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I.

INTRODUCTION

Chronic or irreversible, renal failure is a progressive reduction of


functioning renal tissue such that the remaining kidney mass can no longer
maintain the body’s internal environment. CRF can develop insidiously over
many years, or it may result from an episode of a cure renal failure from which
the client has not recovered. The incidence of CRF varies widely by state and
country. In the United States, the incidence is 268 new cases per million
populations.
Chronic renal failure affects many body systems. It can also lead to many
complications. This is the goal of health care providers, to prevent any
occurrence of complications. One of the complications of CRF is
hyperparathyroidism; this is due to the compensatory mechanism of the
parathyroid hormone once it detects any alteration in the calcium level of the
body.
It is important for clinicians to recognize the problem of
hyperparathyroidism early in the course of chronic kidney disease so that growth
of the parathyroid glands can be prevented or halted, and excessive secretion of
hyperthyroidism can be controlled to help minimize the adverse consequences
on bone and mineral metabolism, which may lead to bone pain and bone
fractures, decreased growth in children, muscle weakness, and elevations in the
calcium phosphorus product, which contributes to calcification of the heart
valves and blood vessels and contributes to the high cardiovascular mortality in
patients with advanced kidney disease.
Early detection of this complication of chronic kidney disease will provide
an opportunity to intervene to control the secretion of parathyroid hormone and,
thus, minimize the problem. Early detection will also allow for the opportunity to
prevent further growth of the parathyroid glands so that the magnitude of the
problem will be lessened as kidney function deteriorates. There is also some
evidence that the control of hyperparathyroidism may help to slow the
progression of kidney disease. Ultimately, it is hoped that with timely intervention

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to control this complication of chronic kidney disease, improved patient outcomes
on in terms of morbidity and mortality will be achieved.
To ensure that the diagnosis of hyperparathyroidism is made early in the
course of chronic kidney disease, it is important to educate primary care
physicians, cardiologists, endocrinologists and other healthcare providers who
may see patients in the early stages of chronic kidney disease, so that they may
assess blood parathyroid hormone levels to uncover this complication and either
embark on the treatment of hyperparathyroidism or consider referral to a
nephrologist for further advice on the appropriate management strategies.
Referral to a nephrologist would appear to be preferable at the present time as
the field is advancing with new therapies being evaluated and implemented in
practice.
At the American Society of Nephrology Renal Week 2004 meeting, results
are being presented on the administration of oral paricalcitol, now in capsular
form, so that its use can be evaluated in patients with earlier stages of kidney
disease (stage III and IV), who are not yet on dialysis. The phase 3 studies of
orally administered paricalcitol showed that this strategy is effective in reducing
the degree of hyperparathyroidism, and that the administration of this vitamin D
analog is not associated with hypercalcemia, hyperphosphatemia, or
hypercalcuria. Thus, the treatment was effective and well tolerated and appeared
to be free of side effects. These studies are important because they provide a
new therapy for the complication of hyperparathyroidism in the course chronic
kidney disease, and, thus, if the diagnosis of this complication can be made
earlier in the course of chronic kidney disease, treatments such as oral
paricalcitol may be effective in managing this complication.
As nurses, we could help our patients by having a deep understanding of
the disease, that we may learn the proper interventions for the chronic kidney
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 chronic

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kidney disease. As nurses, 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, 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.

II. NURSING ASSESSMENT

A. Personal Data and History (Demographic Data)

Mr. x is a 53-year-old male, married living at x. He was born on September


16, 1952 in Laguna. He is married for 29 years now and has six children. He was
not able to finished his desired career during his college years because their
family business was suddenly went bankrupt. According to Mr. x, education is
important that’s why he decided to look for more affordable career. While
studying he decided to work to be able to support his education. With his
perseverance and determination, he was able to finished aircraft maintenance.
But with all of this stress and difficulties happening in his life, he learned how to
smoke. According to him, smoking helps him to be relaxed. He consumed 8
sticks/day. He was also an occasional drinker. He worked as aircraft
maintenance in Clark Air Base in Pampanga for more than 20 years.
Mr. x said that he is fond of eating meat and poultry products. After work,
he only stays at home because he feels very tired after work. At present, he still
works as aircraft maintenance in Clark Air Base in Pampanga.
Mr. x was admitted in x last February 3, 2005. He was admitted due to
body weakness and severe anemia. He was discharged on February 10, 2005.

