GOOD

MORNING
…
 Chronic Kidney
Disease
secondary to
Chronic
Glomerulonephritis
General Objective

The researchers want to gain

knowledge about Chronic Renal
Disease. It is important to researchers
to have adequate knowledge about
disease process, its signs and
symptoms, risk factors and
complications in order for the
researchers to impart right information
to the patients and for future
profession.
Specific Objectives
• To know the different risk factors that could
lead to the development of the disease.
• To know specific signs and symptoms of
the disease and their causes in order to
provide proper nursing interventions to the
client.
• To know the disease process and the
affected parts in order to have proper
health teachings to the client.
• To know probable complications and their
causes in order to prevent them.
Patient’s Profile

• Name: Mr. X
• Age: 34 y/o
• Sex: Male
• Status: Single
• Address: Sampaloc, Talisay Batangas
• Date of Admission: July 11,2009
• Time of Admission: 4:51 pm
• Chief Complaint: Edema and Fever
• Attending Physician: Dr. Atienza and Dr.
Martinez
Patient’s history

• Two months prior to admission, patient had been

complaining of edema, consultation has done and
managed a care of nephrotic syndrome and
complicated UTI. Until one week prior to consult
patient was admitted at Daniel Mercado Hospital
due to bipedal edema fever associated with
difficulty of breathing and abdominal pain.
Impression then has chronic renal disease and
was advised of dialysis but due to financial
constrains patient did not imply here. Consulted
at OPD and was advised of admission.
History of Past Illness

• Patient has no other illness since then.

History of Present Illness

• Patient has fever and edema of lower

extremities which has been the reason
for his hospitalization.
• Family History
He has a familial history of
hypertension.
• Patient is a 34 year old, barber in
Saudi Arabia.
• Non-smoker, non-drinker.
• He has a preference in fatty and salty
foods.
Chronic Kidney Disease
• a condition of progressive reduction of
functioning renal tissue such that the
remaining kidney mass can no longer
maintain the body’s internal environment.
• It involves the progressive loss of
glomerular filtration, a process that can be
slowed but is irreversible and eventually
results in end stage kidney disease. The
kidney cannot maintain metabolic, fluid and
electrolyte balance, resulting in uremia and
azotemia.
 In the Philippines
one of the leading causes
of mortality and
morbidity
ranked #10 among other
diseases.
Stages of Chronic Kidney Disease

GFR*
Stage Description
mL/min/1.73m2

Slight kidney damage with

1 normal or increased More than 90
filtration

Mild decrease in kidney

2 60-89
function
Moderate decrease in
3 30-59
kidney function
Severe decrease in kidney
4 15-29
function

Kidney failure requiring

5 Less than 15
dialysis or transplantation
Risk Factors

• Age >55 years old

• Gender, common on men
• Familial history of diabetes melitus and
hypertension.
• Nephrotoxins such as lead, mercury,
chromium and cadmiun.
• Sedentary lifestyle
• Diet
LEADING Causes
• diabetes mellitus (which is the leading
cause)
• pyelonephritis (inflammation of the renal
pelvis)
• obstruction of the urinary tract
• hereditary lesions, as in polycystic kidney
disease
• vascular disorders; infections

• medications or toxic agents.

• GLOMERULONEPHRITIS
 Some of the patients who is
diagnosed with CRF exhibits the
following signs and symptoms:
hypertension, pulmonary edema,
pericarditis, pruritus
(itching),anorexia, nausea, vomiting
and hiccups. For instance, patient’s
breath may have the odor of urine
(uremic fetor): this condition is
associated with inadequate dialysis.
Potential Complications

• hyperkalemia
• pericarditis
• pericardial effusion
• pericardial tamponade
• hypertension
• anemia
• bone diseases
• metastatic and vascular calcifications.
Management

• Conservative
management
• Dialysis
• Kidney replacement
Review
of
System
BODY SYSTEM METHOD OF FINDINGS ANALYSIS
ASSESSMENT

General Inspection • Patient was observed • Due to poor circulation

Appearance lying on bed with and tissue perfusion
heplock noted. Pale and • Due to excessive
weak in appearance. accumulation of
Appears confused most nitrogenous waste.
of the time

