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Manuel S.

Enverga University Foundation College of Nursing and Allied Health Sciences

A Case Study of a Patient with

“End Stage Renal Disease secondary to Chronic Glumerulonephritis”

In Partial Fulfillment of the Requirement for Nursing Enhancement Program (Related Learning Experience) @ Hemodialysis Unit, QMC (Lucena City)

Presented To: Ms. Claire E. Davila Clinical Instructor

Presented By: Group 4 – B Basco, Christine Lozada, Grace Morin, Angielyn Perez, Maricel Reyes, Ralph Lawrence

December 2012

GENERAL OBJECTIVES
 At the end of our duty in QMC – Hemodialysis Unit, Level IV nursing students of MSEUF-MAIN will be able to impart acquired knowledge and effective skills towards achieving the patient’s optimum level of functioning through promoting, providing and maintaining, physiologic and psychological stability, and health restoration as to apply the right attitudes of the nursing students in rendering care to the patient experiencing hemodialysis due to health condition of END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS, its importance and implication.  readers The aim of this study is to provide understanding to the students as well as the regarding END STAGE RENAL DISEASE secondary to CHRONIC

GLUMERULONEPHRITIS. This study will show the contributing factors, occurrence and complication of the condition which is important in the preventive, promotive and rehabilitative care of the patient.

SPECIFIC OBJECTIVES
Establish a trusting relationship to client and family. Perform the assigned task efficiently and dynamically Understand precisely what END STAGE RENAL DISEASE is. To be able to distinguish its clinical manifestations. To illustrate the Anatomy and Physiology of the affected organ or the part of the body To discuss and outline its pathophysiology. Find out how the health status of the client had been affected by the above disorders by:     Determining its predisposing factors Determining the causative agents of the disease Conducting physical examination Analyzing the results of the laboratory examinations done to the client.

Determine the appropriate nursing care and management that should be provided to the client by:    Being familiar with the various treatment done to the client; Understanding the different drugs ordered for the client and determines its therapeutic effects and adverse reactions. Evaluate the effectiveness of the medical treatment and the nursing care plans rendered to the client. To apply right attitude by respect through providing privacy and maintaining client’s confidentiality.

I – INTRODUCTION
End Stage Renal Disease (ESRD), also known as Chronic Kidney Disease Stage V, is a progressive loss of renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite.

Incidence, race, gender, age, ratio and proportion
Kidney disease is on the rise and is an important cause of death in the Philippines. It is the 9th leading cause of death among Filipinos today. It is said that a Filipino is having the disease hourly or 120 Filipinos per million populations per year. 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. Unfortunately though only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of the whole population probably just died without receiving any treatment. According to DOH said that in the past, chronic glomerulonephritis was the most common cause of chronic renal failure. Today, diabetes mellitus and hypertension have taken center stage in increasing the risk of ESRD which together account for almost 60% of dialysis patients.

There are more males acquiring the condition with a ratio of 2:1. Significance of the Study The significance of this study is to enhance and gain knowledge. This particularly afflicts children and young adolescents. This study also aims to educate the people about the disease of the kidneys specifically END STAGE RENAL DISEASE to serve as their eye opener for understanding how important our kidney is and its functions to our daily life activities. This is an opportunity for us not just to learn more about the causes and treatments of this disease but also an opportunity to show our role and contribution as a nursing student. .The prevalence of kidney/renal diseases has been in an increasing trend. The rate of death due to end-stage renal disease has been in the top ten list of the mortality of the Department of Health (DOH). 10% occur in patients above 40 years. once we encounter it again in the future. (5-15 years of age) while a smaller portion. Rational for choosing the case The group decided to choose this case. especially the end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry (PRDR). END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS for it will be a good study because we are all aware that this is one of the diseases that gives a largest contribution to the morbidity rate here in the Philippines. The information and learning we will gain is advantage for us. This study will serve as guidelines in assessing and providing nursing care. as well as to develop skills and to apply interventions for patient with END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS. It may however be acquired at any time in the lifespan.