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B. Family Health-Illness History

Mother Side Father Side


Lola (+) Lolo Lola Lolo (+)
D HPN

Mo
Po
ma
p

Mr. x
(+) HPN
(+)Kidney
Failure

C. History of Past Illness

Mr. x was known for being hypertensive for 5 years now. He was
diagnosed of hypertension and kidney failure last x. He was hospitalized in St.
Luke’s Hospital because of the said health problem. According to him, his chief
complain that time was only hypertension. He was discharged from the hospital
after six days of confinement. After his discharge, Mr. x consistently having his
blood chemistry and creatinine check-up every month in AUFMC. If the results
are all normal, his check-up becomes every month. These all became routine on
him.

On May 2004, he was hospitalized for the second time in AUFMC. After
two days of confinement in the hospital, he decided to transfer in St. Luke’s
Hospital. Mr. Bean experienced difficulty of breathing and fatigability that time.
He was diagnosed of Pulmonary Congestion.

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D. History of Present Illness

Four days prior to admission, Mr. x experienced easy fatigability. No other


accompanying signs and symptoms. His condition was persisted until one day
prior to admission, he already experiencing body weakness, body malaise, pallor
and fatigability that’s why he consulted AUFMC. He was advised to have
laboratory examination (Hgb and Hct), which revealed anemia and he was
advised to be admitted. His initial vital signs were as follows: T-36.8, RR- 22, PR-
64, BP- 170/100.

E. Physical Examination
February 3, 2005
Upon Admission:
VS:
T - 36.8
RR - 22
PR - 64
BP - 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips

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F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender

GIT: loss of appetite


Renal and Urologic changes: fatigability, oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Skeletal changes: hypocalcemia and hyperphosphatemia

February 7, 2005
Vital Signs:
T - 36
RR - 22
PR - 81
BP - 170/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales

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Abdomen- soft, flat, tender
Cardiovascular changes: hypertension
Renal and urologic changes: oliguria
Hematopoietic changes: anemia

February 8, 2005

Vital Signs:
T - 36.2
RR - 16
PR - 80
BP - 170/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender

Renal and Urologic changes: oliguria


Cardiovascular changes: hypertension

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February 9, 2005

Vital Signs:
T - 36.4
RR - 20
PR - 71
BP - 160/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia

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February 10, 2005

Vital Signs:
T - 37
RR - 17
PR - 85
BP - 180/90

Integumentary
C. Skin- pallor, brown in complexion, with good skin turgor
D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
H. Scalp- hair evenly distributed without any presence of lice and lesions
I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
J. Ears- symmetrical with cerumen, no discharges noted
K. Nose- without flaring of nostrils, no discharges noted
L. Mouth- (-) pallor
M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
N. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia

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F. Diagnostic and Laboratory Procedures

Date Normal
Diagnostic/ Ordered Values
Indication (s) Analysis and
Laboratory Date Result used by
Purpose (s) Interpretation
Procedure Result the
in hospital

1. CBC

Hgb Ordered Usually done 72 120-170 Results were


2/3,4,6, to a pt. with 103 g/L all below the
8,9/05 renal disease 107 normal level,
to determine 118 thus indicating
Result: if the 109 renal
2/3,4,6, kidney’s malfunction
8,9/05 ability to and thereby
release causing
erythorpoieti anemia
n factor is
Hct Ordered already .23
2/3,4,6, affected .31 .40-.50
8,9/05 .33
Used to .36 Result were all
Result: measure RBC .32 below the
2/3,4,6, number and normal range
8,9/05 volume. It is thus, showing
an integral anemia and
part of the renal disease
WBC Ordered evaluation of 7.76
Leukocytes 2/3,4,6, anemic 6.01 5-
8,9/05 patients 9.40 10x109/L
8.58
Result: 9.5 Results were
2/3,4,6, all above
8,9/05 Determines normal level.
any This shows
inflammation presence of
Neutrophils Ordered and infection .81 inflammation
2/3,4,6, .75 and infection
8,9/05 .71 .50-.70
Result: .72
2/3,4,6, .74
8,9/05
Results were

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Determines all above
any acute normal level.
Lymphocytes Ordered bacterial .1 This shows
2/3,4,6, infection .13 presence of
8,9/05 .20 .10-.40 bacterial
.15 infection
Result: .13
2/3,4,6,
8,9/05

Monocytes Ordered Determines .05


2/3,4,6, any chronic .08 Results were
8,9/05 bacterial .04 .00-.07 all within
infection or .09 normal level.
Result: viral infection .07 Showing
2/3,4,6, absence of
8,9/05 chronic
infection

Determines
Eosinophils Ordered any acute .04
2/3,4,6, bacterial .04
8,9/05 infection .05 .00-.07 Some of the
.04 results were all
Result: .06 above normal
2/3,4,6, Level
8,9/05 indicating
presence of
bacteria.

