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 damages the glomerular capillary membrane and results in increased glomerular permeability. (Brunner & Suddarth 10th edition) The main reason why I chose this case is because I got interested 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 according to the Department of Health, Nephrotic syndrome is the 10 th leading cause of mortality in the Philippines in the year 2006 with a percentage of 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 huge percentage of Filipinos are also not knowledgeable about what nephrotic syndrome is. Thats why I made this case study to provide information about nephrotic syndrome and its disease process.

II. History and Physical Examination

A. History of Present Illness 25 days prior to admission, R.S.J, 15 year old male noticed mild swelling of his face, and upper and lower extremities. Consultation was done 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 periorbital area, abdomen, and both upper and lower extremities accompanied by fatigue and malaise. Foamy urine was noticed upon urination. No consultation and interventions made. 3 days prior to admission, R.S.J started having intermittent low grade fever accompanied by dry cough, fatigue and malaise. Generalized edema is still present. No consultation and interventions made. 1 day prior to admission, clinical manifestations of generalized edema, fatigue and malaise still persisted. Pain with a scale of 6/10 was felt in the whole abdominal area which is aggravated when pressure is applied and still persists even at rest. 8 hours prior to admission, symptoms still persisted. R.S.J was brought 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 known allergies. Past immunizations are unrecalled. And there were no foreign and 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 apartment in Caloocan city with 8 occupants including his parents, 3 siblings, and two uncles. His father who works as a contractual worker and earns 300 pesos per day is the breadwinner of the family and supports his medical expenses. His mother is a plain housewife who cares for him and his siblings at home. Before the occurrence of the disease, R.S.J is described to be cheerful, friendly, and playful who is always playing on the streets with his friends. When the symptoms appeared, he decided to stay at home and lessen his socialization with others. D. Physical Examination Mental Status Examination Level of Consciousness Appearance and movement Concious, coherent Stooped posture Clothes fit and appropriate for occasion and weather Dirty skin and nails Maintains eye contact Smiles and frowns appropriately Speaks clearly in moderate pacing Smooth, coordinated movements Responds appropriately to topic discussed and expresses feelings appropriately to the situation and Expresses full and free-flowing thoughts during the interview

Mood Thought process perceptions

Cognitive abilities

Follows directions accurately Oriented to person, place, and time Recalls recent and remote memories

Head and face Head is symmetrical and round Hair is evenly distributed Face is symmetrical (+) Periorbital edema Eyes 2-3mm pupillary constriction, equally reactive to light (+) corneal reflex Pale conjunctiva (+) Periorbital edema Nose Symmetrical, septum at midline No nasal flaring Mouth Moist buccal mucosa with no lesions (+) Yellowish discoloration of the teeth Tongue is symmetrical and at midline with no lesions Thoracic (+) pallor Symmetrical chest expansion Respiratory rate of 24bpm No pain or tenderness upon palpation Dull sound upon percussion (+) Productive cough (+) Fine crackles heard upon auscultation at both lower lobes of the lungs Heart Blood pressure of 100/60 mmHg Heart rate of 110bpm Abdomen (+) abdominal enlargement (+) abdominal pain and tenderness, 4/10 localized in the whole abdominal area, aggravated when pressure is applied, and persists even at rest Urinary (+) scanty, dark yellow, foamy urine Upper and Lower extremities (+) Generalized edema (anasarca) (+) shiny skin, (+) pallor, (+) poor skin turgor Cold to touch No skin lesions +2 pitting edema of the upper and lower extremities (+) Pale nails Capillary refill of 4 seconds (+) bilateral radial pulses strong and equal Muscle strength: RUE 5/5 RLE 5/5 LUE 5/5 LLE 5/5 Walks with arms swinging in opposition Limited range of motion of trunk with pain

