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Clinical Instructor: Mrs. Norma B. Castillo, RN, MN, LLB

General Objectives
At the end of the case presentation, the audience
and presenters will be able to:
Trace the disease process of Acute Renal
Failure Secondary to Hypokalemia with Periodic
Paralysis; R/O Gullian Barre Syndrome and
Pneumonia, identify its signs and symptoms,
complications, diagnostic tests, interventions
effectively and present the role of nurses as care
providers in this type of patient/client efficiently.
Specific Objectives
At the end of the case presentation, the audience and
presenters will be able to:
1. State the definition of Acute Renal Failure Secondary to
Hypokalemia with Periodic Paralysis correctly and
2. Present the anatomy and physiology of Acute Renal
Failure Secondary to Hypokalemia with Periodic
Paralysis concisely andPneumonia
3. Trace the pathophysiology of Acute Renal Failure
Secondary to Hypokalemia with Periodic Paralysis; R/O
Gullian Barre Syndrome and Pneumonia
4. Present the data gathered through Gordons functional
Assessment, Physical Assessment and Laboratory
Findings accurately Pneumonia
5. Discuss the medications taken by the client; its
mechanism of action, indications,
contraindications, adverse effects, and the nursing
responsibilities and/or patient teachings
6. Discuss the relation of the medical interventions
performed by the physician to the patient
7. Create an effective nursing care plan for the
underlying condition of the patient appropriately.
8. Formulate 10 nursing diagnosis in relation to the
health problems assessed correctly.
ARF Secondary to Hypokalemia
Plasma potassium is normally kept at 3.5 to 5.0 mEq
per liter by multiple mechanisms. Levels outside this range
are associated with an increasing rate of death from multiple
causes.1 Hypokalemia is defined as a deficiency of potassium
below 3.5 mEq/L2 in the plasma and increased
gastrointestinal and renal losses are the common culprits.3
Homeostasis of this cation is tightly regulated and achieved
mainly via alteration in renal excretion.4,5
This can be impaired due several factors which can
lead to symptoms ranging from muscle cramps to cardiac
arrest.2 Hypokalemic periodic paralysis is a relatively
uncommon yet potentially life-threatening condition that, if
correctly diagnosed and treated, can be completely reversed.
Weakness is a common, yet nonspecific presentation of
various neurological and non-neurological conditions. While
hypokalemic paralysis is an important cause of acute flaccid paralysis,
there are many clinical differentials like Guillain Barre syndrome,
acute transverse myelitis, polymyositis, poliomyelitis, and porphyria;
that should be considered. Of the differentials, the immediate life-
threatening causes like stroke and space occupying lesions(SOLs)
should be ruled out at the earliest.
Most cases of periodic paralysis are familial or primary
hypokalemic periodic paralysis. We believe this was the cause in our
patient after having ruled out other possible etiologies for the low
serum potassium (secondary periodic paralysis). Sporadic cases are
associated with numerous other conditions including barium
poisoning, hyperthyroidism, renal disorders, certain endocrinopathies
and gastrointestinal potassium losses. Hypokalemic paralysis presents
as acute flaccid weakness with hypokalemia (serum potassium <3.5
mmol/l), without sensory signs, facial, bulbar, autonomic, bladder
and bowel involvement, normal creatine kinase, and NCV.
Hypokalemic familial periodic paralysis is believed to
be due to an increase in muscle membrane sodium
permeability.6,7 There are a multitude of factors that can
trigger weakness or paralysis including acute stress, pain,
anesthesia, surgery, alcohol, strenuous exercise, steroids
etc.8,9 Attacks are typically precipitated by rest or sleep as
was in our patient. Patients remain alert during the attacks.
Patients often report additional symptoms either before,
during, or after attacks. These include paresthesias,
sweating, myalgia, extreme fatigue, thirst, shortness of
breath (either due to anxiety or to the episode itself),
palpitations, clumsiness, irritability, and mental dullness.10
Weakness is a common, yet nonspecific presentation of
various neurological and non-neurological conditions.
Urinary System
The urinary system consists of the kidneys,
ureters, urinary bladder, and urethra. The kidneys
filter the blood to remove wastes and produce urine.
The ureters, urinary bladder, and urethra together
form the urinary tract, which acts as a plumbing
system to drain urine from the kidneys, store it, and
then release it during urination. Besides filtering and
eliminating wastes from the body, the urinary system
also maintains the homeostasis of water, ions, pH,
blood pressure, calcium.
The kidneys are a pair of bean-shaped
organs found along the posterior wall
of the abdominal cavity. The left
kidney is located slightly higher than
the right kidney because the right side
of the liver is much larger than the left
side. The kidneys, unlike the other
organs of the abdominal cavity, are
located posterior to the peritoneum
and touch the muscles of the back.
The kidneys are surrounded by a layer
of adipose that holds them in place
and protects them from physical
damage. The kidneys filter metabolic
wastes, excess ions, and chemicals
from the blood to form urine.

The ureters are a pair of tubes that carry urine

from the kidneys to the urinary bladder. The ureters
are about 10 to 12 inches long and run on the left and
right sides of the body parallel to the vertebral
column. Gravity and peristalsis of smooth muscle
tissue in the walls of the ureters move urine toward
the urinary bladder. The ends of the ureters extend
slightly into the urinary bladder and are sealed at the
point of entry to the bladder by the ureterovesical
valves. These valves prevent urine from flowing back
towards the kidneys.
Urinary Bladder
The urinary bladder is a
sac-like hollow organ used for
the storage of urine. The
urinary bladder is located
along the bodys midline at the
inferior end of the pelvis.
Urine entering the urinary
bladder from the ureters
slowly fills the hollow space of
the bladder and stretches its
elastic walls. The walls of the
bladder allow it to stretch to
hold anywhere from 600 to
800 milliliters of urine.

The urethra is the tube through which urine passes from the
bladder to the exterior of the body. The female urethra is around 2
inches long and ends inferior to the clitorisand superior to the vaginal
opening. In males, the urethra is around 8 to 10 inches long and ends
at the tip of the penis. The urethra is also an organ of the male
reproductive system as it carries sperm out of the body through the
The flow of urine through the urethra is controlled by the
internal and external urethral sphincter muscles. The internal urethral
sphincter is made of smooth muscle and opens involuntarily when
the bladder reaches a certain set level of distention. The opening of
the internal sphincter results in the sensation of needing to urinate.
The external urethral sphincter is made of skeletal muscle and may
be opened to allow urine to pass through the urethra or may be held
closed to delay urination.
Maintenance of Homeostasis
The kidneys maintain the homeostasis of several important
internal conditions by controlling the excretion of substances
out of the body.

Ions. The kidney can control the excretion of potassium,

sodium, calcium, magnesium, phosphate, and chloride ions
into urine. In cases where these ions reach a higher than
normal concentration, the kidneys can increase their
excretion out of the body to return them to a normal level.
Conversely, the kidneys can conserve these ions when they
are present in lower than normal levels by allowing the ions
to be reabsorbed into the blood during filtration. (See more
about ions.)
pH. The kidneys monitor and regulate the levels of
hydrogen ions (H+) and bicarbonate ions in the blood
to control blood pH. H+ ions are produced as a natural
byproduct of the metabolism of dietary proteins and
accumulate in the blood over time. The kidneys
excrete excess H+ ions into urine for elimination from
the body. The kidneys also conserve bicarbonate ions,
which act as important pH buffers in the blood.
Osmolarity. The cells of the body need to grow in an
isotonic environment in order to maintain their fluid and
electrolyte balance. The kidneys maintain the bodys osmotic
balance by controlling the amount of water that is filtered
out of the blood and excreted into urine. When a person
consumes a large amount of water, the kidneys reduce their
reabsorption of water to allow the excess water to be
excreted in urine. This results in the production of dilute,
watery urine. In the case of the body being dehydrated, the
kidneys reabsorb as much water as possible back into the
blood to produce highly concentrated urine full of excreted
ions and wastes. The changes in excretion of water are
controlled by antidiuretic hormone (ADH). ADH is produced
in the hypothalamus and released by the posterior pituitary
gland to help the body retain water.
Blood Pressure. The kidneys monitor the bodys
blood pressure to help maintain homeostasis. When
blood pressure is elevated, the kidneys can help to
reduce blood pressure by reducing the volume of
blood in the body. The kidneys are able to reduce
blood volume by reducing the reabsorption of water
into the blood and producing watery, dilute urine.
When blood pressure becomes too low, the kidneys
can produce the enzyme renin to constrict blood
vessels and produce concentrated urine, which allows
more water to remain in the blood.

