.level

0.25 Na level 134 Hb. 0.83gm/l

Systemic Infection Frequent IV cannnula will introduce microorganism in the blood circulation that would trigger systemic infection.

Reference:Medical Surgical 1st edition by Udan

Promoted good hand washing by client and staff.

Use aseptic technique when manipulating IV/invasive lines.

Encouraged deep breathing, coughing, frequent position changes.

Assessed

Reduces risk of cross-contamination

Reduces bacterial colonization and risk of ascending UTI.

Prevents atelectasis and mobilizes secretions to redue risk of pulmonary infections.

Excoriations

Goal met- Patient had experienced no signs of infection.

skin integrity

Monitored vital signs

from scratching may become secondarily infected.

Fever with increased pulse and a respiration is typical of increase metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONSIDERATIONS

BRAND:

Docard

GENERIC:

Dopamine HCL

DOSAGE:

2 amp in D5W 250cc @ 10 mgtts/min titrate by increment of 3 mgtts/ min

Sympathomimetic Exogenously administered, it produces direct stimulation of beta-1 receptors and variable stimulations.

Indications:

Correction of hemodynamic imbalances present in renal failure.

Contraindications:

Uncorrected tachyarrythmias or ventricular fibrillation.

Nausea, vomiting, tachycardia, anginal pain, palpitation, dysnea, headache, hypotension, hypertension, vasoconstriction, decrease urine output, dyspnea.

1.]Monitor vital signs and ECG during infusion. If BP drops 30mmHg stop infusion and report to physician.

2.]Assess for oxygenation and perfusion deficit: dyspnea, cyanosis, decrease BP, chest pain, dizziness.

3.]Assess patient’s GI complaints: nausea and vomiting.

4.]Monitor BP closely for sudden drop after drug is stopped.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONSIDERATIONS

BRAND:

GENERIC:

Sodium bicarbonate

DOSAGE:

650mg 1tab TID

Alkalinizing agent, Antacid, Electrolyte

Increases plasma bicarbonate, which excess buffers H ion concentration; reverses metabolic acidosis.

Indications:

Treatment of metabolic acidosis.

Contraindications:

Edema, hypertension, severe kidney insufficiency, hypoventilation.

Metabolic alkalosis (dizziness, cramps, thirst, anorexia, N & V, tetany, seizures). Paravenous administration may lead to tissue necrosis.

1.]Assess respiratory and pulse rate.

2.]Monitor fluid balance.

3.]Assess for the symptoms of alkalosis.

4.]Teach patient about sodium restricted diet.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS

NURSING CONSIDERATIONS

BRAND:

Humulin R

GENERIC:

Insulin injection

(Regular insulin)

DOSAGE:

6 “u” IV now

Insulin product, anti-diabetic agent

Increases glucose transport across muscle and fat cell membranes to reduce glucose level.

Indications:

Moderate to severe diabetic ketoacidosis or hyperosmolar hyperglycemia regular insulin. Mild diabetic ketoacidosis. Newly diagnosed diabetes.

Contraindications:

Hypoglycemia. Hypersensitivity to insulin.

Hypoglycemia, insulin resistance, local and generalized allergic reaction.

1. ]Assess V/S.

2. ]Use a tuberculin or insulin syringe for accuracy of measurement.

3. ]Keep in cold location, preferably a refrigerator.

4. Do not freeze.

5. ]Observe closely for S&S of hyper- or hypoglycemia until dosage established.

6.] Monitor BP, BS, LDL, cholesterol and HbA1c.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATIO

N

SIDE EFFECTS NURSING CONSIDERATIONS

BRAND:

Humalog mix 25

GENERIC:

Insulin lispro injection

DOSAGE:

25 ‘u’ SQ 10 mins BB, 12 ‘u” SQ 10 mins BS

Rapid-acting insulin, Anti diabetic agent

Facilitates the transport of glucose into cardiac and skeletal muscle and adipose tissue. It also increases synthesis of glycogen in the liver.