Integumentary Inspection • Pallor • Due to blood loss and

System Palpation decreased hgb - 55
mg/dL
• Dry skin with pruritus • Due to decreased
activity of oil gland
• Bipedal edema (grade • Due to water retention
II) and increase
permeability of
membrane that results
from shifting of fluids
associated with renal
failure
HEENT Inspection • Head is normal in size • Indicates normal
Palpation • Hair is evenly distributed findings
• Eyes are equal rounded
with both pupils reactive to
light, pale conjunctiva
• Ears are symmetrical,
each auricles aligned with
the outer canthus of the
eyes without any
secretions
• Nose is symmetric and
straight with no discharge
or flaring
• Lips are pale and dry • Due to blood loss and
decreased hgb - 55
mg/dL
Respiratory Inspection • Symmetrical movement of • Indicates normal
System Palpation the chest upon breathing findings
Percussion • Respiratory rate- 19 cycles
Auscultation per minute
• With normal breath sounds
Cardiovascular Palpation • Hypervolemia • Due to fluid overload
System Auscultation • Blood pressure – 150/100
mmHg
• With intrajugular catheter • The catheter is a
at right intrajugular vein temporary access for
hemodialysis

Circulatory Inspection • Capillary refill test delayed • Delayed capillary

System Palpation by 5 seconds refill due to blood
loss and with hgb of
55 mg/dL

• Pulse rate – 95 beats per

minute
Gastrointestinal Inspection • Anorexia • Due to uremic toxins
System Auscultation • Nausea • Bleeding is caused
Percussion • Gastrointestinal by uremia
Palpation bleeding manifested by
dark stools
• Abdominal distention
and ascites – 107 cm
• Uremic Fector

Genitourinary Inspection • Decreased urine • Damaged Nephrons

System Palpation output; intake- 275 ml,
output – 120 ml within 8
hours
• Proteinuria
• Decreased urine
sodium
Musculoskeletal Inspection • Decrease in muscle • Due to dietary
System Palpation strength with a restrictions
functional mobility of +2
• Muscle cramps

Hematopoietic Inspection • Anemia • Due to reduced number

System • Defects in platelet of RBC
function
• thrombocytopenia
Anatomy
and
Physiology
The Kidney

The kidneys are a pair of bean-shaped

organs located below the ribs near the middle of
the back. They are protected by three layers of
connective tissue: the renal fascia (fibrous
membrane) surrounds the kidney and binds the
organ to the abdominal wall; the adipose capsule
(layer of fat) cushions the kidney; and the renal
capsule (fibrous sac) surrounds the kidney and
protects it from trauma and infection.
Parts of the Kidney

• Renal Vein carries blood away from the kidney and

back to the right hand side of the heart.
• Renal Artery supplies blood to the kidney from the
left hand side of the heart
• Pelvis is the region of the kidney where urine
collects
• Ureter carries the urine down to the bladder
• Medulla is the inside part of the kidney
• Cortex is the outer part of the kidney
Functions of the Kidney
• Urine formation
• Regulation of electrolytes
• Regulation of acid-base balance
• Control of water balance
• Renal clearance
• Secretions of prostaglandins
• Regulation of calcium and phosphorous balance
• Activates growth hormone
• Detoxify harmful substances (e.g., free radicals, drugs)
• Increase the absorption of calcium by producing calcitriol
(form of vitamin D)
• Produce erythropoietin (hormone that stimulates red blood cell
production in the bone marrow)
• Secrete renin (hormone that regulates blood pressure and
electrolyte balance)
Blood Supply
Each kidney receives its blood supply from the renal
artery, two of which branch from the abdominal aorta. Upon
entering the hilum of the kidney, the renal artery divides
into smaller interlobar arteries situated between the renal
papillae. At the outer medulla, the interlobar arteries branch
into arcuate arteries, which course along the border
between the renal medulla and cortex, giving off still
smaller branches, the cortical radial arteries (sometimes
called interlobular arteries). Branching off these cortical
arteries are the afferent arterioles supplying the glomerular
capillaries, which drain into efferent arterioles. Efferent
arterioles divide into peritubular capillaries that provide an
extensive blood supply to the cortex. Blood from these
capillaries collects in renal venules and leaves the kidney
via the renal vein. Efferent arterioles of glomeruli closest to
the medulla (those that belong to juxtamedullary nephrons)
send branches into the medulla, forming the vasa recta.
Blood supply is intimately linked to blood pressure
Renal artery → Interlobar arteries → Arcuate arteries →

