Professional Documents
Culture Documents
I. INTRODUCTION
A. Definition
B. Statistics
i. International
ii. Local
II. OBJECTIVES
A. General Objective
B. Specific Objectives
III. ANATOMY AND PHYSIOLOGY
IV. VITAL INFORMATION
V. CLINICAL ASSESSMENT
A. Nursing History
B. Past Health Problem/Status
C. Family History of Illness
VI. SOCIAL, CULTURAL, RELIGIOUS BACKGROUND AND PATTERN OF FUNCTIONING.
a. Educational Background
b. Occupational Background
c. Religious practices
d. Economic status
A. Vital Signs
Upon Admission
During our Care
B. Physical Assessment (Cephalocaudal)
I. General Appearance
II. Skin, hair and nails
III. Head, face, and lymphatics
IV. Eyes, ears, nose, mouth and throat
V. Neck and upper extremities
VI. Chest, breast and axilla
VII. Respiratory system
VIII. Cardiovascular system
IX. Gastrointestinal system
X. Genitor-urinary system
XI. Musculoskeletal system
C. General Appraisal
I. Speech
II. Language
III. Hearing
IV. Mental status
V. Emotional status
IX. PATHOPHYSIOLOGY
X. MEDICAL MANAGEMENT
A. Drug Study
B. Medi Map
XI. NURSING MANAGEMENT
A. Concept Map of Nursing Problems
B. Nursing Care Plan
XII. DISCHARGE PLANNING
XIII. JOURNALS
XIV. ACKNOWLEDGEMENT
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OBJECTIVES
A. General Objective
After the discussion of this case presentation, the students will be able to deal and
care for a patients with End – Stage Renal Disease integrally by applying their
knowledge, skills, and positive attitudes based on what they have learned out of the
discussion.
B. Specific Objectives
At the end of individual case discussion, it is expected that the students will be
able to:
Skills
1. Deal patient with ESRD.
Knowledge
1. Define ESRD.
2. Have an overview about the diseases, including its causes and complications.
3. Determine the signs and symptoms and the possible symptomatic treatment of
each.
6. Identify and enumerate the management needed for ESRD and its related
complications.
7. Formulate nursing care plans that will aid in the improvement of patient’s condition.
Attitudes
1. Develop a positive attitude in caring the patient with ESRD throughout the nursing
Process.
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2. To be able to establish rapport with the patient and folks.
INTRODUCTION
A. Definition
End stage kidney disease is the final stage of chronic kidney disease (CKD). It is the most
severe illness with poor life expectancy if untreated. It also called established chronic disease and
occurs when GFR falls below 15 mL/min/1.73 m2. Patients with ESRD are dependent on renal
replacement therapy (RRT) to survive. The incidence of ESRD in the developing world is difficult
to estimate and ranges from 40 per million population (pmp) to 340 pmp. The prevalence of
ESRD can be more accurately recorded as the number of patients receiving RRT.
It is very important to take really good care of our kidneys because our kidneys play a big
role to our body which is to filter our body wastes. Nowadays, cases of ESRD is increasing in
continue to spread all over the world. Having discipline to ourselves regarding our health could be
a big help to prevent diseases because most of us abuse our body that’s why we had a lot
diseases which is developing in our body and most of them could lead to death. Having a good
health is one of the greatest treasures we could have; this could make us disease free of such
serious illness. Regarding ESRD, we could only say that proper nutrition and proper care of our
kidneys is one of the important ways to prevent and to eliminate this disease to occur within us.
And what we said earlier is that, one of the best way to have good health is to have a self-
discipline regarding health care because we are the one who are deciding whether to have a
disease or not. Living with a healthy lifestyle and good health is one of the achievable and could
have a satisfying life.
As student nurses, we could help our patient by having a deep understanding of the
disease, that we may learn the proper interventions for the end-stage renal disease patients. In
this way, we could render quality care for them. We could as well lead them to the proper
treatment to lessen their sufferings brought by the kidney failure, in anyhow. By having a wide
understanding of the disease, we could impart teachings on how we could prevent the occurrence
of the disease. It is our responsibility to render information and impart health teachings to improve
the condition of our patients to the best of our abilities. One of the characteristics that we, student
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nurses, should have is to be informative and only through a keen study of disease such as this
way for us to gain all the information that we need to learn. May this case study served its
purpose through the help of our Lord, Jesus Christ.
B. Statistics
International:
93,327 people commenced treatment for end-stage renal disease annually in the US 2001
(United States Renal Data System, 2003, NIDDK)
31% of cases of ESRD each year occurs in African Americans in America (Renal Data
Report, ANS, 1999)
2% of cases of ESRD each year occurs in native Americans (Renal Data Report, ANS, 1999)
31% of cases of ESRD each year occurs in Caucasians in America (Renal Data Report, ANS,
1999)
Local:
Kidney disease is on the rise and is an important cause of death in the Philippines.
Statistics show that kidney disease among the Filipinos is shooting up every year. Almost 10,000
Filipinos requiring either dialysis for life or a kidney transplant for survival. About 31% of them
have the most advanced stage of the disease.
