Group 5 13B

End Stage Renal Failure Secondary to

Diabetes Nephropathy
 CHAPTER 1
INTRODUCTION
Diabetes Mellitus is the leading cause of end stage renal disease (ESRD) and
renal failure in the United States. Diabetic nephropathy affects 20%-30% of
those with type 1 diabetes 20 years after onset. Although less than 20% of
clients with ESRD have type 2 diabetes (NIDDK,2004).
There are about 6,500 yearly deaths in the country secondary to various
kidney diseases (Kidney Center)
A number of underlying diseases can cause progressive renal failure. Chronic
glomerulonephritis (CGN) is the most common cause (47 percent) of ESRD in
Filipinos. Other causes include chronic pyelonephritis (17 percent), diabetes
mellitus (13 percent), and hypertensive nephrosclerosis (5 percent) (Kidney
Center of the Philippines, Medical City 1975-1981).
er of the Philippine, Medical City 1995-2001)
 OBJECTIVES

• General Objective:

  Within our 3-day clinical exposure at Davao Doctors Hospital,

The group will be able to assess, analyze, plan for nursing
intervention, implement and evaluate the case of our patient who
has End Stage Renal Failure (ESRD) secondary to Diabetes Mellitus
Type 2 secondary to Diabetes Nephropathy.
Specifically our objective is to:
• Establish rapport with the patient and family;
• Gather all important data from the patient himself, from his family
and from the chart as basis for study;
• Make a comprehensive assessment of the patient;
• Enumerate the necessary laboratory test undergone by the patient
for the diagnosis and treatment of the disease;
• To know the anatomy and physiology of metabolic and
renal system;
• Know the pathophysiology of the disease process;
• Identify the different medical/surgical treatment done for
the patient;
• Identify different drugs that is used for treatment with their
specific actions, indications, dose , interactions,adverse
reactions and nursing implications and responsibilities;
• Formulate a plan of care which will based on identified
actual and potential health problem;
• Give recommendations and health teachings based on the
identified actual and potential health problem;
 DEFINITION OF TERMS

• Chronic Kidney Disease. Is long-standing, progressive

deterioration of renal function.
• Dialysis. Done to the patient having chronic renal disease
incapable of cleansing the blood and disposing waste in the
body
• Diabetes mellitus. One of the factor why person acquire
renal failure
• Edema. Is an abnormal accumulation of fluid beneath the
skin or in one or more cavities of the body
• Hypertension. Cause by the malfunction of the kidney as
the result of renal failure.
• Lifestyle. Precipitating factors that causes person to have
chronic renal failure
 CHAPTER II
PATIENT’S PROFILE
A. Personal Profile
• Patient’s name: Mr. X
• Age: 54 years old
• Sex: Male
• Nationality: Filipino
• Religion: Roman Catholic
• Occupation: Businessman
• Civil Status: Married
• Date of Admission: February 20, 2010
• Attending Physician: Dr. Maglana; Dr. Isaguirre; Dr. Coching
• Discharge Diagnosis: ESRD 2˚ DM nephropathy DM type II
• B. Medical History
• When Mr. X was 26 years old, he was diagnosed
with Diabetes Mellitus Type 2. Five years ago, Mr.
X was admitted to St. Luke’s Medical Center and
was diagnosed with benign prostatic hyperplasia.
In the year 2003, Mr. X undergone 3 consecutive
eye operations on the same eye, the first
operation was due to a blood clot, the second and
third operations were due to ocular bleeding. Last
July 2009, Mr. X was admitted twice at St. Luke’s
Medical Center due to edema of the lower
extremities. He was diagnosed to have a
nephropathy secondary to DM. On the same
month and year, he was ordered to undergo
hemodialysis and still continues up to present.
• C. Present Illness
• Two days prior to admission (PTA), Mr. X
experienced body weakness and joint pains in
the lower extremities. BP was taken at home.
No consultation done because the condition
was tolerable. One day PTA, the patient still
experienced body weakness with headache
and nausea. Consultation was done; BP was
taken with medications given. Hours prior to
admission, body weakness still noted and
prompted admission at Davao Doctors
Hospital.
• D. Comprehensive Assessment
• 1.Family background
• Mr. X, 54, years old, one of the six offspring of
Mr. XY and Mrs. XX. His mother has a history
of hypertension and died due to complicated
cardiac problem. His father has a diabetes
mellitus (DM) and died due to cardiac arrest.
Among his five siblings, one of them has DM
and one has hypertension. Among them, Mr.
X is the only one who has renal failure.
• 2.Effects / Expectations of Illness to Family and
Self:
• Mr. X, his wife and his 3 children are very worried
about his present condition. Even though they
know that his condition is already complicated,
they still hope for his recovery. They want Mr. X
to be discharged from the hospital as soon as
possible this is because it has been a long time
that they've staying there. This situation had led
his family members to become more conscious of
there health. They've learned that no matter how
wealthy you are, you can never escape any forms
of illnesses.
• 3. History of Past Illness:
• When Mr. X was 26 years old, he was diagnosed
with Diabetes Mellitus Type 2. Five years ago, Mr.
X was admitted to St. Luke’s Medical Center and
was diagnosed with benign prostatic hyperplasia.
In the year 2003, Mr. X undergone 3 consecutive
eye operations on the same eye, the first
operation was due to a blood clot, the second
and third operations were due to ocular bleeding.
Last July 2009, Mr. X was admitted twice at St.
Luke’s Medical Center due to edema of the lower
extremities. He was diagnosed to have a
nephropathy secondary to DM. On the same
month and year, he was ordered to undergo
hemodialysis and still continues up to present.
• 4. History of Present Illness:
• Two days prior to admission (PTA), Mr. X
experienced body weakness and joint pains in
the lower extremities. BP was taken at home.
No consultation done because the condition
was tolerable. One day PTA, the patient still
experienced body weakness with headache
and nausea. Consultation was done; BP was
taken with medications given. Hours prior to
admission, body weakness still noted and
prompted admission at Davao Doctors
Hospital.
 GUIDELINES PATIENT DAY 1 DAY 2 DAY 3

