Republic of the Philippines

ISABELA STATE UNIVERSITY

Echague, Isabela

COLLEGE OF NURSING

A Case Study of End-Stage Renal Disease

Secondary to Interstitial Nephritis
Submitted to the Faculty and Staff
of the College of Nursing

Presented By:
Caleja, Dianne G.
Capistrano, Vince Carl B.
Crisostomo, Nikolai S.
Iglesia, Vhenson E.
Lacaden, Silver R.
Lagmay, Alexia Nadine S.
Neri, Raizza Shien Marie S.
Paredes, Norelie P.
Simon, Franzine Eliza P.
Group 5 Members

December 2023

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 Republic of the Philippines
ISABELA STATE UNIVERSITY
Echague, Isabela

COLLEGE OF NURSING

TABLE OF CONTENTS
TITLE
PAGE
I. THE OBJECTIVE OF THE STUDY……………………………………….…...…..….2
II. OVERVIEW OF THE DISEASE……………………………………….…..…..……....3
III. DEMOGRAPHIC DATA & 11 GORDON’S FUNCTIONAL
HEALTHPATTERNS…………………………………………………………….….….17
IV. ANATOMY AND PHYSIOLOGY OF KIDNEY………………………….………..…31
V. ANATOMY AND FUNCTIONS AND DIALYSIS MACHINE……………………...35
VI. VASCULAR ACCESS…………………………………….…….…………………..….39
VII.PATHOPHYSIOLOGY…………………………………………………………………41
VIII. HEMODIALYSIS TREATMENT PROCESS…………………………..…….…...42
IX. DIAGNOSTICS/LABORATORY RESULTS AND
INTERPRETATION…………………………………………………………………….44
X. HEMODIALYSIS PRESCRIPTION…………………………………………………...46
XI. NURSING CARE PLAN………………………………………………………………..49
XII. DRUG STUDY………………………………………………………………………..…55
XIII. DISCHARGE PLANNING…………………………………..……………………….64
XIV. REFERENCES……………………………………………………………………….....66

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 I. THE OBJECTIVE OF THE STUDY

General:

At the end of the case presentation, the student nurses, as well as the clinical instructors, will
be able to further understand and gain comprehensive analysis about End-Stage Renal Disease
secondary to Interstitial Nephritis.

Specific:

At the end of the case presentation, the student nurses will be able to:

1. Define End-Stage Renal Disease secondary to Interstitial Nephritis, explain its etiologic agent,
epidemiology, prognosis, clinical manifestations, diagnostic procedures, complications and
management,

2. Discuss relevant topics about the client’s condition through patient health history,

3. Determine if the physical examination shows unusual results and provide appropriate nursing
care,

4. Describe, analyze and interpret the findings of the laboratory examinations,

5. Determine the contrast between the anatomical and physiological structure involved in the
pathophysiological explanation of End-Stage Renal Discase secondary to Interstitial Nephritis,

6. Understand the pathophysiology of End-Stage Renal Discase secondary to Interstitial

Nephritis,

7. Provide appropriate nursing care plan according to patient's needs,

8. Understand the role of the pharmacological therapy being utilized in managing the client with
End-Stage Renal Discase secondary to Interstitial Nephritis,

9. Formulate an effective patient's discharge plan in optimizing health and,

10. Develop critical thinking skills and enhance clinical reasoning in applying theoretical
knowledge about End-Stage Renal Discase secondary to Interstitial Nephritis in actual clinical
practice.

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 II. OVERVIEW OF THE DISEASE
Chronic Kidney Disease (CKD)

Definition

CKD describes kidney damage or a decrease in the glomerular filtration rate (GFR) lasting
for 3 or more months. It is associated with decreased quality of life, increased health care
expenditures, and premature death. Untreated CKD can result in end-stage kidney disease(ESKD),
which is the final stage of CKD. ESKD results in retention of uremic waste products and the need for
renal replacement therapies, dialysis, or kidney transplantation.

Chronic use of analgesic agents, particularly NSAIDs, may cause interstitial nephritis
(inflammation within the renal tissue) and papillary necrosis. Increased age, preexisting kidney
disease, diabetes, and the simultaneous administration of several nephrotoxic agents increase the risk
of kidney damage (Schira, 2017; Schonder, 2017). Interstitial nephritis defines a pattern of renal
injury usually associated with an abrupt deterioration in renal function characterized
histopathologically by inflammation of the spaces between the kidney tubules. This inflammation
lowers your kidneys' ability to clean your blood and make urine. Interstitial nephritis may be
temporary (acute) or may be long-lasting (chronic). The most common symptom of interstitial
nephritis is urinating less than normal. Without treatment, interstitial nephritis can cause kidney
damage or kidney failure.

ETIOLOGY

Kidney diseases occurs when a disease or condition impairs kidney function, causing kidney
damage to worsen over several months or years. For some people, kidney damage can continue to
progress even after the underlying condition is resolved.

Diseases and conditions that can lead to kidney disease include:

• Type 1 or type 2 diabetes

• High blood pressure

• Glomerulonephritis— an inflammation of the kidney's filtering units (glomeruli)

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• Interstitial nephritis- an inflammation of the kidney's tubules and surrounding structures

• Polycystic kidney disease or other inherited kidney diseases

• Prolonged obstruction of the urinary tract, from conditions such as enlarged prostate, kidney stones
and some cancers

• Vesicoureteral- reflux, a condition that causes urine to back up into your kidneys

• Recurrent kidney infection, also called pyelonephritis

RISK FACTORS

Certain factors increase the risk that chronic kidney disease will progress more quickly
to end-stage renal disease, including:

✓ Diabetes with poor blood sugar control

✓ Kidney disease that affects the glomeruli, the structures in the kidneys that filter wastes from the
blood

✓ Polycystic kidney disease

✓ High blood pressured

✓ Tobacco use

✓ Black, Hispanic, Asian, Pacific Islander or American Indian heritage

✓ Family history of kidney failure

✓ Older age

✓ Frequent use of medications that could be damaging to the kidney

STAGES

There are 5 stages of chronic kidney disease

1. Stage 1

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- GFR ≥ 90mL/1.73m^2

- Kidney damage with normal or increased GFR

2. Stage 2

- GFR = 60-89mL/1.73m^2

- Mild decrease in GFR

3. Stage 3

- GFR = 30-59mL/1.73m^2

- Moderate decrease in GFR

4. Stage 4

- GFR = 15-29mL/1.73m^2

- Severe decrease in GFR

5. Stage 5

- GFR<15mL/1.73m^2

- End-stage kidney disease or chronic kidney disease

CLINICAL MANIFESTATIONS

Neurologic

 Asterixis
 Behavior changes
 Burning of soles of feet
 Confusion
 Disorientation
 Inability to concentrate
 Restlessness of legs
 Seizures

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  Tremors
 Weakness and fatigue

Integumentary

 Coarse, thinning hair

 Dry, flaky skin
 Ecchymosis
 Gray-bronze skin color
 Pruritus
 Purpura
 Thin, brittle nails

Cardiovascular

 Engorged neck veins

 Hyperkalemia
 Hyperlipidemia
 Hypertension
 Pericardial effusion
 Pericardial friction rub
 Pericardial tamponade
 Pericarditis
 Periorbital edema
 Pitting edema (feet, hands, sacrum)

Pulmonary

 Crackles
 Depressed cough reflex
 Kussmaul-type respirations
 Pleuritic pain

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  Shortness of breath
 Tachypnea
 Thick, tenacious sputum
 Uremic pneumonitis

Gastrointestinal

 Ammonia odor to breath (“uremic fetor”)

 Anorexia, nausea, and vomiting
 Bleeding from gastrointestinal tract
 Constipation or diarrhea
 Hiccups
 Metallic taste
 Mouth ulcerations and bleeding

Hematologic

 Anemia
 Thrombocytopenia

Reproductive

 Amenorrhea
 Decreased libido
 Infertility
 Testicular atrophy

Musculoskeletal

 Bone fractures
 Bone pain
 Foot drop

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  Loss of muscle strength
 Muscle cramps
 Renal osteodystrophy

DIAGNOSTIC

Urinalysis

➢ General examination of urine to establish information or provide data to establish a tentative

diagnosis and determine whether further studies are to be ordered

➢ Significance of Findings

■ HEMATURIA

◆ causes include acute infection (cystitis, urethritis, or prostatitis), renal calculi, and neoplasm.

◆ causes include systemic disorders, such as bleeding disorders; malignant lesions; and medications,
such as warfarin (Coumadin) and heparin

■ PROTEINURIA

◆ Common benign causes of transient proteinuria are fever, strenuous exercise, and prolonged
standing.

◆ Causes of persistent proteinuria include glomerular diseases, malignancies, collagen diseases,

diabetes mellitus, preeclampsia, hypothyroidism, heart failure, exposure to heavy metals, and use of
medications, such as non-steroidal anti-inflammatory drugs (NSAIDs) and angiotensin-converting
enzyme inhibitors

24 Hour Urine Collection

➢ Urine samples are collected in one or more containers over a period of 24 hours. The containers
are kept in a cool environment and then sent to a lab for analysis. It is often used to check kidney
function and to detect unusual amounts of protein, electrolytes, hormones, and calcium.