The main cause of kidney disease seems to be the increasing diabetic conditions among
the Filipinos. It is seen that about 55% of Filipinos develop kidney disease when they suffer from
diabetes. The Philippine Society of Nephrology (PSN) issued the statement that diabetes is the
single most common cause of kidney failure among diabetes mellitus nephropathy patients.
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ANATOMY AND PHYSIOLOGY
NEPHRONS
- from Greek word “nephros”, meaning "kidney". It is the basic structural and
functional unit of the kidney. Its functions are vital to life and are regulated by the
endocrine system by hormones such as antidiuretic hormone, aldosterone, and
parathyroid hormone. In humans, a normal kidney contains 800,000 to one million
nephrons. Its chief function is to regulate the concentration of water and soluble
substances like sodium salts by filtering the blood, reabsorbing what is needed and
excreting the rest as urine.
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of Henle, and the collecting tubulle. The renal medulla is hypertonic to the filtrate in the
nephron and aids in the reabsorption of water.
Cortex
- is the outer portion of the kidney between the renal capsule and the renal medulla. In the
adult, it forms a continuous smooth outer zone with a number of projections (cortical columns)
that extend down between the pyramids. It contains the renal corpuscles and the renal
tubules except for parts of the loop of Henle which descend into the renal medulla. It also
contains blood vessels and cortical collecting ducts. The renal cortex is the part of the kidney
where ultrafiltration occurs.
A person normally ingests about 1300 mL of oral fluids and 1000 mL of water in food per
day. Of the fluid ingested, approximately 900 mL is lost through the skin and lungs (called
insensible loss), 50 mL through sweat and 200 mL through feces.
When the kidneys are functioning normally, the volume of electrolytes excreted per day is
equal to the amount ingested. The regulation of sodium volume excreted depends on
aldosterone, a hormone synthesized and released from the adrenal cortex. With increased
aldosterone in the blood, less sodium is excreted in the urine, because aldosterone fosters renal
absorption of sodium.
The kidney performs two major functions to assist in this balance. 1.) To reabsorb and
return to the body’s circulation any bicarbonate from the urinary filtrate; 2.) To excrete acid in the
urine.
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Renal clearance
When the kidneys detect to decrease in the oxygen tension in renal bllod flow, they
release erythropoietin that stimulates the bone marrow to produce RBC and carry oxygen
throughout the body.
Vitamin D synthesis
Secretion of prostaglandins
The kidneys eliminate the body’s metabolic waste products which is the urea that excreted
daily for about 25 to 30 mg.
Urine storage
Bladder emptying
TEXTBOOK DISCUSSION
A. Definition
End - stage renal disease, also known as chronic kidney disease (CKD), specifically the
fifth stage of CKD. It means, it is the complete or almost complete failure of the kidneys to
function. The kidneys can no longer remove wastes, concentrate urine, and regulate many other
important body functions.
ESRD almost always follows chronic kidney disease. A person may have gradual
worsening of kidney function for 10 - 20 years or more before progressing to ESRD. Patients who
have reached this stage need dialysis or a kidney transplant.
B. Risk factors
ARF
Obstruction
Diabetes mellitus
- is the leading cause & accounts for more than 30% of clients who receive dialysis.
Hypertension
Lupus erythematous
Polyarteristis
Amyloidosis
C. Signs/Symptoms
CLINICAL MANIFESTATION
Manifested
DISTINCTIVE From the textbook by the Rationale
GROUPING patient
Hyperkalemia
Hyponatremia The salt – wasting properties of some
failing kidneys, in addition to vomiting
and diarrhea.
Hypocalcemia
Electrolyte Hyper-
Imbalances phosphatemia
8
Hypercalcemia
Mildly elevated
serum Mg
↑ serum creatinine Serum creatinine increases as waste
products of protein metabolism
accumulate in the blood. And due to
decrease GFR.
Proteinuria The metabolic function of the kidney
which includes the metabolism fails
which tends protein to be excreted via
urine.
↑ uric acid
Metabolic Carbohydrate
changes intolerance
Elevated
triglycerides
Metabolic acidosis It occurs because of the kidneys inability
to excrete hydrogen ions, ↓ reabsorption
of NaHCO3, ↓ formation of dihydrogen
phosphate and NH3.
Pericarditis
Anemia It occurs because the kidneys are unable
Hematologic to produce erythropoietin, a hormone
changes necessary for RBC production.
Iron or folate
depletion
Hemolysis &
platelet
abnormalities
Transient anorexia, A possible cause of nausea and vomiting
nausea & vomiting is a decomposition of the urea by the
intestinal flora resulting in a high
concentration of ammonia.
Constant bitter
taste
Fetid, fishy or
Gastro-
ammonia-like
intestinal
breath smells
changes Metallic or salty
taste
Stomatitis
Hiccups Due to the accumulation of toxic
substances that stimulates phrenic
nerves.