Inside each kidney are around a million tiny structures called nephrons.
The nephron is the functional unit of the kidney that filters blood to produce urine.
Arterioles in the kidneys deliver blood to a bundle of capillaries surrounded by a
capsule called a glomerulus. As blood flows through the glomerulus, much of the
bloods plasma is pushed out of the capillaries and into the capsule, leaving the
blood cells and a small amount of plasma to continue flowing through the capillaries.
The liquid filtrate in the capsule flows through a series of tubules lined with filtering
cells and surrounded by capillaries. The cells surrounding the tubules selectively
absorb water and substances from the filtrate in the tubule and return it to the
blood in the capillaries. At the same time, waste products present in the blood are
secreted into the filtrate. By the end of this process, the filtrate in the tubule has
become urine containing only water, waste products, and excess ions. The blood
exiting the capillaries has reabsorbed all of the nutrients along with most of the
water and ions that the body needs to function.
Storage and Excretion of Wastes

After urine has been produced by the kidneys, it is

transported through the ureters to the urinary bladder. The urinary
bladder fills with urine and stores it until the body is ready for its
excretion. When the volume of the urinary bladder reaches anywhere
from 150 to 400 milliliters, its walls begin to stretch and stretch
receptors in its walls send signals to the brain and spinal cord. These
signals result in the relaxation of the involuntary internal urethral
sphincter and the sensation of needing to urinate. Urination may be
delayed as long as the bladder does not exceed its maximum volume,
but increasing nerve signals lead to greater discomfort and desire to
Urination is the process of releasing urine from the urinary
bladder through the urethra and out of the body. The process of
urination begins when the muscles of the urethral sphincters relax,
allowing urine to pass through the urethra. At the same time that the
sphincters relax, the smooth muscle in the walls of the urinary
bladder contract to expel urine from the bladder.
Production of Hormones
The kidneys produce and interact with several hormones that
are involved in the control of systems outside of the urinary system.

Calcitriol. Calcitriol is the active form of vitamin D in the human

body. It is produced by the kidneys from precursor molecules
produced by UV radiation striking the skin. Calcitriol works together
with parathyroid hormone (PTH) to raise the level of calcium ions in
the bloodstream. When the level of calcium ions in the blood drops
below a threshold level, the parathyroid glands release PTH, which in
turn stimulates the kidneys to release calcitriol. Calcitriol promotes
the small intestine to absorb calcium from food and deposit it into
the bloodstream. It also stimulates the osteoclasts of the skeletal
system to break down bone matrix to release calcium ions into the
Erythropoietin. Erythropoietin, also known as EPO, is a
hormone that is produced by the kidneys to stimulate the
production of red blood cells. The kidneys monitor the
condition of the blood that passes through their capillaries,
including the oxygen-carrying capacity of the blood. When
the blood becomes hypoxic, meaning that it is carrying
deficient levels of oxygen, cells lining the capillaries begin
producing EPO and release it into the bloodstream. EPO
travels through the blood to the red bone marrow, where it
stimulates hematopoietic cells to increase their rate of red
blood cell production. Red blood cells contain hemoglobin,
which greatly increases the bloods oxygen-carrying capacity
and effectively ends the hypoxic conditions.
Renin. Renin is not a hormone itself, but an enzyme that the kidneys
produce to start the renin-angiotensin system (RAS). The RAS
increases blood volume and blood pressure in response to low blood
pressure, blood loss, or dehydration. Renin is released into the blood
where it catalyzes angiotensinogen from the liver into angiotensin I.
Angiotensin I is further catalyzed by another enzyme into Angiotensin
Angiotensin II stimulates several processes, including stimulating the
adrenal cortex to produce the hormone aldosterone. Aldosterone
then changes the function of the kidneys to increase the reabsorption
of water and sodium ions into the blood, increasing blood volume
and raising blood pressure. Negative feedback from increased blood
pressure finally turns off the RAS to maintain healthy blood pressure

ECG, TSH, free T3 and T4 are the minimum indicated laboratory investigations, with renal and adrenal function also
recommended. It is important to note that this disorder is autosomal dominant in two-thirds of cases; with male preponderance when providing
genetic counselling.11 The basic guidelines to follow when caring for the patient include control of plasma potassium, avoidance of large glucose
and salt loads (which promote intracellular shift), maintenance of body temperature, acidbase balance, and cautious use of neuromuscular
blocking agents.12,13 The specific treatment of hypokalemic FPP is oral potassium supplementation, repeated at 15-30 minute intervals
depending on the response of the ECG, serum potassium level, and muscle strength. Replenishment may be done intravenously if the patient is
vomiting or unable to swallow. Prophylaxis against recurrent periodic attacks has been successful with a wide variety of treatment modalities
including spironolactone and acetazolamide.
Pneumonia is an infection that inflames the air sacs in one or both lungs.
The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm
or pus, fever, chills, and difficulty breathing. A variety of organisms, including
bacteria, viruses and fungi, can cause pneumonia.
Pneumonia can range in seriousness from mild to life-threatening. It is
most serious for infants and young children, people older than age 65, and people
with health problems or weakened immune systems.
The signs and symptoms of pneumonia vary from mild to severe,
depending on factors such as the type of germ causing the infection, and your age
and overall health. Mild signs and symptoms often are similar to those of a cold or
flu, but they last longer.
Many germs can cause pneumonia. The most common are bacteria and
viruses in the air we breathe. Your body usually prevents these germs from infecting
your lungs. But sometimes these germs can overpower your immune system, even if
your health is generally good. Pneumonia is classified according to the types of
germs that cause it and where you got the infection.
Community-acquired pneumonia
Community-acquired pneumonia is the most common type of pneumonia. It
occurs outside of hospitals or other health care facilities. It may be caused by:

Bacteria. The most common cause of bacterial pneumonia in the U.S. is

Streptococcus pneumoniae. This type of pneumonia can occur on its own or
after you've had a cold or the flu. It may affect one part (lobe) of the lung, a
condition called lobar pneumonia.
Bacteria-like organisms. Mycoplasma pneumoniae also can cause
pneumonia. It typically produces milder symptoms than do other types of
pneumonia. Walking pneumonia is an informal name given to this type of
pneumonia, which typically isn't severe enough to require bed rest.
Fungi. This type of pneumonia is most common in people with chronic
health problems or weakened immune systems, and in people who have
inhaled large doses of the organisms. The fungi that cause it can be found in
soil or bird droppings and vary depending upon geographic location.
Viruses. Some of the viruses that cause colds and the flu can cause
pneumonia. Viruses are the most common cause of pneumonia in children
younger than 5 years. Viral pneumonia is usually mild. But in some cases it
can become very serious.
Hospital-acquired pneumonia
Some people catch pneumonia during a hospital stay for
another illness. Hospital-acquired pneumonia can be serious
because the bacteria causing it may be more resistant to
antibiotics and because the people who get it are already sick.
People who are on breathing machines (ventilators), often used
in intensive care units, are at higher risk of this type of

Health care-acquired pneumonia

Health care-acquired pneumonia is a bacterial infection
that occurs in people who live in long-term care facilities or
who receive care in outpatient clinics, including kidney dialysis
centers. Like hospital-acquired pneumonia, health care-
acquired pneumonia can be caused by bacteria that are more
resistant to antibiotics.
Aspiration pneumonia
Aspiration pneumonia occurs when you inhale food,
drink, vomit or saliva into your lungs. Aspiration is more
likely if something disturbs your normal gag reflex, such
as a brain injury or swallowing problem, or excessive use
of alcohol or drugs.

Pneumonia can affect anyone. But the two age groups
at highest risk are:
Children who are 2 years old or younger
People who are age 65 or older
Other risk factors include:

Being hospitalized. You're at greater risk of pneumonia if you're in a hospital intensive care unit, especially if you're on a machine that helps you
breathe (a ventilator).
Chronic disease. You're more likely to get pneumonia if you have asthma, chronic obstructive pulmonary disease (COPD) or heart disease.
Smoking. Smoking damages your body's natural defenses against the bacteria and viruses that cause pneumonia.
Weakened or suppressed immune system. People who have HIV/AIDS, who've had an organ transplant, or who receive chemotherapy or long-
term steroids are at risk.
Pneumonia is an infection of the lung, and can be caused by nearly any
class of organism known to cause human infections, including bacteria, viruses,
fungi, and parasites. In the United States, pneumonia is the sixth most common
disease leading to death, and the most common fatal infection acquired by already
hospitalized patients. In developing countries, pneumonia ties with diarrhea as the
most common cause of death.
Pneumonia is suspected in any patient who presents with fever, cough,
chest pain, shortness of breath, and increased respirations (number of breaths per
minute). Fever with a shaking chill is even more suspicious, and many patients cough
up clumps of mucus (sputum) which may appear streaked with pus or blood. Severe
pneumonia results in the signs of oxygen deprivation, including blue appearance of
the nail beds (cyanosis).
Bacterial pneumonia prior to the discovery of penicillin antibiotics was a
virtual death sentence. Today, antibiotics, especially given early in the course of the
disease, are very effective against bacterial causes of pneumonia. Erythromycin and
tetracycline improve recovery time for symptoms of mycoplasma pneumonia, but do
not eradicate the organisms. Amantadine and acyclovir may be helpful against
certain viral pneumonias.
The lungs constitute the largest organ in the respiratory system. They play an important
role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide.
The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.
Air that is breathed in is filled with oxygen and goes to the trachea, which branches off
into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the
breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three
lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of
elastic, spongy tissue.

