1

I. INTRODUCTION

The researcher’s exposure to the hemodialysis area last June 2005

led her to be more interested in choosing Chronic Renal Failure for her

study. A great number of population in the United States, Africa and as

well as in the Philippines are diagnosed with CRF and these people

diagnosed with this disease are also fighting and surviving with the help

of functioning transplant or through the scheduling usage of different

hemodialysis or peritoneal dialysis that helps each one of them fight this

lifetime.

As a nursing student and a future nurse in a year or less, it

is her responsibility to give efficient and effective care to her future

patients and through this study, it will give the researcher’s view a

broader knowledge and development of skills and attitude in caring for

patients especially those with CRF regardless of age if ever assigned in

the same situation in the future.

After this case study, the researcher expects to gain more facts

about the care of patients with CRF and be well understood about its

occurrence, how it affects the people, how it’s treated and prevented and

through this her knowledge will be shared to CRF patients and to their

significant others so that negative misconceptions about the disease will

be erased. This case study would allow both the researcher and clients

be well educated more as proper knowledge will pave way to a more

effective holistic care.

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Chronic renal failure is a slow insidious process of kidney

destruction. It may go unrecognized for years as nephron units are

destroyed and renal mass is reduced. When the kidneys are no longer

able to excrete metabolic wastes and regulate fluid and electrolyte

balance adequately, the client is said to have (ESRD) End stage renal

disease, the final stage of CRF.

End stage renal disease is increasing in incidence in all age

groups, with a particularly sharp increase in people over age 70. The

incidence if ESRD is highest in African Americans, followed by Native

americans. Diabetic nephropathy and hypertension are the leading

causes of chronic renal failure in the United States. Among African

Americans, hypertension is the leading cause.

The causes of CRF are numerous. Chronic glomerulonephritis,

ARF, polycystic kidney disease, obstruction, repeated episodes of

pyelonephritis, and nephrotoxins are examples of causes. Systemic

diseases, such as diabetes mellitus, hypertension, lupus erythematous,

polyarteritis, sickle cell disease and amyloidosis, may produce CRF.

Diabetes is the leading cause and accounts for more than 30% of clients

who receive dialysis. Hypertension is the second leading cause of CRF.

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II. OBJECTIVES

Student nurse-centered:

After 2 days of SN-patient car, the student-nurse will be able to:

1. discuss chronic renal s as to its:

1.1 definition

I.2 clinical manifestations

I.3 pathophysiology

I.4 disease process and effects of different organ systems

2. identify actual and potential problems of patients with CRF

3. provide the appropriate nursing care according to identified

problems anticipate the client’s needs essential to treatment

4. impart healthy teachings to patient and SO which are helpful for

patients care encourage client to participate in planned activities

and treatment regimen

5.. explain to patient and SO the importance of drug compliance

6. teach the client as well as the significant others ways to be free

from risks of infections

7. state to client the proper intake of meal and snacks given to

him

8. instruct to client the advantages of proper weight monitoring

9. impart health teachings to the client and the significant others

towards health promotion

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Patient-centered:

After 2 days of SN-patient care, the patient will be able to:

1. define CRF

2. cite clinical and classical manifestations of CRF

3. share with the SN the physiologic and psychologic problems

being encountered

4. participate in the SN plan of activities

5. adheres to treatment regimen as evidenced by taking

medications as prescribed

7. perform measures to prevent risks for infection

8. relate the importance of overall health measures (proper aseptic

technique, daily weight monitoring, adequate nutritional intake)

9. apply to daily life the things learned, gained during the client’s

hospitalization

10. demonstrate health promotion behaviors

III. NURSING ASSESSMENT

1. Personal history

1.1. Patient’s profile

Name : Roberto Sumabong Abello

Age: 32 years old

Sex: Male

Civil status: married

 5

Religion: Roman Catholic

Date of Admission: June 24, 2005

Room no: M26

Complaints: fever, vomiting, loss of appetite

Impression or Diagnosis: ESRD 2º to CGN/ CRF 2º to CGN

Physician: Dr.L. Garcia; Dr. K. Licuanan; Dr. Arn. Tan

1.2 Family and individual information, social and health

history

Mr. Abello has two daughters back in Bohol who are now

currently staying with his parents. He is married to a very

caring lady, Mrs. Jenalyn Abello who stays with him in the

hospital. Mr. Abello was an alcohol drinker that could

consume about 1 Tanduay Jr. every night. He recently

stopped a month ago before admitted to Cebu Doctors’

University Hospital due to undesirable health condition felt.

1.3 Level of Growth and Development

1.3.1 Normal development at particular stage

The patient is a middle adult. In middle

adulthood, the individual makes lasting contributions

through involvement with others. During this period,

personal and career achievements have often already been

experienced. Many middle adults find particular joy in

assisting their children and other young people to become

 6

productive and responsible adults. They may also begin to

help aging parents. Using leisure time in satisfying and

creative ways is a challenge that, if met satisfactorily,

enables middle adults to prepare for retirement.

Men and women must adjust to inevitable biological

changes. As in adolescence, middle adults use considerable

energy to adapt self- concept and body image to physiological

realities and changes in physical appearance. High self-

esteem, a favorable body image, and a positive attitude

toward physiological changes are fostered when adults

engage in physical exercise, balanced diets, adequate sleep,

and good hygiene practices that promote vigorous, healthy

bodies

The psychosocial changes in the middle adult may

involve expected events, such as children moving away from

home, or unexpected events, such as marital separation.

