Abra Valley Colleges Bangued, Abra

In Partial Fulfillment of the Requirements in NCM 103 (RLE)

A Case Study about END STAGE RENAL DISEASE

Presented to: The Nursing Faculty of Abra Valley Colleges Bangued, Abra

Presented by: BSN III - Group II Leslie Mae M. Pimentel - Leader Creighton A. Bayongan ± Asst. Leader Christian D. Adres Josephine B. Barber Jhennyffer L. Barcena Cristy A. Baris Arlene A. Bigornia Shielo M. Bogac Harold John B. Bunagan Marife B. Delos Reyes Harmony Cristie V. Gonzalo Mediatrix G. Pasiguen Roxan G. Siwao

October 2010

I.

INTRODUCTION

Chronic Renal Failure is usually the result of a gradually progressive loss of renal function, it occasionally results from a rapidly progressive disease of sudden onset. Few symptoms develop until after more than 75% of glomerular filtration is lost; then the remaining normal parenchyma deteriorates progressively, and symptoms worsen as renal function decreases.

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. If the patient can tolerate it, maintenance dialysis or kidney transplantation can sustain life.

Stages of CRF: 1. Reduced Renal Reserved- GFR of 40-70 mL/min 2. Renal Insufficiency- GFR of 20-40 mL/min 3. Renal Failure ± GFR of 10-20 mL/min 4. ESRD- GFR of less than 10 mL/min

Significance of the Study 1. To discuss Chronic Renal Failure its causes, risk factors, complications and surgical management. 2. To know the Pathophysiology of Chronic Renal Failure 3. To know the anatomy and physiology of the organ/s involved. 4. To be familiar with the medications given to our patient. 5. To effectively use the nursing process in providing holistic care to our patient. 6. To impart knowledge to fellow student nurses to help strengthen their role as health educators in all health care settings.

Risk factors  Age  Gender  Alcoholism  Kidney diseases  DM  Hypertension

Congenital Anomalies such polycystic kidney disease 4. Chronic Infections such as pyelonephritis & TB 3. Calculi Obstruction 5. Chronic used of Nephritic Drugs such as aminoglycosides 7. Chronic Endocrine Disease such as Diabetes Neuropathy Signs and Symptoms: Systemic  Neurologic System: o Listlessness o Attention deficit o Seizure o Burning pain o Irritability o Twitching o Confusion/ Coma o Hiccups.Causes: CRF arises from seven C¶s 1.  Pulmonary System: o Difficulty of breathing o Insufficient breath sound o Crakles/Rales o Kussmaul¶s respiration  Cardiovascular System: o Cardiac failure o Hypotension/hypertension o Anemia o Weight gain o Pulse irregularity o Arrthymia. Chronic Glomerular Disease such as AGN and CGN 2.  Gastrointestinal System : o Metallic taste o Ammonia/acetone breath o N/V o Inflammation o Constipation o Anorexia o GI bleeding  Integumentary System: o Dry skin o Uremic frost skin o Severe itching o Thin and brittle hair o Yellow bronze skin  Genito-Urinary System: o Anorea o Changes in the urine appearance/pattern o Impotence/Infertility o Diluted urine with cast and crystals. Collagen Disease such as SLE 6. .

Possible Complications y y y Anemia Bleeding from the stomach or intestines Heart and blood vessel complications o o o High blood pressure Pericarditis Stroke y y y y Increased risk of infections Malnutrition Seizures Weakening of the bones and increased risk of fractures . Musculoskeletal System : o Gait abnormality o Abnormal fracture o Inability to ambulate o Muscle cramps/spasms.

2010 @ 9:35 am Chief Complaint: DOB 1 day PTA Ward: ICU Admitting Diagnosis: End Stage Renal Disease (ESRD) Final Diagnosis: End Stage Renal Disease (ESRD) Physician: Dr.II. PATIENT¶S PROFILE Hospital #: 914104 Name: Mrs. Lagangilang. AT . 1972 Age: 38 Birthplace: Mindanao Address: Kimpal. DOB Birthdate: March 15. Abra Sex: Female Civil Status: Married Religion: UCCP Nationality: Filipino Date and Time of Admission: September 14.

