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Demographic Data Name: Mrs. NSP Address: Tanauan City, Batangas Age: 66 Gender: Female Religion Affliation: Roman Catholic Marital Status: Married Nationality: Filipino Occupation: N/A Room and Bed: 414 B Admission Date: October 04, 2010 Admission time: 12:40 P.M. Chief Complaint: Difficulty of Breathing Provisional Diagnosis: Chronic Kidney Disease Attending Physician: Dr.Punzalan

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Reason for Seeking Care A. Chief Complaint “Nahihirapan akong huminga dahil sa ubo ko” as verbalized by the patient. B. The patient experienced difficulty of breathing before being admitted. She has been noted to have productive cough with thick, tenacious sputum. One of the manifestations of Chronic Kidney Disease (CKD) on the respiratory system is shortness of breath and cough with thick, tenacious sputum. History of Present Health Concern The patient has manifested cough and phlegm at home. 3 hours while undergoing dialysis, the patient complained of difficulty of breathing associated with chills, negative fever, and pain on lower back and positive body weakness that prompted the patient to be admitted in the ward. Vital Signs upon admission: Blood Pressure: 180 / 90 Heart rate: 86 Respiratory Rate: 22 Temperature: 36.8oC
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III.

IV.

Past Health History A. Past Health History The client did not experience any childhood diseases. She doesn’t have any allergies. She also stated that she did not experience any accident or injuries in the past. She was hospitalized before because she gave birth to her 2 sons via Caesarian Section. The medications she has taken in the past were anti-hypertensive drugs and her medications for Diabetes Mellitus (DM). B. Family History of Illness The client’s patients both died of cerebrovascular accident (stroke). She has 6 siblings, her younger sister also has DM while her younger brother has a heart disease. According to her, the remaining four siblings were all healthy.

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V.

Genogram
CVA HPN CVA

Heart disease DM

DM HPN CKD

Legend: = dead female = dead male = female = male = patient 3

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Review of Systems Neurologic: weakness and fatigue, inability to concentrate, behavioral changes Integumentary: gray-bronze skin, dry, flaky skin, pruritus Cardiovascular: hypertension, bipedal pitting edema, periorbital edema Pulmonary: crackles, shortness of breath, cough with thick, tenacious sputum Gastrointestinal: anorexia Hematologic: anemia Urinary: anuria Reproductive: decreased libido

VII.

Psychosocial Assessment

A. Health perception and health management pattern Before Hospitalization: Before being hospitalized, the client was already concerned about her health because she was already diagnosed with DM. She has followed the prescribed diet for her (low sugar) and has taken her prescribed medications. She tried to consult an “albularyo” just to try it but did not really believe that it can actually improve her health status. She also stated that she never smoked nor drank alcoholic beverages. According to her, she believed that eating too much “butong pakwan” and drinking soft drinks have caused her to develop her present disease (chronic kidney disease).

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During hospitalization: During her hospital stay, the client was obliged to follow a stricter diet. She has adjusted to the diet that was prescribed for her. She was diagnosed with chronic kidney disease and was given additional medications. She stated that the things that were important to her were mainly on financial concerns because only one of his sons was able to support her. Interpretation: When diagnosed with another disease, the patient has adjusted to the diet that was prescribed for her. In the sense that she has already adjusted, it can be inferred that she was concerned about her health. Analysis: According to the stages of Health Behavior change, the client is under the maintenance stage. During this stage, the person strives to prevent relapse by integrating newly adopted behavior into his or her lifestyle. This stage last until the person no longer experiences temptation to return to previous unhealthy behavior. Reference: Page 282 Fundamentals of nursing by Kozier & Erb 8th edition B. Nutritional and metabolic pattern Before Hospitalization: Before being hospitalized the client was following the prescribed diet for her because she was already diagnosed with DM. Basically, she was eating foods that were low in sugar. She also stated that she was eating fish and pork most of the time because they were selling such in the market. Long time ago before she was diagnosed with DM and her present disease, she never ate vegetables because she doesn’t like the taste. She was able to consume 8-10 glasses of water a day. Before, she has a very good appetite that leads her to gain weight up to 81 kg (overweight for her age) then suddenly became 45kg at the present time because she reported loss of appetite.

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Analysis: Although the nutritional content of food is an important consideration when planning a diet. 6 . beliefs about food personal preferences. the client has a regular bowel time pattern every morning. life style. medication and therapy. She defecated only once a week and very little urine output of 10cc during her hospital stay. economics. The character of the stool was soft and firm and brown in color. She has not experienced any difficulty in defecating except when she was experiencing constipation but it seldom happened. she was forced to do so. alcohol consumption advertising and psychologic factors Reference: Page 1237 Fundamentals of nursing by Kozier & Erb 8th edition C. Interpretation: The client changed her unhealthy diet and have loss her appetite brought about by the effect of her disease. the client reported to have difficulty in both defecating and urinating. She was also under a limited fluid intake of up to 5 glasses per day only. Interpretation: The client’s urinary and defecating pattern changed. She urinated for 10-12 times a day and did not experience any difficulty in urinating. She also reported loss of appetite brought about by loss of taste in foods (“walang panlasa”). Elimination Before Hospitalization: Before being hospitalized. an individual’s food preferences and habits are often a major factor affecting actual food intake habits about eating are influenced by development considerations gender ethnicity and culture. the client was under a strict renal diet. Even if she really doesn’t want to eat vegetables. religious practices. During hospitalization: During her hospital stay. once a day.During hospitalization: During her hospital stay.