III. Gordons Functional Health Pattern:

1. Health Perception Health Management Pattern: S Maayos naman pakiramdam ko ngayon. Medyo nabawasan na yung manas ko kung ikukumpara noon. Gusto ko na ngang makauwi kasi matagal na ako dito at wala na rin kaming pang-gastos. Sinusunod lang din naman namin lahat ng utos ng doctor pero minsan hindi namin kinakaya kasi kulang sa pang-bayad. Ngayon lang ako naospital at ngayon lang din ako nakaranas ng ganito. Sa pamilya naman namin eh wala namang may ganitong sakit. Basta sa ngayon, nakikita ko naman na kahit papano e umaayos yung pakiramdam ko, as verbalized by R.S.J O Conscious and coherent, oriented to person, place, and time. Good recall of recent and remote memory. Pupils are equally round and reactive to light, constricts 2-3mm. Able to distinguish sharp and dull sensation. Walks with arms swinging oppositely on both sides noted. Hair is evenly distributed. Generalized edema noted. Pallor of the conjunctiva, skin, and nails noted. A Readiness for enhanced therapeutic regimen 2. Nutritional and Metabolic Pattern: S Hindi ako masyadong magana kumain. Tatlong beses akong kumakain araw-araw. Madalas na ulam namin isda o kaya man baboy pero hindi ako malakas kumain. Hanggang isang cup ng kanin lang ako. Sa merienda naman, madalas chichirya o kaya man tinapay. Hindirin ako masyadong mahilig magkakain ng gulay. Mahilig ako sa mga chichirya, maaalat na pagkain saka cup noodles. Ngayong may sakit ako, binabawas-bawasan ko na yung chichiya saka maaalat kasi bawal. Tapos pinapakain ako ng doctor ng tatlong puti ng itlog kada araw, sinusunod ko naman pero minsan hindi kasi hindi nakakabili saka nakakasawa din at mas lalo akong hindi ginaganahan kumain. Yung pagmamanas ko, bigla na lang nangyari. Pagkagising ko noong December 27, nakita ko na lang manas na yung mukha ko. Nagsimula dun sa may bandang ilalim ng mata ko. Tapos yung braso at hita ko na-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 symmetrical and at midline. Moist buccal mucosa with no lesions noted. Pale sclera and clear conjunctiva noted. Presence of periorbital, upper and lower extremities edema noted. +2 pitting edema of the upper and lower extremities noted. Abdominal swelling and tenderness noted. A Fluid volume excess related to decreased oncotic pressure in the intravascular space as manifested by verbalization of less urine output, observed generalized edema, +2 pitting edema on upper and lower extremities, and ascites. - Risk for impaired skin integrity related to presence of edema secondary to nephrotic syndrome 3. Elimination Pattern: S Hindi naman ako nahihirapan umihi. Sa isang araw nakaka 3-5 ata akong ihi. Pero medyo kakaunti yung iniihi ko, wala pang 30mL kada ihi. Tapos yung itsura niya parang sobrang madilaw tapos parang