IVP was performed and this confirms the diagnosis of our patient. She also claims that she had no known allergies to food and drugs. According to our patient she¶s in and out of the hospital many times. since then they used it every time she¶s undergoing dialysis. 2010 at the left hand as an access for her dialysis. Due to her condition. According to her she had completed her childhood immunization. Our patient was diagnosed with CRF and with a stage of ESRD @ metro Vigan. diabetes mellitus. both his paternal and maternal side had no known serious diseases such as heart attack. She was then admitted on September 14. Familial History According to our patient. History of Past Illness Our patient had experience mumps. 2010 @ APH. Few months later it was damaged with unrecalled reason . and O2 inhalation was hooked via NC at 3-4 Lpm. and cancer but claims that her . HISTORY OF PAST AND PRESENT ILLNESS A. B. and her attending physician suggested that they must have another access for her dialysis then they inserted a catheter on her intrajugular vein on the left side of her neck. AT. History of Present Illness Our patient with her husband went at APH because she experienced DOB. 2010 @ 9:35 am with an admitting diagnosis of ESRD by Dr. her lasts dialysis was on September 07. hooked at the right metacarpal vein infusing well. She was given initial treatment of D5W 1L X KVO regulated @ 10 gtts/min. She was forwarded at ICU and stayed there for28 days. our patient had been advised to have an AV fistula @ Metrovigan on January 10. C. chicken pox and seasonal cough and colds as well as fever during her childhood and used to manage these illnesses by home remedies such as using available health resources by means of using herbal plants that they believe can treat the said illnesses.III. But she claims that she is hypertensive since then.

. Social History According to our patient she got married when she was 25 and God gave them 3 children. Farming is the primary source of their food and income to support their needs. She is fund of eating salty foods and often used ³bagoong´ as sauce in anything she eats she also says that she loves soft drinks. a girl and a twin boy. D. and fever which they treated with herbal medications. She also claims that she had a good relationship with her neighbors.maternal side had a history of hypertension. They also experienced common illnesses such as cough and colds.

Self-Esteem ³Sakno ngatan Deng.IV. feeding. also felt the love rendered by the health care providers in the hospital. 4. She remains silent when asked about her sexual life. she will be self-actualized if she will be treated and to see her children finished their studies. Rapport was established by the staffs and students nurses in order to obtain accurate information regarding his condition. Generalized edema was seen. female she appears weak and often complaints difficulty of breathing. General Survey Our patient is a 38 year old. 2010 @ 8:00 am) A. NURSING ASSESSMENT (September 23. Maslow¶s Hierarchy of Needs: 1. Self-Actualization According to our patient. 3. DAT was maintained. . Physical Assessment 1. Safety and Security Our patient feel safe and secured in the presence her husband who is always there to accompany her in performing activities of daily living such as toileting. B. kastoy met ti kasasaad kon?´ as verbalized by the patient which is an expression of diminishing self-esteem. Love and Belongingness Aside from her husband our patient. 5. and hygiene. Wasn¶t able to pass out urine and stool. Physiologic Needs O2 inhalation was hooked via NC @ 3-4 Lpm. 2.

 No lumps or masses and tenderness were noted on both ears upon palpation. Eyes:  Both eyes reveals that pupils are equally round reactive to light accommodation upon assessment.  Hair is short and brittle with white hair noted  Evenly distributed. Ears:  Able to recognize hear and understand spoken words.  Pale conjunctiva noted. Neck:  Neck has strength when move from different directions with full ROM .Vital Signs: BP: 130/90 mmHg PR: 76bpm Temp. Head:  Round in shape. no tenderness/masses and pain noted. Mouth and Lips:  No lesions were found in the mouth but dry mouth is noted.: 37.5 °C RR: 42 cpm 2.  (+) plaque noted  Incomplete set of teeth.  (+) discharges noted Nose:  Nose is patent upon assessment.  (+) nasal flaring  O2 inhalation via NC @ 3-4 Lpm.  Upon palpation. Cephalocaudal Assessment Integumentary System:  Poor skin turgor noted and anasarca.

