INTRODUCTION

OVERVIEW

Chronic renal failure is a chronic progressive disease that presents by an

ongoing loss of kidney function and performance

This process has normally duration of several years leading to end-stage renal
failure

In this stage dialysis or kidney transplantation becomes obligatory!

Common cause of Chronic Renal Failure:

Glumerulonephritis
Diabetes mellitus
Hypertension
Polycycstic kidney disease
Vesicouretic reflux
Analgesic nephropathy

Symptoms and complications:

Impaired renal function causes pathologic changes in different secondary organ

systems
• Hypertension à Cardiovascular system
• Disturbed vitamin D à Bone
• Changed Ca2+ metabolism à PTH Metabolism
• Neuropathies by uremic toxins à Neuromuscular
• Anaemia by Erythropoietin deficiency à Blood
• Metastatic calcification àSkins
• Disturbed hormone production à Endocrine system

Diagnostic Procedure:

• Clinical Chemistry which includes urea, creatine, uric acid and electrolyte
fluids.
• Complete Blood Count
• Urinalysis
• Ultrasonography
• Renal biopsy
Treatment:
 • Control of blood pressure and underlying disorders
• Possible restriction of dietary protein, phosphate, and K
• Vitamin D supplements
• Treatment of anemia and heart failure
• Doses of all drugs adjusted as needed
• Dialysis for severely decreased GFR, uremic symptoms, or sometimes
hyperkalemia or heart failure
• Renal replacement therapy

Prognosis:
• Progression of CKD is predicted in most cases by the degree of
proteinuria.
• Patients with nephrotic-range proteinuria (> 3 g/24 h or urine
protein/creatinine > 3) usually have a poorer prognosis and progress to
renal failure more rapidly.
• Hypertension is associated with more rapid progression as well.
 OBJECTIVES
General: To gain knowledge about chronic renal failure and to analyze the
pathophysiology of the clinical case presentation and to have a good care
management for the patient.

Specific:
• To know the organs of urinary system.

• To learn about the pathophysiology of chronic renal failure.

• To know the signs and symptoms of chronic renal failure.

• To gain knowledge about the medications prescribed by the physician.

• To formulate appropriate nursing diagnosis related to existing problems.

• To be able to develop compassion, responsibility and understanding to our

patient.
 NURSING HISTORY
1. Personal History:

Name Mr. JP
Age: 73 years old
Sex: Male
Birthday: June 24, 1935
Status: Married
Occupation: Retiree
Address: Quezon City

2. Chief Complaint: Numbness of the lower extremities

3. History of Present Illness

The patient’s history of present illness revealed that one month prior to
admission the patient slipped off in their bathroom and consulted to Philippine
Orthopedic Center, CBC was performed and no fracture was noted. Two weeks
after that incident the patient was noted to developed bed sores and
subsequently manifested edema in both lower extremities associated with
toppering urine output approximately 100 cc per day with no associated chest
pain, orthopnea and dyspnea.

Two days prior to admission the patient experienced numbness of the

lower extremities, thus prompt consult at De Los Santos Medical Center and
subsequently admitted last November 11, 2008

4. Past Health History

Past health history revealed ten years ago the patient was diagnosed to
have Gouty Arthritis due to increased levels of uric acid and maintained
Cerebrex, Meloxican.

5. Family History
♀(+) ♂(+)
With With Hypertension
hypertension and Diabetes Mellitus

“Mr. JP”
With hypertension, Diabetes Mellitus, Gouty
Arthritis
Diagnosis: Chronic Renal Failure
6. Personal and Social History

The patient was 73 years of age and was born on June 24, 1935. He is
second in a brood of four, and was born and was raised in Quezon City.

The patient was a high school graduate. He got married at the age of 20
and blessed with nine siblings, 7 males and 2 females.

He previously worked as a farmer and retired at the age of 55. He was an

alcohol drinker and consumed three bottles per day. He was like wise a heavy
smoker but subsequently quit his vices 20 years ago. He used to drink coffee
moderately. He moved freely and luxuriously enjoyed gardening.

7. A. Usual Patterns of Daily Living

ACTIVITIES BEFORE DURING HOSPITALIZATION SIGNIFICANCE

HOSPITALIZATI
ON
DAY1 DAY2 DAY3

REST AND 6hrs 6hrs 3hrs

8 – 12 hrs in a
SLEEP intermittent intermittent intermittent
day
PATTERN sleep pattern sleep pattern sleep pattern

Fasting every Fasting every NPO due to

3 meals and in 6hrs due to 6hrs due to wound
NUTRITION
between snacks CBG CBG debridement
monitoring monitoring surgery
ELIMINATION

URINE
100cc With foley With foley With foley
catheter (dark catheter (dark catheter (dark
yellow) yellow) yellow)
STOOL
For 5 days , (Once) Black
no stool watery stool (Twice) Black (Twice) yellow
through the watery stool green brown
suppisotory stool.

Total body
TSB by TSB by TSB by
hygiene can be
HYGIENE significant significant significant
performed by
others others others
himself
 COMPETENCIES
CRITERIA ACTUAL OBSERVATION

 Needs assistance in movement

and Feeding
Physical Motor Competencies
 Non ambulatory
 Has hearing difficulty

Mental Competencies

A. Emotional  Has complete understanding of

his condition and seemed
depressed about it.

