ESRD2

I.
Introduction Diagnosis is not the end, but the beginning of practice. ~Martin H. Fischer
End- stage renal disease (ESRD), also known as end-stage renal failure (ESRF), is defined as irreversible decline in kidney function, which is severe enough to be fatal in the absence of dialysis or transplantation. The main function of the kidneys is to remove wastes and excess water from the body. Generally, ESRD occurs when there is less than 10% of renal function remaining. Renal disease increases the complexity of preventive health care. The term 'preventive care' implies taking measures to avoid morbidity and mortality. In patients with kidney failure, preventive strategies frequently focus on the renal-disease-related issues of anemia, mineral metabolism, hypertension, and vascular access for dialysis. Addressing more-general health issues, such as vaccination, cancer screening, control of diabetes mellitus, and lipid management can be postponed in order to prioritize acute issues such as infection, bleeding, malnutrition, volume overload, vascular thrombosis and unstable blood pressure, all of which are common in patients with renal failure. The Quality of Life (QOL) subgroup addressed the burdens ESRD patients face in living with a grave, life-shortening chronic illness while also taking advantage of the life-sustaining technology of dialysis. Discordance lies at the heart of ESRD patients struggle for quality of life. On the one hand, dialysis creates hopeful expectations in them, their families, and their caregivers. On the other hand, at least initially, patients and families may not grasp that comorbidities and reduced life expectancy are a common aspect of ESRD. Clinicians may not have been candid about the life-limiting nature of the disease and accompanying co-morbid conditions. Even though youre in the end stage of life, theres still hope in attaining optimum level of health, because in our modern generation, nothing is impossible. Theres always hope in every stage were going through.
Previously, all patients with end-stage renal disease died, but to-day it is possible to maintain life by dialysis treatment or by transplanting a kidney from another human being. However, it is still a catastrophe for the patient and the patients family because there is a great shortage of kidneys for transplantation, and dialysis treatment is disabling. Two to three times a week the patient is chained to a dialysis machine for many hours and despite that the patient`s health is not optimal. A tedious diet and many drugs are necessary to combat the many complications of end-stage renal failure and the mortality is high. Every year 20-30 per cent of all dialysis patients die, but new patients constantly arrive. A. CURRENT TRENDS ABOUT END STAGE RENAL DISEASE In Chronic Kidney Disease, Ambulatory Blood Pressure Monitoring Seems More Accurate in Predicting Subsequent Health Events ScienceDaily (June 27, 2011) Ambulatory blood pressure (BP) monitoring with collection of BP readings over 24 hours may better predict, in cases of nondialysis chronic kidney disease (CKD), whether patients will experience end-stage renal disease, mortality or cardiovascular events that require hospitalization, according to a report in the June 27 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
An ambulatory blood pressure monitor (ABPM) is worn under a patient's clothing and automatically takes BP readings at repeated intervals of the day and night; this information is collected and brought to the physician's office for analysis. ABPM may help mitigate the possible effects of "white coat hypertension," in which a patient's BP artificially increases simply because of visiting a physician's office. According to background information in the article, this phenomenon is especially prevalent in CKD. Additional research suggests that nighttime BP, removed from physical, emotional and other stresses, may be a better measure of a patient's actual BP status and his or her risk for cardiovascular problems. Roberto Minutolo, M.D., Ph.D., from the Second University of Naples in Italy, and colleagues conducted a study of patients with CKD whose blood pressure was routinely monitored at four Italian nephrology clinics. They recruited 436 participants between 2003 and 2005. Researchers measured each patient's BP three times during a morning office visit, outfitted
him or her with an ABPM that took readings every 15 minutes during the day and every half hour at night, and obtained three more in-office BP readings the next day when patients returned. Participants also kept diaries of their activities, to help researchers interpret the results. During a median followup time of 4.2 years, 86 patients experienced end-stage renal disease and 69 died; researchers also recorded 63 cardiovascular events that were not fatal and 52 deaths related to cardiovascular problems. Risk of both renal and cardiovascular outcomes was highest in participants whose daytime systolic blood pressure (SBP) was 135 mm Hg (milligrams of mercury) or above. The same risk was found for participants in the highest quintile of diastolic blood pressure (DBP), or who had nighttime SBP readings of 124 mm HG or higher. Additionally, nighttime DBP of 70 mm Hg or higher was a predictor of cardiovascular events and end-stage renal disease. "In contrast," the authors note, "office BP measurement (either SBP or DBP) did not predict cardiovascular or renal events." The study suggests that ABPM may be a more useful tool than office BP measurements in assessing the risk that a patient with CKD will experience serious renal or cardiovascular events, and that its predictive value appears independent of other risk factors for these conditions. "Of interest, the lack of predictive value of office BP measurement, as well as office BP target level, raises concerns regarding the adequacy of recommendations of hypertension guidelines that are derived mainly from expert opinion and post hoc analyses rather than randomized trials." They conclude that "interventional studies based on ABPM rather than office BP measurement are urgently required in this high-risk population." Commentary: Taking Blood Pressure Monitoring Out of the Office For the 13 percent of the U.S. population who are believed to have CKD, keeping track of BP is crucial, according to a commentary accompanying the article. David Goldsmith, F.R.C.P, from King's Health Partners AHSC in London, England; and Adrian Covic, M.D., Ph.D., F.R.C.P.(Lond), F.A.S.N., from C.I. Parhon University Hospital in Iasi, Romania point out that declines in kidney function are known to increase cardiovascular risk, with BP being just one factor. "Patients with CKD die of cardiovascular disease as much as, or more often than, their disease progresses to requiring dialysis," they write. "The 'survivors' then reach dialysis, where again it is cardiovascular disease that primarily causes their demise."
The study by Minutolo and colleagues, therefore, expands the evidence in support of ABPM as an important tool for directing the care of patients with CKD. This is especially true, the authors write, given that the study demonstrated a white coat hypertension rate of 43.3 percent. While a prospective, randomized trial of ABPM as a basis for providing BP therapy for patients with CKD is needed, Goldsmith and Covic conclude, "We believe that there are selected cohorts of patients in whom the additional time, effort, and expense of doing ABPM is justified, and this new study by Minutolo and colleagues makes that case stronger for our patients with CKD. It is now harder to defend reliance on clinic BP measurement alone if we nephrologists are serious about targeted BP intervention.
B. REASONS IN CHOOSING THE STUDY
The group chose this case because it was interesting and they wanted to familiarized themselves on the different causative factors and treatment for the disease so that for them to become more efficient in rendering proper care and service to their patient. In addition, as student nurses and as part of the health care team in the future, they may equip themselves with the proper knowledge regarding the disease and its processes, enhance their skills with the proper management of the patient's condition and provide interventions to prevent from occurring or reoccur. The reason why we chose this kind of disease condition for case study is to be able to expand knowledge with regards to the patients condition. As student nurses, the journey of learning new things as explored the world of health care provider. By these case study, student nurses can use this as a guide to future researches that can be related it. Different nursing roles would be also applied while being exposed with the patient in various test and laboratory procedures. Lastly, this study by the group would serve as a future reference for upcoming studies with the same condition.
Objectives: The following are the objectives of this study: SHORT TERM (Client-Centered) After a day of nurse-patient interaction, the client or SO shall have: Established rapport and trust with the student nurses. Given full cooperation with the student nurses as they ask series of questions. Understood the purpose of acquiring related information about the patient and her condition; Complied with the comprehensive physical assessment done by the student nurses. Given the level of understanding that they have about the clients condition. Demonstrated interest and compliance during the course of nursing interaction.
(Patient-Centered) After a day of nurse-patient interaction, the student nurses shall have: Chosen a patient for their case study. Gained the trust and confidence of the patient/SO. Used therapeutic communication skills in interviewing the patient/SO. Familiarized the attitude of the patients family with regards to health. Obtained the personal and pertinent family health-illness history of the client and relate it to the present disease condition. Performed a comprehensive assessment of the patient. Identified predisposing and precipitating factors as to how the patient acquired the disease condition. Comprehensively analyzed and interpreted the different laboratory and diagnostic procedures in relation to the disease condition. Identified nursing problems while utilizing the subjective and objective cues of the patient.
LONG TERM (Client-Centered) After the completion of this case study, the client or SO shall have: Understood the disease process, its causes, and the treatment of the Chronic Renal Failure/ESRD. Identified the relationship of signs and symptoms of the disease to the present illnesses of the patient. Participated in the treatment regimen and complied with the nursing instructions given. Valued nursing care rendered for the improvement of health condition. Identified preventive and promotive factors related to the disease condition.
A. Nurse-Centered After the completion of this case study, the student nurses shall have: Gained knowledge and deeper understanding regarding the patients condition, disease process and treatment regimen. Identified needs, responses and problems based on the assessment gathered. Planned, set goals, and chosen appropriate interventions, which are essential to the construction of a plan of care as well as to deliver quality of nursing care. Formulated conclusions based on findings and enumerate recommendations concerned the management of CKD/ESRD; Evaluated effectiveness of nursing care and medical interventions rendered
II. NURSING ASSESSMENT A. Personal History
1. Demographic Data
Mr. Renal, a 46 year old male, Filipino citizen, married, was born via normal spontaneous delivery on May 07, 1966. He lives at Tabun, Angeles City. Hes the eldest in the six siblings. He was admitted last January 20, 2012 due to difficulty of breathing and his diagnosis is Chronic Kidney Disease. His family currently resides in Angeles City. According to his wife, he drinks alcohol 2 bottles a day, and smokes 1 pack a day.
2. Socio-Economic and Cultural Factors Mr. Renals family is categorized under the nuclear type of family consisting of 6 members. Living with them is their two youngest children. He is a Roman Catholic and was able to finish High School level. The house has 3 bedrooms, a living room, a dirty kitchen and a bathroom. The family has a monthly income of Php 7,500 plus and based from the NEDAs criteria that each family member should have at least Php 2768.60/month and this case each has Php 1875, therefore their family can be categorized as poor. Their poverty has lead to different factors such as poor sanitized environment, malnutrition, emotional and physical stress. Mr. Renals wife prepares and cooks food for the family. He buys food from the public market weekly. He is the one responsible for budgeting the familys expenses. Their family expenses include Php 300 for monthly water bills, Php 800 for electricity, and Php 6,000 for food. Their main source income provides by the wife who is working in the public market at Angeles City. In times of illness, the family consults at a herbularyo and manghihilot. Instead, they choose to look up to the help of physicians through government hospital
consultations. Moreover, the family also resorts to self-medication and use of over-the counter drugs.
B. Family Health History
C. History of Past Illness Mr. Renal had arthritis; he took NSAIDs without consulting a physician. Mr. Renal has stated that he has been hospitalized last November 2011 with the same diagnosis and was for dialysis, but due to lack of funds Mr. Renal was not able to avail dialysis.
D. History of Present Illness
First week of January 2012, he was hospitalized with the primary diagnosis of ESRD (End stage Renal disease) and after a week he was discharged. A day prior to the admission of Mr. Renal at Rafael Lazatin Memorial Hospital, he had been experiencing Difficulty of breathing. Mr. Renal and his wife and daughter decided to seek medical management and so he was admitted on January 20, 2012 at 2:30 am with an admitting diagnosis of End Stage Renal Disease. He was given medicines such as Furosemide, and Kalium Durule. E. Physical Assessment (First NPI) General Appearance: the patient is conscious and coherent. He appears apprehensive at first. The patient shows positive attitude despite on his condition. He has a heplock on his left hand. His wearing white shirt and blue shorts. Time Temperature Pulse Rate Respiratory Rate 8:00 AM Physical Examination 36.9 92 28 Blood Pressure 150/80
Head, Skull and Face: round skull, no nodules, no mass, symmetrical face and facial movements; no tenderness, with mustache and beard
Hair: with dandruff noted, hair evenly distributed, with oily hair, no lice, dark brown in color Nails: intact nails and with pale nail beds, with capillary refill time of less than 3 seconds, with dirty and long nails Skin: warm to touch, no cyanosis. No edema, no nodules, no mass; with surgical suture from herniorrhaphy, with bipedal edema grade II on both lower extremities Eyes: PERRLA, pale palpebral conjunctiva Ears: with cerumen, ears on the same level of the outer canthus of the eye, no tenderness, pinna recoils after being folded Nose: symmetrical to the face, no nasal discharge, no obstruction Mouth and Throat: with dental carries Neck: symmetrical, no edema, no nodules Chest and Lungs: (+) crackles on both lung fields Difficulty of breathing, increase respiratory rate of 28 cycles per minute Abdomen: non-tender, flabby Upper Extremities: symmetrical, with scars, can perform wide range of motion, no edema Lower Extremities: symmetrical, with scars, with bipedal edema grade II
CRANIAL NERVES ASSESSMENT
Cranial Nerve 1. Olfactory Type: Sensory Fxn: Sense of smell
Normal Findings Client must be able to identify the scent of alcohol when asked to smell it.
Actual Findings Mr. Renal was able to identify the scent of alcohol when asked to smell it.
2. Optic Type: Sensory Fxn: Sense of vision and visual fields