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Other Diagnostic Tests

➢ Blood tests

■ BUN / creatinine

➢ Urine culture & sensitivity (C&S)

■ Include colony count

➢ Imaging

■ IVP

■ Retrograde pyelography

■ CAT/ MRI

➢ Surgical procedures

■ Cystoscopy

■ Biopsy

BUN (Blood Urea Nitrogen)

➢ measuring the amount of urea nitrogen in the blood.

Urea nitrogen is a waste product that’s created in the liver when the body breaks down proteins.
Normally, the kidneys filter out this waste, and urinating removes it from the body.

➢ Normal levels

■ adult men: 8 to 20 mg/dL

■ adult women: 6 to 20 mg/dL children: 5 to 18 mg/dL

➢ A higher than normal BUN level may be a sign that the kidneys are not working well.

Creatinine test

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➢ measures the level of creatinine in the blood. Creatinine is a waste product that forms when
creatinine, which is found in your muscle, breaks down.

➢ Normal Level

■ range from 0.9 to 1.3 mg/dL in men and 0.6 to 1.1 mg/dL in women who are 18 to 60 years old.
Normal levels are roughly the same for people over 60.

➢ Patient’s Creatinine Level with ESRD

■ A value higher than 30 mg of albumin per gram of creatinine is considered abnormal, while
values greater than 300 mg/g are considered severely impaired renal function

Urine Culture and Sensitivity (C&S)

➢ a microscopic study of the urine culture performed to determine the presence of pathogenic
bacteria in patients with suspected urinary tract infection.

Sensitivity

➢ refers to the antibiotics tested to be effective in stopping the bacteria.

Intravenous Pyelogram (IVP)

➢ is an x-ray exam and the use of iodinated contrast material injected into veins to evaluate the
kidneys, ureters and bladder and help diagnose blood in the urine or pain in the side or lower back.

➢ This test will show the size and shape of the bladder, kidneys and ureters, and how well they’re
working.

Cystoscopy

➢ a procedure to look inside the bladder using a thin camera called a cystoscope. A cystoscope is
inserted into the urethra (the tube that carries pee out of the body) and passed into the bladder to
allow a doctor or nurse to see inside.

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Renal Biopsy

➢ The word “renal” describes the kidneys. A renal biopsy is also called a kidney biopsy. a procedure
used to extract kidney tissue for laboratory analysis.

NURSING MANAGEMENT

The patient with ESKD requires astute nursing care to avoid the complications of
reduced renal function and the stresses and anxieties of dealing with a lifethreatening illness. Nursing
care is directed toward assessing fluid status and identifying potential sources of imbalance, working
with a renal dietitian to implement a dietary program to ensure proper nutritional intake within the
limits of the treatment regimen, and engaging the patient by encouraging increased self-care and
greater independence. It is extremely important to provide explanations and information to the
patient and family concerning ESKD, treatment options, and potential complications. A great deal of
emotional support is needed by the patient and family because of the numerous changes experienced.
A social worker is also a vital part of the interprofessional care at the dialysis center. Specific
interventions, along with rationale and evaluation criteria, are presented in more detail in the plan of
nursing care for the patient with ESKD.

(EPIDEMIOLOGY)

Chronic kidney disease is a progressive condition that affects >10% of the general
population worldwide, amounting to >800 million individuals. Chronic kidney disease is more
prevalent in older individuals, women, racial minorities, and in people experiencing diabetes mellitus
and hypertension. Chronic kidney disease represents an especially large burden in low- and middle-
income countries, which are least equipped to deal with its consequences. Chronic kidney disease has
emerged as one of the leading causes of mortality worldwide, and it is one of a small number of non-
communicable diseases that have shown an increase in associated deaths over the past 2 decades.
The high number of affected individuals and the significant adverse impact of chronic kidney disease
should prompt enhanced efforts for better prevention and treatment.

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 A multinational study surveying the burden of kidney disease, the 2023 ISN-GKHA
shows that, from the approximately 850 million people affected by chronic kidney disease (CKD)
worldwide, people of every age and race are affected, and people from disadvantaged populations are
at higher risk.

Chronic kidney disease (CKD) is a global public health concern, with prevalence of
9.1%–13.4% of the population worldwide. In the Philippines, its prevalence is 35.94%, which is
much higher than estimated global rates. Aside from its contribution to mortality, the growing burden
of CKD is also illustrated by its associated financial costs. Locally, 94% of end stage renal disease
(ESRD) patients are undergoing center-based hemodialysis (HD), 4% are on peritoneal dialysis (PD)
and only 2% had kidney transplantation (KT). Despite KT being the gold standard treatment for
ESRD, HD is still preferred by most Filipino patients due to transplant costs, low organ donations,
lack of capable infrastructures, and long term immunosuppression therapy.

PROGNOSIS

End-stage renal disease is a progressive disorder, and timely renal replacement therapy
is necessary to prevent death. The disorder is associated with numerous hospitalizations, increase
healthcare costs, and metabolic changes. The mortality rates for patients with end stage renal disease
are significantly higher than those without the disease. Even with timely dialysis, the death rates
vary from 20% to 50% over 24 months. The most common cause of death is hyperkalemia, followed
by adverse cardiac events.

COMPLICATION

There are a number of potential complications of ESKD that necessitate a collaborative approach to
care. These include the following:

• Anemia due to decreased erythropoietin production, decreased RBC lifespan, bleeding in the GI
tract from irritating toxins and ulcer formation, and blood loss in the dialysis circuit and dialyzer
after HD has been completed

• Bone disease and metastatic and vascular calcifications due to retention of phosphorus, low
serum calcium levels, and abnormal vitamin D metabolism

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• Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive
potassium intake from diet, medications, or IV solutions

• Hypertension due to sodium and water retention and malfunction of the renin–angiotensin–
aldosterone system

• Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste
products and inadequate dialysis

(Management)

Medical Management

The goal of management is to maintain kidney function and homeostasis for as long as
possible. All factors that contribute to ESKD and all factors that are reversible (e.g., obstruction) are
identified and treated. Management is accomplished primarily with medications and diet therapy,
although dialysis may also be needed to decrease the level of uremic waste products in the blood and
to control electrolyte balance. The close collaboration of a renal dietitian is essential in dietary
therapy.

Treatment

Dialysis

Types of dialysis include HD, CRRT, and PD. Acute or urgent dialysis is indicated when
there is a high and increasing level of serum potassium, fluid overload, or impending pulmonary
edema, increasing acidosis, pericarditis, and advanced uremia. It may also be used to remove
medications or toxins (poisoning or medication overdose) from the blood or for edema or
hypertension that does not respond to other treatment, and hyperkalemia.

• Hemodialysis (HD) (a procedure that circulates the patient’s blood through an artificial kidney
[dialyzer] to remove waste products and excess fluid). It is used for patients who are acutely ill and
require short-term dialysis for days to weeks until kidney function resumes, as in patients with AKI,
and for patients with advanced CKD and ESKD who require long-term or permanent RRT. HD

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prevents death but does not cure kidney disease and does not compensate for the loss of endocrine or
metabolic activities of the kidneys. Most patients receive intermittent HD that involves treatments
three times a week with an average treatment duration of 3 to 4 hours in an outpatient setting. HD
can also be performed at home by the patient and a caregiver.

• Continuous Renal Replacement Therapy (CRRT) (methods used to replace normal kidney
function by circulating the patient’s blood through a hemofilter) may be performed. It may be
indicated for patients with acute or chronic kidney disease who are too clinically unstable for
traditional HD, for patients with fluid overload secondary to oliguric (low urine output) kidney
disease, and for patients whose kidneys cannot handle their acutely high metabolic or nutritional
needs. Some forms of CRRT may not require dialysis machines or dialysis personnel to carry out the
procedures and can be initiated quickly in the critical-care unit.

• Peritoneal dialysis (PD) is a procedure that uses the patient’s peritoneal membrane (the lining of
the peritoneal cavity) as the semipermeable membrane to exchange fluid and solutes removes toxic
substances and metabolic wastes and to reestablish normal fluid and electrolyte balance. PD may be
the treatment of choice for patients with kidney disease who are unable or unwilling to undergo
hemodialysis (HD) or kidney transplantation.

(SURGICAL)

(Fistula & Kidney transplant)

• Dialysis fistula creation is a commonly performed procedure for patients who suffer from end-
stage renal disease (ESRD) who require permanent vascular access in order to receive long-term
hemodialysis. The ideal dialysis fistula delivers a high flow rate sufficient for effective dialysis, is
suitable for repeated cannulation, and has long-term patency rates with minimal complications.

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• Arteriovenous Fistula is the preferred method of permanent vascular access for dialysis is an
arteriovenous fistula (AVF) that is created surgically (usually in the forearm) by anastomosing
(joining) an artery to a vein, either side to side or end to side.

• Arteriovenous graft can be created by subcutaneously interposing a biologic, semibiologic, or

synthetic graft material between an artery and vein. Usually, a graft is created when the patient’s
vessels are not suitable for creation of an AVF. Patients with compromised vascular systems (e.g.,
from diabetes) often require a graft because their native vessels may not be suitable for creation of an
AVF. Grafts are usually placed in the arm but may be placed in the thigh or chest wall.

• Kidney transplantation is the treatment of choice for select and appropriately screened patients
with ESKD. It is not considered a cure for ESKD since, in general, the transplant will not continue to
function for the entire lifespan of most recipients. Kidney transplantation is an elective procedure,
not an emergency lifesaving procedure. Therefore, patients should be in the best possible physical
condition prior to transplantation.