These changes may result in stress that can affect the

middle adult’s overall level of health.

In the middle adult years, as children depart

from the household, the family enters the postparental

family stage. Time and financial demands on the parents

decrease, and the couple faces the task of redefining their

own relationship.
 7

According to Erikson’s developmental theory, the

primary developmental task of the middle years is to achieve

generativity. Generativity is the willingness to care for and

guide others. If middle adults fail to achieve generativity,

stagnation occurs. This is shown by excessive concern with

themselves or destructive behavior toward their children and

the community.

1.3.2 The ill person at particular stage

Illness in middle adulthood, however may take a

longer recovery period because of the slowing of recuperative

processes. As well, acute illness in middle adulthood are

more likely to become chronic conditions. For those middle

adults who are in the “sandwich generation”, stress levels

may also increase as the middle adult tries to balance

responsibilities related to employment and family life.

The client is able to accept his condition as well as its

treatment. He complies to the medical advice given to her

but is also concerned with her physical outcome and her

family condition and status as well.

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2. Diagnostic Results

DIAGNOSTIC NORMAL RESULT SIGNIFICANCE

TESTS VALUE

June 25, 2005

Glucose 99mg/dl 65-110 Normal
Urea 120Mg/dl 7-20 Increased
nitrogen
Creatinine 22.6mg/dl .7-1.5 Increased
Uric acid 11.9Mg/dl 2.5-7.5 Increased
Sodium 125mmol/dl 137-145 Decreased
Potassium 2.9mmol/dl 3.6-5 Decreased
Chloride 85mmol/dl 98-107 Decreased
Enzymatic 16mmol/dl 22-30 Decreased
CO2
Calcium 6.3mg/dl 8.4-10.2 Decreased
Phosphorus 13mg/dl 2.5-4.5 Increased
Cholesterol 78mg/dl 131-239 Decreased
Triglycerides 215mg/dl 0-250 Normal
ULOL 43mg/dl 0-40 Increased
Total protein 7.6g/dl 6-8 Normal
Albumin 4.1g/dl 3.3-5.5 Normal
A/G ratio 1.2 1.2-2.2 Normal
Globumin 3.5g/dl 2.3-3.5 Normal
AST 45u/L 15-46 Normal
ALT 48u/L 11-66 Normal
ALKP 74u/L 38-126 Normal

URINALYSIS
EXAM
Color Straw
Appearance Slightly
cloudy
Reaction 6 4.6-8 Normal
Specific 1.007 1.016-1.022 Normal
gravity
Protein Trace negative
Glucose Negative negative Normal
Ketones Negative negative Normal
Blood Small negative
Leukocytes Negative negative Normal
Nitrite Negative negative Normal
 9

Bilirubin Negative negative Normal

urobilinogen .2eu/dl 0.2-1.0 eu/dl Normal

July 1, 2005
COMPLETE
BLOOD
COUNT
Hemoglobin 9.84g/dL 14.0-17.5 Decreased
Hematocrit 29.7 41.5-40.4 Decreased
Red blood 3.39x10^6/ul 4.-5.9 Decreased
cells
White blood 4.94x10^3/ul 4.4-11 Normal
cells
MCH 29.0pg 27.5-39.2 Normal
Mean 87.4fl 80-96 Normal
corpuscular
volume
MCHC 33.2% 33.4-35.5 Decreased
Platelet 203000/cumm 150000- Normal
450000

DIFFERENTI
AL COUNTS
Neurophils 56% 40-70 Normal
Lymphocyte 37% 20-40 Normal
s
Monocytes 06% 0-8 Normal
Eosinophils 01% 0-1 Normal

Creatinine 11.9mg/d .7-1.5 Increased

Potassium 3.2mmol/L 3.6-5.0 Decreased
Sodium 138mmol/L 137-145 Normal

3. Present profile of Functional Health Patterns

3.1. Health Perception / Health Management Pattern

Mr. Abello describes himself to be in a fair condition. He’s complete

with the immunizations needed. His complaints regarding his

intermittent fever accompanied with loss of appetite and

vomiting started two weeks prior to his admission at CDUH and

 10

upon consultation to a doctor, he was diagnosed of ESRD thus

prompt treatment and the use of hemodialysis machine was in

great need and so he came to Cebu together with his wife to be

admitted. Some movements are limited due to the pain felt on his

left upper extremity because of the AV shunt insertion

3.2. Nutritional – Metabolic Pattern

Mr. Abello preferably eats anything set on the table and consumes

around 8 glasses of water per day. He was prescribed by the doctor

to consume at most 4 glasses of water each day due to his present

condition. His appetite has remained the same compared to time

before admission. As of the moment, there are no complaints of

nausea and vomiting especially after eating and taking a walk from

the room to the CR. The doctor advised the patient to only eat the

food provided by the hospital. He doesn’t have any vitamin and

food supplements and has no problem with his ability to eat and

swallow food.

3.3. Elimination Pattern

Mr. Abello verbalized that there is seldom pain upon urination and

voids a little amount of urine every time he urinates. No assistive

devices for urinating as well as for his bowel movement. He

defecates once a day.

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3.4. Activity / Exercise Pattern

Mr. Abello is unemployed and spends time with his friends

drinking a lot of alcoholic beverages every night which he recently

stopped a month ago due to the illness felt. No limitations in daily

activities but feels pain upon movement and muscle twitching of

right arm.