Within the lungs, the bronchi branch out into minute pathways that go through the
lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called
alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels.
The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in
carbon dioxide, which is then exhaled from the body.
Inhaling is due to contractions of the diaphragm and of muscles between the ribs.
Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered
membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid
between the layers. The fluid allows the membranes to easily slide over each other during
Baseline Data

I. Biographical Data
Name of the Patient: Patient M.
Address: P-2,Mauswagon, Maningcol Ozamiz City
Gender: Female
Birth date: August 03,1993
Race or Ethnic Background: Pure Bisaya
Primary and secondary languages (Spoken and read): Can
speak and read Filipino and Visayan
Marital Status: Single
Religious or Spiritual Practices: IFI
Educational Level: High school level
Occupation: None
Significant others or support persons: Mother
II. Reasons for Seeking Health Care
Prior to admission, patient had difficulty in
ambulation and difficulty of breathing.
Admission Dx: Acute Renal Failure Secondary to
Hypokalemia with Periodic Paralysis; R/O Gullian
Barre Syndrome.
Admission Date: August 14,2017; 3:36 pm
Actions done: ( Immediate )
Intubated ET size 7 @ level 16
Diazepam cup IVTT stat
Inserted Met. 12 and open to drain
Fast drip PNSS 200 cc
16F with PNSS 1 L @ 30gtts/min.
III. Initial Assessment
Blood Pressure: 90/60 mmHg
Respiratory Rate: 28 cpm
Heart Rate: 70 bpm
Temperature: 37. 0 C
Oxygen Saturation: 99 %
Tubes: none
Intravenous Fluid and date of Insertion:

August 14,2017 ; D5LR il @ 20 gtts/min

August 14,2017 ; PNSS 90 cc infused with KCl 20 mEq- 1 hour x 4 cycle.
History of present Health Concern Using
Character (Describe the sign and Body Weakness Difficulty of Breathing Pain

Onset (When did it begin) August 14,2017 August 14,2017 August 16,2017

Location (Where is it?) Cephalocaudal N/A ; usage of Right foot: plantar

accessory muscle when surface (midfoot)
Duration(How long does it last?) N/A N/A N/A

Severity A rate of 10 in a pain A rate of 10 in a pain A rate of 6 in a pain

scale of 1 out of 10. scale of 1 out of 10 scale of 1 out of 10
Pattern (What makes it better or At first, according to her At first, ET tube was It does not make better
worse?) it does not make better inserted to help her according to her.
but she was given breath, open the airway
immediately a KCl. and then right after
that manifestation
(usage of accessory
muscle when breathing)
oxygen therapy was
Associated factors/how it affects the Body weakness and Body weakness and It was swollen.
client pain pain (Phlebitis: it was the IV
site of PNSS infused
with KCl.)
Past Health History
Problems at birth No problems at birth.
Childhood Illness Fever, cough, and colds, and body weakness.
Immunizations to Completed all the immunizations at birth
Adult None
Accidents None
Prolonged pain or Body weakness ( Patient was admitted last May 2017
pain patterns due to Hypokalemia also).
Allergies No allergies.

Physical, emotional, None

social, or spiritual
Physical, emotional, The patient always pray to God. In fact, shes holding a
social, or spiritual rosary bracelet when I received her.
Family Health History
Age of parents(living or
deceased date)

Parents Illness and Family historyMother side:

longevity HTN
Childrens ages and None

Grandparents Illness and Patient doesnt remember their ages but they died due to
longevity katigulangon
Lifestyle and health Practices Profile
Description of Typical day Kuan ,kaning naa raman ko sa balay, magtabang-tabang
sa akong mama ug panlaba, hinlo ug bisan unsa pa as
verbalized by the patient.
Nutrition and Weight Management Patient doesnt want to eat acidic foods.
Sleep and Rest Usually sleep at 11 pm and wake up at around 6 am.
Substance use None

Self-concept and Self-care No response.

Social Activities Usually stays at home.
Relationships She has a good relationship with her family and relatives.

Values and Belief system Prays to God before she sleeps.

Education and Work Shes only a high school graduate.

Stress levels and Coping styles Mag-ampo lang sa Ginoo, mao rana as verbalized by the
Environment Theyre currently living in Maningcol Ozamiz City and its
not that polluted.
Physical Assessment
Integumentary System Assessment The clients skin is uniform in color with a
Inspect general skin colorInspect skin skin color of medium brown. Skin is warm
integrityInspect for skin lesion and to touch. The skin is intact, a little bit of
ulcersInspect for skin odorAssess for scars in the lower extremities. Phlebitis
edemaAssess skin moistureAssess skin noted in the right plantar ( midfoot).
thicknessAssess skin textureAssess for skin
Nails Assessment The clients fingernails are short and
Inspect nail grooming and cleanlinessInspect clean with no nail color. With no linear
nail color and markingsInspect nail shapeAssess markings. Clients nail has a shape of
nail texture and consistency, whether nail plate convex curve. It is smooth and is intact.
is attach to nail bedTest capillary refill When nails pressed between the fingers,
the nails return to usual color in less than
2 second. Toe nails are with nail color
(pink) , partially clean.
Hair Assessment The hair of the client is brown-black and
Inspect the scalp and hair for general color and is uniform in color. It is thick with an
condition.Inspect and palpate the hair and the evenly distributed amount of hair. Hair is
scalp for cleanliness, dryness, oiliness, parasites dry and has dirty scalp, has a little bit of
and lesionsInspect amount and distribution of dandruff and with lice. No axillary hair.
scalp, body, axillae, and pubic hair
Head and Face Assessment The clients head is round and
Inspect for head sizeInspect for involuntary symmetrical with no involuntary
movementCheck the temporal arteryCheck the movements. Temporal artery is not
temporomandibular joint distended. No tenderness upon palpation.
Its just that her face likely manifests
Cushings syndrome ( moonfaced).
Neck Assessment The neck is in midline position with no
Inspect for the neck position, symmetry, lump visible masses. The trachea is place in
and massesInspect movement of the neck midline of the neck. The thyroid gland is
structureInspect the cervical vertebraeInspect not visible on inspection and the glands
the range of motionInspect the tracheaInspect ascend during swallowing but are not
the thyroid glandInspect for lymph nodes visible. Lymph nodes are palpable on the
right side of the neck.
Eyes Assessment The clients eyes are positioned and
Inspect for the position and alignment of the aligned in the eye socket. The bulbar
eyeball in the eye socket Inspect the bulbar conjunctiva is pinkish. Anicteric sclera.
conjunctiva and scleraInspect the lacrimal Patient can see clearly. Her eyelashes are
apparatusInspect the cornea and lensInspect short, eyelids have a little dark spots.
the iris and pupilInspect the optic discInspect
the retinal vesselsCheck distant visual
acuityCheck for visual fields for gross peripheral
testInspect the eyelids and eyelashes
Ears Assessment The auricles are symmetrical and have
Inspect the auricle, tragus and mastoid the same color with the facial skin. The
processInspect the external auditory auricles are aligned with the outer
canalInspect the tympanic membraneInspect canthus of the eye. No discharges are
for any discharges and discolorationPerform noted.
Whisper testPerform Weber testPerform Rinne
Mouth, Tongue, and Teeth Assessment The clients teeth are a little bit yellowish.
Inspect the teeth and gums(Note the number Gums are pinkish. Client has the ability to
of teeth, color and condition)Inspect the buccal taste.
mucosaInspect and palpate the tongueAssess
the ventral surface of the tongueCheck the
anterior tongues ability to tasteInspect the
hard and soft palate and uvula
Nose and Sinuses Assessment The nose appeared symmetric, straight
Check the external structureCheck the patency and uniform in color. Nasal flaring noted.
of airflow through the nostrilsCheck the No tenderness noted.
internal structureInspect the frontal and
maxillary sinusesCheck for nasal discharges
Throat Assessment I wasnt able to assess.
Inspect the tonsils appearanceInspect the posterior
pharyngeal wall Check the patency of the airflow
Note the odor
Thoracic and Lungs Assessment The clients face is round and the lips light
Inspect the face, lips and chestAssess for breath pink. The chest wall is intact with symmetrical
soundsInspect for shape of the sternumInspect slope expansion. The client exerts effort in
of the ribsObserve quality and pattern of inspiration. The sternum is midline. No
respirationCheck for tenderness and massesCheck tenderness and masses upon palpation.RR= 28
anterior chest expansion cpm Hyperventilation occurs prior to
Breast and LymphaticAssessment Breast is symmetric with no masses upon
Inspect size and symmetry Inspect color and palpation. Nipples are firm with brownish color
textureInspect superficial venous patternInspect the of the areola. No discharges noted.
areolaInspect the nipplesCheck for tenderness and
massesInspect and palpate the axillae
Abdominal Assessment The skin color is lighter than the skin color. No
Observe the color of the skinInspect for scars and scars and striae noted. No lesions and rashes
striaeAssess for lesions and rashesInspect the noted. No masses and tenderness upon
umbilicus, its appearance and locationAssess palpation.
abdominal symmetryInspect abdominal
movementCheck bowel soundsCheck internal
organsCheck for masses and abdominal tenderness
Heart and neck vessels Jugular vein is not distended. Murmur noted. No
Observe and evaluate jugular venous pulseCheck the visible pulsations in the aortic and pulmonic areas.
carotid arteriesCheck the apical pulseCheck for the extra A blood pressure of 90/60 mmHg.
heart soundsCheck blood pressure
Peripheral vascular Assessment The clients hands, finger and arms are warm to
Inspect the fingers, hands, arms, and temperatureInspect touch. The client has the ability to raise her both
the capillary refill timeCheck the brachial pulses, femoral arms, and legs. The capillary refill time is within 2
pulses, popliteal pulse, posterior tibial pulse and dorsalis second. No varicosities noted.
pedis pulsePerform Allen testInspect the superficial
inguinal lymph nodesInspect for varicosities and
Male/Female GenitaliaMale: She has menstruation. August 17,2017 is her
Inspect the base of the penis and pubic hairInspect the first day.
skin of the shaftInspect the foreskinInspect the size,
shape an position of the scrotumCheck urethral
dischargesCheck for inguinal lymph nodes and hernia
Female:Inspect for mons pubisObserve and palpate
inguinal nodesInspect the labia majora and
perineumInspect the labia minora, clitoris, urethral
meatus and vaginal opening inspect the size of the
vaginal opening of the angle of the vaginaInspect the
cervixInspect the vaginal wall
Anus and rectum Assessment No masses in the peri-anal area. Defecate once
Inspect for the peri-anal area(Note for lumps, ulcers, with black brown in color. No other discharges
lesions, rashes and redness)Check the rectumInspect for noted.
the stool characteristicInspect for any other discharges
Musculoskeletal Assessment The extremities are symmetrical in
Inspect size, shape, color and color and size. No heat and
symmetryCheck for edema, heat, tenderness, nodules noted. Only the
tenderness, pain and nodulesCheck for right plantar (midfoot) is swollen.
ROMObserve and assess gaitObserve the The client can move her both legs.
cervical, thoracic and lumbar curves from
the side, then from behindCheck ROM of
cervical spine, thoracic and lumbar
spineCheck ROM of elbows, wrist, hands,
fingers, hips, ankles and feet
Neurologic Assessment A GCS scoring of 15.
Assess GCSCheck 12 cranial nervesAssess
movement, balance, coordination,
sensation and reflexesCheck involuntary
movementsEvaluate gait and
balanceAssess for sensory system