.the goal of nursing is health: its promotion. is based on the “assumption that human beings are the focus of nursing…. preserve. The three interacting relationships involve the individual.Theory of Goal Attainment The concepts of self. The theory of goal attainment. Conceptual and Nursing Theory Imogene M. interpersonal. interaction. perception. King . Imogene M. and social. and reclaim health.Scope and limitation of the study This study would focus only on END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS which indicates the disease process and client’s present health condition and the nursing action relevant for the client’s situation within the rotation at QMC – Dialysis Unit. Nurse-client interactions are thought to be individual perceptions which influence the process of goal attainment. King’s conceptual framework is best described as a holistic view of the complexity in nursing and multiple health care systems. The theory emphasizes the importance of knowledge and information that the nurse and the client both bring to the relationship. role and decision making were selected to represent how individuals and groups in the health care system interact to achieve goals. nurse-client interaction and nursing. transaction. maintenance. “This transaction model developed to represent the process whereby individuals interact to set goals that result in goal attainment” (King. the care of the sick or injured. communication. King's model consists of three interacting systems: personal. The group chose this theory because the primary nursing goal of patient having END STAGE RENAL DISEASE is to assist the patient to achieve. and the care of the dying”. working together to achieve goals. developed by Imogene M. and/or restoration. King. 1981).

Acute Renal Failure. Hypertension is the second leading cause of ESRD. Clinical Manifestations The symptoms for acute and chronic kidney disease may be different. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of normal. ESRD almost always follows chronic kidney disease Causes The causes of ESRD are numerous. However. Symptoms may include:       poor appetite vomiting bone pain headache insomnia itching       dry skin malaise fatigue with light activity muscle cramps high urine output or no urine output recurrent urinary tract infections . Polycystic Kidney Disease. Obstruction. The following are the most common manifestations of chronic renal failure.Related Literature Overview of the disease End – stage renal disease is irreversible and progressive reduction of functioning renal tissue. Systemic diseases such as Diabetes Mellitus. ESRD can develop insidiously over many years or may result from an episode of renal failure from which the client has not recovered. repeated episodes of Pyelonephritis. It is also called Chronic Kidney Disease (CKD) and is labeled stage 5. Various injuries and disease process that may result in kidney failure were Chronic Glumerulonephritis. Hypertension. Lupus Erythematous. and Nephrotoxins. It occurs when the remaining kidney mass can no longer maintain the body’s internal environment which results to renal failure. Sickle Cell Disease and Amyloidosis may produce chronic kidney disease. each individual may experience symptoms differently. Diabetes Mellitus is the leading cause and accounts for more than 30% of clients who receive dialysis.

and other electrolytes . phosphorous. The preparation includes learning about dialysis and the types of dialysis therapies. Changes in DIET:     Eat a low-protein diet Get enough calories if you are losing weight Limit fluids Limit salt. angiotensin receptor blocker.     urinary incontinence pale skin bad breath hearing deficit detectable abdominal mass      tissue swelling irritability poor muscle tone change in mental alertness metallic taste in mouth Treatment Dialysis or kidney transplantation is the only treatment for ESRD. Medications usually include an ACE inhibitor. A patient must prepare for dialysis before it is absolutely necessary. and placement of a dialysis access. or other medications for high blood pressure. potassium.

 Imaging tests. Kidney function tests look for the level of waste products.Other treatments may include:    Extra calcium and vitamin D Special medicines called phosphate binders. such as creatinine and urea. The biopsy sample is sent to a lab for testing to help determine what's causing your kidney problems. to help prevent phosphorous levels from becoming too high Treatment for anemia. Other imaging tests may be used in some cases. such as extra iron in the diet. Kidney biopsy is often done with local anesthesia using a long. thin needle that's inserted through your skin and into your kidney. The doctor may use ultrasound to assess your kidneys' structure. . Procedures and Tests  Blood tests. size and degree to which they reflect sound waves (echogenicity). special shots of a medicine called erythropoietin. Analyzing a sample of your urine may reveal abnormalities that point to chronic kidney failure and help identify the cause of chronic kidney disease. and blood transfusions.  Urine tests. in your blood.  Removing a sample of kidney tissue for testing. iron pills. The doctor may recommend a kidney biopsy to remove a sample of kidney tissue.