Pharmacologic Therapy

Complications can be prevented or delayed with the appropriate medication. Phosphate-

binding agents, calcium and vitamin D supplements, antihypertensive and cardiac medications, as
well as recombinant human erythropoietin are frequently prescribed (Parikh et al., 2019).

• Sodium Bicarbonate - an Alkalinizing agent, Antacid electrolyte, urinary/systemic alkalinizer.

Management for metabolic acidosis (Associated with Chronic Renal Failure)
• Telmisartan/Amlodipine – an Angiotensin II receptor antagonist, calcium channel blocker. An
Antihypertensive drug for hypertension alone or in combination with other hypertensive to lower
blood pressure.
•Carvedilol – a Beta-Adrenergic blocker. Antihypertensive drug treatment of hypertension.
• Sevelamer – a Polymeric phosphate binder. Electrolyte modifier, antihyperphosphatemia agent.
Reduction of serum phosphorus in patients with chronic renal disease on hemodialysis.
• Epoetin Alfa – an Erythropoiesis-stimulating agent (ESA). Erythropoietin drug a treatment for
anemia in patients with chronic renal failure and to reduce need for RBC transfusion.

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• Calcium Carbonate – an Electrolyte replenisher. Antacid, antihypocalcemic, antihyperkalemic,
antihypermagnesemic, antihyperphosphatemic. Calcium carbonate is administered to patients with
chronic kidney disease (CKD) in order to bind dietary phosphorus, decrease phosphorus retention
and avoid a negative calcium balance.
• Ferous Sulfate – an Enzymatic mineral. Iron preparation prevention, treatment of iron deficiency
anemia.

Nutritional Therapy

A referral to a renal dietitian is essential. Dietary intervention is necessary with

deterioration of renal function and includes careful regulation of protein intake, fluid intake to
balance fluid losses, and restriction of potassium and sodium. At the same time, adequate caloric
intake and vitamin supplementation must be ensured. Patients on dialysis need a higher intake of
protein than healthy adults and current protein recommendations for stable patients on HD is 1.2
g/kg/day and PD is 1.2 to 1.3 g/kg/day (National Kidney Foundation Kidney Disease Outcomes
Quality Initiative [NKF KDOQI], 2000). The allowed protein must be of high-biologic value (eggs,
meats, fish). High–biologic-value proteins are those that are complete proteins and supply the
essential amino acids necessary for growth and cell repair. Usually, the fluid allowance per day for
patients who receive in-center HD who are anuric is about 1000 mL daily. For those who produce
urine, recommendations are individualized based on the patient’s 24-hour urinary volume. This is
done in order to limit interdialytic weight gains to less than 4% of estimated dry weight (Gonyea,
2017). Adequate calories are supplied by carbohydrates, protein, and fat to prevent wasting. In
addition, the patient on dialysis loses water-soluble vitamins during the dialysis treatment, so an oral
vitamin B and C supplement is prescribed to be taken after dialysis. Hyperkalemia is usually
prevented by ensuring adequate dialysis treatments with potassium removal and careful restriction of
diet, medications, and fluids for their potassium content.

(Nursing management

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 III. DEMOGRAPHIC DATA & 11 GORDON’S FUNCTIONAL HEALTHPATTERN

Name of Patient: Patient X

Birthday: December 12, 1999
Address: Centro 1, San Guillermo Isabela
Age: 24 years old
Height: 144.78 cm
Weight: 37kg
BMI: 17.7kg/m²
Sex: Female
Race: Filipino
Marital Status: Single
Occupation: Teller at Palawan Pawn Shop
Religion: Catholic
Date started in HD unit: July 20,2023
Frequency of HD: Twice a week for 4 hours in duration (Monday and Thursday)
AVF access: Left upper arm
Machine No.: 1 (Reactive in Hepatitis machine)
Chief Complaint:
Admitting Diagnosis: ESRD secondary to Chronic Glomerulonephritis

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Health perception / Health management

Before Dialysis
Before Dialysis patient’s sense of well-being is characterized by the absence of physical complaints
and the ability to engage in unrestricted activities on a daily basis. When questioned about
maintenance and vitamin supplements, she responds Nothing , but she does use Ibuprofen to alleviate
severe menstrual cramps. Depending on the frequency and duration of the pain, she takes up to three
tablets. Notably, she does not have any vices. She perceives herself as healthy and in good condition,
capable of carrying out her regular daily routine without any hindrance.

During Dialysis
During Dialysis the patient's perception of her health has shifted due to an underlying disease,
leading to a sense of poor health. The impact of this condition has restricted her ability to engage in
activities she previously enjoyed. Consequently, her understanding of the term "healthy" has evolved,
and she now associates it with adhering strictly to recommended medications and lifestyle
restrictions. Despite following these measures, she does not view herself as healthy, highlighting the
profound impact of the underlying disease on her overall well-being.

Nutritional – Metabolic

Before Dialysis
Before dialysis the The patient follows a meal routine of five times a day, with three heavy meals
which she said a maximum of 3 caps of rice and two as snacks like biscuits and soda. When
questioned about her food and drink preferences, she expressed a fondness for salty foods, often
adding a generous amount of salt to her meals. Additionally, she has a preference for beverages,
particularly soft drinks, with a specific liking for soda..

Interestingly, during a social gathering at her home, a friend complimented the food for being salty, a
taste that seemed normal to the patient. It's noteworthy that she has no allergies and does not adhere
to any food restrictions.

During Dialysis
During dialysis the patient undergoes dietary restrictions, prohibiting the consumption of high-salt

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and high-fat foods, encompassing fruits, meats, milk, soft drinks, and energy drinks. She follows her
diet of 3 meals which she said sometimes she’s just having 3 crackers in the morning and a simple
meal in lunch and dinner which she consume half rice.

These limitations cause stress for her as it restricts her ability to enjoy the foods she desires.
Additionally, she adheres to a daily fluid intake of 1 liter due to the presence of edema, emphasizing
the necessary measures taken to manage her health condition. She joins social gathering however,
she limits herself foods that is prohibited to her diet.

Elimination

Before Dialysis
Before Dialysis the patient asked about her daily voiding frequency, the patient mentioned normal
daytime voiding which she said she voided naturally every morning. However, during the night or
midnight, she typically voids three times. She provided a description of her urine, noting that it is
bubbly and emits a coffee-like smell, although she does not experience any pain during
voiding.When ask if how many ml she micturate or at least estimated, the patient said she cannot
define the exact measurement. Her bowel movements occur regularly, almost every day. She
characterizes her stool as solid and less moist, occasionally causing mild pain that she finds tolerable,

During Dialysis
During dialysis the patient experiences a reduced frequency of voiding, likely stemming from her
restricted water intake. Despite this, she does not encounter any difficulties during urination or
elimination. When asked about the smell of her urine, she noted an improvement, mentioning that it
is not consistently smelly like before, although occasional instances of odor still occur.

Exercise / Activity

Before Dialysis
Before Dialysis the patient questioned about her exercise habits, the patient reported that she does
not engage in any form of physical exercise. Despite this, she is capable of performing her Activities
of Daily Living (ADLs), including household chores, dishwashing, and laundry, without
experiencing fatigue or discomfort from minimal exertion.

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The patient's occupation as a Teller at Palawan Pawnshop does not entail outdoor activities; rather,
she remains seated for the entirety of her shift.

During Dialysis
The patient conveyed that she experiences tiredness and occasional fatigue when engaging in
physical activities such as walking. Additionally, she mentioned that she is no longer able to perform
household chores like sweeping and washing clothes, as these tasks induce significant fatigue. She
verbalized that she cannot breath properly in such of activities.

The patient's occupation as a Teller at Palawan Pawnshop does not entail outdoor activities; rather,
she remains seated but doing hand exercise like squeezing exercise by the use of soft ball in her left
hand.

Sleep / Rest

Before Dialysis
Before dialysis the patient typically enjoyed 7 to 8 hours of sleep from 10 pm to 6 am in the morning.
However, there were instances when her sleep duration interrupted to 4 to 5 hours due to her habit of
watching Korean dramas. She noted that this altered sleep pattern did not seem to interfere with or
impact her ability to carry out activities in her daily life. She also added that she does not do
afternoon naps.

During Dialysis
During Dialysis the patient typically adheres to a sleep schedule of going to bed at 12 AM and
waking up around 5 or 6 in the morning. However, when anticipating a therapy session, she adjusts
her sleep routine at 8 PM and waking up at 12 AM. she described it as lack of sleep so what she do
was to sleep during her dialysis.

Cognitive - perception

Before Dialysis
Before dialysis the patient has no issues with hearing however, she experience blurred vison. She
Graduated College at ISU-E. the patient also described the pain as intolerable leading her to use
remedies to alleviate it.

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During Dilaysis
During dialysis the patient maintains a calm demeanor during the interview, speaking with strength
and clarity. Additionally, she can communicate effectively and express herself in a composed
manner. The patient is proficient in both Ilocano and Tagalog languages, and she demonstrates an
understanding of her prescribed medications. Her perception about pain is more or like a normal
sensation or feeling but in a tolerable side.

Self-perception and self-concept

Before Dialysis
Before dialysis the patient perceives herself as healthy and holds a positive self-image. Despite being
on the skinny side, she attributes it to her natural body size. To boost her self-esteem, she indulges in
self-care by treating herself to salon visits. This practice contributes to her overall sense of well-
being and helps maintain a positive outlook on herself.