I. Mental Status

a. state of mental The patient is The patient is conscious, The patient is conscious, The patient is conscious,
consciousness conscious, alert and and coherent and coherent and coherent
coherent

b. orientation The patient is oriented The patient is oriented to The patient is oriented to The patient is oriented to
to person, time, place person, time, place and person, time, place and person, time, place and
and events occurring in events occurring in the events occurring in the events occurring in the
the environment environment environment environment

c. intellectual capacity The patient is able to The patient is able to The patient is able to The patient is able to
understand and understand and understand and understand and
comprehend instructions comprehend instructions comprehend instructions comprehend instructions
and commands and commands and commands and commands

d. vocabulary level The patient is able to The patient is able to The patient is able to The patient is able to
speak and understand speak and understand speak and understand speak and understand
his vernacular, the his vernacular (Visayan), his vernacular (Visayan), his vernacular (Visayan),
National Language and the National Language the National Language the National Language
the Universal language and the Universal and the Universal and the Universal
language language language
e. attention span The patient has a long The patient has a short The patient has a long The patient has a long
attention span attention span with 5-7 attention span, with 15- attention span, with 15-
min concentration. 20 minute concentration 20 minute concentration

f. ability to understand The patient is able to The patient is able to The patient is able to The patient is able to
respond to questions, respond to questions, respond to questions, respond to questions,
commands/ instructions commands/ instructions commands/ instructions commands/ instructions
with coherence with coherence with coherence with coherence

II. Status of Special

Senses

a. auditory perception The patient is able to The patient is able to The patient is able to The patient is able to
hear moderate to loud hear moderate to loud hear moderate to loud hear moderate to loud
sounds and interpret sounds and interpret sounds and interpret sounds and interpret
auditory stimuli auditory stimuli auditory stimuli auditory stimuli
appropriately appropriately appropriately appropriately

b. visual perception The patient is able to The patient is The patient is The patient is
see near and far nearsighted, able to nearsighted, able to nearsighted, able to
objects, interpret the interpret visual stimuli interpret visual stimuli interpret visual stimuli
visual stimuli clearly with the use of clearly with the use of clearly with the use of
appropriately and has eyeglasses. eyeglasses. eyeglasses.
visual acuity of 20/20.
c. speech perception The patient is able to The patient is able to The patient is able to The patient is able to
speak clearly with speak clearly with speak clearly with speak clearly with
coherence coherence coherence coherence

d. tactile perception The patient is able to The patient is able to The patient is able to The patient is able to
feel different textures feel different textures feel different textures feel different textures
and temperature, able to and temperature, able to and temperature, able to and temperature, able to
identify the origin of identify the origin of identify the origin of identify the origin of
stimuli. stimuli. stimuli. stimuli.

e. olfactory perception The patient is able to The patient is able to The patient is able to The patient is able to
smell and identify smell and identify smell and identify smell and identify
different aromas and different aromas and different aromas and different aromas and
odors appropriately odors appropriately odors appropriately odors appropriately

III. Motor Ability

a. current mobility The patient can freely The patient can't move The patient can't move The patient can't move
move both upper and freely, with easy freely, with easy freely, with easy
lower extremities, able fatigablity, with weak fatigablity, with weak fatigablity, with weak
to walk, stand and sit movement of upper and movement of upper and movement of upper and
without support. lower extremities, in lower extremities,in lower extremities,in
complete bed rest with complete bed rest with complete bed rest with
out bathroom privileges. out bathroom privileges out bathroom privileges
b. posture The patient can stand The patient is in The patient is in The patient is in
straight, sit erect and complete bed rest, complete bed rest, complete bed rest,
has proper gait. positioned in high back positioned in high back positioned in high back
rest. rest. rest.

c. range of motion The patient is able to flex The patient is able to flex The patient is able to flex The patient is able to flex
and extend both upper and extend both upper and extend both upper and extend both upper
and lower extremities and lower extremities but and lower extremities but and lower extremities but
with weak movements with weak movements with weak movements

d. muscle and nervous The patient has The patient has a weak The patient has a weak The patient has a weak
status moderate to strong muscular movement with muscular movement with muscular movement with
muscular movements. a musculoskeletal status a musculoskeletal status a musculoskeletal status
With a musculoskeletal score of 3 points = score of 3 points = score of 3 points =
status score of 5 points = dependent on others, dependent on others, dependent on others,
ability to move with muscular strength of with muscular strength of with muscular strength of
independently. With 3= active movement 3= active movement 3= active movement
muscular strength of 5= against gravity with against gravity with against gravity with
active movement against evident fatigability evident fatigability. evident fatigability.
gravity without evident
fatigue.
e. loss of extremities The patient has The patient has The patient has The patient has
complete extremities complete extremities complete extremities complete extremities

IV. Body Temperature

a. ranges Tympanic temperature Tympanic temperature Tympanic temperature Tympanic temperature

ranges from 37 – 37. 5 ranges from 36.0– 36.8 ranges from 36.0-36.5 ranges from 36.0 – 36. 7
degrees centigrade degrees centigrade degrees centigrade degrees centigrade