Client must see the ballpen or penlight distance. clearly at a given
Mr. Renal could see the ballpen at a given distance.
3. Oculomotor Type: Motor Fxn: Pupil constriction and raising of eyelid
Eyes must follow the direction of the movement of the penlight; In lightly dimmed environment, the pupils of the eyes will dilate but upon the introduction of light, pupils will constrict.
Mr. Renals eyes were able to follow the movement of the penlight, (+) PERRLA.
4. Trochlear Type: Motor
The
eye
must of a
follow ballpen
the in
Mr. Renal was able to move eyeball laterally and downward.
movement
Fxn: Downward inward eye movement
different coordination.
directions
with
5. Trigeminal Type: Sensory and Motor Fxn: Jaw movements, chewing and mastication
The client elicited blinking reflex upon touching the cornea with the use of cotton.
Mr. Renal elicited blinking reflex upon touching the cornea.
6. Abducens Type: Motor Fxn: Lateral movements of the eyes
Client must be able to follow the index finger of the examiner.
Mr. Renal was able to follow the index finger of the examiner.
7. Facial Type: Motor and Sensory Fxn: Movement of muscles of the face and sense of taste on the anterior twothirds of the tongue
Client must be able to raise eyebrows, show teeth and puff out cheeks.
Mr. Renal was able to raise eyebrows and show teeth.
8. Acoustic (Vestibulocochlear) Type: Sensory Fxn: Sense of hearing
Client must be able to hear a snap of the finger.
Mr. Renal was able to hear the snap of the finger.
9. Glossopharyngeal Type: Motor and Sensory Fxn: Pharyngeal movements and
Must be able to swallow foods that were chewed.
Mr. Rena has no difficulty on swallowing.
swallowing
10. Vagus Type: Motor and Sensory Fxn: Swallowing and speaking
Must be able to speak clearly.
Mr. Renal speaks clearly.
11. Accessory Type: Motor Fxn: Movement of shoulder muscles
The client must able to elevate his shoulders against resistance
Mr. Renal was able to slightly shrug his shoulders against
resistance on his right upper extremity.
12. Hypoglossal Type: Motor Fxn: Movement of tongue and strength of the tongue
The client must able to move his tongue side to side and protrude his tongue.
Mr. Renal was able to move his tongue side to side.
Diagnostic and Laboratory Procedures Diagnostic/ Laboratory Procedures Date ordered Date Result(s) in Indication(s) or Purpose (s) Results Normal Values Analysis and Interpretation of Results
Creatinine
Date Ordered: January 26 2012
This determines the renal function. The results of these tests are important in assessing excretory
291.55mmol/L
44.2-76.6mmol/L
The result is above the normal values, one of the function of the kidney is to excrete waste products of the body and it is compromised, the body is unable to remove waste products such as creatinine which is a product of protein metabolism, this
Date Results In: January 27, 2012
function of the kidneys especially in grading of chronic renal insufficiency.
then reabsorb and accumulates in the blood thats why there is an increased in creatinine levels of the patient.
Because the patient did not undergo dialysis, the waste products of the body Date Ordered: January 28, 2012 452.24 44.2-76.6mmol/L remain and continuously become abundant and accumulate in the blood. Date Results In: January 29, 2012
Blood Urea Nitrogen
Date Ordered: January 28, 2012
Blood urea nitrogen (BUN) measures the
20.7
2.1-7
Diseased or damaged kidneys
amount of urea Date Results In: January 29, 2012 nitrogen, a waste product of protein metabolism, in the blood. Urea is formed by the liver and carried by the blood to the kidneys for excretion. Because urea is cleared from the bloodstream by the kidneys, a test measuring how much urea nitrogen remains in the blood can be used as a test of renal function.
cause an elevated BUN because the kidneys are less able to clear urea from the bloodstream.
Nursing Responsibilities:
Before: Confirm the patients identity by asking the name or look at the identity bracelet. Gather all the necessary material or equipment that is to be use. Explain to the patients SO that the serum creatinine test is used to evaluate kidney function. Inform the patients SO that this requires blood sample. Explain to the patient that he may experience slight discomfort from the tourniquet and the needle puncture. Instruct the patients SO that he doesnt need to restrict food and fluids. Assure to patients SO that collecting the blood sample take less than 3 minutes.
During: Maintain sterile technique while doing/performing the test. Handle the patient gently. Collect 5-7 mL venous blood.
After: Apply pressure to the venipuncture site. Check the venipuncture site for bleeding. Handle the sample gently to prevent hemolysis. Fill-up the laboratory form properly. Send the sample to the laboratory immediately.
Diagnostic/ Laboratory Procedures
Date ordered Date Result(s) in
Indication(s) or Purpose (s)
Results
Normal Values
Analysis and Interpretation of Results
Hemoglobin
Hemoglobin is the circulating iron containing pigment, which carries oxygen
87 gm/L
110-180 gm/L
Because of the impairment of the kidneys of the patient, there is a decreased production of erythropoietin, erythropoietin is the one which stimulates the red bone marrow to produce erythrocytes, a decrease in erythrocytes contributes to the low hemoglobin of
from the lungs to the tissues. It is a measurement of how earth feeds metal. Hemoglobins ability to transport oxygen depends upon pH and the presence of ferrous iron. Haemoglobin is the most
abundant protein found within the red blood cell. Haemoglobin level measures the amount of intracellular iron. Date Ordered: January 28, 2012 Haemoglobin is synthesized in most bodily tissues but the liver is the largest heme Date Results In: January 29, 2012 producing organ. (The muscles being fed by iron as well as glucose liver). In the bone marrow heme is transformed into haemoglobin. 77 gm/L 110-180 gm/L
the patient.
The patient`s hemoglobin level is below normal, this leads to easy fatigability and DOB of the patient.
The patient`s hemoglobin level is still decreased because the kidneys cannot produced more erythropoetin and also because of low dose of epoetin given to
the patient.
Hematocrit
Hematocrit represents the packed cell volume of red blood cells. It is
0.26
0.37-00.47
Kidney affectation leads to a loss of excretory function; fluid shifting occurs from intracellular spaces going to extracellular and interstitial spaces which leads to fluid retention. The patient`s hematocrit level is below the normal values,
the percentage of the total volume occupied by packed red blood cells when a given volume of whole blood is centrifuged at a constant speed for a constant period
of time. HCT is one of the most precise ways of measuring the degree of anemia. Hematocrit combined with serum iron and hemoglobin is a diagnostic tool for determining iron Date Ordered: January 28, 2012 excess or deficiency. 0.23 0.37-00.47
hemodilution occurs due to fluid retention in his body which is manifested by edema in the face and extremities as well as weight gain. This is also due to the anemia experience by the patient.
The hematocrit level is still low Date Results In: January 29, 2012 because of affectation of the kidneys, fluid shifting still occurs Date Ordered: 0.30 0.37-00.47 and edema is
February 3, 2012
evident.
Date Results In: February 4, 2012
The patient`s hematocrit level is still low as evidenced by anemia.
Nursing Responsibilities: Before: Explain the procedure to the patient and use the results in planning care. Instruct the patient what to expect (especially pain/ discomfort). Inform the patient that he/he need not to restrict food or fluids. Ask the patient to relax and dont move while doing the procedure.
During: Provide antiseptic technique. Provide comfort measures. Assist patient in comfortable position. Assist the medical technologist whenever necessary.
After: Ensure subdermal bleeding has stopped before removing the pressure. If a hematoma develops at the venipuncture site, apply warm compress. If the hematoma is large, monitor pulse distal to the venipuncture site. Send the sample to the laboratory. Notify the physician or the laboratory of medications the patient is taking that might affect the results; they may need to be restricted. Document the procedure and findings
Results
Normal Values
RBC
It is the measure of erythrocytes, a cellular component of blood involve in the transportation of
3.03/mcl
4.2 to 5.4/mcL
The result is below the normal level which indicates that there is decrease oxygenation in the blood that is caused by decrease erythropoietin production of the kidney.
oxygen and carbon dioxide.
3.5/mcl
4.2 to 5.4/mcL The result is below the normal level which indicates
that there is decrease
oxygenation in the blood.
White Blood Cells
The measurement of the total and differential WBC count is part of all routine laboratory diagnostic
25.2 X 109/L
5-10 X 109/L
The
amount
of
WBC is above the normal because presence infection lungs. in of range the of the
evaluation. It is especially helpful in the evaluation of the patient with infection, neoplasm, allergy or immunosuppression. 12.3 X 109/L 5-10 X 109/L
The amount of WBC is decrease
which means that the body responsed to the medication given to the Date Ordered: January 29, 2012 patient.
Segmenters
This is done to determine the capability of the body to destroy cells
0.79
0.52-0.70
Neutrophils increased
are which
indicates presence of infection. bacterial
Date Results In: October 20, 2011
that are infected with the virus or other infectious organisms.
Lymphocytes
Date Ordered:
Lymphocyte
0.21
0.20-0.40
The amounts of
January19, 2012
determines the presence of
lymphocytes are within the normal range.
immunologic disorder. It Indicates the amount of lymphocytes participating with macrophages at a site of local injury.
Nursing Responsibilities: Before: Explain the procedure to the patient and use the results in planning care. Instruct the patient what to expect (especially pain/ discomfort). Inform the patient that he/he need not to restrict food or fluids. Ask the patient to relax and dont move while doing the procedure.
After: Ensure subdermal bleeding has stopped before removing the pressure. If a hematoma develops at the venipuncture site, apply warm compress. If the hematoma is large, monitor pulse distal to the venipuncture site. Send the sample to the laboratory. Notify the physician or the laboratory of medications the patient is taking that might affect the results; they may need to be restricted. Document the procedure and findings.
Results
Normal Values
Sodium
The Sodium test is used to measure serum levels of sodium in relation to the amount of water in the body. It is used to
129.5mmol/L
135-145mmol/L
The result of the test was decrease which means that the patient is having hyponatremia which is caused by excess fluid shifting to extracellular and interstitial spaces causing dilutional
evaluate fluidelectrolyte and acid-base balances a renal and adrenal functions. 132.7 135-145mmol/L
hyponatremia.
Date Ordered: January 31, 2012 Fluid shifting is still present that
caused dilutional hyponatremia of the patient. Date Results In: February 1, 2012
Potassium
Potassium helps to maintain cellular osmotic equilibrium and to regulate muscle activity, enzyme
3.48mmol/L
3.5-5.0mmol/L
The result is within the normal level.
activity and acid balance. It is also influences renal function. Its purpose is to evaluate clinical
signs of potassium excess
5.7
3.5-5.0mmol/L
Because of the damage of the
(hyperkalemia) or potassium depletion Date Results In: February 1, 2012 (hypokalemia). It is also use to monitor renal function, acid-base balance and glucose metabolism. It is also use to evaluate neuromuscular and endocrine disorders. To detect the origin of arrhythmias.
nephrons, there is a decrease GFR permeability that leads to impairment of the tubules to excrete potassium, potassium then accumulates in the blood that cause hyperkalemia.
Nursing Responsibilities:
Before: Explain the procedure to the patient and use the results in planning care. Instruct the patient what to expect (especially pain/ discomfort). Inform the patient that he/he need not to restrict food or fluids. Ask the patient to relax and dont move while doing the procedure.
After: Ensure subdermal bleeding has stopped before removing the pressure. If a hematoma develops at the venipuncture site, apply warm compress. If the hematoma is large, monitor pulse distal to the venipuncture site. Send the sample to the laboratory. Notify the physician or the laboratory of medications the patient is taking that might affect the results; they may need to be restricted. Document the procedure and findings.
Analysis and Results Normal Values Interpretation of Results
Chest X-ray
Date ordered: January 25, 2012
This is done to evaluate the organs and structures in the
There are diffuse alveolo interstitial densities seen in
The lungs on a chest X-ray film should be clear and
Due to the decreased oxygen supply to the lungs,
Date performed: January 26, 2012
chest of the client to both lungs; heart is note for presence or accumulation of secretions in the lungs that may aggravate the patients condition. Impression: Pulmonary congestion and/or edema; cardiomegaly,cannot rule out pleural effusuin,left enlarged. Left hemi: diaphragm and sulcus are obscured.
no visible secretions it became a good on the lungs. The lung fields should be clean in an x-ray film. medium for invading microorganism growth, thus, as a compensatory mechanism; the body releases chemical mediators that cause vasodilation and further resulting to fluid accumulation in the lungs. There
is also bacterial infection present that`s why there is an increase WBC of the patient.
NURSING RESPONSIBILITIES: Chest X-ray Assess if the patient is pregnant Instruct patient to remove all clothes Assist patient in wearing the gown Remove all materials that might interfere with the exam example is jewelry. Ensure comfortable position for the patient.
Analysis and Results Normal Values Interpretation of Results
Kidney, urether and bladder ultrasound
Date ordered: January 29, 2012
To determine the size, shape and position of the
Both kidneys are small in size with thinning of the cortex and increased cortical echogenecity. The right kidney measures 6.5 cm x 42 cm x 3.2 cm with cortical thickness of 0.84 cm while the left kidney measures 5.93 cm x 3.86 cm x 3.7 cm with cortical thickness of 0.84 cm.
The kidneys are between the super iliac crest and diaphragm. The renal capsules are outlined, sharply the cortex produce more echo than the medulla.
Due to the nephrotoxic medication he took, there is a decrease renal perfusion that leads to chronic kidney disease of the patient.
Date performed: January 30, 2012
kidneys, their internal structures and perirrenal tissues.
A mass was noted on the right kidney. Both pelvocalyces are not dilated. No lithiasis was seen.
Nursing Responsibilities: Prior: Introduce yourself. Note and report all allergies. Explain the procedure to the patient. Instruct the patient not to eat and drink 8 hours before the ultrasound.
During: Assist patient in supine position. Water soluble gel is placed on abdomen tip to allow better sound transmission.
After: Help the patient remove any residual gel.
Anatomy and Physiology
The Urinary System is a major system in the human body. The body first takes nutrients from what we eat and it serves by giving energy and for self repair. After the foods are metabolized, the Urinary system works by excreting body waste to keep the chemicals and water in our body balanced. An individual normally excretes 1 to 2 liters of urine each day. The urinary system removes a type of waste called urea from your blood. Urea is produced when foods containing protein, such as meat, poultry, and certain vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys.
The Urinary system functions by:

a. Regulating the blood volume - The kidneys conserve or eliminate water from the
blood, which regulates the volume of blood in the body.

b. Regulating the Blood pressure The kidneys regulate the Blood pressure by
adjusting the volume of blood in the body, adjusting the flow of blood into and out of the kidney and by the action of the Enzyme Renin.
c. Regulation of Ph The kidneys excrete H ions into urine at the same time, the
kidneys conserve bicarbonate ions which are important buffers of H*.

d. Regulation of the ionic composition of blood e. Production of Red blood cell - by the hormone erythropoietin f.
Rm Synthesis of Vitamin D the kidneys synthesizes Calcitrol which is an active form of Vitamin D.
g. Excretion of waste products and foreign substance by the production of Urine
PARTS OF THE URINARYSYSTEM: a. Kidneys The kidneys are two brownish bean shaped organ about the size of the fist. They are placed below the ribs in the upper right and left back part of the abdominal cavity. The right kidney is usually a little lower than the left due to slight displacement because of the liver. The upper portions of the kidneys rest on the lower surface of the diaphragm and are enclosed and protected by the lower margins of the rib cage. The left kidney is slightly longer than the right and is closer to the midline. The kidneys assume slightly different positions with changes in body positions. They Remove liquid waste from the blood in the form of urine and balances the salts and other substances in the blood. They also produce erythropoietin; a glycoprotein which is a hormone produced by the kidney that promotes the formation of red blood cells in the bone marrow. The kidneys eliminate urea in the blood through nephrons which are functional unit of the kidneys responsible for the actual purification and filtration of the blood. Each nephron
are about 1.2 million and are consist of blood capillaries called Glomerulus and a small tube called Renal tubule, the urine passes through the nephrons and renal tubules during elimination. The Kidney is divided into: Inner Medulla The Medulla is the Inner part of the kidney. It is where the amount of salt and water in the urine is controlled. It is also where biliions loop of henle can be found. This works by pumping sodium ions very hard and the ADH hormone makes the loop work which results concentrated urine. Outer Cortex The cortex is the outermost part of the kidney where the blood is filtered. Billions of Glomeruli are found in the cortex and each glomerulus is surrounded by the Bowmans capsule. b. Ureters Ureters are narrow tubes that carry urine to the bladder. They usually have a length of 10 to 12 inches. The ureters consist of mucous, muscular and outside connective tissue covers. The muscular coat has circular and longitudinal layers. The ureters, which are muscular tubules, carry urine from the renal pelvis of the kidney to the Urinary bladder. Urine drains through the ureters to the urinary bladder by gravity, but the smooth muscular walls of the ureters also help impel urine along. They compress in a series of wavelike contractions (peristalsis) that move the urine through the ureters in only one direction. When urine has entered the urinary bladder, it is prevented from flowing back into the ureters by small, valvelike folds of membrane that flap over the ureter openings. It functions by transporting the urine to the urinary bladder. c. Urinary Bladder
The Urinary bladder is a hollow, muscular sac that stores the urine temporarily. It is located in the pelvis behind the pelvic bones in the lower abdomen. It is about 2 to 3 inches in length and can collect up to 1-2 litersof urine. The linings of the Urinary bladder are the mucous membrane (inner lining), Connective tissue (middle layer) and the muscle tissue (outer layer). There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder the two of the openings are from the ureters and form the base of the trigone. 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. The third opening, at the apex of the trigone, is the opening into the urethra. d. Urethra The Urethra is a tube that functions by allowing the urine to pass outside the body. It is a thin walled tube that carries urine from the Urinary bladder going outside the body. It usually has a length of 1 to 1.5 inches in women and 6 to 8 inches in males. The brain signals the bladder to tighten the bladder which squeezes it outside. Also, the brain also signals the sphincter muscles to relax to let the urine pass out the body. Urination occurs then. e. Glomerulus The glomerulus is the main filter of the nephron, It is a knot of extremely tiny blood vessels located within the Bowman's capsule. The glomerulus is semipermeable which allows water and soluble wastes to pass through and be excreted out of the Bowman's capsule as urine. The filtered blood passes out of the glomerulus into the efferent arteriole to be returned through the medullary plexus to the intralobular vein. f. Nephron The nephron is the functional unit of the kidney which is responsible for the actual purification and filtration of the blood. About one million nephrons are in the cortex of each kidney, and each one consists of a renal corpuscle and a renal tubule which carry out the functions of the nephron. The renal tubule consists of the convoluted tubule and the loop of Henle.. The nephron is part of the homeostatic mechanism of your body. This system helps
regulate the amount of water, salts, glucose, urea and other minerals in your body. The nephron is a filtration system located in your kidney that is responsible for the reabsorption of water, salts. This is where glucose eventually is absorbed in your body. The Nephron is consists of: Renal Corpuscle The Renal corpuscle is the basic filtration structure of the kidney. Urine is produced in two well-defined regions of the kidneys, the renal cortex and the renal medulla. Within these structures lie the renal corpuscles and excretory tubules, together known as nephrons. By regulating blood concentration of water and salts, the renal corpuscle maintains blood chemistry at desirable levels. Bowmans Capsule Bowmans Capsule Is the Enlarged end of a nephron that sorrounds the Glomerulus. A cupshaped structure and It a part of the filtration system in the kidneys. When blood reaches the kidneys for filtration, it passes the Bowman's capsule first, with the capsule separating the blood into two components: a cleaned blood product and a filtrate which is moved through the nephron. As the filtrate travels along the nephron, additional impurities are removed, and the filtrate is concentrated into urine for the purpose of expelling waste products and excess water. Proximal Convuluted Tubule The section of a nephron situated between Bowman's capsule and the loop of Henle in the vertebrate kidney. Reabsorption of salt, water, and glucose from the glomerular filtrate occurs in this tubule; at the same time certain substances, including uric acid and drug metabolites, are actively transferred from the blood capillaries into the tubule. Both activities are facilitated by finger-like projections (see brush border) on the inner surface of the tubule, which increase its effective surface area.
Loop Of Henle The loop of Henle is a part of a nephron. It is a tiny tube located inside the kidneys which filters solutes. Each kidney contains thousands individual nephrons which pass between the cortex of the kidneys and the medulla, connecting to collecting ducts which route urine to the ureter so that it can be expressed. The loop of Henle is an important part of the whole system, as it allows the kidneys to filter out salt and maintain the correct balance of water in the body. Distal Convuluted Tubule The distal convoluted tubule is the most distal portion of the nephron and is responsible for the reabsorption of sodium, water and secretion of hydrogen potassium.The distal convoluted tubule (DCT) is a portion of kidney nephron between the loop of Henle and the collecting duct system. Collecting duct system system begins in the renal cortex and extends deep into the medulla. As the urine travels down the collecting duct system, it passes by the medullary interstitium which has a high sodium concentration as a result of the loop of Henle's countercurrent multiplier system. Though the collecting duct is normally impermeable to water, it becomes permeable in the presence of antidiuretic hormone (ADH). As much as three-fourths of the water from urine can be reabsorbed as it leaves the collecting duct by osmosis. Thus the levels of ADH determine whether urine will be concentrated or dilute. Dehydration results in an increase in ADH, while water sufficiency results in low ADH allowing for diluted urine. Lower portions of the collecting duct are also permeable to urea, allowing some of it to enter the medulla of the kidney, thus maintaining its high ion concentration. g. Renal Vein Renal veins are blood vessels that carry deoxygenated blood out of the kidney to the inferior vena cava. Renal veins lie or are located anterior to the corresponding renal arteries and join with the inferior vena cava at close to ninety degree angles. The inferior vena cava is a major vein that carries blood to the right atrium, where the blood is sent off to become reoxygenated.
h. Pelvis: This is where or the location where the urine collects, it is a cavity at the innermost area of a kidney that connects to the ureter. URINE PRODUCTION: There are three major processes for the production of Urine, this consists of:
A. Filtration Filtration is the movement of small solutes and water across the filtration membraneas a result of pressure difference. The amount of Filtrate produced is called Glomerular Filtration rate (GFR) which is 125 ml/min or about 180 L/ day. Approximateky 99% of filtrate is reabsorbed and less than 1% becomes urine. B. Tubular Secretion Is the process of addition of solutes across the walls of the nephron into the filtrate. Maintaining Water-Salt Balance The kidneys also functions to maintain the water-salt balance in the blood as well as the blood pressure and blood volume. Alteration of Water Salt balance includes dehydration, blood loss, ingestions of too much water and salt. Direct control of water excretion in the kidneys is exercised by the anti-diuretic hormone (ADH) which is released by the pituitary gland. Atrial natriuretic hormone (ANH) is released by the atria of the heart when cardiac cells are stretched due to increased blood volume. it inhibits the secretion of renin by the juxtaglomerular apparatus and the secretion of the aldosterone by the adrenal cortex which promotes the excretion of sodium. sodium is excreted so is water hence, this causes blood pressure and volume to decrease.
ANTIDIURETIC HORMONE (ADH) Antidiuretic hormone is a hormone secreted by the anterior pituitary gland and increass water permeability in the distal convuluted tubules. Antidiuretic hormone regulated blood osmolality by altering water reabsorption. An increase in blood osmolality or a decrease in blood pressure stimuates increased antidiuretic hormone secretion that increase water reabsorption which results into decrease blood osmolality,increased blood volume and blood pressure, increased urine concentration and decrease urine volume. On the other hand,