During Dialysis
During dialysis the patient perceives herself as less healthy and still holds at least a positive-image
regardless of the changes of her body, although the patient said she remains skinny like before. With
a fistula in her left wrist and in the brachial part, leading to occasional feelings of irritation and
discomfort. To address the visibility of the fistulas, she opts to cover them with jackets or clothing.
This has resulted in a decline in her self-esteem, but she handles the situation by adopting a
dismissive attitude and shrugging off the impact on her confidence.

Role - Relationship

Before Dialysis
Before the dialysis the patient role in their family was she provides for them, described herself as the
Bread winner. While she lives with her parents and described her relationship with her family as
okay, highlighting a particularly close bond with her mother. Additionally, she mentioned having a
boyfriend, and they have been together for eight years, with their relationship still ongoing.

During Dialysis
During dialysis the patient role in their family is still the provider. The impact of her being the
provider now that she’s under going dialysis has shifted to dual responsibility to herself and the

21
needs of her family. Although she said that they force her to stay to San Guillermo branch she
emphasized the crucial support she receives from her family, particularly her mother, who is
consistently by her side during therapy. Her mother serves as a great source of support, especially
during these challenging times. Additionally, the patient highlighted the role of her boyfriend, noting
that he becomes her comfort zone and provides support when she experiences stress. This network of
support from both her family and her boyfriend plays a significant role in her overall well-being and
coping mechanisms.

Sexuality – Reproductive

Before Dialysis
Before dialysis the patient mentioned having a regular monthly menstrual cycle. She described the
pain she experienced as painful cramps in her abdomen radiating to her back with a pain scale of
9/10. Despite being sexually active, she does not use any contraceptives. During her menstruation,
she experiences severe period cramps.

During Dialysis
During the Dialysis the patient continues to experience regular menstrual periods, and there has been
a positive change as she now reports being able to tolerate the pain during her period. Despite
experiencing discomfort in the past, her ability to manage the pain suggests an improvement in her
overall menstrual well-being. Additionally, she remains sexually active.

Coping – Stress Tolerance

Before Dialysis
Before Dialysis the patients coping mechanisms during times of stress, the patient mentioned that she
engages in conversations with her boyfriend. However if this is too much personal she lives it by her
own and never talk it with anybody. Additionally, when feeling sad, she indicated that she tends to
shrug off the emotions or consciously avoids dwelling on them, choosing not to entertain the
negative feelings.

During Dialysis
During Dialysis the patient stated, “nakaka stress ang maistress ading, kaya tinutuon ko nalang sa
panonood ng Kdrama”. Essentially, her coping mechanism involves immersing herself in Korean

22
dramas. She also mentioned that she confides in her boyfriend like stressors that she encountering
during her dialysis, although, at times, he becomes a source of her stress.

Values – Belief

Before Dialysis
Before dialysis the patient stated that she’s a Roman Catholic but not active in church. They do and
practice hilot, atang, and using herbal medicines.

During Dialysis
The patient clarifies that her lack of active participation in church activities does not diminish the
importance of her faith, particularly during these times. She emphasizes that she fully accepts and
acknowledges the presence of God in her life. They still practice hilot, atang, and using of herbal
medicine.

23
 General Description of Client
Patient came ambulatory without complaints during pre-assessment
(-) DOB and not in distress
Identified the patient and dialyzer correctly
Assessed access site, AVF on her left upper arm., (+) bruit & thrill
HD treatment started with good flow and ultrafiltration set to 3.2 L
Secured blood lines and watched out for
Seated in High Fowler's position, with her lower extremities straight, awake, attentive, and
responsive.
Vital Signs:

Oxygen Saturation: 98%

Heart Rate: 88 bpm

Respiratory Rate: 19cpm

Temperature: 36.8°C

Blood Pressure: 130/70 mmHg

Body Parts

Body Parts Method used Findings Interpretation

SKIN: Inspection  Skin brown, dry, and Hemodialysis treatment
bulge on AVF site extracts toxic nitrogenous
substances from the blood
and remove excess fluid
and limited fluid intake
between treatments can
cause dry skin.
Overtime, frequent
insertion of AV needle,
AV fistula get larger
allowing more blood to
flow through the fistula
and vein in order to
provide a high enough
blood flowrate during
hemodialysis treatment.
 Scar 1cm in size from
previous AVF in left Presence of scars are due
24
 wrist to the death of first AVF.

 Current AVF site is

placed in upper left arm. Normal

Palpation  Cool skin temperature, Normal

not too nor too cold, and
equal bilaterally on arms
and legs.

 The skin has calluses in Calluses were palpated

the right ring finger. due to handwriting
placement of the patient.

 Absence of pruritis, Normal

edema, lesions and
masses upon palpation.

 Skin rebounds and does

not remain indented Normal
when pressure is
released in less than 2
seconds.

NAILS Inspection  Nails are intact, firm, Normal

and convex shaped.

 No clubbing Normal

Palpation
 Fingernails are covered
Can’t assess for capillary
with black nail polish
fill

HEAD Inspection  Head is upright and Normal

generally round,
symmetrical, and
proportional in the body.

 Hair was colored with

ash blonde, Baseline hair Normal
color is black, and the
distribution consistent
with no dryness or
oiliness and no lesions
present.

25
  Scalp is free from scars,
lice dandruff, and Normal
mumps.

Palpation
 No masses, lumps, and
areas of tenderness.
Normal

FACE Inspection  The client’s face is oval Normal

in shape.

 Positive function of Normal

cranial nerve VII: Patient
can demonstrate
different facial
expressions such as
frowning, smiling and
able to raise eyebrow

 Absence of rashes, Normal

bruising and edema

 No presence of
involuntary movement. Normal
Palpation  No tenderness in the Normal.
frontal sinus, maxillary
sinus, and ethmoid sinus

EYES: Inspection  Parallel, symmetrical, Normal

and non-protruding eyes.

 Eyeballs are
Normal
symmetrically aligned in
sockets without
protruding or sinking.
 No discharge, drooping
or twitching of both Normal
eyelids

 Bulbar conjunctiva and Bulbar conjunctiva and

palpebral conjunctiva are palpebral conjunctiva is
white in color. white in color due to

26
 decrease of hgb.
 The sclera is yellowish.

Inspection reveals
yellowish in color around
the sclera, that is possibly
 Patient has cause by positive test on
symmetrically aligned Hepatitis B
and evenly distributed
eyebrows, and eyelashes. Normal

 The iris is round and

Normal
black in color.

 Pupils are equal, round,

and reactive to light and
accommodation
(PERRLA). No cataract.
EARS Inspection  No obstruction or Normal
discharge, no odor
emanating, absence of
lesion

 Able to hear adequately Normal

with normal speaking
volume.

 Auricle and pinna recoils

Palpation after folding. Normal
 No masses palpated
NOSE Inspection  Nose in midline and Normal
symmetric

 No nasal flaring and Normal

both nares are patent.

Palpation  No bone and cartilage Normal

deviation,

 No tenderness noted Normal

upon palpation.

27
MOUTH Inspection  Symmetrical and patient Normal
is wearing lipstick. No
swelling and lesions
around lips

 Gums are pinkish, no

gum bleeding or
Normal
receding gums

 Presence of few dental

caries in first and second Too much salt in diet can
molar
damage teeth and
increased risk of tooth
 Patient doesn’t have any
dentures. decay leading to tooth
decay.
 Tongue is positioned in
the center and able to
move freely Normal

 Frenulum is intact
Normal

NECK Inspection  Neck is proportional to Normal

the size of the head and
body

 No lesion nor presence

of jugular vein Normal
 The patient can swallow
effortless.
Normal
 Patient was able to flex,
extend and move neck
laterally Normal
Palpation  No enlargement of Palpation reveals normal.
thyroid glands. No
complaints of pain upon
palpation

THORAX

28
  Anterior Inspection  Chest is symmetric. Normal

 No abnormalities in size Normal

such barrel or pigeon,
funnel chest

 Sternum is in the midline Normal

with downward ribs
slope.

 No usage of accessory Normal

muscles during
respiration
Palpation
 No pain nor tenderness
upon palpation Normal

 Lungs are resonance and

downward is dull
Percussion Normal

 Regular heart rhythm

Auscultation
with each heartbeat is
heard with moderate Normal
intensity

 Absence of any
adventitious sounds such
as wheezing, rhonchi, Normal
crackles and stridor

 Posterior Not assessed Unable to assess due to Not performed

patient’s unable to change
her position because of her
AVF access connected to
machine.
ABDOMEN Not assessed Unable to assess due to Not performed
patient’s position

29
UPPER Inspection  Complete numbers of Normal
EXTREMITIES fingers and limbs

 Can lift right arms up Normal

and down, left arm
unable to assess because
of the AVF connected to
machine, can rotate
shoulder, able to flex and
extend wrist and elbow.

 Able to open and close

hands and grip
Normal
 No deformity nor skin
discoloration
Normal
 There is scar in left
wrist.
Scars is due to the death
of previous AVF access.

 Absence of redness,
swelling and tenderness
Palpation
upon palpation
Normal
LOWER Inspection  Lower extremities are Normal
EXTREMITIES symmetrical.