To determine
any allergic
reaction of
the body
Results were
all within the
normal level.
This shows no
allergic
reactions.

Nursing Responsibilities:

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1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding

Diagnosti
Date
c/ Analysis and
Ordered Indication (s)
Laborator Result Interpretatio
Date Purpose (s)
y n
Result in
Procedure

2. Ordered: This is usually HBSAG- non-reactive Result


Hepatitis 2/3/05 done before ANTI-HCV- non- revealed
Profile proceeding in reactive that the
Performe hemodialysis. ANTI-HBC- non- patient has
d: This is to reactive no hepatitis
2/5/05 determine if ANTI-HBS-reactive virus and
the patient was HAV-IGM- non- was not
expose to the reactive exposed to
virus of if there any of it.
is presence of
hepatitis virus
In the blood of
the patient.

Nursing Responsibilities:

1. Explain the procedure to the patient


2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site

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4. Handle the specimen as if it were capable of transmitting hepatitis
5. Immediately discard the needle in the appropriate receptacle
6. Send the specimen to the laboratory promptly

Normal
Date Indication Analysis
Diagnostic/ Values
Ordered (s) and
Laboratory Result used by
Date Purpose Interpretati
Procedure the
Result in (s) on
hospital

3.Urinalys Ordered: To Color: straw, Laboratory


is 2/3,6,7/0 diagnose light yellow, results
5 and light yellow revealed
monitor that there
Result: renal or Appearance: is presence
2/3,6,7/0 urinary slightly turbid of albumin
5 tract in the
disease pH: 5 blood; this
indicates
Specific Gravity: that the
1.020, 1.025, glomerular
1.020 cannot
filter large
Albumin: molecules
3+ such as
that of
Sugar: negative albumin. It
also
revealed
Pus Cells: 1- that there
2/HPF, 0-2/HPF, is bacterial
2-5 /HPF infection
as
Red cells: 1- evidenced
3/HPF, by
1-3/HPF,4-6/HPF presence
of bacteria,
Epithelial Cells: pus cells
Rare and red
cells in the
Mucus thread: urine.
Rare, (-), (-)

Bacteria: (-),

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few, (-)

Amorphous
urates:
Moderate,
moderate, few

Nursing Responsibilities:

1. Explain the procedure to the patient


2. Tell the patient that no fasting is required
3. Instruct the patient to catch the midstream urine for better result
4. Send the specimen to the laboratory promptly

Normal
Date
Diagnostic/ Indication Values Analysis and
Ordered
Laboratory (s) Result used by Interpretatio
Date
Procedure Purpose (s) the n
Result in
hospital

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4. Ordered: This test 1499 44.20- Results
Creatinin 2/3,4,6,8/0 was 1430 150.30 were all
e 5 ordered in 1649 umol/L above the
order to 731 normal level
Result in: evaluate indicating
2/3,4,7,9/0 renal renal
5 function. malfunction.
The kidney
cannot
excrete
nitrogenous
waste
product of
137 protein
135-150 leading to
5. Na+ Ordered: To mmol/L its
2/3/05 evaluate accumulatio
fluid and n in the
Result in: electrolyte blood
2/3/05 imbalance
and 4.78 Normal
identify 3.5-5.5 result which
6. K+ Ordered: renal mmol/L means
2/3,6/05 dysfunctio there is still
n fluid and
Result in: electrolyte
2/3,7/05 To balance
evaluate 6.4
fluid and 8.5-10.5
7. Ordered: electrolyte mg/dl Normal
Calcium 2/3/05 imbalance result which
and means
Result in: identify there is still
2/3/05 renal fluid and
dysfunctio electrolyte
n 186 balance
30-150
Ordered: To u/L
8. 2/3/05 evaluate Results
Phosphat muscle were all
e Result in: contraction above the
2/3/05 , nerve normal level
impulse indicating
transmissi renal
on, and malfunction.

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blood
clotting

To Results
evaluate were all
the above the
metabolis normal level
m of indicating
carbohydra renal
tes, bone malfunction.
formation
and acid-
base
balance.