3.5. Cognitive / Perceptual Pattern

Mr. Abello doesn’t have any defects in sensory perception. He

hasn’t encountered any complaints such as vertigo and

insensitivity to tactile stimulation. He is also able to read and write

finishing the third year level in high school.

3.6. Rest / Sleep Pattern

Mr. Abello verbalized that he has only five hours of sleep in a day

combining the afternoon naps he takes once in awhile. His naps

taken in the afternoon makes it very hard for him to go to sleep at

night time. Back in Bohol, sleeping routine includes watching a

movie or any TV sop or etc then goes to sleep. He doesn’t have any

sleeping aids nor takes any sleeping pills.

3.7. Self-Perception Pattern

He is most concerned of being in his best condition again since he

and his wife needs to go back to Bohol for their two children whom

they left with his parents. He is hoping to get well soon to make up

for the expense he has cost his family and parents and would to
 12

put his parenting responsibility to a great deal of extent since he

has been a drunkard for many years.

3.8. Role Relationship Pattern

He speaks English, tagalong and bisaya. His communication skills

can be well understood and hi can directly answer the questions

addressed to him. He is very cooperative and takes initiative in

telling the health personnel attending to him about what he feels

and the things bothering him such as the muscle twitching and

pain felt on his right arm. His family lives together with her sister-

in-law’s family. His being a drunkard for a long period of time

pave way to parenting difficulties and now that he is being

hospitalized, he realized the mistakes he has done and wants to

change for the family.

3.9. Sexuality – Reproductive Pattern

His being weak and ill has changed his sexual relations with his

partner but touch with care and love is still very evident between

the couple.

3.10. Coping – Stress Tolerance Pattern

He makes decisions at home with the help and guidance of his wife

whom he confides all the time. He is hoping to be out of the

hospital as soon as possible and change for the better and stop

drinking so that the can preserve his health and specially care
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and be the breadwinner of the family. He sleeps when he is

stressed and requires a peaceful environment so he can fully relax.

3.11. Value – Belief System

He was brought up to see God as his guidance and source of

strength. He is a devoted Roman Catholic who practices going to

church on Sundays and first Fridays together with his family and

with relatives as well on special occasions like Christmas, Easter

and New Years.

4. Pathophysiology and Rationale

4.1 Normal Anatomy and Physiology of Organ or System Affected.

Renal System

The kidneys are essentially regulatory organs which maintain the

volume and composition of body fluid by filtration of the blood and

selective reabsorption or secretion of filtered solutes.

The kidneys are retroperitoneal organs (located behind the

peritoneum) situated on the posterior wall of the abdomen on each

side of the vertebral column, at about the level of the twelfth rib. The

left kidney is lightly higher in the abdomen than the right, due to the

presence of the liver pushing the right kidney down.

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The kidneys take their blood supply directly from the aorta via the

renal arteries; blood is returned to the inferior vena cava via the renal

veins. Urine (the filtered product containing waste materials and

water) excreted from the kidneys passes down the fibromuscular

ureters and collects in the bladder. The bladder muscle (the detrusor

muscle) is capable of distending to accept urine without increasing

the pressure inside; this means that large volumes can be collected

(700-1000ml) without high-pressure damage to the renal system

occuring.

When urine is passed, the urethral sphincter at the base of the

bladder relaxes, the detrusor contracts, and urine is voided via the

urethra.

Structure of the kidney

On sectioning, the kidney has a pale outer region- the cortex- and a

darker inner region- the [Link] medulla is divided into 8-18

conical regions, called the renal pyramids; the base of each pyramid

starts at the corticomedullary border, and the apex ends in the renal

papilla which merges to form the renal pelvis and then on to form the

ureter. In humans, the renal pelvis is divided into two or three spaces

-the major calyces- which in turn divide into further minor calyces.

The walls of the calyces, pelvis and ureters are lined with smooth
 15

muscle that can contract to force urine towards the bladder by

peristalsis.

The cortex and the medulla are made up of nephrons; these are the

functional units of the kidney, and each kidney contains about 1.3

million of them.

Structure of the Nephron

 The nephron is the unit of the kidney responsible for ultrafiltration

of the blood and reabsorption or excretion of products in the

subsequent filtrate. Each nephron is made up of:

 A filtering unit- the glomerulus. 125ml/min of filtrate is formed by

the kidneys as blood is filtered through this sieve-like structure. This

filtration is uncontrolled.

 The proximal convoluted tubule. Controlled absorption of glucose,

sodium, and other solutes goes on in this region.

 The loop of Henle. This region is responsible for concentration and

dilution of urine by utilizing a counter-current multiplying mechanism-

basically, it is water-impermeable but can pump sodium out, which in

turn affects the osmolarity of the surrounding tissues and will affect

the subsequent movement of water in or out of the water-permeable

collecting duct.
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 The distal convoluted tubule. This region is responsible, along with

the collecting duct that it joins, for absorbing water back into the

body- simple maths will tell you that the kidney doesn't produce

125ml of urine every minute. 99% of the water is normally

reabsorbed, leaving highly concentrated urine to flow into the

collecting duct and then into the renal pelvis.