bumubula na makapal yung itsura. Sa pagdumi naman, hindi naman ako nahihirapan. Nakaka dumi ako ng isa o dalawa kada-araw. Malambot na buo at kulay brown yung itsura saka wala namang halong dugo. O Abdominal swelling and tenderness noted. Scanty, dark yellow, foamy urine noted. Soft, formed brown stool noted. Normoactive borborygmi sounds heard on the LUQ at a rate of 8 bowel sounds per minute. A Urinary retention related to stimulation of renin-angiotensinaldosterone system as manifested by verbalization of intake exceeding urine output and scanty, dark yellow, foamy urine. 4. Activity Exercise Pattern: S Kaya ko nang kumain, umupo, tumayo at maglakad ng pakontikonti mag-isa. Pag maliligo saka magbibihis e kailangan ko pa din ng konting tulong kasi medyo mahina pa ako. Pero noong bago ako maconfine hinang-hina talaga ako kaya lahat ng pagkilos ko noon e kailangan may tumutulong sakin. Noong wala pa akong sakit, ang exercise ko lang e palakad lakad kapag lumalabas ng bahay. Pero mula nung magkasakit ako hanggang ngayon e lagi lang akong naka-higa saka naka-upo kasi nanghina ako tapos manas pa yung braso, hita at mga paa ko, as verbalized by R.S.J O Skin is pale and cold to touch. Capillary refill time of 4 seconds noted. Bilateral radial pulse strong and equal noted. Pulse rate of 110bpm. Symmetrical chest expansion, dull sound upon percussion, and respiratory rate of 24 bpm noted. Productive cough noted with fine crackles heard upon auscultation at both lower lobes of the lungs. No shortness of breath noted. Stooped posture noted. Limited range of motion of the trunk noted. Muscle strength of 5/5 on both upper and lower extremities. Hemoglobin level of 63 g/L. A Ineffective tissue perfusion related to decreased oxygen carrying capacity 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 kasi may mag-bBP, magbibigay ng gamot, at kung anu-ano pa. Wala naman akong ibang ginagawa para makatulog. Basta pumipikit lang ako tapos gamit ko isang unan lang. Pag gumigising ako, pakiramdam ko na nakapagpahinga naman ako ng maayos. Nanghihina lang talaga ako ng konti dahil sa sakit ko, as verbalized by the R.S.J. O Conscious and coherent, oriented to person, place, and time. No presence of dark circles under the eyes. Patient was able to sleep twice within 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 parang may nakadagan. Mas lalong masakit kapag nadadaganan pero kapag nakahiga lang ako natitiis ko naman. Wala nang ibang parte ng katawan kong kumikirot, basta yung buong tiyan lang. Pawala-wala naman yung kirot, minsan meron, minsan wala. Wala naman akong ginagawa para mawala yung kirot, basta pinapahinga ko na lang. Sa pag-dedesisyon naman sa sakit ko, inaasa ko na lang sa mga magulang ko kasi mas alam nila yung tama para sakin. Basta ang gusto ko lang eh gumaling, as verbalized by R.S.J

O Conscious and coherent, oriented to person, place, and time. Able to recall recent and remote memories noted. Follows directions accurately and responds appropriately to topics discussed and expresses feelings appropriately to the situation noted. Pupils are equally round and reactive to light, constricts 2-3mm. Able to distinguish sharp and dull sensation noted. Facial grimace and guarding behavior when pressure is applied on the abdominal area noted. A Acute pain related to irritation of nerve endings as manifested by verbalization of pain, facial grimace, and guarding behavior.

7. Self-perception Self-concept Pattern: S Noong wala pa akong sakit, nakakapaglaro pa ako sa labas tapos nakakaalis kasama mga kaibigan ko. Pero mula noong magkasakit ako, lagi na lang akong nasa bahay at nakakulong. Nahihirapan ako na may sakit ako lalo na pag nakikita ko yung sarili ko na manas tapos nanghihina pa ako lalo na noong bago pa ako ma-confine. Nakakalungkot din kasi hindi ko na magawa yung mga dati kong nagagawa, as verbalized by R.S.J O Calm during assessment noted. Patient speaks in a well modulated voice with no slurring of speech noted. Maintains eye contact and glances at the speakers direction during conversation. Use of hand gestures while speaking noted. A Situational low self-esteem related to social role changes as manifested by expressions of helplessness. 8. Role relationship Pattern: S Walo kami sa bahay. Kasama ko yung magulang ko, tatlo kong kapatid saka yung dalawa kong tito. Masaya naman kami kasi kasama namin yung isat isa. Madalas may problema pero nasosolusyunan din naman kahit papano. Masaya din ako kasi hindi ako pinabayaan ng pamilya ko mula noong magkasakit ako. Inaalagaan nila ako saka binibigyang 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 are present 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 voice noted. Shoulders and chest are not broad. 10. Coping Stress Pattern: S Biglaan kasi tong pagkakasakit ko kaya noong umpisa e nalungkot at na-stress talaga ako na bakit ba nangyari sakin to. Dati kapag nastress ako, lumalabas lang ako ng bahay tapos maggagala para mahimasmasan. Pero noong may sakit ako, minsan sinasarili ko na lang. Pero lagi naman andyan yung pamilya ko kaya sinasabi ko kila mama yung nararamdaman ko. Nakakatulong din kasi kapag may kumakausap sakin tungkol sa problema ko kasi nailalabas ko yung mga saloobin ko, as verbalized by R.S.J

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 pa akong sakit. Wala rin naman kaming sinusunod na mga tradisyon, as verbalized by R.S.J O Patient is calm. No alterations in mood noted. No presence of religious materials at bedside noted. A Risk for Impaired religiosity related to lack of social integration