Demographic Data
Name: Patient M. Age: 24 years old
Sex: Female Civil Status: Single
Address: P-2, Mauswagon, Maningcol Ozami City
Birthdate: August 3,1993
Religion: IFI
Occupation: None
Date of Admission: August 14,2017

Chief Complaint(s) : Prior to admission, the patient had difficulty in

ambulation and difficulty of breathing.

Admission Dx: ARF Secondary to Hypokalemia with Periodic

Paralysis, R/O Gullain Barre Syndrome
Health Perception and Management
A. absences from work/school, colds in past year, general health, important things you do
to keep healthy, use of cigarettes/ alcohol/drugs, self-examination, accidents at
B. Has it been easy to find ways to carry our doctors or nurses suggestions?
Yes, as stated by the patient. Even though at times its hard to
easily find a way to by the prescriptions given due to financial incapability.
C. What do you think caused current illness?
Ingnani najud ni siya sukad pas bata, baw oy ngano bitaw as stated by the

D. Things most important to your health.


E. Actions taken since symptoms started. Have your actions helped? How can we be most

F. How often do you exercise?

History of Past Illness:
The client had experienced body
History of Present Illness:

Prior to admission, patient complaints of body

weakness and difficulty of breathing.
NUTRITIONAL Prior to admission, the The clients diet is soft N/A Her diet is soft diet
/METABOLICdaily food intake client does not have diet. No eating because of
(supplements, vitamins, types any problem in her discomfort noted. decreased muscle
of snacks)daily fluid nutrition. Shes not contraction due to
intakeWeight loss/gain. Height picky when it comes to hypokalemia. If she
loss/gainAppetite. foods. She drinks more was given foods that
Breastfeeding. Infant than 8 glasses of water are hard to chew,
feeding.Food or eating: per day. she would have
Discomfort, swallowing been aspirated and
difficulties, diet restrictions, as well as
able to follow.Healing any indigestion.
problems?Skin problems
(lesions, dryness)Dental
problemsSkin assessment, oral
mucous membranes, teeth,
actual weight/height,
ELIMINATION Bowel Patient defecates N/A N/A N/A
elimination pattern (Frequency, thrice a week.
character, discomfort, problem
with bowel control, use of
laxatives)Urinary elimination
pattern (Frequency, problem
with bladder control)Excess
problemsBody cavity drainage,
suction, etc.examine excretions
or drainage
ACTIVITY / EXERCISEEnergy Patient usually stays The patient is lying N/A Patient is
for desired and/or required at home. She doesnt on the bed. She has hypokalemic.
activitiesExercise pattern have that full energy body weakness. Shes
(Type, Regularity)Spare time to do strenuous given oxygen
(leisure) activitiesChild-play activities. She can therapy. Her blood
activitiesPerceived ability for feed, groom, take a pressure is 90/60
feeding, grooming, bathing, bath, dress and shop mmhg. Her heart
general mobility, toileting, all by herself. No rate is 63 bpm with
home maintenance, bed other problems respiratory rate of 28
mobility, dressing and noted. cpm.
shoppingGait. Posture.
Absent body part. Range of
motion (ROM) joints.Hand
grip (can pick up
pencil)Respiration. Blood
pressure. General
appearance. Musculoskeletal,
cardiac and respiratory
SLEEP / RESTGenerally rested Usually sleeps at 11 Usually sleeps at 11 N/A Sleeping patterns
and ready for activity after pm and wakes up at pm and wakes up at doesnt affect her.
sleepSleep onset around 6 am. around 6 am.
problemsDreams, early
periodsSleep routineSleep
apnea symptoms
COGNITIVE-PERCEPTUALHearing Patient has no problem No problems when it N/A Shes hypokalemic.
difficulty, hearing in hearing and in vision. comes to hearing and And her family history
aidVisionWearing glasses (Last She doesnt wear vision. REFER TO includes asthma, DM,
checked, when last glasses. COLDSPA in Baseline HTN and PTB. And
changed)Change in memory Date. having asthma and
(Concentration)Important PTB history, its a
decisions easy/difficult to factor that
makeEasiest way to learn ( any contributes her
difficulties, discomfort, pneumonia.
pain)COLDSPAOrientation (Hears
newsprintsGrasps ideas and
spokenVocabulary levelAttention
SELF PERCEPTION/SELF N/A N/A N/A The patients doesnt
CONCEPTDescribe yourselfFeel want to talk.
good (or not so good) about
selfChanges in things you can
doProblemsChanges in the way
you feel about self or body
(generally of since illness
started)Things frequently make
you angry, annoyed, fearful,
anxious, depressed, not able to
control things (and what
helps)Ever feel you lose
hope?Eye contact. Attention
spanVoice and speech
patternBody postureClient
nervous (5) or relaxed (1) (rate
scale 1-5)Client assertive (5) or
passive (1) (rate scale 1-5)
ROLE RELATIONSHIPLive Shes a good daughter Her mother and her N/A So far, they have a
alone/Family (Family according to her mother sister watches her in good relationship.
structure)Family problems you and her twin. the hospital.
have difficulty handlingFamily or
others depend on you for
thingsHow well are you
managingHow families/others
feel about your illnessProblems
with childrenBelong to social
groups, close friendsFeel lonely
(Frequency)income sufficient for
needsFeel part of (or isolated in)
your neighbourhoodInteraction
with family members or others
SEXUALITY / August 17,2017 is her N/A Her menstruation is
REPRODUCTIVESexual Her menstruation is not first of menstruation. not regular.
relationships satisfying regular. It skip two
(Changes, problems)Use of months.
COPING / STRESS N/A She was given KCl N/A Due to a good
TOLERANCEAny big changes in supplementation and rapport with the
your life in last year or two Diazepam to relax. health care team,
(Crisis)Most helpful in talking There are also patient gains trust to
things overTense or relaxed medications prescribed cooperate in the
most of the time (When tense, by the physician for her interventions given.
what helps)Any medications, Pneumonia.
drugs, alcohol to relaxHow do
you handle big problems in your
life (Are these successful?)
VALUES/BELIEF Pray always and Unable to go to N/A Religion has a
PATTERNGenerally, get stays positive. church due to her big impact in her
things you want from condition but the life. It deepens
lifeImportant plans for patient is still the patients
futureReligion important praying every faith to God and
to you (Does this help single minute. In expresses that
when difficulties arise? fact shes holding God is her
will being here interfere a rosary bracelet strength and
with any religious when I received savior.
practices? her.
Precipitating Factor


Predisposing Factor
Age: 24 Years Old HTN

Other factor is the activation of

Renal and Gastrointestinal aldosterone secretion (Always
Disease remember RAAS)

Impairs intestinal Shifting of potassium from the

smooth muscle- extracellular fluid to intracellular
Excretion of
causes her to vomit fluid
through urine
Muscle relaxation

Decreased (Metabolic acidosis)

Body weakness potassium 2.59


Difficulty of
Cardiac Complications
Cardiac dysrhythmias. Tachycardia, hypertension

Muscular Complications
Muscle fibers break down, Paralysis

Diabetic Complications
Hyperglycemia and

Other complications
Hypokalemia can also lead to metabolic acidosis, respiratory
acidosis, renal cystic disease and hepatic encephalopathy.