 (+) scars and lesions were noted. Abdomen:  (-) scar noted  (+) abdominal bloating noted. Infusing well. Chest:  (+) adventitious sounds upon auscultation (wheezing)  Respiratory Rate 42 breathes per minute from the normal range of 1620 breaths per minute.  Warm to touch. Genitourinary:  Never defecated and urinated during our shift Upper and Lower extremities:  With an ongoing IVF of D5W1L @ 600cc level regulated @ 30gtts/min @ the right metacarpal vein. . IJ catheter @ the right side with intact dressing.

The kidneys also have several non-excretory metabolic and endocrine .V. they are major controller of fluid and electrolyte homeostasis. Consequently. ANATOMY AND PHYSIOLOGY Kidneys The kidneys balance the urinary excretion of substances against the accumulation within the body through ingestion or production.

lungs. insulin degradation. The kidneys help regulate the pH of the body fluids. pH regulation. The kidneys are the major excretory organs of the body. They lie between the 12th thoracic and third lumbar vertebrae. Buffers in the blood and the respiratory system also play important roles in the regulation of pH . prostaglandin synthesis. including blood pressure regulation. Adult kidneys are average approximately 11 cm in length. 3. Most waste products are metabolic by products of cells and substances absorbed from the intestine. 4.5 cm in thickness. erythropoietin production.functions. 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. on either side of the ventral column. The kidneys help regulate the concentration of the major ions in the body fluids. The skin. The kidney has a characteristic curved shape.5 cm in width. 5 to 7. liver. and 2. from the blood. Ion concentration regulation. Functions of the Urinary System The major functions of the urinary systems are performed by the kidneys and the kidneys play the following essentials roles in controlling the composition and volume of body fluids: 1. many of which are toxic. in the posterior aspect of the abdomen. The left kidney is usually positioned slightly higher than the right. calcium and phosphorus regulation and Vitamin D metabolism. but they cannot compensate if the kidneys fail to function. with a convex distal edge and a concave medial boundary. and intestines eliminate some of these waste products. Excretion. They remove waste products. The kidneys are located retroperitoneally. 2.

The renal circulation then empties into the inferior vena cava. When the urinary bladder reaches a volume of a few hundred mL. The triangleshaped portion of the urinary bladder located between the opening of the ureters and the opening of the urethra is called trigone. in controlling the concentration of red blood cells in the blood. the efferent arteriole and the peritubular capillaries. . Renal Blood flow and Glomerular Filtration The kidney receive 20% to 25% of the cardiac output under resting conditions. 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. which causes the smooth muscle of the urinary bladder to contract and most of the urine flows out of the urinary bladder through urethra.5. arcuate veins. and the renal vein. averaging more than 1 L of arterial blood per minute. 6. and its size depends on the quantity of urine present. The urethra carries urine from the urinary bladder to the outside of the body. and progressively branch into lobar arteries. The urinary bladder is a hollow muscular container that lies in the pelvic cavity just posterior to the pubic symphysis. The urinary bladder can hold from a few milliliters to a maximum of about 1000 mL of urine. a reflex is activated. Blood flows from the interlobular arteries through the afferent arteriole. participate in the synthesis of vitamin Ureters. interlobar veins. It functions to store urine. Red blood cell concentration The kidneys participate in the regulation of red blood cell production and therefore. The urethra is a tube that exits the urinary bladder inferiorly and anteriorly. The blood leaves the kidney in venous system closely corresponding to the arterial system: interlobular veins. the glomerular capillaries. enter the kidney. The renal arteries branch from the abdominal aorta at the level of he second lumbar vertebra. Vitamin D synthesis The kidneys along with the skin and the liver. Some of the peritubular capillaries carry a small amount of blood to the renal medulla in the vasa recta before entering the venous drainage.

they lose the ability to concentrate urine.040. Urine formation The chief function of the kidneys is to produce urine. There are three important processes by which urine is formed. urine has a specific gravity that normally varies from 1. and the specific gravity no longer varies as it does when the kidneys function normally.010 to 1. When the kidneys are diseased. The amount of these dissolved substances is indicated by it specific gravity. used as a standard is 1. Because of the dissolved materials it contains. It is 5% water and 5% dissolved solids and gases.000.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. The specific gravity of pure water. tubular reabsorption and tubular secretion. The Path of the Formation of Urine Blood enters the Efferent arterioles Passes through the Glomeruli To Bowman¶s capsule Now it becomes filtrate (blood minus RBC¶s and plasma protein protein Continues through the proximal convulated tubule To the loop of Henle To the distal convulated tubule To the collecting tubule (at this about 99% of the filtrate has been reabsorbed) . Each part of the nephrons performs a special function. They are glomerular filtration.