Quezon Oct. 28. Patient AAA has history of family hypertension. and the patient remained in the hospital for 3 days. and elevated blood pressure. Joseph Michael Abcede. shortness of breath and body weakness but he ignore it. Talipan purok Maligaya Pgbilao. History of present illness 2 days prior to admission patient AAA felt dizzy. 1978 Lucena City Filipino Roman Catholic Businessman July 9. . His blood pressure was 270/170mmHg and the doctor ordered antihypertensive medication to decrease blood pressure. body weakness. loss of appetite. Prior to admission.II – CLINICAL SUMMARY General Data Profile Name: Address: Birthday: Birth Place: Nationality: Religion: Occupations: Date of admission: AAA Brgy. MD Chief Complaint Patient was admitted @ MCDGH with chief complaint of vomiting. shortness of breath. 2012 End stage renal disease secondary to chronic glomerolunephritis Admitting Diagnosis: Admitting Physician: Dr. patient was brought to ER-QMC for consultation and ROD ordered laboratory examination like CBC and urinalysis in order to know the problem and give right medication for the patient.

Carvidolol Amlodipine. Cavite. Losartan. Domestic Travels - According to the patient. Childhood Illness b. Lucena Family History – Genogram Legends: = Male = Female = Patient . None According to the patient it was his first hospitalization when the doctor diagnosed him End stage renal failure Clonidine. Medications or currently taking g.a. he only experienced simple cough and colds The patient has complete immunizations - - The patient had no allergic reactions in any foods and drugs. Accidents e. Immunizations c. Hospitalization f. Allergies d. - Tagaytay. Ferrous Sulfate.

he decided to have an owned business.In the family genogram of our client. Hypertension is one of the leading causes of ESRD in the Philippines. we found out that the theory of Erikson correlates with the information that we’ve gathered to the patient. Based on our interview with the patient. Psychosocial Theory – According to Erik Erikson According to this theory young adulthood had intimate relationship with another person and a commitment to work and relationship. And they help each other to provide all the needs of the family. however there are diseases that could contribute to his disease. there are no kidney disorders in their family. According to the patient. Both of his parents had a history of stroke and experiencing hypertension. After the patient resigned in his previous work. . he really loves his wife and their 6 kids.

Quezon. When it comes with decision making. Since he was diagnosed with End Stage Renal Disease. the genital stage correlates to the patient’s age because the patient wanted to gain independence and decision making by working and from his age the patient wanted to be a good husband to his wife and father to their children. the patient is the one who make decision for his problem as long as he knows that he can solve it with his own. he has a maintenance medication for hypertension and currently undergoing a hemodialysis twice a week. Unlike when he was not already diagnosed with ESRD. Talipan Pagbilao. there are trees and lots of houses. In the surroundings of their house. . Although their house is in front of the Barangay Health Center.Psychosexual theory – According to Sigmund Freud According to this theory. The patient is in the stage of independency. he is always drinking alcohol after his work. he didn’t even make a consultation whenever he feels ill. Environment / Living Condition The patient lives in Brgy. and fatty foods that he wants but now he is very strict with regards to his food and he is also a former driver in a bank where he resigned because of his present condition. consumed 2 packs of cigarettes a day and eats a lot of salty.