Decrease blood osmolality of Increase blood pressure stimulates Amtidiuretic hormone secretion which decreases water reabsorption which results into increase blood osmolality, decreased blood volume and blood pressure, decreased urine concentration and increased urine volume RENIN-ANGIOTENSIN-ALDOSTERONE Renin is a enzyme secreted by the granular cells in the juxtaglomerular apparatus. It enters the circulation and acts on a protein in the liver called Angiotensinogen. Renin functions to remove amino acids from the angiotensinogen for the production of Angiotensin I. Angiotension Converting Enzyme (ACE) functions to conver angiotensin I to produce Angiotensin II which stimulates the secretion of aldosterone which is a steroid hormone secreted by the adrenal glands. Aldosterone passes te circulatory system from the adrenal Glands going to the distal convuluted tubule and collecting ducts where it duffusese into plasma membranes and binds to intracellular receptors, the binding of Aldosterone and Intracellular receptors increases the synthesis of transport proteins which increase the movement of Na+ across the apical and basal membranes of the nephron cells which results into the rate of Na+ and Cl- transport out of the filtrate back into the blood increases. Na+ regulates the water content of the body. This mechanism regulates blood volume by controlling the total Na+ content of our body. Increase amount of aldosterone promotes Na+ reabsorption and Cl follows the Na+. As Na+ and Cl reabsorbed, water follows by osmosis while ADH maintains blood osmolality, Increased Na + reabsorption increase water reabsorption and blood volume without changing the osmolality of the blood, also Decreased aldosterone decreases blood reabsorption and volume.
IV. THE PATIENT AND HIS ILLNESS A.1. Pathophysiology (Book-Centered)
A.2. SYNTHESIS OF THE DISEASE (Book-Centered)
B.1. Definition of the disease
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to be at risk of kidney problems, such as those with high blood pressure or diabetes and those with a blood relative with chronic kidney disease. Chronic kidney disease may also be identified when it leads to one of its recognized complications, such as cardiovascular disease, anemia or pericarditis.
Stages All individuals with a glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. The rationale for including these individuals is that reduction in kidney function to this level or lower represents loss of half or more of the adult level of normal kidney function, which may be associated with a number of complications. All individuals with kidney damage are classified as having chronic kidney disease, irrespective of the level of GFR. The rationale for including individuals with GFR > 60 mL/min/1.73 m2is that GFR may be sustained at normal or increased levels despite substantial kidney damage and that patients with kidney damage are at increased risk of the two major outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular disease. The loss of protein in the urine is regarded as an independent marker for worsening of renal function and cardiovascular disease. Hence, British guidelines append the letter "P" to the stage of chronic kidney disease if there is significant protein loss.
Stage 1 Slightly diminihed function; kidney damage with normal or relatively high GFR (90 mL/min/1.73 m2); Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies. Stage 2 Mild reduction in GFR (6089 mL/min/1.73 m2) with kidney damage; Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine test or imaging studies. Stage 3 Moderate reduction in GFR (3059 mL/min/1.73 m2); British guidelines distinguish between stage 3A (GFR 4559) and stage 3B (GFR 3044) for purposes of screening and referral. Stage 4 Severe reduction in GFR (1529 mL/min/1.73 m2) Preparation for renal replacement therapy Stage 5 Establihed kidney failure (GFR <15 mL/min/1.73 m2, permanent renal replacement therapy (RRT), or end stage renal disease (ESRD) A.2.2. Modifiable and Non-Modifiable Factors MODIFIABLE FACTORS Diabetes Diabetes mellitus is a chronic disease of absolute or relative insulin deficiency or resistance characterized by disturbances in carbohydrate, protein, and fat metabolism. High levels of blood sugar make the kidneys filter too much blood. In time, the stress of overwork causes the kidneys to lose their filtering ability. Waste products then start to build up in the blood. This causes the kidney function to deteriorate possibly contributing to CKD.
Hypertension - High blood pressure is one of the leading causes of CKD. Over time, high blood pressure can damage blood vessels throughout your body. This can reduce the blood supply to important organs like the kidneys. High blood pressure also damages the tiny filtering units in your kidneys. As a result, the kidneys may stop removing wastes and extra fluid from the blood. The extra fluid in the blood vessels may build up and raise blood pressure even more.
Kidney stones - In most cases, kidney stones are formed when there is too little fluid, an overabundance of crystal-forming minerals in the urine, and/or lower-than-normal levels of the chemicals that breakdown these minerals in the urine. Renal stones that are left in the body for periods of time can affect the flow of urine through the kidneys. In certain types of kidney stones, the jagged edges may damage small vessels in the kidney as it passes causing scarring. The scarred area may then cause impairment of the kidney function.
Lower urinary tract scarring/blockage - Scarring from infections or a malformed lower urinary tract system (birth defect) can force urine to back up into the kidney and damage it. Blood clots or plaques of cholesterol that block the kidney's blood vessels can reduce blood flow to the kidney and cause damage.
Drug abuse - Use of certain nonprescription drugs, such as heroin or cocaine, can damage the kidneys, and may lead to kidney failure and the need for dialysis.
Overuse of painkillers and allergic reactions to antibiotics - Heavy use of painkillers containing ibuprofen, naproxen, or acetaminophen have been linked to interstitial nephritis, a kidney inflammation that can lead to kidney disease. Allergic reactions or side effects of antibiotics like penicillin and vancomycin may also cause kidney damage.
Glomerulonephritis Glomerulonephritis is the condition which is characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the glomerular filtration rate (GFR) and retention of uremic toxins. If
disease progression is not halted with therapy, the net result is chronic kidney disease (CKD).
NON-MODIFIABLE FACTORS Age: >65yrs. - Chronic kidney disease is extremely common in older people. In those aged over 75 years, CKD is present in 1 out of 2 people. However, many of the elderly people with CKD may not have diseased kidneys, but have normal ageing of their kidneys. Although severe kidney failure will not occur with normal ageing of the kidneys, old age predisposes the client to various diseases which may be risks factors for developing CKD. These include high blood pressure, heart diseases, or diabetes mellitus.
Premature birth - About one in five very premature infants (less than 32 weeks gestation) may have calcium deposits in parts of the kidney called nephrons. This is termed as nephrocalcinosis. Sometimes, individuals with this condition may go on to develop kidney problems later in life.
Family history of kidney diseases - Some kidney diseases result from hereditary factors. Polycystic kidney disease (PKD), for example, is a genetic disorder in which many cysts grow in the kidneys. PKD cysts can slowly replace much of the mass of the kidneys, reducing kidney function and leading to kidney failure.
Family history of hypertension - It is generally accepted that genetics contribute to hypertension, which predisposes the risk for developing kidney diseases if not treated properly.
Diseases: SLE, sickle cell anemia, cancer, AIDS, Hepatitis C, and CHF Having these certain diseases put the client at higher risk for kidney disease.
A.2.3. Signs and Symptoms Proteinuria Proteinuria, also called albuminuria or urine albumin, is a condition in which urine contains an abnormal amount of protein. Proteins are too big to pass through the kidneys' filters into the urine. However, proteins from the blood can leak into the urine when the filters of the kidney, called glomeruli, are damaged.
Edema - Edema is the medical term for swelling caused by a collection of fluid in the small spaces that surround the body tissues and organs. Edema occurs from the low levels of albumin reserves in the body. This causes decrease of oncotic pressure disabling reabsorption of fluids back into the intravascular spaces. Fluids then would accumulate in the interstitial spaces giving rise to edema.
Metabolic acidosis CKD causes tubular function damage which disrupts the acid-base balance of a client. There is impairment in the elimination of hydrogen ions in the body which leads to the accumulation of H+ ions causing metabolic acidosis.
Hyperkalemia, hyperphosphatemia, hypocalcemia CKD patients also experience electrolyte imbalances. The kidney is unable to eliminate potassium and phosphorus ions in the body leading to an abnormally increased level of these ions in the blood. Hyperphosphatemia, in turn, has a reciprocal effect on the calcium level as this causes elimination of calcium giving rise to hypocalcemia.
Increased BP Diseased kidneys are less able to help regulate blood pressure. A high blood pressure arises from the activation of Angiotensin II from the RAAS system as a compensatory mechanism of the body to intravascular pressure changes of the body. Angiontensin II is a potent vasoconstrictor which causes narrowing of the blood vessels resulting to hypertension.
Fluid overload Another reason for the existence of the accumulation of fluids came from the activation of the RAAS system. Angiotensin II, which is a potent vasoconstrictor, stimulates the adrenal cortex to release aldosterone. Aldosterone is a
hormone that increases the reabsorption of sodium ions and water in the collecting ducts and distal convoluted tubule of the kidneys' functional unit, the nephron. Thus, fluid accumulates as water is reabsorbed.
Increased BUN - Urea nitrogen is a normal waste product in the blood that comes from the breakdown of protein from ones diet and ones body metabolism. It is normally removed from the blood by the kidneys. However, when kidney function slows down, the BUN level rises.
Increased creatinine - Creatinine is a waste product in the blood that comes from muscle activity. It is normally removed from the blood by the kidneys. However, when kidney function slows down, the creatinine level also rises due to failure to eliminate it.
Gouty arthritis - Uric acid is a chemical created when the body breaks down substances called purines. Purines may be found in the diet such as liver, anchovies, mackerel, dried beans and peas, beer, and wine. Most uric acid dissolves in blood and travels to the kidneys, where it passes out in urine. Failure to eliminate uric acid results to hyperuricemia. Uric acid may then be deposited in the bodys joints/soft tissues causing gouty arthritis.
Decreased hemoglobin and hematocrit The kidney plays an important role in the production of a hormone called erythropoietin. Erythropoietin is responsible for regulating red blood cells production through stimulating the red bone marrows to produce them. A decrease in this hormone because of loss of kidney function results to decrease in RBCs of the body which in turn, leads to a decrease in hemoglobin and hematocrit concentration of the blood.
B.1. Definition of the disease
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite.
