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Group 5 13B
End Stage Renal Failure Secondary to Diabetes Nephropathy
CHAPTER 1INTRODUCTION
Diabetes Mellitus is the leading cause of end stage renal disease (ESRD) andrenal failure in the United States. Diabetic nephropathy affects 20%-30% ofthose with type 1 diabetes 20 years after onset. Although less than 20% ofclients with ESRD have type 2 diabetes (NIDDK,2004).There are about 6,500 yearly deaths in the country secondary to variouskidney diseases (Kidney Center)A number of underlying diseases can cause progressive renal failure. Chronicglomerulonephritis (CGN) is the most common cause (47 percent) of ESRD inFilipinos. Other causes include chronic pyelonephritis (17 percent), diabetesmellitus (13 percent), and hypertensive nephrosclerosis (5 percent) (KidneyCenter of the Philippines, Medical City 1975-1981). er of the Philippine, Medical City 1995-2001)
OBJECTIVES
• General Objective:
Within our 3-day clinical exposure at Davao Doctors Hospital, The group will be able to assess, analyze, plan for nursing intervention, implement and evaluate the case of our patient who has End Stage Renal Failure (ESRD) secondary to Diabetes Mellitus Type 2 secondary to Diabetes Nephropathy.
Specifically our objective is to:• Establish rapport with the patient and family;• Gather all important data from the patient himself, from his family
and from the chart as basis for study;• Make a comprehensive assessment of the patient;• Enumerate the necessary laboratory test undergone by the patient
for the diagnosis and treatment of the disease;
• To know the anatomy and physiology of metabolic and renal system;
• Know the pathophysiology of the disease process;• Identify the different medical/surgical treatment done for
the patient;• Identify different drugs that is used for treatment with their
specific actions, indications, dose , interactions,adverse reactions and nursing implications and responsibilities;
• Formulate a plan of care which will based on identified actual and potential health problem;
• Give recommendations and health teachings based on the identified actual and potential health problem;
DEFINITION OF TERMS
• Chronic Kidney Disease. Is long-standing, progressive deterioration of renal function.
• Dialysis. Done to the patient having chronic renal disease incapable of cleansing the blood and disposing waste in the body
• Diabetes mellitus. One of the factor why person acquire renal failure
• Edema. Is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body
• Hypertension. Cause by the malfunction of the kidney as the result of renal failure.
• Lifestyle. Precipitating factors that causes person to have chronic renal failure
CHAPTER IIPATIENT’S PROFILE
A. Personal Profile• Patient’s name: Mr. X• Age: 54 years old• Sex: Male• Nationality: Filipino• Religion: Roman Catholic• Occupation: Businessman• Civil Status: Married• Date of Admission: February 20, 2010• Attending Physician: Dr. Maglana; Dr. Isaguirre; Dr.
Coching• Discharge Diagnosis: ESRD 2˚ DM nephropathy DM type II
• B. Medical History• When Mr. X was 26 years old, he was diagnosed
with Diabetes Mellitus Type 2. Five years ago, Mr. X was admitted to St. Luke’s Medical Center and was diagnosed with benign prostatic hyperplasia. In the year 2003, Mr. X undergone 3 consecutive eye operations on the same eye, the first operation was due to a blood clot, the second and third operations were due to ocular bleeding. Last July 2009, Mr. X was admitted twice at St. Luke’s Medical Center due to edema of the lower extremities. He was diagnosed to have a nephropathy secondary to DM. On the same month and year, he was ordered to undergo hemodialysis and still continues up to present.
• C. Present Illness• Two days prior to admission (PTA), Mr. X
experienced body weakness and joint pains in the lower extremities. BP was taken at home. No consultation done because the condition was tolerable. One day PTA, the patient still experienced body weakness with headache and nausea. Consultation was done; BP was taken with medications given. Hours prior to admission, body weakness still noted and prompted admission at Davao Doctors Hospital.
• D. Comprehensive Assessment• 1.Family background• Mr. X, 54, years old, one of the six offspring of
Mr. XY and Mrs. XX. His mother has a history of hypertension and died due to complicated cardiac problem. His father has a diabetes mellitus (DM) and died due to cardiac arrest. Among his five siblings, one of them has DM and one has hypertension. Among them, Mr. X is the only one who has renal failure.