Activity and exercise pattern Before Hospitalization: Before being hospitalized. Reference: Page 1105 Fundamentals of nursing by Kozier & Erb 8th edition 7 . Analysis: According to researchers at Harvard’s School of Public Health (HSPH). During her spare time. amber transparent in color and faint aromatic in odor. the amount and quality of fluid or food intake. During hospitalization: During her hospital stay. a mixture of healthy eating and regular physical activity is the best form of health promotion and maintenance. She stated she did not require assistance or supervision from another person or device when doing self-care activities. she watched television programs and listened to the radio. She cannot perform her usual daily activities anymore. Reference: Page 1264 Fundamentals of nursing by Kozier 7th edition Page 1340 Fundamentals of nursing by Kozier 7th edition D. Regular physical activity is important for everyone and a sedentary lifestyle increases the chances of becoming over weight as well as developing a number of chronic diseases. lifestyle. pathologic process and medications. daily patterns. the client was still not doing any exercises mainly because of her condition.Analysis: Normal urinary output is approximately equal to the fluid intake (1200-1500 cc) straw. Elimination can be affected by a person’s developmental stage. the client was not really fond of doing exercises. Interpretation: The client became dependent on some of her activities due to her situation. emotional states. Her usual daily activities were doing the household chores such as cooking and cleaning the house. the level of activity. She often prayed rosary by herself. She also stated that she already needed assistance in taking a bath because she might fall.

She did not experience any problem in falling asleep. Some of the factors that often are influential in sleep disturbances include the following: *side effects of medication *pain from arthritis. Cognitive-perceptual pattern Before Hospitalization: Before being hospitalized. Analysis: The quality of sleep is often diminished in elders. 8 . She was watching television programs and listening to the radio as a form of relaxation.E. She sometimes took a nap in the afternoon for 1 hour. She was not able to sleep for 3 consecutive days in the hospital. the client reported having a regular sleep pattern of 6-8 hours of sleep at night. increases stiffness or impaired mobility *depression Reference: Page 1169 Fundamentals of nursing by kozier & Erb 8th edition F. the client reported having difficulty falling asleep probably because of the side effects of the medications she have taken (Mucobron). Interpretation: The client’s sleeping pattern changed due to her situation and the adverse reaction of her medication. She reported that she forget things easily. During hospitalization: During her hospital stay. the patient had no difficulty on hearing and has blurring of vision but did not wear eye glasses. Sleep-rest pattern Before Hospitalization: Before being hospitalized.

the meninges thicken. the ability to perceive the environment and react appropriately is diminished changes in the nervous system may also affect perceptual capacity changes in the cognitive structure occur as a person ages. During hospitalization: During her hospital stay. nothing changed about the client’s cognitive perceptual pattern. particularly verbal activity. If the aging person’s senses are impaired. Self-perception pattern Before Hospitalization: Before being hospitalized. Analysis: Perception or the ability to interpret the environment depends in the awareness of the senses. Her changes in memory were evidenced by forgetting to pray the rosary that was her usual activity in the hospital while lying on bed. and brain metabolism slows as yet. she got easily irritable and always hot-headed. little is known about the effect of these physical changes in the cognitive functioning of the older adult life-long mental activity. the client described herself as someone who cannot spend a day without laughing (happy person). She was also very familyoriented. the client felt very lonely because she cannot perform her usual activities anymore brought about by her illness. Interpretation: The client has manifested a neurologic effect of her disease such as inability to concentrate on the things to be done. The brain loses mass with aging. She felt very sorry for herself but still was not losing hope because she said she was never left by her family. Reference: Page 418 Fundamentals of nursing by Kozier & Erb 8th edition G. 9 .During hospitalization: During her hospital stay. In addition blood flow to the brain decreases. According to her husband. She dealt with her problem on a positive way. help the elder retain a high level of cognitive function and helps maintain long-term memory.

Role relationship pattern Before Hospitalization: The client was living with her family together with her husband and one son.Interpretation: The client has manifested a neurologic effect of her disease such as behavioral changes. They were able to handle such problem by trusting God that he will never let them to suffer and through “diskarte” as stated by her husband. Interpretation: The client values her family so much and they play a vital role in the wellbeing of the client. During hospitalization: During her hospital stay. They were only 3 who were living in the house. She cannot mingle with her friends anymore because of her current situation. Before her other son who works abroad left. The usual problem that arouse in their family was more on financial needs because her son who was working abroad was the only who was able to support their financial needs. Reference: Page 353 Fundamentals of nursing by Kozier & Erb 8th edition H. maturity starts from 65 years to death. Analysis: According to Erikson’s stages of development. Her other son was working abroad. he visited the client and prayed for her. the one who stayed with the client in the hospital was her husband while his other son stayed in their house. They worry a lot when a member of the family developed an illness. 10 . Integrity indicates acceptance of worth and uniqueness of one’s own life and acceptance of death while despair indicates sense of less or contempt for others. They have their own schedule of switching on who will stay next. She also stated that she was fond of mingling with other people especially to their neighbors. The client belonged to a social group in their area called “Senior Citizens”.