V. Respiratory Status

a. characteristics The patient has The patient has The patient has The patient has
respiratory rate range of respiratory rate range of respiratory rate range of respiratory rate range of
16-20 cpm, with equal 21-28 cpm, with equal 23-26 cpm, with equal 20-25 cpm, with equal
depth of respiration depth of respiration depth of respiration depth of respiration

b. use of respiratory The patient has no The patient has no The patient has no The patient has no
aids oxygen inhalation, oxygen inhalation, oxygen inhalation, oxygen inhalation,
tracheostomy tube or tracheostomy tube or tracheostomy tube or tracheostomy tube or
endotracheal tube endotracheal tube endotracheal tube endotracheal tube

c. interference with The patient has clear The patient has clear The patient has clear The patient has clear
respiration breath sounds on both breath sounds on both breath sounds on both breath sounds on both
lungs, without lungs, without lungs, without lungs, without
tracheobronchial tracheobronchial tracheobronchial tracheobronchial
secretions secretions secretions secretions
VII. Nutritional Status

a. condition of the The patient has pinkish The patient has pale The patient has pale The patient has pale
buccal cavity buccal cavity with buccal cavity with buccal cavity with buccal cavity with
enough moisture. dryness noted. dryness noted. dryness noted.

b. digestion of food The patient has appetite, The patient has appetite, The patient has appetite, The patient has appetite,
able to consume whole able to consume whole able to consume whole able to consume whole
amount of food served amount of food served amount of food served amount of food served

c. weight 54 kg 49kg 49 kg 49 kg

VIII. Elimination Status

a. bowel The patient is able to The patient is able to The patient is able to The patient is able to
defecate 2 times a day, defecate 2 times a day, defecate 2 times a day, defecate 2 times a day,
with soft stool, golden with soft stool, golden with soft stool, golden with soft stool, golden
brown in color, aromatic brown in color, aromatic brown in color, aromatic brown in color, aromatic

b. bladder The patient is able to The patient is able to The patient is able to The patient is able to
urinate freely, with urine urinate freely with urine urinate freely with urine urinate freely with urine
output of 30-40 ml/hour output of 20 cc for 8 output of 50 cc for 8 output of 40 cc for 8
depending on the intake hours with a total intake hours with a total intake hours with a total intake
and patient's weight, with of 650 cc, with of 450 cc , with of 540 cc, with
transparent urine transparent urine, dark transparent urine, dark transparent urine, dark
characteristics ranging amber in color, with amber in color, with amber in color, with
from yellow to dark aromatic smell aromatic smell aromatic smell
amber, with aromatic
c. abnormalities The patient has proper The patient has The patient has The patient has
excretory process decreased urine output. decreased urine output. decreased urine output.

IX. State of Skin And

Appendages

a. skin The patient has intact The patient has pale, The patient has pale, The patient has pale,
and fair skin, with even cold and dry skin, with cold and dry skin, with cold and dry skin, with
distribution of decreased skin turgor, decreased skin turgor, decreased skin turgor,
temperature, with with edema noted on with edema noted on with edema noted on
proper moisture, with both lower extremities, both lower extremities, both lower extremities,
normal skin turgor with round- shaped with round- shaped with round- shaped
hyperpigmentations on hyperpigmentations on hyperpigmentations on
both tibial area, with both tibial area, with both tibial area, with
small dry necrosed small dry necrosed small dry necrosed
tissue on the right pedal tissue on the right pedal tissue on the right pedal
phalange. phalange. phalange.
b. hair The patient has fine, The patient has fine, The patient has fine, The patient has fine,
strong and silky hair, strong and dry hair, with strong and dry hair, with strong and dry hair, with
with even distribution, even distribution, with even distribution, with even distribution, with
with normal porosity. decreased porosity. decreased porosity. decreased porosity.

c. nails The patient has well The patient has well The patient has well The patient has well
trimmed nails, properly trimmed nails, properly trimmed nails, properly trimmed nails, properly
keratinized, with pink keratinized, with pale keratinized, with pale keratinized, with pale
nail beds. nail beds. nail beds. nail beds.

X. State of Physical
Rest and Comfort

a. sleep/rest pattern The patient is able to The patient is able to The patient is able to The patient is able to
sleep 6-8 hours a day sleep 6-8 hours a day sleep 6-8 hours a day sleep 6-8 hours a day
with resting time in the with resting time in the with resting time in the with resting time in the
middle of the day middle of the day middle of the day middle of the day

b. presence of The patient is The patient is The patient is The patient is

pain/discomfort comfortable. comfortable. comfortable. comfortable.

c. use of supportive aids No use of supportive No use of supportive No use of supportive No use of supportive
aids aids aids aids
XI. Emotional Status

a. emotional reaction The patient is able to The patient has a fair The patient has a fair The patient is able to
react appropriately to disposition. He feels disposition. He feels react appropriately to
situations, with happy irritable, irritable and seldom situations, with happy
disposition smiles. disposition

b. body image The patient has a high The patient has a high The patient has a high The patient has a high
self-esteem and is self-esteem and is self-esteem and is self-esteem and is
confident with his body confident with his body confident with his body confident with his body
structures structures structures structures

c. ability to relate to The patient is The patient is The patient is The patient is
others cooperative, with less cooperative, with less cooperative, with less cooperative, with less
interaction to people interaction to people interaction to people interaction to people
around him. around him. around him. around him.
 E. Diagnosis/ Impression
ESRD 2˚ DM nephropathy DM type II
 CHAPTER III
Review of Anatomy and Physiology