Cortical radial arteries → Afferent arterioles →

Glomerulus → Efferent arterioles → Vasa recta →

Arcuate vein → Renal vein

The Nephrons

• Functional and structural unit of the kidney

• Each kidney has over one million nephrons
Two types of Nephron
1. Cortical Nephron (80-85%)
located at outermost part of cortex
2. Juxtamedullary Nephron
distinguished by long loops of henle
Parts of the Nephron
• The afferent arteriole receives blood rich in oxygen from the
renal artery.
• The glomerulus is a knotted up capillary that contains small
pores.
• The efferent arteriole is smaller in diameter than the afferent
arteriole and increases the pressure in the glomerulus aiding
pressure filtration
• Bowman's capsule collects the filtrate
• Proximal Convoluted Tubule has a brush border with many
villi to increase the surface area for selective reabsorption.
• Loop of Henle dips down into the hypertonic environment of
the kidney medulla and is responsible for the reabsorption of
water from the filtrate
• Distal Convoluted Tubule is the site of tubular secretion
• Peritubular Capillary Network acts as the blood supply to the
nephron.
• Collecting duct receives filtrate from several nephrons.
Functions of the Nephron

• Filtration
• Reabsorption
• Secretion
URINE FORMATION

Three processes occurring in successive portions of

the nephron accomplish the function of urine formation:

• Filtration of water and dissolved substances out of the

blood in the glomeruli and into Bowman's capsule;
• Reabsorption of water and dissolved substances out of the
kidney tubules back into the blood (note that this process
prevents substances needed by the body from being lost in
the urine);
• Secretion of hydrogen ions (H+), potassium ions (K+),
ammonia (NH3), and certain drugs out of the blood and into
the kidney tubules, where they are eventually eliminated in
the urine.
Pathophysiology
 Body system
Manifestation
In
Chronic Kidney Disease
 BODY CAUSES SIGNS AND SYMPTOMS ASSESSMENT
SYSTEM PARAMETERS

HEMATO- •SUPPRESSION OF RBC •ANEMIA •HEMATOCRIT

POETIC PRODUCTION •LEUKOCYTOSIS •HEMOGLOBIN
•DECREASED SURVIVAL •DEFECTS IN •PLATELET COUNT
TIME OF RBC. PLATELET FUNCTION •OBSERVE BRUISING,
•BLOOD LOSS THROUGH •TROMBOCYTOPENIA AND OTHER SIGNS
BLEEDING AND DIALYSIS AND SYMPTOMS OF
•MILD BLEEDING
THROMBOCYTOPENIA
•DECREASED ACTIVITY
OF PLATELET

CARDIO- •FLUID OVERLOAD •HYPERVOLEMIA •VITAL SIGNS

VASCULAR •RENIN-ANGIOTENSIN •HYPERTENSION •BODY WEIGHT
MECHANISM •TACHYCARDIA •ECG
•ANEMIA •ARRYTHMIAS •HEART SOUNDS
•CHRONIC •CONGESTIVE HEART •MONITOR
HYPERTENSION FAILURE ELECTROLYTES
•CALCIFICATION OF SOFT •PERICARDITIS •ASSESS FOR PAIN
TISSUES
•UREMIC TOXINS IN
PERICARDIAL FLUID
•FIBRIN FORMATION ON
EPICARDIUM
 GASTRO- • CHANGES IN • ANOREXIA • MONITOR INTAKE
INTESTINAL PLATELET • NAUSEA AND AND OUTPUT
ACTIVITY VOMITING • HEMATOCRIT
• SERUM UREMIC • GASTROINTESTIN • HEMOGLOBIN
ACID AL BLEEDING • GUALAC TEST FOR
• ELECTROLYTE • ABDOMINAL STOOLS
IMBALANCE DISTENSION • ASSESS THE
• UREA COVERTED • DIARRHEA QUALITY OF
TO AMMONIA BY • CONSTIPATION STOOLS
SALIVA • UREMIC FECTOR • ASSESS FOR
ABDOMINAL PAIN

NEUROLOGIC • UREMIC TOXINS • LETHARGY • LEVEL OF

• ELECTROLYTE • CONFUSION ORIENTATION
IMBALANCES • CONVULSION • LEVEL OF
• CEREBRAL • STUPOR CONSCIOUSNESS
SWELLING • COMA • REFLEXES
RESULTING FROM • SLEEP • EEG
FLUID SHIFTING DISTURBANCE • ELECTROLYTE
• UNUSUAL LEVEL
BEHAVIOR
• ASTERIXIS
• MUSCLE
IRRITABILITY
MUSCULO- • UREMIC TOXINS • MUSCLE CRAMPS • ELECTROLYTE
SKELETAL • DECREASED • LOSS OF MUSCLE LEVEL
CALCIUM STRENGTH • REFLEXES
ABSORPTION • RENAL • PAIN ASSESSMENT
• DECREASED OSTEODYSTROPHY
PHOSPHATE • RENAL RICKETS
EXCRETION • BONE PAIN
• BONE FRACTURES