All individuals with a glomerular filtration rate (GFR) <60 mL/min/1.73 m2 for 3 months are classified as having chronic kidney disease, irrespective of the presence or absence of kidney damage. The rationale for including these individuals is that reduction in kidney function to this level or lower represents loss of half or more of the adult level of normal kidney function, which may be associated with a number of complications. All individuals with kidney damage are classified as having chronic kidney disease, irrespective of the level of GFR. The rationale for including individuals with GFR > 60 mL/min/1.73 m2is that GFR may be sustained at normal or increased levels despite substantial kidney damage and that patients with kidney damage are at increased risk of the two major outcomes of chronic kidney disease: loss of kidney function and development of cardiovascular disease. The loss of protein in the urine is regarded as an independent marker for worsening of renal function and cardiovascular disease. Hence, British guidelines append the letter "P" to the stage of chronic kidney disease if there is significant protein loss. Stage 5 Establihed kidney failure (GFR <15 mL/min/1.73 m2, permanent renal replacement therapy (RRT), or end stage renal disease (ESRD) B.2. Predisposing/ precipitating factors Drug abuse The client uses nonprescription drugs such as NSAID to manage his Arthritis that can damage the kidneys, and may lead to kidney failure and the need for dialysis. A.2.3. Signs and Symptoms Metabolic acidosis CKD causes tubular function damage which disrupts the acid-base balance of a client. There is impairment in the elimination of hydrogen ions in the body which leads to the accumulation of H+ ions causing metabolic acidosis.
(Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis. It is a form of hyperventilation, which is any breathing pattern that reduces
carbon dioxide in the blood due to increased rate or depth of respiration. Kussmaul breathing is characterized as labored, deep breathing.) Hyperkalemia, hyperphosphatemia, hypocalcemia CKD patients also experience electrolyte imbalances. The kidney is unable to eliminate potassium and phosphorus ions in the body leading to an abnormally increased level of these ions in the blood. Hyperphosphatemia, in turn, has a reciprocal effect on the calcium level as this causes elimination of calcium giving rise to hypocalcemia. Increased BP Diseased kidneys are less able to help regulate blood pressure. A high blood pressure arises from the activation of Angiotensin II from the RAAS system as a compensatory mechanism of the body to intravascular pressure changes of the body. Angiontensin II is a potent vasoconstrictor which causes narrowing of the blood vessels resulting to hypertension.
Increased BUN - Urea nitrogen is a normal waste product in the blood that comes from the breakdown of protein from ones diet and ones body metabolism. It is normally removed from the blood by the kidneys. However, when kidney function slows down, the BUN level rises.
Increased creatinine - Creatinine is a waste product in the blood that comes from muscle activity. It is normally removed from the blood by the kidneys. However, when kidney function slows down, the creatinine level also rises due to failure to eliminate it.
Decreased hemoglobin and hematocrit The kidney plays an important role in the production of a hormone called erythropoietin. Erythropoietin is responsible for regulating red blood cells production through stimulating the red bone marrows to produce them. A decrease in this hormone because of loss of kidney function results to decrease in RBCs of the body which in turn, leads to a decrease in hemoglobin and hematocrit concentration of the blood.\
Medical Management Indication or Purpose Clients response to treatment
Medical Management
Date 1/20/12-1/21/12
General Description
Heplock
A small tube connected to a catheter in a vein in the arm for easy access.
Heplock was given to the patient to prevent fluid and electrolyte imbalance and for easy access to administer drugs The patient was able to comply with all of his medication regimens.
III. THE PATIENT AND HIS CARE A. MEDICAL MANAGEMENT a. IVF, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy Heplock Before: Check the patients name and doctors order before administration. Explain to the patient the indication of heplock as well as the procedure. Prepare all the materials needed for heplock insertion Wash hands. Clean the insertion site.
During: After: Always check the site if it is intact and in place. Document Put the tourniquet to the patient wrist Choose the best vein Put on clean gloves and clean the venipuncture site. Insert the needle and secure the venipuncture site.
Medical Management
Date 1/21/12-1/28/12
General Description Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air with the intent of treating or preventing the symptoms and manifestations of hypoxia.
Indication or Purpose Oxygen Therapy is
Clients response to treatment Client experiences reduced
Oxygen Administration (2-3)
given to the patient to difficulty in ventilating. prevent hypoxia and provide adequate oxygen supply.
Oxygen therapy Before: Checks for the doctors order Check the patients identity Explain to the patients significant other the importance of the treatment. Position the oxygen tank properly to avoid accidents or injury. Check the oxygen tank for any leakage or deficiency
During: Check if it is tolerated by the patient
After: Monitor therapeutic effectiveness of the therapy. Report any undesirable effect of the treatment to the physician.
Medical Management/Treatment
Date Ordered Date Performed Date Changed
General Description
Indication(s) or Purposes
Clients Response to Treatment
0.9 NaCl/PNSS
D.O. January 21/23/24/25/27, 2012
PNSS is an isotonic solution. It is used as a plasma volume expander. Also, if it is anticipated that blood will be given, normal saline is used because
PNSS was ordered because Mr. Renals
Mr. Renals serum sodium level, as of
serum sodium is below October 27, 2011, normal level. Also, blood transfusion was ordered that is why it was given because it is remained below normal level. Mr. Renal received blood transfusion without
it is the only fluid compatible with blood administration.
the only fluid compatible with blood transfusion.
any complications.
Before
During
After
Check the physicians order for IVF solution and explain to the client the procedure.
Maintenance of aseptic technique. Proper procedure and steps in infusing IV solution.
Adjust the drops per minute as needed and record per minute. Monitor the client for fluid overflow. Inspect site for pain, swelling,
Check the patency of the IV line and needle. Check the type of infusion condition of the vein and medical condition of the patient.
Count drops per minute in the drip chamber.
coolness or pallor at the site of insertion. Inspect acts for redness, swelling, heat and pain which may indicates
phlebitis
Medical Management/Treatment
Date Ordered Date Performed Date Changed
General Description
Blood Transfusion: PRBC
D.O. January 22/26, 2012
Packed red blood cells are red blood cells that have been
The patient suffered anemia as manifested by the decrease in her RBC, hemoglobin, and hematocrit levels due to kidney damage. The kidneys are the ones responsible for the
Mr. Renals level of hemoglobin and hematocrit are still below normal range.
separated from whole blood for transfusion purposes.
production of erythropoietin which stimulates RBC production in the red bone marrow. PRBCs are used to restore oxygen carrying capacity to the blood of a patient that is suffering from anemia.
Before
During
After
Wash hands Check physians order for confirmation.
Wash hands. Organize bedside all needed equipments at
Wash hands and keep equipments in proper place to keep them sterile. Document relevant data
Check consent
the for
informed blood
Explain procedure and its purpose. Do not give clear intravenous fluids other than PNSS when having blood
Check IVF regularly to maintain proper regulation. Instruct client to limit movements so as to maintain cannula in place. Note signs for anaphylactic shock.
transfusion. Check clients fluid and nutritional status. Apply a timing label on the solution container. Give medications
transfusion. Place the blood tubing as a side drip. Once inserted, regulate IVF as indicated. Monitor vital signs every 15 mins. for 1 hour
(antihistamine) as ordered.
DRUGS: NAME OF DRUGS; GENERIC NAME; BRAND NAME DATE ORDERED; DATE TAKEN/GIVEN; ROUTE OR ADMINISTRATION; DOSAGE; FREQUENCY OF ADMINISTRATION CLASSIFICATIO N; GENERAL ACTION INDICATION(S) OR PURPOSE(S) (Patient- Centered) CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECS
Generic
Name: January 2012
20-31, 80 dyspnea with BP < Classification: 90/60mmhg mg SIVP q8 when BP < 90/60 Loop Diuretic Electrolyte and
The Drug was given The
client
Furosemide
to the patient to responded to the eliminate water and medications as
Brand Name: Lasix
mmhg
salt in the body, seen by increase
water edema was present urinary frequency. lower extremities of the patient.
balance agent both
General Action: 40mg IV prior to BT Rapid-acting potent sulfonamide loop diuretic It inhibits the reabsorption of sodium and chloride from the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodium rich dieresis.
The Drug was given The Client to the patient before responded well to blood transfusion to the medications, remove volume of extra no edema or blood complications
elements to prevent were seen. edema.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Obtain history of allergy to furosemide and its components. Obtain baseline data of Blood Pressure of the patient. Do not use discolored drug or solutions
During After: Monitor patient for adverse reactions. Report swelling in ankles or fingers, unusual bleeding or bruising, dizziness, numbness, fatigue, muscle weakness or cramps. Adhere to the standard precautions. Prepare the medication. Administer at the right route. Watch patient for signs and symptoms of adverse effects. Monitor BP.
NAME OF DRUGS; GENERIC NAME; BRAND NAME
DATE ORDERED; DATE TAKEN/GIVEN ;
ROUTE OR ADMINISTRAT ION; DOSAGE; FREQUENCY OF ADMINISTRAT ION
CLASSIFICATION; GENERAL ACTION
INDICATION(S) OR PURPOSE(S) (PatientCentered)
CLIENTS RESPONSE TO THE MEDICATION W/ ACTUAL SIDE EFFECS
Generic Potassium Chloride
Name: January 2012
20-28, 1 Tab BID
Classification: Electrolyte
The given
Drug to
was The
client
the responded well to
General Action:
patient to prevent the medications as hypokolemia seen in increase in
Brand Name: Kalium Durule
Potassium chloride is during treatment potassium level. a major cation of the of diuretics and to intracellular fluid. It assess plays an active role in maintaining the of normal nerve impulses in the function. heart, skeletal brain and muscle; conduction for
renal
contraction of cardiac skeletal and smooth muscles; maintenance
of
normal
renal
function,
acid-base
balance, carbohydrate metabolism gastric secretion. and
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Obtain history of allergy to Potassium chloride and its components Review Laboratory results for possible presence of Hypokalemia.
During After: Monitor patient for adverse reactions. Report hyperkalemia, dysrrhythmia, severe hemolytic reactions and dehydration. DATE ORDERED; DATE TAKEN/GIVEN ; ROUTE OR ADMINISTRAT ION; DOSAGE; FREQUENCY OF ADMINISTRAT ION CLASSIFICATION; GENERAL ACTION INDICATION( S) OR PURPOSE(S) (PatientCentered) Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking Oral drug: In upright sitting position Watch patient for signs and symptoms of adverse effects.
RE
ME
SID
Generic
Name: January 21, 2012- 1 Sachet TID
Classification:
The Drug was The to
Kremezine (AST February 4, 2012 120)
Spherical Carbon given adsorbent
the resp
patient because the m it absorbs toxins to the body
General Action: Brand Name: Kremezine The drug into acts binding
by which delays the surfaces introduction for
that adsorbs a number of needed substances with the dialysis active carbon
which treatments used putatively has a high in renal failure. and selective involved directly or indirectly - in the pathogenesis of liver diseases and
gastrointestinal diseases, Renal diseases while not binding digestive
enzymes or fat-soluble vitamins involved in
nutritional balance.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Review Laboratory results for assessment of kidney function
During After: Monitor patient for adverse reactions. Document