Indications:

Diabetes mellitus. In combination with sulfonylureas to treat high blood glucose n adults over 65 years of age.

Contraindications:

Use during episodes of hypoglycemia. Hypersensitivity to insulin lispro.

Hypersensitivity to insulin.

1. ]Document diseaseonset, level ofcontrol previousagents trialed, andthe outcome.

2.] Monitor VS, CBC,HbA1c, U/A;microalbumin andrenal functionstudies.

3. ]Review signs andsymptoms ofhypoglycemia andappropriatemanagement.

4. ]Continue BP control,diet and exercise for disease control.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTSNURSING

CONSIDERATIONS

BRAND: Encifer

GENERIC:

Iron sucrose

DOSAGE:

Amp 20 mg/mL (brown, sterile, aqueous soln) x 5's.

Vitamins & Minerals Hematinic.Iron sucrose is dissociated by the reticuloendothelial system into iron and sucrose. Encifer iron component appears to distribute mainly in the blood and to some extent in the extravascular fluid.

Indications:

Treatment of iron deficiency anemia in the following patients: Hemodialysis Dependent Chronic Kidney Disease (HDD-CKD) patients receiving an erythropoietin.

Contraindications:

Patients with evidence of iron overload, in patients with known hypersensitivity to iron sucrose or any of its inactive components and in patients with anemia not caused by iron deficiency.

Hypotension, chest pain, hypertension, hypervolemia, CHF, cramps, musculoskeletal pain, diarrhea, nausea, vomiting, abdominal pain, elevated liver enzymes, skin irritation, pruritis, application site reaction, dizziness, dyspnea, pneumonia, cough, headache, fever, asthenia, malaise.

.

1. ]Watch for serious hypersensitivity reactions of iron sucrose.

2. ]Medication is administered 1 to 3 times/wk. Do not administer more than 3 times/wk.

3. ]For IV administration only.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTSNURSING

CONSIDERATIONS

BRAND:

Dormicum

GENERIC:

Midazolam

DOSAGE:

15mg ½ tab OD

Hypnotics & Sedatives

Depresses the limbic system and reticular formation (subcortical level of CNS) by increasing or facilitating the inhibitory neurotransmitter activity of GABA.

Indication:

Disturbances of sleep

Contraindication:

Hypersensitivity.

Amnesic episodes

1]. Monitor blood pressure, heart rate and rhythm, respiration, airway integrity,arterial oxygen, saturation,. Emergency equipment shoud be nearby.

2.] Its onset of action is 1 hour.The action lasts for 2-6 hours.

3. ]Dormicum is given may be slower in the elderly than in younger adults.

4. ]Inform patient that drug may cause amnesia.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATIO

N

SIDE EFFECTS NURSING CONSIDERATIONS

BRAND:

Iberet folate

GENERIC:

Multivitamin with iron

DOSAGE:

1 tab OD

Vitamins and minerals

Component of hemoglobin for oxygen transport; enzymes for energy metabolism.

Indications:

Supplement for diet.

.

Contraindications:

Thalassemia, sideroblastic anemia, hemochromatosis & hemosiderosis. Children.

Nausea, constipation, diarrhea or stomach pain.

1.] Document indication for therapy.

2. ]Assess metabolic panel and vitamin levels as indicated.

3. ]List agents prescribes to ensure none interact or impact vitamin absorption.

4. ]Take with food for best absorption.

DRUG NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION/ CONTRAINDICA

TIONSIDE EFFECTS

NURSING CONTRAINDICATIONS

BRAND:

Minitran

GENERIC:

Nitroglycerin patch

DOSAGE:

5 mg OACW x 16 h

anti angina Reduces cardiac oxygen demand by decreasing left ventricular end diastolic pressure (pre -load) and to lesser extent systemic vascular resistance (after load). Also increases blood flow through the collateral coronary vessels.