Relationships are particularly close. Antihypertensive decreased sexual desire failure. an effect of her disease on her reproductive system. Sexually – Reproductive Pattern Before Hospitalization: The client has not been really active in having sexual intercourse with her husband due to her age.Analysis: Family roles are especially important to people because family relationship are particularly close. diuretics decreased vaginal lubrication and decreases sexual. Interpretation: Some of the factors that have caused the loss of interest in sexual intercourse of the patient were the effect of her disease in her reproductive system decreasing her libido and the adverse effects of the medications she was taking. Relationships can be supportive and growth producing or at the opposite extreme highly stressful if there in violence or abuse. Reference: Page 1009 Fundamentals of nursing by kozier & Erb 8th edition I. She was also taking medications that have an adverse effect of decreasing sexual desire. Reference: Page 1028 Fundamentals of nursing by Kozier & Erb 8th edition 11 . Beta-blockers decreases sexual desire. Most frequently the impact is negative but sometimes there is a positive impact. Analysis: Many prescription medications have side effects that affect sexual beyond those intended for that purpose. cardiotonics decreased sexual desire. During Hospitalization: The client has loss interest in doing sexual interaction that indicated decreased libido.

Emotion-focused coping does not improve the situation.J. Interpretation: The client found her family as the people whom she can count on whenever she has problems. 12 . Emotion-focused coping includes thoughts and actions that relieve emotional distress. For the client her family played the 2nd most important role in her life second to God. A coping strategy (coping mechanism) is a natural or learned way of responding to a changing environment or specific problem or situation. Analysis: Coping may be described as dealing with changes successfully or unsuccessfully. When she has problems. During Hospitalization When she knew about her illness. She doesn’t belong to any religious group but regularly attended the mass. Value-belief pattern Before hospitalization For the client. she was able to handle them accordingly.Stress Tolerance Before hospitalization The client dealt with her problems on a positive way and found her family most helpful in talking things over. but the person often feels better. the things that she was considered most important in her life were God and her family. the client became lonely but never lost hope because she knew her family would never leave her alone. Coping. Reference: Page 1068 Fundamentals of nursing by kozier & Erb 8th edition K. She believed her religion have helped her a lot when difficulties started to arise.

During Hospitalization During her hospital stay. she was not able to go to the church and attend the mass regularly but still performed her obligation to serve the lord by praying the rosary. Analysis: Values are enduring beliefs or attitudes about the worth of a person. object. questions of value underlie all moral dilemmas. Reference: Page 80 Fundamentals of nursing by Kozier & Erb 8th edition 13 . She values her religion very much. ideas or action. including nurse’s ethical decision making. Values are important because they influence decisions and actions. Even though they may be unspoken and perhaps even unconsciously held. Interpretation: The client still finds time to serve God despite her situation.

00 g/L 120. Encourage intake of diet as ordered. 2. There is a decrease in hematocrit signifies anemia due to inability of the kidney to secrete erythropoietin. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 4. Lippincott Company Hemoglobin 107. Instruct the family member to 14 1. Instruct the family member to consult the dietitian about the diet.B.37 – 0.00 – 150. 2010 Nursing Consideration Encourage intake of diet as ordered. Administer medication as prescribed. Administer medication as prescribed. Lippincott Company Medical Surgical Nursing . Laboratory and Diagnostics LABORATORY RESULTS HEMATOLOGY ANALYTE RESULT NORMAL RANGE SIGNIFICANCE Oct. 2. Medical Surgical Nursing by J.B.47 Low. Encourage activity within limits and avoid fatigue 3.00 Low. Hematocrit 0. 4. 1. There is a decrease in hemoglobin signifies anemia due to inability of the kidney to secrete erythropoietin. 5.33 Vol % 0. Medical Surgical Nursing by J. 4.VIII. Encourage activity within limits and avoid fatigue 3.

Systemic: chills.0 -6. Provide periods of rest of sleep/ rest to conserve energy and oxygen. Lippincott Company RBC count 3.8 x10 12/L 4. hematuria. 5. Instruct the family member to consult the dietitian about the diet. 5.by J. Assess for local and systemic sign of infections: Local: pain on urination. edema. Administer medication as prescribed.0 Low. Medical Surgical Nursing by J. Lippincott Company consult the dietitian about the diet.B. 1. Medical Surgical Nursing by J.B. Encourage activity within limits and avoid fatigue 3. 1. and tachycardia. cloudy urine and redness. 15 .0 – 10. Lippincott Company WBC count 35.0 x10 9/L 5. 2. or drainage in areas of skin breakdown. There is a decrease in red blood cells signifies anemia due to inability of the kidney to secrete erythropoietin. 4. Encourage intake of diet as ordered. Provide periods of rest of sleep/ rest to conserve energy and oxygen. In increase WBC infection is indicated.B. fever.0 High.

4.00 – 37. 2.00 – 38.90 pg 32.MCV 85. MCH MCHC 27. Provide periods of rest of sleep/ rest to conserve energy and oxygen. Medical Surgical Nursing by J.00 31.00 – 110.B. 3. There is a decrease in MCV signifies anemia due to inability of the kidney to secrete erythropoietin. Lippincott Company 2.50 g/dL 26. Encourage activity within limits and avoid fatigue 3.00 Low.00 Within the normal range Within the normal range 16 . Administer medication as prescribed. Maintain aseptic technique when performing invasive/noninvasive to prevent introduction of organisms. 5. Instruct client and family member to avoid exposure to others with infection.90 fL 86. 1. Encourage intake of diet as ordered. Instruct the family member to consult the dietitian about the diet.

