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A Case Study-Final
A Case Study-Final
A Case Study-Final
On
In Partial Fulfillment of
The Requirements
In Nursing Care
Management
102
Submitted to:
Submitted by:
Haspe, Maria Flor
Kalaw, Herniňo C.
Lanchita, Jovelle Ann
Maynopas, Glaiza
Mendoza, karen
Nidwelan, Arbert
Date of Submission:
Contents Pages
Acknowledgement
Introduction
Objectives of the Study
A. General Objectives
B. Specific Objectives
Identification of the Case
Background and family History
Socioeconomic Status
Medical Health History
A. Past Illness
B. Present Illness
Developmental Task
Definition of terms
Anatomy and Physiology,
Pathophysiology of the disease
Symptoms
A. Present or Absent
Schematic Diagram
Medical Management
A. Ideal
B. Actual
Nursing Theories
Lab Findings
Drug Study
Nursing Assessment
A. General Survey
B. Vital Signs
C. Skin
D. Hair
E. Nails
F. Skull and Face
G. Mouth
H. Neck
I. Chest
J. Upper and Lower Extremities
K. Elimination
L. Urinary
Nursing Care Plans
Discharge Plan Method
A. Medication
B. Exercise
C. Treatment
D. Health teaching to the Family
E. Out-patient follow up
F. Diet
Journals
Reactions
Prognosis and Results
Ideal Prognosis
Summary
Evaluation
Nursing Implications
Acknowledgement
The proponents of this case study would like to express their sincerest appreciation
and gratitude to the following persons who in one way or another exerted their effort in
making this study possible.
To our clinical instructor, Mrs. Analiza Duhig- Casalta for providing us with significant
inputs in constructing this case study.
To our patient, for allotting his time with us during our data gathering for the
completion of this study.
To the staff of Medicine Ward of Davao Medical Center for allowing us to scan our
patient’s laboratory results, to the different authors of books, internet and journals
which helped in the contribution to materialized our research.
To our parents and guardians, for the interminable financial and moral support that
they’ve extended.
To our friends, classmates and group mates for allocating their resources, time and
venture to make this study attainable.
And most of all to our Almighty Father, the source of our faith, for the strength that had
sustained the advocates of this case study in constructing this complex endeavor
easily.
OBJECTIVES
A. General Objective:
This case study aims to provide the future researchers and students a broader
knowledge on Chronic Renal Failure
B .Specific Objectives:
Present the personal data, medical and health history and developmental
background of Mr. X
Discuss the Normal anatomy and physiology related to the disease process
Our patient Mr. X is the eldest among the six children of Mr. and Mrs. Smith, 34
y.old, born on October 5, 1974.
His wife Mrs. Frail is a housewife; she spent her time taking good care of their
two children.
They are currently residing at Bato-Bato, San Isidro Davao Oriental and living
with his two children namely; Jing and Jong.
He had his elementary education at Bato-Bato elementary school and took his
secondary education at San Isidro National High School located at San Isidro Davao
Oriental. He did not finish his tertiary education due to financial constraints.
Socioeconomic Status
MEDICAL HEALTH HISTORY
Immunizations: OPV
Allergies: none
Taken Medications:
Past Illness; Nephrolithiasis
Arthritis
Developmental Task
Definition of Terms
Nephrolithiasis
Uropathy
Arthritis
Bloodstream
Erythropoietin
gluconeogenesis
bilirubin
calyces
microvilli
juxtaglomerular
Oliguria
Anuria
Pruritus
Renal osteodystrophy
Creatinine
Pericarditis
Anatomy and Physiology
I.
