INTRODUCTION

As part of our clinical experience I was posted in Dialysis Unit for

two week from to . Here I have taken history of patient and
done physical examination. I have prepared case study on Acute renal failure
which is the life threatening condition if not treated. I have assessed about its
causes, symptoms and treatment modalities.

My patient, Mr. Kapil Shah suffering from ARF admitted on

with the symptoms of oliguria with high blood pressure. Here the patient
treated with diuretics and other antihypertensives. After the reports finalized
for Acute renal failure patient taken on Dialysis after the insertion of Intra
cardiac catheter. I have provided comprehensive care to the patient with
administration of medication, Dietary management, Prevention of
complications, Psychological support to patient and family members, Patient
education. After the discharge of patient I have explained about continuing
care at home with explanation of drugs. Also encouraged about follow up, diet,
yoga and exercises.

 This case study includes following:

 Identification data
 Present and Past medical history
 Family history
 Allergies and Medication
 Functional health pattern
 Physical assessment
 Laboratory investigation
 Details of medication
 Review of Anatomy
 Disease condition
 Nursing Process
 Health education
 Conclusion
 Bibliography

1
 HISTORY OF THE PATIENT

IDENTIFICATION DATA:

Name of patient - Mr. Kapil Shah

Age - 55

Gender - Male

Bed no - 3

Dr. Unit -

IPD No - 786956

OPD No - 21

Date of admission -

Educational status - 12 th pass

Occupation - Business

Monthly income - 10,000

Religion - Hindu

Mother tongue - Gujrati

Marital status - Conscious

Address - Gondal

Diagnosis - Acute Renal Failure

Surgery performed - Central Venous Catheterization

2
PRESENT COMPLAINTS:

C/o Decreased urinary output

Swelling all over the body

Nausea and Vomiting

Shortness of breath

Fatigue and Weakness

PRESENT MEDICAL HISTORY:

 The patient came at the Civil Hospital of Gondal on with the

symptoms of swelling, decreased urinary Output and difficulty in
breathing. Here he was immediately admitted due to high blood
pressure with uremia.

PAST MEDICAL HISTORY:

 The patient was admitted for High Blood Pressure before 3 yers at Civil
hospital Gondal. Also patient has Diabetes mellitus since 5 yrs.

PAST SURGICAL HISTORY:

 Patient has no any history of surgical procedure.

3
 FAMILY HISTORY:

Family tree:

Kapilbhai (∆ ARF) Jaswantiben

Rajivbhai Mukeshbhai Poonamben

MALE: Jay

FEMALE:

PATIENT:

FAMILY INFORMATION:

Sr.no Name of family member Relationship Age Education occupation Marital

with patient status
th
1 Kapil J Shah Self 55 12 pass Business Marrie
d
th
2 Jaswanti K Shah Wife 50 10 pass House wife Marrie
d
3 Mukesh K Shah Son 35 B.com Business Marrie
d
4 Poonam R Shah Daughter in 33 B.A House wife Marrie
law d
5 Rajiv K Shah Son 28 B.com Business Unmarr
ied
th
6 Jay K Shah Grand son 12 6 std. --- ---

4
  Family income per year: 30,000
 Family history of illness: No any

ALLERGIES AND MEDICATION:

 Patient has no allergy from any substance.

 Patient was on antihypertensive drugs since 3 years.

HABITS:

 Patient continuously smoking for 20 yrs. He smokes 6 cigarettes per

day.

FUNCTIONAL HEALTH PATTERN:

 INTERPERSONAL RELATIONSHIP:

The patient has good relationship among family members and members
are caring and very supportive to kapilbhai.

 HYGIENE:

The patient has good health practices but due to illness can’t do own
daily activities.

 REST/SLEEP:

The patient has complain of impaired sleeping pattern.

 ELIMINATION PATTERN:

The patient has decreased urinary output with normal bowel moments.