symmetrical facial movement .Ambulatory .Ambulatory .(+)blink reflex .Auricle color same -Due to ineffective tissue perfusion Eyes Ears .Healthy in Appearance .Due to limited oral fluid intake Hair Nails .With full range of motion of neck and upper and lower extremities .Short clean cut nails Actual Findings .With smooth skin and free from any type of wounds .No eye discharge .Thick hair .due to decrease production of erythropoietin that leads to decrease level of oxygen in the upper and lower extremities Skull and Face .With good capillary refill of 1-2seconds .With full range of motion of neck and upper and lower extremities -able to speak clearly and articulate each word being spoken without any difficulty .Eyebrows hair evenly distributed/skin intact .With pinkish conjunctiva .Rounded smooth skull contour .With good skin turgor .Evenly distributed hair .With pinkish nail beds .(+)blink reflex .Eyebrows hair evenly distributed/skin intact .Symmetrical facial movement .With slightly weak in appearance .Rounded smooth skull contour .With pale conjunctiva .Physical Assessment Parameters General Appearance Normal Findings .With smooth skin and free from any type of wounds -Evenly distributed hair -Thick hair -With poor capillary refill of 3-4 seconds -With pale nail beds -With short clean cut nails Interpretation -Due to his illness condition the patient is slightly weak in appearance Skin .No eye discharge .Able to speak clearly and articulate each word being spoken without any difficulty -With good gag reflex -With slightly poor skin turgor .Auricle color same .with good gag reflex .

No atrophy .with symmetrical contour -With mass on the right portion of the neck .Flat rounded -Flat rounded abdomen abdomen .With symmetrical contour .Dry and pale lips -with pale gums .Symmetrical and lower extremities) .Due to limited oral fluid intake .Auricle are mobile firm and not tender .With pink gums .No abdominal distention distention .Mouth uniform consistency.Symmetrical .Due to hypersecretion of T3 and T4 .No edema and discharge .Mouth Neck as facial skin .No atrophy . absence of nodules and masses .No edema and discharge .With full range of motion .Mouth uniform consistency.Due to limited intake of food and oral fluid but still the patient has normal findings in abdomen Musculosketal (Upper .Able to hear on both ears .Symmetrical contour -Symmetrical contour . absence of nodules and masses .With full range of motion .Able to hear on both ears .No masses Abdomen as facial skin .Auricle are mobile firm and not tender .No abdominal .Pinkish lips .

5L -1L including the food and fluids -thin than the normal body built 47.  Nutritional/ Metabolic -Five times a day with in between snacks (fast food lovers) consuming 1L of fluids -very good -during hemodialysis. -good a. Glass of water per day -2. Number of meals per day b.5 kg 5”4’ Because of the condition of the client. Height and weight . Body built -he has good body built 72 kg 5”4’ e.Patterns of Functioning Functional Health Pattern  Health management Pattern Before During Interpretation Hospitalization Hospitalization Self-medicated (over the counter drugs) He is dependent to health care team and the medication with the prescription of M. he has limitation when it comes to food so as to avoid excess fluids and electrolytes. Despite of his situation he has a good appetite but he limit himself to eat. d. During the dialysis he’s allowed to drink and eat but in moderate amount with strictly monitor due to his condition. he tries to eat foods that he can’t usually eat. Appetite c.D Hemodialysis The medications and treatments are rendered by the health care team and he usually seeks medical attention due to his condition.

Amount of urine per day c. Amount defecated per day  -moderate Activity and Exercise -active exercise -limited every day (jogging movement and basketball) because of the body weakness -not easily get tired -easily get tired due to his condition -can do ADL but limited unlike before The patient wasn’t able o do his usual routine before like exercise and he is easily get tired but despite of his condition is not hindrance to do some ADL but in limited time and action. Consistency of the feces -formed or semiformed e. Orientation b. a. and toxins in the body.he is appropriately responds to verbal and physical stimuli The client is oriented and the cognitive and perceptual status is totally intact and appropriately responds to the questions given. electrolytes. Responsiveness . place and person -he is appropriately responds to verbal and physical stimuli -aware to time. ADL -independent  Cognitive/Perceptual -aware to time. Frequency of bowel movement -4 times a day -once or twice a day -formed or semiformed -moderate d. a. Exercise b. Fatigability c. Elimination -10 times a day -30-60cc/hour -4 times a day -<30 cc/hour The dialysis removes the excess fluid. Frequency of urination b. place and person . a.