Ulcer disease
↑ serum amylase
Constipation
Depression of
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hormonal antibody
formation
Suppression of
delayed
Immunologic
hypersensitivity
changes
Decreased
chemotactic
function of the
leukocytes
Changes in Medication toxicity
medication
metabolism
HPN Due to water retention.
Arterial
Cardio- calcifications
L ventricular
vascular
hypertrophy & HF
changes Chest pain Due to the accumulation of toxins in the
body because the kidney is failing in
filtering it.
Dysrhythmias
Atherosclerosis
Anasarca Due to water retention as a result of ↑
hydrostatic pressure or for activation of
renin – angiotensin aldosterone system
Respiratory Pulmonary edema
Pleuritis
changes
Osteomalacia
Osteitis fibrosa
Osteoporosis
Musculo- Osteosclerosis
skeletal Muscle cramps These may result from osmolar changes
D. Complications
Uremia
- If there is failure of kidney to function well, urea and other waste products, which
are normally excreted into the urine, are retained in the blood.
Shock
Pericarditis
Seizures
Coma
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E. Treatment
Intensive dialysis and thoracentesis to relieve pulmonary edema & pleural effusion.
Kidney transplantation
Diet:
Low protein diet to limit accumulation of end-products of protein metabolism that the
kidneys can’t excrete.
High-protein diet for patients on continuous peritoneal dialysis
High-calorie diet to prevent ketoacidosis & tissue atrophy.
Sodium, potassium & phosphorus restrictions to prevent elevated levels.
Medications:
Loop diuretics, such as furoemide to maintain fluid balances.
Cardiac glycosides, such as Digoxin to mobilze fluids causing edema.
Calcium carbonate (Caltrate) to treat renal osteodystrophy by binding phosphate &
supplementing calcium.
Antihypertensives to control blood pressure and edema.
Antiemetics to relieve nausea & vomiting.
Famotidine or ranitidine to decrease gastric irritation.
Docusate to prevent constipation.
Iron & folate supplements or RBC transfusion to treat anemia.
Synthetic erythropoietin to stimulate the bone marrow to produce RBCs; conjugated
estrogens & desmopressin to combat hematologic effects.
Antipruritics to relieve itching.
Phosphate-removing drugs to decrease serum phosphate levels.
F. Diagnostic studies
Urinalysis
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- aids in diagnosis (specific gravity fixed at 1.010, proteinuria. glycosuria, RBCs,
leukocytes, casts or crystals, depending on the cause).
- reveals elevated BUN, creatinine, low sodium level & potassium levels, increased
aldosterone secretion, low hemoglobin level & hematocrit, decreased RBC survival time,
mild thrombocytopenia, platelet defects & hyperglycemia.
Renal ultrasound
Abdominal (KUB)radiograph
Aortorenal angiography
Retrogade pyelogram
Renal arteriogram
Voiding cystourethrogram
Renal biopsy
13
- This can be done endoscopically to examine tissue cells for histologic
diagnosis.
- It is done to examine renal pelvis, flush out calculi, hematuria & remove
selected tumors.
ECG
EEG
G. Nursing considerations
Bathe the patient daily using superfatted soaps & skin lotion without alcohol to ease
pruritus
Turn the patient often & use a convoluted foam mattress to prevent skin breakdown.
Provide good oral hygiene by encouraging or performing frequent brushing with a soft
brush or sponge tip to reduce breath odor & providing sugarless hard candy & mouthwash
to minimize the metallic taste in the mouth & alleviate thirst.
Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak pulse rate.
Carefully assess the patient’s hydration status; check for jugular vein distention,
auscultate the lungs for crackles, carefully measure daily intake & output, record daily
weight & document peripheral edema.
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Monitor for bone or joint complications.
Encourage deep breathing & coughing to prevent pulmonary congestion, auscultate the
lungs often, stay alert foe clinical effects of pulmonary edema & administer diuretics &
other medications as ordered.
Observe for signs of bleeding & monitor hemoglobin level & hematocrit & check stool,
urine & vomitus for blood.
Report signs of pericarditis such as pericardial friction rub and chest pain.
CLINICAL ASSESSMENT
A. Nursing History
1 week prior to admission, Mr. N.D. had a very low appetite wherein he only eats bread
and milk in the morning and drinks about 5-7 bottle of soft drinks a day, and experienced an
episode of nausea.
And four days prior to admission, Mr. N.D. had several episodes of vomiting associated
with epigastric discomfort. Vomiting still persisted until on the day of admission, thus brought to ER
of St. Anthony college Hospital of Roxas City and was admitted.
STROKE
B. Past Health Problem
HYPERT
Mr. N.D is a known prohibited drugs user. He was admitted in Dao Provincial Hospital last
ENSION
November 2009 due to Urinary Tract Infection but has been treated for just about a week or more.
LEGEND:
POOR
Mr. N.D has also experienced a burning sensation in the chest and a pain in the epigastric
HEARING
ACUITY
area thus; he thought to have an ulcer because of that manifestation. Other health problems than
what have been mentioned were just fever and common colds.