B. Social  Has difficulty in relating and

interacting with others because
of his hearing deficiency.
C. Spiritual
 The patient wholly depends to a
device being finding peace and
solace by means of prayer.
 CLINICAL APPRAISAL
General physical
Normal Present condition
appearance
a. Skin Presence of skin lesions on
Smooth and soft
both and upper extremities
Rounded
(normocepahlic) smooth Nomocephalic, absence of
b. Head
skull contour absence nodule of masses
of nodule or masses
Hair evenly distributed, - Equally reactive to light
skin intact eyebrows and accommodation
c. Eyes
systematically aligned. - Both eyes coordinated
Equal movement un parallel
- Located symmetrically
No flaring of nostrils, - With nasal flaring
d. Nose
symmetric - Presence of yellow
green discharge
e. Mouth Outer lips, pink in color - Cracked and dry lips
- Symmetrically located
Coordinated, smooth - Movement with full
f. Neck movements with no range of motion
discomfort - Lymph nodes are
palpable
- With crackles on both
lung field
- With productive cough
Chest wall intact, no (yellow phlegm)
g. Heart/lungs
tenderness, no masses - No palpitation of heart
murmurs
- RR 20, BP 140/70, PR
80
No evidence of - No tenderness, flat in
h. Abdomen
enlarged liver shape
- Flexes and extends
Symmetric in without difficulty but
i. Upper appearance and with assistance.
extremities movements are done - Slow muscle
with ease movement and weak
muscle tone
 THEORETICAL FRAMEWORK

DOROTHEA OREM focused on the question “What is

nursing? And “When do people need nursing care?”
from this she derived that people need nursing when
they are incapable to care for themselves. In 1971 she
presented the self care deficit theory of nursing which
has three interconnecting theories: theory of self care,
theory of self care deficit, and theory of nursing
systems.

The Theory of Self-Care

According to this theory, self care is a learned behaviour and a deliberate action
in response to a need. Orem identified three categories of self-care requisites:
First is the Universal self- care requisite which is common to all human being and
includes both physiological and social interaction needs Second, is the
developmental self-care requisites which are the needs that arises as the
individual grows and develops. And the third is the health deviation self-care
requisite which is a result from the needs produced by disease or illness.

Theory of Self-Care Deficit

This theory purports that nursing care is needed when people are affected by
limitations that do not allow them to meet their self care needs. The relationship
between the nurse and the client is established when a self care deficit is
present.

Theory of Nursing Systems

This theory attempts to answer the question “What do nurses do?” the nurse
determines whether or not there is a legitimate need for a nursing care. Orem
identified three types of nursing system: wholly compensatory, partly
compensatory, and supportive educative. In the wholly compensatory nursing
system, the nurse supports and protects the client, compensates for the clients
inability to care for self and attempts to provide care for client. In the partly
compensatory nursing system, both the nurse and the client perform care
measures, the nurse compensates for what the client cannot do, the client is able
to perform selected self care activities but also accepts care performed by the
nurse for needs the client is unable to meet independently. In the supportive-
educative nursing system, the nurse actions are to help clients develop their own
self care abilities through knowledge, support and encouragement.

For us, theory of self care means a person should have the ability in performing
the activities of daily living to be able to meet his/her own needs. The first two
categories of self care requisites were met by our client because he used to
perform activities independently including gardening.

One month before he has admitted in the hospital he can no longer walk because
of the numbness of his lower extremities. He had also undergone surgery for
debridement of his wounds. We have observed that our client is unable to
perform activities such as feeding, dressing, bathing and toileting. This is where a
self care deficit exists. In the nursing theory system, our patient falls to wholly
compensatory because he can no longer performed any activities.
 ANATOMY AND PHYSIOLOGY

THE HUMAN KIDNEY

The renal capsule is the membranous covering of the

kidney. It directly covers the renal cortex, which forms the
Capsule
outer stratum
Each part of the capsule links to its explanation.

The cortex of the kidney is the outer section which covers

the internal medulla. The cortex is visible near the outer
Cortex
edge of the cross-sectioned kidney. It is composed of blood
vessels and urine tubes and is supported by a fibrous matrix.

The calyces (plural for calyx) are the recesses in the internal
medulla of the kidney which enclose the pyramids. They are
Calyx used to subdivide the sections of the kidney anatomically,
with distinction being made between major calyces and
minor calyces.

The renal columns are lines of the kidney matrix which

support the cortex of the kidney. They are composed of lines
Renal Column
of blood vessels and urinary tubes and a fibrous, cortical
material.

Pyramid The renal pyramids are conical segments within the internal
medulla of the kidney. The pyramids contain the secreting
 apparatus and tubules and are also known as the
malphighian pyramids.

The renal sinus is the cavity within the kidney which houses
Renal Sinus
the renal pyramid. Nerves and blood vessels pass into the
renal sinus through the hilus.

The hilus is the slit-like opening in the middle of the concave

Hilus medial border of the kidney. Nerves and blood vessels pass
through the hilus into the renal sinus within.

