case study - nephrotic

7/28/2019 Case Study - Nephrotic

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I. Introduction

Nephrotic syndrome is a primary glomerular disease

characterized by a marked increase in protein in the urine(proteinuria), decrease in albumin in the blood (hypoalbuminemia),edema, and high serum cholesterol and low-density lipoproteins(hyperlipidemia). It is apparent in any condition that seriously damagesthe glomerular capillary membrane and results in increased glomerularpermeability. (Brunner & Suddarth 10th edition)

The main reason why I chose this case is because I gotinterested with the disease process and manifestations seen with R.S.J,a 15 year old patient who has nephrotic syndrome. Also, it is a serious

medical condition that the public should be informed of since accordingto the Department of Health, Nephrotic syndrome is the 10th leadingcause of mortality in the Philippines in the year 2006 with a percentageof 13.8%. This means that a lot of Filipinos suffer from this disease.And despite being a part of the leading causes of mortality, a hugepercentage of Filipinos are also not knowledgeable about whatnephrotic syndrome is. Thats why I made this case study to provideinformation about nephrotic syndrome and its disease process.


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II. History and Physical Examination

A. History of Present Illness

25 days prior to admission, R.S.J, 15 year old male noticed mildswelling of his face, and upper and lower extremities. Consultation wasdone on a local health center where in Furosemide 40 mg tab was

given which provided slight decrease in edema.

12 days prior to admission, edema progressed in the periorbitalarea, abdomen, and both upper and lower extremities accompanied byfatigue and malaise. Foamy urine was noticed upon urination. Noconsultation and interventions made.

3 days prior to admission, R.S.J started having intermittent lowgrade fever accompanied by dry cough, fatigue and malaise.Generalized edema is still present. No consultation and interventionsmade.

1 day prior to admission, clinical manifestations of generalizededema, fatigue and malaise still persisted. Pain with a scale of 6/10was felt in the whole abdominal area which is aggravated whenpressure is applied and still persists even at rest.

8 hours prior to admission, symptoms still persisted. R.S.J wasbrought to Jose Reyes Memorial Medical Center Emergency Room,hence admission to Male Medical Ward.

B. Past Health History

R.S.J didnt have any previous hospitalizations. No knownallergies. Past immunizations are unrecalled. And there were no foreignand local travels for the past 6 months.

C. Socio-cultural Health History

R.S.J is the eldest among the 4 children. He lives in an apartmentin Caloocan city with 8 occupants including his parents, 3 siblings, andtwo uncles. His father who works as a contractual worker and earns300 pesos per day is the breadwinner of the family and supports his

medical expenses. His mother is a plain housewife who cares for himand his siblings at home.

Before the occurrence of the disease, R.S.J is described to becheerful, friendly, and playful who is always playing on the streets withhis friends. When the symptoms appeared, he decided to stay at homeand lessen his socialization with others.

D. Physical Examination

Mental Status ExaminationLevel of Consciousness Concious, coherent

Appearance and movement Stooped postureClothes fit and appropriate for occasion andweatherDirty skin and nailsMaintains eye contactSmiles and frowns appropriatelySpeaks clearly in moderate pacingSmooth, coordinated movements

Mood Responds appropriately to topic discussed and

expresses feelings appropriately to the situationThought process and Expresses full and free-flowing thoughts during the


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Follows directions accuratelyCognitive abilities Oriented to person, place, and time

Recalls recent and remote memories

Head and faceHead is symmetrical and roundHair is evenly distributed

Face is symmetrical(+) Periorbital edema

Eyes2-3mm pupillary constriction, equally reactive tolight(+) corneal reflexPale conjunctiva(+) Periorbital edema

NoseSymmetrical, septum at midlineNo nasal flaring

MouthMoist buccal mucosa with no lesions(+) Yellowish discoloration of the teethTongue is symmetrical and at midline with nolesions

Thoracic(+) pallorSymmetrical chest expansionRespiratory rate of 24bpmNo pain or tenderness upon palpation

Dull sound upon percussion(+) Productive cough(+) Fine crackles heard upon auscultation at bothlower lobes of the lungs

HeartBlood pressure of 100/60 mmHgHeart rate of 110bpm

Abdomen(+) abdominal enlargement(+) abdominal pain and tenderness, 4/10 localizedin the whole abdominal area, aggravated when

pressure is applied, and persists even at restUrinary

(+) scanty, dark yellow, foamy urineUpper and Lower extremities

(+) Generalized edema (anasarca)(+) shiny skin, (+) pallor, (+) poor skin turgorCold to touchNo skin lesions+2 pitting edema of the upper and lowerextremities(+) Pale nailsCapillary refill of 4 seconds(+) bilateral radial pulses strong and equalMuscle strength:RUE 5/5 RLE 5/5LUE 5/5 LLE 5/5Walks with arms swinging in oppositionLimited range of motion of trunk with pain