 No amputation nor Normal

deformity nor skin
discoloration

 Able to flex and extend

knees, ankle and toes Normal
with control.

Palpation
 No pain complaint upon
Normal
palpation

 Absence of redness,
swelling, skin Normal
discoloration

 No edema is noted.

30
 IV. ANATOMY AND PHYSIOLOGY OF KIDNEY

URINARY SYSTEM

Figure 1. Anatomy of the Urinary System (Adopted from Brunner & Suddarth’s Textbook of Medical-Surgical Nursing,
12th ed.)
The renal and urinary systems include the kidneys, ureters, bladder, and urethra. Urine is
formed by the kidney and flows through the other structures to be eliminated from the body.

The kidneys are a pair of bean-shaped, brownish-red structures located retroperitoneally

(behind and outside the peritoneal cavity) on the posterior wall of the abdomen— from the 12th
thoracic vertebra to the third lumbar vertebra in the adult (Fig. 1). The average adult kidney weighs
approximately 113 to 170 g (about 4.5 oz) and is 10 to 12 cm long, 6 cm wide, and 2.5 cm thick
(Brunner & Suddarth, 2012). The right kidney is slightly lower than the left due to the location of the
liver.

Externally, the kidneys are well protected by the ribs and by the muscles of the abdomen and
back. Internally, fat deposits surround each kidney, providing protection against jarring. The kidneys
and surrounding fat are suspended from the abdominal wall by renal fascia made of connective tissue.
The fibrous connective tissue, blood vessels, and lymphatics surrounding each kidney are known as

31
the renal capsule. An adrenal gland lies on top of each kidney. The kidneys and adrenals are
independent in function, blood supply, and innervation.

Figure 2. Internal structure of the kidney (Adopted from Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing, 12th ed.)

The renal parenchyma is divided into two parts: the cortex and the medulla. The medulla,
which is approximately 5 cm wide, is the inner portion of the kidney. It contains the loops of Henle,
the vasa recta, and the collecting ducts of the juxtamedullary nephrons. The collecting ducts from
both the juxtamedullary and the cortical nephrons connect to the renal pyramids, which are triangular
and are situated with the base facing the concave surface of the kidney and the point (papilla) facing
the hilum, or pelvis. Each kidney contains approximately 8 to 18 pyramids. The pyramids drain into
minor calices, which drain into major calices that open directly into the renal pelvis. The renal pelvis
is the beginning of the collecting system and is composed of structures that are designed to collect
and transport urine. Once the urine leaves the renal pelvis, the composition or amount of urine does
not change.

The cortex, which is approximately 1 cm wide, is located farthest from the center of the
kidney and around the outermost edges. It contains the nephrons (the functional units of the kidney),
located within the renal parenchyma and are responsible for the initial formation of urine.

32
URINE FORMATION

The healthy human body is composed of approximately 60% water. Water balance is
regulated by the kidneys and results in the formation of urine. Urine is formed in the nephrons
through a complex three-step process: glomerular filtration, tubular reabsorption, and tubular
secretion.

1. Glomerular filtration: The normal blood flow through the kidneys is about 1200 mL/min.
As blood flows into the glomerulus from an afferent arteriole, filtration occurs. The filtered fluid,
also known as filtrate or ultrafiltrate, then enters the renal tubules. Under normal conditions, about
20% of the blood passing through the glomeruli is filtered into the nephron, amounting to about 180
L/day of filtrate. The filtrate normally consists of water, electrolytes, and other small molecules,
because water and small molecules are allowed to pass, whereas larger molecules stay in the
bloodstream. Efficient filtration depends on adequate blood flow that maintains a consistent pressure
through the glomerulus. Many factors can alter this blood flow and pressure, including hypotension,
decreased oncotic pressure in the blood, and increased pressure in the renal tubules from an
obstruction.

2. Tubular reabsorption, and Tubular secretion: The second and third steps of urine
formation occur in the renal tubules. In tubular reabsorption, a substance moves from the filtrate
back into the peritubular capillaries or vasa recta. In tubular secretion, a substance moves from the
peritubular capillaries or vasa recta into tubular filtrate. Of the 180 L (45 gallons) of filtrate that the
kidneys produce each day, 99% is reabsorbed into the bloodstream, resulting in the formation of 1 L
to 2 L of urine each day. Although most reabsorption occurs in the proximal tubule, reabsorption
occurs along the entire tubule. Reabsorption and secretion in the tubule frequently involve passive
and active transport and may require the use of energy. Filtrate becomes concentrated in the distal
tubule and collecting ducts under hormonal influence and becomes urine, which then enters the renal
pelvis.

RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM (RAAS)

33
 Figure 3. The RAA System (Adopted from Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 12th ed.)

When the kidneys are functioning normally, the volume of electrolytes excreted per day is
equal to the amount ingested.The regulation of sodium volume excreted depends on aldosterone, a
hormone synthesized and released from the adrenal cortex. With increased aldosterone in the blood,
less sodium is excreted in the urine, because aldosterone fosters renal reabsorption of sodium.
Release of aldosterone from the adrenal cortex is largely under the control of angiotensin II.
Angiotensin II levels are in turn controlled by renin, an enzyme that is released from specialized cells
in the kidneys (Fig. 3). This complex system is activated when pressure in the renal arterioles falls
below normal levels, as occurs with shock, dehydration, or decreased sodium chloride delivery to the
tubules. Activation of this system increases the retention of water and expansion of the intravascular
fluid volume, thereby maintaining enough pressure within the glomerulus to ensure adequate
filtration.

34
 V. ANATOMY AND FUNCTIONS OF DIALYSIS MACHINE

THE HEMODIALYSIS MACHINE

There are 5 main components in hemodialysis

treatment, 1) Vascular Access; 2) Dialyzer; 3)
Dialysate: 4) Water Treatment; and 5) Hemodialysis
machine. The hemodialysis machine is essential to
carry out hemodialysis treatment. The main function
of it includes:

 BLOOD RELATED FUNCTIONS

To transport blood from the patient via a blood

pump to the artificial kidney called a dialyzer and
back to the patient. This must be done safely by
detecting air bubbles, monitoring pressures, activating audible/visual alarms whenever a
problem occurs and also infusing adequate anticoagulant to prevent clotting.

 DIALYSATE RELATED FUNCTIONS

 To prepare the dialysis fluid by heating and deaerating the reverse osmosis water and
proportioning it with the dialysate concentrate. This must be done safely by constantly
monitoring conductivity and temperature of the dialysate.
 To pump the correct amount of dialysate to the dialyzer at a constant flow rate and
pressure.
 To detect any form of blood leak from the dialyzer into the dialysate compartment.
 To aid in the removal of excess fluid from the blood by application of negative pressure
gradient to the dialysate side.

35
MAIN COMPONENTS OF THE HEMODIALYSIS MACHINE

A) BLOOD PUMP

A pump with internal components exposed to

blood would present various problems in cleaning and
sterilization. Therefore, peristaltic roller pumps,
which work by progressively compressing special
segments of the blood tubing (pump segment) are
used. Consistent pump flow rate require accurate
occlusion. Most pumps use spring-loaded occlusion to
minimize any form of mechanical damage to the red
blood cells. The blood pump facilitates flow of blood
from the vascular access (AVF) of the patient to the dialyzer and back to the patient.

The usual blood flow rate Is about 250-300 ml/min. The higher the blood flow rate (Qb)
the better the quality and efficiency of dialysis treatment. Many patients are dialyzed with a
blood flow rate of more than 350 ml/min without any complications.

B) HEPARIN INFUSION PUMP

This is a continuous infusion pump used to

infuse certain amount of heparin (anticoagulant)
into the patient via the infusion line on the arterial
blood line to prevent clotting. This is continued
throughout the dialysis, usually at a constant rate of
about 1000 units per hour. The infusion is usually
stopped 30 minutes before the end of treatment.

36
C. MONITORING DEVICES

Blood Circuit Pressure Monitor

These are “T” tubes attached to both

arterial and venous blood lines and they permit
monitoring of pressure at various points in the
blood circuit.

They include:

Arterial Pressure Mnitoring:

• To monitor if arterial blood supply is adequate or not

• To detect if dialyzer is getting clotted when pressure monitoring is after blood pump
segment.

Venous Pressure Monitoring:

To detect any kink or clot on venous line distal to the venous chamber.

• To help in calculation of TMP (Transmembrane Pressure) • To detect accidental separation

of bloodline from AVF needle.

Air Bubble Detector. (ABD)

This is located just distal to the venous pressure monitor.

The purpose of ABD is to prevent air bubbles which may have
inadvertently entered the blood circuit from being returned to the
patient. The air bubbles detector is attached to a relay switch
which automatically clamps the venous bloodline and shuts off the
blood pump whenever air is detected.

37
DIALYSATE

The function of dialysate is to correct the chemical composition of the uraemic blood to
normal physiological level. This means:

➤ to remove waste products

➤ to normalize the electrolytes by removing some salt

To normalize the pH by adding some buffer

➤to maintain all vital substances

38
 VI. VASCULAR ACCESS

Access to the patient’s vascular system must be established to allow blood to be removed,
cleansed, and returned to the patient’s vascular system at rates between 300 and 800 mL/min.