350000 Within the normal range 17 .Platelet count 267000/cumm 150000 .

015 % 0. 2. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. Medical Surgical Nursing by J. Medical Surgical Nursing by J. cloudy urine and redness. hematuria. Instruct client and family member to avoid exposure to others with infection. Lippincott Company Lymphocytes 0.370 – 0. Decrease lymphocytes infection is indicated. Lippincott Company . 1. or drainage in areas of skin breakdown. cloudy Neutrophils 0. Systemic: chills.500 Low. Assess for local and systemic sign of infections: Local: pain on urination. fever.720 High.200 – 0. 2010 ANALYTE RESULT NORMAL RANGE SIGNIFICANCE Nursing Consideration 1. and tachycardia.SCHILLING’S DIFFERENTIAL Oct. Assess for local and systemic sign of infections: Local: pain on urination. 18 hematuria. 4.941 % 0.B. edema. Increase Neutrophils infection is indicated.B. 3.

060 0. and tachycardia.140 0.000 – 0.010 Within the normal range Within the normal range Within the normal range 19 .044 % 0. Instruct client and family member to avoid exposure to others with infection.000 % 0.000 – 0.000 – 0. 3. edema. fever.000 % 0. or drainage in areas of skin breakdown. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. Eosinophils Monocytes Basophils 0. 2. Systemic: chills.urine and redness.

Assess for urine ferrous. 4. Provide oral hygiene. 2. 3. stomatitis and gastro inttinal bleeding. Lippincott Company Low.SINGLE FINDINGS Oct. 3. Sodium 125. 2. Lippincott Company High. Accurate measurement and recording of intake and output. Medical Surgical Nursing by J. odor of breath.00 mmol/L 135.51 – 0. Promote skin care to prevent uremiafrost and pruritus. Promote skin care to prevent uremiafrost and pruritus. Assess for urine ferrous. Blood Urea Nitrogen 31. (PPD’s Nursing Drug Guide Nursing Consideration 1. odor of breath. Medical Surgical Nursing by J.B. 2. Indicates reduction in filtrate formation and function of the tubular epithelium and inability of the kidney to excrete metabolic waste products of protein through urine cause increase in BUN and Creatinine.00 – 23. 3.B. stomatitis and gastro inttinal bleeding. Provide oral hygiene.29 mg/dL 8.97 mg/dL 0. Decrease in sodium indicates fluid overload/excess due to inability of the kidney to excrete such fluid. Indicates reduction in filtrate formation and function of the tubular epithelium and inability of the kidney to excrete metabolic waste products of protein through urine cause increase in BUN and Creatinine. Encourage patient to remain within prescribed 20 .00 1. 2010 ANALYTE RESULT NORMAL RANGE SIGNIFICANCE High.00 Creatinine 3.00 – 148. Monitor for weight gain and edema.95 1.

4.60 mmol/L 3.2nd edition) fluid restriction. Provide hard candy and chewing gum on ice cube as thirst-quenchers. Potassium 3.50 – 4.50 Within the normal range 21 .

Lippincott Company . 2. Instruct the family member to consult the dietitian 22 Hematocrit 0. 2. Lippincott Company Hemoglobin 113. Encourage activity within limits and avoid fatigue 3. 7. Administer medication as prescribed.00 – 150.37 – 0.HEMATOLOGY ANALYTE RESULT NORMAL RANGE SIGNIFICANCE Oct.36 Vol % 0. Encourage activity within limits and avoid fatigue 3.B.00 Low.B. Administer medication as prescribed. Instruct the family member to consult the dietitian about the diet. There is a decrease in hematocrit signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J. There is a decrease in hemoglobin signifies anemia due to inability of the kidney to secrete erythropoietin. 4.47 Low. 1. 2010 Nursing Consideration 1. Medical Surgical Nursing by J.00 g/L 120. Encourage intake of diet as ordered. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 4. Encourage intake of diet as ordered.

and tachycardia. 23 WBC count 25. Systemic: chills.0 -6.0 Within the normal range 1.0 – 10. cloudy urine and redness. edema. or drainage in areas of skin breakdown. hematuria. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 3.0 High. Maintain aseptic technique when performing invasive/noninvasive to prevent introduction of organisms.about the diet. Medical Surgical Nursing by J. Assess for local and systemic sign of infections: Local: pain on urination. Instruct client and family member to avoid exposure to others with infection. 2.1 x10 12/L 4. In increase WBC infection is indicated. fever.5 x10 9/L 5.B. RBC count 4. Lippincott Company .

00 – 110.00 26.350000 Within the normal range Within the normal range Within the normal range Within the normal range 24 .90 pg 31.00 150000 .00 31.60 g/dL 275000/cumm 86.40 fL 27.00 – 38.00 – 37.MCV MCH MCHC Platelet count 88.