SKIN • ANEMIA • PALLOR • OBSERVE FOR

• PIGMENT RETAINED • PIGMENTATION BRUISING
• DECREASED • PRURITUS • ASSESS SKIN
ACTIVITY OF OIL • ECCYMOSIS COLOR
GLAND • EXCORIATION • ASSESS SKIN
• DECREASED SIZE OF • UREMIC FROST INTEGRITY
SWEAT GLAND • DRY SKIN • OBSERVE FOR
• PHOSPHATE SCRATCHING
DEPOSIT
 GENITO- •DAMAGED •DECREASED URINE •MONITOR INTAKE AND
URINARY NEPHRONS OUTPUT OUTPUT
•DECREASED URINE •SERUM CREATININE
SPECIFIC GRAVITY •BUN
•PROTEINURIA •SERUM
•CAST AND CELLS IN ELECTROLYTES
URINE •URINE SPECIFIC
•DECREASED URINE GRAVITY
SODIUM •URINE ELECTROLYTES

REPRODUCTIVE •HORMONAL •INFERTILITY •MONITOR INTAKE AND

ABNORMALITIES •DECREASED LIBIDO OUTPUT
•ANEMIA •IMPOTENCE •MONITOR VITAL SIGNS
•HYPERTENSION •AMENORRHEA •HEMATOCRIT
•MALNUTRTITION •DELAYED PUBERTY •HEMOGLOBIN
•MEDICATIONS
Laboratory
Results
 Hematology(July 18, 2009)
Actual Value Normal Values Significance

Hematocrit 0.16 0.42-0.52 % Result is below normal. Decrease in

level of hematocrit signifies anemia.
This is cause by impaired production
of erythropoietin in the kidney.
Erythropoietin stimulates bone
marrow to produce RBC.
Hemoglobin 55 140-170 Result is below normal. Decrease in
lnumber of hemoglobin signifies
anemia
RBC 1.88 4.0-6.0 x 10 Result is below normal. Decrease in
number of RBC signifies anemia. This
is cause by impaired production of
erythropoietin in the kidney.
Erythropoietin stimulates bone
marrow to produce RBC.
WBC 8.9 5.0-10.0 The result is normal. No current
infection.
Platelet count 142,000 150,000-350,000 Result is below normal. Decrease in
number of platelets signifies risk for
bleeding. This is due to excessive
nitrogenous waste in the blood.
Diferrential count

Neutrophils 0.85 0.55-0.65% Result is above normal. This

indicates the presence of
bone marrow suppression.

Lympocytes 0.15 0.25-0.35% Result is below normal. This

indicates the presence of
bone marrow suppression.

Eosinophils 0.00 0.02-0.04% Result is below normal. This

indicates the presence of
bone marrow suppression.
Interpretation
The kidney produce erythropoietin the stimulates
bone marrow to produce red blood cells that increase
hemoglobin and hematocrit.

In chronic kidney disease, the production of

erythropoietin is impaired thus decreasing the
ability of the bone marrow to produce red blood
cells and decreasing the number of hemoglobin
and the hematocrit level resulting to anemia.

There was bone marrow suppression thereby

increasing the neutrophils while lympocytes and
eosinophils decrease because of anemia
 Blood Chemistry (July 18, 2009)
TEST RESULT NORMAL RANGE Significance

Creatinine 2,482.40 62.00-133.00 The result is above normal. The result

shows that kidneys cannot excrete
nitrogenous wastes.
Sodium 155.4 135-148 The result is above normal. The result
shows the inability of the kidneys to
maintain the homeostasis of the
internal environment of the body.
Potassium 5.93 3.5-5.5 The result is above normal. The result
shows the inability of the kidneys to
maintain the homeostasis of the
internal environment of the body
Phosphorous 10.8 2.5-4.5 The result is above normal. The result
shows the inability of the kidneys to
maintain the homeostasis of the
internal environment of the body
Calcium 1.08 1.12-1.32 The result is below normal. The result
shows the inability of the kidneys to
maintain the homeostasis of the
internal environment of the body
Interpretation

Creatinine is a break-down product of creatine

phosphate and a nitrogenous waste.Creatinine is
excreted mainly in the urine.