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III. Gordons Functional Health Pattern:

1. Health Perception Health Management Pattern:

S Maayos naman pakiramdam ko ngayon. Medyo nabawasan nayung manas ko kung ikukumpara noon. Gusto ko na ngang makauwikasi matagal na ako dito at wala na rin kaming pang-gastos. Sinusunodlang din naman namin lahat ng utos ng doctor pero minsan hindinamin kinakaya kasi kulang sa pang-bayad. Ngayon lang ako na-ospital at ngayon lang din ako nakaranas ng ganito. Sa pamilya namannamin eh wala namang may ganitong sakit. Basta sa ngayon, nakikitako naman na kahit papano e umaayos yung pakiramdam ko, asverbalized by R.S.J

O Conscious and coherent, oriented to person, place, and time. Goodrecall of recent and remote memory. Pupils are equally round andreactive to light, constricts 2-3mm. Able to distinguish sharp and dullsensation. Walks with arms swinging oppositely on both sides noted.Hair is evenly distributed. Generalized edema noted. Pallor of theconjunctiva, skin, and nails noted.

A Readiness for enhanced therapeutic regimen

2. Nutritional and Metabolic Pattern:

S Hindi ako masyadong magana kumain. Tatlong beses akongkumakain araw-araw. Madalas na ulam namin isda o kaya man baboypero hindi ako malakas kumain. Hanggang isang cup ng kanin langako. Sa merienda naman, madalas chichirya o kaya man tinapay.Hindirin ako masyadong mahilig magkakain ng gulay. Mahilig ako samga chichirya, maaalat na pagkain saka cup noodles. Ngayong maysakit ako, binabawas-bawasan ko na yung chichiya saka maaalat kasibawal. Tapos pinapakain ako ng doctor ng tatlong puti ng itlog kadaaraw, sinusunod ko naman pero minsan hindi kasi hindi nakakabili sakanakakasawa din at mas lalo akong hindi ginaganahan kumain. Yungpagmamanas ko, bigla na lang nangyari. Pagkagising ko noong

December 27, nakita ko na lang manas na yung mukha ko. Nagsimuladun sa may bandang ilalim ng mata ko. Tapos yung braso at hita kona-manas din. Tapos pakiramdam ko sobrang nanghihina talaga ako,as verbalized by R.S.J

O Skin is cold to touch, shiny in appearance, no lesions and rashes.Pallor of the skin noted. Poor skin turgor noted. Tongue is symmetricaland at midline. Moist buccal mucosa with no lesions noted. Pale scleraand clear conjunctiva noted. Presence of periorbital, upper and lowerextremities edema noted. +2 pitting edema of the upper and lowerextremities noted. Abdominal swelling and tenderness noted.

A Fluid volume excess related to decreased oncotic pressure in theintravascular space as manifested by verbalization of less urine output,observed generalized edema, +2 pitting edema on upper and lowerextremities, and ascites.

- Risk for impaired skin integrity related to presence of edemasecondary to nephrotic syndrome

3. Elimination Pattern:

S Hindi naman ako nahihirapan umihi. Sa isang araw nakaka 3-5 ataakong ihi Pero medyo kakaunti yung iniihi ko wala pang 30mL kada


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bumubula na makapal yung itsura. Sa pagdumi naman, hindi namanako nahihirapan. Nakaka dumi ako ng isa o dalawa kada-araw.Malambot na buo at kulay brown yung itsura saka wala namang halongdugo.

O Abdominal swelling and tenderness noted. Scanty, dark yellow,foamy urine noted. Soft, formed brown stool noted. Normoactiveborborygmi sounds heard on the LUQ at a rate of 8 bowel sounds per minute.

A Urinary retention related to stimulation of renin-angiotensin-aldosterone system as manifested by verbalization of intake exceedingurine output and scanty, dark yellow, foamy urine.