ESRD
C. Family Genogram
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PATTERNS OF FUNCTIONING
Nutritional History
a. Drinking Patterns
Mr. N.D is not fond of drinking water. And before he experienced those manifestations
before his admission, Mr. N.D is fond of drinking carbonated beverages like soft drinks for at least
5 – 7 bottles a day. He is also a known alcoholic drinker wherein he drinks together with his peer
every afternoon.
b. Eating Patterns
Mr. N.D told that when or after taken prohibited drugs before, his appetite also decreases.
At that time, he does not eat for almost 2 days and only drinks a lot of soft drinks to relieve his
thirst. But then, when his appetite came back, he eats every food that is being served in the table
very well.
Breathing Patterns
HOME HOSPITAL
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RR = 21 bpm
Mr. N.D does not experience any problem in Mr. N.D had an episode of SOB during the few
respiration before. days of his admission in this institution but was
relieved when in semi – or in high – fowler’s
position.
Circulation
Temperature 36°C
Pulse rate 75 bpm
Respiration rate 21 bpm
Blood pressure 120/70 mmHg
Apical rate 82 bpm
IVF
Left carpal vein # 2 PNSS 1L + 20 mEqs NaCl x 60 cc/°
Side Drip #2 D5W 500 cc + 100 mEqs NaHCO3 x 24°x 2
cycles
Right carpal vein #1 PNSS 500 cc x KVO
Mr. N.D usually sleeps at night after drinking Mr. N.D is weak and tends to sleep during day
alcoholic beverages with his peer and the time time if not feeling well or if he wants to. He
of sleeping is depending upon to his usually sleeps at 9 in the evening and rises at
companion and if when are they going to finish 5 – 5:30 in the morning.
drinking. Thus, he sleeps at continuously
without any difficulty or deprivation in sleeping.
His usual waking up time is 6 in the morning
because he has work at 9 am.
b. Personal Hygiene
Home Hospital
Mr. N.D takes a bath once a day before going Mr. N.D can perform personal hygiene by
to work. He is also conscious about his himself like brushing his teeth at least once
personal hygiene. every other day.
c. Elimination Patterns
Bowel Movement
FREQUENCY PROBLEMS / DIFFICULTIES
Home Hospital Home Hospital
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after lunch time the he defecates constipation.
twice a day.
Urination
FREQUENCY PROBLEMS / DIFFICULTIES
Home Hospital Home Hospital
A. Educational Background
B. Occupational Background
C. Religious practices
-He does not attend to mass every Sunday and even praying the rosary every afternoon.
D. Economic status
SOCIO-CULTURAL HEALTH
A. Cultural Health
He does not believe to any superstitious beliefs. Rather, he believes on what he wanted to
do and that’s the reason why there is a conflict between his parents.
B. Recreational Pattern
Mr. N.D’s usual recreation is just watching television and talking with their borders
because he has only a little time for recreation due to his work. But if he had time for that,
then he is having fun with his friends; wherein they drink together every evening.
C. Environmental Pattern
He lives in a complicated situation of life due to his vices. He is living near at the roadside
together with his wife, which is seven months pregnant, at his Auntie’s custody. He is prone
also to accident because of the influence of his friends.
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D. Interaction Pattern
According to him, he is not closed to her parents. Instead, he wants to be with his friends
and enjoys a lot if they are hanging out. He is not sweet to his wife and seems he is ‘siga” the
way he talks.
E. Coping Pattern
Before, he was neglected by his family when they knew that he is a drug user. But then,
they gave him another chance if he will stop taking prohibited drugs.
On the first few days after his admission, he was not visited by his parents & relatives.
Only his wife is the one taking care of him throughout his admission.
A week after, his Aunt visited him and gave an assurance that she will help him related to
his financial problems.
Now, his parents are also helping in taking care of him.
CLINICAL INSPECTION
A. Vital Signs
Upon Admission
Temperature Respiratory rate Apical pulse Radial pulse Blood pressure
37.5°C 20 bpm 92 bpm 79 bpm 110/80 mmHg
B. Physical Assessment
General Appearance:
Mr. N.D is consciously lying on bed which appears weak, fatigue, with complaints
of pain in the anterior chest and with an ongoing IVF of #2 PNSS 1L + 20 mEqs NaCl x
60 cc/̊ at 500 cc level and a secured side drip of #2 D5W 500 c + 100 mEqa NaHCO3 x
24̊ x 2 cycles infusing well on the left carpal vein, #1 PNSS 500 cc x KVO at the right
carpal vein which is used for Blood Transfusion & O2 @ 2 Lpm via nasal cannula.
He is coherent and physically and mentally conscious wherein responsiveness to
any stimulus is observed, with non – edematous lower & upper extremeties noted but the
face is edematous during our 1st week of duty. Yet, anasarca was developed during our
second duty in the ward.
Cephalocaudal
Normal
Fair complexion.
Skin is soft and no scar,
bruise or petechiae noted.
Normal
Normocephalic, absence
of nodules, hair is evenly
distributed, black in color,
straight and smooth.
Symmetrical feature of
the face.