In CKD, excretion of the nitrogenous wastes is

impaired thus resulting in an increase in level of
nitrogenous wastes like creatinine.
 Increased serum level of the sodium, phosphorous
and potassium is caused by loss of excretory renal
function.

The impaired conversion of the vitamin d to its

active form causes the decreased serum level of calcium
which then causes the increased serum level of
phosphorous.

Hyperparathyroidism also causes the decreased

level of the calcium.
 Urinalysis (July 18, 2009)
Result Significance

Physical Color Light Yellow Normal.

ph 5.0 Normal
Transparency Turbid The result is abnormal. The urine contains
bacteria, cells, sugar traces and albumin
that contribute to the transparency of it.

Specific Gravity 1.020 Normal

Albumin +++ The result is abnormal. The result shows
that the nephrons are failing to filter
protein in the glomerulus.
Sugar Trace The result is abnormal. The result shows
that the nephrons are failing to reabsorb
glucose in the tubules.
Pus cells 4-6/hpf The result is abnormal. The result shows
RBC 0-2/hpf that the functions of the nephrons are
Epithelial cells Many Impaired.
Bacteria Few
Interpretation
The increased permeability of the capillary
causes the excessive passage of protein in the
urine.

The impaired tubular reabsorption of glucose

causes the traces of sugar in the urine.

The transparency of the urine is turbid. There

are many substances that causes the turbidity of
it.
Ultrasound

Impression:
• Normal size kidneys with Renal parenchymal Disease.
• Normal size prostate gland with concretions.
• Minimal ascites.
• Normal liver, spleen, pancreas, and aorta.
• Gall bladder polyp.

The result from the ultrasound of the whole abdomen

shows that there is a renal disease that causes some
abnormalities in the different systems of the body.
Excessive accumulation of nitrogenous waste in the body is
one effect of the renal desease. These nitrogenous waste
irritates mucosal lining that causes gastrointestinal
bleeding and minimal ascites.
 Medical
and
Surgical
Management
• Medical Mangement
• Hemodialysis
Hemodialysis is a method for removing waste products such as
potassium and urea, as well as free water from the blood when the
kidneys are in renal failure. The principle of hemodialysis is the same
as other methods of dialysis; it involves diffusion of solutes across a
semipermeable membrane. Hemodialysis utilizes counter current flow
, where the dialysate is flowing in the opposite direction to blood flow
in the extracorporeal circuit. Counter-current flow maintains the
concentration gradient across the membrane at a maximum and
increases the efficiency of the dialysis. Fluid removal (ultrafiltration) is
achieved by altering the hydrostatic pressure of the dialysate
compartment, causing free water and some dissolved solutes to
move across the membrane along a created pressure gradient. The
dialysis solution that is used is a sterilized solution of mineral ions.
Urea and other waste products, potassium, and phosphate diffuse
into the dialysis solution. However, concentrations of sodium and
chloride are similar to those of normal plasma to prevent loss.
Sodium bicarbonate is added in a higher concentration than plasma
to correct blood acidity. A small amount of glucose is also commonly
used. Side effects caused by removing too much fluid and/or
removing fluid too rapidly include low blood pressure, fatigue, chest
pains, leg-cramps, nausea and headaches. These symptoms can
occur during the treatment and can persist post treatment; they are
sometimes collectively referred to as the dialysis hangover or dialysis
washout.
• Surgical Management
• Intrajugular catheter
An intrajugular catheter is surgically inserted
at right intrajugular vein last July 20, 2009. It is a
temporary access for hemodialysis and it is
functional for 4 to 6 weeks.
 Nursing
Care
Management
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSES

Subjective: Ineffective After 8 hrs of  Provided for diet restrictions, After 8 hrs of
nursing as indicated, while providing nursing
“Nanghihina ako “, Tissue interventio intervention
adequate calories to meet the
as verbalized. Perfusion ns the s the patient
body’s needs. Restrictions of
Objective: related to patient will
protein help limit BUN.
was able to
be able to demonstrate
 Pale and weak in Inadequate demonstrat  Encouraged client to eat rich in behavioral
appearance oxygen e Iron but except fatty and salty lifestyle
 Dry skin carrying behavioral foods. change to
lifestyle improve
 Capillary refill capacity of change to
 Provided psychological report
circulation
the for client especially when
time 5 seconds improve
progression of the disease and
 ( +) abdominal blood as circulation.
resultant of treatment (dialysis)
distention 107 evidenced by may be long term.
cm. decrease  Encouraged quiet, restful
 Confuse most of hemoglobin, atmosphere conserves energy/
the time RBC, as lower tissue oxygen demand.