4. Activity Exercise Pattern:

S Kaya ko nang kumain, umupo, tumayo at maglakad ng pakonti-konti mag-isa. Pag maliligo saka magbibihis e kailangan ko pa din ngkonting tulong kasi medyo mahina pa ako. Pero noong bago ako ma-confine hinang-hina talaga ako kaya lahat ng pagkilos ko noon e

kailangan may tumutulong sakin. Noong wala pa akong sakit, angexercise ko lang e palakad lakad kapag lumalabas ng bahay. Pero mulanung magkasakit ako hanggang ngayon e lagi lang akong naka-higasaka naka-upo kasi nanghina ako tapos manas pa yung braso, hita atmga paa ko, as verbalized by R.S.J

O Skin is pale and cold to touch. Capillary refill time of 4 secondsnoted. Bilateral radial pulse strong and equal noted. Pulse rate of110bpm. Symmetrical chest expansion, dull sound upon percussion,and respiratory rate of 24 bpm noted. Productive cough noted with finecrackles heard upon auscultation at both lower lobes of the lungs. No

shortness of breath noted. Stooped posture noted. Limited range ofmotion of the trunk noted. Muscle strength of 5/5 on both upper andlower extremities. Hemoglobin level of 63 g/L.

A Ineffective tissue perfusion related to decreased oxygen carryingcapacity of the blood as manifested by verbalization of weakness,hemoglobin level of 63 g/L, and decreased capillary refill time.

5. Sleep Rest Pattern:

S Okay naman ang pag-tulog ko. Nakakatulog ako ng mga 6 na oras

sa gabi. Tapos paputol-putol sa umaga, mga dalawang oras lang kasimay mag-bBP, magbibigay ng gamot, at kung anu-ano pa. Wala namanakong ibang ginagawa para makatulog. Basta pumipikit lang ako taposgamit ko isang unan lang. Pag gumigising ako, pakiramdam ko nanakapagpahinga naman ako ng maayos. Nanghihina lang talaga akong konti dahil sa sakit ko, as verbalized by the R.S.J.

O Conscious and coherent, oriented to person, place, and time. Nopresence of dark circles under the eyes. Patient was able to sleep twicewithin the shift noted.

A Readiness for enhanced sleep

6. Sensory-Cognitive-Perceptual Pattern:

S Medyo makirot yung tiyan ko. Mga 4/10 lang yung sakit na parangmay nakadagan. Mas lalong masakit kapag nadadaganan pero kapagnakahiga lang ako natitiis ko naman. Wala nang ibang parte ngkatawan kong kumikirot, basta yung buong tiyan lang. Pawala-walanaman yung kirot, minsan meron, minsan wala. Wala naman akongginagawa para mawala yung kirot, basta pinapahinga ko na lang. Sapag-dedesisyon naman sa sakit ko, inaasa ko na lang sa mga

magulang ko kasi mas alam nila yung tama para sakin. Basta anggusto ko lang eh gumaling, as verbalized by R.S.J


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O Conscious and coherent, oriented to person, place, and time. Ableto recall recent and remote memories noted. Follows directionsaccurately and responds appropriately to topics discussed andexpresses feelings appropriately to the situation noted. Pupils areequally round and reactive to light, constricts 2-3mm. Able todistinguish sharp and dull sensation noted. Facial grimace andguarding behavior when pressure is applied on the abdominal areanoted.

A Acute pain related to irritation of nerve endings as manifested byverbalization of pain, facial grimace, and guarding behavior.

7. Self-perception Self-concept Pattern:

S Noong wala pa akong sakit, nakakapaglaro pa ako sa labas taposnakakaalis kasama mga kaibigan ko. Pero mula noong magkasakit ako,

lagi na lang akong nasa bahay at nakakulong. Nahihirapan ako na maysakit ako lalo na pag nakikita ko yung sarili ko na manas taposnanghihina pa ako lalo na noong bago pa ako ma-confine.Nakakalungkot din kasi hindi ko na magawa yung mga dati kongnagagawa, as verbalized by R.S.J

O Calm during assessment noted. Patient speaks in a well modulatedvoice with no slurring of speech noted. Maintains eye contact andglances at the speakers direction during conversation. Use of handgestures while speaking noted.

A Situational low self-esteem related to social role changes asmanifested by expressions of helplessness.

8. Role relationship Pattern:

S Walo kami sa bahay. Kasama ko yung magulang ko, tatlo kongkapatid saka yung dalawa kong tito. Masaya naman kami kasi kasamanamin yung isat isa. Madalas may problema pero nasosolusyunan dinnaman kahit papano. Masaya din ako kasi hindi ako pinabayaan ngpamilya ko mula noong magkasakit ako. Inaalagaan nila ako sakabinibigyang atensyon. Marami din akong kaibigan kaso di ko na sila

nakikita mula noong nagkasakit ako, as verbalized by R.S.J

O No evidence of physical and psychosocial abuse noted. Parents arepresent at the bedside.