• The anatomy and physiology of the human kidney, evolved over millennia,
enable this organ to excrete waste, regulate homeostatic processes and
produce important hormones.
• One of the most complex, beautifully “engineered” organs of the human
body, the kidneys perform several essential tasks including the excretion of
waste products, the maintenance of homeostatic balance in the body and
the release of important hormones. To achieve this, human kidneys have a
highly developed, superbly refined anatomy and physiology.
• Location and Basic Structure of the Kidneys
• The kidneys are located near the vertebral column at
the small of the back; the left kidney lying a little
higher than the right. Each is identical in structure and
function. They are bean-shaped, about 10 cm long and
6.5 cm wide. Each kidney comprises an outer cortex
and an inner medulla. The kidney is supplied with
oxygenated blood via the renal artery and drained of
deoxygenated blood by the renal vein. In addition,
urine produced by the kidney as part of its excretory
function, drains out via narrow “tubules” and the
ureter, in turn connected to the bladder.
• The Nephron
• The main functional unit of the kidney is the nephron.
There are approximately one million nephrons per
kidney. The role of nephrons is to make urine by:
• * Filtering blood of small molecules and ions such as
water, salt, glucose and other solutes including urea.
Large “macromolecules” like proteins are untouched.
• * Recycling the required quantities of useful solutes
which then re-enter the bloodstream. (A process called
reabsorption)
• * Allowing surplus or waste molecules/ions to flow
from the tubules/ureter as urine.
• Filtration and Reabsorbtion in the Kidneys
• During progress through the nephron, some solutes like sodium
chloride, potassium and glucose are reabsorbed, along with water,
back into the bloodstream. This maintains a correct balance of
these chemicals within the blood, assisting blood pressure
regulation, for example. The filtration and reabsorbtion of glucose
within the kidneys also helps to maintain correct levels of vital
blood sugars. When this regulation breaks down very serious health
consequences can follow.
• Urea and uric acid are nitrogen containing waste products from
metabolic processes in the body. These substances are potentially
toxic and are partially excreted by the kidneys to maintain good
health. Interestingly, of the filtrate which enters each nephron from
the blood, only about 1% actually leaves the body as urine because
of the various reabsorbtion mechanisms driven by osmosis,
diffusion, and active transport.
• Tubular Secretion in the Kidneys
• Another, less familiar, mechanism for urine production in the
kidneys is tubular secretion. Specialized cells move solutes directly
from the blood into the tubular fluid. For example, hydrogen and
potassium ions are secreted directly into the tubular fluid. This
process is “coupled” or balanced by the re-uptake of sodium ions
back into the blood.
• Tubular secretion of hydrogen ions, augmented by control of
bicarbonate levels, is important in maintaining correct blood pH.
When the blood is too acidic (acidosis) more hydrogen ions are
secreted. If the blood becomes too alkaline (alkalosis), hydrogen
secretion is reduced. In maintaining blood pH within normal limits
(about 7.35–7.45) the kidney can produce urine with pH as low as
that of acid rain or as alkaline as baking soda!
• The Kidney as an Endocrine Gland
• In addition to its excretory and homeostatic roles, the
kidneys also release two important hormones into the
blood. These are:
• * Erythropoietin which acts on bone marrow to
increase the production of red blood cells
• * Calcitriol which promotes the absorption of
calcium from food in the intestine and acts directly on
bones to shift calcium into the bloodstream.
• Finally the kidney produces the enzyme renin, an
important regulator of blood pressure.
 CHAPTER IV
A.Etiology
PATHOPHYSIOLOGY
Pre-disposing Factors Actual Rationale

Increasing Age Mr. is 54 years old. Among older adult ( 24-64 y/o) and elderly person, the
presentation and course of renal failure may be altered
because of age-related changes in the kidney and
occurrent medical conditions . Normal aging is associated
with a decline in the GFR and subsequently with reduced
homeostatic regulation under stressful conditions. This
reduction of GFR makes these persons more susceptible
to the detrimental effects of nephrotoxic drugs and other
medical conditions.( Porth, 2005)

Sex The client is a male. ESRD is more prevalent in men, 54 % of ESRD patients
are men whereas 46% are women. This also refers to the
dominance of males in the relapse of toxins (Nowak,
2005). In both study populations, males were more likely
to have ESRD due to hypertension.
( http://www.niddk.nih.gov/fund/reports/womenrd/poster/p
oster5.htm)
Race Mr. is from an Asian ethnic Renal disease is more common in patients of Asian ethnic
group( Filipino) origin than white Caucasians in the United Kingdom. The
incidence rate of end-stage renal failure expressed for the
estimated population of pts. with diabetes Mellitus in
Asian ethnics was 486.6 cases per M person years
compared to 35.6 in white caucasians. The high incidence
of end stage renal failure had secondary to DM for most
patients in Asian ethnic group. (Bullock, 2000)

Genetics Maternal side: Hypertension (+)
Paternal side: Diabetes Mellitus 2 (+)
Diabetes Mellitus from a genetic predisposition (i.e.
diabetogenic genes), a hypothetical triggering event that
involves an environmental agent that incites an immune
response and immunologically mediated beta cell
destruction. Much evidence has focused on the inherited
major compatibility complex ( MHC) genes that encode
three human leukocyte antigens ( HLA_DP, HLA_DQ and
HLA_DR) found on the surface of body cells. Insulin gene
regulating eta cell replication and function has been
identified on chromosome 11. (Porth, 2005)
Precipitating Factors Actual Rationale

Lifestyle(diet, exercise,) Mr. loves to eat salty, fatty & sugary Foods that are high in calories (saturated fats), lack of
foods such as antioxidants and fibbers as well as high in phosphorus,
cured meats (ham, sausage, bacon, potassium, and
corned beef,), chicken and pork viand, sodium can lead to a high probability of  occurrent of ma
cheese and butter, coke soda(more often ny a diseases such as renal failure. These foods can bui
every meal) and coffee. ld up in the bloodstream and cause harm when they can
not be eliminated by the kidneys. ( Mc Cance, 1994)
Mr. has sedentary lifestyle with no or
A lack of physical activity is one of the leading
irregular .
causes of preventable death
physical activity. He is an owner of one bi
g transportation company and works only worldwide. It contribute to anxiety, high blood pressure
in computer and papers. and cardiovascular disease due to reduce insulin sensiti
vity, increase blood sugar and cholesterol levels. ( McCa
nce, 1994)