Disruption of Precipitating Factor:
Predisposing Factor: mucociliary -Smoking
- Age: ____ activity -Alcohol
- Gender: ____ intoxication

Multiplication of
microorganisms in the
bronchi and/or alveoli

Inflammatory reaction

White blood cells,

neutrophils, migrate to
Activation of pain alveoli

Producing exudates in
the alveoli
Chest pain

Interferes with
diffusion of O2 & CO2

Pathophysiology of Pneumonia
Medical management
Management Date General Description Indication Clients Response
D5LR 08-14- 1 liter 20 gtts/mmin MOA: restores Fluid & Rehydrated
17 fluid and electrolyte balances, Electrolyte
produces diuresis, and acts as replenishment
alkalizing agent
PNSS infused 08-14- 1 liter PNSS ; 90 cc PNSS infused Fluid & Stabilized potassium
with 20 mEq 17 with 20 mEq of potassium chloride Electrolyte level in the blood.
KCl MOA: Restores fluid and electrolytes replenishment
balances, for potassium
supplementation of the body.
CBC 08-14- A (CBC) gives important information Bleeding and Segmenters: 87.25 %
17 about the kinds and numbers of Inflammation IncreasedLymphocyt
cells in the blood, especially , , and es: 6.90 % Decreased
CHEST X-RAY 08-14- Diagnostic x rays are useful in To identify Reveals right lobar
AP 17 detecting abnormalities within the abnormalities. pneumonia
body. They are a painless, non-
invasive way to help diagnose
problems such as broken bones,
tumors, dental decay, and the
presence of foreign bodies.
Urinalysis 08-14- Urinalysis is the physical, chemical, Acute renal Pus cells: 2-3/hpfEpithelial cell:
17 and microscopic examination of urine. failure few/hpfBacteria: few/hpf
It involves a number of tests to detect
and measure various compounds that
pass through the urine.

ECG 12 08-14- The standard 12-lead Heart disease _

leads 17 electrocardiogram is a
representation of the heart's
electrical activity recorded from
electrodes on the body surface.
Blood 08-14- Blood transfusion is generally the Blood Replenished blood.
transfusion 17 process of receiving blood or blood replacement
products into one's circulation due to
intravenously. Transfusions are used bleeding ( to
for various medical conditions to prevent
replace lost components of the blood. hypotension )
Sodium 08-14- Is used to screen for adrenal gland Acute renal August 14,2017 : 142.90 mmol/L
Level 17 disease, electrolyte balance, water failure
balance, and kidney disease.
Potassium 08-14- Is used to screen for cell lysis Acute Renal August 14,2017: 1.94 mmol/L
Level 17 syndrome and to assess the effect of Failure August 15,2017- 2.56 mmol/L
TPN, adverse effects of diuretics, August 16,2017: 3.12 mmol/L
kidney dialysis, and underlying cause August 17,2017: 3.59 mmol/L
of high blood pressure.
Calcium 08-14-17 Is used to screen for parathyroid Acute renal August 14,2017 : 3.12
Level gland function, kidney function failure mmol/L
and bone disease.
BUN 08-14-17 Is used to test for kidney function Acute renal August 14,2017: 23.18
and dehydration. failure mg/dl (increase)
CREATININE 08-14-17 Is used to test for kidney function Acute renal August 14,2017:
and dehydration. failure 1.255mg/dl (increase)
ARTERIAL 08-14-17 It is performed to assess how well Oxygen Fully Compensated
BLOOD GAS lungs exchange oxygen and carbon Saturation of Metabolic Acidosis
dioxide. the blood.
Omeprazole 08-14-17 40 IVTT q24hTherapeutic: Anti- To stop Patient reports no vomit.
emetic; Proton Pump Inhibitor vomiting.
MOA: Diminished accumulation of
acid in the gastric lumen with
lessened gastroesophageal reflux.
Healing of duodenal ulcers.
Endotrachea 08-14-17 Endotracheal intubation is a To open the The client was able to
l Tube medical procedure in which a tube airway for breath.
is placed into the windpipe breathing.
(trachea) through the mouth or
nose. In most emergency
situations, it is placed through the
Ceftriaxone 08-15-17 1 gm IVTT q12h (-) ANST To fight for Client reports no
Therapeutic: Anti-infective MOA: infection. infection.
Bactericidal action against
susceptible bacteria.
Piperacillin 08-16-17 4.5 gm q8h ANST (-) Therapeutic: To fight for Client reports no
Tazobactam Anti-infective / Anti-bacterial MOA: infection. infection.
it binds to bacterial cell wall
membrane, causing cell death.
Salbutamol + 08-16-17 1 amp for neb q8h Therapeutic: To promote Client reports
Ipatropium Bronchodilator MOA: Inhibits airway expansion of airways.
Neb choolinergic receptors in bronchial expansion /
smooth muscle rsulting in secrete
decreased concentrations of cyclic secretions.
guanosine monophosphate (cGMP).
Decreased levels of cGMP produce
local bronchodilation.
Diazepam amp IVTT stat Therapeutic : Muscle Relaxant Clients body
Anxiolytic MOA: Depressed CNS ( response if relaxation
GABA ) , inhibitory of muscle.
neurotransmitter. Skeletal muscle
Piperacillin 4.5 gm Every 8 hours It binds to bacterial cell wall membrane, causing cell
Tazobactam after (-) death. Spectrum is extended compared with other
ANST penicillins.Therapeutic effect: death of susceptible
Salbutamol + 1 neb Every 8 hours Inhibits choolinergic receptors in bronchial smooth
Ipatropium neb muscle rsulting in decreased concentrations of cyclic
guanosine monophosphate (cGMP). Decreased levels of
cGMP produce local bronchodilation.Therapeutic effect:
bronchodilation without systemic anti cholinergic
Diazepam amp IVTT Stat. Depressed CNS ( GABA) Inhibitory neurotransmitter.
Relief of anxiety. Sedation. Amnesia. Skeletal muscle
relaxation. Decreased seizure activity.
Omeprazole 40 mg IVTT Every 24 hours Diminished accumulation of acid in the gastric lumen
with lessened gastroesophageal reflux. Healing of
duodenal ulcers.
Ceftriaxone after (-) 1 gm Every 12 hours Bactericidal action against susceptible bacteria.
Potassium Chloride 1 tab Thrice a day Essential for contraction of cardiac, skeletal, and smooth
muscle; gastric secretion; renal function; tissue
synthesis; and carbohydrate metabolism.Therapeutic
effect: Replacement. Prevention of deficiency.
8-14-17 D5LR iL 20 Fluid and
gtts/min electrolyte
PNSS infused with 20 mEq KVO replenishment
8-15-17 D5LR iL 20
PNSS infused with 20 mEq KVO
8-16-17 D5LR il 20
PNSS infused with 20 mEq KVO
8-17-17 D5LR il 20 gtts/min
PNSS infused with 20 mEq KVO
August 14, Pls. admit pt. to ICU
3:36pm Secure consent to care
Monitor V/S 1o to include O2 Sat.
NPO temporarily
IVF: D5LR 1L @ 20gtts/min
Labs:CBC with PC, BT-Stat, ECG 12 leadsU/ACXR APS, Na, K+, Ca+ -
Meds: Omeprazole 40mg IVTT every 24o
Monitor I&O every shift
Relay lab results once available
For referral to MS on care for further eval. & mgt.
Refer accordingly
Chart ET tube level & pattern every 1o
Insert another line @ PNSS 1L @ KVO
Aug. 14, 2017
4:42pm Dr. Calumba informed
Start 20 mEq KCl + 90cc PNSS to run x 1 hr x 4 cycle on right hand
Start 2 mEq KCl + 20cc PNSS to run x 1 hr x 4 cycle
For repeat S & K+ after 4th cycle of KClClose monitoring
Refer accordingly
Aug. 15, 2017 May have soft diet with precautions
K+ - 3.12R Send for thyroid panelRepeat K+ @ 4th cycle
L4/5 4/53/5 Start ceftriaxone 1g every 12 hr IV infusion every 12 hrKCl 1tab
3/5 8:50pm TIDR
efer immediately if dyspnea reoccur
Start KCl PNSS with 90cc PNSS + 20 mEq KCl run for 2 hr x 5 cycle
D/C ceftriaxone
Piperacillin + Tazobactam 4.5gm every 8H ANST (-)
Salbutamol + ipratropium neb every 8h
May insert NGT
Aug. 17, 2017K+ O2 Nebular x 2-3 via nasal cannula
3.59 Repeat CBC
Aug. 18,2017 Levofloxacin 750 mg/cup 1 cup OD.
Revise 02 inhalation @ 3-5 lpm prn for dyspnea
Continue meds.
Aug. 19,2017 Repeat CBC
Aug. 20,2017 D/C Piperacillin Tazobactam
Meropenem 1 gm q8H ANST (-)
Blood GS/CS
Aug. 21,2017 Continue meds.
Repeat Serum K+ , Na+
Aug.22,2017 Repeat CBC tomorrow AM
Continue meds.
HEMATOLOGY ( August 14,2017)

Name of lab Result Normal value Interpretation Impression / analysis

Hematocrit 46.8 % 36.7- 47.1 % Within normal -
Hemoglobin 15.75 g/dl 12.50- 16.30 g/dl Within normal -
RBC 5.13 x 10 ^ 4.06-5.63 x 10 Within normal -
12/L ^12/L range
WBC 24.43 x 10^ 3.60- 10.20 x Above the Indicates
9/L 10^9/L normal range infectionLeukocytopenia
Platelet count 357 x 10^g/L 152.4-347.9 10^g/L Within normal -
Differential count: -
Neutrophils 87.25 50 70 % Above the Indicates
normal range infectionThrombocytope
Lymphocytes 6.90 25 - 40% Below normal Indicates
range infectionThrombocytope
Monocytes 5.44 3- 11 % Within normal -
Eosinophils 0.34 0-10 % Within normal -
Basophils 0.07 0- 2 % Within normal -
August 19,2017
Name of lab Result Normal value Interpretation Impression / analysis
Hematocrit 45.7 % 36.7- 47.1 % Within normal -
Hemoglobin 15.29 g/dl 12.50- 16.30 g/dl Within normal -
RBC 4.92 x 10 ^ 4.06-5.63 x 10 Within normal -
12/L ^12/L range
WBC 18.16 x 10^ 3.60- 10.20 x Above the Indicates
9/L 10^9/L normal range infectionLeukocytopeni
Platelet count 310 x 10^g/L 152.4-347.9 Within normal -
10^g/L range
Differential count: -
Neutrophils 57.93 50 70 % Within normal -
Lymphocytes 29.24 25 - 40% Within normal -
Monocytes 8.95 3- 11 % Within normal -
Eosinophils 3.77 0-10 % Within normal -
Basophils 0.11 0- 2 % Within normal -
Fully Compensated Metabolic Acidosis

pH 7.394 7.35-7.45 Within normal range

PCO2 18.11 35-45 mmHg Below normal range
PO2 204 80-105 mmHg Above normal range
Be-ecf 14 -2 - + 3 Above normal range
HCO3 11.11 22-26 mmol/L Below normal range
TCO2 12 23-27 mmol/L Below normal range
SO2 100 95-98 % Within normal range
Reveals pneumonic consolidation at the
right hillar region. There are also infiltrates along
the left paracardiac area. The heart is not
enlarged.Both costrophrenic angles are sharp.