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4.2 Schematic diagram

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4.3 Disease process and effects on different organs and systems

The pathogenesis of CRF involes deterioration and

destruction of nephrons with progressive loss of renal function. As

the total GFR decreases and clearance is reduced, serum urea

nitrogen and creatinine levels increase. Remaining functioning

nephrons hypertrophy as they filter a larger load of solutes. A

consequence is that the kidneys lose their ability to concentrate

urine adequately. To continue excreting the solute, a large volume of

dilute urine may be passed, which makes the client susceptible to

fluid depletion. The tubules gradually lose their ability to reabsorb

elcetrolyes. Occasionally, the result is salt wasting, in which urine

contains large amounts of sodium, which leads to more polyuria.

As renal damage advances and the number of functioning

nephrons declines, the total GFR decreases further. Thus the body

becomes unable to rid itself of excess water, salt, and other waste

products through the kidneys. When the GFR is less than 10 to 20

ml/min, the effect of uremic toxins on the body becomes evident. If

the disease is not treated by dialysis or transplantation, the outcome

of CRF is uremia and death

The clinical manifestations of the early stages of renal failure depend

on the disease process and contributing factors. As nephron

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destruction progresses to ESRD, the manifestations become similar

and are described as uremic syndrome. The clinical course of

irreversible renal disease and uremic syndrome follows a pattern:

 Reduced renal reserve refers to the state in which BUN is

high-normal but the client has no clinical manifestations.

Normal functioning is evident as long as the client is not

exposed to unusual physiologic and psychosocial stress.

 Renal insufficiency reflects a more advanced pathologic

process with mild azotemia when the client is receiving a

general diet. Impaired urine concentration, nocturia and mild

anemia are common findings. Renal function is easily

impaired by stress.

 Renal failure is indicated by severe azotemia, acidosis,

impaired urine dilution, severe anemia, and a number of

electrolyte imbalances, such as hypernatremia, hyperkalemia

and hyperphosphatemia

 ESRD is characterized by two groups of clinical

manifestations; deranged excretory and regulatory

mechanisms and a distinctive grouping of gastrointestinal,

cardiovascular, neuromuscular, hematologic, integumentary,

skeletal, and hormonal manifestations. The kidneys can no

longer maintain homeostasis.

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GASTROINTESTINAL CHANGES

The entire gastrointestinal system is affected. Transient anorexia,

nausea and vomiting are almost universal. Clients often experience a

constant bitter, metallic or salty taste and their breath commonly

smells fetid, fishy or ammonia-like.

Constipation is a common problem. It often results from

phosphate-binding agents, restriction of fluids and high-fiber foods

(many of which are rich in potassium and phosphorus), and

decreased activity.

CARDIOVASCULAR CHANGES

The most common clinical manifestation is hypertension produced

through the following:

 Mechanisms of volume overload

 Stimulation of the rennin-angiotensin system

 Sympathetically mediated vasoconstrictions;

 Absence of prostaglandins
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Artherosclerosis is accelerated because of abnormal

carbohydrate and lipid metabolism, impaired fibrinolysis and

hyperthyroidism.

RESPIRATORY CHANGES

Some of the respiratory effects, such as pulmonary edema can be

attributed to fluid overload. Pleuritis is a frequent finding, especially

when pericarditis develops. A characteristic condition called uremic

lung is a type of pneumonitis that responds well to fluid removal.

Metabolic acidosis causes a compensatory increase in respiratory rate

as the lungs work to eliminate excess hydrogen ions.

MUSCULOSKELETAL CHANGES

The musculoskeletal system is affected early in the disease

process, and up to 90% of clients with CRF experience renal

osteodystrophy. This condition develops insidiously and takes several

forms: osteomalacia, osteitis fibrosa, osteoporosis and osteosclerosis.

INTEGUMENTARY CHANGES

Integumentary problems are particularly uncomfortable for some

clients with CRF. The skin is also often very dry because of atrophy of

the sweat glands. Sever and intractable pruritis may result from

secondary hyperparathyroidism and calcium deposits in the skin.

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Pruritis can lead to excoriated skin caused by continued scratching.

Hair is brittle and tends to fall out; nails are thin and brittle as well.

REPRODUCTIVE CHANGES

Reproductive system changes can be alarming. Women commonly

experience menstrual irregularities, particularly amenorrhea, and

infertility. However some women with CRF have conceived and had

successful full-term pregnancies. Men commonly report impotence of

both physiologic and psychological causes. They may also experience

testicular atrophy, oligospermia (decreased sperm count), and

reduced sperm motility. Both genders report decreased libido,

possibly from both physiologic and psychological factors.

ENDOCRINE CHANGES

CRF also affects endocrine system, such as the insulin utilization

and parathyroid function discussed already. Pituitary hormones, such

as growth hormone and prolactin, may be increased in some people.

The levels of luteinizing hormone and follicle-stimulating hormone

vary greatly from client to client. Thyroid stimulating hormone is

usually normal, but it may show a blunted response to thyrotropin-

releasing hormone; this commonly results in hypothyroidism.