One quarter of the total blood output from the heart comes to
the kidneys along the renal artery. Two renal arteries arise
from the abdominal section of the aorta; each artery supplies
Renal Artery
a lobe of the kidney. The incoming artery divides into four or
five branches, eventually forming arterioles, each of which
leads to the compact ball of capillaries called the glomerulus.

Cell waste is discharged in the veins for excretion through

the kidneys. The body circulates about 425 gallons of blood
through the kidneys on a daily basis, but only about a
thousandth of this is converted in urine. The remainder goes
back into circulation through the renal arteries. From the
Renal Vein Bowman's capsule, the blood is carried through the compact
network of capillaries that forms the glomerulus within the
capsule. The capillaries eventually reconverge into small
venules which lead to the larger renal veins. There are two
renal veins, one extending from each lobe of the kidney, and
opening into the vena cava.
 THE NEPHRON
Nephron Functional unit of Kidney

Renal
site of plasma filtration
Corpuscle
glomerulus is composed of capillaries where
Glomerulus filtration occurs

Bowmans glomerular (Bowman’s) capsule is doublewalled

capsule epithelial cup that collects filtrate

A renal tubule consists of a proximal convoluted tubule

Renal Tubule (PCT), loop of Henle (nephron loop) and distal convoluted
Tubule (DCT).

The proximal tubule regulates the pH of the filtrate by exchanging hydrogen

Proximal ions in the interstitium for bicarbonate ions in the filtrate; furthermore, it is
Tubule responsible for secreting organic acids, such as creatinine and other bases,
into the filtrate.

The portion of the nephron that leads from the proximal convoluted tubule to
the distal convoluted tubule. The loop has a hairpin bend in the renal
Loop of
medulla. The main function of this structure is to reabsorb water and ions
Henle from the urine. To do this, it uses a countercurrent multiplier mechanism in
the medulla. It is named after its discoverer, F. G. J. Henle.

Distal convoluted tubules of several nephrons drain into a

single collecting duct and many collecting ducts drain into a
Distal Tubule small number of papillary ducts It is partly responsible for the regulation of
potassium, sodium, calcium, and pH.

Collecting The collecting duct system is the last component of the kidney to influence
Ducts the body's electrolyte and fluid balance. In humans, the system accounts for
4-5% of the kidney's reabsorption of sodium and 5% of the kidney's
reabsorption of water. At times of extreme dehydration, over 24% of the
 filtered water may be reabsorbed in the collecting duct system.

LABORATORY
LABORATORY RESULTS
November 10, 2008
PHILIPPINE ORTHOPEDIC CENTER
HEMATOLOGY

TEST RESUL REFERENCE SIGNIFICANCE

T INTERVALS
Component
Hemoglobin 106 127 – 183 g/L It is below normal which
indicate anemia and fluid
retention.
Hematocrit .31 .32 -.54 It is below normal which
indicate anemia.
Leucocyte 20.89 4.5 – 10 x10 g/L It is above normal which
indicate bacterial infection.
Differential Count
Segmenters .91 .50 - .70
Lymphocytes .04 .20 - .40
Monocytes .05 .00 - .07 It is within normal range.
Platelet Count 306 150 – 400 10^ g/L It is within normal range.
Indices
MCV 73 82 – 92 fL It is below the normal
range which indicates
anemia.
MCH 25 28 -32 pg It is below normal range
which indicate anemia.
MCHC 35 32 -38 It is within normal range.
 DE LOS SANTOS MEDICAL CENTER
HEMATOLOGY

TEST RESULT REFEREN SIGNIFICANCE

CE
INTERVAL
S
11/11/08 11/12/08 11/13/08
Hemoglobin 98 93 98 137–175 g/L It is below normal
which indicate
anemia and fluid
retention.
Hematocrit .28 .27 .29 .40 - .51 It is below normal
which indicate
anemia.
Red Cell 3.28 3.37 3.52 4.63 – 6.08 It is below normal
Count 10ˆ12/ L which indicate fluid
overload.
MCV 80.0 80.7 83.0 80 – 96 fL It is within normal
range.
MCH 28.2 27.6 27.8 27.5 – 33.2 It is within normal
pg range.
MCHC .356 .343 .336 .323 - .365 It is within normal
range.
RDW .133 .134 .140 .115 - .145 It is within normal
range.
White Cell 18.91 18.21 19.20 4.23 – 10.04 It is above normal
Count 10ˆg/L which indicate
bacterial infection.

Neutrophils .79 .85 .73 .55 - .65 It is above normal

which indicate
bacterial infection
and acute gout It is
within normal
range.
Lymphocyte .17 .13 .08 .25 - .35
s
Monocytes .03 .01 .01 .02 - .10
Stabs .04 .03 .05 .03 - .05

CLINICAL CHEMISTRY
 TEST RESULT REFERENCE SIGNIFICANCE
NAME INTERVALS
11/12/08 11/14/08
It is above normal
25.7
Urea 11.7mmol/L 3.2- 7.1 which indicate renal
mmol/L
disease
It is above normal
170.
121 umol/L 58.-110. which indicate renal
creatinine umol/L
disease