Medications Client usually medicate himself with over The deleterious effects of aspirin and the NSAIDS on
the counter drugs such Paracetamol, the kidney are thought to result from their ability to
mefenamic acid, aspirin, etc. whenever inhibit the vasodilatory effects of prostaglandin ,
he got fever or experience pain. predisposing to ischemia of the renal papillae. (Porth,
2007)
Toxins At 17 year old, Mr. started to drink Toxic substances such as alcohol can damage the
alcohol beverages (beer-240ml) and kidneys by causing a decrease in renal blood flow:
can consumed 14 bottles a day. obstructing urine flow, directly damaging
tubulointerstitial structures, or by producing
hypersensitivity reactions
( Porth, 2007)
Pre-existing factors Actual Rationale
Diabetes Mellitus type2 The client was diagnosed with DM type 2 at Long term complications, which are becoming more
the age of 26 years old and started inducing common as more people live longer and gradually leadt to
insulin injection 2x a day morning & the disabilities of body systems. It appears that increase
evening). This complication was further level of blood glucose may play a role in micro vascular
diagnosed into a more serious condition of complications certainly lad to nephropathy.
diabetic nephropathy and just last year, he Nephropathy or renal disease secondary to diabetic
was diagnosed of ESRD. micro vascular changes in the kidney is a common
complication of diabetes. If blood glucose level are elevated
consistently for a significant period of time, the kidneys
filtration mechanism is stressed, allowing blood proteins to
leak into the urine . As a result, the pressure in the blood
vessels of the kidney increases. It is thought that this
elevated pressure serve as the stimulus for the development
of nephropathy.
Patients with type 2 diabetes develop renal ds. Within
10-15 years after diagnose of diabetes.(Smeltzer, 2008)
Hypertension Mr. has a BP of 120/110 . The kidney is an essential organ in the long term
control of pressure. Hypertension attributed to the
rennin-angiotensin mechanism within the kidney.
Continued high pressure for hypertension destroy the
arteries of the kidneys leading to kidney failure.
(Smeltzer, 2008)

•Symptomatology

Symptomatology Actual Rationale

Neurotic Manifestation Neurotic style is the outward manifestation of the
/
-confusion inability to introspect, learn about one's perception of a
/
-seizures situation, respective role,effect on others' effect on self
-agitation for developing and engaging in more effective bahavior
-inability to concentrate (C. Porth, 2007).
Cardiovascular Manifestation / Due to sodium and water retention
-Hypertension or for activation or renin
-Hyperkalemia angiotensin aldosterone system.
-Edema / Hypertension is the most
-Pulmonary edema important modifiable risk factor for
-Pericarditis end-stage renal disease,
-Hyperlipidemia hyperlipidemia exacerbated by
uncontrolled diabetes mellitus (C.
Porth, 2007).
Anemia / In renal failure, erythropoietin production usually is insufficient to
stimulate adequate RBC production by the bone marrow. The
accumulation of uremic toxins further suppresses RBC
production in the bone marrow, and the cells the are produced
have a shortened life span (C. Porth, 2007).
Nausea and Vomiting / A possible cause of nausea and vomiting is the decomposition
of the urea by the intestinal flora, resulting in a high
concentration of ammonia. PTH increases gastric acid secretion
and contribute to gastrointestinal problems (C. Porth, 2007).
Generalized itching / Pruritus results from the high perspiration owing to decreased
size of the sweat glands and diminished activity of the oil glands
(C. Porth, 2007).
  Decreased levels of active vitamin D lead to a decrease in
Muscle weakness
/ intestinal absorption of calcium with a resultant increase in PTH
levels vitamin D also regulates osteoblast differentiation,
thereby affecting bone matrix formation and mineralization.
 
Weight loss
/ Abnormal breakdown of the nutrients in the body can cause
weight loss(C. Porth, 2007).
• D. Narrative
• Chronic renal failure can result from a number of conditions that
cause permanent loss of nephrons, including diabetes and
hypertension, this may also resulted from different factors both
genetics and environmental agents.
• Typically, the signs and symptoms of chronic renal failure occurs
gradually and do not become evident until the disease is far advanced.
This is because of the amazing compensatory ability of kidneys. Thus,
progression of chronic renal failure occurs in gradual deterioration of
glomerular filtration, tubular reabsorption capacity and endocrine
functions of the kidneys. Four stages had been identified in chronic
renal failure: Diminished renal reserve, renal sufficiency, renal failure
and end – stage renal disease.
• The GFR is considered the best measures of overall function of the
kidneys. Its normal function for young adults is 120-130 mL/ 130
mL/min. In the first stage, Diminished Renal Reserve, GFR drops to
approximately 50% of normal. At this point, the serum BUN and
creatinine levels still are normal , nd no symptoms of impaired renal
function are evident. Because of diminished reserve, development of
azotemia increases with an additional renal insult, due to nephrotoxic
drugs.
• Stage 2- Renal Insufficiency represents a reduction in the GFR to 20%
to 50% of normal. The kidneys initially have tremendous adequate
capabilities. As nephrons are destroyed, the remaining nephrons
undergo changes to compensate for those that are lost. In this process,
remaining nephrons must filter more solutes particles from blood.
Thus, during this stage azotemia, anemia, and hypertension begin to
appear. Furthermore, retard deterioration of renal function leads
kidneys in difficulty eliminating the waste products and makes the
remaining nephrons easily disrupte, after which renal failure
progresses rapidly.
• Renal failure develops when the GFR is less than 20% of normal. At
this point, the kidneys cannot regulate volume and solute
composition , and edema, metabolic acidosis and hyperkalemia
develop. Overt uremia may ensue with neurologic, gastrointestinal and
cardiovascular manifestations.
• End-stage renal disease( ESRD) occurs when the GFR is less than 5% of
normal.All renal functions are severely decreased, and homeostatis is
significantly altered Thus, resulted from multiple organ failure.At this
final phase of renal failure, treatment with dialysis or transplantation is
necessary for survival.
•  
 CHAPTER V
COURSE IN THE WARD/TREATMENT/
INTERVENTIONS
A. Medical
A.1 Doctor’s Order