• 2.Effects / Expectations of Illness to Family and Self:
• Mr. X, his wife and his 3 children are very worried about his present condition. Even though they know that his condition is already complicated, they still hope for his recovery. They want Mr. X to be discharged from the hospital as soon as possible this is because it has been a long time that they've staying there. This situation had led his family members to become more conscious of there health. They've learned that no matter how wealthy you are, you can never escape any forms of illnesses.
• 3. History of Past Illness:• When Mr. X was 26 years old, he was diagnosed
with Diabetes Mellitus Type 2. Five years ago, Mr. X was admitted to St. Luke’s Medical Center and was diagnosed with benign prostatic hyperplasia. In the year 2003, Mr. X undergone 3 consecutive eye operations on the same eye, the first operation was due to a blood clot, the second and third operations were due to ocular bleeding. Last July 2009, Mr. X was admitted twice at St. Luke’s Medical Center due to edema of the lower extremities. He was diagnosed to have a nephropathy secondary to DM. On the same month and year, he was ordered to undergo hemodialysis and still continues up to present.
• 4. History of Present Illness:• Two days prior to admission (PTA), Mr.
X experienced body weakness and joint pains in the lower extremities. BP was taken at home. No consultation done because the condition was tolerable. One day PTA, the patient still experienced body weakness with headache and nausea. Consultation was done; BP was taken with medications given. Hours prior to admission, body weakness still noted and prompted admission at Davao Doctors Hospital.
GUIDELINES PATIENT DAY 1 DAY 2 DAY 3
I. Mental Status
a. state of mental
consciousness
The patient is
conscious, alert and
coherent
The patient is conscious,
and coherent
The patient is conscious,
and coherent
The patient is conscious,
and coherent
b. orientation The patient is oriented
to person, time, place
and events occurring in
the environment
The patient is oriented to
person, time, place and
events occurring in the
environment
The patient is oriented to
person, time, place and
events occurring in the
environment
The patient is oriented to
person, time, place and
events occurring in the
environment
c. intellectual capacity The patient is able to
understand and
comprehend instructions
and commands
The patient is able to
understand and
comprehend instructions
and commands
The patient is able to
understand and
comprehend instructions
and commands
The patient is able to
understand and
comprehend instructions
and commands
d. vocabulary level The patient is able to
speak and understand
his vernacular, the
National Language and
the Universal language
The patient is able to
speak and understand
his vernacular (Visayan),
the National Language
and the Universal
language
The patient is able to
speak and understand
his vernacular (Visayan),
the National Language
and the Universal
language
The patient is able to
speak and understand
his vernacular (Visayan),
the National Language
and the Universal
language
e. attention span The patient has a long
attention span
The patient has a short
attention span with 5-7
min concentration.
The patient has a long
attention span, with 15-
20 minute concentration
The patient has a long
attention span, with 15-
20 minute concentration
f. ability to understand The patient is able to
respond to questions,
commands/ instructions
with coherence
The patient is able to
respond to questions,
commands/ instructions
with coherence
The patient is able to
respond to questions,
commands/ instructions
with coherence
The patient is able to
respond to questions,
commands/ instructions
with coherence
II. Status of Special
Senses
a. auditory perception The patient is able to
hear moderate to loud
sounds and interpret
auditory stimuli
appropriately
The patient is able to
hear moderate to loud
sounds and interpret
auditory stimuli
appropriately
The patient is able to
hear moderate to loud
sounds and interpret
auditory stimuli
appropriately
The patient is able to
hear moderate to loud
sounds and interpret
auditory stimuli
appropriately
b. visual perception The patient is able to
see near and far
objects, interpret the
visual stimuli
appropriately and has
visual acuity of 20/20.
The patient is
nearsighted, able to
interpret visual stimuli
clearly with the use of
eyeglasses.
The patient is
nearsighted, able to
interpret visual stimuli
clearly with the use of
eyeglasses.
The patient is
nearsighted, able to
interpret visual stimuli
clearly with the use of
eyeglasses.
c. speech perception The patient is able to
speak clearly with
coherence
The patient is able to
speak clearly with
coherence
The patient is able to
speak clearly with
coherence
The patient is able to
speak clearly with
coherence
d. tactile perception The patient is able to
feel different textures
and temperature, able to
identify the origin of
stimuli.
The patient is able to
feel different textures
and temperature, able to
identify the origin of
stimuli.
The patient is able to
feel different textures
and temperature, able to
identify the origin of
stimuli.
