I.

Background of the study Nephrotic syndrome is a non specific disease in which the kidneys are damaged, causing them to leak large amount of proteins (at least 3 grams per day) from the blood into the urine. It is characterized by proteinuria(.3.5 g/day), hypoalbuminemia, hyperlipidemia and edema. The most common sign is excess fluids in the body. This may take several forms as: Puffiness around the eyes, characteristically in the morning, Edema over the legs which is pitting (i.e. leaves a little pit when the fluid is pressed out which resolves over a few seconds), Fluid in the pleural cavity causing pleural effusion, Fluid in the peritoneal cavity causing ascites and Hypertension (rarely). Some patients may notice frothy urine, due to lowering of the surface tension bythte severe proteinuria. Actual urinary complaints such hematuria or oliguria are uncommon. May have features of underlying cause, such rash associated with SLE, or neuropathy with diabetes. Examinations should also exclude other causes of gross edemaespecially the cardiovascular and hepatic system. The glomeruli of the kidneys are the parts that normally filter the blood. They consist of capillaries that are fenestrated (leaky due to little holes called fenestrae or windows) and that allow fluids, salt and other small solutes to flow through, but normally not proteins. In nephrotic syndrome, the glomeruli become damage due to inflammation and hyalinization so that proteins such as albumins immunoglobin and anti-thrombin can pass through the kidney into the urine. An albumin is the major protein in the blood which maintains osmotic pressurethis prevents the leakage of the blood from vessels into tissue. However, experiments show that edema formation in nephrotic syndrome is more so due to micro vascular damage and intense salt and water retention by the damaged kidneys (due to increase angiotensin secretion). The mechanism is very complex and still not fully understood. In response to leakage of albumin, the liver begins to make more of all proteins, and levels of large proteins (such as alpha 2-macroglobulin and lipoproteins) increase. The excess lipoproteins end up in the urine filtrate, which is then reabsorbed by the tubular cells which end up shedding and forming oval fat bodies or fatty casts.

II. Objectives General Objectives: At the end of the study or learning, the level 3 nursing students will be able to rectify, expound, and relate all ideas or perception to the nursing approach in doing valid and outmost care with the patient experiencing an outset of Nephrotic syndrome. Specific Objectives: the level 3 student nurses will be capable of: 1. Propose the over all assessment findings with the patient experiencing a Nephrotic syndrome. 2. Expound thoroughly and articulately the anatomy and physiology of the systems involved in Nephrotic syndrome. 3. An intricate illustration and explanation of the pathophysiology of the Nephrotic syndrome with regards to the patient. 4. Devise a well planned, with the principle of SMART a comprehensive nursing care plan that is applicable to the patient with Nephrotic syndrome. 5. Inculcate health teachings for the patient to follow and be in great help for his condition. 6. Elucidate and discuss the rationale of the different nursing interventions to the patient and to the family as well. 7. Evaluate the effectiveness and accuracy of the outcome of the nursing interventions. 8. Provided the needed information or knowledge to attain a healthy living.

II. Personal Data Name: I.B.P. Gender: Male Age: 67 y/o Address: P5 B33 L5 Palkparan D.C. Birthdate: July 28, 1940 Birthplace: Misamis Religion: Roman Catholic Height: 55 Civil Status: Married Nationality: Filipino Attending Physician: Dr. M Date and time of admission: February 2, 2008; 2:57pm Chief complaint: Edema; unable to walk Admitting Diagnosis: Nephrotic Syndrome

III. Nursing Assessment A. History of Present Illness The patient was known to have type I Diabetis Mellitus and hypertension for about 3 years. At August 2006, he was admitted at Philippine General Hospital wherein his previous diagnosis of DM Type I was confirmed. Catapres & Norvasc were his maintenance medication for hypertension. After 1 year, at December 2007, he was admitted at JPR Hospital in Cavite at the third floor complaining of progressive edema on both his lower extremities; inability to walk; blurring of vision and hypertension After a series of laboratory tests, he was diagnosed with nephrotic syndrome.