Approximately 1 ml of urine is formed per minute and goes to the renal pelvis To the ureter To the bladder To the urethra To the urinary meatus .

Diet (salty foods) Number of substances that are normally excreted accumulate in the body.Hypertensive .Age (38) . and the kidneys are unable to excrete end products of metabolism Precipitating factors . including nitrogenous waste.Gender (female) Renal Malfunction Nephrons are permanently destroyed Kidneys become unable to respond to excessive or decreased salt and fluid intake Synthesis of erythropoietin diminishes. PATHOPHYSIOLOGY Predisposing factors . electrolytes.VI. and uremic toxins Signs and Symptoms Musculoskeletal System  Gait abnormality  Inability to ambulate  Loss of muscle strength Pulmonary System  DOB  Insufficient breath sound  Kussmaul s respiration Integumentary System  Dry Skin  Uremic frost skin  Severe itching  Thin and brittle hair  Yellow bronze skin Cardiovascular System  Hypertension     Anemia Weight gain Pulse irregularity Arrhythmia Genitourinary System  Changes in urine pattern Gastrointestinal System  Ammonia breath  Anorexia Neurologic System  Leastlessness  Attention deficit  Irritability .Lifestyle .

Pericardidits .Management  Dialysis  Medications .Sodium Bicarbonate 1 tab TID .Hydrocor sone 100mg IV q 6 .Stroke  Increased risk in infections  Malnutrition  Seizures  Weaking of the bones and increase risk of fractures  Possibly death .Furosemide 20mg IV OD .Salbutamol nebule 2.5cc q 4 - Untreated  Complications may occur  Anemia  Bleeding from the stomach or intestine  Heart and blood vessel complications: .High blood pressure .Paracetamol 300mg IV q 4 .Calcium Carbonate 1 tab TID .Rani dine 50mg IV q 12 .

For females. If the specific gravity of your urine is under 1. There are several different methods for collection of a urine sample. A scientist or lab technician performs the requested testing and provides the requesting medical professional with the results of the CBC. The patient is then instructed to begin to urinate. is a test panel requested by a doctor or other medical professional that gives information about the cells in a patient's blood. and potassium levels.010. the external head of the penis is similarly cleansed and rinsed. Water has a specific gravity of one. Knowing the specific gravity of your urine is very important because the number indicates whether you are hydrated or dehydrated. The most common is the midstream clean-catch technique. decreased arterial pH and bicarbonate.  Renal Scan A Renal Scan is used to help diagnosis kidney disease and certain problems with the rest of the urinary tract. and low hemoglobin (Hb) level and hematocrit (HCT). you are hydrated. If your urine is above 1. Specific gravity is an expression of the weight of a substance relative to the weight of an equal volume of water. serum creatinine. Ideal . It is primarily used to evaluate the function and size of the kidneys. The specific gravity of your urine is measured by using a urinometer.007. Small amounts of protein or ketoacidosis tend to elevate results of the specific gravity.VII. DIAGNOSTICS EXAMS  Urinalysis This test detects ion concentration of the urine. Blood studies show elevated blood urea nitrogen. Hands should be washed before beginning. you are dehydrated. the external genitalia (sex organs) are washed two or three times with a cleansing agent and rinsed with water.  Urine Culture A urine culture is a diagnostic laboratory test performed to detect the presence of bacteria in the urine (bacteriuria). In males.  Complete Blood Count A complete blood count (CBC). and the urine is collected midstream A. also known as full blood count (FBC) or full blood exam (FBE) or blood panel.