Right Lobar pneumonia
Urinalysis (August 16,2017)
Color Yellow
Transparency Slightly cloudy
Specific Gravity 1.015
Ph 6.5
Pus cells 2-3 /hpf
Epithelial Cells Few/hpf
Bacteria Few/hpf
Sodium Level 08-14-17 Acute renal failure August 14,2017 : 142.90
mmol/LAugust 21,2017: 137.50
Potassium Level 08-14-17 Acute Renal August 14,2017: 1.94 mmol/L
Failure August 15,2017- 2.56 mmol/L
Ausgut 16,2017: 3.12 mmol/L
August 17,2017: 3.59 mmol/L
August 21,2017: 3.83 mmol/L
Calcium Level 08-14-17 Acute renal failure August 14,2017 : 3.12 mmol/L
BUN 08-14-17 Acute renal failure August 14,2017: 23.18 mg/dl
CREATININE 08-14-17 Acute renal failure August 14,2017: 1.255mg/dl
ARTERIAL BLOOD GAS 08-14-17 Oxygen Saturation Fully Compensated Metabolic
of the blood. Acidosis
August 17,2017 Immunology

T3 0.88 ng/ml 0.69- 2.02 ng/ml Within normal range

T4 9.61 g/dl 5-13 g/dl Within normal range
Tsh 0.02 uIU/mL 0.4-5.5 uIU/mL Below the normal

August 23,2017
Gram stain; Culture and Sensitivity
Specimen: Blood
Comment: After 24 hours of incubation
Organism: No growth

1. Impaired physical mobility related to decreased potassium level in the body

as evidenced by body weakness; decreased muscle strength.
2. Fatigue related to decreased potassium level in the body.
3. Impaired tissue integrity related to decreased potassium level in the body.
4. Impaired gas exchange related to altered oxygen supply as evidenced by
difficulty of breathing.
5. Ineffective airway clearance related to neuromuscular dysfunction.
6. Ineffective breathing pattern related to neuromuscular dysfunction;
hyperventilation as evidenced by use of accessory muscle to breathe.
7. Risk for activity intolerance related to respiratory problem.
8. Imbalanced nutrition: less than body requirements related to increase
metabolic demand as evidenced by electrolyte imbalance.
9. Acute pain related to body weakness and difficulty of breathing.
10. Impaired urinary elimination related to decreased potassium level in the
10 Nursing Diagnosis: Pneumonia

1. Ineffective airway clearance related to pleuritic pain as manifested by dyspnea.

2. mpaired gas exchange related to alveolar-capillary membrane changes as
evidenced by dyspnea.
3. Acute pain related to inflammation of lung parenchyma as manifested by reports
of pleuritic chest pain.
4. Risk for deficient fluid volume related to excessive fluid loss.
5. Risk for imbalanced nutrition: less than body requirements related to increased
metabolic needs secondary to fever and infectious process.
6. Activity intolerance related to imbalance between oxygen supply and demand as
manifested by exertional dyspnea.
7. Risk for infection related to inadequate secondary defenses such as presence of
existing infection.
8. Impaired gas exchange related to altered oxygen supply as evidenced by difficulty
of breathing.
9. Ineffective airway clearance related to neuromuscular dysfunction.
10. Ineffective breathing pattern related to neuromuscular dysfunction;
hyperventilation as evidenced by use of accessory muscle to breathe.
Subjective: Dili Impaired At the end of 8 1.Encourage clients/SOs 1.Enhances commitment to plan, At the end of 8
ko kalihok, physical hours nursing involvement in decision making as optimizing outcomes. hours nursing
akong mga tiil dili mobility interventions, much as possible. 2.To educate the client regarding interventions, the
maarsa, luya related to the client will be 2.Review safety measures as safety measures based on her client was able
kayo akong decreased able to: individually indicated. condition. to:
lawas as potassium 1. Verbalize 3.Conduct an evaluation to clients 3.To assess clients 1. Verbalized
verbalized by the level in the understanding learning according to the previous understanding on the topic. some
patient. body as of situation and discussion. 4. To reduce risk of pressure understanding of
evidenced individual 4.Assist or have client reposition self ulcers and promote clients situation and
Objective: by body treatment on a regular schedule as dictated by comfort. individual
Difficulty in weakness; regimen and individual situation. 5. To maintain position of function treatment
ambulation decreased safety 5.Support affected body parts or joints and reduce risk of pressure ulcers. regimen and
Body weakness muscle measures. using pillows, rolls, foot 6.To develop individual exercise safety measure
strength. 2. Maintain supports/shoes, air mattress, water and mobility program, and identify randomly.
position of bed, and so forth. appropriate mobility devices. 2. Maintain
function and 6. Consult with physical or 7. Promotes well-being and position of
skin integrity as occupational therapist, as indicated. maximizes energy production. function and skin
evidenced by 7. Encourage adequate intake of 8. To promote skin integrity. integrity.
absence of fluids and nutritious foods. 9. Enhances self-concept and 3. Maintain or
contractures, 8. Provide regular skin care to include sense of independence. increase strength
foot drop, pressure area management. and function of
decubitus, and 9. Encourage participation and self- affected and/or
so forth. care; occupational, diversional, or compensatory
3. Maintain or recreational activities. body part.
strength and
function of
affected and/or
body part.

Subjective: Fatigue At the end 1.Discuss therapy regimen relating 1.To Identify At the end of 8 hours
Walay kusog related to of 8 hours to individual causative factors and causative factors nursing interventions, the
ang akong decreased nursing help client-SO(s) to understand 2.That indicate the client was able to:
lawas, galuya potassium intervention relationship of fatigue to illness. need to alter 1. Reported a little
jud tanan level in the s, the client 2. Instruct the client in ways to activity level. improvement in sense of
akong pamati, body. will be able monitor responses to activity and 3.To have baseline energy.
dili nako to: significant signs-symptoms. data. 2. Identified basis of fatigue
malihok-lihok 1. Report 3. Promote overall health 4.Presence of and individual areas of
akong mga tiil improved measures. anemia and control.
ug kamot as sense of 4. Provide supplemental oxygen, as hypoxemia reduces
verbalized by energy. indicated. oxygen available
the patient. 2. Identify 5. Assist client to identify for cellular uptake
Objective:Diffi basis of appropriate coping behaviors. and contributes to
culty in fatigue and 6. Encourage client to do whatever fatigue.
ambulationBo individual possible such as, self-care, sit-up in 5.Promote sense of
dy weakness areas of chair, go for walk, interact with control and
control. family, and play games. improves self-
3. Perform 7. Encourage nutritionally dense, esteem.
activities of easy to prepare and consume 6. Increase activity
daily living foods and avoidance of caffeine level, as tolerated.
and and high-sugar foods and 7. To promote
participate beverages. energy.
in desired 8. Refer to comprehensive 8. To improve
activities at rehabilitation program, physical stamina, strength
level of and occupational therapy for and muscle tone to
ability. programed daily exercises and enhance sense of
activities. well-being.
Subjective: Impaired At the end of 8 1.Encourage verbalizations of 1. To promote At the end of 8 hours
Wala juy tissue hours nursing feelings and expectation self-function nursing interventions,
umoy akong integrity interventions, regarding g condition and and the client was able to:
kalawasan as related to the client will be potential for recovery of identification. 1.Verbalized
verbalized by decreased able to:Verbalize structure and function. 2. To reduce understanding of
the patient. potassium understanding pain or condition and causative
Objective:Bod level in the of condition and 2.Discuss importance of early discomfort factors.
y weakness body. causative detection and reporting of and to 2. Demonstrated
factors.2. changes in condition or any improve behaviors and lifestyle
Display unusual physical discomforts quality of life. changes to promote
progressive or changes in pain 3. To optimize healing and prevent
improvement in characteristics. healing complications or
wound or lesion potential. recurrence.
healing. 3. 3.Emphsize needs for 4. To limit
Demonstrate adequate nutritional and metabolic
behaviors and fluid intake. demands,
lifestyle changes maximize
to promote 4.Stress importance of energy
healing and follow-up care, ass available for
prevent appropriate. healing, and
complications or meet comfort
recurrence. 5.Encourage adequate needs.
periods of rests and sleep. 5. To promote
6. Promote early mobility, circulation and
assist with or encourage prevent
position changes, active or excessive
passive and assistive tissue
exercises. pressure.
Subjective:Patient Impaired gas exchange After nursing - Note respiratory rate, - Provides insight into the
complaints of difficulty in related to altered oxygen interventions, the depth, use of accessory work of breathing and
breathing. supply as evidenced by patient will be muscles, pursed-lip adequacy of alveolar
Objective:Use of difficulty of breathing. able breathing; areas of ventilation. - Affects
accessory muscle when to;Demonstrate pallor/cyanosis, such as ability to clear airways of
breathingNasal improved peripheral versus secretion - All vital signs
flaringUse of oxygen ventilation and central or general are impacted by changes
therapy adequate duskiness.- Note in oxygenation.- Elevation
oxygenation of character and or upright position
tissues by ABGs effectiveness of cough facilitates respiratory
within client's mechanism.- Monitor function by gravity.- to
usual parameters vital signs and cardiac clear or maintain open
and absence of rhythm. - Elevate head airway, when client is
symptoms of of bed and position unable to clear secretions,
respiratory client approximately. - or improve gas diffusion
distress.Verbalize Provide airway when client is showing
understanding of adjuncts and suction, disaturation of oxygen by
causative factors as indicated. - oximetry or ABGs.- for
and appropriate Maintain adequate mobilization of secretions,
interventions input and output. - but avoid fluid overload.-
Participate in Administer medications generally used to prevent
treatment as indicated. and control symptoms,
regimen within reduce frequency and
level of ability or severity of exacerbations,
situation and improve exercise