A Readiness for enhanced family process

9. Sexuality Reproductive Pattern:

S (Not assessed)O Minimal secondary characteristics like noted. No facial, chest, and abdominal hair

noted. Minimal hair in the axilla noted. Voice is well-modulated. No deepening of voicenoted. Shoulders and chest are not broad.

10. Coping Stress Pattern:

S Biglaan kasi tong pagkakasakit ko kaya noong umpisa e nalungkotat na-stress talaga ako na bakit ba nangyari sakin to. Dati kapag na-stress ako, lumalabas lang ako ng bahay tapos maggagala paramahimasmasan. Pero noong may sakit ako, minsan sinasarili ko nalang. Pero lagi naman andyan yung pamilya ko kaya sinasabi ko kilamama yung nararamdaman ko. Nakakatulong din kasi kapag may

kumakausap sakin tungkol sa problema ko kasi nailalabas ko yungmga saloobin ko, as verbalized by R.S.J


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O No overt signs of stress noted.

A Readiness for enhanced family coping

11. Value Belief Pattern:

S Katoliko ako pero hindi talaga ako pala-simba kahit noong wala paakong sakit. Wala rin naman kaming sinusunod na mga tradisyon, asverbalized by R.S.J

O Patient is calm. No alterations in mood noted. No presence ofreligious materials at bedside noted.

A Risk for Impaired religiosity related to lack of social integration

IV. Pathophysiology:


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V. Laboratory Procedures and Results:

A. Complete Blood Count

Exam Name NormalValues Unit Result Interpretation

Hemoglobin 130 170 g/L 63.0 Low hemoglobin level is causedby a decrease in red blood cellswhich occurs when the kidneysare damaged and the productionof erythropoietin, a hormone thatstimulates the bone marrow toproduce red blood cells, isdiminished. A hemoglobin level of63.0 g/L would result to a

decrease in the oxygen carryingcapacity of the blood which wouldcompromise the distribution ofoxygen to the different vitalorgans.

Hematocrit 0.40 0.54 0.19 Low hematocrit level is caused bya diminished percentage of redblood cells in the bloodstream.

Red blood cell 4.50 6.50 10^12/L

2.34 Low level of red blood cells iscaused by damage in the kidneyswhich would impair the production

of erythropoietin, a hormoneproduced by the kidneys thatstimulates the bone marrow toproduce red blood cells.

MCV 80 100 81 NormalMCH 27 32 g/L 27 NormalMCHC 32 38 g/dL 33 NormalWhite BloodCell

4 10 10^9/L

17.2 An increase in number of whiteblood cells is indicative of anactive inflammatory process.Since R.S.Js immune system is

depressed due to the decreasednumber of immunoglobulins,bacterias like S. Pneumoniae havehigh chance of breaking into thebodys defenses thus resulting toone of the common complicationsof nephrotic syndrome which isPneumonia.

Neutrophil

0.0 56.0 % 79.3 An increase in number of neutrophils is indicative of anactive inflammatory process since

it is one of the first responders ofthe inflammatory cells to migrate


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Lymphocyte

0.0 34.0 % 11.7 Normal

Basophil 0.0 1.0 % 0.5 Normal

Monocyte 0.0 3.0 % 7.5 An increase in number of monocytes is indicative that themacrophages are doing its workto phagocytize or uptake, digest,and destroy the bacteria that

invaded the bodys defenses. Eosinophi

l

0.0 3.0 % 1.0 Normal

Platelet Count 150 500 10^9L 571 An increase in the platelet countis due to the loss of antithrombinIII, a protein molecule that helpsprevent clotting. In R.S.Js case,antithrombin III is diminished dueto the loss of plasma protein orhypoalbuminemia. Since there is alow level of antithrombin and

there is an increase in plateletcount, it would result to having anincreased risk in developing bloodclot.