(+) chest pain;
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ESRD
Facial grimace
Nails Inspection Absence of thin nails Normal
Palpation Normal
(-) Tenderness
Ears Inspection Color same as facial skin
Auricle aligned with outer
canthus of the eye Normal
Responsive to moderate
voices.
Nose Inspection Symmetric with the nasal Normal
septum at the center
Mouth Inspection With plaques Poor oral hygiene
(+) DOB
Normal
Chest movement is
symmetrical upon
respiration.
Auscultation
(-) tenderness, (-)
masses.
Abdomen Inspection Uniform in color Normal
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Abdominal girt = 94 cm Due to fluid
accumulation.
urinary bladder
Normal
Liver is not palpable
Extremities Right arm muscle cramps ESRD; due to
hypokalemia
Cardiovascular Inspection Chest pain ESRD
Auscultation Hypertensive. Bp =
140/100 mmHg
Gastrointestinal Inspection Anorexia, nausea & Due to the
vomiting. decomposition of
the urea by the
intestinal flora
resulting in a high
concentration of
ammonia.
Due to the
accumulation of
Hiccups. toxic substances
that stimulates
phrenic nerves.
Genitourinary Difficulty in urinating ESRD
(+) oliguria
(+) foley catheter
UO = 50 cc,
Normal
Urine is clear in color and
is aromatic
C. General Appraisal
i. Speech
-He is oriented and converses appropriately without any problem in his speech.
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ii. Language
iii. Hearing
-He is able to hear moderate sounds and interpret auditory stimuli appropriately.
-He is worried about his condition and he really wanted that his disease will be treated. He
has a low self – esteem and is no t confident with his body structures; is cooperative
and can interact to people around him.
v. Mental status
-He is conscious, alert, coherent and oriented to person, time, place and events occurring
in the environment. He is fond of asking questions about something most especially
about his condition and able to comprehend instructions and commands.
Urinalysis
Test Result Normal Significance
Values
Macroscopic
Protein 3+ 0 Due to increase creatinine which indicates renal failure,
and at that time the kidney is failing to metabolize the
protein, thus protein is being excreted via urine without
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undergoing metabolism & impaired metabolism of renal
tubule.
Microscopic
RBC/hpf 3-8 0 – 2 / hpf It occurs because the kidneys are being damaged and a
presence of cyst in right kidney.
WBC/hpf 8-23 0 – 5 / hpf Infection; The body compensates to fight against bacteria,
& the dead WBC are being excreted in the urine since the
kidney cannot filter it.
Bacteria Few Invasion of pathogens in the urinary tract.
ABG Analysis
Test Result Normal Values Significance
pH 7.263 7.35-7.45 • Fully compensated metabolic acidosis &
pCO2 21.1 35-45 mmHg
pO2 154.1 80-100 mmHg respiratory alkalosis
HCO3 9.2 22-26 mmol/L It occurs because of the kidneys inability to excrete
hydrogen ions, ↓ reabsorption of NaHCO3, ↓
formation of dihydrogen phosphate and NH3.
O2 Sat. 99% 97-100% Normal
Urinalysis
Test Result Normal Values Significance
Macroscopic
Transparency Hazy Clear Due to presence of bacteria.
Specific gravity 1.005 .1.10 – 1.25 Due to the fluid that accumulates in the body.
Protein 2+ Negative Due to increase creatinine which indicates
renal failure, and at that time the kidney is
failing to metabolize the protein, thus protein is
being excreted via urine without undergoing
metabolism.
Microscopic
RBC/hpf 20-31 0 – 2 / hpf It occurs because the kidneys are being
damaged and a presence of cyst in right
kidney.
WBC/hpf 8-12 0 – 5 / hpf Infection; the body compensates to fight
against bacteria, & the dead WBC are being
excreted in the urine since the kidney cannot
filter it.
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Bacteria Few Invasion of bacteria in the urinary tract.
Ultrasound: KUB
Significance
Kidneys:
The right kidney measures approximately:
Coronal = 110.6 x 50.7 x 43mm (LWT) with a cortical thickness of 17.1 mm.
The borders are fuzzy.
There is increased parenchymal echopattern.
A 7.1 x 6.2 x 7.0 mm (LWH) with a volume of .2 ml cystic mass is noted in the inferior
pole.
There is no caliectasia.
There is no lithiasis.
Impression:
Normal urinary bladder ultrasonically.
Diffuse renal parenchymal disease, both kidneys.
Renal cyst, inferior pole, right kidney.
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Precipitating factors:
Lifestyle
-alcoholic
drinker
Predisposing
factors: -illegal drugs
Family user
history of
Hypertensi -carbonated
on
PATHOPHYSIOLOGY drinker for
about 5-7
bottles/day
Renal cyst
26
Hypertension,
Further loss of nephron function blood pH =
↓7.263
Proteinuri
Continuous decline in renal a
function
Anemia
oliguria
END-STAGE RENAL
DISEASE (ESRD)
Nausea &
Anemia
vomiting
27
Failure to Metabolic Decreased
produce Fatigue & hydrogen
acidosis
erythropoietin weakness excretion
Impaired
function of
RAAS
Chest pain
Decrease
Hiccups excretion of
nitrogenous
Anorexia waste
↑ rennin
Nausea &
secretion
vomiting
hypokalemia
Water retention
Edema
Vomiting
Hypertension
Anorexia
Muscle
cramps
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MEDICAL MANAGEMENT
A. Drug Study
31
and beverages that contain caffeine (tea, cola, coffee);
these increase stomach acid.