5
  DIETIC HISTORY:
 General appearance: Anxious
 Appetite: poor
 Diet: Normal vegetarian
 Meal pattern: Normal
 Need assistance: Needed

PHYSICAL ASSESSMENT

GENERAL APPERANCE
 Level of consciousness - conscious
 Orientation - Oriented
 Activity - Lethargic
 Body built - moderate

ANTHROPOMETRIC MEASUREMENT

1. Height: 5.4’’

2. Weight: 65 kg

3. Mid upper arm circumference: 17 cm

VITAL SIGN

1. Temperature: 100 F

2. Pulse: 96bpm

3. Respiration: 22/min

4. Blood pressure: 140/90mmhg

5. SPO2: 96%

6
6. Pupil: Normal

7. Pain: Flank pain at hips

HEAD

 Hair: equally distributed

 Color of hair: white & black
 Scalp: no dandruff
 Pediculosis: absent

FACE

 Face: Anxious
 Facial puffiness: present

EYES

 eye brows: symmetrical

 eye lid/lashes: swelling
 eye ball : normal
 conjunctiva: pale
 sclera: normal
 puncta: normal
 cornea: regular ridges
 iris: normal
 eye discharge: absent
 use of glasses: yes

 Pupil:
 Equally reacting to light

7
NOSE

 Nasal septum: central

 Nasal polyps: absent
 Nasal discharge absent

MOUTH

 Number of teeth: 30
 Denture: absent
 Dental carries: absent
 Odor of mouth: other
 Gums: weak

LIPS

 healthy
 Cleft lips : absent
 Stomatitis: absent

SINUS

 Maxillary sinus infection : no

 Frontal sinus infection: no

EARS

 Size: Normal
 Shape: Normal
 Position and alignment: Normal
 Redness: absent
 Discharge: absent
 Cerumen: absent
 Lesions : absent

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 Foregin body: absent
 Hearing acquity: well
 Use of hearing Aid: no
 Tuning fork test:
 Weber test: Normal conduction
 Rinner test: Normal conduction

BREAST

 Male:
- Lump: No
- Swelling: No
- Gynacomastia: Absent

 Female:
- Symmetry : ----
- Pain: ----
- Lump; ----
- Discharge: ----
- Trauma: ----
- History of present breast disease/surgery: ----

RESPIRATORY SYSTEM

 Respiratory rate; 22/min

Inspect the chest

 Thoracic cage-shape- normal

 Configuration- normal
 Skin colour and condition - pallor
 Chest expansion- asymmetric

9
Percussion

 Lung filed: clear

 Resonance: Hyperesonance
 Diaphragmatic excursion: normal

Auscultation

 Breathing sound- Broncho vesicular

 Adventitious sound- no any
 Respiratory pattern- normal

CARDIOVASCULAR SYSTEM

 Pulse: 96 bpm
 Heart sound: S1. S2 heard
 Abnormal heart sound: S3 OR S4- absent
 Murmurs: absent
 Carotid pulse rate: normal
 Blood pressure: 140/90mmhg

DIGESTIVE SYSTEM

 Abdominal girth: 55 cm
 Diarrhea/constipation absent

Inspection

 Size- rounded
 Symmetry – normal
 Scar- no any
 Lesions- no any
 Redness- absent

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Palpitation

 Tenderness- absent
 Fluid collection- absent

Percussion

 Ascites/peritonitis: no
 No gas/fluid collection; no

Auscultation

 bowel sounds normal

GENITO URINARY SYSTEM

 frequency of urination: Decreased

 urine last voided: In morning
 colour: pale straw with anuria (45ml/day )
 catheter present: yes
 urethral discharge: absent

INTIGUMENTORY SYSTEM

 skin colour Brownish

 dermatitis: absent
 allergies if any: no any
 lesion/abrasions: absent
 tenderness/redness: Redness present
 surgical scar: no any
 abnormal growth: no
 secretion: no

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MUSCULOSKELETAL SYSTEM

 range of motion possible

 joint swelling
 weakness
 extremity strength- equal

SPINE

 lordosis/kyphosis/scoliosis absent

MENTAL STATUS

 Memory: Impaired
 Knowledge: Normal
 Thinking: Normal
 Judgment: Normal
 Insight: Affected