November 11, 2008

TEST NAME SI REFERE CONVENT REFEREN SIGNIFICANCE

RESULT NCE IONAL CE
VALUE VALUE
Urea 30.7mmol 3.2 - 7.1 86 mg/dL .9 – 20 It is above normal
/L which indicate renal
disease
Creatinine 216 58. - 110. 2.4 mg/dL .66 -1.25 It is above normal
umol/L which indicate
impaired renal
function.
SGPT (ALT) 55 u/L 21 - 72 55 u/L 21 – 72 It is within normal
range.
SGOT (AST) 68u/L 17 - 59 68 u/L 17 – 59

Total 56.9 g/L 63 - 82 5.7 g/L 6.3 - 8.2 It is below normal

protein which indicate
nephrosis and
uncontrolled diabetes
mellitus.
Albumin 23.6 g/L 35 - 50 2.4 g/L 3.5 – 5 It is below normal
range which indicate
nephritis
Globulin 33.2g /L 25 - 35 3.3 g/L 2.5 - 3.5 It is within normal
range.
Sodium 120.4 137 - 145 120 137 - 145 It is below normal
mmol/L mEq/L which indicate chronic
renal insufficiency.
Potassium 4.23 3.5 - 51 4.2 mEq/L 3.5 – 51 It is within normal
mmol/L range.

URINALYSIS RESULT
November 11, 2008
 REFERENCE VALUES RESULTS
COLOR YELLOW LIGHT YELLOW
TRANSPARENCY CLEAR TURBID
REACTION 4.8-7.8 5.0
SP. GRAVITY 1.015-1.025 1.015
ALBUMIN Negative Trace
SUGAR Negative Negative
ACETONE Negative Negative
BILIRUBIN Negative Negative
BLOOD Negative Moderate
URUBILINOGEN Negative Negative

MICROSOPIC
WBC Too numerous to count
RBC 8-12/HRF
EPITHELIAL CELLS OCCASSIONAL
MUCUS THREADS OCCASSIONAL
BACTERIA MANY
CRYSTALS AMORPHOUS URATES
CASTS FEW
-There is presence of bacteria which
indicates infection of the external
genitalia.
-The WBC is too numerous to count which indicates infection.

CLINICAL CHEMISTRY
November 13, 2008
 REFEREN
TEST REFERENCE
SI RESULT CE CONVENTIONAL SIGNIFICANCE
NAME VALUES
VALUES
Sodium 137.-145. 134 mEq/L 137 It is below
Low normal range
which
indicates
chronic renal
insufficiency.
Potassiu 4.17 3.5-5.1 4.2 mEq/L 3.5-5.1 It is within
m mmol/L normal range.

Calcium 1.87 2.1-2.55 7.5 mEq/L 8.4-10.2 It is below

Low mmol/L normal range
which
indicates renal
failure.

CLINICAL CHEMISTRY
Nov. 12, 2008
TEST NAME SI REFERENC CONVENT REFERENCE SIGNIFICANCE
RESULT E VALUES IONAL VALUES
It is above
Phosphorous 1.54 normal range
0.81-1.45 4.6 mg/dl 2.5-4.5
High mmol/L which indicates
renal disease

TRANSRECTAL ULTRASOUND
November 11.2008

Note:
Limited scanning due to overlying bowel gas and fecal materials within the
rectum as well as patient inability to assume proper position and further tolerate
the procedure.

The prostate gland is borderline enlarged in size with normal parenchymal echo
pattern; measuring 4.09 x 3.74 x 2.86 cm with an approximate weight of 22.70 is
detected. The anatomic and surgical capsules are intact.

The peri-prostatic fatty tissues are unremarkable. The semi-prostatic angles ate
maintained.
Note of foley catheter balloon tip within the urinary bladder.

Impression:
Borderline prostatomegaly with concretions
RADIOLOGY
November 11, 2008
Required Exam: Chest AP
Roentological findings:

Frank parenchymal infiltrates seen.

Trachea is deviated to the right.`
The cardiac shadow is not enlarged.
Aorta is segmentally calcified.
Spurs line the thoracic vertebral bodies.
The left costophrenic angle is blunted.

Impression:
 Right tracheal deviation, may be from prominent aortic knob.
 Atheromatous Aorta
 Pleural reaction left
 Thoracic os
ULTRASOUND OF THE KIDNEY AND URINARY BLADDER:
Nov. 12, 2008

Right kidney measures 10.5 x 5.93 x 5.74 cm with cortical thickness of .32 cm
while the left kidney measures 10.4 x 4.99 x 5.26 cm with cortical thickness of
1.33 cm. both kidneys are normal in size. There is focal dilatation of the right
lower pole calyces. The central echo complex in the left side is intact with no
evidence of hydronephrosis. The cortices show normal thickness and
echogenicity.
There are anechoic cysts seen in both kidneys as follows
Right kidney
Lower 1.6 x 1.66 x 1.44 cm
Left kidney
Mid 2.08 x 2.20 x1.90 cm
Lower 3.24 x 2.96 x 2.97 cm

The urinary bladder is normal in volume and configuration and distended to

4.73.5 ml its wall is not thickened. No lithiasis nor mass seen. The foley catheter
balloon tip is noted in place.
IMPRESSION:
Focal pelvocaliectasia, right.
Renal cysts bilateral.
Normal ultrasound of the urinary bladder.