A.1. Family History Noted to have history of hypertension Noted to have history of DM from the mothers side A.2. Vital Signs (February 8, 2008, 12:00pm) BP: 160/ 90 mmHg (Stage 1 Hypertension) PR: 78 beats per minute RR: 22 cycles per minute Temp: 37.1C A.3. Nursing Theory Hendersons Definition of Nursing. Henderson (1996) conceptualized the nurses role as assisting sick or healthy individuals to gain independence in meeting the 14 fundamental needs: a. Breathing normally b. Eating and drinking adequately c. Eliminating body wastes d. Moving and maintaining desirable position e. Sleeping and resting f. Selecting suitable clothes g. Maintaining body temperature within normal range by adjusting clothing and modifying the environment h. Keeping the body clean and well groomed to protect the integument i. Avoiding strangers in the environment and avoiding injury to others j. Communicating with others; expressing emotions, needs, fears or opinions k. Worshipping according to ones faith l. Working in such a way that one feels a sense of accomplishment m. Playing or participating in various forms of recreation n. Learning, discovering or satisfying the curiosity that leads to normal development and health, and using available health facilities. Her emphasis on the importance of nursing independence from, and interdependence with, other health care disciplines are well recognized.

A.4. Maslows Hierarchy of Needs 1. Physiologic Needs Upon his hospitalization, the patient verbalized irregular urinary and bowel patterns. During his hospitalization, a condom catheter was inserted to the patient as ordered by the physician and demonstrated an abnormal urine output (20cc/hr and below). His bowel elimination pattern frequency is on every-other-day basis. The patient verbalized that his food consumption during his stay in the hospital was not adequate enough to satisfy his appetite and he often verbalized that Gutom na ako at nauuhaw. In terms of his personal belongings such as clothes and shelter, he verbalized that he is contented with what his family has. 2. Safety Needs Before his illness weakened him, he was independent and very industrious in everything he does. When he was younger, he served as the familys breadwinner but now things have changed, with the presence of his illness, he is now dependent to his family members especially to his wife. In everything he does, assistance is a prerequisite before he achieves his desired position. 3. Love & Belongingness From our observation, even though the head of the family (the patient) is ill, the family members still show respect and unconditional love and concern for their father/husband. They are trying to find means to acquire money in order to finance the medications of the patient. 4. Self-Esteem Needs The self-esteem of the patient was not affected by his present condition. He still has the initiative to do things even though he cant do it without assistance. 5. Self Actualization The patient wasnt fully able to verbalize his views about his underlying condition and what the effects to his health might be. However, he is also focused on his spiritual living of being a part of the Roman Catholic citizen in the country.

A.5. Physical Assessment Assessment General Health and Appearance Result Analysis

2/4 functional level (requires help from another There is poor circulation of blood in person for assistance and supervision) & the lower extremities that causes ROM___, weakness on lower extremities, weakness. ambulatory with assistance, oriented, no foul odor, with mood swings present Dry, black pigmentation is present on the lower It indicates fluid retention. There is extremities, with pitting edema in both legs with shifting of fluid from intravascular to edema grade of +2, no readily detectable interstitial compartment thus, causing distortion, disappears in 10-15secs decreased elasticity of skin. Rounded, absence of nodules and masses upon palpations, symmetrical facial features, and scalp is dry; color of the hair is in combination of white and gray. ______________

Skin

Head

Eyes

Change in visual field, blurred vision, with pale Blurred vision develops as the lens conjunctiva, cornea is without lesions, conjunctiva and retina are exposed to is clear, Pupils are equal, measuring 2-3 mm in hyperosmolar fluids. It can be an diameter, round and reactive to light and indicator of hyperglycemia. accommodation. Ears are normal in appearance; normal hearing status, auditory canal appears with moderate amount of cerumen and without any lesions. Tympanic membranes are intact. Hearing is adequate. ______________