 RBC- 1.88 revealed by  Maintained head and neck in

midline or neutral position to
Normal 4-6x10/L laboratory
promote circulation/ venous
 Hemoglobin- 55 result. drainage.
Normal 140-  Encouraged use of relaxation
170g/dl activities and exercises
 IJ catheter @ techniques to decrease tension
level.
intrajugular vein,  Encouraged early ambulation to
dry and intact. enhances venous return.
 V/S:  Noted mentation it may be
BP- 150/100mmHg altered by increase creatinine.
PR-85bpm
 ASSESSMENT NURSING PLANNING INTERVENTIONS/RATIONALE EVALUATION
DIAGNOSIS

S: “Masakit ang Pain After 6  Performed comprehensive After 6 hours

hours of of nursing
opera ko sa leeg” related nursing assessment of pain to include intervention
to intervention location, characteristics, onset the patient
as verbalized
surgical the patient frequency, duration, quality, reported
O: will be able that pain is
incision as to report severity to assess etiology or relieved and
 weak evidenced that pain precipitating contributory controlled as
 (+) facial grimace by is relieve and factors evidenced by
control pain scale of 3
P- With IJ catheter verbal  Monitored vital signs for baseline
inserted at right report data
intrajugular vein,  Performed pain assessment each
time pain occurs. Note and
dry and intact
investigate changes from
Q- Lancenating pain
previous reports to rule out
R- Pain is localized in worsening of underlying condition
neck  Assessed for referred pain as
S- score of 8 on pain appropriate to evaluate client’s
scale response to pain
T- started last night  Provided comfort measures, quiet
environment and calm activities
as reported (July
to promote non- pharmacological
20, 2009)
pain management
 V/S:  Encouraged adequate rest period
• T- 36.5C to prevent fatigue
• P- 85bpm  Encouraged diversional activities
• R- 18cpm to assist client to explore
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSES

Subjective: Impaired After 8 hrs of  Noted presence of conditions/ After 8 hrs of

nursing situations that may impair skin nursing
“Medyo nangangati skin interventions interventions
integrity.
ang binti ko“, integrity the patient the patient
 Handled client gently and
as verbalized. related to will be able
stretching of linens regularly to
was able to
to demonstrate
Objective: Impaired demonstrate maintain skin integrity. behaviors
 Pale and weak Metabolic behaviors  Provided protection by use of techniques to
in appearance state as techniques pads, pillows foam mattress to prevent skin
to prevent breakdown as
 The skin is evidenced skin
increase circulation and tissue
evidenced by
by perfusion.
flaky breakdown. keeping the
 Limited or avoided of plastic
 Poor skin pruritus. nails short and
materials and removed wet/ elevating lower
turgor wrinkled linens. Moisture extremities
 Generalized potentiates skin breakdown and using of
Suggested use of ice, colloidal pads.
dryness of the 
bath, and lotions to decrease
skin
irritable itching.
 With bipedal
 Recommended keeping nails
edema grade short to reduce risk for dermal
II injury when sever itching is
 Serum present.
Creatinine  Recommended elevation of lower
extremities when sitting to
2,482.40
enhance venous return and
Normal 62.00-
reduce edema formation.
133.00 umol  Instructed client low salt, low
 Normal size fat diet.
kidneys with
 ASSESSMENT NURSING PLANNING INTERVENTIONS/RATIONALE EVALUATION
DIAGNOSIS