DIABETIC CHART
(every 6 hours)
 DATE TIME Urine Sugar
Am Pm
November 11 , 2008 6:00 112 mg/dL
November 12, 2008 12:00 90 mg/dL
6:00 117 mg/dL
6:00 90 mg/dL
November 13 ,2008 12:00 131 mg/dL
6:00 141mg/dL
6:00 97mg/dL
November 14, 2008 12:00 113 mg/dL
6:00 98mg/dL
6:00 87mg/dL

MISCELLANEOUS REPORT

November 11, 2008

Specimen: urine
Examination: Gram Stain

Findings:
Gram Negative bacilli – Many
WBC – Many

PATHOPHYSIOLOGY
Č diabetes mellitus
Male
Č gouty arthritis 10 Yrs
Č HPTN
Mr. X 72 yrs. old
Alcohol Drinker
Smoker
 Over production of Uric acid

KIDNEY

High concentration of uric in the plasma

Decrease Renal
Decrease hydrostatic pressure Blood flow

Decrease Glomerular Filtration Rate

Accumulation of uric acid w/in the kidney

interstinum and tubules

Due to Low PH
on the tubular
system Formation of uric precipitate

Decrease Renal tubular Obstruction

reabsorption of
sodium on the
distal tubule Decrease reabsorption and secretion of solute
UREMIC Toxin

Increase water
retention Decrease Decrease ability to Shortened RBC
excretion of URINE absorb Bicarbonate survival
and Hydrogen Ions
Fluid Overload
Decrease excretion Inhibits production
of Potassium METABOLIC of Erythropoeisis
ACIDOSIS
EDEMA/ HPN

HYPERKALEMIA ANEMIA

CHRONIC RENAL FAILURE 2º

TO CHRONIC RENAL DISEASE
DRUG STUDY
 ALLOPURINOL
NAME OF DRUG
(Zyloprim)

ACTION/KINETICS  Inhibits production of uric acid.

CONTRA-  Hypersensitivity in pregnant women and lactating

INDICATIONS women

 May experience an increase in gout attacks for several

months after you begin taking Allopurinol.
 Do NOT take more than the recommended dose or use
for longer than prescribed without checking with your
doctor.
SPECIAL  Allopurinol is not useful for relieving an acute gout
CONCERNS attack.
 Lab tests, including uric acid levels and kidney and liver
function, may be performed while you use Allopurinol .
These tests may be used to monitor your condition or
check for side effects. Be sure to keep all doctor and
lab appointments.

Seek medical attention right away if any of these SEVERE

side effects occur:
SIDE EFFECTS  CNS: Drowsiness
 GI: Diarrhea, Hepatitis, nausea, vomiting
 Derm: Rash, Urticaria

 Ampilcillin increases he risk of rash

DRUG  Warfarin increases sffect of this drug.
INTERACTIONS  ACE Inhibitors increases the risk of hypersensitivity
reaction

 A typical starting dose is one 100-milligram tablet per

day.
DOSAGE  Doctor will probably start you on a low dosage,
increasing it gradually each week until you reach the
dosage that is best for you.

Nursing Considerations
Administration:  Oral
 Assess patient for any adverse reaction. Report
Assessment:
immediately to the physician.
  Follow the diet and exercise program given to you by
your health care provider
 Instruct the patient to take Allopurinol after meals to
Patient Teaching:
decrease stomach upset.
 Drinking extra fluids while you are taking Allopurinol is
recommended

ZINC OXIDE
NAME OF DRUG
(Calmoseptine Ointment)
ACTION/KINETICS  .Calmoseptine Ointment is an analgesic,
antiseptic, antipruritic, and skin protectant
 combination
Contraindicated if:
 if pregnant, planning to become pregnant, or are
breast-feeding
CONTRA-  if taking any prescription or nonprescription
INDICATIONS medicine, herbal preparation, or dietary
supplement
 Have allergies to medicines, foods, or other
substances
 Avoid getting this medication in your mouth or
eyes.
SPECIAL
 Avoid applying other skin medications on the
CONCERNS
same treatment area with zinc oxide, unless your
doctor has told you to.
Seek medical attention right away if any of these side
effects occur:
SIDE EFFECTS  Allergic reactions (rash; hives; itching; difficulty
breathing; tightness in the chest; swelling of the
mouth, face, lips, or tongue).
DRUG  No specific interactions with Calmoseptine
INTERACTIONS Ointment are known at this time.
 Apply enough of this medication to cover the
DOSAGE entire area to be treated as prescribe by the
physician.
NURSING CONSIDERATIONS
Administration:  Topical
 Assess patient for any adverse reaction.
 Assess for any signs of infection such as redness
Assessment:
and warmth or oozing skin lesions. Report
immediately to the physician.
 Teach and instruct patient the proper
administration of the medication
Patient Teaching:
 Instruct patient for proper hygiene before and after
administering the medication