The patient is able to
feel different textures
and temperature, able to
identify the origin of
stimuli.
e. olfactory perception The patient is able to
smell and identify
different aromas and
odors appropriately
The patient is able to
smell and identify
different aromas and
odors appropriately
The patient is able to
smell and identify
different aromas and
odors appropriately
The patient is able to
smell and identify
different aromas and
odors appropriately
III. Motor Ability
a. current mobility The patient can freely
move both upper and
lower extremities, able
to walk, stand and sit
without support.
The patient can't move
freely, with easy
fatigablity, with weak
movement of upper and
lower extremities, in
complete bed rest with
out bathroom privileges.
The patient can't move
freely, with easy
fatigablity, with weak
movement of upper and
lower extremities,in
complete bed rest with
out bathroom privileges
The patient can't move
freely, with easy
fatigablity, with weak
movement of upper and
lower extremities,in
complete bed rest with
out bathroom privileges
b. posture The patient can stand
straight, sit erect and
has proper gait.
The patient is in
complete bed rest,
positioned in high back
rest.
The patient is in
complete bed rest,
positioned in high back
rest.
The patient is in
complete bed rest,
positioned in high back
rest.
c. range of motion The patient is able to flex
and extend both upper
and lower extremities
The patient is able to flex
and extend both upper
and lower extremities but
with weak movements
The patient is able to flex
and extend both upper
and lower extremities but
with weak movements
The patient is able to flex
and extend both upper
and lower extremities but
with weak movements
d. muscle and nervous
status
The patient has
moderate to strong
muscular movements.
With a musculoskeletal
status score of 5 points =
ability to move
independently. With
muscular strength of 5=
active movement against
gravity without evident
fatigue.
The patient has a weak
muscular movement with
a musculoskeletal status
score of 3 points =
dependent on others,
with muscular strength of
3= active movement
against gravity with
evident fatigability
The patient has a weak
muscular movement with
a musculoskeletal status
score of 3 points =
dependent on others,
with muscular strength of
3= active movement
against gravity with
evident fatigability.
The patient has a weak
muscular movement with
a musculoskeletal status
score of 3 points =
dependent on others,
with muscular strength of
3= active movement
against gravity with
evident fatigability.
e. loss of extremities The patient has
complete extremities
The patient has
complete extremities
The patient has
complete extremities
The patient has
complete extremities
IV. Body Temperature
a. ranges Tympanic temperature
ranges from 37 – 37. 5
degrees centigrade
Tympanic temperature
ranges from 36.0– 36.8
degrees centigrade
Tympanic temperature
ranges from 36.0-36.5
degrees centigrade
Tympanic temperature
ranges from 36.0 – 36. 7
degrees centigrade
V. Respiratory Status
a. characteristics The patient has
respiratory rate range of
16-20 cpm, with equal
depth of respiration
The patient has
respiratory rate range of
21-28 cpm, with equal
depth of respiration
The patient has
respiratory rate range of
23-26 cpm, with equal
depth of respiration
The patient has
respiratory rate range of
20-25 cpm, with equal
depth of respiration
b. use of respiratory
aids
The patient has no
oxygen inhalation,
tracheostomy tube or
endotracheal tube
The patient has no
oxygen inhalation,
tracheostomy tube or
endotracheal tube
The patient has no
oxygen inhalation,
tracheostomy tube or
endotracheal tube
The patient has no
oxygen inhalation,
tracheostomy tube or
endotracheal tube
c. interference with
respiration
The patient has clear
breath sounds on both
lungs, without
tracheobronchial
secretions
The patient has clear
breath sounds on both
lungs, without
tracheobronchial
secretions
The patient has clear
breath sounds on both
lungs, without
tracheobronchial
secretions
The patient has clear
breath sounds on both
lungs, without
tracheobronchial
secretions
VII. Nutritional Status
a. condition of the
buccal cavity
The patient has pinkish
buccal cavity with
enough moisture.
The patient has pale
buccal cavity with
dryness noted.
The patient has pale
buccal cavity with
dryness noted.