12
 LABORATORY INVESTIGATION

Sr. Name of investigation Normal Patient’s findings Remarks

no Findings

1 WBC 4000-10000 12000 per cumm Increased

2 RBC 3.9 – 5.8 2.9 mill/cumm Decreased

3 Hemoglobin 12 -16 9 gm/dl Decreased

4 Platelets 150 – 490 214 thous/cumm Normal

5 M.C.H.C 32 – 36 33.4 gm/dl Normal

6 M.C.H 24 – 32 30.4 pg Normal

7 M.C.V 75 – 92 90 fl Normal

8 R.D.W SD 35 – 47 40.6 fl Normal

9 Serum Creatinine 0.7 – 1.35 5 mg/dl Increased

10 BUN 10 -20 40 mg/dl Increased

11 Sodium 135 – 145 150mEq/L Increased

12 Potessium 3.6 – 5.2 6.1 mmol/L Increased

13 Calcium 8.6 – 10.3 9 mg/dl Normal

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 ANY OTHER INVESTIGATIONS

1. USG KUB
 RIGHT KIDNEY: Size – 11.1 × 4.5 cm
Echopattern: appears dark
Hydronephrosis: moderate
Calculus: No
Cyst: No
 LEFT KIDNEY: Size - 10.6 × 4.9
Echopattern: Normal
Hydronephrosis: Mild
Calculus: No
Cyst: No
 BLADDER: Full , wall thickness 5mm, internal echoes –

 CONCLUSION: Bilateral sweling of medulla of kidney with

hydronephrosis

2. X Ray Abdomen
3. ECG

SIGNIFICANT DATA
 My patient Mr. kapil shah suffering from acute kidney failure, through
physical examination and laboratory investigations I have found
following :
 Dysphnea
 Decreased urine output with ankle edema
 Cellular dehydration
 High levels of creatinine and urea
 Decreased hemoglobin
 Inflammation of glomerulus and renal tubule with decreased GFR

14
 DETAILS OF MEDICATION

Drug name Dose& route Action Indications Side-effects Nursing

responsibilities

Frusemide (Lasix) 40 mg BD IV Antihypertensiv Hypertension, Headache, *Assess therapeutic

e Nephrotic Fatigue, Blurred response,improvement
Loop Diuretic Syndrome, Acute vision, Nausea, in edema of feet and
Inhibits renal faliure Diarrhoea, increased urine output
reabsorption of Anemia, *Assess vitals regularly
Sodium and Weakness, *Assess side effects
water molecule Cramps *Patient education
at proximal and *Assess complications
distal renal of ARF
tubule

Prednisolone 30 mg BD Severe Headache, mood *Assess side effect and

Orally Antinflamatory inflammation, changes therapeutic response
Decreases Autoimmune Tachycardia, * Assess vitals
inflammation by disease,Ulcerative Hyperglycemia, * Diet education
the suppression colitis,Rheumatoi Weakness, * Observe signs of
of polymorpho- d arthritis Nausea,Diarrhea immunosupperesion
Nuclear , Decreased * Patient education
lucocytes. immune rsponse

15
 DETAILS OF MEDICATION

Drug name Dose& route Action Indications Side-effects Nursing

responsibilities

Amikacin 15 mg/kg Antibiotic UTI, Septicemia, Skin rash, *Assess patient for
body weight 8 It interferes Maningitis and other ototoxicity, side
hourly with protein CNS infection, Headache, Effects
IV synthesis in Intrabdominal Vomiting, *Evaluate therapeutic
germ cell Infection, Respiratory Nausea, response
binding cause tract infection eosinophillia * Maintain I/O chart
misplacing of * Regular checkup of
genetic code Weight gain
cause the * Patient education
death of
becteria.
Uremia, Headache, * Assess Vitals
Vitamin K 2.5 – 25 Activation of Hypoprothombinemi brain damage, regularly
mg/day Blood clotting a Nausea, * Assess side effects
IM proteins Hemophilia and other Rashes, * Diet education
hemorrhagic disease Dyspnea , * Evaluate therapeutic
anemia Response

16
 REVIEW ANATOMY & PHYSIOLOGY

The Urinary system consist of two kidneys, two Ureters, BladderAnd Urethra.
The right kidney little more inferior to the left kidney due to presence of liver
on right side of the body. The kidneys are located between T12 to L3. They
receives blood from renal arteries.