Ears

Nose

No deviation, nasal mucosa appears pink and without abnormal discharge, no nasal polyps or other lesions are noted, frontal and maxillary are not tender. Lips are moist with no cyanosis or pallor; Appears to have an incomplete set of teeth; buccal mucosa is moist in appearance. Tongue shows no lesions, ability to protrude, move from side to side; pharyngeal mucosa is pink, without lesions and signs of inflammation Neck is supple, no limited range of motion. No evidence of tracheal deviation. Thyroid gland is in normal size. Palpations reveal no nodules and masses No chest pain, no dyspnea and cough noted. Normal breath sounds are auscultated in both lung fields. No chest pain, palpitations and tightness. Normal capillary refill: less than 3 secs. Peripheral edema is present in arms, legs and feet. Pitting edema scale is +2. No lesions or marked ridges in the abdomen. Symmetric movement of abdomen during respiration. Abdominal girth is 55cms. Abdomen is distended. Pain in the right hypochondriac area. Pain scale is 4/10. irregular elimination pattern noted Urine: amber, aromatic smell; frequency irregular. The patient is with condom catheter is

______________

Mouth and Throat

______________

Neck

Respiratory

______________

Cardiovascular system

______________

Gastrointestinal

______________

Genitourinary

______________

Musculoskeletal

Lacking muscle tone, Poor muscle strength on lower extremities. Limitation of movement is present. Pain upon movement is present especially in the spine. Positive for edema on both extremities. Edema grade is +2 (Depression 58mm). No deformities or swelling on the joints and bones Can smile, frown, clench teeth, turn head from side to side against resistance; and tongue midline on protrusion

______________

Neurologic

______________

IV. Anatomy and Physiology Urinary Tract The urinary tract is made up of the kidneys, the ureters, the bladder and the urethra.

Kidneys The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the back. They remove the wasted products from the blood; maintain a balance of electrolytes and other substances in the blood, and produce erythropoietin (a hormone that triggers the production of red blood cells in the bone marrow).

Ureters The ureters, one from each kidney, deliver urine to the bladder. The ureter enters through the back of the bladder, entering at an angle such that when the bladder fills, the ureter openings are forced closed. A cross section of the ureter reveals three layers of tissue: (1) An inner mucosa consists of transitional epithelium covered by a lamina propria of connective tissue. Mucus secretions protect the ureter tissues from the urine. A middle muscularis layer consists of longitudinal and circular layers of smooth muscle fibers. The muscle fibers force the urine forward by peristalsis. The outer adventitia consists of areolar connective tissue containing nerves, blood vessels and lymphatic vessels Urethra The urethra is a tube which connects the urinary bladder to the outside of the body. The urethra has an excretory function in both sexes, to pass urine to the outside and also a reproductive function in the male, a passage for sperm. The external urethral sphincter is a smooth muscle that allows voluntary control of urination

(2) (3)

Bladder The bladder is smooth, collapsible muscular sac that stores urine temporarily. It is located in the retroperitoneally in the pelvis just posterior to the pubic symphysis.

Urine formation Urine is formed through a combination of four basic processes: 1) glomerular filtration, 2) tubular reabsorption, 3) tubular secretion, and 4) water conservation. Blood is under high pressure in the glomerulus; thus, plasma (except for plasma proteins) moves into the glomerular capsule. This fluid is called filtrate. As the filtrate moves along the tubules, it is referred to as tubular fluid. Most of the water and many other molecules are reabsorbed into the blood, while some substances are secreted into the tubular fluid. Once the fluid moves into the collecting, duct it is called urine. While in the collecting duct, additional water is removed from the urine, concentrating the wastes. Although about 45 gallons of filtrate is produced daily, most of the water is reabsorbed; if not, we would quickly die of dehydration. The conservation of water is largely due to the long loop of the nephron, which establishes a concentration gradient in the kidney tissue. Water can leave the collecting duct by osmosis and return to the bloodstream in the surrounding peritubular capillaries.