DATE ORDERED; DATE TAKEN/GIVEN; ROUTE OR ADMINISTRATI ON; DOSAGE; FREQUENCY OF ADMINISTRATI ON CLASSIFICATION; GENERAL ACTION INDICATION(S) OR PURPOSE(S) (Patient- Centered)
Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects.
RE
ME
Generic Name: Calcium Carbonate January 21, 2012- February 4, 2012 Brand Name: Caltrate Plus
1 TAB TID
Classification: Supplement
The Drug was given The to the patient
to resp
General Action:
prevent hypocalcemia the in diuretic therapy and
Calcium carbonate is an to prevent inorganic salt used as an hyperphosphotemia in antacid. It is a basic renal disease. compound that acts by neutralizing hydrochloric gastric acid in
secretions.
Subsequent increases in pH may inhibit the
action of pepsin. An increase in bicarbonate
ions and prostaglandins may also confer effects.
cytoprotective
Calcium carbonate may also be used as a
nutritional
supplement
or to treat hypocalcemia.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Review Laboratory results for assessment of kidney function Assess blood pressure, ECG readings, renal function, magnesium, phosphate, and potassium concentrations.
During After: Monitor patient for adverse reactions (Hypercalcemia, Gi upset, constipation, polyuria, Loss of appetite) Document Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects.
DATE ORDERED; DATE TAKEN/GIV EN;
INDICATION(S) OR PURPOSE(S) (Patient- Centered)
Generic Name: January Tranexamic Acid
24, 500mg/cap
TID Classification: Antifibrinolytic antihemorrhagic
The Drug was given The to the patient
client
2012- January q6 26, 2012
to responded well to medications
prevent bleeding and the
formation of clots in as evidenced by Brand Name: Cyklokapron. 500mg IV q6 Competitively inhibits activation of plasminogen (via binding to the kringle domain), 500mg/cap TID (3doses) thereby General Action: blood transfusion. no signs of
bleeding.
reducing conversion of plasminogen to plasmin (fibrinolysin), an enzyme that degrades fibrin clots, fibrinogen, and other
plasma including
proteins, the
procoagulant factors V and VIII. Tranexamic
acid also directly inhibits plasmin activity, but
higher doses are required than are needed to reduce plasmin formation
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Review Laboratory results for assessment of kidney function Assess blood pressure, ECG readings, renal function, magnesium, phosphate, and potassium concentrations and Blood clotting time
During After: Monitor patient for adverse reactions (chest Pain, vomiting, cyanosis, difficulty of breathing) Document Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects.
DATE ORDERED ; DATE TAKEN/GI VEN;
ROUTE OR ADMINISTR ATION; DOSAGE; FREQUENC Y OF ADMINISTR ATION
Generic Name: Metoclopramide
January 25- 1amp IV now Classification: 29, 2012 then PRN x Antiemetic GI Stimulant
The Drug was given The
client
to the patient to responded well to prevent vomiting in the current treatments. medications
vomiting Brand Name: Reglan
as evidenced y decreased occurrence of
General Action: Metoclopramide "prokinetic" drug is a that
vomiting.
stimulates the muscles of the gastrointestinal tract
including the muscles of the lower esophageal sphincter, stomach, and small intestine by interacting with receptors
for
acetylcholine
and
dopamine on gastrointestinal muscles and nerves thus preventing vomiting.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Review Laboratory results for assessment of kidney function Assess blood pressure, ECG readings, renal function, magnesium, phosphate, and potassium concentrations
During Adhere to the standard precautions. Limit Patients activities as to side effects of the drug: Dizziness Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects. Be aware that during early treatment period, serum aldosterone may be elevated; after prolonged administration periods, it returns to pretreatment level After: Monitor patient for adverse reactions (Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors) Document
DATE ORDERED; DATE TAKEN/GI VEN;
ROUTE OR ADMINISTR ATION; DOSAGE; FREQUENCY OF ADMINISTR ATION
Generic Name: Ferrous
January
24, Ferrous Sulfate Classification: + Folic Acid 4, TID General Action: Folic acid helps your body produce and maintain new cells, and also helps prevent changes to DNA that may lead to cancer. Ferrous sulfate and folic acid is used to treat iron deficiency anemia (a lack of red blood cells caused by having too little iron in the body). Supplement
The Drug was given to The
client
Sulfate 2012February 2012
the patient to prevent responded well to folic acid deficiency the medications and and anemia. his perfusion improving. peripheral is
+ Folic Acid
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Review Laboratory results such as Complete blood count to assess for deficiencies such as anemia
During Adhere to the standard precautions. Limit Patients activities as to side effects of the drug: Dizziness Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects
After: Note Side effects such as diarrhea, constipation, nausea and vomiting, darkened urine color, stomach pain, and blood in stools. Document
DATE ORDERED; DATE TAKEN/GI VEN;
ROUTE OR ADMINISTR ATION; DOSAGE; FREQUENCY OF ADMINISTR ATION
Generic Name: Amplodipine
January 2012February
23, 5mg 1 tab BID
Classification: Calcium Channel blocker Antihypertensive Antiangina
The Drug was given to The client responded the patient to lower well to the
4,
Blood pressure.
medications as seen by normal blood pressure.
Brand Norvasc
Name: 2012
General Action: Inhibits calcium ions from entering the slow channels select voltage sensitive areas of vascular smooth muscle and myocardium during depolarization thus decreasing blood pressure and angina.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Monitor Clients Blood Pressure to serve as baseline data. Instruct patient to take Drug with meals to prevent GI upset
During After: Note Adverse Side effects such as irregular heartbeats, swelling of the hands and feet, dizziness and constipation. Document Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects Monitor Blood Pressure or cardiac rhythm
DATE ORDERED; DATE TAKEN/GIVE N;
ROUTE OR ADMINISTRATI ON; DOSAGE; FREQUENCY OF ADMINISTRATI ON
INDICATION(S) OR PURPOSE(S) (PatientCentered)
Generic Name: Clonidine Hydrochloride
January 21 2012January 26, 2012
75 mcg /tab 8L x Classification: BP 160/90mmhg Antihypertensive
The
Drug
was The client
given to the patient responded well to to lower Blood the medications as seen by normal blood pressure.
General Action: Brand Catapress Name: Clonidine stimulates alphaadrenoreceptors in the brain stem. This action results in reduced sympathetic outflow from the central nervous system and in decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure
pressure.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Monitor Clients Blood Pressure to serve as baseline data. Instruct patient to take Drug with meals to prevent GI upset Inform patient not to take alcohol during the course of the therapy
During Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects Monitor Blood Pressure or cardiac rhythm
After: Inform patient not to stop taking the drug unless doctor ordered. Note Adverse Side effects such as severe headache blurred vision, buzzing in your ears, anxiety, blanching of fingers, chest pain, shortness of breath, nightmares) Document
DATE ORDERED; DATE TAKEN/GIVE N;
Generic Name: Epoietin Alfa
January 24 2012- January 30, 2012
4000 SC 2x IMC
Classification: Erythropoietin Stimulator Colony Stimulating Factor
The Drug was given to The
client
prevent anemia and to responded well to decrease the bodys need the medications. for red blood cell
Brand Epoietin
Name:
transfusion.
General Action: The drug acts by causing the bone marrow to produce oxygen-carrying red blood cells, when the body senses a decrease in red blood cells or a deficiency in the supply of oxygen, more erythropoietin is produced, and this
increases the number of red blood cells which is given to prevent anemia.
Nursing Responsibilities: Before Explain the procedure to the patient and the significant other about the importance of the drug, its uses and effects. Prepare medication at the right time and with the right dosage. Monitor Clients Blood Pressure to serve as baseline data. Instruct patient to take Drug with meals to prevent GI upset Inform patient not to take alcohol during the course of the therapy
During After: Inform patient not to stop taking the drug unless doctor ordered. Note Adverse Side effects such as severe headache blurred vision, buzzing in your ears, anxiety, blanching of fingers, chest pain, shortness of breath, nightmares, paresthesia) Document Adhere to the standard precautions. Prepare the medication. Administer at the right route or assist the patient in taking drug Watch patient for signs and symptoms of adverse effects Monitor Blood Pressure
Diet Date Ordered Type of Diet Date Performed Date Changed January 21, 2012 Soft Diet Clients Response or Reaction to the diet Clients Response or Reaction to the diet The pt. was able to comply with the said diet.
General Description
Indication or Purpose
A diet consisting The Diet is given Client has easy of bland foods that to the patient to consumption of are softened by facilitate easy food. of
cooking, mashing, consumption pureeing, blending. Low Salt Low Fat Diet January 26, 2012 A diet that aids in To preventing patients or food.
decrease Clients blood pressure and decreased. further
blood The patient was able to follow the diet well.
complications and pressure consist mainly in prevent
limited amounts of increase in blood fat and consisting pressure and
chiefly of easily decrease edema. digestible foods of high carbohydrate content. In a low fat diet.
Nursing Responsibilities Before Check doctors order Explain indication/purpose of diet to the patient Check clients choice of food. Obtain initial assessment about progress management
During Encourage to increase oral fluid intake of the patient Give foods in small frequent meals to check tolerance Assist patient when feeding Observe aspiration precaution
After d. Activity/Exercise Provide patient oral hygie
Date Ordered Type of Exercise Date Performed Date Changed
General Description
Complete Bed Rest with no bathroom privileges
D.O. 01/20/12
Resting in bed or just restricting your activity and
To allow the patient to rest and avoid further injury. It is also indicated for
The patient is unable to ambulate.
D.P. 01/20/12
may not go to bathroom
whenever necessary.
patients who cannot tolerate activity.
Moderate High Back Rest
D.O. 01/20/12
The head of bed would be raised not higher than
Maximizes lung expansion and promote ease of
The patient is unable to move.
D.P. 01/20/12
90 and not lower breathing. than 45
Before
During
After
Check the physicians order before the exercise
Provide safety precaution Provide comfort measures Promote a quite environment conducive for rest.
Monitor the position/activity of the patient every 2 hours.
Identify the patient before the exercise or activity
Obtain initial assessment about the progress of the activity.
Provide adequate rest periods
Explain the procedure and importance to the patient.
Encourage verbalization of feelings about the activity.
Ensure that the client understands the rationale for the said activity
Assess for patients condition, how he responds to the activity.
Document.
S> O O> Patient
Impaired exchange related Altered oxygencarrying capacity
gas By the process of Short term: diffusion to exchange the of After 4 hours of NI, the patient will participate in treatment
>assess patients condition
>to s/sx
determine Short term: The patient shall have participated in treatment within
manifested: >restlessness >tachycardia >dyspnea >nasal flaring > weakness
oxygen and carbon dioxide occurs in the of capillary membrane The area. alveolar-
regimen within level of ability.
>monitor VS
regimen >to baseline data
obtain level of ability.
blood.
relationship
between ventilation (airflow) perfusion and (blood >Note respiratory rate >to degree compromised evaluate of Long term: The patient shall Long term: >to degree compromised evaluate of have demonstrated improved ventilation adequate >to maintain oxygenation of and
flow) affects the efficiency of the gas exchange.
Normally there is a The patient may manifest: >cyanosis >abnormal
>auscultate After 2-3 days balance between breath sounds of NI, the ventilation and perfusion; however, patient will certain demonstrate conditions can improved
tissues by ABGs
ABGs >>diaphoresis
offset this balance, ventilation and >elevate head of resulting impaired in adequate gas oxygenation of bed
airway
within normal
clients limits
and absence of >to optimal expansion drainage secretions promote symptoms chest respiratory and distress. of
exchange. Altered tissues by ABGs blood flow from a within pulmonary embolus, normal clients >encourage limits frequent
or and absence of position of changes
decreased cardiac symptoms output can or shock respiratory cause distress.
ventilation without perfusion. Conditions that >keep environment allergen free
>to
reduce
irritant effect on airways
cause changes or collapse alveoli. factors gas include altitudes, hypoventilation, and altered of the Other affecting exchange high
>helps >encourage adequate rest >to underlying >administer conditions
limits
oxygen needs
treat
oxygen-carrying capacity blood reduced hemoglobin. Other patients at risk for impaired exchange those gas include with a of the from
medications as indicated
history of smoking or pulmonary
problems, obesity, prolonged periods of immobility, and chest or upper
abdominal incisions.
Nursing Care Plan #: Hyperthermia
ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
OBJECTIVES
NURSING INTERVENTIONS
RATIONALE
EXPECTED OUTCOMES
S> O>The patient
Hyperthermia The febrile response is Short term: a complex physiologic reaction to the disease indicating the onset of After 2 3 hours of in inflammation infection. or nursing interventions patients The core the
Independent: 1. Establish Rapport
Independent:
Short Term:
1. To gain the trust The patients shall and cooperation 2. Assess patients general condition 2. To know and determine needs 3. Monitor and 3. To obtain baseline data for future Long term: 4. Monitor core The patient shall have 4. To evalutate the core maintained temperature temperature. patients have within limits. decreased normal
manifested: >Increase body temperature >Fluhed skin >Warm to touch >Restlessness >Crying irritability and
body temperature of temperature will be human is intricately decreased controlled by normal limits. record Vital Signs within
autonomic, endocrine, and responses. behavioral The Long term: After 2 4 days of nursing interventions the patient will be able to maintain core temperature within
hypothalamus is the central of this process, functioning as the
comparison
thermostat, controlling May Manifest: >The patient the thermoregulatory that heat
mechanisms balance
the normal range and demonstrate
effects and degree of within the normal
may manifest: >Tachypnea >Tachycardia
production with heat decreased loss. Integral to the restlessness and 5. rate.