Nursing Responsibilities:

1. Explain the procedure to the patient

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2.Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding

III. ANATOMY AND PHYSIOLOGY

Function of the Urinary System


The major functions of the urinary systems are performed by the kidneys
and the kidneys plays the following essentials roles in controlling the composition
and volume of body fluids:
1. Excretion. The kidneys are the major excretory organs of the body. They
remove waste products, many of which are toxic, from the blood. Most waste
products are metabolic by- products of cells and substances absorbed from
the intestine. The skin, liver, lungs, and intestines eliminate some of these
waste products, but they cannot compensate if the kidneys fail to function.
2. Blood volume control. The kidneys play an essential role in controlling
blood volume by regulating the volume of water removed from the blood to
produce urine.
3. Ion concentration regulation. The kidneys help regulate the concentration
of the major ions in the body fluids.
4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in
the blood and the respiratory system also play important roles in the
regulation of pH
5. Red blood cell concentration. The kidneys participate in the regulation of
red blood cell production and therefore, in controlling the concentration of red
blood cells in the blood.
6. Vitamin D synthesis. The kidneys. Along with the skin and the liver,
participate in the synthesis of vitamin D.

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Kidneys
The kidneys balance the urinary excretion of substances against the
accumulation within the body through ingestion or production. Consequently,
they are major controller of fluid and electrolyte homeostasis. The kidneys also
have several non-excretory metabolic and endocrine functions, including blood
pressure regulation, erythropoietin production, insulin degradation, prostaglandin
synthesis, calcium and phosphorus regulation and Vitamin D metabolism.
The kidneys are located retroperitoneally, in the posterior aspect of the
abdomen. On either side of the ventral column. They lie between the 12 th thoracic
and third lumbar vertebrae. The left kidney is usually positioned slightly higher
than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5
cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved
shape, with a convex distal edge and a concave medial boundary.

Ureters, Urinary Bladder and Urethra


The ureters are small tubes that carry urine from the renal pelvis of the
kidney to the posterior inferior portion of the urinary bladder. The urinary bladder
is a hollow muscular container that lies in the pelvic cavity just posterior to the
pubic symphysis. It functions to store urine, and its size depends on the quantity
of urine present. The urinary bladder can hold from a few milliliters to a maximum
of about 1000 mL of urine. When the urinary bladder reaches a volume of a few
hundred mL, a reflex is activated, which causes the smooth muscle of the urinary
bladder to contract and most of the urine flows out of the urinary bladder through
urethra. The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle-shaped portion of the urinary bladder located between the
opening of the ureters and the opening of the urethra is called trigone. The
urethra carries urine from the urinary bladder to the outside of the body.
Renal Blood flow and Glomerular Filtration
The kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of he second lumbar

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vertebra, enter the kidney, and progressively branch into lobar arteries. Blood
flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the
peritubular capillaries carry a small amount of blood to the renal medulla in the
vasa recta before entering the venous drainage. The blood leaves the kidney in
venous system closely corresponding to the arterial system: interlobular veins,
arcuate veins, interlobar veins, and the renal vein. The renal circulation then
empties into the inferior vena cava.

Physiology
Characteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are
removed from the plasma and eliminated by the kidneys. It is 5% water and 5%
dissolved solids and gases. The amount of these dissolved substances is
indicated by it specific gravity. The specific gravity of pure water, used as a
standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are
diseased, they lose the ability to concentrate urine, and the specific gravity no
longer varies as it does when the kidneys function normally.
Urine formation
The chief function of the kidneys is to produce urine. Each part of the
nephrons performs a special function. There are three important processes by
which urine is formed. They are glomerular filtration, tubular reabsorption and
tubular secretion

The path of the Formation of Urine

Passes To Bowman’s Now it becomes


Blood enters capsule filtrate (blood
through the
the minus RBC’s and
Glomeruli plasma
Efferent
protein

To the To the distal


collecting To the loop of Continues through the
tubuleconvulated tubule
(at this about proximal 19
convulated
Henle 1 ml of
Approximately The 1 ml of urine
To the
99% urinary
of the filtrate urine is formed per goestubule
to the renal
meatus
has been To the To the To the
minute pelvis
urethra bladder ureter
Fluid and Electrolyte Balance
Electrolyte Balance
Electrolytes are important constituents of body fluids. These are
compounds that separate into positively and negatively charged ions and carry
an electric current in solution. The main source of electrolytes is food. A few of
the most important ions are considered here.
1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid
volume. It is the main positive in extracellular fluids. Sodium is required for
nerve impulse conduction and is important in maintaining acid-base balance.
2. Potassium- important in the transmission of nerve impulse; a major positive
ion in the intracellular fluids. It is involved in cellular enzyme activities and
helps regulate the chemical reactions by which carbohydrate is converted to
protein.
3. Calcium-required for bone formation, muscle contraction, nerve impulse
transmission, and blood clotting
4. Phosphate- essential in the metabolism of carbohydrates, bone formation and
acid-base balance. They are found in the cell membrane and in the nucleic
acids.
5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.