Indications:

Prophylaxis of angina, hypertension

Contraindications:

Severe anemia, increase intracranial pressure, allergy to adhesives, hypersensitivity to nitrates and orthostatic hypotension.

Orthostatic hypotension, tachycardia, palpitation, rash.

1.] Assess location, duration, intensity,and precipitating factors of the patient’s angina pain.

2.]Evaluate therapeutic effectiveness (cardiac status) and adverse response (hypotension, arrhythmias)

3.]Dosed should be reduced gradually when discontinuing after long-term therapy.

4.]Apply transdermal (TD) patches to area without hair: press hard to adhere if patch becomes dislodged, apply a new one.

5.Do not discontinue abruptly.

6.]Closely monitor vital signs.

7.] Use caution when near a microwave oven, leaking radiation may heat patch’s metallic backing and cause burns.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONTRAINDICATIONS

BRAND:

Ciprobay

GENERIC:

Ciprofloxacin

DOSAGE:

500 mg 1 tab OD

Anti-infectives(Quinolones)

Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria

Indications:

Infection of the kidneys, and urinary tract, genital organs, abdomen, and skin.

Contraindications:

Hypersensitivity to ciprofloxacin on other quinolones

Nausea, diarrhea, abdominal pain, anorexia, dizziness, headache, very rarely, insomnia, peripheral, sweating, convulsion.

1.]Assess renal function before and during therapy: urine output, BUN and creatinine.

2.]Assess for possible adverse reactions: G.U: interstitial nephritis.

3. ]Document indication for therapy, type, onset, and characteristic of symptoms

4. ]Assess patient for s/sx’s of infection before and during treatment fever, characteristic of urine

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONTRAINDICATIONS

BRAND:

Norvasc

GENERIC:

Amlodipine

DOSAGE:10 mg / tab ½ / tab OD

Calcium Channel Blocker

Possible slight decrease in myocardial contractility. CO is increased; moderate decreased in peripheral vascular resistance.

Indication:Hypertension

Contraindication:Sick sinus syndrome; second-third degree atrio ventricular (AV) block, except with a functioning pacemaker.

Headache, fatigue, lethargy, dizziness, depression, paresthesia,hallucination, malaise, anxiety, tremor, vertigo, migraine, amnesia, nausea, abdominal discomfort, cramps, diarrhea.

1.]Teach patient to use as directed even if feeling better.

2.]Monitor Vs , ECG, CBC

3.]Report any symptoms of chest pain, SOB, dizziness, swelling of extremities, irregular pulse.

4.]Record BP and pulse.

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONTRAINDICATIONS

BRAND:

Burinex

GENERIC:

Bumetanide

DOSAGE:

1 mg tab OD

Loop diuretics Acts in the thick ascending limb of the loop of Henle, where it inhibits the co-transport of sodium, potassium, and chloride from the luminal filtrate. Increases excretion of water, sodium, potassium, calcium and chloride; decreases uric acid secretion; and cause no change in urinary pH.

Indications:

Hypertension.

Contraindications:

Anuria. Hepatic coma or severe electrolyte depletion.

Electrolyte & fluid changes: Excess water loss, dehydration electrolyte depletion including hypokalemia hyponatremia, hypovolemia, thromboembolism, circulation collapse.

1.] Monitor electrolytes, liver and renal function studies: causes for low potassium

2.] Monitor VS. Repeat duiresis may cause dehydration and circulatory collapse (especially in the elderly.)

3.]Assess BP before and during therapy with patient lying, standing, and sitting as appropriate; orthostatic hypotension can occur rapidly.

4.]Advise the patient to take the medication in the morning.

DRUG NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION/ CONTRAINDICAT

ION

SIDE EFFECTS NURSING CONTRAINDICATIONS

BRAND:

Catapres

GENERIC:

Clonidine hydrochloride

DOSAGE:

150 mg /tab 1 tab BID

Antihypertensive(centrally-active drug)

Stimulates centrally alpha adrenergic receptors, to inhibit sympathetic cadio accelerator and vaso constrictor centers.