 Roles / Relationship He has a good relationship with his parents He has a good relationship with his parents and they are one of the reason why is more strong despite of his condition. As a son b. Despite of his condition he has still a good relationship with his family and became more bonded and intact with each other. He became stronger to face his situation because of his family. He has more time to take care of his children due to his condition but still good provider to them. With good relationship to his siblings became more bonded due to his condition. . He never blames the Lord about his condition instead His faith becomes stronger than before. a. Coping/Stress -Socialize with his friends -He always speak out to his wife and he want to take care of his children He has a good coping techniques despite of his condition  Values and Beliefs He is aware that GOD really exists He is aware that GOD really exists. As a husband With a very good relationship with his wife and a good provider as a husband  As a father With a very good relationship to his children and good provider to his children as a father Become more stronger and bonded with each other despite of his condition. and his faith is more strengthened than before. As a brother With good relationship to his siblings c.

2012 July 9.65 0.36 12 – 16 37-45 150-400 Interpretation LOW the patient has anemia - fL Pg % g/Dl % 10^9/L .01 0.25 . T4 For CBC. serum crreatinine.0. 2012 July 14. 2012 Parameter RBC WBC Segmenters Lymphocytes Eosinophils Monocytes Basophils MCV MCH MCHC HGB HCT Platelet Results 9.08 82 – 92 27 – 32 32 .4. Dayahan for Endoscopy For TSH.0. 2012 October 2.01 0.5 5 – 10 0.1 0.05 0. 2012 Doctor’s Order (+) Headache when taking Atenolol Shift Atenolol to Lozartan (Lifezar) 100mg/tab 1 tab OD For pH CBC.5 Units 10 ^12/L 10^9/L Normal Range 4 .55 . Phosporus July 4. T3.Course in the Ward Date June 6.35 0. Calcium. Creatinine. calcium.01 0. phosphorus To: QMC Hemodialysis Unit Please accommodate patient for 2x/ week hemodialysis ESRD secondary to Chronic Glomerulonephritis For referral to Dr. 2012 Laboratory / Diagnostic Exam October 3.

off 0.C Virus Pt. isn't considered significant and causes no symptoms.00 Cut-off 10. A low hemoglobin count can also be caused by an abnormality or disease. count 0.IMPLICATIONS:  A low hemoglobin count is a below average concentration of the oxygen – carrying hemoglobin proteins in your blood. July 15. count 2. 2009 Pt. 2009 HBSAG Hepa.392 Remarks Non-reactive Non-reactive III – CLINICAL DISCUSSION OF THE DISEASE Anatomy and Physiology . In many cases. a low hemoglobin count is referred to as anemia.reactive Anti-HBS July 10.055 Cut. In these situations.075 0.00 Remarks Non.018 0. a low hemoglobin count is only slightly lower than normal.

The main blood vessel that brings blood to the kidney from the aorta.This is the outer covering of the kidney.This is the working unit of the kidney.This is a solid portion of the kidney where blood vessels travel to and from the nephron. Urethra Is a tube that exits the urinary bladder inferiorly and anteriorly.Kidneys are solid organs found in the middle back that are responsible for removing water and water soluble waste from the blood.One of multiple cone-shaped portions of the kidney where urine is removed from blood and drained into the renal calices.The main blood vessel that brings blood away from the kidney back to the inferior vena cava Renal capsule. Renal artery . Renal column. And a kidney plays the following essential roles in controlling the composition and volume of body fluids:       Excretion Regulation of blood volume and pressure Regulation of the concentration of solutes in the blood Regulation of extracellular fluid ph Regulation of the red blood cell synthesis Vitamin D synthesis Structures of the kidney: Renal pyramid . . Ureter Are small tubes that carry urine from the renal pelvis of the kidney to the posterior inferior portion of the urinary bladder Bladder its functions is to store urine. and its size depend on the quantity urine present. Nephron. Renal vein .

antigen – antibody formation. systemic disease)  DM  CGN  HPN  LSE  ARF  Nephrotoxins  Pyelonephritis  Polycystic Kidney Disease Glomerular – Capillary Membrane Inflammation Decreased renal blood flow Glomerular Permeability Decreased GFR    Activation of Renin – Angiotensin Aldosterone Sysstem HEMATURIA PROTEINURIA INCREASED BUN AND CREATININE Na and water retention Decreased vasopressor activity HYPERETENSION Prolonged hypertension Arterial walls are damaged Atherosclerosis in glomerular capillaries .Pathophysiology Book based INITIATING EVENT (infection.