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Electrolytes must be kept in the proper concentration in both intracellular and
extracellular fluids. Although some electrolytes are lost in the feces and through
the skin as sweat, the job of balancing electrolytes is left mainly to the kidneys.
There are several hormones that are involved in this process. Aldosterone
produced by the adrenal cortex promotes the reabsorption of sodium and the
elimination of potassium. Hormones from parathyroid and thyroid glands regulate
calcium and phosphate levels. Parathyroid hormones increases blood calcium,
levels by causing the bones to release calcium and by causing the kidneys to
reabsorb calcium. The thyroid hormone calcitonin lowers blood calcium by
causing calcium to be deposited in the bone.

IV. THE PATIENT AND HIS ILLNESS


SYNTHESIS OF THE DISEASE (CLIENT CENTERED)

Chronic Renal Failure

Chronic or irreversible, renal failure is a progressive reduction of


functioning renal tissue such that the remaining kidney mass can no longer
maintain the body’s internal environment. Chronic Renal failure can develop
insidiously over many years, or it may result from an episode of acute renal
failure from which the client has not recovered.

Precipitating Factors
 Chronic glomerular disease such as glomerunephritis
 Chronic infections such as chronic pyelonephritis or tuberculosis
 Congenital anomalities such as polycystic
 Vascular diseases, such as renal nephrosclerosis or hypertension
 Obstructive processes such as calculi
 Collagen diseases such as systemic lupus erythematosus
 nephrotoxic agents such as long-term aminoglycoside
 endocrine diseases such as diabetic neuropathy

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Such conditions gradually destroy the nephrons and eventually cause
irreversible renal failure. Similarly, acute renal failure that fails to respond to
treatment becomes chronic renal failure.

Predisposing Factors
 Sex- both sexes are affected by chronic renal failure. But in 1998, based on
United States Renal Data System, a higher total number of males with ESRD
was found
 Age- CRF can be found in people of any age, from infants to the very old.
The elderly population also is the most rapidly growing ESRD population in
the United States. Note that age 30 years progressive physiological
glomerulosclerosis. Aging also results in concomitant progressive
physiological decrease in muscle mass such that daily urinary creatinine
excretion also decreases.

Clinical Manifestations
The clinical manifestations of CRF are present throughout the body. No
organ system is spared.
 Electrolyte imbalances
Electrolyte balance may be upset by impaired excretion and
utilization in the kidney. Although many clients maintain normal serum
sodium level, the salt-wasting properties of some failing kidneys, in
addition to vomiting and diarrhea, may cause hyponatremia. Because the
kidneys are efficient at excreting potassium, potassium levels usually
remain within normal limits until late in the disease.
Several mechanisms contriburte to hypocalcemia. Conversion of
25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to
absorb calcium) is decreased, which results in reduced intestinal
absorption of calcium. At the same time, phosphate is not excreted, which
causes hyperphosphatemia. Because calcium and phosphate are

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inversely related, a high phosphate level results in a reduced calcium
level.
 Metabolic changes
In advancing renal failure, BUN and serum creatinine rise as waste
products of protein metabolism accumulate in the blood. The serum
creatinine level is the most accurate measure of renal function. The
proteinuria accompanying renal disease and sometimes inadequate
dietary intake of proteins cause hypoproteinuria, which lowers the
intravascular oncotic pressure. Metabolic acidosis occurs because of the
kidney’s inability to excrete hydrogen ions. Decrease reabsorption of
sodium bicarbonate and decreased formation of dihydrogen phosphate
and ammonia contribute to this problem. Acidosis accentuates
hyperkalemia and the reabsorption of calcium from the bones.
 Hematologic changes
The primary hematologic effect of renal failure is anemia, usually
normochromic and normocytic. It occurs because the kidneys are unable to
produce erythropoietin, a hormone necessary for red blood cell production.
Frequently, the fatigue, weakness, and cold intolerance accompanying the
anemia lead to a diagnosis of renal failure.
 Gastrointestinal changes
The entire gastrointestinal system is affected. Transient anorexia,
nausea, vomiting are almost universal. Clients often experience a constant
bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or
ammonia-like. Stomatitis, parotitis and gingivitis are common problems
because of poor oral hygiene and the formation of ammonia from salivary
urea. Accumulations of gastro may be a major cause of ulcer disease.
Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be
present. Serum amylase level may be increased, although they do not
necessarily indicate pancreatitis.
 Immunologic changes