Vascular Access Devices

Figure 4. Vascular access for hemodialysis

Immediate access to the patient’s circulation for acute hemodialysis is achieved by inserting a
double-lumen, noncuffed, large-bore catheter into the subclavian, internal jugular, or femoral vein
by the physician (Fig. 4). This method of vascular access involves some risk (eg, hematoma,
pneumothorax, infection, thrombosis of the subclavian vein, inadequate flow). Infection rates,
however, remain high and septicemia continues to be a common cause for hospital admission.

Arteriovenous Fistula

39
 Figure 5. Arteriovenous fistulas are created by anastomosing a patient’s vein to an artery. This illustrates a side toside
anastomosis (Adopted from Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 12th ed.)

The preferred method of permanent access is an arteriovenous fistula (AVF) that is created
surgically (usually in the forearm) by joining (anastomosing) an artery to a vein, either side to side or
end to side (Fig.5). Needles are inserted into the vessel to obtain blood flow adequate to pass through
the dialyzer. The arterial segment of the fistula is used for arterial flow to the dialyzer and the venous
segment for reinfusion of the dialyzed blood. This access will need time, (2 to 3 months) to “mature”
before it can be used. As the AVF matures, the venous segment dilates due to the increased blood
flow coming directly from the artery. Once sufficiently dilated it will then accommodate two large-
bore (14-, 15-, or 16-gauge) needles that are inserted for each dialysis treatment. The patient is
encouraged to perform hand exercises to increase the size of these vessels (ie, squeezing a rubber
ball for forearm fistulas) to accommodate the large-bore needles. Once established, this access has
the longest useful life and thus is the best option for vascular access for the chronic hemodialysis
patient

40
VII. PHATOPHYSIOLOGY

41
 VIII. HEMODIALYSIS TREATMENT PROCESS

Pre HD Treatment

 Instruct patient to weigh himself and write it on the whiteboard.

 Pre assessment occurs. Assess patient if he is conscious and coherent and for any presence of
symptoms such as tachycardia/bradycardia, irregular heart rhythm, chest pain, dizziness,
fever/cough, wheezes/rales/crackles, DOB, nausea/vomiting, diarrhea and edema. Check for
signs and symptoms of hematoma, flat spot, pseudo aneurysm and infection.
 Check dialysis machine for any presence of disinfectants (chlorine) using test strip; blue if
positive and clear if negative.
 Assess vascular access (AVF & Femoral Catheter) for its patency; palpate for thrill and
auscultate for bruit.
 Clean the vascular access (AVF & Femoral Catheter) using aseptic technique.
 Proceed with cannulation (Gauge 16), then initiation; connect bloodlines to the vascular
access (arterial tube to femoral catheter and venous tube to AVF), set up Heparin rate and
UF volume on the dialysis machine and start dialysis treatment.
 Teach patient to minimize movement on the vascular access and avoid putting pressure on it.
 Check vital signs.
 Promote comfort and encourage patient to rest and sleep.

During HD Treatment

 Monitor vital signs on the first 30 minutes and then every hour.
 Monitor patient for any potential complications.
 Monitor dialysis machine from time to time.
 Check patient from time to time to promote comfort and ensure safety.

Post HD Treatment

 When UF volume is achieved, it's time to terminate the dialysis treatment.

 Dialysis machine alarms to signal hemodialysis treatment is ended. Proceed with termination;
disconnect bloodlines from the cannula; start reinfusion and drain the venous tube to the
container. Then begin with disinfection.

42
 Decannulation; apply pressure to the site with a cherry, and then cover it with dressing.
 Check patient's vital signs.
 Administer epoetin (SQ) as prescribed by the Doctor.
 Patient teaching; instruct patient to limit salty and fatty foods intake, strictly limit fluid intake,
avoid excessive exercise, avoid potassium rich foods, take his home medications after
hemodialysis and strictly comply to hemodiaylsis treatments.
 Observe patient and instruct not to stand immediately.
 Instruct patient to weigh himself and note it to the whiteboard.

43
 IX. DIAGNOSTIC/LABORATORY RESULT AND INTERPRETATION

 Hematology (November 2, 2023)

TEST RESULTS REFERENCE INTERPRETATION

DATA

Hemoglobin 8.3 130-180 g/L

(Hgb)
Hematocrit (Hct) 26.3 F (37-47)
RBC 3.78 4.0-5.4 X 1012/L Low - Impaired kidneys
Mean Corpuscular 69.8 80-100 fL produce less erythropoietin, a
hormone responsible for
volume (MCV) stimulating the bone marrow
Mean Corpuscular 22.3 27.34 pg in producing RBC
hemoglobin
(MCH)
Mean Corpuscular 320 320-360 g/L Normal
hemoglobin
concentration
(MCHC)

White Blood Cell 5.9 5-10x1011/L Normal

(WBC)
Segmenters 55 50-70 Normal
Neutrophils
Lymphocytes 37.2 20-25% Low - Increased lymphocyte
prevents progression of CKD
Monocytes 7.60 3.8 High - In CKD Stage 1-5,
monocyte counts are higher
Eosinophils 5.80 2-4 High - Present in <10% of
patients with drug-induced
acute tubulointerstitial
nephritis
Basophils 0.40 0-1 Normal
Platelet 255 150-450 x 1011/L Normal

 Clinical Chemistry (November 2, 2023)

44
 TEST RESULTS REFERENCE INTERPRETATION
VALUES

Sodium 137.8 135-145 mmol/L Normal

Potassium 4.27 3.5-5.1 mmol/L Normal
Phosphorus 2.71 0.81-1.46 mmol/L Low - Impaired kidneys
cannot eliminate excess
phosphate in the blood
resulting to uremic
patients

 Immunology (November 2, 2023)

TEST RESULTS REFERENCE INTERPRETATION

VALUES
FT3 3.32 2.10-4.16 pg/mL Normal
FT4 12.9 8.70-16.50 pg/mL Normal
TSH 4.35 0.28-4.5 ulU/mL Normal

 Hepatitis Profile (July 14, 2023)

TEST RESULTS INTERPRETATION

HbSag Reactive The prevalence of the
HBV infection to the
patient could be due to
a not very strict
adherence to standard
precautions and
routine hemodialysis
precautions.
Anti HCV Non-reactive Normal

45
 X. HEMODIALYSIS PRESCRIPTION

DATE DOCTOR’S RATIONALE NURSING RATIONALE

ORDER RESPONSIBILITY
November Schedule: To make sure Provide health To verify the
13, 2023 3x a week that the teaching to the patient’s
7:00 am treatment is patient about the understanding of the
effective option importance of benefits and
for removing following the importance of
the waste frequency of compliance to
products and hemodialysis frequency of
extra fluids treatment in a week hemodialysis
from the blood. as ordered by the treatment.
physician
Duration: 4 hours of Take and record the To provide
4 hours dialysis provide vital signs q1hr. information about
enough time patients’ underlying
for extra fluid physiological
volume to be condition.
eliminated
without causing Monitor the patient
undesirable for shortness of To ensure that the
dialysis breath, headache, patient does not
symptoms. nausea, vomiting, experience
restlessness and complications such
altered level of as hypotension and
consciousness during disequillibrium
the treatment syndrome that can
occur during the
treatment/procedure.

Monitor the dialysis

machine’s screen, To ensure the
bloodlines and efficiency and safety
dialysis needles. of the patient’s
dialysis session and
avoid
exsanguination.
Dialyzer: To allow Ensure proper To avoid
Highflux efficient identification of the mismatching the
elimination of dialyzer of the dialyzer of the
waste products patient patient, as it can
and fluids from cause harm when
the blood, as mismatched
well as for Note how many
faster and more times the dialyzer
effective waste was used To check for
substance efficiency of the
removal. dialyzer
Ensure that the

46
 coupling are attached To prevent leakage
properly of blood in the
dialyzer and
dialysate
Bath: To maintain Check the amount of To promote
HCO3 acid-base the bicarbonate continuous dialysis
(Bicarbonate) balance solution throughout treatment
the treatment, inform
the lab technician if
the solution is low in
amount.
Dialysate To regulates Check if the dialysate To ensure that
Flow Rate: the treatment’s flow rate is set dialysate is not
500 effectiveness according to the under or over
by managing doctor’s order infused throughout
waste removal the treatment.
and maintain
the
concentration
gradient
between the
patient’s blood
and dialysate
solution.

Access: The access Instruct the patient to To keep the fistula

Left point provides wash the fistula area area free from
Arteriovenous a reliable with antibacterial microorganisms and
Fistula pathway for soap before each dirt
dialysis and treatment.
ensuring
effective blood
cleansing. Palpate for the thrill To evaluate the
Thus, allows and Auscultate for patency of the
to facilitate the bruit of the fistula patient's vascular
hemodialysis, access.
enabling blood
to be removed
and returned
during
treatment,

Heparin: It works as an Assess for the To manage if the

1 cc anticoagulant patient’s clotting test patient is at high risk
which keeps for bleeding
the blood
flowing
through the
dialysis system
without
clotting.