ROCEPHIN®
NAME OF DRUG
(ceftriaxone sodium)
ACTION/KINETICS  Anti infective
CONTRA-  .Contraindicated in patients with known allergy to
INDICATIONS the cephalosporin class of antibiotics.
 Patients with renal failure normally require no
adjustment in dosage when usual doses of
ceftriaxone are administered, but concentrations
SPECIAL of drug in the serum should be monitored
CONCERNS periodically. If evidence of accumulation exists,
dosage should be decreased accordingly.
 Should be given cautiously to penecillin sensitive
patients.
 LOCAL REACTIONS - pain, indurations and
tenderness
 HYPERSENSITIVITY - rash. Less frequent was
pruritus, fever or chills.
SIDE EFFECTS
 GASTROINTESTINAL - diarrhea. nausea or
vomiting,
 CENTRAL NERVOUS SYSTEM - headache or
dizziness
 Must not be co-administered with calcium-
containing IV solutions, including continuous
DRUG
calcium-containing infusions such as parenteral
INTERACTIONS
nutrition, in neonates because of the risk of
precipitation of ceftriaxone-calcium salt.
DOSAGE  1-2 gr every 12 hrs

NURSING CONSIDERATION
Administration: May be administered intravenously or intramuscularly
Before therapy with ceftriaxone is instituted, careful inquiry
should be made to determine whether the patient has had
Assessment:
previous hypersensitivity reactions to cephalosporines,
Penicillin’s or other drugs.
Skipping doses or not completing the full course of therapy
may (1) decrease the effectiveness of the immediate
Patients Teaching: treatment and (2) increase the likelihood that bacteria will
develop resistance and will not be treatable by ceftriaxone
or other antibacterial drugs in the future.

CELECOXIB
NAME OF DRUG
(Celebrex)
ACTION/KINETICS Non steroidal anti-inflammatory drug (NSAID).
CONTRA- Do NOT use Celebrex if:
INDICATIONS  you are allergic to any ingredient in Celebrex
 you have recently had or will be having bypass
 heart surgery
 you have severe liver problems
 you are in the last 3 months of pregnancy
 nonsteroidal anti-inflammatory drug (NSAID) (eg,
ibuprofen)
Before using Celebrex :
Tell your doctor or pharmacist if you have any medical
conditions, especially if any of the following apply to you:
 Pregnant, planning to become pregnant, or are
breast-feeding
 Taking any prescription or nonprescription
SPECIAL medicine, herbal preparation, or dietary supplement
CONCERNS  Have allergies to medicines, foods, or other
substances
 History of kidney or liver disease, diabetes, or
stomach or bowel problems (eg, bleeding,
perforation, ulcers)
 History of swelling or fluid buildup, asthma, growths
in the nose (nasal polyps), or mouth inflammation
Seek medical attention right away if any of these side
effects occur:
 Abdominal pain
 Diarrhea
SIDE EFFECTS  Headache
 Indigestion
 Nausea
 respiratory infection
 sinus inflammation
 Anticoagulants risk of stomach bleeding may be
increased
 Fluconazole, may increase the risk of Celebrex 's
side effects
DRUG
 Cyclosporine, lithium, methotrexate, or quinolones
INTERACTIONS
the risk of their side effects may be increased by
Celebrex
 Angiotensin-converting enzyme (ACE) inhibitors
(their effectiveness may be decreased by Celebrex
 Recommended daily dose is 200 milligrams, taken
DOSAGE
as a single dose or in 100-milligram doses 2x a day.
NURSING CONSIDERATIONS
Administration:  Oral
Assessment:  Assess patient for any adverse reaction.
 Assess for any signs of infection such as redness
and warmth or oozing skin lesions. Report
 immediately to the physician
 .Patients should be advised to stop the drug
immediately if they develop any type of rash and
contact their physicians as soon as possible.
 Patients should promptly report signs or symptoms
of unexplained weight gain or edema to their
physicians.
 Patients should be informed of the warning signs
and symptoms of hepatotoxicity (e.g., nausea,
fatigue, lethargy, pruritus, jaundice, right upper
Patient Teaching:
quadrant tenderness, and "flu-like" symptoms).
Patients should be instructed that they should stop
therapy and seek immediate medical therapy if
these signs and symptoms occur.
 Patients should be informed of the signs and
symptoms of an anaphylactoid reaction (e.g.
difficulty breathing, swelling of the face or throat).
 Patients should be informed that in late pregnancy
Celebrex should be avoided because it may cause
premature closure of the ductus arteriosus.

BISACODYL
NAME OF DRUG
(Dulcolax)

Bisacodyl is a stimulant laxative. Use to treat constipation

ACTION/KINETICS
and to cause evacuation of the colon.
 Contraindicated if:
 you are allergic to any ingredient in Dulcolax
Suppositories
CONTRA-
 you have severe stomach pain; appendicitis; severe
INDICATIONS
constipation; stomach, intestinal, or rectal bleeding;
or intestinal blockage
 you are having abdominal surgery

 Do not use for longer than 1 week without checking

with your doctor.
 Do not take additional laxatives or stool softeners
with Dulcolax Suppositories.
 Rectal bleeding or failure to have a bowel
movement after use of a laxative may be a sign of a
serious condition. Stop use and contact your doctor.
SPECIAL  If you develop nausea, vomiting, or stomach pain,
CONCERNS stop using Dulcolax Suppositories.
 If you notice a sudden change in bowel habits that
lasts for 2 weeks or more, do not continue using
Dulcolax Suppositories.
 Use Dulcolax Suppositories with caution in the
ELDERLY; not recommended for use in CHILDREN
younger than 6 years old; safety and effectiveness
in these children have not been confirmed.