The kidneys are retroperitoneal meaning that they are postirior to parietal
peritoneum. The uretars are also retroperitoneal take urine to the bladder.
The urinary bladder is located anterior to the parietal peritoneum.

KIDNEY:

The kidney is a bean shaped organ. The outer surface of the kidney is
covered by renal capsule. The depression on medial side is hillum is the
passage of nerves, blood vessels, lymphatic vessels enter and exits. The kidney
sectioned in a coronal plane to study internal anatomy. The outer part of
kidney known as renal cortex . The renal medulla is deep to the cortex and is
divided into renal columns and renal pyramid. Each pyramid ends in the

17
papilla and drips urine into small funnel shaped structure called minor
calyces. The minor calyces join to form major calyces takes urine to the renal
pelvis. The renal pelvis occupies most of the renal sinus, a space in the kidney.
It takes urine to the uretar.

Functions of kidney:

The kidney is the major excretory and osmoregulatory organ in the

human body and has following functions:

 Removal of metabolic waste products

 Regulation of water contents in body fluids
 Regulation of pH of body fluids
 Regulation of chemical composition and substances
 It coverts vitamin D from supplements of the sun to the active form of
vitamin D that is needed by the body
 Kidney also secretes a hormone erythropoietin which stimulates
production of Red blood cells from bone marrow.

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 MICROSCOPIC STRUCTURE OF KIDNEY:

NEPHRON:
The kidney contains about 1-2 million functional units, the
nephron. The nephron is essentially a tubule closed at one end and that
joins a collecting duct at the other end. The close or blind end is
indented to form the cup – shaped glomerulus (Bowmen’s capsule)
which almost completely encloses a network of tiny arterial capillaries.
The glomerulus resemble a coiled tuft and are shown in figure. It is
about 3cm long.
It has three parts:
 The proximal convoluted tubule
 The medullary loop
 The distal convoluted tubule

Function of nephron:

 Filtration of blood
 Reabsorption of necessary components
 Tubular secretions of ions
 Formation of urine

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 Disease condition

Renal failure is a failure of the kidneys to maintain internal homeostasis.

Renal failure is a situation in which the kidneys fail to function adequately. It
is characterized by the reduction in the excretory and regulatory functions of
kidney. It usually occurs at terminal stages of the disease processes. If the
kidney function fails, the waste products accumulates in blood and the body
leading to a disruption in endocrine and metabolic functions as well as fluid,
electrolyte and acid base disturbances.

ACUTE RENAL FAILURE

Acute renal failure is a sudden and complete loss of the ability of the kidneys
to remove waste and concentrate urine without losing electrolytes. It occurs
when the kidneys stop working over period of hours, days or in some cases
weeks. Acute renal failure is a sudden decline in renal function, usually
marked by:

 Decreased glomerular filtration rate (GFR)

 Incresed concentration of blood urea nitrogen (BUN, Azotemia) and
creatinine
 Urine output is less then 400ml per day(oliguria)
 Hyperkalemia
 Sodium retention

20
 RISK FACTORS

Picture of book Patient’s picture

 Advanced age  Present

 Diabetes
 High blood pressure  Present
 Heart failure
 Kidney disease  Present
 Liver disease
 Being hospitalised for serious
condition
 Peripheral artery disease

ETIOLOGY

Picture of book Patient’s picture

 Decreased interruption of  Present

blood supply to kidney
(Hypertension)
 Circulatory volume depletion  Present
from dehydration
 Decreased cardiac output
 Liver failure
 Acute tubular necrosis
 Glomerulonephritis  Present
 Kidney stone
 Bladder cancer

21
 PATHOPHYSIOLOGY
In response to renal injury, there is thought to be an increase in intra –
glomerular pressure with hypertrophy, as the kidney attempts to adapt to
nephron, loss to maintain constant glomerular filtration