S: “Namamanas ang Excess fluid After 4 hours Noted presence of medical After 4 hours
of nursing condition that potentiate fluid of nursing
mga paa ko” as volume intervention intervention the
excess to assess causative or
related to the patient will patient
verbalized precipitating factors
compromised be able to
Noted presence of edema to
verbalized
O: verbalize understanding
regulatory understanding evaluate degree of excess of individual
(+) pitting bipedal mechanism as of individual Restricted sodium and fluid intake dietary and fluid
edema Grade II evidenced by dietary and to promote mobilization and restrictions
fluid “hindi na ako
Intake greater edema restrictions
elimination of excess fluid
masyadong
Recorded I&O accurately for
than output baseline data
kakain ng maalat
at lilimitahan ko
•Intake- 275ml Evaluated edematous extremities, na ang pag inom
•Output- 120ml change in position frequently to ng tubig” as
reduce tissue pressure and risk of verbalized
Lab Result skin breakdown
•Serum Creatinine- Set an appropriate rate of fluid
2,482.40 (62-133N) intake throughout 24-hour period to
prevent peaks in fluid level
•Na- 155.4 (135- Reviewed dietary restrictions and
1448N) safe substitutes for salt to promote
•K- 5.93 (3.5-5.5N) wellness
Reviewed laboratory data to
•Ca- 1.08 (1.12- evaluate degree of fluid and
1.32N) electrolyte imbalance
•Phosphorous- 10.8 Administered medications as
ordered
(2.5-4.5N)
V/S:
 ASSESSMENT NURSING PLANNING INTERVENTIONS/ EVALUATION
DIAGNOSIS RATIONALE

O: Risk for After 8 hours  Ascertained knowledge of After 8 hours of

of nursing safety needs/ injury nursing
 Confused most of Injury interventio intervention
prevention and motivation
the time related to n the the patient
to prevent injury in home,
altered patient will
community, and work
did not
 Weak in not experience
peripheral experience setting. injury
appearance tissue injury  Assessed muscle
 Lab Result perfusion. strength, gross and fine
• Serum Creatinine- motor coordination to
identify risk for falls.
2,482.40 (62-  Provided information
133N) regarding disease/
• Hct- 0.16 (0.42- condition that may result
in increased risk of
0.52%N) injury.
• Hgb- 55 (140-  Encouraged to eat foods
170N) rich in iron except salty
and fatty foods.
• RBC- 1.88 (4.0-  Encouraged adequate rest
6.0x10N) to prevent fatigue and
 V/S: injury.
 Assisted when going to
• 36.5C comfort room.
• P- 95bpm  Provided protection by
• R- 18cpm use of pads, pillows, foam,
mattress to increase
• Bp-150/100mmHg circulation and tissue
perfusion
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSES

Objective: Risk for After 8 hrs of  Assessed laboratory results for The patient was
nursing infections such as (elevated WBC able to
 Hemoglobin- Infection interventio identify
and positive blood cultures) to
55 Normal related to ns the intervention
prevent and treat infections.
140-170 g/dl excessive patient will
 Assessed temperature,
s to
be able to prevent/
 WBC 8.9 nitrogenous identify respiratory and urinary system reduce risk
Normal 5.0- waste and interventio changes as disease progress to for
10.0 x10/L inadequate ns to provide information about infections
prevent/ after 8
 Serum secondary reduce risk
presence of infection caused by
hours
defenses. progressive chronic disease and
Creatinine for
infections. effect on system.
2,482.40  Advised proper hygiene by all
Normal 62.00- caregivers between therapies/
133.00 umol clients. A first line defense
 IJ catheter against healthcare associated
infections.
@
 Handled client gently and
intrajugular
stretching of linens regularly to
vein, dry and maintain skin integrity.
intact.  Covered with sterile dressings and
 V/S: protect the sites to prevent
BP- contamination.
 Cleansed incisions / insertion
150/100mmH
sites per facility protocol with
g
appropriate solution to reduce
PR-85bpm potential for catheter related
RR-19cpm blood stream infections.
T- 36.5◦C  Instructed client low salt, low fat
Normal M (140- diet.
Name of Drugs Action Indication Contraindication Adverse Reaction Nursing consideration

Spironolactone Antagonizes Short term Acute renal Gynecomastia, ►Obtain baseline data
(Aldactone) Aldosterone pre-operative insufficiency, before initiation of
in the distal treatment of anuria, Agranulocytosis, therapy such as V/S,
tubules, primary and hyperkalemia.
Classification Increasing hyperaldosteronim headache,
degree of edema
Diuretics Na and long term, present and
water maintenance drowsiness, laboratory studies.
excretion therapy for ►Monitor for
idiopathic lethargy, manifestation of
hyperaldosteronis hyperkalemia; MS;
m GI disturbance,
fatigue, muscle
manage of
essential Inability to weakness; CV:
hypertensionand achieve arrhytmias,
management of or maintain hypotension, Neuro:
edematous erection. parethesias,
condition. confusion, Resp.:
dyspnea.
►Assess fluid volume
status: I & O ratios
and record, count or
weight diapers as
appropriate, weight,
distended red veins,
crackles in lung, color,
quality, and specific
gravity of urine, skin
turgor, moist mucous
membranes should be
reported.
►Monitor electrolytes: K,
Name of Drugs Action Indication Contraindication Adverse Reaction Nursing consideration