Seek medical attention right away if any of these side

effects occur:
 Cramps; faintness; stomach discomfort.
 Weakness, increased sweating, and convulsions
SIDE EFFECTS
(seizures) may be especially likely to occur in
elderly patients, since they may be more sensitive
than younger adults to the effects of rectal
laxatives.

DRUG  No specific interactions with Dulcolax are known at

INTERACTIONS this time.

DOSAGE  10 mg single dose

NURSING CONSIDERATIONS
Administration:  Rectal

Assessment:  Assess patient for any adverse reaction

Patient Teaching:  Teach and instruct patient Follow your doctor's
 orders if this laxative was prescribed.

 Follow the manufacturer's package directions if you

are treating yourself

NUBAIN®
NAME OF DRUG
(Nalbuphine Hydrochloride)
NUBAIN (nalbuphine hydrochloride) is a synthetic opioid
ACTION/KINETICS
agonist-antagonist analgesic of the phenanthrene series.
CONTRA-  NUBAIN should not be administered to patients
 who are hypersensitive to nalbuphine
INDICATIONS hydrochloride, or to any of the other ingredients in
NUBAIN.
 NUBAIN should be administered as a supplement
to general anesthesia only by persons specifically
trained in the use of intravenous anesthetics and
SPECIAL
management of the respiratory effects of potent
CONCERNS
opioids.
 Naloxone, resuscitative and intubation equipment
and oxygen should be readily available.
Cardiovascular
 Hypertension, HPN, bradycardia, tachycardia.
Gastrointestinal
 Cramps, dyspepsia, bitter taste.
Respiratory
SIDE EFFECTS  Depression, dyspnea, asthma.
Dermatologic
 Itching, burning, urticaria.
Miscellaneous
 Speech difficulty, urinary urgency, blurred vision,
flushing and warmth.
DRUG  NUBAIN is physically incompatible with nafcillin and
INTERACTIONS keterolac.
 The recommended single maximum dose is 20 mg,
DOSAGE
with a maximum total daily dose of 160 mg.
NURSING CONSIDERATIONS
 Administered subcutaneously, intramuscularly or
Administration:
intravenously.
 Asses for time, location and intensity of pain before
administering medication.
Assessment:
 Assess for BP, pulse and respiration before and
during administration
 Advice patient to cal for assistance when
ambulating for the medication may case
drowsiness.
Patient Teaching:  Caution patient to change positions slowly to
minimize orthotastic hypotention
 Encourange patient to turn, cough and breathe
every 2hrs to prevent atelectasis.

TRAMADOL
NAME OF DRUG
(Ultram)
Tramadol hydrochloride tablets are indicated for the
ACTION/KINETICS management of moderate to moderately severe pain in
adults.
  Patients who have previously demonstrated
CONTRA-
hypersensitivity to Tramadol,
INDICATIONS
 Contra indicated for pregnant woman.
 Impaired renal function results in a decreased rate
SPECIAL and extent of excretion of Tramadol dosing
CONCERNS reduction is recommended
 Use cautiously with geriatric patient.
Adverse Reactions for Tramadol Hydrochloride
Dizziness/Vertigo Pruritus
Nausea CNS Stimulation
SIDE EFFECTS Constipation Sweating
Headache Dyspepsia
Vomiting Dry Mouth
Diarreah Asthenia
Use with Carbamazepine
 Reduced analgesic effect of Tramadol
DRUG
Use with Quinidine
INTERACTIONS
 increased concentrations of Tramadol and reduced
concentrations of M1
Adults (17 years of age and over)
DOSAGE  The total daily dose may be 50 mg as tolerated
every 3 days to reach 200 mg/day (50 mg q.i.d.).
NURSING CONSIDERATIONS
Administration:  Oral
 Check for the patients condition
Assessment:
 Assess for adverse reaction
 Tramadol tablets may impair mental or physical
abilities required for the performance of potentially
hazardous tasks
 Should not be taken with alcohol containing
beverages.
 Tramadol tablets should be used with caution when
Patient Teaching: taking medications such as tranquilizers, hypnotics
or other opiate containing analgesics.
 The patient should understand the single-dose and
24-hour dose limit and the time interval between
doses, since exceeding these recommendations
can result in respiratory depression, seizures and
death.

HYDROXYZINE
NAME OF DRUG
(Atarax, Ucerax)
 Suppresses activity in key regions of sub cortical
ACTION/KINETICS
areas of CNS
CONTRA-
 Hyper sensitivity to hydroxyzine
INDICATIONS
SPECIAL  Reduce dosage with used concomitantly with CNS
CONCERNS depressants.
 Dry mouth, drowsiness, tremor, convulsion, and
SIDE EFFECTS
involuntary motor activity.
 The concomitant administration of tramadol and
DRUG
sedative hypnotics increases the risk of CNS and
INTERACTIONS
respiratory depression.
DOSAGE  25ml
Nursing Consideration
Administration:  Parenteral

 Assess patient condition before therapy and re

Assessment: assess regularly thereafter.
 Monitor for drug induce adverse reaction.

 Instruct patient to take 1 hour after meal or 2 hours

before meal to facilitate absorption.
Patient Teaching:
 Advice patient to avoid alcohol and other products
containing CNS depressants.