MPV 6.0 11.0 8.1 Normal

B. PT, PTTTest name Normal Value Unit Result InterpretationProthrombin time 11.3 15.3 Sec 14.9 Normal

PT control Sec 13.3 Normal

PT INR 1.16 Normal

PT % Activity 70 100 % 80 Normal

APTT 29 37 Sec 29.9 Normal

APTT control Sec 31.3 Normal

C. Creatinine, Na, KTest Normal Values Unit Result Interpretation

Creatinine

Adult: 45 104Neonate: 27

87

Infant: 14 34Child: 23 68

umol/L 144.40

High level of creatinine indicates a decreasein the kidneys glomerular filtration ratewhich impairs the clearance of creatinine by

the kidneys

Na + 135 143 mmol/L

136.00

Normal

K + 3.4 4.82 mmol/L

3.58 Normal

D. UrinalysisPhysical

Normal

values

Result Interpretation

Color Yellow Light yellow Light yellow urine could be due to the diureticsthat R.S.J is taking which forces the body toeliminate the excess fluid

Characteristic

Clear Slightlyturbid

Foamy characteristic of urine is due to theincrease amount of protein being secreted bythe kidneys

pH 5-6 5.5 NormalSpecificgravity

1.010 1.030

1.025 Normal

Chemical

Sugar Negative Negative NormalProtein Negative +2 A +2 protein in the urine is indicative of an


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allows passage of protein in the urine.Bilirubin Negative Negative NormalMicroscopicRBC Negative/ra

re10-12 Red blood cells that appear in the urine is

indicative of an increase in the glomerularpermeability which allows passage of red bloodcells in the urine.

WBC Negative/ra

re

28-30 White blood cells that appear in the urine is

indicative of an increase in the glomerularpermeability which allows passage of whiteblood cells in the urine. However, it may alsobe a sign of infection.

Crystals None None found NormalEpithelialcells

Few None found Normal

Bacteria None Few It may be a sign of infection.

E. Arterial Blood Gas

Test Normal Values Result

Interpretation

pH 7.35 7.45 7.35 Normal (Acidosis)pO2 80 100

mmHg97 Normal

pCO2 35 45 mmHg 23 Alkalosis (Respiratory)O2Sat

95% orgreater

97 Normal

Hct 35 50% 25 Decreased hematocrit level indicates low percentage of redblood cells in the blood

HCO

3

22 26

mEq/mL

12.7 Acidosis (Metabolic)

Impression: Metabolic Acidosis, Fully Compensated (This is due to the retention ofmetabolic wastes because the kidneys filtration process is impaired as indicated by adecrease in the glomerular filtration rate and high level of creatinine.)

F. Pleural FluidTest Reference Unit Result Interpretation

LDH in PF U/L 3309.00 Increase level of LactateDehydrogenase in thepleural fluid is indicative ofan ongoing inflammatoryprocess.

Glucose in PF 1.65 4.95 mmol/L

2.86 Normal

Total protein inPF

15 45 mg/dL 2256.10 Increase level of TotalProtein in the pleural fluid isindicative of an ongoinginflammatory process.

G. Chest X-rayFindings:The inner bronchovascularmarkings are prominent with hazyinfiltrates in both mid to lowerlung zones.

Impression:- Pneumonia Bilateral

Explanation:Pneumonia is a common complication in Nephrotic syndrome. Its main cause ishypoalbuminemia. A low level of protein would result to a decrease in oncoticpressure in the intravascular space which would lead to fluid shifting into thepleural cavity thus leading to pleural effusion. Also, since there is a decreased

level of protein, immunoglobulin will also be diminished and would make thepatient at risk for infections like pneumonia.


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H. Whole Abdominal Ultrasound:Findings:The liver is normal in size (right lobe 15 cm) with well defined borders andhomogenous parenchymal echogenicity. No focal cystic or solid mass lesion seen.The intra- and extra-hepatic biliary radicles and portal venous channels are notdilated. The gallbladder is inadequately distended (length 5.5cm). The wall ishowever thin with no pericholecystic fluid. The common bile duct is not dilated. Notransducer tenderness elicited.

The pancreas is prominent however parenchymal echogenicity is normal andborders are distinct. The head, neck, and body measures 3.0 2.0 and 2.1 cm inthickness respectively. No focal mass lesion seen. The pancreatic duct is notdilated. The abdominal aorta is normal in diameter. The spleen is high normal insize (11.1 x 4.8cm) parenchymal echogenicity is normal. No focal mass lesionnoted.

The right and left kidneys are enlarged (14 x 6.4cm and 15 x 7.6cm respectively)with well-defined borders. Parenchymal and cortical echogenicity are diffuselyincreased bilaterally. Cortical thickness is adequate with distinct cortico-medullary

differentiation. The renal sinus echoes are centrally oriented with no evidence ofectasia or lithiases. No focal cystic or solid mass lesions seen. The urinary bladderis adequately distended with abundant luminal medium-echoes. No intravesicalmass lesion or luminal stones noted.