Tell client not to smoke; interferes with healing and drug’s
effectiveness
32
Brand Name Aldazide
Generic Name Spironolactone
Drug class K – sparing diuretics
Dosage 25 mg 1 tab BID
Indications Edema
Contraindications Acute renal insufficiency, anuria, hyperkalemia, pregnancy.
Adverse reaction Gynaecomastia, drowsiness, lethargy, rash, headache, mental
confusion, ataxia, impotence, menstrual irregularities,
agranulocytosis.
Mechanism of Action Promotes water and Na excretion and hinders potassium
excretion by antagonizing aldosterone in distal tubule.
Nursing Responsibilities Monitor electrolyte level, fluid intake and output, weight and
blood pressure.
Assess patient’s condition before starting therapy and
regularly thereafter to monitor drug’s effectiveness.
Maximum antihypertensive response may be delayed up to
2 weeks.
Be alert for adverse reactions and drug interactions.
33
Contraindications In pt. With metabolic and respiratory alkalosis, patients who are
losing chlorides from vomiting or continuous GI suction,
patients taking diuretics known to produce hypochloremic
alkalosis, patients with hypocalcemia in which alkalosis may
produce tetany, hypertension, seizures or heart failure; and
patients with acute ingestion of strong mineral acids.
Adverse reaction Belching, flatulence, gastric distension, hypernatremia,
hyperosmolaity, hypokalemia, metabolic alkalosis, iiritation and
pain in injection site.
Mechanism of Action Restore body’s buffering capacity and neutralizes excess acid.
Nursing Responsibilities To avoid risk of alkalosis, obtain blood pH, PaO2, PaCO2,
and electrolyte level.
If NaHCOe3 is being used to produce alkaline urine,
monitor urine pH every 4 – 6 hours.
Give drug with water, not milk; drug may cause
hypercalcemia, alkalosis or possibly renal calculi.
34
35
Risk factors:
B. Medi Map
Excessive intake of illegal
drugs
Laboratory and Diagnostic Test
Excessive alcoholic and Urinalysis Signs & symptoms:
carbonated drinker for Hematology Hyponatremia
about 5-7 bottles/day Serum electrolytes test: ↑ serum creatinine
Pathophysiology:
Proteinuria
In end stage renal disease (ESRD), the Potassium, chloride
Metabolic acidosis
blood flow to the kidneys may be drastically reduced Serum creatinie Anemia
due to all the damage to the filtering structures in the ABG analysis Anorexia, nausea & vomiting
kidney (the glomeruli). Urine output decreases as a
Ultrasound: KUB Hypertension
result, and toxic substances build up in the blood. The
Chest pain
sum effect of this is "uremia," a complex biochemical END-STAGE RENAL DISEASE Muscle cramps
syndrome that results from this toxic buildup. Blood Nursing interventions: Confusion
urea nitrogen and creatinine are two blood markers
Anasarca
that rise in renal disease. Electrolyte levels can also Turn the patient often & use a convoluted foam mattress to prevent skin Pallor
become deranged in renal disease.
breakdown.
Report signs of pericarditis such as pericardial friction rub and chest pain.
36
37
NURSING MANAGEMENT
Ineffective renal tissue
perfusion r/t decreased
hemoglobin
Impaired gas exchange concentration in blood.
r/t decreased O2 3. Imbalance nutrition: less
carrying capacity of the than body requirements r/t
blood loss of appetite and
vomiting.
42
the blood. production and thus RR = 20 bpm
Objective: elevate or maintain The
Bp = 140/100 mmHg RBC level. No any complaints of
RR = 21 bpm DOB.
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Encouraged to lungs.
perform foot exercises
every hour when This will promote
awake. venous return and
better circulation.
Encouraged a deep
breathing exercise. Promotes optimal lung
expansion.
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Serum creatinine = RBC level.
↑1679.6 umol/L Adminitered Amlodipine
45
(pyuria) antagonizing aldosterone
KUB: in distal tubule that leads
-Diffuse renal to decrease Bp.
parenchymal Administered
Furosemide 20 mg IVTT
disease, both Inhibits reabsorption of
q8h
kidneys. Na & Cl from the
- Renal cyst, proximal and distal
inferior pole, tubules & ascending limb
right kidney. of the loop of Henle,
leading to a Na-rich
dieresis that leads to
decrease Bp.
Provided O2 @ 2 Lpm
via nasal cannula. To provide oxygen
needed by the body for
Independent: functioning.
Monitored VS.
To monitor patient from
any changes in his
status. Elevated VS may
indicate poor circulation
and oxygenation.