.into a sterile container. a urinary collection bag (plastic bag with an adhesive seal on one end) is attached over the labia in girls or a boy's penis to collect the specimen.  Intravenous Pyelogram (IVP) An intravenous pyelogram (also known as IVP. including the kidneys. The contrast is excreted or removed from the bloodstream via the kidneys.  Renal function Test Renal function test are used to determine effectiveness of the kidney¶s excretory functioning. In infants. such as oxygen. and the contrast media becomes visible on xrays almost immediately after injection. X-rays are taken at specific time intervals to capture the contrast as it travels through the different parts of the urinary system. and bladder. intravenous urogram or IVU) is a radiological procedure used to visualize abnormalities of the urinary system. This gives a comprehensive view of the patient's anatomy and some information on the functioning of the renal system. to evaluate the severity of kidney¶s disease and to follow the patient¶s progress. pyelography. An injection of x-ray contrast media is given to a patient via a needle or cannula into the vein.  ABG Analysis Blood is taken from an artery in wrist. acids and carbon dioxide as well as the pH of the blood that provides a means of assessing the adequacy of ventilation and oxygenation. arm or groin. The blood is tested for the amount of gases in it. typically in the arm. ureters.

pus cells and red cells in the urine. light yellow Slightly turbid +++ 1-2/hpf 1-3/hpf ++ + NORMAL VALUE Amber straw Clear Negative 0-1hpf Negative Negative Negative SIGNIFICANCE significant significant significant significant significant significant Significant Interpretation: Laboratory results revealed that there is the presence of albumin in the blood which indicates that the glomerulus cannot filter large molecules such as that of albumin. 2010) LAB TEST COLOR TRANSPARENCY ALBUMIN PUS CELLS RBC BACTERIA EPITHELIAL CELLS RESULT Straw . It also revealed that there is bacterial infection as evidenced by the presence of bacteria.B. Actual URINALYSIS (September 15. .

4 103/mm3 2. causing anemia (Decreased erythropoietin synthesis 2Û to renal malfunction).23 L 10 6/mm3 6.4 u m 174% 3 NORMAL VALUES 4.0-52.0 10.0 150-450 .5 31.8 L g/dL 18.0 36.500 80-97 26. 2010) RESULT WBC RBC HGB HCT PLT PCT MCV MCH MCHC RDW MPV PDW 7.9H g/dL 17.179 % 82 um3 30.80-5.0 6.0 3.0 100-180 SIGNIFICANCE Non-significant Significant Significant Significant Non-significant Non-significant Non-significant Non-significant Significant Significant Non-significant Non-significant Interpretation: HCT and HGB were all below the normal level.3 L % 241 10 3/ mm3 .3 pg 36.HEMATOLOGY (September 15.0-15.5-33.5-11.5-35. .7H % 7.0-17.80 12.100-. thus indicating renal malfunction and thereby.0-11.

Surgical  Dialysis It refers to the diffusion of solute molecules through a semipermeable membrane. the patient's blood is then pumped through the blood compartment of a dialyzer. MANAGEMENT A. It is a substitute for some kidney excretory functions but does not replace the kidney¶s endocrine and metabolic functions. passing from the side of higher concentration to that of lower concentration. and water and wastes move between these two solutions. Blood flows through the fibers. Ideal Management 1.for management of hyperphosphatemia in chronic renal failure  Calcium supplements .for hypocalcaemia associated with chronic renal failure  Calcitriol and other Vitamin D supplements . dialysis solution flows around the outside the fibers. The fiber wall acts as the semipermeable membrane.for acid-base disturbance  Loop Diuretics with fluid restrictions as needed  Use of ACE inhibitors . has been shown to slow the progression of renal failure 2.for management of anaemia associated with chronic renal failure  Phosphate binders . The purpose of dialysis is to maintain the life and well-being of the patient. exposing it to a partially permeable membrane. Hemodialysis In hemodialysis.in patients both with and without proteinuria. The dialyzer is composed of thousands of tiny synthetic hollow fibers. Medical  Erythropoietin agonists . The cleansed blood is then returned via the circuit back to .VIII. Types: 1.for hypocalcaemia and hyperparathyroidism associated with chronic renal failure  Sodium bicarbonate .