Date/Time Order

March 3,2010  Decrease Oxygen to PRN

 For chest X-ray portable AP sitting upright

 May sit-up on bed

 N-AC (Flumucil) 600g 1 tab + ¼

 For PFI on Monday

March 5, 2010  Please give another dose of alphanedon (xanon)

11:45am 250µmg 1 tab now

March 6,2010  May do cervical X-ray portable for request

10:20am
11pm  Increase Mesoperem to 500g IV q12* with
supplemental extra dose post HD
March 7,2010
8am May discontinue domperidon

12:30pm  Increase norgesic forte 1 tab TID RTC PC

3am  MIR C- Nephro

 For HD on Tuesday (prior to PPT)

March 8, 2010  Sitaglipitin (Sonuria) 50mg, 1 tab OD as lunchtime

 Decrease norvomix 14u (2 pre dinner)

8am  Heparin on Tuesday TID

1pm  Suggest transfusion of 1 unit PRBC during HD
tomorrow if Dr. with AP

 Continue norgenic forte TID x 3 days then decrease prn

3:45pm  Please secure 1 unit PRBC of patients blood during

hemodialysis tomorrow
March 9, 2010  Stand by 1 unit PRBC
12pm  Resume domperidone 1 tab TID

 Omeprazole 40 mg 1 tab OD

 Decrease novomix 18u SQ q6* (5-11-5-11)

12:15  Agreed to be reffered to Dr. isaguire for co-ngt.

 12:15  Agreed to be reffered to Dr. isaguire for co-ngt.
March 10, 2010  MRIC – refer
9:50am  Continue medications
11:20am  Decrease norvomix - 14u SQ AC-BP

10u SQ AC-Soppu (give insulin just before eating)

10:50pm  MRIC

 Update Dr. maglana Referred AD schedule tomorrow

 Will await infectious clearance and once cleared, inform cardio

service with out fail

 For possible insertion of permanent pacemaker

A.2 Laboratories/ diagnostic procedure

1. Hematology

Test Name Result

Blood Type “A”

RH Type Pos (+)

Date Test Result Normal Values Justification

February Hemoglobin 110 140-170g/L >decreased Hemoglobin may lead to

20, 2010 anemia that can result to kidney
disease and other chronic illness.
(http://www.aabb.org).
Hematocrit 0.33 0.40-0.50 >Decreased Hematocrit are the
same as for Hemoglobin and may
indicate low thymus function (
http://www.wisegeek.com/what-is
-a-differential-white-cell-count.ht
m)

Erythrocytes 4.08 4.5-5.0 >Decreased Erythrocyte may due

to anemia and low Hemoglobin. A
blood test that measures the
number of RBC's (
http://www.wisegeek.com/what-is
-a-differential-white-cell-count.ht
m)

Leukocytes 10.70 5.0-10.0 10ˆ9/L High white blood cell count could
indicate Infection,
inflammation, trauma,
tissue damage,
use of certain medications, such
as corticosteroids, antibiotics or
anti-seizure drugs, and allergy
(http://www.steadyhealth.com/arti
cles/What_does_high_white_bloo
d_cells_count_indicate__a723.ht
ml).
Segmenters 0.684 0.55-0.65 > An increase in value of these
cells generally indicates the
presence of an acute bacterial
infection or some inflammation
going on inside the body (
http://www.wisegeek.com/what
-is-a-differential-white-cell-coun
t.htm)

Lymphocytes 0.196 0.35-0.45 >people with a decreased

lymphocyte count may be more
susceptible to certain types of
infections
(http://www.associatedcontent.
com/article/2044911/what_cau
ses_a_decreased_lymphocyte.
html)
 Eosinophils 0.022 0.02-0.04 Normal

Monocytes 0.098 0.06-0.12 Normal

Basophils 0.000 0. -0.02 Normal

MCV 84.5 80-97fL Normal

MCH 29.10 27.0-31.2 pg Normal

MCHC 340 318-354 Normal

Date Test Result Normal Values Justification

March 8, 2010 Hemoglobin 98 140-170g/L >decreased Hemoglobin may

lead to anemia that can result
to kidney disease and other
chronic illness.
(http://www.aabb.org).
Hematocrit 0.30 0.40-0.50 >Decreased Hematocrit are the same as
for Hemoglobin and may indicate low
thymus function (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)

Erythrocytes 3.03 4.5-5.0 >Decreased Erythrocyte may due to

anemia and low Hemoglobin. A blood
test that measures the number of RBC's (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)

Leukocytes 8.60 5.0-10.0 10ˆ9/L Normal

Thrombocytes 383.00 140-440 10ˆ9/L Normal

Segmenters 0.660 0.55-0.65 > An increase in value of these cells

generally indicates the presence of an
acute bacterial infection or some
inflammation going on inside the body (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)
Lymphocytes 0.180 0.35-0.45 >people with a decreased lymphocyte
count may be more susceptible to
certain types of infections(
http://www.associatedcontent.com/articl
e/2044911/what_causes_a_decreased_
lymphocyte.html
)

Eosinophils. 0.061 0.02-0.04 >The level of eosinophils can be too

high in response to allergies. They can
also be too high when exposed to
certain types of bacteria (
http://www.medfriendly.com/eosinop
hil.html
)
Monocytes 0.099 0.06-0.12 Normal

Basophils 0.000 0. -0.02 Normal

MCV 75.40 80-97fL >The MCV relates to the

average size of the red blood
cell. MCV is decreased in Iron
deficiency (
http://www.wisegeek.com/what-i
s-a-differential-white-cell-count.
htm)

MCH 24.10 27.0-31.2 pg >The MCH is decreased in the

same conditions as the MCV (
http://www.wisegeek.com/what-i
s-a-differential-white-cell-count.
htm)
.