V. Pathophysiology Precipitating factors Age Race Family History Gender Damaged glomerular capillary membrane Predisposing factors DM Hypertension Lifestyle Obesity

Increased permeability to protein and loss of negative (-) charge Edema

Pitting edema Hands Feet (pedal edema) Puffiness around the eyes Abdomen (ascites) Pleural effusion

Increased loss of plasma proteins particularly albumin in urine (Proteinuria)

Infection

Hypovolemia Hypokalemia

Decreased albumin in the blood (Hypoalbuminemia)

Hyperlipidemia Hypertension

Anemia Brief explanation on how the sign and symptoms occur

NEPHROTIC SYNDROME

Decrease intravascular oncotic pressure

Leakage of extracellular fluid from blood to interstitial

Edem a

Hypovolemi a

Intravascular volume fails

Stimulating activation of reninangiotensin-aldosterone axis and sympathetic nervous system, release of vasopressin

Increased potassium excretion

Hypokalemi a Promote renal salt and water retention and restore intravascular volume

Edem a

CHEMISTRY Albumin

RESULTS 19g/L

NORMAL VALUES 35-50g/L

INTERPRETATION Hypoalbuminemia; excretion of protein in the urine due to kidney damage Normal Normal Normal Normal

BUN Creatinine Sodium Potassium VII. Medical Management 7.2 Laboratory Results Table 1. Taken on (02-02-08)

5.6 mmol/L 103 mmol/L 128 mmol/L 2.9 mmol/L

3.2-7.1 mmol/L 71-133 mmol/L 137-145 mmol/L 3.6-5.0 mmol/L

Table 2. Taken on (02-02-08)

CHEMISTRY Hemoglobin

RESULTS 9.8 gms%

NORMAL VALUES 12-17 gms%

INTERPRETATION Decreased; due to loss of protein, there is also loss of transferrin that causes decrease hemoglobin Decreased; contain pigment hemoglobin, when there is a decrease in hemoglobin, there is also decrease in erythrocyte Indicates decrease immunity

Erythrocytes, Volume Fraction (Hct)

27.0 vol%

40-45 vol%

Leukocytes, number on concetration Table 3.Taken on (02-04-08)

3,700/mm3

5,000-10,000/mm3

URINE Physical Pus Cells RBC Epithelial cells Color Transparency PH Specific Gravity Yeast cells 3-5/hpf 0-2/hpf Few Yellow Clear 5.0 1.021 Many Normal Normal Normal Normal Normal Normal Normal Represent an infection Proteinuria (7gm/24 hours or greater); changes to capillary endothelial cells, the glomerular basement membrane or podocytes which normally filter serum protein Glycosuria; Diabetes Mellitus

Chemical

Albumin

++++

Sugar

Repeat Test Table 4. Taken on (02-03-08) CHEMISTRY Potassium RESULTS 3.0 mmol/L NORMAL VALUES 3.6-5.0 mmol/L INTERPRETATION Hypokalemia; abnormally high aldosterone levels can cause excessive urinary losses of potassium

Drug Study Brand Name Felodipine 5 mg OD Calcium Channel Blocker Specific Action Antihypertensive Mechanism of Action Inhibits the movement of calcium ions across the membranes of cardiac and vascular smooth muscle as compared to cardiac muscle; leads to arterial and coronary artery Indication Essential hypertension, alone or in combination with other antihypertensive s Contraindications In patients with allergy to felodipine and other calcium channel blocker (heart block) Side Effects/ Adverse reaction headache, fatigue, flushing, rash, nausea, abdominal discomfort, constipation Nursing Responsibility 10 Rs Assess for allergy to felodipine and heart block Monitor BP and PR Report for side effects of drug Take drug with meals if

vasodilation and decrease peripheral vascular resistance.

upset stomach occurs Assess patient before starting therapy

Drug Name Ciprofloxacin 250 mg OD

Specific Action Antibacterial

Mechanism of Action Inhibits bacterial DNA.gyrase thus preventing replication in susceptibe bacteria

Indication Treatment of infection

Contraindications In patients with allergy to drug

Side Effects/ Adverse reaction Nausea, vomiting, dry mouth, diarrhea, abdominal pain

Nursing Responsibility 10 Rs Monitor BP and PR Report for side effects of drug Ensure the patient is well hydrated Nursing Responsibilities *10 Rights *Patients who have asthma ,