Lippincott Company Lymphocytes 0.865 % 0. 1. 3.720 High. Medical Surgical Nursing .B. Increase Neutrophils infection is indicated. cloudy urine and redness. edema. Assess for local and systemic sign of infections: Local: pain on urination.200 – 0. hematuria. Medical Surgical Nursing by J.SCHILLING’S DIFFERENTIAL ANALYTE RESULT NORMAL RANGE SIGNIFICANCE Nursing Consideration 1. Decrease lymphocytes infection is indicated. Assess for local and systemic sign of infections: Local: pain on 25 Neutrophils 0.500 Low. Systemic: chills.370 – 0. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. or drainage in areas of skin breakdown. Instruct client and family member to avoid exposure to others with infection. and tachycardia.058 % 0. fever. 2.

hematuria.000 – 0. and tachycardia.060 0. Systemic: chills.010 Within the normal range Within the normal range Within the normal range 26 .056 % 0.000 – 0. cloudy urine and redness. Eosinophils Monocytes Basophils 0.140 0. Instruct client and family member to avoid exposure to others with infection.001 % 0. Lippincott Company urination. edema.B.000 – 0. 3. or drainage in areas of skin breakdown. fever. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms.020 % 0. 2.by J.

Tip of the central venous line is at the level of the superior vena cava. Atherosclerotic aorta 27 .X-RAY RESULT Interpretation: CHEST PA Haziness seen in the left base. Interpretation: Pneumonia left base. Diaphragm and sulci are intact. Heart is enlarged. Cardiomegaly. Bones and soft tissue outline are unremarkable. Thoracic aorta is calcified.

which is a temporary reservoir for the urine. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism. ureters. In addition to maintaining fluid homeostasis in the body. urinary bladder. The urinary system consists of the kidneys. The kidneys form the urine and account for the other functions attributed to the urinary system. Anatomy and Physiology THE URINARY SYSTEM The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. and urethra. The ureters carry the urine away from kidneys to the urinary bladder.IX. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside. the urinary system controls red blood cell production by secreting the hormone erythropoietin. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. 28 .

each kidney is approximately 3 cm thick. and excrete the wastes in the urine. one on each side of the vertebral column. 6 cm wide. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae. reddish region. or functional tissue. The right kidney usually is slightly lower than the left because the liver displaces it downward. called the renal sinus. The ureter and renal vein leave the kidney. on the medial side. next to the capsule. The kidneys are the organs that filter the blood. The hilum leads to a large cavity. The wide bases of the pyramids are adjacent to the cortex and the pointed ends. It is roughly bean-shaped with an indentation. They are the organs that perform the functions of the urinary system. This means they are retroperitoneal. connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside. In the adult. called renal fascia. Each kidney is held in place by connective tissue. A tough.Kidneys The kidneys are the primary organs of the urinary system. which helps to protect it. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The renal medulla consists of a series of renal pyramids. The other components are accessory structures to eliminate the urine from the body. 29 . are directed toward the center of the kidney. called renal papillae. This surrounds a darker reddish-brown region called the renal medulla. called the hilum. which appear striated because they contain straight tubular structures and blood vessels. within the kidney. and 12 cm long. The cortex and medulla make up the parenchyma. fibrous. remove the wastes. The kidneys protected by the lower ribs. of the kidney. and the renal artery enters the kidney at the hilum. called perirenal fat. The outer. is the renal cortex. and is surrounded by a thick layer of adipose tissue. lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum.

A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. called nephrons. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A nephron has two parts: a renal corpuscle and a renal tubule. The middle layer. the fibrous coat. called the glomerulus. The wall of the ureter consists of three layers. It descends from the renal pelvis. called the glomerular capsule. which monitors blood pressure and secretes renin. in the parenchyma (cortex and medulla). The renal pelvis is a large cavity that collects the urine as it is produced. The main function of this layer is peristalsis to propel the urine. about 25 cm long that carries urine from the renal pelvis to the urinary bladder. The outer layer. From the major calyces the urine flows into the renal pelvis and from there into the ureter. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. This layer secretes mucus which coats and protects the surface of the cells. Ureter Each ureter is a small tube.The central region of the kidney contains the renal pelvis. is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop. the muscular coat. and enters the urinary bladder on the posterior inferior surface. 30 . which is located in the renal sinus and is continuous with the ureter. is transitional epithelium that is continuous with the lining of the renal pelvis and the urinary bladder. the mucosa. behind the parietal peritoneum. along the posterior abdominal wall. is a supporting layer of fibrous connective tissue. surrounded by a double-layered epithelial cup. Several minor calyces converge to form a major calyx. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus. The inner layer. Each kidney contains over a million functional units. The renal corpuscle consists of a cluster of capillaries. consists of inner circular and outer longitudinal smooth muscle.

Contraction of this muscle expels urine from the bladder. at the apex of the trigone. formed by three openings in the floor of the urinary bladder. and below the parietal peritoneum. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. It is located in the pelvic cavity. On the superior surface. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. which is composed of smooth muscle. There is a triangular area. The next layer is the muscularis.Urinary Bladder The urinary bladder is a temporary storage reservoir for urine. posterior to the symphysis pubis. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. the outer layer of the bladder wall is parietal peritoneum. In all other regions. Two of the openings are from the ureters and form the base of the trigone. It is composed of connective tissue with elastic fibers. called the trigone. 31 . The third opening. The second layer in the walls is the submucosa that supports the mucous membrane. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. is the opening into the urethra. The rugae and transitional epithelium allow the bladder to expand as it fills. the outer layer is fibrous connective tissue. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter. the mucosa has numerous folds called rugae. When the bladder is empty.