Failure of renal circulation and glomerular or tubular dysfunction

Damaged tubules cannot conserve sodium normally which activates rennin

angiotensin – aldosterone system

Sodium and fluid retention which leads to edema

Sudden and complete loss of kidney functions

Reduced blood flow to kidney due to renal vasoconstriction and decreased

GFR

Oliguria

Increased serum creatinine, BUN level and retention of other metabolic waste

Increased circulatory overload and sodium retention

Acute renal failure

22
 CLINICAL MANIFESTATION

Picture of book Patient’s picture

 Oliguria  Present
 Dark coloured urine
 Dryness of skin  Present
 Azotemia  Present
 Edema or fluid retention causes  Present
swelling in legs and ankles or
feet
 Hypertension and Rapid heart  Present
rate
 Flank pain  Present
 Shortness of breath.  Present
 Nausea and vomiting  Present
 Anemia  Present
 Fatigue and weakness  Present

DIAGNOSTIC EVALUTION

Picture of book Patient’s picture

 Complete blood count  Done

 Blood chemistry report  Done
 Urine analysis  Done
 Electrocardiogram
 USG KUB  Done
 X ray KUB  Done
 Kidney Biopsy
 CT scan
23
 MADICAL MANAGEMENT

Picture of book Patient’s picture

 Antihypertensive (Diuretics)  Injection Lasix 40 mg BD per

 Sodium Polystyrene sulfonate day
 Antibiotics  Injection Amikacin
 IV Sodium bicarbonate  Injetion Vitamin K
 Anticonvulsant in case of  Tablet Prednisolone
seizures  Injection Periset
 Antiemetics  Iv fluids Dialysis
 IV fluids  Dialysis
 Nutritional therapy
 Dialysis

SURJICAL MANAGEMENT

Picture of book Patient’s picture

 For Dialysis:  Intra cardiac catheterisation

- AV fistula
- AV Graft
- Intra cardiac catheterisation
 Kidney transplant

24
 NURSING DIAGNOSIS

1. Fluid volume excess related to decreased glomerular filtration rate,

decresed urinary output and sodium retention as evidenced by weight gain,
edema, intake greater then output.

2. Risk for decreased cardiac output related to fluid overloaded, fluid shifts,
fluid deficit and electrolyte imbalance, severe acidosis

3. Imbalanced nutrition: Less than body requirements related to protin

catabolism; dietary restrictions to reduce nitrogenous waste products,
increased metabolic needs, anorexia, nausa, vomiting evidenced by weaknes.

4. Risk for infection related to depression of immunologic defenses

(secondary to uremia), invasive procedure/devices and changes in dietary
intake.

5. Risk for deficient fluid volume related to excessive loss of fluid (diuretic
phase of ARF, with rising urinary volume and vomiting)

6. Activity intolerance related to anemia, altered metabolic state and

retention of waste products evidenced by fatigue.

7. Ineffective Therapeutic Regimen management related to complexity of

regimen.

8. Knowledge deficit regarding condition and therapeutic regimen

25
 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
*Regular *Inserted Urinary catheter
Subjective Data: Fluid volume Maintenan assessment of for continuous evaluation for Patient
Patient excess ce of intake and output urinary output verbalized
complains that related to normal including iv fluids *Maintained I/O chart: that edema
he has swelling decreased fluid and Intake -700 ml is improved
at ankle and feet. GFR, electrolyte Output – 45 ml And weight
decreased levels and is reduced.
urinary excess * Regular *The patient has gained 2.5
Objective Data:
output and fluid assessment of kg weight per day
Assessed the
sodium weight
location of
edema. Taken retention as
history of evidenced by * Administration of Administrated 40 mg lasix IV
decreased edema, medication BD
urinary output. weight gain,
intake * Preparation of *Prepared patient and family
greater than patient for dialysis members for dialysis.
output. Informed about need for
intra cardiac catheterization.

26
 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
*Assess factors *Observed that patient and
Subjective Data: Ineffective To improve responsible for significant other have lack of Effective -
Dyspnea therapeutic effect of ineffective understanding about disease ness of
Increased age regimen therapeuti therapeutic *I have asked the patient and therapeutic
Chronic disease related to c regimen regimen significant others that what regimen is
chronicity of .
they know about disease. maintained
disease * Inform all the *Then I had given
complexity of details about information regarding,
Objective Data: treatments disease according *What is ARF
Lack of to level of under- *What it actually causes to
awareness about standing of patient body
disease *Importance and need of
prognosis and treatments
need for
*Need of diet required for
education
ARF
related to
disease *Finally what are the
prognosis are explained
I have given psychological
support to patient and family.