MCHC 319 318-354 Normal

 2. Serum Electrolytes

Date Test Result Normal Values Justification

February Clotting Time 4'30” 2-6 min-sec Normal

24, 2010

Bleeding Time 2'45” 1-3 min-sec Normal

Date Test Result Normal Values Justification

March 8, 2010 Clotting time 4' 2-6 min-sec Normal

Bleeding time 1'2'” 1-3 min-sec Normal

Date Test Result Normal Values Justification

February Phosphorus 3.82 0.81-1.58 mmol/L Hyperphosphatemia is common in

20, 2010 renal failure. Other causes include
increase intake, decrease output or a
shift from the intracellular to
extracellular space.(Brunner et al.,,
Medical Surgical Nursing, 11th ed., pg.
332)

Calcium 1.76 2.12-2.52 mmol/L Hypocalcemia is common in patients

with renal failure because this patients
frequently have elevated serum
phosphate level. Hyperphosphatemia
usually causes a reciprocal drop in the
serum calcium level. (Brunner et al.,,
Medical Surgical Nursing, 11th ed., pg.
325)
Magnesium 1.69 0.74-0.99 mmol/L > Most common cause of
hypermagnesia is renal
failure. In fact, most
patients with advanced
renal fialure have atleast
a slight elevation in serum
magnesium levels. This
condition is aggravated
when such patients
receive magnesium to
control seizures or
inadvertently take one of
the many commercial
antacids that contain
magnesium salts.
(Brunner et al.,, Medical
Surgical Nursing, 11th ed.,
pg. 330).
Potassium 7.00 3.5-5.1 mmol/L The major cause of
hyperkalemia is decreased renal
excretion of potassium. Fot this
reason, significant hyperkalemia
is commonly seen in patients
with untreated renal failure,
particularly those in whom
potassium levels increase as a
result of infection or excessive
intake of potassium in foods or
medications.(Brunner et al.,,
Medical Surgical Nursing, 11th
ed., pg. 323).

Sodium 122.00 136-145 mmol/L > Decreased sodium is

associated with parallel changes
in osmolality. Sodium has major
role in controlling water
distribution throughout the body,
because it does not easily cross
the cell wall membrane and
because of its abundance and
high concentration in the body.
(Brunner et al.,, Medical Surgical
Nursing, 11th ed., pg. 315).
 3. Immunologic Section

Date Test Result Normal Values Justification

Februry TSH (Thyroid 0.751 0.27- 42uIu/ml Normal

25, 2010 Stimulating
Hormone)
• 4. Chest Xray
• March 8, 2010
• A comparison with the radiograph dated March 3,
2010 discloses no change in the infiltrates and degree
of pulmonary congestion in both lungs. The lateral cp
sinuses are sharp.
• 5. Chest A.P. Supine Adult
• March3, 2010 2:42 PM
• Heart size cannot be evaluated due to the position.
Pulmonary vascularity is accentuatedwhich may be due
to the position. Both lungs are hazy. The lateral
costophrenic sinuses are sharp. Hili are not enlarged.
Visualized osseus structures are normal.
• Impression:
• Consider Pneumonic
• 6. Cervical Spine ADLO
• March 6, 2010 1:00 PM
• There is normal cervical lordosis. Anterior
spurs are seen from C4 to C5. Vertebral bodies
show normal height. Disc spaces, neural
foraminae + pedicles are preserved.
Prevertebralsoft tissue are not thickened.
• Impression:
• Degenerative Joint Disease
• A.3 Hemodialysis
•  
• March 9, 2010
• HEMODIALYSIS
• In hemodialysis (HD), blood is shunted through an
artificial kidney (dialyzer) for removal of
toxins/excess fluid and then returned to the
venous circulation. Hemodialysis is a fast and
efficient method for removing urea and other
toxic products and correcting fluid and electrolyte
imbalances but requires permanent arteriovenous
access. Procedure is usually performed three
times per week for 4 hr. HD may be done in the
hospital, outpatient dialysis center, or at home.
• Nursing Management:
• Evaluate reports of pain, numbness/tingling; note extremity
swelling distal to access.
• Monitor temperature. Note presence of fever, chills,
hypotension.
• Measure all sources of I&O. Have patient keep diary.
• Weigh daily before/after dialysis run.
• Monitor BP, pulse, and hemodynamic pressures if available
during dialysis.
• Place patient in a supine/Trendelenburg’s position as
necessary.
• Assess skin around vascular access, noting redness, swelling,
local warmth, exudate, tenderness.
• Avoid contamination of access site.
• Monitor serum sodium levels. Restrict sodium intake as
indicated.
 B. Pharmacological