The second part. In males.Urethra The final passageway for the flow of urine is the urethra. The internal urethral sphincter surrounds the beginning of the urethra. In females. The opening to the outside is the external urethral orifice. passes through the prostate gland and is called the prostatic urethra.5 inches) long. where it leaves the urinary bladder. is called the membranous urethra. the spongy urethra. The third part. is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. a short region that penetrates the pelvic floor and enters the penis. only 3 to 4 cm (about 1. next to the urinary bladder. 32 . the urethra is short. and transports both urine and semen. a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The external urethral orifice opens to the outside just anterior to the opening for the vagina. Another sphincter. The first part. This sphincter is smooth (involuntary) muscle. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. These two sphincters control the flow of urine through the urethra. the urethra is much longer. and the external urethral orifice opens to the outside at the tip of the penis. about 20 cm (7 to 8 inches) in length. This portion of the urethra extends the entire length of the penis. the external urethral sphincter. is the longest region.

Pathophysiology Modifiable: Lifestyle Diet Exercise Non-Modifiable: Age (66 yrs old) Gender Family history F s Thickening and/or an in the amount of collagen in the basement membranes of the small vessels Legend: = Risk factors = Pathology = Clinical manifestations = Treatment GFR = NCP CREATINE Impaired/sluggish blood flow Glumerulosclerosis LAB: BUN Renal blood flow Stage 1 Reduced Renal Reserve GFR of 35% to 50% of Normal 33 .IX.

Stage 2 Renal insufficiency GFR is 25% to 35% of Normal Remaining nephrons undergo changes to compensate for those damage nephrons Filtration of more concentrated blood by the remaining nephrons Hypertrophy of nephrons Intolerance and exhaustion of the remaining nephrons Further damage of the nephrons Dialysis Stage 3 Renal failure GFR of 15% to 20% of normal Impaired kidney function & urination Reduction in renal capillaries Scarring of glomeruli Atrophy & Fibrosis of Renal tubules >85% of kidney damage Continuous decline in renal function 34 .

pruritis Cardiovascular: -hypertension -pitting edema of feet . flaky skin . tenacious sputum Gastrointestinal: -anorexia Activity intolerance related to fatigue. Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough Imbalanced Nutrition less than body requirement related to GI disturbances as evidenced by altered taste sensation.behavioral changes Integumentary: -gray-bronze skin -dry. anemia.Stage IV ESRD GFR of 15% of normal or less Continuous multisystem affectation Neurologic: -weakness and fatigue -inability to concentrate . Anti-hypertensive (Therabloc) (Norvasc) (Pritor Plus) Mucolytic Expectorant (Mucobron) ((9(( Hematologic: -anemia Urinary: -anuria Reproductive: -decreased libido Immune: -infection LAB: LAB: Antibiotic Vigocid WBC HCT HGB RBC Chest x-ray 35 . Impaired Skin Integrity related to accumulation of toxins in the skin as evidenced by pruritus Fluid volume excess related to decrease urine output as manifested by edema. retention of waste products and dialysis procedure.periorbital edema Pulmonary: -shortness of breath -crackles -cough with thick.

Objective:  Edema 36 . Objective:        Shortness of breath Cough w/ thick tenacious sputum V/s taken as follow: Bp:180 / 90 Temp:36.X. Prioritized List of Nursing Problems CUES Subjective: “nahihirapan ako huminga dahil sa ubo ko”as verbalized by the patient. Loss of respiratory function can be life threatening. a HIGH PRIORITY problem that is life threatening. NURSING DIAGNOSIS 1. Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough 2. Interventions are needed quickly to resolve other associated problems. a HIGH PRIORITY problem. It can contribute to ineffective airway clearance through the accumulation of fluids in the pulmonary system. JUSTIFICATION INEFFECTIVE AIRWAY CLEARANCE is the inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway. Fluid volume excess related to decrease urine Subjective: output as manifested by edema “namamanas ang paa ko” as verbalized by the patient.8oC RR:22 PR:86 FLUID VOLUME EXCESS is the increased isotonic fluid retention.

Activity intolerance related to fatigue. needs of the body.  behavioral changes 4. It is a result of medical problem. flaky skin pruritis IMPAIRED SKIN INTEGRITY is altered epidermis and/or dermis. 37 . Imbalanced Nutrition less than body requirement related to GI disturbances as evidenced by altered taste sensation. Subjective: 5. retention of waste products and dialysis procedure. A LOW PRIORITY problem that is not currently health Objective: threatening bur it could be if it were to persist. It is a LOW PRIORITY problem that is cause by other higher  inability to concentrate priority problems. this will change to a medium priority. Therefore measures to promote intact skin will be a LOW PRIORITY. It will almost certainly resolve in a >gastrointestinal day or two as the medical problem is treated. therefore it will resolve  weakness and fatigue as they resolve. Subjective: ACTIVITY INTOLERANCE is insufficient “nanghihina ako” as verbalized by the patient physiological or psychological energy to endure or complete required or desired Objective: daily activities. If the medical problem does not  anorexia resolve quickly. but it is not a contributing factor.3. Subjective: IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS is insufficient “Wala akong ganang kumain simula ng intake of nutrients to meet the metabolic nagka-sakit ako” as verbalized by the patient. Impaired Skin Integrity related to accumulation of toxins in the skin as evidenced by pruritus “Ang kati ng balat ko” as verbalized by the patient. Objective:    gray-bronze skin dry. anemia.