IV. Pathophysiology:

V. Laboratory Procedures and Results:

A. Complete Blood Count Exam Name Normal Values Hemoglobin 130 170 Unit g/L Resul Interpretation t 63.0 Low hemoglobin level is caused by a decrease in red blood cells which occurs when the kidneys are damaged and the production of erythropoietin, a hormone that stimulates the bone marrow to produce red blood cells, is diminished. A hemoglobin level of 63.0 g/L would result to a decrease in the oxygen carrying capacity of the blood which would compromise the distribution of oxygen to the different vital organs. 0.19 Low hematocrit level is caused by a diminished percentage of red blood cells in the bloodstream. 2.34 Low level of red blood cells is caused by damage in the kidneys which would impair the production of erythropoietin, a hormone produced by the kidneys that stimulates the bone marrow to produce red blood cells. 81 Normal 27 Normal 33 Normal 17.2 An increase in number of white blood cells is indicative of an active inflammatory process. Since R.S.Js immune system is depressed due to the decreased number of immunoglobulins, bacterias like S. Pneumoniae have high chance of breaking into the bodys defenses thus resulting to one of the common complications of nephrotic syndrome which is Pneumonia. 79.3 An increase in number of neutrophils is indicative of an active inflammatory process since it is one of the first responders of the inflammatory cells to migrate at the site of inflammation.

Hematocrit Red blood cell

0.40 0.54 4.50 6.50 10^1 2/L

MCV MCH MCHC White Cell

Blood

80 100 27 32 32 38 4 10

g/L g/dL 10^9/ L

Neutrophi l

0.0 56.0

Lymphoc yte Basophil Monocyte

0.0 34.0 0.0 1.0 0.0 3.0

% % %

11.7 0.5 7.5

Normal Normal An increase in number of monocytes is indicative that the macrophages are doing its work to phagocytize or uptake, digest, and destroy the bacteria that invaded the bodys defenses. Normal An increase in the platelet count is due to the loss of antithrombin III, a protein molecule that helps prevent clotting. In R.S.Js case, antithrombin III is diminished due to the loss of plasma protein or hypoalbuminemia. Since there is a low level of antithrombin and there is an increase in platelet count, it would result to having an increased risk in developing blood clot. Normal

Eosinophi l Platelet Count

0.0 3.0 150 500

% 10^9L

1.0 571

MPV B. PT, PTT Test name Prothrombin time PT control PT INR PT % Activity APTT APTT control

6.0 11.0

8.1

Normal Value 11.3 15.3

Unit Sec Sec % Sec Sec

70 100 29 37

Result 14.9 13.3 1.16 80 29.9 31.3

Interpretation Normal Normal Normal Normal Normal Normal

C. Creatinine, Na, K Test Normal Values Unit Creatini Adult: 45 104 umol/L ne Neonate: 27 87 Infant: 14 34 Child: 23 68 Na + 135 143 mmol/ L K+ 3.4 4.82 mmol/ L D. Urinalysis Physical Color Characteristi c pH Specific gravity Chemical Sugar Protein Normal values Yellow Clear 5-6 1.010 1.030 Negative Negative

Result 144.4 0

Interpretation High level of creatinine indicates a decrease in the kidneys glomerular filtration rate which impairs the clearance of creatinine by the kidneys Normal Normal

136.0 0 3.58

Result Light yellow Slightly turbid 5.5 1.025 Negative +2

Interpretation Light yellow urine could be due to the diuretics that R.S.J is taking which forces the body to eliminate the excess fluid Foamy characteristic of urine is due to the increase amount of protein being secreted by the kidneys Normal Normal Normal A +2 protein in the urine is indicative of an increase in the glomerular permeability which

Bilirubin Microscopic RBC

Negative Negative/ra re Negative/ra re

Negative 10-12

allows passage of protein in the urine. Normal Red blood cells that appear in the urine is indicative of an increase in the glomerular permeability which allows passage of red blood cells in the urine. White blood cells that appear in the urine is indicative of an increase in the glomerular permeability which allows passage of white blood cells in the urine. However, it may also be a sign of infection. Normal Normal It may be a sign of infection.