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4.4 Classical and Clinical Symptoms

CLASSICAL CLINICAL RATIONALE

SYMPTOM SYMPTOM
Hypertension manifested Due to sodium and water retention of
from activation of the rennin
angiotensin – aldosterone system
Pulmonary Not manifested Dute to fluid overload
edema
Pericarditis Not manifested Due to irritation of the pericardial
lining by uremic toxins
Pruritis Not manifested Uremic frost, the deposit of urea
(severe crystals on the skin.
itching)
Anemia manifested Due to inadequate erythropoietin
production, the shortened life span
of RBCs, nutritional deficiencies and
the patient’s tendency to bleed,
particularly from the GI tract.
Fatigue, agina and shortness of
breath results from decreased
erythropoietin.
Calcium and Not manifested Serum calcium and phosphate levels
Phosporus have a reciprocal relationship in the
imbalance body; as one rises, the other
decreases. With decreased filtration
through the glomerulus of the
kidney, there is an increase in their
serum phosphate level and a
reciprocal or corresponding
decreasing the serum calcium level.
The decrease serum calcium levels
causes increased secretion of the
parathormone from the parathyroid
glands. In renal failure, however the
 24

body does not respond normally to

the increased secretion of the
parathormone; as a result, calcium
leaves the bone, often producing
bone changes and bone disease. In
addition, the active metabolite of
vitamin D normally manufactured by
the kidney decreases as renal failure
progresses.
GI Not manifested Due to accumulation of uremic waste
 Nausea products
 Vomiting
 Hiccups

NEURO

 ALOC
 Muscle
twitching
manifested
 seizure
Reduced manifested As glomerular filtration decreases
Renal (due to nonfunctioning glomeruli),
REserve the creatinine clearance value
decreases, where as the serum
creatinine and BUN levels increases.
Serum creatinine is the more
sensitive indicatior of renal function
because of its constant production in
the body. The BUN is affected not
only by renal disease but also by
protein intake in the diet,
catabolism, parenteral medication
and medications such as
corticosteroids.
Metabolic Not manifested Metabolic acidosis occurs because
acidosis the kidney cannot excreate increases
loads of acid. Decreased acid
secretion primarily results from
inability of the kidney tubulues to
excrete ammonia and to reabsorb
sodium bicarbonate. There is alos
excretion of phosphates and other
organic acids.
 25

IV. NURSING INTERVENTION

1. Care guide of patient with disease condition

a. Collaborative care

Preventing acute renal failure is a goal in the care of all

clients, especially for those in high-risk groups. Maintaining

blood volume, cardiac output, and blood pressure is vital to

preserve kidney perfusion. Nephrotoxic drugs are avoided if

possible. When a nephrotoxic drug must be used, keeping the

client well hydrated and avoiding additional nephrotoxins

help reduce the risk of renal failure. Care for the client with

chronic renal failure focuses on eliminating factors that may

further decrease renal function and on slowing the progress of

ESRD.

b. Diet and Fluid Management

When the kidneys cannot effectively regulate fluid and

electrolyte balance and eliminate metabolic waste products,

intake of these substances must be regulated. Fluid and

 26

sodium intake is restricted. The daily fluid intake is

calculated by allowing 500 ml of insensible losses and adding

the amount of urine during the previous 24 hours. Clients

with CRF should notify the physician of any weight gain of

more than 5 pounds over a two day period. Sodium and

potassium intake is regulated. Salt substitutes containing

potassium are avoided.

c. Pharmocology

All nephrotoxic drugs are avoided and used with extreme

caution. Drug dosages may be adjusted because excretion is

slowed and half-life is prolonged.

Diuretics such as furosemide (lasix may be ordered to

reduce fluid volume, lower blood pressure, and lower serum

potassium levels. Other antihypertensive drugs such as ACE

inhibitors are prescribed to maintain the blood pressure with

in normal levels

Sodium bicarbonate or calcium carbonate may b used to

manage the electrolyte imbalances and acidosis

accompanying renal failure.

 27

Folic acid and iron supplements are used to combat

anemia. A multiple-vitamin preparation is also often

prescribed, because anorexia, nausea and dietary restrictions

may limit nutrient intake.

d. Dialysis

When conservative management is no longer effective to

maintain fluid and electrolyte balance and prevent uremia,

dialysis is considered. Dialysis is diffusion of solutes across a

semi-permeable membrane from an area of higher

concentration to one of lower concentration. In dialysis, a

semipermeable membrane separates blood from an isotonic

dialyzing solution. Water and solutes such as urea, creatinine

and electrolytes diffuse across this membrane, but proteins

do not. Dialysis compensates the kidneys inability to

eliminate excess water and solutes.

e. Hemodialysis

Hemodialysis, electrolytes, waste products, and excess

water are removed from the body by diffusion and filtration.

The client’s blood is pumped to a dialyzing membrane unit,

 28

where it moves past a semipermeable membrane. Dialysate is

warmed to body temperature and passed along the other side

of the membrane. Solutes diffuse through the membrane into

the dialysate to diffuse into the blood. Excess water is

removed from the blood by creating a higher fluid pressure on

the blood side of the membrane.

Clients on hemodialysis may experience both systemic and

fistula complications. Hypotension is the most frequent

complication occurring during hemodialysis. Bleeding may

occur due to altered clotting and the use of heparin during

dialysis. Infection is a significant risk. Dialysis dementia is a

progressive, potentially fatal neurologic complication that may

affect clients on long-term hemodialysis

AV fistula problems include infection, and clotting or

thrombosis. These complications may cause fistula failure

and require development of a new site. AV fistula failure can

have a psychological impact resulting in depression and

altered self-concept.