Brand name ROWATINEX (Classification: Genitourinary

Action Inhibits prostaglandin synthesis and

Dosage

Indication Urolithiasis, nephrolithiasis, cystitis, renal

Contraindicatio n Hypersensitivity to drug

Adverse Reaction dizziness, headache, dyspnea,

drugs)

peripherally mediated analgesia

colic, urinary tract infection, post-op, prophylaxis

nausea, diarrhea

aspirin induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reaction *Assess pain (note type, location and intensity) prior to 1-2 hour following administration *Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headache, or influenza like syndromes( chill s, fever, muscle aches, pain) occur

Brand name FUROSEMIDE (Classification: Loop Diuretics Cardiovascula r Drugs)

Action Inhibits sodium and chloride absorption at the proximal tubules and ascending loop of Henle leading to excertion of water together with sodium chloride and potassium diuretics, anti hypertensive

Contraindicatio n Adult 20- Treatment of Anuria in patients 80mg edema receiving single associated prolonged lithium dose with therapy, daily congestive Hypersensitivity preferably heart failure, to sulfonylureas in the hepatic morning cirrhosis and renal disease, hypertension

Dosage

Indication

Adverse Reaction Fluid and electrolytes imbalanced after either single doses or prolonged administration, Allergy, Hypotension, Rashes, Dizziness

Nursing Responsibilities * 10 Rights *Assess patients condition before starting the therapy *Monitor vital signs * Assess for fluid volume status: urine color, quality and specific gravity, inputoutput ratio, weight, skin turgor, mucus membrane, edema, pulses, distended red veins and crackles in the lungs *Dehydration symptoms in decreasing output, thirst, hypotension, dry mouth and mucus membranes should be reported

Brand name OMEPRAZOLE (Classification: proton-pump inhibitors Gastrointestinal/ Hepatobillary Drugs)

Action Suppresses gastric secretion by inhibiting hydrogen/ potassium ATAnd now the pase enzyme system in the gastric cell: Characterized as a gastric acid pump inhibitor, since it blocks the final step of acid production

Dosage Adult 1020mg/day for 2-4 weeks

Indication Conditions where inhibition of gastric acid secretion may beneficial including aspiration syndromes, dyspepsia, GERD, peptic ulcer disease and ZollingerEllison syndrome

Contraindicatio n Not given to patients with hepatic impairment, hypersensitivity, combination therapy with clarithromycin should not be used in the patients with hepatic impairment

Adverse Reaction Headache, diarrhea, skin rash, may discontinue upon severity, arthralgia

Nursing Responsibilities *10 Rights *Assess patients condition before starting therapy *Monitor vital signs *Asses other medications patient may be taking for effectiveness and interaction *Monitor therapeutic effectiveness and adverse reactions at beginning of therapy and periodically throughout the therapy *Assess knowledge/ teach appropriate use of this medication, intervention to reduce side effects and adverse symptoms to report

VIII. Problem List (based on Maslows Hierarchy of Needs) 1. Decreased cardiac output related to increased blood pressure 2. Risk for impaired skin integrity related to decreased skin elasticity secondary to shifting of fluid from intravascular to interstitial 3. Impaired physical mobility related to pedal edema on both lower extremities secondary to nephrotic syndrome 4. Irregular Bowel Movement related to decrease peristaltic movement secondary to decreased body mobility 5. Hopelessness related to situation development

NCP1 Assessment Subjective: Talagang ganyan yung BP niya, palaging mataas, as verbalized by the patient. Objective: Increased BP 160/90 Hypertension stage 2 Diagnosis Inference Decreased Impaired renal cardiac output function related to increased blood pressure Loss of plasma (hypertension) protein, albumin secondary to (proteinuria) impaired renal function Hypoalbuminemi a Decreased oncotic pressure Shifting of fluid from vascular space to extracellular compartment Sodium retention Increase in fluid volume Planning After 6-12 hours of nursing interventions, the patient will be able to demonstrate a decrease in blood pressure or maintain a desirable result of blood pressure. Intervention > Assess for dyspnea, tightening of chest, and palpitations > Monitor vital signs especially the blood pressure every 4 hours. >Elevate edematous extremities and avoid restrictive clothing. a. Position patient flat on bed while raising legs 20-30 degrees. b. Use of comfortable, loose clothing. Rationale > Provide a baseline data to know the measure to do. > To check if the cardinal signs are normal > To facilitate adequate circulation Evaluation Goal not met as evidenced by: The patient still has a high blood pressure. a. BP of 160/90 over the 6-12 hours of nursing interventions

> To determine if the GIT and GUT are functioning normally > To maximize comfort and sleep periods

Increase in systemic vascular resistance Hypertension Decreased cardiac output

> Monitor input and output every 4 hours.