nephrons are destroyed Glomerular Sclerosis Further loss of functional nephrons (ESRD) END STAGE RENAL DISEASE .Progressive deterioration of GF. tubular secretion and reabsorption Kidney attempt to maintain GFR Glomerular hyperfiltration Decreased renal mass.

retention of sodium. salty and fatty foods)  Non-modifiable Risk factors o Family history of Hypertension Develops Urinary Tract Infection (UTI) Initiating event (infection. junk foods.Client based  Modifiable Risk factors o Cigarette smoking o Drinking alcohol o Fast food lovers o High intake of food rich in sodium o Over use of over the counter drugs o Lifestyle (eating processed foods. water and waste Renal blood flow and glomerular filtration are decreased Rapidly progressive glomerulonephritis Severe glomerular injury (chronic glomerulonephritis) Chronic Renal Failure (ESRD) END-STAGE RENAL DISEASE . antigen-antibody formation. systemic disease) Renal insufficiency.

The patient should adhere to his scheduled hemodialysis to excrete the metabolic waste that the kidneys cannot excrete. strict adherence to his diet and to prevent further complications through collaborative management of the health care team. Prioritized List Nursing Problem DIAGNOSIS Decreased Tissue Perfusion r/t to constricted peripheral blood vessels as manifested by increase blood pressure of 200/130 RANK REASON The group decided to prioritize first the decreased tissue perfusion due to decrease circulating RBCs in the blood therefore decrease oxygen level. Circulation should be prioritized first among the problems.IV – NURSING PROCESS Long Term Objectives The study aims to restore and maintain the patient’s body weight. 1 Fluid Volume Excess r/t decrease Glomerular filtration Rate and sodium retention as manifested by increase BP of 200/130 Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute secondary defense 2 3 . Kidney transplantation is needed to attain the patient’s optimum wellness. to prevent further deteriorating his ill condition. The group ranked the Fluid volume excess as number two because it is the presenting problem in our patient. We ranked it as our least priority because in the case of the patient frequent IV cannula will introduce microorganism in the blood circulation that would trigger systemic infection since there is only a risk and problems the first thing that should be managed since this problem can be fatal if left untreated.

making sure that the purpose of the medication s d i s c l o s e d b y t h e health care provider.   Advise patient to take the prescribed medicines continuously at home. clean and calm environment for alleviating the patient’s discomfort o Provide safety measure to promote safe environment and individual safety  Exercise should be promoted in a way by stretching hand and feet every morning. & frequency. But if there is presence of pain rest should be provided. Encourage the patient to keep active to adhere to exercise program and to remain as self –sufficient as possible. on exact dosage.Discharge Plan (METHOD) Clients with Renal Disease are instructed to take the following plan for discharge: Medication  Medications should be taken regularly as prescribed.  Assist patient in doing ADLs. Treatment  Instructed the patient to continue medication and compliance to strict regimen. Medication as follows: o – Amlodipine 5mg/tab 1tab OD (7pm) o – Lozartan (Lifezar) 100mg 1 tab OD (7am) o – Clonidine (Catapres) 150 mg/tab 1 tab BID (10am-10pm) o – Carvedilol 25mg 1 tab OD (12nn) Environment  Maintain quiet. . time.

Protect the client from exposure to infectious agents. Encouraged activity within prescribed limits but avoid fatigue. City Diet   Advised the patient to follow the Doctors Order regarding her diet with strict 1L of fluids per day including the food fluid. .Health teaching          Encouraged a diet high in carbohydrates within the prescribed sodium. phosphorus and protein limits. Advised the patient to a renal diet. potassium. Encouraged patient to avoid salty and fatty foods Encouraged patient to have enough rest Instructed the patient to do exercise as tolerated such as walking. Out –patient check-up  Instructed to comeback for the next hemodialysis on November 30. 2012 Friday at Dialysis Unit at Quezon Medical Center Lucena. Emphasized the importance of practicing proper hand washing Instructed to do deep breathing and coughing exercises Encouraged patient to eat nutritious foods.