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Impairment of the immune system makes the client more susceptible
to infection. Several factors are involved, including depression of humoral
antibody formation, suppression of delayed hypersensitivity and decreased
chemotactic function of leukocytes. Immunosuppression is an important part
of the medical management of renal diseaes such as glomerulonephritis.
 Cardiovascular changes
The most common clinical manifestation is hypertension, produced
through:
mechanism of volume overload, stimulation of the renin-angiotensin system,
sympatheically mediated vasoconstriction, absence of prostaglandins.
 Respiratory changes
Some of the respiratory effects such as pulmonary edema can be
attributed to fluid overload. Metabolic acidosis causes a compensatory
increase in respiratory rate as the lungs try to eliminate excess hydrogen
ions.
 Musculoskeletal changes
The etiologic mechanism involves the kidney-bone-parathyroid and
calcium-phosphate-vitamin D connections. As the GRF decreases, the
phosphate excretion decreases and calcium elimination increases. Abnormal
levels of calcium and phosphate stimulate the release of parathyroid hormone
that mobilizes calcium from the bones and facilitates phosphate excretion.
 Integumentary changes
The skin is also often very dry because of atrophy of the sweat glands.
Severe and intractable pruritus may result from secondary
hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is
evident.

V. The Patient and his Care

A. Medical Management
Medical Date General Indication Client’s Client’s

24
initial
ordered response
Manageme (s) reaction to
Date Description to the
nt Purpose (s) the
performed treatment
treatment

1. D5 LRS iL x Ordered: To Patient felt Patient


KVO 2/3,7,9/05 maintain discomfort fluid status
Performed: fluid was
2/3,7,9/05 balance of maintained
Changed: the pt.
2/3/05
D/C
2/10/05
2. D5 NaCl iL x
KVO Ordered: A
2/3/05 crystallized Patient
Performed: solution To fluid status
2/3/05 that is maintain was
available in fluid maintained
a variety of balance of
concentrat the pt.
ed water
and
calories
are
provided. It
is
hypertonic
3. Ordered: solution Patient
Subclavian 2/7/05 containing experience
catheteriz Performed: equal d bleeding
ation 2/7/05 amounts of and felt
Na and Cl discomfort Patient did
on incision not show
A catheter site any further
tube is bleeding
inserted Temporary
into vein in access for
either your hemodialy
Ordered: neck, sis
2/3/05 chest, leg
4.Blood or near the During the
Transfusi Performed: groin. It blood
on 2/3/05 has two transfusion
chambers , patient Patient did
to allow was manifest

25
two-way chilling for some
flow of a short reaction
blood To period of such as
immediatel time. chilling but
It is y restore There was there was
intravenou blood no further not further
s volume to adverse reaction
replaceme treat reaction after the
Ordered: nt of loss severe noted upon treatment
2/7,8,9/05 or anemia, to the
5. destroyed be able to transfusion
Hemodial Performed: blood maintain
ysi 2/7,8,10/0 compatible oxygen
s 5 citrated transport
human to the Patient
blood it is different was
also the parts of slightly There was
introductio the body nervous no adverse
n of whole about the reaction
blood or treatment noted
blood . during and
Componen after the
t procedure
It is
indicated
for the
Medical patient
treatment because
used to the
promote kidneys
excretion cannot
of wastes function
materials very well
from the to excrete
blood of the
patient. nitrogenou
s waste
products,
thus
leading to
its
accumulati
on in the
blood.

Nursing Responsibilities

26
1. Blood transfusion
Before
a. Assess client for history of previous BT and any adverse reactions
b. Ensure that the client has an 18 to 19 gauge IV catheter in place
c. Use 0.9% sodium chloride IVF
d. Verify the ABO group, Rh type, client and blood numbers and expiration
date.
e. Take baseline vital signs before initiating BT
f. Identify the patient prior to transfusion
g. Explain the purpose of the transfusion

During
a. Start transfusion slowly
b. Maintain prescribed transfusion rate
c. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post
transfusion
After
a. Monitor for adverse reactions
b. Documentation

2. Hemodialysis

Before
a. Explain the purpose of the transfusion
b. Have client void
c. Chart client’s weight
d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension
(unless ordered otherwise)
During

27
a. Obtain and record vital signs before and every 30 mins. during the
procedure
b. Ensure bedrest with frequent position changes for comfort
c. Proper heparinization must be done to prevent coagulation during the
therapy
d. Inform client that headache and nausea may occur
e. Monitor closely for bleeding since blood has been heparinized for
procedure
After
a. Weight the patient after the therapy and record
b. Monitor vital signs especially hypotension.
c. Assess for complications (hypovolemic shock, dialysis disequilibrium
syndrome)
Date
ordered Route of
Client’s
Date admin. Indication
Name of General response
Taken Dosage (s)
Drug action to
Date and freq. Purpose(s)
medication
changed or Of admin.
D/C