A. Components of the urinary system
two kidneys
two ureters
one urinary bladder
one urethra
the kidneys
-regulate blood volume and composition
-help regulate blood pressure
-synthesize glucose
-release erythropoietin
-participate in vitamin D synthesis
-excrete wastes in the urine
the ureters transport urine from the kidneys to the urinary bladder
the urinary bladder stores urine
the urethra discharges urine from the body
B. The remaining parts of the urinary system- passageways and storage areas
the kidneys help regulate the blood levels of Na +, K+, Ca2+, Cl-, and
HPO42-
like the liver, the kidneys can use the amino acid glutamine in gluconeogenesis
gluconeogenesis is the synthesis of new glucose molecules
can release glucose into blood to maintain normal blood glucose level
-drugs
-environmental toxins
-Superficial
-smooth-textured reddish area
-deep
-reddish-brown inner region
-consists of 8 to 18 cone-shaped renal pyramids
4. Renal lobe- a renal pyramind + its overlying area of renal cortex + 1/2 of
each
adjacent renal column
7. Urine formed by the nephrons drains into large papillary ducts- extend
through
the renal papillae
8. Papillary ducts drain into cuplike structures called minor and major calyces
(singular, calyx)
9. From the major calyces, urine drains into a large cavity called the renal pelvis
10. Urine leaves the renal pelvis through the ureter
A. the kidneys are abundantly supplied with blood vessels- they process blood
B. the kidneys receive 20 - 25% of the resting cardiac output via the right and left
renal arteries
C. In adults, blood flow through both kidneys (renal blood flow) is about 1200 ml
per minute
D. Blood supply of the kidneys
V. The Nephron
C. the distal convoluted tubules of several nephrons empty into a single collecting
duct
1. The ascending limb- the first part of the loop of Henle
- dips into the renal medulla
Symptomatology
Etiology
Predisposing Rationale
Gender According to Ignatavicius and
Workman. Overall incidence is higher
in men.
Age According to Ignatavicius and
Workman. The incidence of stone
disease in the adult population is
relatively high. About 12% of adult will
have at least one episode of renal
stone disease.
Precipitating
Diet Increase sodium in diet
Urinary Retention (job) According to Ignatavicius and
Workman. Taking for granted the urge
to urinate will contribute to the
formation or renal calculi.
Vices Increase alcohol/ liquor’s on his young
age (Udan, MAN- Medsurg 2009)
Pathophysiology
Predisposing Precipitating
Gender ● Diet
Age ● Vices
● Urinary retention
(job)
↓
Supersaturation of the urine
↓
IDEAL
Diagnosis
G. Electrolytes, BUN, creatinine, phosphate, Ca, CBC, urinalysis (including urinary
sediment examination)
H. Ultrasonography
I. Sometimes, renal biopsy
ACTUAL
02/ 15/09
9AM
02/ 16/ 09
B. Chemical Exam
Sugar:( -)
pH:
C. Microscopic Exam
Epithelial Cells: +1
Squamous
Puss Cells: > 100 hpf
RBC 2-4 hpf
Bacteria
Yeast Cells
Oil Globules
Spermatozoa
Nursing Theories
Lab Findings
B. Chemical Exam
Na 136.00 136-155.00
K 3.7 3.5-5.5
Crea 2134.60 53.00-115.00
C. Microscopic Exam
IPP
Squamous
Puss Cells: > 100
hpf
RBC 2-4
hpf
Bacteria
Yeast Cells
Oil Globules
Spermatozoa
Drug Study
Nursing Assessment
Integument
Skin
Inspection: presence of rash
Palpation: presence of edema, dry, warm to touch
Nails
Inspection: brittle
Palpation: capillary refill of <5 secs
Hair
Palpation: brittle texture
Neck
Palpation: no jugular vein distention
Chest
Posterior
Inspection: use of accessory muscle
Palpation: alteration in regular rhythm and depth, symmetric chest expansion,
Auscultation: crackles noted.
Heart
Auscultation: apical heart rate – 92 bpm
Abdomen
Inspection: bloated abdomen
Extremities
Inspection: presence of rashes.
Palpation: presence of edema
Nursing Care Plans
NCP Actual
Cues and Nursing Objectives Implementatio Rationale Goals
evidences’ diagnosis n
>to facilitate
less
occurrence
of
complication
s
Discharge Plan Method
Journals
Prognosis and Results
Actual Prognosis
NUTRITION/DIET Ö Patient
usually
consumed
unhealthy
foods that are
high in sodium
and fats..
REACTION TO Ö Refuse to
MEDICAL have
MANAGEMENT Hemodialysis.
FAMILY SUPPORT Ö Home Against
Medical
Advice.
LEGEND: RATINGS:
GOOD = 2.4 - 3.0 GOOD: 1X3 = 3
FAIR = 1.7 - 2.3 FAIR: 1X2 2
POOR = 1.0 -1.6 POOR: 3X1 =3
TOTAL: 8/5 = 1.6
The result of 1.6 signals a POOR PROGNOSIS. Wherein, out of the result, 1
criteria is graded as good, 2 are fair and 3 are poor. Therefore, our client and also his
family need to be provided with information on ways to promote health Treatment,
lifestyle modification and the clients Treatment compliance. Our client has poor
prognosis because of Home Against Medical Advice (HAMA). Patient also refuses
hemodialysis.
Ideal Prognosis