> To reduce tension and promote rest > To reduce anxiety > To provide adequate oxygen supply

> Encourage periods of adequate rest and sleep. > Provide a quiet and relaxing environment > Encourage relaxation techniques

> To maintain adequate nutrition and fluid balance > to provide pharmacologica l therapy for the patients health maintenance

Reference: Medical and surgical nursing 11th edition Authors: Smeltzer, Bare, Hinkle, Cheever

> Encourage to breathe deeply during activities. > Provide health education on fluid restriction and diet

prescribed: low salt and fat > Administer medications as ordered by the physician. NCP2 Assessment Subjective: Hindi ko na talgang kayang gumalaw lalo na kapag tatayo, babangon sa kama at maglakad lalo na kapag papuntang banyo. As evidence by the male patient. Objective: >Limited range of motion >Limited ability to perform

Diagnosis Impaired physical mobility related to pedal edema on both lower extremities secondary to nephrotic syndrome

Inference Damage glomerular capillarity membrane Loss of plasma proteins which is albumin Hypoalbuminemia Deacrease Oncotic pressure(osmoti c pressure exerted by albumin)

Planning After 6-12 hours of nursing interventions, the patient will be able to demonstrate willingness and participation in activities such as ambulation, self-care activities, and recreational activities.

Intervention > Assess the changes in skin and muscle mass >Maintain strict skin hygiene by using mild soap, drying gently and thoroughly and lubricating with lotion > Massage bony prominences and avoid friction when walking > Keep bed clothes dry, keep bed free

Rationale >To check for the condition of skin and muscle > To prevent dryness and skin infection

Evaluation Goal met as evidenced by: a. the patient complied on the prescribed diet for his condition b. the patient kept his lower extremities elevated when > Friction in sitting the skin can c. The patient lead to tissue verbalized the break down importance of > To prevent having a friction or regular pressure to the exercise skin > To maintain

gross or fine motor skills. >Cant ambulate without assistance. > Slowed movements > Suggested functional level: 3- Requires help from other persons and equipment device. > With severe pitting edema at both lower extremities > Edema grade is +2

Fluid moves from intracellular to extra cellular, intravascular Sodium retention

from wrinkles and crumbs > Provide protection by using of pads, pillows, foam or mattress >Emphasize the importance of following the prescribed diet and adequate

patients safety and eliminate excessive tissue pressure > To maintain general good health and skin turgor

Edema -Major manifestation of nephrotic syndrome - Soft, pitting and commonly occur around the eyes (Periorbital), in dependent areas (sacrum, ankles, and hands) and abdomen (ascites). Reference: Medical and surgical nursing 11th edition Authors: Smeltzer, Bare,

Hinkle, Cheever

Nursing Diagnosi s SUBJECTIVE Irregular Hindi naman bowel normal ang movement pagtae nyan related to eh, 6 na araw decrease siya hindi peristaltic nakadumi movement tapos secondary kahapon to dumumi siya, decrease ngayon body nahihirapan mobility nanaman daw as verbalized by the patients daughter OBJECTIVE * no bowel movement for the day *with abdominal tenderness

NCP3 Assessment

Inference Constipation is a passage of unduly dry, hard stools. This definition makes to mention frequency. Some person may be constipated and yet have a daily bowel movement, while others who regularly defecate no more than three times a week are not constipated. The habits of elimination vary greatly among healthy persons. Therefore, defining constipation on the basis of frequency of elimination is meaningless until careful comparisons are made with the persons usual habit. Students have shown

Planning After 6-8 hours of nursing interventions, the patient should be able to have proper or acceptable pattern of bowel elimination