Amlodipi Ordered:
ne 2/3/05
besylate
Taken: PO 5 mg Calcium To Patient did
antagonist,
• norvas 2/3-10/05 decrease not show
OD antihyperte
nsive
increase any side
c blood effects
pressure

Metoprol Ordered:
ol tartate 2/3/05 Beta Patient did
PO 50 mg blockers, To decrease not show
• neoblo Taken: OD antihyperte increase any side
2/3-10/05 nsive drug blood effects
c pressure

28
Ordered:
2/3/05
Iron Patient’s
stool was
Taken: PO 1 cap deficiency
For patient dark green
Iberet- 2/3-10/05
BID having in color
folic acid
anemia
changed:
2/3/05

Ordered:
2/3/05
Patient did
not show
furosemi Taken: Diuretic
any side
2/3-10/05
de PO 40 mg For oliguric effects
patient
• lasix OD

Ordered:
2/3/05

Taken:
Patient did
2/3-10/05 Calcium
To treat not show
supplemen
calcium PO 1 tab. hypocalce any side
D/C: t
carbonat mia effects
2/3/05 TID
e

Nursing Responsibilities

Prior:
1. Check and determine the prescribed the drug.
2. Inform the patient about the prescribed the drug.
3. Explain the procedure, purpose, indication and side effects of the drug.

During:
1. Check vital signs to obtain baseline data.

29
2. Monitor BP
3. Prepare the drug and the materials
4. Observe for initial assessment.
5. Observe for any initial response to the treatment.

After:
1. Observe for any intolerance and side effects on the prescribed drug.

Date ordered Client’s


General Indication (s)
Type of diet Date started response to
description Purpose (s)
Date changed the diet

DAT Ordered: Any foods To provide Patient


2/3/05 and fluids nutrients followed the
Started: that are needed by diet
2/3/05 being the body
Changed: tolerated by
2/3/05 the patient

Low salt, Ordered:


low protein 2/3/05 To decrease Patient
Started: Foods that further strictly
2/3-10/05 has low salt production of complied with
and protein purine which the
value can prescribed
contribute in diet
increasing
level of
creatinine in
the blood

Nursing Responsibilities

Prior:
1. Check and determine the prescribed diet
2. Inform the SO about the prescribed diet
3. Explain the procedure and purpose of the prescribed diet
4. Cite foods that are restricted.

30
During:
1. Check vital signs to obtain baseline data
2. Observe for initial response.

After:
1. Inform SO if it would be changed
2. Observe and monitor for changes

Date ordered Client’s


Type of General Indication (s)
Date started response to
activity description Purpose (s)
Date changed the activity

Bed rest Ordered: An activity To decrease Patient


2/3/05 wherein the consumption strictly
Started: patient is not of oxygen complied with
2/3-10/05 allowed to do and to be the
any activity. able to prescribed
Patient stays conserve activity
at bed. energy

Nursing Responsibilities

1. Explain the procedure to patient.


2. Explain importance of activity.
3. Assist patient in doing the activity.

B. Surgical Management

Arteriovenous Fistula

An AV fistula requires advance planning because a fistula takes a while


after surgery to develop (in rare cases, as long as 24 months). But a properly
formed fistula is less likely than other kinds of vascular accesses to form clots or
become infected. Also, fistulas tend to last many years, longer than any other
kind of vascular access.

31
A surgeon creates an AV fistula by connecting an artery directly to a vein,
usually in the forearm. Connecting the artery to the vein causes more blood flow
into the vein. As a result, the vein grows larger and stronger, making repeated
insertions for hemodialysis treatment easier. For the surgery, you will be given a
local anesthetic. In most cases, the procedure can be performed on an outpatient
basis.

These fistulas require up to 6 weeks to mature before they can be used,


which makes this approach inappropriate for immediate hemodialysis. Peritoneal
dialysis or large venous access catheters may be used while the fistula is
maturing. External arteriovenous shunts are rarely used.