2. Actual Patient Care

2.1 NCP
 29

NEEDS / NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE

CUES / DIAGNOSIS BASIS OF CARE ACTIONS
PROBLEMS
Physiologic Risk for Renal After 8 hours measures to
deficit infection: failure of nursing prevent
hemodialysis affects the intervention, infection:
Risk for therapy immune the patient 1. use -handwashing
Infection related to system, will be able standard and standard
impaired increasing to precautions precautions help
Cues: renal the risk for demonstrate and good prevent spread
-patient function infection. ways to be washing at all of infection to
undergoes Invasive free from times and from the
hemodialysis treatments risks of client. Clients
-insertion of and infections by on hemodialysis
needles catheters maintaining have an
-insertion of further aseptic increased risk of
catheter increase technique at hepatitis B and
-possible the risk all times C and HIV
transfusion infections.
for blood Medical (Medical
Surgical Surgical Nursing
Nursing by by Burke,
Burke, Lemone, Mohn-
Lemone, Brown pg 530)
Mohn- -aseptic
Brown pg 2. use strict technique is
530 aseptic vital to reduce
technique in the risk of
handling introducing an
ports, infectious
catheters and organism
incisions (Medical
Surgical Nursing
by Burke,
Lemone, Mohn-
Brown pg 530)
-an elevated
temperature or
3. monitor increased pulse
temperature rate may
and vital indicate
signs at least infection
every 4 hours (Medical
Surgical Nursing
by Burke,
 30

Lemone, Mohn-
Brown pg 530)
-high or low
WBC counts
may indicate an
4. monitor infection;
WBC and increasing
differential numbers of
immature WBCs
in the
circulation may
indicate
infection
(Medical
Surgical Nursing
by Burke,
Lemone, Mohn-
Brown pg 530)
-culture is used
to determine the
presence of
pathogen
5. culture (Medical
urine , Surgical Nursing
peritoneal by Burke,
dialysis, fluid Lemone, Mohn-
and other Brown pg 530)
drainage as -these measures
indicated decrease the
risk of
respiratory
infection
6. turn or (Medical
ambulate Surgical Nursing
frequently; by Burke,
encourage Lemone, Mohn-
coughing and Brown pg 530)
deep -teach the client
breathing and family how
to reduce the
spread of
infection. The
client and family
need to know
7. restrict and understand
 31

visits from how to reduce

obviously ill the risk of
family infection at
members home and
hospital
(Medical
Surgical Nursing
by Burke,
Lemone, Mohn-
Brown pg 530)

NEEDS / NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE

CUES / DIAGNOSIS BASIS OF CARE ACTIONS
PROBLEMS
Physiologic Excess fluid Electrolyte After 8 hours measures to
overload volume: imbalances of nursing reduce fluid
decrease may intervention, volume:
Excess fluid and develop the aptient [Link] -helps determine
volume elevated because of will be able accurate input treatment,
fluid and water to and output especially fluid
Cues: electrolytes retention demonstrate record restriction,
-abnormal related to and reduced fluid hourly urine
diagnostic impaired impaired volume by output
results kidney renal weight loss measurements
-decrease function function maybe done in
and acute renal
increase Medical failure
electrolyte Surgical 2. weigh daily -weigh often
levels Nursing as ordered, use provides a more
-increase byBurke, consistent accurate
weight for Lemone, technique and assessment of
the past Mohn- timing to fluid volume
months Brown pg ensure than intake and
-small urine 530 accuracy output records,
output particularly in
oliguric patients
3. document -changes in the
vital signs at vital signs may
least every 4 indicate either
hours fluid volume
excess or deficit.
Hypertension
can further
 32

damage kidneys
4. restrict fluid -fluid restriction
as ordered. helps minimize
Provide fluid retention
frequent and the
mouth care complications of
and encourage fluid volume
using hard excess,
candies to especially the
decrease the client being
thirst response manage with
dialysis
5. administer -reduces total
medications as liquid consumed
prescribed
6. administer -diuretics may
diuretics as promote
ordered and urination
monitor
response
7. monitor
electrolytes
and for
manifestations
of imbalance.
Report
abnormal
results

NEEDS / NURSING SCIENTIFIC OBJECTIVES NURSING RATIONALE

CUES / DIAGNOSIS BASIS OF CARE ACTIONS
PROBLEMS
Physiologic Imbalanced The After 8 hours measures to
deficit nutrition: manifestations of nursing improve
less than of uremia and intervention, nutritional
Imbalanced body dietary the patient intake: -food intake
nutrition requirement restrictions will be able 1. monitor records help
s related to often affect to eat 100% and determine the
Cues: effects of food intake. of prescribed document adequacy of
-loss of uremia The client may diet food intake nutritional
appetite not eat including including the intake and
-patient is enough to snacks amount and identify the
 33

diagnosed meet type of food need for

with metabolic consumed nutritional
chronic needs. supplements
renal 2. administer -anorexia,
failure Medical anti-emetic nausea and
-electrolyte Surgical drugs 30-60 vomiting are
imbalance Nursing by minutes common. Anti-
-not all the Burke, before eating emetic drugs
food on the Lemon, Mohn- reduce nausea
tray was Brown pg 530 and the risk of
eaten vomiting with
food intake
3. provide -the client may
mouth care have a metallic
prior to care taste and bad
breath. Mouth
care improves
taste and
promotes
appetite
4. provide -these
frequent measures
small meals promote food
or between intake in the
meal snack fatigues or
anorexic
patient
5. arrange for -the client is
dietary more likely to
consultation. eat favorite
Provide foods.
preferred Involving the
foods to the client in
extent planning
possible and promotes a
plan with sense of
family control and
learning about
dietary
restrictions
6. monitor -changes in
serum and values may
electrolytes indicate either
and albumin improving or
diagnostic declining
 34

results nutritional
status
7. administer -parenteral
and monitor nutrition
parenteral maybe
nutritional necessary to
intake as prevent
ordered catabolism in
the client with
renal failure