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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
(+) fatigue
Administered Has significant
(+) weakness
Chlorpromazine antiemetic, hypotensive,
(+) anorexia
hydrochloride 50 mg ¼ and sedative effects;
(+) nausea &
tab HS moderated
vomiting.
anticholinergic and
(+) anasarca
extrapyramidal effects.
(+) right arm muscle
cramps
Independent:
(+) dry skin & lips Discouraged beverages These may decrease
that are caffeinated or appetite and lead to
Serum electrolytes: carbonated. early satiety and will
-K = ↓ 3.27 make the client feel
mmol/L full easily.
-Na = ↓ 129.5
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mmol/L Encouraged range of Metabolism and
motion exercise. utilization of nutrients are
enhanced by activity.
HOB.
Provided good oral Noxious tastes, smells,
and sight
hygiene and dentition. are prime deterrents to
Eliminated smells from appetite and can
produce nausea and
the environment. vomiting with increased
respiratory difficulty.
Reduces gastric
stimulation & vomiting
response
To prevent abdominal
distention
Junk foods
have
empty calories that
provide no nutritional
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help to the client.
To provide ample
information and
Instructed to avoid gas- awareness.
producer, very hot & very
cold foods
To provide nourishment
needed by the body for
Instructed to
avoid junk foods. metabolic demand.
Encouraged to eat.
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Subjective: 4.Impaired urinary To relieve abdominal Dependent: Inhibits reabsorption of Goal met.
“Indi ako kaihi”, as elimination r/t discomfort & eliminate Administered Na & Cl from the
verbalized. diminished renal retention of urine after 30 Furosemide 20 mg IVTT proximal and distal Obtained 80 cc of clear
function. mins of nursing q8h tubules & ascending limb urine after
Objective: intervention. of the loop of Henle, catheterization.
Bp = 140/100 mmHg leading to a Na-rich
(+) anasarca dieresis. Reported relief of
Distended urinary hypogastric area.
bladder
(+) Oliguria Administered Aldazide Promotes water and Na Total urine output within
(+) fatigue 25 mg 1 tab BID excretion and hinders the shift = 210 cc.
potassium excretion by
(+) weakness
antagonizing aldosterone
Pain @ hypogastric Independent: in distal tubule.
area Monitored VS.
No urine output for 7 To evaluate any
hours manifestation caused by
(+) tenderness abdominal discomfort &
Intake exceeds bladder retention like BP,
output. I = 230 cc, O RR, AR.
= 120 cc
Monitored I & O. Provides information
Difficulty upon about kidney function
urination and presence of
Adm. Dx: CKD 2° to complications.
nepholithiasis
Maintained client Allows relaxation of
Urinalysis: on semi-fowler’s or abdominal & perineal
- RBC/hpf = ↑3 – 8 position of comfort muscles to promote
/ hpf bladder emptying.
(hematuria)
- WBC/hpf = ↑8 –
23 / hpf
(pyuria) Foley catheter inserted & To facilitate elimination
KUB: secured as order. of urine that can
-Diffuse renal decrease abdominal
parenchymal discomfort.
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disease, both
kidneys. Demonstrated proper To facilitate drainage
-Renal cyst, positioning of catheter and prevent reflux.
inferior pole, drainage tubing and bag.
right kidney.
Provide catheter care. To prevent ascending
UTI which may
aggravate the condition
Subjective: 5. Fluid volume excess To stabilize fluid volume Dependent: Inhibits reabsorption of Goal met.
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“Nagpalanghabok r/t the excessive within the shift. Administered Na & Cl from the
gidman sa”, as accumulation of fluid Furosemide 20 mg IVTT proximal and distal Bp = 130/90mmHg
verbalized by the folks. in the interstitial space q8h tubules & ascending limb
2° to ↑ hydrostatic of the loop of Henle, RR = 20 bpm
Objective: pressure. leading to a Na-rich
Bp = 140/100 mmHg dieresis. (-) DOB
RR = 21 bpm
(+) DOB Administered Aldazide Promotes water and Na Total urine output within
Abdominal girth = 94 25 mg 1 tab BID excretion and hinders the shift = 210 cc.
cm potassium excretion by Total fluid intake = 190
(+) anasarca antagonizing aldosterone cc.
in distal tubule.
(+) anorexia
Distended urinary Provided O2 @ 2 Lpm To provide oxygen
bladder via nasal cannula. needed by the body for
(+) of bruits in 4 functioning.
abdominal quadrants
upon auscultation.
(+) weight gain over Independent:
a short period of Monitored & recorded To obtain baseline data
time. Weight before vital signs
admission = 68 kg,
current weight = 72
kg. Instructed to limit fluid & To monitor kidney
Fluid intake exceeds Na intake. function and fluid
output. Intake = 230 retention
cc, output = 120 cc.
(+) fatigue Elevated edematous This increases venous
(+) weakness extremities. return and, in turn,
decreases edema.
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Encouraged quiet, restful To conserve energy &
atmosphere. lower tissue oxygen
demand.