Nursing management

Actual SOAPIE

February 3, 2005

S> “madali akong mapagod”

O> received patient on semi-fowler’s position, with an ongoing IVF of D5 NM 1 L


X120 cc/hr @ 900 cc level, infusing well on the right hand
> Afebrile, with pink conjunctiva and lips, easy fatigability, appears weak

32
>VS taken and recorded as follows: T-36, PR-64, RR-18, BP-150/90

A>altered peripheral tissue perfusion r/t decrease circulating hemoglobin


P>after 6 hrs of nursing interventions, patient will have an improvement on tissue
perfusion as evidence by decrease in paleness in lips and conjunctiva, and
increase in activity tolerance

I > monitored VS and recorded


> Established rapport
> Provided adequate rest to conserve energy
> Discussed the effect of decrease hemoglobin in the body
> Instructed to eat nutritious food especially those rich in iron
> Maintained IVF regulation
> Monitored Intake and Output strictly
> Monitored patient’s response to blood transfusion

E >goal met as evidence by decreased in paleness and increased activity


tolerance

Actual SOAPIE

February 08. 2005

S>

O> received patient on supine position, awake, afebrile with pale conjunctiva,
appears weak with easy fatigability
> VS taken and recorded as follows: T-36, PR-90, RR-16, BP-170/90

A > decreased cardiac output r/t vascular resistance secondary to hypertension

33
P > after 6 hrs of nursing interventions, patient will improve cardiac output as
evidence by normal vital signs and decreased in paleness and fatigability

I > monitored VS and recorded


> Established rapport
> Instructed to avoid strenuous activity
> Provided calm environment
> Encourage to ambulate early
> Assisted in changing position
> Instructed SO to avoid introducing stress to the patient
> Monitored I&O strictly

E > goal met as evidence by decreased in paleness and fatigability

VI. Patient’s Daily Progress in the Hospital


A. Patient’s Daily Progress Chart (from admission to discharge)
Admissi Discharg
Days 2 3 4 5 6 7
on
2/3 2/4 2/5 2/6 2/ 2/8 2/9 2/10
7
A. Nursing Problems
1. Altered tissue perfusion * * * * * * * *
2.Decreased cardiac output * * * * * * * *
3. Fluid volume excess * *
4. Fatigue * * *
5. Activity Intolerance * * * *
B. Vital Signs
T 36 36. 36. 36. 36 36. 36. 37
1 4 1 2 4
RR 18 20 20 20 22 16 20 17
PR 64 62 84 81 81 80 71 85

34
BP 150/ 160 140 170 17 170 160 180/
90 / / / 0/1 / 90 / 90
100 80 80 10 100
C. Diagnostic Procedures
1. CBC     
2. Creatinine   
3. Urinalysis   
4. Hepatitis profile 
D. Medical Management
1. D5 LRS 1 L   
2.D5 NaCl 
3. Blood transfusion 
4. Hemodialysis   
5. Subclavian catheterization
E. Drugs
1. Norvasc        
2. Neobloc        
3. Iberet +Folic        
4. Calcium carbonate
5.furosemide        
F. Diet
1. DAT 
2. Low salt low protein        
G. Activity / Exercise
1. Bed rest        

B. Discharge Planning
Mr. x was discharge last x, Upon discharged, Mr. x’s physical appearance
was improved. There was absence of paleness in the conjunctiva and lips,
fatigability is decrease, and with decrease creatinine level as compared when he
was admitted in the hospital. His vital signs were as follows: T- 36.5, PR- 85, RR-
18, BP- 140/100.

M> Instructed to complied strictly with the following home medications


 Norvasc 10 mg 1 tab OD
 Iberet+FA 1 tab BID
 Ketosteril 1 tab TID after meals
 Alutab 1 tab TID during meals
 Furosemide 40 mg 1 tab OD for edema or oliguria

35
 Mucosolvan 1 tsp. TID
 Augmentin 375 mg 1 tab TID
 Nifedipine lozenges QID
>For twice a week hemodialysis
E>Bed rest
T>proper wound care (subclavian and fistula)
H>strict compliance to the medications and in hemodialysis
O>follow-up check up on February 15, 2005
D>avoid foods rich in salt and protein
>Limit fluid intake

VII. Conclusion and Recommendations

Chronic renal failure is an irreversible and progressive disease. It is cause


by many factors. Knowing the precipitating factors leading to the development of
this health problem, people should have an extra care when it comes to health.

Giving care to a patient whether pediatric, geriatric, a medical case or


surgical case makes no difference. Rendering care to everyone who needs it is a
real sense of responsibility. In making this case study, I was able to work well
because I know for myself that I did my best for my patient.

We can say that nursing is significant therapeutic and dynamic process. It


is therefore significant for the nurse caring for the patient to wholeheartedly
understand what she is doing like in carrying out some basic skills in relation to
identified goals, comfort and care, interventions and prevention of illness.

VIII. Bibliography

Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company

36
Philadelphia
Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation
Springhouse, Pennsylvania
Pagana (2002). Mosby’s Manual of Diagnostic and Laboratory Tests.

MIMS. (2003)
www.yahoo.com
www.google.com

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