CIPROFLOXACIN
NAME OF DRUG
(Arflox, C-flox, Ciloxan)
 Inhibits bacterial DNA gyrase thus preventing
ACTION/KINETICS
replication in susceptible.
CONTRA-
 Hypersensitivity to quinolones.
INDICATIONS
 Severe renal impairment (createnine) clearance
SPECIAL less than 30ml/min/1.73m² or serum creatinine
CONCERNS concentration greater than 2mg/100ml) should not
receive 1000mg XR tablet.
 Nausea, diarrhea, vomiting, transient increase in
SIDE EFFECTS transaminases and rush anorexia Dizziness and
headache.
DRUG  Omeprazole, theophyline. Certain NSAID (but not
INTERACTIONS ASA) can provoke convulsions.
DOSAGE  250-500mg.
Nursing Consideration
Administration  Orally.
 Assess patient for signs and symptoms of
infection before and during treatment.
Assessment
 Monitor hematologic, electrolyte and hepatic
status.
 Instruct patient to take all medication prescribed
Client/family for the length of time ordered.
teaching  Advise patient to report occurrence of any adverse
reaction.

FOLIC ACID
NAME OF DRUG
Apo-folic,folate,folvite,novofolacid,vitB
 Stimulates the production of RBC,WBC and
ACTION/KINETICS
platelets.
  Uncorrected pernicious, a plastic, or normocyctic
CONTRA-
anemias(neurologic damage will progress despite
INDICATIONS
correction of hematologic abnormalities.)
SPECIAL  Do not confuse folic acid with folinic acid
CONCERNS (leucovorin calcium.)
 Rashes,irritability,difficulty sleeping malase
SIDE EFFECTS
confusion and fever
 Pyrimethamine,metotrexate,trimethoprime and
DRUG triamterene prevent the activation of folic
INTERACTIONS acid(leucovorin should be used instead to treat
overdoses these drugs.)
DOSAGE  5mg

Nursing Consideration
Administration  Orally
 Assess patient for signs of megaloblastic anemia
before and periodically trough out therapy.
Assessment
 Monitor plasma folic acid level, hemoglobin,
hematocrit, and reticulosyte count before and
periodically during therapy.
 Encourage patient to comply with diet
Client/family recommendation of healthcare professional.
teaching  Explain that folic acid may make urine more
intensely yellow.

NAME OF DRUG OMEPRAZOLE

(Omepron)
  Suppresses gastric secretion by inhibiting
ACTION/KINETICS hydrogen/potassium ATPase enzyme system in the
gastric parietal cell.
 Hypersensitivity,combination therapy with
CONTRA-
clarithromycin should not be used in patient with
INDICATIONS
hepatic impairment.
SPECIAL  Should be taken before meals and should be
CONCERNS swallowed whole.
 Angina, tachycardia, bradycardia, palpitation
SIDE EFFECTS
headache, dizziness, rash, and abdominal pain

 Clearance of benzodiazepines may be decreased

DRUG
period serum concentrations of clarithromycin and
INTERACTIONS
omeprazole maybe increased.
DOSAGE  40mg

Nursing Consideration
Administration  Orally
 Assess GI system:bowel sounds hourly,abdomen
for pain and swelling,loss of appetite.
Assessment
 Monitor hepatic enzyme:AST,ALT increased
alkaline phosphatase during treatment.

Client/family  Take as directed before eating.

teaching  Do not crushed or chew capsules.

NAME OF DRUG NITROFURACONE

(Furacin ointment jelly solcoserv)
  It is bactericidal at high concentrations,not cytotoxic
ACTION/KINETICS
and does not cause pain.
CONTRA-
 Hypersensitivity,large areas burns ,ulceration
INDICATIONS
SPECIAL  Discontinue if irritation develops. Renal impairment
CONCERNS and external ear or perforated eardrum.
SIDE EFFECTS  Contact dermatitis,super infection

 Probenecid and sulfinpyrazone prevent high urinary

DRUG
concentrations.
INTERACTIONS
 Antacids may decrease absorption

DOSAGE  Dosage depends on the size of the affected area.

Nursing Consideration
Administration  topical

 Assess patients condition before therapy and regularly

Assessment thereafter to monitor drug effectiveness.
 monitor intake and output ratios

Client/family
teaching
 CHLORPHENAMINE, DEXTROMETHORPAN/
NAME OF DRUG
GUAIFENESIN/ PARACETAMOL
(Dynatussin)

 Reduces viscosity of tenacious secretions by

ACTION/KINETICS
increasing respiratory tract fluid.
 Hypersensitivity.some products contain alcohol
CONTRA-
and should be avoided in patient with known
INDICATIONS
intolerance
SPECIAL
CONCERNS
 Dizziness,headache,nausea,diarrhrea,stomach
SIDE EFFECTS
pain and vomiting.
DRUG
 None significant
INTERACTIONS
DOSAGE  200-400mg

Nursing Consideration
Administration  Orally
 Assess lung sounds, frequency and type of cough
Assessment and character of bronchial secretions periodically
during therapy.
 Instruct patient to cough effectively. Patient should
sit upright and take several deep breaths before
Client/family
attempting to cough.
teaching
 inform patient that drug may occasionally cause
dizziness