WBC

28-30

Crystals Epithelial cells Bacteria

None Few None

None found None found Few

E. Arterial Blood Gas Test pH pO2 pCO2 O2 Sat Hct Normal Values 7.35 7.45 80 100 mmHg 35 45 mmHg 95% or greater 35 50% Resu lt 7.35 Normal (Acidosis) 97 Normal 23 97 25 Alkalosis (Respiratory) Normal Decreased hematocrit level indicates low percentage of red blood cells in the blood Acidosis (Metabolic) Interpretation

HCO 22 26 12.7 3 mEq/mL Impression: Metabolic Acidosis, Fully Compensated (This is due to the retention of metabolic wastes because the kidneys filtration process is impaired as indicated by a decrease in the glomerular filtration rate and high level of creatinine.)

F. Pleural Fluid Test Reference LDH in PF

Unit U/L

Result 3309.00

Glucose in PF Total protein in PF

1.65 4.95 15 45

mmol /L mg/dL

2.86 2256.10

Interpretation Increase level of Lactate Dehydrogenase in the pleural fluid is indicative of an ongoing inflammatory process. Normal Increase level of Total Protein in the pleural fluid is indicative of an ongoing inflammatory process.

G. Chest X-ray Findings: Impression: The inner bronchovascular - Pneumonia Bilateral markings are prominent with hazy infiltrates in both mid to lower lung zones. Explanation: Pneumonia is a common complication in Nephrotic syndrome. Its main cause is hypoalbuminemia. A low level of protein would result to a decrease in oncotic pressure in the intravascular space which would lead to fluid shifting into the pleural cavity thus leading to pleural effusion. Also, since there is a decreased level of protein, immunoglobulin will also be diminished and would make the patient at risk for infections like pneumonia.

H. Whole Abdominal Ultrasound: Findings: The liver is normal in size (right lobe 15 cm) with well defined borders and homogenous parenchymal echogenicity. No focal cystic or solid mass lesion seen. The intra- and extra-hepatic biliary radicles and portal venous channels are not dilated. The gallbladder is inadequately distended (length 5.5cm). The wall is however thin with no pericholecystic fluid. The common bile duct is not dilated. No transducer tenderness elicited. The pancreas is prominent however parenchymal echogenicity is normal and borders are distinct. The head, neck, and body measures 3.0 2.0 and 2.1 cm in thickness respectively. No focal mass lesion seen. The pancreatic duct is not dilated. The abdominal aorta is normal in diameter. The spleen is high normal in size (11.1 x 4.8cm) parenchymal echogenicity is normal. No focal mass lesion noted. 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 diffusely increased bilaterally. Cortical thickness is adequate with distinct cortico-medullary differentiation. The renal sinus echoes are centrally oriented with no evidence of ectasia or lithiases. No focal cystic or solid mass lesions seen. The urinary bladder is adequately distended with abundant luminal medium-echoes. No intravesical mass 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 of Glomerulonephritis 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 has glomerulonephritis which is one of the risk factors in having nephrotic syndrome. Glomerulonephritis is the inflammation of the glomeruli of the kidneys which if not treated could lead to damage in the glomerular capillary membrane and would progress to an increase in the glomerular permeability which is present in nephrotic syndrome.

VI. Drug Analysis:

Drug ATORVASTATI N (Lipitor) Classification Anti-lipidemic Dosage 20mg tab OD HS Mode of Action Inhibits Hmg-COA reductase, the enzyme that catalyzes the 1st step in cholesterol synthesis pathway, resulting in decrease in serum cholesterol Indication Elevated serum triglyceride s, cholesterol (hyperlipide mia) Side Effects - Nausea - Headache - Muscle, joint aches and pains Contraindicati on - Allergy to atorvastatin - Active hepatic disease Nursing Responsibilities 1. Assess if there is allergy to Atorvastatin. 2. Administer Atorvastatin at the same time each day, preferably in the evening. 3. Avoid drinking grapefruit juice while taking Atorvastatin because it may decrease its metabolism and it will make the patient at risk for toxic effects. 4. Eat small frequent meals to counteract nausea. 5. Have adequate time of rest and sleep after taking the drug to counteract headache and to relax the muscles and joints. Nursing Responsibilities 1. Assess for allergy in Furosemide. 2. Assess and grade the edema