hyper/hyponatremia. This pressure gradient causes water and dissolved solutes to move from blood to dialysate. The popularity of µslow continuous therapies¶ for the treatment of critically ill patients with renal failure is increasing. where the peritoneal membrane acts as a semipermeable membrane. and allows the removal of several litres of excess fluid during a typical 3 to 5 hour treatment. a sterile solution containing glucose is run through a tube into the peritoneal cavity. fluid overloaded patients and patients with sepsis and septic shock in management of acute renal failure especially in the intensive care unit setting. 2. CRRT initiated for ARF in critically ill patients should serve as a renal µreplacement¶ therapy mimicking as artificial kidney support. This usually is done by applying a negative pressure to the dialysate compartment of the dialyzer. The techniques which are most commonly used are slow continuous hemodialysis and hemodiafiltration. Slow continuous hemofiltration and slow continuous ultrafiltration also are commonly used. the abdominal body cavity around the intestine. Management in initial hours to counter the derangements in critically ill patients is the most vital thing in the therapy. .  Continuous Renal Replacement Therapy (CRRT) CRRT is a mode of renal replacement therapy for hemodynamically unstable. Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer membrane. acidosis/alkalosis and rapid correction of pulmonary/peripheral edema by gradual and consistent removal of extra fluid retained in the body. It should enhance recovery of the native kidneys with prevention of hyperkalemia. Peritoneal Dialysis In peritoneal dialysis.the body.

depending on whether a biological relationship exists between the donor and recipient. longer than any other kind of vascular access. you will be given a local anesthetic. which makes this approach inappropriate for immediate hemodialysis. But a properly formed fistula is less likely than other kinds of vascular accesses to form clots or become infected. A surgeon creates an AV fistula by connecting an artery directly to a vein. Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants. Kidney transplant Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease. In most cases. fistulas tend to last many years. Connecting the artery to the vein causes more blood flow into the vein. as long as 24 months). making repeated insertions for hemodialysis treatment easier. . the vein grows larger and stronger. For the surgery. usually in the forearm.  Arteriovenous Fistula An AV fistula requires advance planning because a fistula takes a while after surgery to develop (in rare cases. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the donor organ. External arteriovenous shunts are rarely used. the procedure can be performed on an outpatient basis. Also. As a result. These fistulas require up to 6 weeks to mature before they can be used. Peritoneal dialysis or large venous access catheters may be used while the fistula is maturing.

y y y Instructed to do deep breathing relaxation to promote generalized relaxation Positioned in semi-fowlers to promote comfort.  Ranitidine HCl 50 mg IV qØ 8°  Hydrocortisone 50 mg qØ 8°  Salbutamol nebule 2. Nursing Management y y y y Recognize the patient for risk of recurrence for infection Monitored Intake &output Monitored V/S every hour to serve as baseline data Encouraged to avoid high protein. sodium and potassium rich foods to prevent further complications.B. . Administered medications as ordered. Actual 1.5cc qØ 4°  Furosemide 25 mg IV OD  Paracetamol 300 mg IV PRN  Calcium Carbonate 1 tab TID  Sodium Bicarbonate 1 tab TID 2. Medical Management y y y D5W1L x 8° @ 30gtts/min @ the right metacarpal vein O2 inhalation was hooked via NC @ 3-4 Lpm Meds.

. Emphasized the importance of proper hygiene to promote comfort.XI. Instructed patient to have enough rest to gain strength. Advised to use hard candy. y y y y y Advised to drink limited amounts only when thirsty. chewing gum to moisten mouth. HEALTH TEACHINGS y y y Encouraged patient to do deep breathing to facilitate lung expansion. y Instructed to eat nutritious foods (high in calorie diet) to strengthen the immune system. sodium and potassium foods to prevent further complication and may slow the progress of renal failure. Instructed to avoid rich in protein. Advised to eat food before drinking fluids to alleviate dry mouth. y Advised patient not to see things complicatedly regarding her condition but rather take it as a challenge to strengthen her faith in God. Reinforced SO and patient the importance of treatment because lack of cooperation may lead to failure of therapy.

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