hyperthermia Monitor heart note progress
and range and demonstrated decreased restlessness irritability.
and
process are the heat. irritability. Sensitive receptors
changes of condition.
and
located in the anterior hypothalamus which is sensitive to elevations in the body temp, and increase or decrease output in the thermal set point. of A number exogenous 6. 5. Dysryhtmias and changes are ECG
common due to the Monitor and direct effect of on cardiac
record all sources of hyperthermia fluid loss such as blood urine, vomiting and tissues. diarrhea. Provide 6. To and
substances can evoke fever. such The pyrogens as toxins or
7. comfortable environment
detect
infectious
agents
electrolyte losses or by dehydration due to in the temperature.
induce the production of pro-inflammatory
stretching the linens, increase cleaning surroundings.
cytokines which enter the hypothalamic and
circulation
stimulate the release of
8.
Perform tepid
prostaglandin elevates
which the set
sponge bath every 7. 15 mins.
To provide an
environment conducive for testing and recovering.
thermoregulatory
point to increase heat conservation and heat production is an effort to fight the invading microorganisms, leading to increase in body temperature. 9. Remove excess
clothing or blankets to promote heat loss.
8. heat
This enhances loss by and
evaporation 10. Teach conduction.
significant others on the importance of providing adequate fluids electrolytes. and 9. To enhance heat
loss by radiation and conduction. Adding blankets
11.
Encourage
clothes
significant others to promote bed rest to
inhibits the bodys natural ability to
patient.
reduce temperature.
body
12.
Document and 10. To prevent and
record findings and interventions done. dehydration support volume perfusion.
circulating and tissue
Dependent: 1. Administer antipyretics as directed by the physician. 11. To decrease stress and promote faster recover.
12. documentation
Proper
enables the members of the health care team to track the health of the patient for proper of
implementation care.
Dependent: 1. To lower the body temperature and
facilitate recovery/.
Nursing Care Plan #: Activity Intolerance
ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC EXPLANATION
OBJECTIVES
RATIONALE
EXPECTED OUTCOMES
S> O>The patient
Activity intolerance related Imbalance between oxygen supply and as to
Decrease oxygen carrying capacity of Hgb and decreased
Short term:
Independent: 1. Rapport Establihed 1. To gain the trust cooperation 2. Assess patients general condition 2. To know and determine patients needs Monitor and 3. To obtain and
Short The
term: patient
manifested: >Tachypnea >Weakness >Fatigue
shall be able to use identify techniques to enhance activity tolerance
After 2 4 hours of nursing interventions the
nutrition in cells results decreased production to ATP since
patient will be able to use identified to activity
demand
evidenced by Tachypnea, May Manifest: Weakness, >Tachycardia in Fatigue. response activiy >Exertional dyspnea >Abnormal to
techniques enhance
oxygen is needed for oxidation of
tolerance such as 3.
Long term:
having enough rest record Vital Signs
CHO/glucose it periods. will result to decreased energy or muscle weakness then activity and After 2 4 days of Long term:
baseline data for future comparison 4. Note presence of factors contributing to fatigue 4. Fatigue affects both the clients
The
patient
shall be able to report
measurable increase activity in
heart rate
Intolerance occurs. In kidney fatigue chronic disease, occurs
nursing interventions the report 5.
actual
and tolerance.
perceived ability to participate in Note clients activities.
patient will be able to
measurable increase reports of weakness, in tolerance. activity fatigue, dfficulty pain, 5. Symptoms be result
due to increase protein degeneration.
accomplishing tasks, may and/or insomia.
of/or contribute to intolerancea
6. Ascertain ability activity. to stand or move about degree of
assistance necessary/use equipment. 6. To determine current status and 7. Adjust activities needs associated with participation in needed/desired 8. Plan care to activities. of
carefully rest
balance with 7. To prevent
periods
activities
overexertion
9. Provide positive atmosphere, acknowledging difficulty situation client. of for the the while 8. To reduce
fatigue
10. comfort and
Promote measures for 9. To help
provide
minimize frustration and
relief of pain
rechannel energy 11. Plan for progressive increase of activity
level/participation in exercise training, as tolerated by client. 10. To enhance
ability 12. Encourage participate
to in
client to maintain activities. positive suggest relaxation attitude; use of 11. Both activity and
techniques, such as tolerance visualization/guided energy, appropriate as improve progressive training.
health status may with
12. sense being
To enhance of well
Ineffective tissue perfusion r/t altered blood profile AEB decrease hemoglobin and hematocrit count
ASSESSMENT
NURSING DIAGNOSI S
SCIENTIFIC EXPLANATIO N Patient is suffering from chronic kidney disease is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the bodys internal environment. As a result, the kidney function deteriorates and
OBJECTIVE S
RATIONALE
EXPECTE D OUTCOME
S>
Ineffective renal tissue
Short term: After 2-4 hours of nursing interventions, the patient will be able to maintain adequate tissue perfusion AEB adequate peripheral pulses, RR within the normal limits, and absence of cyanosis.
Independent: Monitor and record vital signs Check capillary refill time and conjunctiva for paleness. Elevate head of bed to 30 degrees. To promote ease of breathing and adequate To determine blood circulation adequacy. To obtain baseline data for comparison.
Short term: The patient shall have maintained adequate tissue perfusion AEB adequate peripheral pulses, RR within the normal limits, and absence of cyanosis.
O> The patient manifested: Restlessness Pale face Body weakness Poor skin turgor Decreased Hgb level of 100gm/L and Hct level of 0.30 GCS of 3 Capillary refill of >3secs.
perfusion r/t altered blood profile AEB decrease hemoglobin and hematocrit count
there is decreased > VS as of follows: BP: 100/60mmHg PR: 90bpm RR: 27cpm T: 37.7C production of erythropoietin that leads to decrease haemoglobin and hematocrit count > Patient may manifest: Cyanosis Oliguria Abnormal ABG levels Metabolic acidosis Weak/absent pulses leading to less oxygen being delivered to the body tissues. Long term: After 4 days of nursing interventions, the patient will maintain adequate perfusion as individually appropriate AEB improvement in the Hbg and Hct levels and capillary refill time of less than 2 secs.
Maintain a peaceful environment for resting.
ventilation. To allow
Long term: The patient shall have
patient to rest maintained well and be able to conserve adequate perfusion as individually appropriate AEB To prevent deterioration of muscles and joints and increase muscle improvemen t in the Hbg and Hct levels and capillary refill time of less than 2 secs. To prevent bed sores or
Perform active and passive range of motion exercises.
energy.
Change position every 2 hours. Enforce safety measures
strength.
pressure ulcers.
such as raising the siderails.
To prevent further injury.
Interdependent: Refer to medical technologist for RBC, Hgb,and Hct results. To measure or determine improvement Dependent: Administer oxygen inhalation via nasal cannula as ordered. Administer To assist with the perfusion of of treatment outcomes.
ferrous sulfate as prescribed. Arrange for blood transfusion as ordered.
the body tissues.
To treat anemia.
To achieve increase in Hgb and Hct concentration s in the blood.
Risk for impaired skin integrity r/t accumulation of nitrogenous waste products
ASSESSMEN T
NURSING DIAGNOSI S
SCIENTIFIC EXPLANATIO N Due to the
OBJECTIVE S
NURSING INTERVENTIONS Monitor and record vital signs
RATIONALE
EXPECTE D OUTCOME
S>
Risk for
Short term: After 2-4 hours of nursing interventions, the patient will be able to be maintain an intact skin and
To obtain baseline data for comparison
Short term: The patient shall have maintained an intact skin
impaired skin decrease GRF O> Patient manifested the following: - Poor skin turgor - Dry and scaly skin on the limbs integrity r/t accumulation of nitrogenous waste products rate on the renal system that resulted to decrease oncotic pressure, there is retention of
Note presence of condition
That can impair skin integrity
and be freed from injury.
nitrogenous waste be free from in the body and sodium and water retention. This injury. Review pertinent laboratory Long term: After 7 days of nursing results Albumin less Long term: than 3.5 correlates to decreased wound healing/incre The patient shall have manifested improved skin integrity
> VS as of follows: BP:
results to edema and due to water retention in the
100/60mmHg PR: 90bpm RR: 27cpm T: 37.7C
interstitial space there is evident edema.
interventions, the patient will manifest improved skin integrity AEB
ased pressure ulcers Skin is thin, Handle patient gently less elastic and prone to injury such as bruising and skin tears Reduces Observed for reddened/blanc ed areas or skin rashes and institute treatment immediately To prevent Massage bony friction or ikelihood of progression to skin breakdown
AEB reduction of edema
The patient may manifest: - Disruption of skin surface - Open wound or sores
reduction of edema
prominences and use proper positioning
shear injury
To increased Provide protection by use of pads, pillow, or foam circulation and limit excessive tissue pressure To prevent Provide adequate clothing To maintain Emphasize importance of adequate nutritional/fluid intake To reduce Recommend risk of general good health and skin turgor vasoconstrict ion
keeping of nail short or wearing gloves
dermal injury when severe itching is present
ACTUALSOAPIEs SOAPIE #1 S> O> received patient lying on bed with an ongoing IVF of #1 PNSS 1L @ 550cc level regulated @ KVO rate infusing well on right hand; with intact NGT at the left nostril; with oxygen inhalation via nasal cannula at 3 LPM; with poor skin turgor; with dry mouth; with pale face; VS taken as follows: BP: 100/60mmhg; PR: 90bpm; RR: 28cpm; T: 37.7c A> Ineffective tissue perfusion r/t decreased hgb and hct concentration in blood P> After 4 hours of nursing interventions, the client will be able to maintain adequate tissue perfusion AEB adequate peripheral pulses, RR within normal limits and absence of cyanosis. I>established rapport >Monitored and recorded vital signs >Assessed patient general condition
>Provided oral care >Due meds given >Instructed SO for frequent position changes every 2 hours E> GOAL met client was able to maintain adequate tissue perfusion AEB adequate peripheral pulses, RR within normal limits and absence of cyanosis
VI. PATIENTS DAILY PROGRESS IN THE HOSPITAL
Date
Admission: January 20, 2012 21 22 23 24 25 26 27
Nursing Problems: 1. Activity intolerance 2. Hyperthermia
3.
Vital Signs:
1.Temperature
2. Pulse Rate
3.Respiratory Rate 5. blood Pressure
37.3C 37.0 C 37.6 C 36.0 C 36.4 C
37.2 C
36.8 C 97bpm Diagnostic / Laboratory Procedures: 87bpm 19 cpm 28 cpm 30 cpm 34 cpm 170/90mmHg 120/80mmHg 150/80mmHg 160/100mmHg 120/80mmHg 120/70mmHg 120/70mmHg 25 cpm 120/90mmHg 30 cpm 17 cpm 19 cpm 110 bpm 97 bpm 100 bpm 87bpm 87bpm 87bpm 36.2 C
Medical Management: Na = 37.1 K= 4.10 Na= 132.1 K= 5.87 K=5.87
DRUGS
DIET
EXERCISE Bed Rest
Date 28 Nursing Problems: 1. Activity intolerance 29 30 31
February 1, 2012 2 3 4 5
2. Hyperthermia
3.
Vital Signs:
1.Temperature
38.0 C
36.6 C
39.0
36.8 C
37.5 C
36.0 C
36.3C
36.7 C
37.6 C
2. Pulse Rate 100 bpm 3.Respiratory Rate 87bpm
97bpm 80bpm 78bpm 90bpm 88bpm 76bpm 79bpm
5. blood Pressure 29 cpm 25 cpm
27 cpm 28 cpm 17 cpm 16 cpm 16 cpm 18cpm 16 cpm
120/70mmHg 120/80m Diagnostic / Laboratory Procedures: mHg 120/90mmHg 120/90mmHg 120/90mmHg 120/80mmHg 120/70mmH g 120/90mmHg 120/90mmHg
Crea=14.5 BUN= 149.34 Creatinin = 18.25 K=6.0 K=4.69
Hgb=77 WBC=6. 3 Hct=0.23 RBC= 2.68 Medical Management: Seg=0.71 EOS=0.0 1 Mono=0. 04 Lymph=0 .24
DRUGS
DIET
EXERCISE Bed Rest
VI. CONCLUSION
The completion of the case study enabled the group to broaden their knowledge on one of the most common cases encountered in the Medicine Ward of their resident hospital. Kidney diseases ranked as 10th in the leading causes of death of Filipinos as announced by the Department of Health. With this in mind, the group had chosen the case of Mr. Renal to be their subject of study in order to expand their knowledge of the different mechanisms that happen during the course of the disease. CKD is a fatal disease for it may result to end-stage renal failure if not given early treatment. Therefore, the primary role of nurses in line with this is to help spread preventive measures on how to maintain and take care of ones health especially the kidneys.
RECOMMENDATION This study is recommended to patients with the same disease condition, for them to know what to expect and also know how to avoid the said condition by means of changing their diet and lifestyle. The study is also recommended for student nurses in order to give an opportunity to expand their knowledge regarding the disease, its underlying process, treatment, as well as its promotive aspects.
LEARNING DERIVED During the study, the group has proven that CKD is one of the leading causes of mortality in the country. And in line with this disease are the many factors that can cause this kind of disease condition. While studying this case, they were able to identify the different factors and the different treatment and preventive managements that can be used on the said disease condition. The group also realized that a public hospital is a very important health care facility that can provide health services to the less fortunate people of the society. During their shift in the Medicine ward, they were able to understand better the role of nurses. As future nurses, it is a
continuing challenge for them to learning how to maximize the resources that are available and be knowledgeable in such a way that they may be able to disseminate essential health information to their clients.
VII. BIBLIOGRAPHY A. Books Brunner & Suddarth. (2010). Handbook of Laboratory and Diagnostics Tests. Lippincott Williams & Wilkins. Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2008). Nurses pocket guide: Diagnoses, prioritized interventions, and rationales. Philadelphia: F.A. Davis Company Philadelphia:
B. Internet Sources Witten, B. (2011). Life Options. Retrieved from http://www.lifeoptions.org/ last February9, 2012 Broscious, S.K., & Castagnola, J. (2006). Chronic Kidney Disease. Critical Care Nurses. 26. Retrieved from http://ccn.aacnjournals.org/content/26/4/17.full last February 9, 2012 Bakris, G.L., & Ritz, E. (2009). Hypertension and Kidney Disease, A Marriage that Should Be Prevented, Kidney International, 75. Retrieved from http://www.worldkidneyday.org/page/prevalence-of-disease last February 9, 2012 Anonymous. (2010). Kidney failure one of top causes of death. Sun Star Davao. Retrieved from http://www.sunstar.com.ph/davao/kidney-failure-one-top-causes-death last February 9, 2012