47
Blood Flow To determine Collaborate with the To ensure that the
Rate (BFR): how much physician in BFR is set to what
200-250 blood moves regulating the blood the patient can
mL/min through the flow rate for the tolerate
dialyzer per whole duration of
minute and treatment
allows for more
effective
removal of
wastes and
excess fluid
from the blood
stream
Dry Weight: To determine Weigh the patient To provide baseline
37kg the target before the data for the amount
weight and hemodialysis session of ultrafiltration
facilitate the volume to be
right amount of removed from her
fluid volume body
removal during
dialysis.
Notify the patient To inform the
about her weight gain patient about the
amount of UFV to
be removed during
the hemodialysis
treatment
EPOETIN Erythropoiesis- In preparing the To avoid foaming
stimulating medication, avoid that could cause
4000 IU, agent (ESA). excessive agitation of damage of the
SUBQ Following vial medication.
administration,
an increase in
reticulocyte To promote patient's
count occurs safety as the
within 10 days, Obtain the blood medication can
and increases pressure of the possibly cause an
in Hgb, Hct, patient before increase in blood
and RBC count administering epoetin pressure
are seen within
2–6 wks.
To prevent
Observe the patient’s medication errors
10 rights of and promote
medication patient's safety
administration

Instruct the patient to

avoid potentially To reduce the risk of
hazardous activity. seizures in pts with
chronic renal failure
48
 XI. NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Independent:
“Tatta kit ado ti han Fatigue related to After 20 minutes  Identify the  Important After 20 minutes of
ko maubran ta duray increased physical of health teaching presence of information can be health teaching the
kunting galaw ko exertion as evidenced the patient will physical and/or obtained from patient is able to
lang or nu agubraak by difficulty in able to identify the psychological knowing if fatigue is identify the activities of
dyay bahay eh maintaining usual activities of daily condition. a result of an daily living to avoid
mabannog nak physical activity. living to avoid that underlying that concerns her
dagos, nu maminsan concerns her condition or disease current situation.
kasla madik pay current situation process (acute or
makaangis”. As chronic).
verbalized by the
patient.
 Review medication  Many medications
regimen/other drug have the potential
use. side effects of
causing/exacerbatin
g fatigue.

 Assess vital signs.  To evaluate fluid

status and
cardiopulmonary
response to activity.

 Note recent lifestyle  That can be causing

changes, including or exacerbating
conflicts and level of fatigue.
developmental
issues.

49
 Have client self-  Fatigue may vary in
evaluate fatigue and intensity and is
describe its effects often accompanied
on ability by irritability, lack
to .participate in of concentration,
desired activities. difficulty making
decisions, and
relationship
difficulties that can
add to stress level
and aggravated
sleep problems.

 Encourage  To promote energy.

nutritional dense,
easy-to-prepare,
and easy-to-
consume food and
avoidance of
caffeine and high-
sugar foods and
beverages.

50
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective: Independent: Goal met.
 Artery vein Risk for infection After 20 minutes of  Assess sign and  Changes in skin  Patient’s
fistula access to related to alteration nursing intervention, symptoms of color and elevated environment is
the blood stream in skin integrity as patient will be able to infection temperature would well ventilated.
in the left evidenced by identify interventions especially be signs of
brachial part frequent insertion of to prevent or reduce temperature as developing localized  Patient is
AVF needles to risk of infection. well as changes infection. afebrile and
access the in skin color and vital signs are
bloodstream. warmth at site of normal.
AVF access site,
redness, or  Patient
tenderness. verbalized
understanding
 Emphasize the  It serves as a first of interventions
importance of line defense against in preventing
hand washing. infection. risk of infection

 Maintain aseptic  To minimize the risk

technique during of introducing
the duration of pathogens and
hemodialysis ensure patient
treatment. safety.

 Provide clean,  Provide comfort and

well-ventilated
reduce risk of
environment.
infection.

Dependent:
 Administer/  To determine
51
 monitor effectiveness of
medication therapy or presence
regime. of side effects

Collaborative:
 Cleanse insertion  This is a first-line
site as per facility defense against
protocol with healthcare-
appropriate associated
antimicrobial infections.
topical or
solution

52
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Independent:
“wen, nagsisiping Sexually pattern After 20 minutes of  Provide  Sense of trust or After 20 minutes of
kami nung bf ko, related to insufficient nursing intervention atmosphere in comfort enhances nursing intervention
awan condom nga knowledge or skill patient will be able to which discussion ability to discuss patient were able to
gamit mi. Hindi oral, deficit about identify individually of sexual sensitive matters. identify individually
sa baba mismo” as alternatives related to appropriate method problems is appropriate method of
verbalized by the sexuality. of contraception. encourage and contraception.
client. permitted.

 Encourage  Sexuality also

discussion of includes feelings,
individual attitude,
situation, with relationship, self-
opportunity for image, ideals, and
expression of behaviors, and
feelings without influences how one
judgement. experiences the
world.

 Provide sex  It provides

education, knowledge and
explanation of promotes a safe,
normal sexual informed, and
functioning when respectful approach
necessary. to sexuality and
relationships.

53
Dependent:
 Discuss methods,  Assist individual to
effectiveness, and make informed
side effects of decision on a
contraceptives, if method that meets
indicated. own values or
religious belief.

54
 XII. DRUG STUDY

DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

Generic Name: Pharmacotherapeutic: Management of metabolic Frequent: Flatulence, BEFORE:
Sodium Bicarbonate Alkalinizing agent acidosis (Associated with belching. Verify the patient.
Chronic Renal Failure) Ensure the 12 rights of drug
Brand Name: Clinical: administration.
Neut Antacid electrolyte, Assess for signs and symptoms of
urinary/systemic acidosis.
Dosage: alkalinizer Do not give PO medication within 1 hr
1tab ACTION CONTRAINDICATION ADVERSE EFFECTS of antacids.
Dissociates to provide Hypernatremia, Excessive, chronic use may
Frequency: bicarbonate ion. alkalosis, unknown produce metabolic alkalosis DURING:
TID abdominal pain, (irritability, twitching, Watch for signs of metabolic alkalosis,
Therapeutic Effect: hypocalcemia, severe paresthesia, cyanosis, slow fluid overload.
Route: Neutralizes pulmonary edema. or shallow respirations, Assess for clinical improvement of
PO hydrogen ion headache, thirst, nausea). metabolic acidosis (relief from
concentration, raises Fluid overload results in hyperventilation, weakness,
blood, urinary pH. headache, weakness, disorientation).
blurred vision, behavioral
changes, incoordination, AFTER:
muscle twitching, elevated Instruct patient not to take too much
B/P, bradycardia, antacid with sodium bicarbonate as it
tachypnea, will decrease the effectiveness of
wheezing, coughing, certain drugs that need stomach acid to
distended neck veins. work.
Extravasation may occur at
the IV
site, resulting in tissue
necrosis, ulceration.

55
DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pharmacotherapeutic: Treatment of hypertension Frequent (6%–4%): BEFORE
Carvedilol Beta-Adrenergic blocker Fatigue, dizziness Verify the patient.
Ensure the 12 rights of drug
Brand Name: Clinical: Occasional (2%): Diarrhea, administration.
Coreg Antihypertensive bradycardia, rhinitis, back Assess B/P, apical pulse immediately
pain. before drug is administered (if pulse is
Dosage: 60
6.25mg Rare (less than 2%): beats/min or less or systolic B/P is less
Orthostatic hypotension, than 90 mm Hg, withhold medication,
Frequency: drowsiness, UTI, viral contact physician).
OD infection. Receive full medication history and
screen for interactions.
Route: ACTION CONTRAINDICATION ADVERSE EFFECTS
PO Possesses nonselective Bronchial asthma or Overdose may produce DURING
beta-blocking and alpha- related bronchospastic profound bradycardia, Take with food.
adrenergic blocking conditions, cardiogenic hypotension, bronchospasm, B/P 1 hr after dosing as guide for
activity. shock, decompensated HF cardiac insufficiency, tolerance.
requiring intravenous cardiogenic shock, cardiac Assess pulse for quality, regularity,
Causes vasodilation. inotropic therapy, severe arrest. Abrupt withdrawal rate; monitor for bradycardia.
hepatic impairment, may Assist with
Therapeutic Effect: second- or third-degree result in diaphoresis, ambulation if dizziness occurs.
Hypertension: Reduces AV block, severe palpitations, headache, Assess for evidence of HF: dyspnea
cardiac bradycardia, or sick sinus tremors. May precipitate HF, (particularly
output, exercise-induced syndrome (except in pts MI in on exertion or lying down), peripheral
tachycardia, reflex with pacemaker). pts with cardiac disease; edema, distended neck veins.
orthostatic tachycardia; thyroid storm in pts with Monitor I&O (increase in weight,
reduces thyrotoxicosis; peripheral decrease in urine output may indicate
peripheral vascular ischemia in pts with existing HF).
resistance. peripheral vascular disease.
Hypoglycemia may
occur in pts with previously AFTER

56
controlled diabetes. May Compliance with therapy regimen is
mask symptoms of essential to control hypertension.
hypoglycemia. Instruct the patient to report excessive
fatigue, prolonged dizziness.
Instruct the patient to restrict salt and
alcohol intake.

57
DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pharmacotherapeutic: Reduction of serum Frequent (20%–11%): BEFORE:
Sevelamer Polymeric phosphate phosphorus in patients with Infection, pain, Verify the patient.
binder chronic renal disease on hypotension, diarrhea, Ensure the 12 rights of drug
Brand Name: hemodialysis dyspepsia, administration.
Renagel, Renvela Clinical: nausea, vomiting. Assess for bowel
Electrolyte modifier, Occasional (10%–1%): obstruction.
Dosage: antihyperphosphatemia Headache, constipation,
80mg 1tab agent hypertension, increased
cough. AFTER:
Frequency: Instruct the patient to take with meals,
TID ACTION CONTRAINDICATION ADVERSE EFFECTS swallow tablets whole; do not chew,
Binds with dietary Bowel obstruction Thrombosis occurs rarely crush, dissolve, or divide tablets.
Route: phosphorus in GI tract, Instruct the patient to report persistent
PO allowing phosphorus to be headache, nausea, vomiting, diarrhea,
eliminated hypotension.
through normal digestive
process, decreasing serum
phosphorus level.