(not present in R.S.J)

Drug FUROSEMIDE (Lasix)

Classification Loop diuretic

Dosage 40mg TIV Q8H

Mode of Action Inhibits reabsorption of Sodium and Chloride from the

Indication Edema

Side Effects -Increase volume and frequency of urination -Feeling faint on

Contraindicati on - Allergy to Furosemide - Anorexia - Severe

proximal and distal tubules and ascending loop of Henle, leading to a sodium-rich diuresis

arising -Drowsiness -Increased thirst -Loss of body potassium -GI upset

renal failure - Hepatic coma (not present in R.S.J)

3. Monitor and record daily body weight at the same time and wearing the same clothes to monitor fluid changes. 4. Monitor and record daily urinary output patterns 5. Monitor serum electrolytes, hydration, liver, and renal function. 6. In preparing for the drug, be sure to store it at room temperature and avoid exposure to light for it may slightly discolor the solution. 7. Give the drug with food or milk to prevent GI upset. 8. Provide frequent mouth care to alleviate increased feeling of thirst 9. Be sure that a urinal is available at bedside to prevent going in and out of the bathroom frequently 10. Instruct to avoid sudden or rapid change in position 11. Advise to

avoid activities that require concentration and keen attention 12. Refer to the physician and dietary department in arranging a potassium-rich diet or adding supplemental potassium

Drug SPIRONOLACT ONE (Aldactone)

Classification Potassiumsparing diuretc

Dosage 25mg tab TID

Mode of Action Competitively blocks the effects of aldosterone in the renal tubule, causing loss of sodium and water and retention of potassium.

Indication Adjunctive therapy in edema associated with nephrotic syndrome

Side Effects - Increase volume and frequency of urination - Dizziness - Confusion - Feeling faint on arising - Drowsiness

Contraindicati on - Allergy to spironolacton e - Hyperkalemi a (not present in R.S.J)

Nursing Responsibilities 1. Assess for allergy in Spironolactone. 2. Assess and grade the edema 3. Monitor and record daily body weight at the same time and wearing the same clothes or hospital gown to monitor fluid changes. 4. Monitor and record daily urinary output patterns 5. Monitor serum electrolytes, hydration, liver, and renal function. 6. Provide frequent mouth care to alleviate increased

feeling of thirst 7. Be sure that a urinal is available at bedside to prevent going in and out of the bathroom frequently 8. Instruct to avoid sudden or rapid change in position 9. Advise to avoid activities that require concentration and keen attention

Drug METOPROLOL

Classification Beta1-selective adrenergic blocker

Dosage 50mg tab OD

Mode of Action Competitively blocks betaadrenergic receptors in the heart and juxtaglomerular apparatus, decreasing the influence of the sympathetic nervous system on these tissues and the excitability of the heart, decreasing cardiac output and the release of renin,

Indication Hypertensio n, alone or along side with diuretics -

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

Contraindicati on - Sinus bradycardia - Cardiogenic shock - Heart failure (not present in R.S.J)

Nursing Responsibilities 1. Assess vital signs particularly blood pressure and heart rate. 2. Ensure that patient swallows the whole tablet. Do not cut, crush, or chew. 3. Give oral drug with food to facilitate absorption. 4. Advise to eat small frequent meals to stimulate appetite 5. Advise to avoid activities that require concentration and

and lowering BP

keen attention 6. Advise not to stop taking the drug unless instructed by the physician. Indication Hypertensio n Reduces loss of protein in the urine (proteinuria ) Side Effects - GI upset - Loss of appetite - Change in taste perception - Mouth sores - Rash - Fast heart rate - Dizziness - Light-headedness Contraindicati on - Allergy to enalapril (not present in R.S.J) Nursing Responsibilities 1. Assess allergy to enalapril 2. Assess vital signs particularly blood pressure and heart rate. 3. Monitor patient while on diuretic therapy for excessive hypotension 4. Provide frequent mouth care to prevent mouth sores. 5. Instruct to change in position slowly 6. Advise to limit activities requiring alertness and precision 7. Advise not to stop taking the drug without consulting the physician Nursing Responsibilities 1. Monitor arterial blood gas