There is moderate fluid collection noted in the abdominal and pelvic cavities.Impression:

Bilaterally enlarged and echogenic kidneys, features are suggestive ofGlomerulonephritis

Urinary bladder echoes, probably a collection of inflammatory debris

Moderate ascites

Inadequately distended gallbladder Unremarkable sonogram of the liver, pancreas, and spleen

Interpretation:- The whole abdominal ultrasound highly suggests that R.S.J hasglomerulonephritis which is one of the risk factors in having nephrotic syndrome.Glomerulonephritis is the inflammation of the glomeruli of the kidneys which if nottreated could lead to damage in the glomerular capillary membrane and wouldprogress to an increase in the glomerular permeability which is present innephrotic syndrome.


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VI. Drug Analysis:Drug Classification Dosage Mode of Action Indication Side Effects Contraindicati

onNursing

Responsibilities

ATORVASTATIN(Lipitor)

Anti-l ipidemic 20mg tabOD HS

Inhibits Hmg-COAreductase, theenzyme thatcatalyzes the 1ststep in cholesterolsynthesis pathway,resulting indecrease in serumcholesterol

Elevatedserumtriglycerides,cholesterol(hyperlipidemia)

- Nausea- Headache- Muscle, jointaches and pains

- Allergy toatorvastatin- Activehepaticdisease

(not presentin R.S.J)

1. Assess if there isallergy toAtorvastatin.2. AdministerAtorvastatin at thesame time each day,preferably in theevening.3. Avoid drinkinggrapefruit juice whiletaking Atorvastatinbecause it may

decrease itsmetabolism and it willmake the patient atrisk for toxic effects.4. Eat small frequentmeals to counteractnausea.5. Have adequatetime of rest and sleepafter taking the drugto counteractheadache and torelax the muscles andjoints.

Drug Classification Dosage Mode of Action Indication Side Effects Contraindication

NursingResponsibilities

FUROSEMIDE(Lasix)

Loop diuretic 40mg TIVQ8H

Inhibitsreabsorption ofSodium andChloride from the

Edema -Increase volumeand frequency ofurination-Feeling faint on

- Allergy toFurosemide- Anorexia- Severe

1. Assess for allergyin Furosemide.2. Assess and gradethe edema


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proximal and distaltubules andascending loop ofHenle, leading to asodium-richdiuresis

arising-Drowsiness-Increased thirst-Loss of bodypotassium-GI upset

renal failure- Hepaticcoma(not presentin R.S.J)

3. Monitor and recorddaily body weight atthe same time andwearing the sameclothes to monitorfluid changes.4. Monitor and recorddaily urinary outputpatterns5. Monitor serumelectrolytes,hydration, liver, andrenal function.6. In preparing forthe drug, be sure to

store it at roomtemperature andavoid exposure tolight for it mayslightly discolor thesolution.7. Give the drug withfood or milk toprevent GI upset.8. Provide frequentmouth care toalleviate increasedfeeling of thirst9. Be sure that aurinal is available atbedside to preventgoing in and out ofthe bathroom

frequently10. Instruct toavoid sudden or rapidchange in position11. Advise to


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avoid activities thatrequire concentrationand keen attention12. Refer tothe physician anddietary department inarranging apotassium-rich diet oradding supplementalpotassium

Drug Classification Dosage Mode of Action Indication Side Effects Contraindication NursingResponsibilities

SPIRONOLACTONE(Aldactone)

Potassium-sparing diuretc

25mg tabTID

Competitivelyblocks the effectsof aldosterone inthe renal tubule,causing loss ofsodium and waterand retention ofpotassium.

Adjunctivetherapy inedemaassociatedwithnephroticsyndrome

- Increase volumeand frequency ofurination- Dizziness- Confusion- Feeling faint onarising- Drowsiness

- Allergy tospironolactone- Hyperkalemia


1. Assess for allergyin Spironolactone.2. Assess and gradethe edema3. Monitor and recorddaily body weight atthe same time andwearing the sameclothes or hospitalgown to monitor fluidchanges.4. Monitor and recorddaily urinary outputpatterns5. Monitor serumelectrolytes,

hydration, liver, andrenal function.6. Provide frequentmouth care toalleviate increased


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feeling of thirst7. Be sure that aurinal is available atbedside to preventgoing in and out ofthe bathroomfrequently8. Instruct to avoidsudden or rapidchange in position9. Advise to avoidactivities that requireconcentration andkeen attention



METOPROLOL Beta1-selectiveadrenergic

blocker

50mg tabOD

Competitivelyblocks beta-adrenergicreceptors in theheart andjuxtaglomerularapparatus,decreasing theinfluence of thesympatheticnervous system onthese tissues and

the excitability ofthe heart,decreasing cardiacoutput and therelease of renin,

Hypertension, alone oralong sidewithdiuretics

- Drowsiness- Dizziness- Light-headedness- Blurred vision- Nausea- Loss of appetite