ESRD2

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

ESRD2

Uploaded by

Copyright:

Available Formats

I.

B. REASONS IN CHOOSING THE STUDY

II. NURSING ASSESSMENT A. Personal History

B. Family Health History

D. History of Present Illness

CRANIAL NERVES ASSESSMENT

Cranial Nerve 1. Olfactory Type: Sensory Fxn: Sense of smell

2. Optic Type: Sensory Fxn: Sense of vision and visual fields

Client must see the ballpen or penlight distance. clearly at a given

Mr. Renal could see the ballpen at a given distance.

3. Oculomotor Type: Motor Fxn: Pupil constriction and raising of eyelid

4. Trochlear Type: Motor

Mr. Renal was able to move eyeball laterally and downward.

Fxn: Downward inward eye movement

Mr. Renal elicited blinking reflex upon touching the cornea.

6. Abducens Type: Motor Fxn: Lateral movements of the eyes

Client must be able to follow the index finger of the examiner.

Mr. Renal was able to raise eyebrows and show teeth.

8. Acoustic (Vestibulocochlear) Type: Sensory Fxn: Sense of hearing

Client must be able to hear a snap of the finger.

Mr. Renal was able to hear the snap of the finger.

9. Glossopharyngeal Type: Motor and Sensory Fxn: Pharyngeal movements and

Must be able to swallow foods that were chewed.

Mr. Rena has no difficulty on swallowing.

Must be able to speak clearly.

Mr. Renal speaks clearly.

11. Accessory Type: Motor Fxn: Movement of shoulder muscles

The client must able to elevate his shoulders against resistance

Mr. Renal was able to slightly shrug his shoulders against

resistance on his right upper extremity.

Mr. Renal was able to move his tongue side to side.

Date Ordered: January 26 2012

Date Results In: January 27, 2012

function of the kidneys especially in grading of chronic renal insufficiency.

Blood Urea Nitrogen

Date Ordered: January 28, 2012

Blood urea nitrogen (BUN) measures the

Diseased or damaged kidneys

Diagnostic/ Laboratory Procedures

Date ordered Date Result(s) in

Indication(s) or Purpose (s)

Analysis and Interpretation of Results

Date Ordered: January 19, 2012

Hemoglobin is the circulating iron containing pigment, which carries oxygen

Date Results In: January 20, 2012

Date Ordered: January 19, 2012

Hematocrit represents the packed cell volume of red blood cells. It is

Date Results In: January 20, 2012

Date Results In: February 4, 2012

The patient`s hematocrit level is still low as evidenced by anemia.

Diagnostic/ Laboratory Procedures

Date ordered Date Result(s) in

Indication(s) or Purpose (s)

Analysis and Interpretation of Results

Date Ordered: January 19, 2012

It is the measure of erythrocytes, a cellular component of blood involve in the transportation of

Date Results In: January 20, 2012

oxygen and carbon dioxide.

Date Ordered: January 28, 2012

Date Results In: January 29, 2012

that there is decrease

oxygenation in the blood.

White Blood Cells