Drug ENALAPRIL

Classification ACE Inhibitor

Dosage 5mg tab OD

Mode of Action Blocks the conversion of angiotensin I to angiotensin II, decreasing the blood pressure, decreasing aldosterone secretion slightly increasing serum K+ levels, and causing Na+ and fluid loss

Drug SODIUM BICARBONATE

Classification Systemic Alkalinizer

Dosage 1 tab

Mode of Action Increases plasma bicarbonate,

Indication Treatment of

Side Effects Systemic alkalosis: - Headache

Contraindicati on - Metabolic and

NaHCO3

Urinary Alkalinizer Antacid Electrolyte

buffers excess hydrogen ion concentration, raises blood Ph

metabolic acidosis

Nausea Irritability Weakness

(not present in R.S.J)

respiratory alkalosis - Hypocalcem ia (alkalosis may precipitate tetany) (not present in R.S.J)

2. Check serum potassium level prior to giving sodium bicarbonate for it may increase risk of metabolic acidosis in states of hypokalemia 3. Instruct to chew oral tablet thoroughly before swallowing, and follow it with a full glass of water. Nursing Responsibilities 1. Assess for allergy to fluoroquinolones 2. Administer oral drug without regard to meals with a glass of water. 3. Ensure that patient is well hydrated during the course of therapy. 4. Instruct to eat small frequent meals 5. Advise to avoid doing activities that require concentration and attention. 6. Avoid exposure to sunlight, use a sunscreen if needed. 7. Instruct to complete the course of therapy as ordered

Drug LEVOFLOXACI N (Levaquin)

Classification

Dosage

Mode of Action

Indication Treatment of Pneumonia

Side Effects - Nausea - Vomiting - Abdominal pain - Drowsiness - Dizziness - Sensitive to sunlight

Fluoroquinolone 750mg tab Bactericidal: Antibiotic OD Interferes with DNA by inhibiting DNA gyrase replication in susceptible gram-negative and gram-positive bacteria, preventing cell reproduction.

Contraindicati on - Allergy to fluoroquinolo nes

by the physician. Drug FLUCONAZOL E Classification Antifungal Dosage Mode of Action Indication Treatment of peritonitis Side Effects Nausea Vomiting Diarrhea Headache Contraindicati on Hypersensitivi ty to fluconazole Nursing Responsibilities 1. Assess for allergy to fluconazole 2. Instruct to eat small frequent meals 3. Provide a calm and quiet environment 4. Instruct to have adequate rest and relaxation 5. Instruct to complete taking the drug in its full course

100mg tab Binds to sterols in OD the fungal cell membrane, changing membrane permeability

VII. Nursing Care Plan:

Assessment S Yung pagmamanas ko, bigla na lang Diagnosis Rationale Fluid volume Edema in excess nephrotic related to syndrome is Planning Goal: After 1 week of Interventions Independent 1. Assess causative/precipitating Rationale 1. To know what to avoid in the patients present Evaluation After 1 week of nursing intervention, the patient was able

nangyari. Pagkagising ko noong December 27, nakita ko na lang manas na yung mukha ko. Nagsimula dun sa may bandang ilalim ng mata ko. Tapos yung braso at hita ko namanas din. Tapos pakiramdam ko sobrang nanghihina talaga ako. Konti lang din yung iniihi ko, wala pang 30mL kada ihi, as verbalized by R.S.J O Skin is cold to touch, shiny in appearance. Presence of periorbital, upper and lower extremities edema noted. +2 pitting edema of the upper and lower extremities noted. Abdominal swelling and tenderness noted.

decreased oncotic pressure in the intravascula r space as manifested by verbalization of less urine output, observed generalized edema, +2 pitting edema on upper and lower extremities, and ascites.