27
 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes
Subjective Data: Risk for Maintaining *Assess vitals regularly *The vitals are: Patient have
Patient decreased adequate Temperature: 100 F reduced
complains cardiac output cardiac Pulse : 69 bpm chances for
shortness of related to fluid output Respirations : 22/min decreased
breath overload, fluid * Regular observation * Observed ECG cardiac
shift, fluid of signs of decreased changes and pallor output
deficit and cardiac output
electrolyte
imbalance *Administer *Administrated calcium
medication gluconate Iv and
Objective Data: oxygen
supplementation
Assessed pallor according to doctors
and cyanosis prescription
with decreased
pulse rate * Provide * Given comfortable
comprehensive care position and advised
complete bed rest

28
 NURSING CARE PLAN
Assessment Nursing Expected Planning Intervention Evaluation
diagnosis outcomes

Subjective Data: Activity Performing *Assessment *Assessed paleness of The activity

Relatives intolerance activities skin and mucous of patient is
complains about related to within membrane improved
reduced activity anemia. tolerance * Observed increased
of patient Altered level waste products in
metabolic blood through blood
state, retention report
of waste * Provide * Provided clean bad
products as comprehensive care and comfortable
evidenced by position. Also assisted
activity of in daily care activities
Objective Data:
Observed patient * Advised patient to
activity of take complete bad rest
patient is to conserve energy
reduced * Observed signs of
pressure sores
* Dietary management *Advised to take
energy rich food with
salt restriction.

29
30
 HEALTH EDUCATION
I given health education on various aspects of health, disease condition its
causes, sign and symptoms, diagnostic investigation, treatment and follow-up
during his stay in the hospital and at the time of discharge.

1. Disease condition
Informed about basic details of Acute renal failure, what is it, causes of
ARF, sign and symptoms, treatment modalities, complications and
prognosis of patient. I explained about dialysis, why it is needed,
procedures required for dialysis, side effects of it and advantages.

2. Medication
I have explained all the drugs which patient has prescribed. The effect of
this drugs on disease, main side effects. The patient informed about
time, route and frequency of drugs.

3. Nutrition
Patient require high phosphate, calcium with carbohydrates. This may
include seeds, low fat milk, egg white, beans etc. The patient should
avoid salt and high protein in diet. The patient can take fruits and green
leafy vegetables.

4. Home care
I have explained about the drugs required after discharge; its time,
frequency, route. Encourage about regular inatake of medicines and
dietary requirements. Encouraged for regular exercise and yoga.

5. Follow-up
Encouraged about the importance of regular follow up and information
regarding dialysis extended after discharge. Informed about the signs of
complications like confusion , coma, hypotension etc. Informed patient
that he must came to hospital if any symptoms of complication occur.

31
 CONCLUSION
After the completion of this case study as a clinical assignment, I have learned
about following:

 Acute renal failure:

 Causes and risk factors of ARF
 Pathophysiology of ARF
 Clinical manifestation of ARF
 Diagnostic evaluation required for ARF
 Medical and surgical management for ARF
 Nursing management for ARF

Through this case study, I have compared these points from book to
reality.

I have learned indeatiled about Dialysis machine and procedure. The

principal of dialysis machine, its operating system, need of AV fistula or
IVC, management during the dialysis and required drugs and other
treatment modalities

Finally, I have learnt about the communication skill, knowledge, Advance

Nursing care and improved my leakings.

BIBLIOGRAPHY
1. Waugh Anne & Allison Grant (2014), “Ross and Wilson : Anatomy and
Physiology in Health and Illness”, Elsevier publication, printed in China.
2. Smeltzer Suzanne, Bare Brenda and at.al, “ Brunner & Suddarth’s
Textbook of Medical Surgical Nursing”, Wolters Kluwer (India) Pvt Ltd,
India; Sanat Printers.
3. Shanbhag Tara, Smita Shenoy and at.al (2016), “Pharmacology for
Nurses”, Elsevier publication, India; Thomson press, India.
4. Kaur Navdeep (2015) “Textbook of Advance Nursing Practice”, Jaypee
Brothers Medical Publishers; Rajkamal Electric press, Hariyana.

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33