Subjective: 6.Pain r/t the To demonstrate a relief Dependent: Goal met as evidenced
“Gasakit man gyapon accumulation of toxic of pain as evidenced by Provided O2 @ 2 Lpm To provide an oxygen by a decreased in pain
akon dughan”, as substances 2° decreased pain scale of via nasal cannula as needed by the body for scale of 2.
verbalized. impaired renal 2 or 3 after 4 hours of ordered. compensation.
function. nursing intervention. RR = 20 bpm
Objectives: Independent:
Bp = 140/100 mmHg Provided comfort Promotes relaxation, (-) DOB
RR = 21 measures & an reduces muscle tension,
(+) DOB environment conducive and enhances coping. (-) facial grimace
(+) weakness for rest.
(+) fatigue
To monitor client’s pain
(+) pallor
Monitored V/S. status. Pain can cause
(+) hiccups elevation of VS.
(+) facial grimace
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(+) anterior chest This position makes
pain with a pain Assisted to sit on chair. patient comfortable &
scale of 5. helps in relieving client’s
(+) anorexia pain.
Adm. Dx: CKD 2° to
Nephrolithiasis. Encouraged to limit Water and Na retention
intake of fluid & Na – rich in the body may
Serum creatinine =
foods. contribute to the chest
1679.6 umol/L
pain & discomfort as the
fluids accumulate in the
chest cavity.
Subjective: 7. Altered comfort r/t To provide pt’s comfort Independent: Goal partially met.
“Ginasinidoh ako”, as persistent hiccup. within the shift. Provided rest periods. To facilitate comfort,
54
verbalized. sleep, and relaxation. Still have a complaint of
discomfort but the
Objective: Provided diversional Distraction techniques episodes had lessen.
Bp = 140/100 mmHg activities like watching TV heighten one’s
RR = 21 bpm and talking with others. concentration upon non- “Nag-ayo-ayo na yanda‘,
(+) DOB painful stimuli as verbalized.
(+) facial grimace to decrease one’s
(+) persistent hiccup awareness
(+) weakness
Provided relaxation Relaxation exercises
(+) fatigue techniques and cheerful Techniques are used
Chest pain conversations. to bring about a state of
progresses during physical and
hiccups. mental awareness and
tranquility.
55
- Na = ↓ 129.5 sheets to move patient in
mmol/L bed and discourage
-Creatinine = patient or caregiver from
↑1679.6 elevating HOB
umol/L repeatedly.
56
DISCHARGE PLANNING
edications
Encourage the patient to have a strict compliance with regards to the medication to attain
therapeutic effects.
Explain to the patient the use and side effects of the medications so that he will be aware
of its effects.
Give adequate instructions to the significant others about the importance of the following
medications and dietary regimens so that the patient’s condition can remain stable as
soon as possible.
xercise
Instruct the patient to practice moving his lower extremities to promote blood circulation
and even to improve the range of motion of his foot or feet so that he could somehow, able
to ambulate with himself in later times.
Educate the patient about bed exercises such as leg exercise, since patient is always on
bed and have limitations on his physical activity because his still weak.
Teach how to perform range-of-motion exercises because it helps reduce stiffness and
maintain or increase proper joint movement and flexibility.
reatment
Aware the patient to avoid over work for the following days and must have adequate bed
rest to regain energy or strength.
By means of anticipating the needs on the course of healing and curing process,
train the patient to focused to himself by not always depending on the interventions that
are not highly needed just to ease or prevent any health problem regarding his condition.
ome teaching
To promote adherence to the therapeutic programs. Teach the following:
Weighed self every morning to avoid fluid overload.
Measure alloted fluids and save some for ice cubes, sucking on ice is thirst quenching.
57
Eat food before drinking fluids to alleviate dry mouth.
ut-patient
Remind the patient that he must come back to the hospital one week after, for the follow-
up check-up to confirm if the patient’s condition is really restored. Also to know if there are
complications sited during the check up to know if patients condition have worsen or not.
Advise patient and the family to report to the physician if any recurrence or severity of
symptoms, any adverse effects to the medication, and any development of complications.
iet
Instruct him to avoid foods high in phosphorus, potassium & sodium because it can lead
to high probability of current of many diseases. These foods also can build up in the
bloodstream & can cause harm when they cannot eliminate by the kidneys.
Encourage cessation of toxic substances such as alcohol and illegal drugs in order to
prevent totally the worsening again of the problem and it can damage the kidneys by
causing a decrease in renal blood flow, obstructing urine flow, directly damaging
tubulointestinal structures or by producing hypersensitivity reaction.
Advise to eat nutritious food would somehow help the patient on regaining some strengths
or energy to his body, such as green leafy vegetables
Inform the client and the client’s relatives on the specific types of food that may help
speed up the recovery from the condition.
pirituality
Encourage the patient to read the Bible and pray to God always, ask for guidance and
pray for the healing and restoration of health.
Ask the patient to reflect on the Bible Scripture, “For I will restore health to you and heal
you on your wounds.” says the Lord. (Jeremiah 30:17).
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