gastric upset. palpitations. chest pain  GI: nausea.  Assess fluid volume status  Monitor blood pressure and pulse. peripheral edema. diarrhea. constipation. if blood pressure drops call prescriber  Monitor platelet count. severe aortic stenosis. severe obstructive coronary artery disease. flatulence. hypotension. PR. dizziness  CV: dysrhythmia. may co-administer with other antihypertensives. ADVERSE EFFECT  CNS: headache. syncope. hypertension. second or third degree heart block. gingival NURSING RESPONSIBILITY  Exercise the ten rights of giving medication upon administering.Drug Study NAME OF THE DRUG Amlodipine (AMVASC) Therapeutic Classification:  Antihyperten siv  Calcium Channel Blocker DOSAGE Doctor’s Order: 10mg/tab 1 OD 7PM ACTION INDICATION CONTRA INDICATION Sick sinus syndrome. produces relaxation of coronary vascular smooth muscle and peripheral vascular smooth muscle. hypertensivity. ECG.  Monitor cardiac status: blood pressure.RR Inhibits calcium ion influx across cell membrane during cardiac depolarization. fatigue. .increasing myocardial oxygen delivery in patient with vasospastic angina. vomiting. dilates coronary arteries. anorexia.

 Monitor blood pressure  Monitor apical or pulse ratebefore administration  Assess for edema in feet and legs daily. diarrhea. A mixture of nonselective Bblocking and ablocking activity. pulmonary edema. postural hypotension. cardiogeneric shock. severe bradycardia. BUN. bronchial asthma. or 3rd degree heart block. dependent edema. 2nd.NAME OF THE DRUG Generic name: Carvedilol Classifications: Antihyper tensive DOSAGE Doctor’s Order: 25 mg 1 tab OD 12nn ACTION INDICATION CONTRA INDICATION Hypersensitivity. reflex orthostatic tachycardia. causes reduction in peripheral vascular resistance and vasodilatation Essential hypertension alone or in combination with other antihypertensive . pharyngitis. peripheral edema  GU: UTI  Resp: rhinitis.  Monitor input and output and weight daily. dyspnea NURSING RESPONSIBILITY  Exercise the ten rights of giving medication upon administering. headache  GI: abdominal pain. class IV decompensated cardiac failure. exercise inducedtachycardia. increased AST/ ALT. creatinine. decreases cardiac output. fluid overload. ADVERSE EFFECT  CNS: seizures. dizziness. increased alkaline phosphatase  CV: bradycardia.  Monitor renal studies including protein.

 Do not drive or engage in other potentially hazardous activity during the first 90 d of therapy because of possible seizure activity. thrombocyt osis. Reduces need for blood in anemic surgical patients. Hypoxia and anemia generally increase the production of erythropoietin.  Monitor for hypertensive encephalopathy in patients with CRF during period of increasing Hct. The potential for seizures exists during periods of rapid Hct increase  Important to comply with antihypertensive medication and dietary restrictions. clottin g of AV fistula. patients may or may not be on dialysis.  Other: Sw eating. NURSING RESPONSIBILITIES  Control BP adequately prior to initiation of therapy and closely monitor and control during therapy.NAME OF THE DRUG Generic Name: Epoetin Alfa (Renogen) -Human Recombinant Erythropoietin Therapeutic Classification:  Blood formers  Hematopoietic growth factor DOSAGE Doctor’s Order:  4000u 2x a week ACTION INDICATION CONTRA INDICATION Uncontrolled hypertension and known hypersensitivity to mammalian cell– derived products and albumin (human) ADVERSE EFFECT  CNS: Seiz ures. Autologous blood donations for anticipated transfusions. .  Monitor for premonitory neurological symptoms. bone pain. heada che. other anemias related to malignancies and AIDS.  CV: Hyper tension  GI: Nausea .  Hematolog ic: Iron deficiency. Elevates the hematocrit of patients with anemia secondary to chronic kidney failure (CRF). arthralgias. diarrhea. Glycoprotein that stimulates RBC production. Hypertension is an adverse effect that must be controlled.

