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Chronic Renal Failure

Chronic Renal Failure

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Published by: Ericka B. Banaszczuk on Aug 08, 2010
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02/13/2013

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Case Presentation

Chronic Renal failure

Personal Data
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Name: MCVM Age: 15 y/o Birthday: September 26, 1994 Place of Birth: Manila Address: Paranaque Sex: Female Religion: Roman Catholic Nationality: Filipino Date of admission: April 19, 2010 Admitting Impression: Chronic renal failure secondary to neurogenic bladder secondary to spina bifida.

History of Present Illness
MCVM was apparently well until 36 hours PTA. She had headache described as throbbing located at fronto temporal area with the severity of 7/10. No consult was done nor medication taken until 30 hours PTA, patient had seizure described as upward rolling of eyeball, stiffening of extremities and cyanosis lasting for 30 seconds. Patient was then rushed to Taguig Pateros District Hospital but patient opted to transfer to another hospital due to poor service. 28 hours PTA, she had another episode of seizure with the same characteristics hence consult Makati Medical Center when CBC was one and revealed anemia. BUN crea was done which showed marked increase about 4x higher than the normal. PT, PTT, Potassium and Phosphorus are in normal range. Patient was advised admission but due to no available room patient noted to transfer to our institution and was subsequently admitted.

Medical History
MCVM is born termed to 24 y/o G1P0 via NSD at Paranaque Medical Center with no known feto-maternal complication with no know maternal complication. Patient is on breastfed until 4th months and was shifted thereafter. She was started on solid foods at 6th month of age. No known allergies to drugs and foods. Patient MCVM is fully immunized but the father cant recall the date of her immunization. She had her menarch when she was 10 y/o and regular menstruation.

She had 2 previous hospitalizations. Her first hospitalization was last 2005 when she 11 y/o. Patient was diagnosed with spina bifida since birth, had s/p correction and s/p spinal traction at San Martin de porres Hospital. Since then patient had urinary and bowel incontinence with no maintenance medications. On 2007-2009 she had recurrent UTI and admitted to Asian Hospital last 2007

Family History
No known heredofamilial disease except asthma on paternal side.

Psychosocial History
MCVM is a 3rd year high school student from Montessori Paranaque and tells us of having many friends and good social network. Hobbies include going out and reading books. Her considered problems are school works such as projects and assignments and copes up with stress by sleeping and playing. Of her parents she is more attached to her father because her parents are separated and she considers her father as a support person.

ACTIVITIES OF DAILY LIVING

BEFORE DURING INTERPRETATION HOSPITALIZATION HOSPITALIZATION
FLUIDS & NUTRITION

C.M. eats three times a day (breakfast, lunch, dinner). She prefers to eat fried food (e.g. chicken, pork, etc.) along with one cup of rice. She drinks 23 glasses of Coke during meals.

C.M. was on NPO then was shifted to a low phosphorus diet with a dietary prescription of a total of 1800 calories (protein 70 calories, fat 690 calories, carbohydrates 1040 calories); she hasn·t drunk any liquid despite her relatives· urgings, but on 4-22-10 she drank 210 cc of water; on IVF (PNSS 1L x 12 hours) then shifted to heplock; has had blood transfusion (2 packs RBC type O Rh (+))

A low phosphorus diet was ordered for maintaining a normal level of calcium in the blood, since a high level of phosphorus in the blood could cause loss of calcium, which is important in bone formation; her refusal of drinking anything was caused by a feeling of fullness in the bladder; IVF was for maintaining electrolyte balance and renewal of fluids; heplock is for IV medications; blood transfusion was for a low hemoglobin count To prevent fluid overload due to renal failure

Limited fluid intake to 1liter per day

BEFORE HOSPITALIZATION
BOWEL & ELIMINATION

DURING HOSPITALIZATION

INTERPRETATION

C.M. wears a diaper everyday and everytime she goes to school. She consumes 5-6 diapers a day with regular bowel movement (one to two times a day).

C.M. has had no bowel movement since her admission, and constantly complains of pain in the anal area; still undergoing hemodialysis, she has very little urine output (100-200 cc a day). Instead of using diapers, she was instructed by the doctor to use underpads.

Her negative bowel movement must be due to her limited activities, and pain in the area; her small amount of urine output was because of her hemodialysis; the use of underpads is for comfort and an easier way to measure the output.

BEFORE HOSPITALIZATION
ACTIVITIES & EXERCISE

DURING HOSPITALIZATION

INTERPRETATION

C.M. goes to Regis Grace Montessori in Taguig. She travels by jeepney, leaving the house at around 6:30 am and goes home at around 4:00 pm. During school hours, she stays with her friends. To pass the time when at home, she reads books and surfs the web. She also talks with her friends via cellphone. During weekends and special occasions, she goes malling with her family.

Due to her complain of pain in the anal area, she stays at bed most of the time. She has limited activities, and spends most of the time resting on her bed and watching TV.

The pain makes it difficult for her to move around.

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

ANALYSIS

REST AND She sleeps at SLEEP around 8:00 PM and wakes up at around 4:30 AM to go to school. During weekends she sleeps at around 9:00 PM and wakes up at around 8:00 AM.

She sleeps longer during her confinement and sleeps at around 9:00 PM and wakes up around 9:00 AM. However, due to the nursing care rendered, her sleep is sometimes disturbed with feelings of pain and irritation.

She has a
longer rest period but due to frequent nurse and doctor visits, her sleep is disturbed and sometimes feeling of in pain and irritated.

BEFORE HOSPITALIZATION

DURING HOSPITALIZATION

ANALYSIS

ORAL AND She brushes her HYGIENE teeth every after

She brushes her teeth at night before going to meals. She takes sleep with her a bath two to grandmother·s three times a day. help. Sometimes, she took full bath but mostly partial bath. And also perineal care had done by relative or staff nurse at least once a day.