- Sinusbradycardia- Cardiogenicshock- Heart failure


1. Assess vital signsparticularly bloodpressure and heartrate.2. Ensure that patientswallows the wholetablet. Do not cut,crush, or chew.3. Give oral drug withfood to facilitateabsorption.4. Advise to eat small

frequent meals tostimulate appetite5. Advise to avoidactivities that requireconcentration and


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and lowering BP keen attention6. Advise not to stoptaking the drug unlessinstructed by thephysician.



ENALAPRIL ACE Inhibitor 5mg tabOD

Blocks theconversion ofangiotensin I toangiotensin II,decreasing theblood pressure,

decreasingaldosteronesecretion slightlyincreasing serumK+ levels, andcausing Na+ andfluid loss

Hypertension

Reducesloss ofprotein in

the urine(proteinuria)

- GI upset- Loss of appetite- Change in tasteperception- Mouth sores- Rash

- Fast heart rate- Dizziness- Light-headedness

- Allergy toenalapril


1. Assess allergy toenalapril2. Assess vital signsparticularly bloodpressure and heartrate.

3. Monitor patientwhile on diuretictherapy for excessivehypotension4. Provide frequentmouth care toprevent mouth sores.5. Instruct to changein position slowly6. Advise to limitactivities requiringalertness andprecision7. Advise not to stoptaking the drugwithout consulting thephysician



SODIUMBICARBONATE

SystemicAlkalinizer

1 tab Increases plasmabicarbonate,

Treatmentof

Systemic alkalosis:- Headache

- Metabolicand

1. Monitor arterialblood gas


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NaHCO3 UrinaryAlkalinizer

AntacidElectrolyte

buffers excesshydrogen ionconcentration,raises blood Ph

metabolicacidosis

- Nausea- Irritability- Weakness

(not present inR.S.J)

respiratoryalkalosis- Hypocalcemia (alkalosismayprecipitatetetany)


2. Check serumpotassium level priorto giving sodiumbicarbonate for it mayincrease risk ofmetabolic acidosis instates of hypokalemia3. Instruct to cheworal tablet thoroughlybefore swallowing,and follow it with afull glass of water.

Drug Classification Dosage Mode of Action Indication Side Effects Contraindicati

on

Nursing

ResponsibilitiesLEVOFLOXACIN(Levaquin)

FluoroquinoloneAntibiotic

750mg tabOD

Bactericidal:Interferes with DNAby inhibiting DNAgyrase replicationin susceptiblegram-negative andgram-positivebacteria,preventing cellreproduction.

TreatmentofPneumonia

- Nausea- Vomiting- Abdominal pain- Drowsiness- Dizziness- Sensitive tosunlight

- Allergy tofluoroquinolones

1. Assess for allergyto fluoroquinolones2. Administer oraldrug without regardto meals with a glassof water.3. Ensure that patientis well hydratedduring the course oftherapy.4. Instruct to eatsmall frequent meals5. Advise to avoiddoing activities thatrequire concentrationand attention.6. Avoid exposure to

sunlight, use asunscreen if needed.7. Instruct tocomplete the courseof therapy as ordered


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by the physician.



FLUCONAZOLE

Antifungal 100mg tabOD

Binds to sterols inthe fungal cellmembrane,changingmembranepermeability

Treatmentofperitonitis

- Nausea- Vomiting- Diarrhea- Headache

-Hypersensitivity tofluconazole

1. Assess for allergyto fluconazole2. Instruct to eatsmall frequent meals3. Provide a calm andquiet environment4. Instruct to haveadequate rest andrelaxation5. Instruct to

complete taking thedrug in its full course

VII. Nursing Care Plan:Assessment Diagnosis Rationale Planning Interventions Rationale Evaluation

S Yungpagmamanas ko,bigla na lang

Fluid volumeexcessrelated to

Edema innephroticsyndrome is

Goal:

After 1 week of

Independent1. Assesscausative/precipitating

1. To know what to avoid inthe patients present

After 1 week ofnursing intervention,the patient was able


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nangyari.Pagkagising konoong December27, nakita ko nalang manas nayung mukha ko.Nagsimula dun samay bandangilalim ng mata ko.Tapos yung brasoat hita ko na-manas din. Tapospakiramdam kosobrangnanghihina talaga

ako. Konti langdin yung iniihi ko,wala pang 30mLkada ihi, asverbalized byR.S.J

O Skin is cold totouch, shiny inappearance.Presence ofperiorbital, upperand lowerextremitiesedema noted. +2pitting edema ofthe upper andlower extremities

noted. Abdominalswelling andtenderness noted.