and his blood pressure became 160/100.  Bounding carotid.Pulses in the legs/ feet may be diminished. . 200/130mmhg Planning After 4 hours of nursing intervention the patient will demonstrate increase perfusion as individually appropriate Intervention  Nurse patient interaction. cool increase tissue moist skin and delays perfusion as capillary time may be due manifested seen to peripheral patient cooperative vasoconstriction and interested.NCP Based on the sequence of Prioritized problems Assessment Subjective: Objective:  Oliguria  Hyper-tensive  Cold and clammy skin  Hgb 9. quality of central and peripheral pulses. Rationale  To establish rapport Evaluation Goal met  Provide objective data for After 4 hours of monitoring nursing intervention the patient was able to demonstrate  Presence of pallor. jugular. radial.  Measure and recorded blood pressure  Observe skin color.5 g/dL Nursing Diagnosis Decrease tissue perfusion related to peripheral vasoconstriction as manifested by high blood pressure. temperature and capillary refill time  Note presence. reflecting effects of vasoconstriction and venous congestion. moisture. and femoral pulses may be observed/ palpated.

 It decrease discomfort and may reduce sympathetic stimulation  Encourage compliance with  Adherence to diet and fluid restrictions and dietary and fluid dialysis schedule restrictions therapy prevents excess fluid and sodium accumulation  Monitor response to medications to control blood pressure. minimize environmental activity and noise  Provide adequate rest period of time and limit the number of visitor and the length of stay  It helps reduce sympathetic stimulation. promotes relaxation and reduces physical stress and tension that affect blood pressure. Explain the importance of providing calm.  Response to drug therapy is dependent on both individual as well as the synergistic effects of the drug . restful surroundings.

Note presence of edema. To note for presence of nausea and vomiting To prevent fluid overload and monitor intake and output To monitor fluid retention and evaluate degree of excess For presence of crackles or congestion To determine fluid retention 5. . patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess Intervention 1. Monitor and record vital signs 3. Auscultate breath sounds    8. Note amount/rate of fluid intake from all sources 6. Compare current weight gain with admission or previous stated weight 7.Assessment Diagnosis Excess fluid volume r/t decrease Glomerular filtration Rate and sodium retention as manifested by increase blood pressure of 200/130 Planning After 4 hours of nursing interventions. Assess possible risk factors 4. Assess patient’s appetite To obtain baseline data To assess precipitating and causative factors. Establish rapport      Rationale To gain trust and rapport Evaluation Goal met The patient demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess Subjective (none) Objectives  Blood pressure of 200/130 mmHg  Oliguria noted 2.

Serum electrolyte. . 15. 11. Measure abdominal girth for  changes. 12. Weigh client Weight gain may indicate fluid retention and edema. Encourage quiet. Evaluate mentation for confusion and personality changes. Restrict sodium and fluid intake if indicated To monitor fluid and electrolyte imbalances  . Change position of client timely.    May indicate increase in fluid retention May indicate cerebral edema. Review lab data like BUN. To prevent pressure ulcers. 10. restful atmosphere. 14.  To lessen fluid retention and overload. 13.  To conserve energy and lower tissue oxygen demand. . Creatinine.9.

Assessment Nursing Diagnosis Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute secondary defense Planning Intervention Rationale Evaluation Subjective (none) Objectives  Decrease hemoglobin 9. coughing frequent position changes  It Prevents atelectasis and mobilizes secretion to reduce risk of pulmonary infections Excoriations from scratching may become secondarily infected Fever and increase pulse and respiration is typical increase metabolic rate resulting from inflamatory process  Asses skin integrity   Monitor vital signs  . Reduce risk of cross contamination Reduces bacterial colonization  Explain the importance of deep breathing.5g After 4 hours of nursing intervention the patient will not experience sign and symptom of infection    NPI established and maintained Promoted good hand washing Use aseptic technique when manipulating/IV invasive lines    To gain trust Goal met After 4 hours of nursing intervention the patient did not experienced any sign and symptom of infection.