Assist patient to assume position of comfort e. 3. however patient. rhonchi. e.g. Keep environmental pollution to a minimum e. Rationale Evaluation GOAL MET: 1.g. 4. Note adventitious breath sound e. crackles. Nursing Care Plans Diagnosis Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough Assessment Subjective: “nahihirapan ako huminga dahil sa ubo ko”as verbalized by the patient.g.g elevate head of bed. Some degree of bronchospasm is present with obstruction air way and may/may not be modified in adventitious breath sounds. Elevation of the head of the bed facilities respiratory –function by use of gravity. To provide baseline data. maintain patent airway with breath sound clear/clearing Nursing Intervention Independent: 1. 4.8˚C RR: 22 PR: 86 Planning After 2hours of nursing intervention the patient will demonstrate behaviours to improve airway clearance. Precipitators of allergic type of respiratory reaction that can trigger/exacerbates onset of cough effect. 2. After 2hours of nursing intervention the patient demonstrated behaviours to improve airway clearance. Objective:  Shortness of breath  Cough w/ thick tenacious sputum  V/s taken as follow: Bp: 180 / 90 Temp: 36. wheezes.g dust smokes &feather pillows. Auscultate breath sounds. cough effectively and expectorant secretions 3.XI. cough expectorate secretions. 38 . in severe distress will seek the position that most eases breathing. Monitor vital signs 2. have patient lean on over bed table or sit on edge of bed. e.

especially if patient is elderly. 39 . 6. acutely ill. hacking.g persistent.5. Observe characteristics of cough e. and moist. To treat underlying as cause. Coughing is most effective in an upright or in a head down-position after chest percussion. 5. Cough can be persistent but ineffective. Assist with measures to improve effectiveness of cough effect Dependent: 6. Administer medications prescribed. or debilitated.

foods 4. 2. Explain to patient and family rationale for restrictions. Fluid volume excess related to decrease urine output as After 2 hours of manifested by nursing edema. Understanding promotes patient and family cooperation with fluid restriction. dietary restrictions. will be determined on basis of weight urine output and response to therapy. respiratory rate and effort. 3. pulse rate and rhythm e. daily weight b. skin turgor and presence of edema d. Limit fluid intake to 2. b. intervention the patient will maintain dietary and fluid restrictions. medications and fluids used to take medications: oral and intravenous. Evaluation GOAL MET: After 2hours of nursing intervention the patient was able to maintain dietary and fluid restrictions. 40 .Identify potential source of fluid: a. blood pressure. Increasing patient with the discomforts comfort promotes resulting from fluid compliance with restrictions. Fluid restrictions prescribed volume. 5. 3. Assist patient to cope 5. Objective:  edema Diagnosis Planning Nursing Intervention Independent: 1.Assessment Subjective: “namamanas ang paa ko” as verbalized by the patient. intake and output balance c. Rationale 1. 4.Assess fluid status: a. Assessments provide baseline and on-going database for monitoring changes and evaluating interventions. Unrecognized sources of excess fluid may be identified.

4.Assessment Subjective: “Wala akong ganang kumain simula ng nagka-sakit ako” as verbalized by the patient. Assess patient nutritional dietary patterns: a. Past and present dietary patterns are considered in planning meals.anorexia. diet history b. Assess nutritional status: a. Lack of understanding of dietary restrictions. 41 . b. Baseline data allow for monitoring of changes and evaluating effectiveness of intervention. Information about contributing to altered other factor that may nutritional intake: be altered or eliminated to promote a. imbalanced less than body requirement related to GI disturbances as evidenced by altered taste sensation. nausea and adequate dietary vomiting intake is provided. food preferences c. dietary restrictions. weight changes b. Increased dietary preferences within intake is encouraged. 3. diet history food preferences c. calorie count 2. After 4hours of nursing intervention the patient was able to follow the prescribed diet 2. Planning Nursing Intervention Independent: Rationale Evaluation GOAL MET: After 4 hours of nursing intervention the patient will be able to follow the prescribed diet 1. Objective: >gastrointestinal  anorexia Diagnosis Nutrition. Provide patient food 4. Assess for factors 3. calorie count 1.

Indicates factor contributing to fatigue: contributing to severity of fatigue. Encourage patient to 4. 4. Adequate rest is rest after dialysis encouraged after treatment. 1. Planning Nursing Intervention Independent: Rationale Evaluation GOAL MET: After 4 hours of nursing intervention the patient was able to demonstrate decrease in physiological signs of intolerance. 42 . tolerated.Assess factor 1. Promotes activity and exercise within limits and adequate rest. retention of waste products 2.Encourage alternating activity with rest 3. anemia b.Assessment Subjective: “nanghihina ako” as verbalized by the patient Objective: >inability to concentrate >weakness and fatigue >behavioral changes Diagnosis Activity intolerance related to fatigue. assist if fatigue. After 4 hours of nursing intervention the patient will demonstrate decrease in physiological signs of intolerance.Promote independence 2. a. anemia. Promotes improved in self-care activities as self-esteem. 3. dialysis treatments which are exhausting to many patients. retention of waste products and dialysis procedure. fluid and electrolyte imbalances c.