Decreases incidence of
hypercalcemic episodes in
pts
receiving calcium acetate
treatment.

58
DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pharmacotherapeutic: Treatment for anemia in Frequent (24%–11%): BEFORE:
Epoetin Alfa Erythropoiesis- patients with chronic renal Hypertension, headache, Verify the patient.
stimulating agent (ESA). failure and to reduce need nausea, arthralgia. Ensure the 12 rights of drug
Brand Name: for RBC transfusion administration.
Epokine Clinical: Occasional Assess B/P before initiation (80% of
Erythropoietin (9%–7%): Fatigue, edema, pts with chronic renal failure have
Dosage: diarrhea, vomiting, chest history of hypertension).
4000IU pain, skin reactions at Consider that all pts eventually need
administration site, supplemental iron therapy.
Frequency: asthenia, dizziness.
3x a week DURING:
ACTION CONTRAINDICATION ADVERSE EFFECTS Monitor aggressively for increased B/P
Route: Stimulates division, Pure red cell aplasia, Hypertensive (25% of pts require antihypertensive
Subcutaneous differentiation of uncontrolled hypertension. encephalopathy, therapy, dietary restrictions).
erythroid progenitor cells thrombosis,
in bone marrow. Chronic renal cerebrovascular accident, AFTER:
Failure pts: Increased risk MI, Instruct the patient to immediately
Therapeutic Effect: for serious cardiovascular seizures occur rarely. report any severe headache.
Induces erythropoiesis, reactions (e.g., stroke, MI) Hyperkalemia occurs Instruct patient to avoid potentially
releases reticulocytes when Hgb levels greater occasionally in pts with hazardous activity during first 90 days
from bone marrow. than 11 g/dL are achieved chronic renal of therapy (increased risk of seizures in
with epoetin alfa. failure, usually in those pts with chronic renal failure during
who do not comply with first 90 days).
medication regimen, Advise the patient that specific dietary
dietary regimen must be maintained.
guidelines, frequency of
dialysis regimen.

59
DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pharmacotherapeutic: Calcium carbonate is Milk-alkali syndrome BEFORE:
Calcium Carbonate Electrolyte replenisher administered to patients (headache, decreased Verify the patient.
with chronic kidney appetite, Ensure the 12 rights of drug
Brand Name: Clinical: disease (CKD) in order to nausea, vomiting, unusual administration.
Antacid, antihypocalcemic, bind dietary phosphorus, fatigue). Watch out for hypocalcemia
antihyperkalemic, decrease phosphorus symptoms, such as paresthesia,
Dosage: antihypermagnesemic, retention, and avoid a Rare: Urinary urgency, twitching of the muscles,
500mg, 1g antihyperphosphatemic. negative calcium balance. painful urination. laryngospasm, colic, cardiac
arrhythmias, and the signs of Chvostek
Frequency: ACTION CONTRAINDICATION ADVERSE EFFECTS or Trousseau.
TID Essential for function, Calcium-based renal Hypercalcemia
integrity of nervous, calculi, hypercalcemia, Early signs: Constipation, DURING:
muscular, skeletal systems. ventricular fibrillation. headache, dry mouth, Check for bradycardia, paralytic ileus,
Plays an increased severe constipation, nausea, vomiting,
important role in normal Cautions: Chronic renal thirst, irritability, decreased anorexia, and thirst in the patient.
cardiac/renal function, impairment, hypokalemia, appetite, metallic taste, If you notice any of these
respiration, blood concurrent use with fatigue, weakness, hypercalcemia symptoms, get in touch
coagulation, digoxin. depression. with your doctor or another medical
cell membrane and capillary Later signs: expert right away.
permeability. Assists in Confusion, drowsiness,
regulating release/storage hypertension, AFTER:
of photosensitivity, Inform patient that constipation may
hormones/neurotransmitters. arrhythmias, nausea, result from calcium carbonate.
Neutralizes/reduces gastric vomiting, painful urination. Instruct the patient to report extreme
acid (increases pH). constipation, it could be a sign of
poisoning.
Therapeutic Effect: Recommend to the patient not to use
Replaces calcium in tobacco products or drinks that are
deficiency states; controls high in alcohol or caffeine.
hyperphosphatemia in end- Advise patients to continue eating a
stage renal disease; relieves diet rich in vitamin D.

60
heartburn, indigestion.

61
DRUG NAME CLASSIFICATION INDICATION SIDE EFFECTS NURSING RESPONSIBILITIES
Generic Name: Pharmacotherapeutic: Prevention, treatment of Occasional: Mild, transient BEFORE:
iron deficiency anemia nausea.
Ferrous Sulfate Enzymatic mineral Verify the patient.
Ensure the 12 rights of drug
Rare: Heartburn, anorexia, administration.
Brand Name: Clinical: constipation,
Assess nutritional status, dietary
Fer-In-Sol, Fer-Iron, Iron preparation diarrhea. history.
Slow-Fe
Question history of hemochromatosis,
hemolytic anemia, ulcerative colitis.
ACTION CONTRAINDICATION ADVERSE EFFECTS
Dosage: Question use of antacids, calcium
1tab Essential component in Hemochromatosis, Large doses may aggravate supplements.
formation of Hgb, hemolytic anemias. existing GI tract disease
myoglobin, enzymes. (peptic ulcer, regional
Promotes effective
Frequency: enteritis, ulcerative colitis). DURING:
erythropoiesis. and
TID Severe iron poisoning occurs Assess for clinical improvement,
transport, utilization of
most often in children, record relief of iron-deficiency
oxygen
symptoms (fatigue, irritability, pallor,
manifested as vomiting, paresthesia of extremities, headache).
Route: severe abdominal pain,
PO Therapeutic Effect: diarrhea, dehydration,
followed AFTER:
Prevents iron deficiency
by hyperventilation, pallor, Advise patient to expect stool color to
cyanosis, cardiovascular darken.
collapse.
Instruct the patient to use dropper or
straw and allow solution to drop on
back of tongue, To prevent mucous
membrane and teeth staining with

62
 liquid preparation.
If GI discomfort occurs, instruct the
patient to take after meals or with
food.
Instruct the patient not to take the drug
within 2 hrs of other medication or
eggs, milk, tea, coffee, cereal.
Instruct the patient not take take
antacids or OTC calcium supplements
as it can decrease iron absorption by
33% if taken concomitantly.

LEGEND:
Red - Book Based
Green - Internet Based

63
 XIII. DISCHARGE PLANNING (METHOD)

Medication
 Instruct the patient to take the prescribed home medication after hemodialysis. The following
medications are:
1. Sodium Bicarbonate 1 tab three times a day
2. Carvedilol 6.25mg once a day
3. Sevelamer 80mg 1 tab three times a day
4. Epoetin Alfa 4000IU 3x a week
5. Calcium Carbonate 500mg 1g three times a day
6. Ferrous Sulfate 1 tab Three times a day
 Instruct the patient to take the medication regularly as prescribedwith the right dose, right time,
and right frequency.
 Instruct the patient to check for the expiration date of the drug before taking it.
 Instruct the patient not to take any of the medications during hemodialysis treatment as the
dialysis works by filtering and cleansing the blood.

Environment/ Exercise
 Instruct the patient to avoid lifting heavy objects using her hand with the AV fistula.
 Instruct the patient to avoid excessive exercise.
 Maintain a quiet, clean, and calm environment to alleviate the patient's discomfort.
 Instruct the patient to perform ball squeeze exercise at home by slowly squeezing and releasing
the ball using the hand with an AVF. This may help in improving the muscle tone and make the
vein larger and easier to insert dialysis needle.

Treatment
 Instruct the patient to strictly comply with the hemodialysis treatment schedule.
 Instruct the patient to report immediately if she experience symptoms of headache, nausea,
vomiting, restlessness and altered level of consciousness as these are manifestations of
complications of hemodialysis.

64
Hygiene
 Instruct the patient to practice infection prevention and control in hemodialysis settings by
cleaning the fistula site with soap and water before each dialysis treatment and to practice hand
hygience by washing hands or using hand sanitizer before and after dialysis.
 Instruct the patient not to wear any tight or restrictive clothing on the arm with fistula.
 Educate the patient to avoid sleeping and carrying heavy objects on the arm with fistula.

Outpatient Referral
 Provide the contact of the attending physician (with permission) if uncontrolled complications
arise.

Diet
 Instruct the patient to continuously adhere to the prescribed fluid restriction of 1,000 mL a day.
 Instruct the patient to follow a specific dietary regimen of renal diet which includes foods low in
sodium (beef, pork and chicken with no added seasonings), low potassium (carrots, cabbage,
cauliflower, cucumber, eggplant) and low protein (bread, oatmeal, rice)

Spiritual
 Encourage the patient to maintain her spiritual relationship by always praying and having faith
regarding her health.
 Encourage the participation of the significant other in providing emotional support and strong
bond to the patient.

65
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