Subjective:Naglisod ko Ineffective airway clearance After nursing - Assess level of - Information is essential
related to neuromuscular interventions, the consciousness/cogniti for identifying potential for
ug ginhawa as verbalized
dysfunction. patient will be able on and ability to airway problems, providing
by the patient.
to;Maintain airway protect own airway. - baseline level of care
Objective:Use of
patency.Expectorat Monitor respirations needed, and influencing
accessory muscle when
e/clear secretions and breath sounds, choice of interventions.-
breathingRR-28 cpmNasal
readily.Demonstrat noting rate and indicative of respiratory
e sounds.- Position distress and/or
absence/reduction head appropriate for accumulation of
of congestion with age and condition. - secretions.- to open or
breath sounding Suction nose, mouth maintain open airway
clear, noiseless and trachea, as airway in an at-rest or
respirations, and necessary. - Elevate compromised individual.- to
improved oxygen head of bed, clear airway when
exchange.Verbalize encourage early excessive or viscous
understanding of ambulation, or secretions are blocking
causes and change client's airway or client is unable to
therapeutic position every 2 cough or swallow
management hours. - Encourage effectively.- to take
regimen.Demonsta deep breathing and advantage of gravity
rte behaviors to coughing exercises or decreasing pressure on the
improve or splint-chest/incision.- diaphragm and enhancing
maintain clear Administer drainage of/ventilation to
airway.Identify analgesics, as different lung secretions.-
potential prescribed. to maximize effort. - to
complications and relax smooth respiratory
how to initiate musculature, reduce airway
appropriate edema, and mobilize
preventive or secretions.
corrective actions.
Subjective: Nag-lisod ko Ineffective breathing After nursing - Note emotional - Anxiety may be causing
ug ginhawa adtung paadmit pattern related to interventions, the responses. - Assess for or exacerbating acute or
palang ko as verbalized by neuromuscular dysfunction; patient will be able concomitant chronic
the patient. Objective:- hyperventilation as to;Establish a normal, pain/discomfort.- hyperventilation.- this
Patient used accessory evidenced by used of effective respiratory Administer oxygen at may restrict respiratory
muscles to breath as accessory muscles to breath. pattern as evidenced lowest concentration effort.- for management
observed. by absence of cyanosis indicated and of underlying pulmonary
and other prescribed respiratory condition, respiratory
signs/symptoms of medications.- distress, or cyanosis.- to
hypoxia, with ABGs Encourage assist client in "taking
withing clients normal slower/deeper control" of the situation.
or acceptable respirations, use of - to evaluate breathing
range.Verbalize pursed-lip technique, sounds and secretions.-
awareness of causative and so on.- Auscultate to verify maintenance/
factors.Initiate needed and percuss chest.- improvement of O2
lifestyle Monitor pulse saturation.- to limit level
changes.Demonstrate oximetry, as indicated. of anxiety. - to promote
appropriate coping - Maintain calm relaxation and reduce
behaviors. attitude in dealing with anxiety.- to promote
client and SOs.- Assist deeper respirations and
client in the use of cough.- to limit fatigue. -
relaxation techniques.- to prevent worsening the
Medicate with condition and for it not
analgesics, as to re-occur.- this may
prescribed.- Encourage cause abdominal
adequate rest periods.- distention and impair
Avoidance of known breathing efforts.
irritants, allergens, and
etc. - Avoid
overeating/gas forming
GenericNa 1tab TID/PO IV Maintain acid Hyperkalemi CNS: confusion, Assessment:Assess signs
me: Treat balance and a and severe weaknessGI: and symptoms of
Potassium ment/ electrophysiolo renal Abdominal pain. hyperkalemiaMonitor
Chloride Preve gic balance of impairment Diarrhea, nausea pulse, bp and ECGLab
Brand ntion the cell. Use and testsImplementation:
Name: of Contraction of cautiously vomitingLocal: Administer with or after
Pharmacol potass smooth muscle, in: DM , irritation IV meals to decrease GI
ogic Class: ium cardiac, and cardiac siteNeuro: irritations.Patient/ Family
Therapeuti deplet skeletal. disease, paralysis, TeachingExplain to the
cClass: ion Therapeutic renal paraesthesia patient the purpose of
effect: impairment the
Replacement, medication.Encourage
prevention of compliance of
deficiency.. recommended
diet.Instruct patient to
report dark tarry stools,
weakness, fatigue. Notify
physicians for nausea and
vomiting and
diarrhea.Emphasize to
monitor serum levels.
GenericName 40mg IVTT GERD/ Binds to an Hypersensit Adverse reactions: CNS: PO: Administer doses before
: q 24H maintenan enzyme on ivity; dizziness, drowsiness, meals, preferably in the
OMEPRAZOL ce of gastric Metabolic fatigue, headache, morning. Maybe concurrently
E Brand healing in parietal cells alkalosis weakness. CV: Chest pain used with antacids.Patient/
Name:Losec, erosive in presence and GI: Abdominal pain, Family TeachingInstruct
Prilosec esophagiti of acidic hypocalcemconstipation, diarrhea, patient to take medication as
Pharmacologi s. gastric pH, ia (Zegerid flatulence, nausea and directed. Take missed meds as
c Duodenal preventing only)Use vomiting Derm: itching, rash soon as remembered.May
Class:Proton ulcers.Sho the final Cautiously Misc. allergic reactions cause dizziness. Avoid
pump rt-term transport of in: Liver driving.Advice patient to
inhibitors treatment hydrogen disease avoid alcohol, aspirin, foods
TherapeuticCl of active ions into the (dosage that can make GI
ass:antiulcer benign gastric reduction irritation.Advice patient to
agents gastric lumen. may be report onset of black, tarry
Pregnancy: ulcer.Path necessary) stools, diarrhea, abdominal
Category C ologic pain; or persistent headache
hypersecr to health care professional
etory promptly.
of risk of
critically ill
Generic Name: 1 gm IVTT q12H Treatm Bind to bacterial Contraindicated CNS: seizures (high Assess patient for signs
Ceftriaxone ANST ent of cell wall in: doses).GI: and symptoms of infection
Brand Name: the membrane, Hypersensitivity Pseudomembranous prior to and throughout
Rocephin followin causing cell to cephalosporins; colitis, diarrhea, therapy.Before initiating
PharmacologicC g death. Serious cramps, nausea, therapy, obtain a history
lass THIRD infectio hypersensitivity to vomiting.Derm: to determine previous use
GENERATIONCE ns penicillins.Use rashes, of and reactions to
PHALOSPORIN caused Cautiously in: urticaria.Hematagranu penicillins or
TherapeuticClas by Renal impairment locytosis, bleeding cephalosporins. Persons
s: ANTI- suscepti (dose adjustments (increase with with a negative history of
INFECTIVESPRE ble necessary); cefotetan and penicillin sensitivity may
GNANCY organis History of GI cefoxitin), still have an allergic
CATEGORY B ms: disease, especially eosinophilia, hemolytic response.Observe patient
Urinary colitis; Geri: anemia, neutropenia, for signs and symptoms of
Tract Dosage hrombocytopenia.Loca anaphylaxis (rash,
Infectio adjustment due to l: pain at IM site, pruritus, laryngeal edema,
n age-related phlebitis at IV wheezingDiscontinue the
decrease in renal site.Misc: allergic drug and notify physician
function may be reactions including or other health care
necessary; may anaphylaxis and serum professionalimmediately if
also be at increase sickness, these symptoms occur.
risk for bleeding superinfection.. Keep thromepinephrine,
with cefotetan or an antihistamine,and
cefoxitin; OB: resuscitation equipment
Pregnancy and close by in the event of an
lactation (have anaphylactic
been used safely). reaction.Instruct patient to
report signs of