Intervention *Review the patients condition and noted the recommended diet

Rationale

Evaluation

-to determine the Goal was diet precautions to not met as the patient evidenced by: No bowel movement after 6-8 hours of nursing intervention

*Review daily -to identify dietary regimen causative or contributing factor *Determine the -to note fluid amount of fluid deficits intake *Promote the importance of limited fluid intake in his condition *Palpate the abdomen *Educate the patient to -to promote wellness and prevention of worsening in his edematous extremities -to note for the presence of distention masses -to promote return

for almost a week *abdominal girth-55cm *with limited range of motion *cannot ambulate without assistance

clearly that lack of activity leads to poor muscle tone, a poor appetite, and sluggish intestinal activity causing a person to be constipated. Source: Fundamentals of Nursing 7th edition p578-579

ambulate *Assist the patient to change position frequently *Provide the information about the relationship of diet, exercise, and fluid *Administer stool softeners, mild stimulants or bulk forming agents as directed or ordered by the physician

of acceptable pattern of elimination -to encourage mobilization and help to solve the problem of elimination -to promote wellness and awareness for the patient

-to facilitate return to usual or acceptable pattern of elimination

NCP4 Assessment Subjective: Hindi ko masyadong nararamdaman ang katawan ko kapag

Diagnosis Risk for impaired skin integrity related to decreased skin elasticity secondary to

Inference Shifting of fluid from intravascular to interstitial

Planning After 2-3 hours of nursing intervention, patient will demonstrate behaviors or

Intervention > Assess the changes in skin and muscle mass >Maintain strict

Rationale >To check for the condition of skin and muscle > To prevent

Evaluation Goal met as evidenced by: a. the patient complied on the prescribed diet for his

tumatayo ako, siguro dahil sa manas ko, as verbalized by the patient Objective: -Dry skin -Edema in the hands and feet -Edema Score Hands: (+3: 528mm drepression) Feet(+2: 224mm depression) -black pigmentation at lower extremities

shifting of fluid from intravascular to interstitial

Activation of ReninAngiotensin System Sodium and water retention Edema Decreased skins elasticity Risk for impaired skin integrity

techniques to prevent skin break down.

skin hygiene by using mild soap, drying gently and thoroughly and lubricating with lotion > Massage bony prominences and avoid friction when walking > Keep bed clothes dry, keep bed free from wrinkles and crumbs > Provide protection by using of pads, pillows, foam or mattress

dryness and skin infection

condition b. the patient kept his lower extremities elevated when sitting > Friction in c. The patient the skin can verbalized the lead to tissue importance of break down having a > To prevent regular friction or exercise. pressure to the skin > To maintain patients safety and eliminate excessive tissue pressure > To maintain general good health and skin turgor > To enhance circulation

Reference: Medical and surgical nursing 11th edition Authors: Smeltzer, Bare, Hinkle, Cheever

>Emphasize the importance of following the prescribed diet and adequate fluid intake >Encourage regular exercise

>Advise the patient to elevate lower extremities when sitting >Recommend keeping nails short

>To enhance venous return >To reduce risk of dermal injury when severe itching is present. Rationale -Baseline of the patient -to determine characteristics -to gain participation Evaluation After nursing interventions goal are partially met. The patient was able to gain positive self-esteem and participation

Nursing Diagnosis SUBJECTIVE Hopelessnes ayoko na s related to parang wala situation naman development nangyayari as verbalized by the patient OBJECTIVE *lack of initiative *lack of involvement *decreased affect

NCP5 Assessment

Inference Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilized energy on own self Source: NANDA Book

Planning After a shift of nursing interventions the patient will be able to gain positive selfesteem

Intervention *Assess vital signs *Note behaviours indicative of hopelessness *Discuss use of defense mechanism

*Establish therapeutic -to gain trust relationship *Encourage client to verbalized and explore feelings and perception -baseline of the patient

*Encourage structured increase in physical mobility *Demonstrate and encourage use of relaxation technique such as : Proper -positioning -diversional activities X. Health Teaching General Objectives: To promote a good quality of life and wellness to the patient. Specific Objectives of treatment includes: Control of Infection Control of Edema and promotion of good nutrition Treatment includes: Objectives A.) General Objectives (supportive) Content Monitoring and maintaining euvolemia (the correct amount of fluid in the body) -monitoring urine output, BP regularly - Fluid restrict to 1L - diuretics (IV furosemide) Monitoring kidney function

-to continuity in the condition

-therapeutic management

Resource In this health teaching, materials like visual aids and pamphlets are needed to be used. The time and effort of the student nurse for providing information are also needed.