Sodium Increase Treatment for Hypoventilation, Hypernatraemia ►Obtain patient

Bicarbonate bicarbonate, metabolic hypocalcemia, and serum history, including
which excess acidosis; further in all hyperosmolarity.
(Na acid drug history and
buffers H ion promotion situations
carbonate) concentrations, of gastric where Na
any
reverse and urine intake must be hypersensitivity
Classification metabolic alkalinizati restricted like
Fluid acidosis, on in the cardiac ►Assess respiratory
electrolytes neutralizes case of ion insufficiency, and pulse rate,
gastric acid, toxication edema, rhythm, depth,
which forms with weak hypertension,
lung sounds.
hydrogen, organic severe kidney
NaCL, and acids. insufficiency.
raises blood ►Monitor fluid balance
pH. (I&O ratio, edema)
notify physician of
fluid overload.

►Monitor for
manifestation by
hyponatermia:
increase BP, cold,
clammy skin,
anorexia nausea
and vomiting.

►If the patient is

vomiting withhold
medication and
immediately inform
physician.
 Nursing
Name of Drugs Action Indication Contraindication Adverse Reaction
consideration

Nifedipine Inhibits calcium Treatment of Hypersensitivity, Dizziness, ►Monitor BP,

(Calciblock) ion influx across vasospastic angina, immediate release pulse before
cell membrane chronic stable nifedipine flushing, therapy.
during cardiac angina, contraindicated in
Classification depolarization, hypertension. unstable angina
Antagonist produces and after recent headache, ►Assess
relaxation of MI, severe aortic therapeutic
coronary and stenosis, severe hypotension, effectiveness and
peripheral hypotension and adverse reaction
vascular muscle decompensate peripheral edema,
and it dilates heart failure.
►Assess
coronary vascular
arteries. tachycardia and knowledge and
palpitations. teach patient
proper use of the
Nausea and other medication;
GI disturbance, possible side
effects and
rashes, adverse symptoms
pain, to report.
fever and
►Observe for the
abnormalities liver 12 rights in
function. administering
medication.
 Nursing
Name of Drugs Action Indication Contraindication Adverse Reaction
consideration

Etoricoxid Inhibits Relief of acute Active peptic Immune system ►Assess for pain
(Arcoxia) prostaglandin pain. ulceration. disorders, of
synthesis by Patient nervous inflammation,
decreasing experienced system,
Classification enzymes. bronchospasm cardiac,
characteristi
Analgesic , nasal polyps, respiratory, cs of pain.
acute rhinitis, skin, renal
angioneurotic and urinary ►Monitor blood
edema. disorders. counts before
Patient with therapy
hypertension,
established
ischemic ►Assess for
heart disease hypersensitivi
and ty to
cerebrovascul medication.
ar disorders.
►Monitor kidney

Observe for the

12 rights in
administering
medication.an
d liver
function
tests.
 Nursing
Name of Drugs Action Indication Contraindication Adverse Reaction
consideration

Clonidine Stimulates Management of all Hypersensitivity Local skin ►Perform blood

(Catapres) central alpha grades of to Clonidine, irritation, studies
Adrenergic hypertension sick drowsiness,
receptors to with the syndrome. dry mouth,
Classification Inhibit expectation dizziness,
►Assess BP
Antihypertensive Sympathetic of headache. before
Cardio hypertension Anxiety medication
accelerator and due to fatigue
vasoconstrictor phaeochromo sleep disturbances, ►Monitor baseline
center. cytoma urinary retention, for
burning and
renal, liver
itching
sensation of function
eye. before
medication.

►Observe for the

12 rights in
administering
medication.
Name of Drugs Action Indication Contraindication Adverse Reaction Nursing
consideration

Calcium Decrease total Antacid, calcium Hypercalcemia, Constipation, ►Assess for

Carbonate acid load of GI supplement, bone tumors, inflatulence, adverse reaction
tract. Increase osteoporosis and severe renal diarrhea, renal
(Calci-aid)
esophageal hyperthyroidism. failure,. dysfunction, acid ►Assess for
sphincter tone, rebound. hypercalcemia
Classification strengthens
Antacid gastric mucosal ►Advice to
barrier and increase fluid
reduce pepsin intake.
activity by
elevating gastric ►Observe for the
pH. 12 rights in
administering
medication.