2.2 DRUG THERAPEUTIC RECORD

DRUG/ CLASSIFICATION/ INDICATIONS/ PRINCIPLES TREATMENT EVALUATION

DOSE/ MECHANISM CONTRAINDICATION OF CARE
FREQUENC S/ SIDE EFFECTS
Y/ ROUTE
NaHCO3 Electrolyte INDICATIONS: 1. parenteral 1. monitor 1. reversal of
650 mg Systemic -treatment of medications patient’s input metabolic
1 tab TID PO Alkalinizer metabolic acidosis, by IV route and output acidosis
8–1–6 Urinary severe diarrhea, 2. patient 2. monitor 2. increase
Alkalinizer minimization of uric should chew vital signs urinary and
Antacid acid crystalluria in oral tablets 2. increase serum pH
gout; symptomatic thoroughly fluid intake 3. decrease
-Increases plasma relief of upset before gastric
bicarbonate, stomach from swallowing discomfort
buffers excess hyperacidity with a glass of
hydrogen ion water
concentration, CONTRAINDICAITON 3. report andy
raises blood pH; S: side effects
reverses the -allergy to such as
clinical components of irritability,
manifestations of preparation, low headache,
acidosis; increases serum chloride, tremors and
the excretion of secondary to vomiting confusion
free base in the
urine, effectively SIDE EFFECTS:
raising the urinary -irritability, headache,
pH; neutralizes or tremors, confusion,
reduces gastric swelling of extremity,
acidity resulting in black or tarry stools,
an increase in the pain at injection site
gastric pH which
inhibits proteolytic
activity of pepsin

Herax Gout preparations INDICATIONS: 1. take drugs 1. encourage 1.

25 mg Anti-anxiety -symptomatic as prescribed verbalization improvement
1 tab BID Antihistamine treatment of anxiety, 2. avoid 2. give drugs in symptoms
PO Antiemetic GAD, symptomatic excessive as prescribed of CHF
 35

8–6 treatment of allergic dosage 3. maintain 2. decrease BP

-Actions maybe origin report eye to eye
due to difficulty in contact with
suppression of CONTRAINDICATION breathing, patient
subcortical areas -previous tremors, loss
of the CNS; has hypersensitivity, of
clinically pregnancy, lactation, coordination
demonstrated intermittent acute
antihistamine, porphyria
analgesic,
antiposmodic and SIDE EFFECTS:
bronhodilator -sedation,
action somnolence,
dizziness, dry mouth,
urinary retention,
rarely tremors and
convulsion

Calcium Vitamins and INDICAITONS: 1. in large 1. monitor

Carbonate Calcium -osteoporosis, calcium doses, serum serum levels
(Calci-acid) Electrolyte malabsorption and calcium 2. monitor
1 cap TID Antacid deficiency conditions concentration vital signs
PO and kidney
8–1–6 -Essential CONTRAINDICATION function
elements of the S: should be
body, helps -hypercalcemia, monitored
maintain severe renal failure 2. do not
functional administer
integrity of the SIDE EFFECTS: oral drug
nervous system -constipation within 1-2
and muscular hour or
system, helps antacid
maintain cardiac solution
function, blood 3. let patient
coagulation; is an chew antacid
enzyme co-factor tablet
and affects
secretory activity
of endocrine and
exocrine gland

Alu-Tab Antacid and INDICATIONS: 1. special 1. monitor

1 tab TID PO Antiulcerants -uncomplicated peptic precautions on input and
8–1–6 ulcer, and gastric patients with output
-Nuetralizes or hyperacidity; hypo- 2. monitor
reduces gastric phosphate binding in phosphatemia vital signs
acid resulting in renal dysfunction and CRF may
an increase in the cuase
pH of the stomach CONTRAINDICATION phosphate
and duodenal S: depletion
bulb and inhibitng -hypophosphatemia
proteolytic activity
of pepsin which SIDE EFFECTS:
protects the lining -constipation
 36

of the stomach
and duodenum;
binds with
phosphate ions in
the intestine to
from insoluble
aluminum

2.3 SOAPIE

SOAPIE # 1

S – “Nagkawala man iya gana sa pagkaon” as verbalized by his wife.

O – Received patient on bed, conscious, awake, coherent, with weight of 48

kgs and D5LR 1L infusing well on left arm at KVO rate; complaints of

decreased appetite as evidenced by left overs on plate and chief

complaint upon admission; electrolyte imbalance noted on chart; patient

diagnosed with chronic renal failure

A - Physiologic deficit: Altered nutrition, less than body requirements: loss of

appetite related to effects of uremia

P - to improve nutritional intake

I - monitored and documented food intake; let patient do mouth care;

provided frequent small meals was advised to significant other; provided

snacks prior to patient’s preference as long as not restricted on diet and

provided ample time to chew food; monitored and charted vital signs and

patient’s intake and output

 37

E – patient was able to eat his whole meal for lunch

SOAPIE # 2

S - “nagkadako man iyang timbang kumpara sa mga ni agi na bulan.” As

verbalized by his wife

O – patient received on bed, conscious, awake, coherent, with a weight of

48.35 Kgs noted the night before; urine output of patient yesterday

during 3-11 pm shift was only 30 cc having an intake of 340 cc of water;

no signs of sweating and stays in bed all the time; imbalanced electrolyte

levels; patient diagnosed with CRF

A- Excess fluid volume: Imbalanced electrolyte levels related to impaired

kidney function

P - to reduce fluid volume by weight loss

I - maintained accurate I & O records; weighed daily as ordered; documented

vital signs; restricted fluids as ordered by the physician; provided mouth

care; advised eating of hard candies to decrease thirst response;

administered medications with meals and as ordered; monitored serum

electrolytes and for maintenance of imbalances

 38

E – patient decreased his weight from 48.35 of yesterday’s weight and 47 kgs

today

2.4 Health Teaching Plan

OBJECTIVES CONTENT METHODOLOGY

General objectives:
After 8 hours of
nursing intervention,
the patient will be able
to acquire skills,
positive attitude and
knowledge in caring
for patients
undergoing
hemodialysis.