Time Frame 1-2 hours of providing significant and relevant information about the disease and ways of caring and preventing it.

B.) Specific treatment of underlying cause

Control of blood pressure (often high in people with kidney disease) is important in all patients. A type of blood pressure drug known as an ACE inhibitor has been proven to be particularly good at protecting kidney function and reducing the amount of protein in the urine. You are very likely to be prescribed one of these. Fluid retention is managed by diuretics. This help by restricting the amount of salt in the diet and by avoiding excessive fluid intake. If a lot of fluid has been retained, it is important that diuretic therapy is carefully controlled by regular blood tests and weighing. Some patients require to be admitted to hospital. According to the type of kidney disease diagnosed by the biopsy, treatment to control the cause of nephrotic syndrome may be recommended.

C.) Dietary recommendations

Limit high protein animal foods to 1oz per meal ( preferably to

lean cuts of meat, fish and poultry) Limit high phosphorus foods such as cheese, tofu, and yogurt, including cokes and colas because excess of phosphorus can lead to renal failure. Advise to eat moderate potassium rich foods, like, vegetables and fruits such as avocado, okra, potatoes, pumpkin, sweet potatoes, tomatoes, tomato juice, bananas, honeydew, and oranges. Avoid saturated fats and eat unsaturated fats in moderation. Eat low-fat desserts only. D.) Discharge advice (Health Teaching) Monitor fluid intake, which includes all fluids and foods that are liquid at room temperature. Explain about the need of treatment and advice to continue it at home

Avoid cold and draughts Avoid contact with people suffering from upper respiratory tract infection Advice to maintain the personal hygiene Emphasis on the high protein diet Explain the administration of the medicine and its continuation To come for the frequent medical checkup.

XI. Conclusion General Objectives: Towards the end of the case study or learning, the level 3 nursing students were able to rectify, expound, and relate all ideas or perception to the nursing approach by exhibiting a valid and outmost care with the patient that has been diagnosed with Nephrotic syndrome. Specific Objectives: The level 3 student nurses will be able to accomplished: 1. Proposed the over all assessment findings with the patient experiencing a Nephrotic syndrome. 2. Expounded thoroughly and articulately the anatomy and physiology of the systems involved in Nephrotic syndrome. 3. An intricate illustration and explanation of the pathophysiology of the Nephrotic syndrome with regards to the patient. 4. Devised a well planned, with the principle of SMART a comprehensive nursing care plan that is applicable to the patient with Nephrotic syndrome. 5. Inculcated health teachings for the patient to follow and be in great help for his condition. 6. Elucidated and discuss the rationale of the different nursing interventions to the patient and to the family as well. 7. Evaluated the effectiveness and accuracy of the outcome of the nursing interventions. 8. Provided the needed information or knowledge to attain a healthy living.

Decreased albumin in the blood (Hypoalbuminemia)

Loss of transferrin (transferrin is a glycoprotein found in blood plasma that act as carrier for iron in blood stream)

Anemia

BRAND NAME ROWATINEX ANTIUROLITHIC

DOSAGE BID 50 mg

ACTION Promotes diuresis and relaxes urinary tract spasm, thus passage of stones

INDICATION Treatment for urinary tract spasm and inflammation with association of urolithiasis

CONTRA INDICATION

SIDE EFFECT

NURSING RESPONSIBILITY

Hypersensitivity Dizziness, 10 Rs to this drug headache, nausea Assess patient before therapy Liquid intake should be increase during therapy Store at temp not exceeding 30 degrees Celsius Monitor for I and O