Reduces normal irritation and risk of skin breakdown. Monitor fluid intake and hydration of skin and mucous membranes. Detects presence of dehydration or over dehydration that affects circulation and tissue integrity at the cellular level. Inspect skin for changes in color. and vascularity. Indicates areas of poor circulation/ breakdown that may lead to decubitus formation/ infection. lotions. flaky skin  pruritis Diagnosis Impaired skin integrity related to accumulation of toxins n the skin as evidenced by pruritis.Investigate reports of itching 43 . Rationale Evaluation GOAL MET: 1. Although Dialysis has largely eliminated skin problems After 2 hours of nursing intervention the patient maintained intact skin 3. 2. and ointments may be desired to relieve dry crackle skin. 3.keep linen dry. 2.Assessment Subjective: “Ang kati ng balat ko” as verbalized by the patient Objective:  gray-bronze skin  dry. Note redness. restrict use of soaps. Planning After 2hours of nursing intervention the patient will maintain intact skin Nursing Intervention Independent: 1. excoriation. wrinkle free 5. 5.Provides soothing skin care. 4. Baking Soda and cornstarch bath decrease itching and are less drying than soaps. purpura. turgor. apply ointments or creams 4. Observe for ecchymosis.

moist compresses to apply pressure (rather than scratch). encourage use of gloves during sleep if needed. itching can occur because the skin is excretory route for waste product. 44 . Prevents direct dermal irritation and promotes evaporation of moisture on the skin. Suggest wearing loose filling cotton garments. 6. 7.associated with uremic frost. Recommend client use cool. Pruritic areas keep finger nails short. 7. 6. Alleviates discomfort and reduces risk of dermal injury.

dizziness. Nursing consideration >Always remember the ten rights of giving medication. fatigue. >Monitor patient’s blood pressure. hypoglycemia in non diabetic patients. acute unstable heart failure. Angina pectoris Contraindication >sinus bradycardia heart block other than first degrees cardiogenic shock. mental depression. precipitation of severe CHF. hypotension. diarrhea.XII. nausea. Drug name Generic name: Atenolol Drug Study Dosage Frequency 25 mg 1 tab OD Classification Antihypertensive Indication >Hyperten sion. Adverse Reactions >Bradycardia. >Monitor hemodialysis patient’s closely because of hypotension risk. Brand name: Therabloc 45 .

unresponsi ve CHF. tachycardia. >Monitor blood pressure frequently during initation of therapy. Anti-anginal/ Antihypertensive drugs >Reductio >Marked anemia n of Blood severe pressure hypotension. >Notify prescribed if signs of heart failure occurs such as swelling of hands and feet or shortness of breathing. nausea. Nursing consideration >Always remember the ten rights of giving medication. 46 . >monitor patient carefully. abdominal pain. hypotension. restlessness. unstable angina. dizziness.Drug name Generic name: Amlodipine Brand name: Norvasc Dosage Frequency 10 mg 1 tab OD Classification Indication Contraindication Adverse Reactions >Headache.

constipation .Drug name Generic name: Tazobactam Brand name: Vigocid Dosage Frequency Classification Indication Contraindication Adverse Reactions Nursing consideration Antibiotic 2. >Hypersensitivit y to penicillin. >Always remember the ten rights of giving medication. and super infection. allergic reactions. headache. vomiting. lower respiratory tract. >Diarrhea.25 g / IV TID >Treatment of systemic or local bacterial infection caused by sensitive organisms. rash. 47 . nausea. >Monitor if the patient experiencing diarrhea or fever.

>Always remember the ten rights of giving medication. anginal attacks. tachycardia. 48 . >mucolytic expectorant for excessive dry. excitability. >Coronary thrombosis.Drug name Mucobron Dosage Frequency 1 cap TID Classification Indication Contraindication Adverse Reactions Nursing consideration Anti-cough and cold remedies. >Sleep disturbances. >Give some idea to the patient for her not to remember her illness like watching television. and asthma. hypertension. hacking and useless coughing. raised blood pressure.

Nursing consideration >Always remember the ten rights of giving medication. edema. >Contraindication with patient hypersensitive to other thiazimides. 49 . >Monitor fluid intake and output. sinusitis. nausea. upper respiratory tract infection. >Monitor blood pressure. diarrhea.Drug name Dosage Frequency Classification Indication Contraindication Adverse Reactions >Fatigue and flu like symptoms of dizziness. Brand name: Pritor Plus GlaxoSmith Kline Generic name: Hydrochlorothiazide 80/125 mg 1 tab AntiHypertensive Treatment for hypertension.

10th edition by Smeltzer and Bare Medical Surgical Nursing by J. Kozier and Erb Brunner and Suddarth’s Medical-surgical nursing volume 2.com/eLibrary/Medicine/Physiology/Urinary/Urinary.htm 50 .web-books.B. Snyder. 8th edition by Berman. 6th edition by Doenges Nursing 2005 Drug Handbook Lippincott Williams and Wilkins PPD’s Nursing Drug Guide 2nd edition http://www.References:        Kozier and Erb’s Fundamentals of nursing volume 1. Lippincott Company Nursing Care Plans.

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