Specific objectives:
After 45 minutes of
student nurse-patient
and significant other
interaction, the client
will be able to:

1. define the following 1. TERM Informal discussion

term in their own level a. hemodialysis - most common used
of understanding method of dialysis
1.1 hemodialysis

2. explain the pathway 2. PATHWAY FOR HEMODIALYSIS Informal discussion

for hemodialysis -In hemodialysis, electrolytes and waste products Visual aids
and excess water are removed from the body by
diffusion and filtration. The client’s blood is
pumped to a dialyzing membrane unit, where it
moves past a semi-permeable membrane.
Dialysate is warmed to body temperature and
passed along the other side of the membrane,
solutes diffuse through the membrane into the
dialysate. Medications can be added to the
dialysate to diffuse into the blood. Excess water is
 39

removed by eradicating a higher fluid pressure on

the blood side of the membrane. Clients typically
undergo 2 or 3 sessions of hemodialysis per week
for a total of 12 hours. Hemodialysis can be done
at home but usually occurs in an out-patient
dialysis center

3. enumerate different 3. COMPLICATIONS Informal discussion

possible complications -clients on hemodiaylsis may experience both
for patients systemic and fistula complications. hypertension
undergoing is the most frequent complication occurring
hemodialysis during hemodialysis. Bleeding may occur due to
altered clotting and the use of heparin during
dialysis, infection is a significant risk

4. site important things 4. IMPORTANT THINGS TO BE DONE Informal discussion

to be done before and Visual aids
after hemodialysis BEFORE DIALYSIS
a. use standard precaution at all times
b. document vital signs, lung sounds and
weight
c. taking of blood pressure on vascular site
should be avoided
AFTER DIALYSIS
a. document vital signs, weight and vascular
access site
b. monitor possible adverse effects of
dialysis such as muscle cramping,
headache, nausea and vomiting, seizure
and hypertension
c. provide psychological support; listen
actively for feelings of grief, hopelessness
or anger

5. demonstrate ways to 5. WAYS TO PREVENT INFECTION Informal discussion

prevent infection a. proper medical handwashing Demonstration
b. dress site aseptically Return demonstration
c. disposed needles properly

V. EVALUATION AND RECOMMENDATION

 40

The survival rate of people with CRF has improved with the advent

and improvement of dialysis and transplantation. At 1 year after dialysis

begins, the survival rate is about 79%. After 5 years, the rate decreases

to 33%.

The client must comply with dietary and fluid intake modifications

and take prescribed medications as ordered. They must monitor and

record weight and blood pressure daily and care for the vascular access

or peritoneal catheter as ordered. Noncompliance with the regimen leads

to complications. The client or family must perform dialysis at home or

keep scheduled dialysis appointments and attend to it regularly.

VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO:

NURSING PRACTICE

The study is one tool in giving way to a more holistic

and effective care in patients with CRF. Preventive measures will

then be well emphasized thus stop worsening the lives of the

people prone to this disease. Having a good outlook and positive

attitudes is another thing we can get out of this case study. Being

positive and confident in dealing with these patients will make the

patients feel at ease and trust their nurses more which aids in

giving effective and better care.

 41

NURSING EDUCATION

This study will make a contribution to nursing

education as it would help future nurses and student nursed be

more knowledgeable regarding this disease, equipped in their

nursing care and be able to correct misconceptions regarding the

disease

NURSING RESEARCH

Research is a vital part to every theory, formula and

newly concept rendered to the society. This study can be a good

basis for the future researchers and professionals so that better

interventions and knowledge will soon be made and imparted to all

patients, their significant others and professionals dealing that will

deal with this disease.

This study will aid as basis for future researchers of this

kind of disease and broaden knowledge of the researcher. This will

also add information needed by other students that will help them

understand this disease condition and its other facts that is

essential when dealing with CRF patients

 42

VII. BIBLIOGRAPHY

The Lippincott Manual of Nursing Practice

4th edition by Lilian Shaltis Brunner and Doris Smith Suddarth

Medical Surgical Nursing

Vol. 1&2, 10th edition by Brunner and Suddarth

Nursing Care plan Guide

by Ulrich and Canore 6th edition

Nursing Pocket Guide

8th edition by Doonges and Moorhouse

Maternal and Child Health Nursing

Vol. 1, 4th edition by Adelle Pilliteri

Dictionary of Medical Terms

Rothenberg and Chapman
3rd ed

2003 Lippincotts Nursing Drug Guide

by Amy M. Karch

MIMS
Vol. 32 Number 4 2003
 43

Fundamentals of Nursing
Vol. 2, 5th edition by Potter and Perry

Medical Surgical Nursing

by Burke, Lemone, Mohn-Brown pg 530

[Link]