She can only do partial bath because she complains of difficulty when moving around. Satisfaction of hygienic needs is achieved dependent on the help of others.

Physical Assessment

IX. DISEASE ENTITY

The body takes nutrients from food and converts them to energy. After the body has taken the food that it needs, waste products are left behind in the bowel and in the blood. The urinary system keeps the chemicals and water in balance by removing a type of waste called urea from the blood. Urea is produced when proteins, found in meat products, are broken down in the body.

‡ Two kidneys - a pair of purplish-brown organs located below the ribs toward the middle of the back. Their function is to: ± Remove liquid waste from the blood in the form of urine. ± Keep a stable balance of salts and other substances in the blood. ± Produce erythropoietin, a hormone that aids the formation of red blood cells. ‡ The kidneys remove urea from the blood through tiny filtering units called nephrons. Each nephron consists of a ball formed of small blood capillaries, called a glomerulus and a small tube called a renal tubule. Urea, together with water and other waste substances, forms the urine as it passes through the nephrons and down the renal tubules of the kidney.

‡

Two ureters - narrow tubes that carry urine from the kidneys to the bladder. Muscles in the ureter walls continually tighten and relax forcing urine downward, away from the kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop. About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from the ureters. Bladder - a triangle-shaped, hollow organ located in the lower abdomen. It is held in place by ligaments that are attached to other organs and the pelvic bones. The bladder's walls relax and expand to store urine and contract and flatten to empty urine through the urethra. Two sphincter muscles - circular muscles that help keep urine from leaking by closing tightly like a rubber band around the opening of the bladder. Nerves in the bladder - alert a person when it is time to urinate, or empty the bladder. Urethra - the tube that allows urine to pass outside the body. The brain signals the bladder muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain signals the sphincter muscles to relax to let urine exit the bladder through the urethra. When all the signals occur in the correct order, normal urination occurs.

‡

‡ ‡ ‡

Chronic Kidney Disease
‡ ‡ Chronic kidney disease occurs when one suffers from gradual and usually permanent loss of kidney function over time. This happens gradually, usually months to years. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Loss of kidney function also causes other problems such as anemia, high blood pressure, acidosis (excessive acidity of body fluids), disorders of cholesterol and fatty acids, and bone disease STAGES OF CKD

‡

Stage 1 2 3 4 5

Description Slight kidney damage with normal or increased filtration Mild decrease in kidney function

GFR* mL/min/1.73m2 More than 90 60-89

Moderate decrease in kidney 30-59 function Severe decrease in kidney function Kidney failure 15-29 Less than 15

‡

Stage 5 CKD is also called established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF) At this advanced stage of kidney disease the kidneys have lost nearly all their ability to do their job effectively, and eventually dialysis or a kidney transplant is needed to live. Because the kidneys are no longer able to remove waste and fluids from the body, toxins build up in the blood, causing an overall ill feeling. Kidneys also have other functions they are no longer able to perform such as regulating blood pressure, producing the hormone that helps make red blood cells and activating vitamin D for healthy bones.

‡

‡

PATHOPHYSIOLOGY

TREATMENT and MANAGEMENT

Name, Class, Dose, Route,Freque ncy

Mechanism of action

Indication

Contraindication

Side effects

Nursing responsibilitie s

Calcium carbonate
Class: antacid 1tab p.o OD

Decrease total acid load of GI tract. Increase esophageal sphincter tone, strengthens gastric mucosal barrier and reduce pepsin activity by elevating gastric pH.

To treat hyperphosphatemia for client with renal disorders.

Constipation, Hyperflatulence, calcemia, diarrhea, hyperhypercalciuria, calcemia, bone alkalosis, tumors, renal severe renal dysfunction, failure, gastric parenteral hypersecretion, calcium acid rebound therapy

-Give antacid 1-3 hours after meals -encourage client to drink at least 2oz. of water to ensure that the drug reaches the stomach -warn client to avoid taking antacids with milk or foods rich in vitamin D -Do not administer oral drugs within 12 hour of antacid administration

Diphenhydramine
(benadryl) Class: antihistamine 35mg IV Q8

Decrease Used in allergic symptoma response by tic relief antagonizing the effect of of allergic histamine conditions for H1 such as receptor site urticaria in blood and vessels, GI, pruritic respiratory skin system

disorders

Drowsiness, Acute dizziness, asthmatic fatigue, attacks , nausea, severe liver vomiting, disease, urinary lower retention, respiratory constipation, disease, blurred MAOI vision, dry therapy, mouth and narrow throat, angle glaucoma, hypotension stenosing peptic ulcer

-inform client that one of the side effects of the drug is drowsiness -encourage client to avoid performing activities alone when drowsiness occur -provide safe environment for the client(e.g putting siderails up)

Paracetamol
Class: analgesic, antipyretic 500mg/tab 1tab p.o prn

Decreases fever by inhibiting the effects of pyrogens on the hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and vasodilation.

Treatment Hyper- Drowsiness, -Give with nausea, food or of fever sensitivity, vomiting, milk to inabdominal decrease tolerance pain, hepa- gastric to totoxicity symptoms - Give 30 tartazine, mins. alcohol, Before or 2 table hours after sugar, meals saccharin

Hemodialysis
is the most common method used to treat advanced and permanent kidney failure. ‡ In hemodialysis, your blood is allowed to flow, a few ounces at a time, through a special filter that removes wastes and extra fluids. The clean blood is then returned to your body. Removing the harmful wastes and extra salt and fluids helps control your blood pressure and keep the proper balance of chemicals like potassium and sodium in your body.

NURSING CARE PLAN

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