caused by the albumin loss which decreases the oncotic pressure and permits fluid to escape from the intravascular space to the interstitial spaces. The decrease in blood volume would also stimulate the antidiuretic hormone to reabsorb water. (Pediatric Nursing, Muscari, 2005)

nursing intervention, the patient will be able to limit further addition to present excess in fluid volume and will be able to lessen edema Objectives: After 8 hours of nursing intervention, the patient will be able to: - Identify negative factors that would cause excess in fluid volume - Identify appropriate behaviors and diet that would help lessen edema - Verbalize understanding of individual dietary and fluid

factors 2. Monitor vital signs.

condition 2. An increase in blood pressure indicates vasoconstriction which is a result of the release of catecholamines from the renin-angiotensinaldosterone-system

to limit further addition to present excess in fluid volume and edema was lessened. After 8 hours of nursing intervention, the patient was able to identify negative factors that would cause excess in fluid volume. After 8 hours of nursing intervention, the patient was able to identify appropriate behaviors and diet that would help lessen edema After 8 hours of nursing intervention, the patient was able to verbalize understanding of individual dietary and fluid restrictions After 8 hours of nursing intervention, the patient was able to demonstrate behaviors to monitor fluid status

3. Monitor intake and output accurately. Noting the amount, color, and 3. Intake and output is vital characteristics of urine. component in monitoring a patient with nephrotic syndrome. Foamy urine is indicative of protein that was excreted by the kidneys. Fluid intake more 4. Record daily weight than the urine output and abdominal girth indicates fluid retention. every morning 4. These are good 5. Assess and grade indicators of fluid retention. the extent of edema. 6. Auscultate breath sounds and note for presence of crackles. 5. To monitor the extent of fluid shifting from the intravascular to the interstitial spaces. 6. This could indicate congestion from pleural effusion or presence of bacterial infection which is pneumonia, a common complication of nephrotic syndrome.

7. Review recent laboratory results particularly hemoglobin, hematocrit, creatinine,

restrictions - Demonstrate behaviors to monitor fluid status

serum electrolytes, urinalysis 8. Elevate edematous extremities using pillows 9. Change patients position frequently 10. Provide a wrinklefree bed 11. Place on semifowlers position 12. Provide quiet and calm environment. Limit external stimuli. 13. Promote bed rest 14. Explain special dietary restrictions as ordered. Low salt (Na <2g/day), high protein (2-3 egg whites/meal) and carbohydrates diet, and limit in oral fluid intake to less than 1 liter per day.

7. These are vital markers that would indicate patients fluid status. Any deviations from normal should be referred to the physician. 8. To promote circulation 9. To reduce tissue pressure and prevent skin breakdown. 10. To reduce tissue pressure and prevent skin breakdown. 11. To promote lung expansion 12. To conserve patients energy

13. To conserve patients energy 14. High protein diet would help lessen breakdown of lipoproteins which would help prevent hyperlipidemia. Also, protein would help stabilize the oncotic pressure in the intravascular space which

Dependent 15. Administer

prescribed medications. (Included in the drug study) Collaborative 16. Refer to the dietary department regarding the prescribed dietary regimen 17. Collaborate with the family members and other members of the healthcare team such as the physician, medical technologists, and dietician in rendering holistic care to the patient

would lessen the edema. Sodium attracts water; therefore limit in sodium intake would lessen water retention.

16. This would ensure appropriate diet for the patient in accordance to the doctors prescription and his needs. 17. The physician would explain the necessary restrictions to the patient in collaboration with the medical technologists who would relay recent laboratory results done to the patient, and to the dietician who would formulate a necessary meal plan for the family to implement at home. The nurse would act as a main mediator in communicating with the different members of the health care team.

VIII. Recommendation:
As I finish the case study of nephrotic syndrome, I was able to encounter limitations such as inadequate assessment data gathered from the patient. I recommend that to be able to further understand the disease process, a daily weight and abdominal girth record should be monitored. Also, I recommend that other laboratory studies should be seen and examined such as the serum triglycerides of the patient to further evaluate the extent of the synthesis of lipoproteins due to hypoalbuminemia.

CLINICAL CASE STUDY

(NEPHROTIC SYNDROME)

Borja, Mary Grace T. RNHEALS Male Medical Ward