Generic Brand Classificatio Mechanism Indication Contra- Adverse Dosag Nursing

Name Name n of Action Indication Reaction e Responsibilit
y

omeprazol Prilosec Prilosec

Omeprazol Omeprazol >Contraindicate 40 mg >Advise Pt.
e diarrhea,
e is in a e is in a d to those who (8am) To take
nausea,
class of class of are 1 tablet caution
vomiting,
drugs called drugs called hypersensitive to P.O engaging in
headaches
proton proton the drug. O.D activities
, rash and
pump pump requiring
dizziness.
inhibitors inhibitors alertness
(PPI) that (PPI) that such as
block the block the driving or
production production using
of acid by of acid by machinery.
the the
stomach. stomach.
Generic Brand Classification Mechanism Indication Contra-Indication Adverse Dosage Nursing
Name Name of Action Reaction Responsibility

desloratadine
Acnius antihistamine It is used to .>treatment >Contraindicated >dizziness, 5mg >Advise Pt.
treat the of allergies. to those who are fatigue, (8am) To take
1 tablet caution
symptoms Provides hypersensitive to heache,
P.O engaging in
caused by relief of the drug and its tachycardia, activities
O.D
histamine. seasonal components dry mouth requiring
Histamine allergy alertness
is a symptoms such as
chemical and allergic driving or
that is nasal using
machinery.
responsible conditions
>pt. May
for many of (rhinitis) such report
the signs as runny Adverse
and nose, Reaction to
symptoms sneezing, the drug.
of allergic and >instruct pt.
reactions watery/itching To
immediately
eyes
place the
tablet on hius
tongue after
open ing
Generic Brand Classificatio Mechanis Indication Contra- Adverse Dosag Nursing
Name Name n m of Action Indication Reaction e Responsibilit
y

Ketoprofen Fastu Analgesic Relieves Mild to Hypersensitivity headache, As >tell patient

m Gel pain, fever moderate to the drug dizziness, ordere to report any
and pain nervousne d allergic
inflammati minor aches ss, skin reaction
on. It and pain or rashes,
inhibits fever pruritus,
prostaglan tinnitus,
din blurred
synthesis vision
Brand Classification Mechanism Indication Contra-Indication Adverse Dosage Nursing
Name of Action Reaction Responsibility

Caltrate
Replaces Supplement >Contraidicated Pain, 1 tab >Should be
Plus Cacium
and for Ca in patients with bradycardia, PO od taken with food
Supplement
maintains deficiency & hypecalcemia, cardiac >instruct
calcium; conditions that and renal calculi arrest, patient to
raises require nausea and report any sign
calcium level increased Ca vomiting of its adverse
intake; may reaction
reduce the
risk of
osteoporosis
later in life.
Generic Brand Classificati Mechanism Indication Contra- Adverse Dosage Nursing
Name Name on of Action Indication Reaction Responsibility
Meropenem
Meronem anxiolytics Readily Complicated >Hypersensitivit Headache, 1 vial IV >warn patient
penetrates skin and skin y to the drug insomnia, infusion to avoid
the cell wall structure >Use cautiously confusion, hazardous
of most infection to patient with tachycardia, activities that
gram cause by renal diarrhea. require
positive Staphylococc impairment alertness and
and gram us aureus motor
negative cooordination
bacteria to until CNS
reach affects are
penicillin- known.
binding >advise pt. To
protein report any
targets, signs of
where it Adverse
inhibits cell effects of the
wall drug.
synthesis.
 CHAPTER VI
DISCHARGE PLANNING
Basic health teaching is the greatest need of a patient after admission.
The nurse should clearly teach the patient and family on how to comply
with medications and other regimen to facilitate improvement of the
patient health status thus providing also continuity of care to the patient.
• M – Medication
• Explained the importance of the prescription including the name of the
drug (GENERIC AND BRAND NAME), purpose of medication, duration of
administration, appropriate dosage, the adverse effect, side effect,
formulation of medications.
• Informed the patient and the family about the medication prescribed by
the physician including the purpose, dose, schedule and the side effect of
the drugs.
• Instructed the patient and the family that the compliance of the regimen
is really needed and may discontinue if ordered by the physician.
• Encouraged the patient and the family to report any unusualities
regarding the administration of drugs.
• E – Exercise
• Informed the patient and the family to have a moderate exercise to
promote physiological well-being, reducing the risk and
strengthening the immune system.
• Encouraged the patient to have a deep breathing exercise.
• Light exercise on both arms and legs to promote circulation in the
heart.
• T – Treatment
• Encouraged the patient to keep follow-up appointment.
• Medications are recommended for this aim to improve the proper
blood flow and proper circulation in our body. This promotes
healing and reduces pain and discomfort.
• Nutritional management-nutrition, proper diet and weight control
• Prompt exercise
• Health teachings to facilitate awareness an knowledge to the
patient regarding his illness.
• H – Hygiene
• Encouraged the patient to have a proper hand washing with soap and
water before and after eating and whenever they spend time around
people with cold or other illness.
• Encouraged patient to brush teeth properly.
• Encouraged patient to keep hands away from his nose and mouth.
• Educate the patient on proper hygiene by instructing to wear cotton
clothes and changing underwear to avoid irritation and provide comfort.
• Educate the patient properly initiate the regular hygiene with assistance as
necessary.
• O – Outpatient order
• Encouraged patient to stay indoors with the doors and windows closed if
air pollution levels are high.
• Encouraged patient to keep himself away from smoke.
• Encouraged patient to have enough sleep and rest everyday.
• Encouraged the significant other to monitor the temperature of the
patient.
• Provided patient information regarding his condition and instruct to follow
why the doctor instructed.
• D – Diet
• Encouraged patient to eat healthy and well-balanced diet.
• Encouraged patient to avoid foods that are high in carbohydrates,
fatty foods, and salty foods.
• Provided all the essential food constitutes (vitamins and minerals).
• Patient must maintain the reasonable weight.
• Instructed the patient to eat nutritious food such as fruits and
vegetables and in strict diabetic diet low salt and low fat diet.
• Increased oral fluid intake.
• S – Spiritual
• Encourage patient and the family to maintain realistic hope over the
course of the illness.
• Encourage the patient and the family to take time to be introspective
in the search for peace and harmony.
• Help patient and the family obtain spiritual help.
• Encourage patient to pray everyday and ask for God’s guidance and
strength in order to lighten up his feelings towards his condition.