Indications:

Management of all grades of hypertension.

Contraindications:

Hypersensitivity to clonidine

Drowsiness, sedation, confusion, dizziness, headache, fatigue, malaise, nightmares,nervouseness, restlessness, anxiety, mental depression,dry mouth, severe hypotension.

1.] Perform eenal studies:protein, BUN, creatinine: watch for increased levels that may indicate nephritic syndrome: polyuria, oliguria, frequency.

2.]Monitor input and output.

3.]Advise patient to use caution when changing position.

4.]Teach patient not to skip or discontinue medication without consulting physician.

DRUG NAME

CLASSIFICATION

MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONTRAINDICATION

S

BRAND:

Kalcinate

GENERIC: Calcium Gluconate

DOSAGE:

1amp SIVP

Calcium Salt Essential for maintaining normal function of nerves, muscles, the skeletal system, and permeability of cell membranes and capillaries.

Indications:

Management of hypocalcemia, hypocalcemic tetany, hyperkalemia with cardiac toxicity.

Contraindications:

Digitalized clients, sarcoidosis, renal or cardiac disease, ventricular fibrillation. Cancer clients with bone metastases, renal calculi, hypophosphatemia,

Venous irritation, tingling sensation, feeling of oppression or heat, chalky taste, fatigue, GI symptoms (anorexia, IV, nausea and vomiting, abdominal pain, dry mouth, thirst)

1.]If a precipitate is noted in the syringe do not use.

2.]IV rate should not exceed 0.5-2 ml / min.

3.]Monitor calcium levels and renal function.

hypercalcemia

DRUG NAME

CLASSIFICATION MECHANISM OF ACTION

INDICATION/ CONTRAINDICATION

SIDE EFFECTS NURSING CONSIDERATION

BRAND:

Plavix

GENERIC:

Clopidogrel

DOSAGE:

75mg/tab ½ tab only

Antiplatelet drug

(anticoagulant thrombolytic)

Blocks ADP receptors, which prevent fibrinogen binding at that site and thereby reduce the possibility of platelet adhesion and aggregation.

Indication:

Reduction of atherosclerotic events in patients with atherosclerosis. Treatment of patients suffering from non-ST segment elevation.

Contraindication:

Hypersensitivity. Severe liver impairment.

GI bleeding, bruising, hematoma, epistaxis, hematuria, eye bleeding, intracranial bleeding, GI disturbances, diarrhea, rush.

1.]Assess for symptoms of stroke, MI during treatment

2.]Monitor signs of bleeding; hemoglobin and hematocrit periodically

3.]Monitor liver function studies: AST, ALT, bilirubin, creatinine if patients is on long-term therapy; thrombocytopenia, neutropenia may occour.

DRUG NAME MECHANISM OF ACTION

INDICATION / CONTRAINDICATION

SIDE EFFECTS NURSING CONSIDERATION

Brand Name:

Humulin-N

Generic Name:

Decreases blood glucose by transport of glucose into cells and the conversion of glucose to glycogen indirectly increases blood pyruvate and lactate, decreases phosphate and potassium.

Indication:

Management of type1 DM or insulin dependent diabetis mellitus and type 2 diabetis mellitus which cannot be controlled by diet, exercise or weight reduction alone.

Contraindication:

Hypoglecemia , hypersensitivity reactions.IV administration of insulin suspension, diabetic coma.

Insulin resistance; allergic reactions that include redness, pain, itching, swelling or inflammation. Hypoglycemia, temporary visual impairment. Insulin administration may cause insulin antibodies to form.

1. Obtain patient history, including drug history and any know allergies.

2. Monitor fasting blood glucose, 2 hours after meals; also glycosylated Hgb may be measured to identify treatment effectiveness.

3. Monitor urine ketones during illness; insulin requirements may increase during stress, illness.

4. Monitor body weight periodically; changes in weight may necessitate changes

in insulin dose.

5. Assess for hypoglycemic reaction that can occur during peak time.