Generic amp IVTT STAT This drug is A benzodiazepine Contraindicated in CNS- drowsiness, Warn patient to avoid
Name:Diazepam prescribed to that probably patients dysarthria, slurred activities that require
Brand Name: treat:AnxietyMuscl potentiates hypersensitive to speech, tremor, alertness and good
Valium e Spasm Adjunct effects of GABA , drug or soy fatiqueCV- collapse, coordination until
Pharmacologic treatment for depresses the protein or in bradycardia, effects of drugs are
Class:Benzodiaze seizure disorder CNS, and patients hypotensionEENT- unknownInstruct
pine Therapeutic suppresses the experiencing blured vision, patient to avoid alcohol
Class:Anxiolytic spread of seizure shockContraindica nystagmus and while taking drugNotify
activity ted in patients diplopiaGI- diarrhea, pt. that smoking may
with acute constipation and decrease drugs
closure nauseaGU- effectivenessInstruct
glaucomaUse incontinence and urine pts caregiver on the
cautiously in retentionHematologic- proper use of diastat
patients with liver neutropeniaRespirator rectal gel
or renal y- resp. depression and
impairment, apneaSkin- rash and
depression, and phlebitis at injection
history of siteOther- Altered
substance abuse libido

Generic Name: gm q8H This drug is Inhibits ell wall Contraindicated CNS- headache, Instruct patient to
Piperacillin ANST (-) prescribed synthesis during in patients insomnia, fever, report adverse
Tazobactam to bacterial hypersensitive seizures, anxietyCV- reactions
Brand Name: treat:Moder multiplication to drug or other arrhythmia, chest promptlyTell patient
Piperacillin ate to penicillinsUse pain, edema, to alert a health care
Pharmacologic severe cautiously in hypertension, professional about
Class:Extended nosocomial patients with tachycardiaEENT- discomfort at the IV
Spectrum pneumonia bleeding RhinitisGI- diarrhea, site
Penicillin Beta- caused by tendencies, constipation, nausea,
Lactamase piperacillin- uremia, pseudomembranous
Inhibitor resistant hypokalemia, colitis, abdominal
Therapeutic and allergies to pain, Stool changes,
Class:Antibiotic other drugs, vomitingGU-
especially candidiasis and
cephalosporins, intestinal
because of nephritisHematologic
possible cross- - leukopenia,
sensitivity neutropenia,
DyspneaSkin- Pruritus
and rashOther-

Generic Name:Salbutamol + This drug is Depressed CNS ( Contraind HeadacheDizzi Instruct pt. not to
Salbutamol + Ipatropium neb 1 prescribed to GABA ) Inhibitory icated in nessNauseaDry drive or any
Ipatropium neb q8H treat and prevent: neurotransmitter. patients mouthTremors activities that
neb Brand Symptoms of and Relaxed the muscles hypersens ConstipationM require alertness
Name: caused by around the airways itive to uscle because this drug
Pharmacologic ongoing lung so that they open up drug crampsChest can cause
Class:Ipratropi disease and you can breathe Inform painConfusion dizziness and
um more easily. the Rash vision
Therapeutic physician changesInstruct
Class:Broncho first pt. to limit
dilator history of alcohol intake
BP, heart
, difficulty
using the
Discharge Summary



ADMITTING DIAGNOSIS: Acute Renal Failure Secondary to Hypokalemia

with Periodic Paralysis; R/O GBS


CHIEF COMPLAINT Prior to admission, the patient had difficulty in ambulation and
difficulty of breathing.
Discharge Planning
Continue medication

Medication as prescribed:
Health Teaching
Nutrition. A referral to nutritionist is made because of the
dietary changes required.
Problems to report. The patient and family should know what
the problems to report to the healthcare provider are.
Follow-up Examinations. The importance of follow-up examinations
and treatment is stressed to the patient and family because of
changing physical status and renal functions.

Cannot figure out prognosis yet because patient

is met once. But the recovery from acute kidney
failure depends on what caused the disease. If the
cause does not stem from damage to kidney tissue
itself, the prognosis is good and the patient will
probably make a full recovery. Partial recovery of renal
function may occur in situations in which the injury
does not completely resolve. In general, the more ill a
patient is during the onset of renal failure, the worse
the outcome. Severe cases of acute renal failure can
result in death.
1.Treatment will depend on the cause of your acute kidney failure. The goal is
to restore normal kidney function. Preventing fluids and wastes from
building up in your body while your kidneys recover is important. In the
majority of cases, a kidney specialist called a nephrologist makes an
2.The doctor will restrict your diet and the amount of liquids you eat and
drink. This will reduce the buildup of toxins that the kidneys would normally
eliminate. A diet high in carbohydrates and low in protein, salt, and
potassium is usually recommended.
3.The doctor may prescribe antibiotics to treat or prevent any infections that
occur at the same time. Diuretics may help your kidneys eliminate fluid.
Calcium and insulin can help avoid dangerous increases in your blood
potassium levels.
4.You may need dialysis, but its not always necessary. Dialysis involves
diverting blood out of your body into a machine that filters out waste. The
clean blood then returns to your body. If your potassium levels are
dangerously high, dialysis can save your life. Dialysis is necessary if there are
changes in your mental status or if you stop urinating. You may also need
dialysis if you develop pericarditis or inflammation of the heart. Dialysis can
help eliminate nitrogen waste products from your body.
Self-treatment of acute kidney failure is not
recommended. Kidney failure can be a very
serious condition that requires medical care
1.It may be possible to receive some or all treatment at home. Treatment in
some cases can be administered by a home health nurse under the
supervision of a physician.
2.In cases in which recovery of kidney function is incomplete, dialysis, a
process by which the blood is cleared of wastes and excess water, is used.
Dialysis, when needed for acute renal failure, is performed at a hospital or
dialysis center. Home dialysis may be appropriate in cases in which kidney
failure is permanent and dialysis is needed indefinitely.
3.Patients with kidney diseases will usually be required to follow a renal diet
(kidney diet), that is often low in protein and potassium.
4.The doctor will arrange follow-up visits as needed for the underlying cause
of the kidney failure and the severity of the disease. Underlying condition(s)
will be monitored and appropriate lab tests will be performed to be sure that
the kidney failure has resolved. Preventive measures may be needed in some
situations to prevent the problem from occurring again.
5.Yearly physical exams by the doctor include blood tests and urinalysis to
monitor kidney and urinary tract health.
6.Drink enough fluids to keep the kidneys functioning properly.
7.Avoid taking substances or medications that can poison or
damage kidney tissues. Ask the doctor about substances to avoid.
8.Persons at risk for chronic kidney disease may need more
frequent testing for kidney function and other problems that occur
with declining kidney function. Difficulties urinating or blood in
the urine should prompt a visit to the physician as soon as
9.Correct dehydration: Intravenous fluids, with electrolyte
replacement if needed
10.Fluid restriction: For those types of kidney failure in which
excess fluid is not appropriately eliminated by the kidneys
11.Increase blood flow to the kidney: Usually related to improving
heart function or increasing blood pressure
12.Correct chemical (electrolyte) abnormalities: Keeps other body
systems working properly.
Take the entire course of any prescribed medications. After a patients temperature returns to
normal, medication must be continued according to the doctors instructions, otherwise the
pneumonia may recur. Relapses can be far more serious than the first attack.
Get plenty of rest. Adequate rest is important to maintain progress toward full recovery and to
avoid relapse.
Drink lots of fluids, especially water. Liquids will keep patient from becoming dehydrated and help
loosen mucus in the lungs.
Keep all of follow-up appointments. Even though the patient feels better, his lungs may still be
infected. Its important to have the doctor monitor his progress.
Encourage the guardians to wash patients hands. The hands come in daily contact with germs
that can cause pneumonia. These germs enter ones body when he touch his eyes or rub his
nose. Washing hands thoroughly and often can help reduce the risk.
Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g.
smoke). Smoking damages ones lungs natural defenses against respiratory infections.
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when
Protect others from infection. Try to stay away from anyone with a compromised immune
system. When that isnt possible, a person can help protect others by wearing a face mask and
always coughing into a tissue.

Hospitalized Patients. For patients who need hospitalization

for pneumonia, the death rate is 10 - 25%. If pneumonia develops in
patients already hospitalized for other conditions, death rates range
from 50 - 70%, and are higher in women than in men. Streptococcus
pneumoniae is the most common cause of pneumonia and, in fact, all
bacterial upper respiratory infections. It can produce severe
pneumonia, with mortality rates of 10%. Nevertheless, pneumococcal
pneumonia responds very well to many antibiotics. Complications of
pneumonia includes Respiratory Failure. Respiratory failure is one of
the top causes of death in patients with pneumococcal pneumonia.
Acute respiratory distress syndrome (ARDS) is the specific condition
that occurs when the lungs are unable to function and oxygen is so
severely reduced that the patient's life is at risk. Failure can occur if
pneumonia leads to mechanical changes in the lungs (ventilatory
failure) or oxygen loss in the arteries (hypoxemic respiratory failure).
Antibiotic treatment for non-severe pneumonia with

Antibiotics are not routinely recommended for

children with non-severe pneumonia (i.e. fast
breathing with no chest in drawing or danger sign)
with a wheeze but with no fever (< temperature 38
C), as the cause is most likely to be viral.