decreasedoncoticpressure intheintravascular space asmanifestedbyverbalizationof less urineoutput,observedgeneralizededema, +2pitting

edema onupper andlowerextremities,and ascites.

caused bythe albuminloss whichdecreasesthe oncoticpressure andpermits fluidto escapefrom theintravascularspace to theinterstitialspaces. Thedecrease inblood

volumewould alsostimulate theantidiuretichormone toreabsorbwater.

(PediatricNursing,Muscari,2005)

nursingintervention,the patient willbe able to limitfurther additionto presentexcess in fluidvolume and willbe able tolessen edema

Objectives:

After 8 hours ofnursing

intervention,the patient willbe able to:

- Identifynegativefactors thatwould causeexcess in fluidvolume

- Identifyappropriatebehaviors anddiet that wouldhelp lessenedema

- Verbalizeunderstandingof individualdietary andfluid

factors

2. Monitor vital signs.

3. Monitor intake andoutput accurately.Noting the amount,color, andcharacteristics of urine.

4. Record daily weightand abdominal girthevery morning

5. Assess and gradethe extent of edema.

6. Auscultate breathsounds and note forpresence of crackles.

7. Review recentlaboratory resultsparticularlyhemoglobin,hematocrit, creatinine,

condition

2. An increase in bloodpressure indicatesvasoconstriction which is aresult of the release ofcatecholamines from therenin-angiotensin-aldosterone-system

3. Intake and output is vitalcomponent in monitoring apatient with nephroticsyndrome. Foamy urine is

indicative of protein thatwas excreted by thekidneys. Fluid intake morethan the urine outputindicates fluid retention.

4. These are goodindicators of fluid retention.

5. To monitor the extent offluid shifting from theintravascular to theinterstitial spaces.

6. This could indicatecongestion from pleuraleffusion or presence of

bacterial infection which ispneumonia, a commoncomplication of nephroticsyndrome.

to limit furtheraddition to presentexcess in fluidvolume and edemawas lessened.

After 8 hours ofnursing intervention,the patient was ableto identify negativefactors that wouldcause excess in fluidvolume.

After 8 hours of

nursing intervention,the patient was ableto identifyappropriatebehaviors and dietthat would helplessen edema

After 8 hours ofnursing intervention,the patient was ableto verbalizeunderstanding ofindividual dietaryand fluid restrictions

After 8 hours ofnursing intervention,

the patient was ableto demonstratebehaviors to monitorfluid status


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restrictions

- Demonstratebehaviors tomonitor fluidstatus

serum electrolytes,urinalysis

8. Elevate edematousextremities usingpillows

9. Change patientsposition frequently

10. Provide a wrinkle-free bed

11. Place on semi-fowlers position

12. Provide quiet andcalm environment.Limit external stimuli.

13. Promote bed rest

14. Explain specialdietary restrictions asordered. Low salt (Na


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prescribedmedications.(Included in the drugstudy)

Collaborative16. Refer to the dietarydepartment regardingthe prescribed dietaryregimen

17. Collaborate withthe family membersand other members of

the healthcare teamsuch as the physician,medical technologists,and dietician inrendering holistic careto the patient

would lessen the edema.

Sodium attracts water;therefore limit in sodiumintake would lessen waterretention.

16. This would ensureappropriate diet for the

patient in accordance tothe doctors prescriptionand his needs.

17. The physician wouldexplain the necessaryrestrictions to the patient incollaboration with themedical technologists whowould relay recentlaboratory results done tothe patient, and to thedietician who wouldformulate a necessary mealplan for the family toimplement at home. Thenurse would act as a mainmediator in communicating

with the different membersof the health care team.


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VIII. Recommendation:

As I finish the case study of nephrotic syndrome, I was able to encounterlimitations such as inadequate assessment data gathered from the patient. Irecommend that to be able to further understand the disease process, a dailyweight and abdominal girth record should be monitored. Also, I recommendthat other laboratory studies should be seen and examined such as the serumtriglycerides of the patient to further evaluate the extent of the synthesis oflipoproteins due to hypoalbuminemia.


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CLINICAL CASE STUDY

(NEPHROTIC SYNDROME)

Borja, Mary Grace T.

RNHEALS

Male Medical Ward

case study - nephrotic

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