The patient has pale
buccal cavity with
dryness noted.
b. digestion of food The patient has appetite,
able to consume whole
amount of food served
The patient has appetite,
able to consume whole
amount of food served
The patient has appetite,
able to consume whole
amount of food served
The patient has appetite,
able to consume whole
amount of food served
c. weight 54 kg 49kg 49 kg 49 kg
VIII. Elimination Status
a. bowel The patient is able to
defecate 2 times a day,
with soft stool, golden
brown in color, aromatic
The patient is able to
defecate 2 times a day,
with soft stool, golden
brown in color, aromatic
The patient is able to
defecate 2 times a day,
with soft stool, golden
brown in color, aromatic
The patient is able to
defecate 2 times a day,
with soft stool, golden
brown in color, aromatic
b. bladder The patient is able to
urinate freely, with urine
output of 30-40 ml/hour
depending on the intake
and patient's weight, with
transparent urine
characteristics ranging
from yellow to dark
amber, with aromatic
smell
The patient is able to
urinate freely with urine
output of 20 cc for 8
hours with a total intake
of 650 cc, with
transparent urine, dark
amber in color, with
aromatic smell
The patient is able to
urinate freely with urine
output of 50 cc for 8
hours with a total intake
of 450 cc , with
transparent urine, dark
amber in color, with
aromatic smell
The patient is able to
urinate freely with urine
output of 40 cc for 8
hours with a total intake
of 540 cc, with
transparent urine, dark
amber in color, with
aromatic smell
c. abnormalities The patient has proper
excretory process
The patient has
decreased urine output.
The patient has
decreased urine output.
The patient has
decreased urine output.
IX. State of Skin And
Appendages
a. skin The patient has intact
and fair skin, with even
distribution of
temperature, with
proper moisture, with
normal skin turgor
The patient has pale,
cold and dry skin, with
decreased skin turgor,
with edema noted on
both lower extremities,
with round- shaped
hyperpigmentations on
both tibial area, with
small dry necrosed
tissue on the right pedal
phalange.
The patient has pale,
cold and dry skin, with
decreased skin turgor,
with edema noted on
both lower extremities,
with round- shaped
hyperpigmentations on
both tibial area, with
small dry necrosed
tissue on the right pedal
phalange.
The patient has pale,
cold and dry skin, with
decreased skin turgor,
with edema noted on
both lower extremities,
with round- shaped
hyperpigmentations on
both tibial area, with
small dry necrosed
tissue on the right pedal
phalange.
b. hair The patient has fine,
strong and silky hair,
with even distribution,
with normal porosity.
The patient has fine,
strong and dry hair, with
even distribution, with
decreased porosity.
The patient has fine,
strong and dry hair, with
even distribution, with
decreased porosity.
The patient has fine,
strong and dry hair, with
even distribution, with
decreased porosity.
c. nails The patient has well
trimmed nails, properly
keratinized, with pink
nail beds.
The patient has well
trimmed nails, properly
keratinized, with pale
nail beds.
The patient has well
trimmed nails, properly
keratinized, with pale
nail beds.
The patient has well
trimmed nails, properly
keratinized, with pale
nail beds.
X. State of Physical
Rest and Comfort
a. sleep/rest pattern The patient is able to
sleep 6-8 hours a day
with resting time in the
middle of the day
The patient is able to
sleep 6-8 hours a day
with resting time in the
middle of the day
The patient is able to
sleep 6-8 hours a day
with resting time in the
middle of the day
The patient is able to
sleep 6-8 hours a day
with resting time in the
middle of the day
b. presence of
pain/discomfort
The patient is
comfortable.
The patient is
comfortable.
The patient is
comfortable.
The patient is
comfortable.
c. use of supportive aids No use of supportive
aids
No use of supportive
aids
No use of supportive
aids
No use of supportive
aids
XI. Emotional Status
a. emotional reaction The patient is able to
react appropriately to
situations, with happy
disposition
The patient has a fair
disposition. He feels
irritable,
The patient has a fair
disposition. He feels
irritable and seldom
smiles.
The patient is able to
react appropriately to
situations, with happy
disposition
b. body image The patient has a high
self-esteem and is
confident with his body
structures
The patient has a high
self-esteem and is
confident with his body
structures
The patient has a high
self-esteem and is
confident with his body
structures
The patient has a high
self-esteem and is
confident with his body
structures
c. ability to relate to
others
The patient is
cooperative, with less
interaction to people
around him.
The patient is
cooperative, with less
interaction to people
around him.
The patient is
cooperative, with less
interaction to people
around him.
The patient is
cooperative, with less
interaction to people
around him.
E. Diagnosis/ ImpressionESRD 2˚ DM nephropathy DM type II
CHAPTER IIIReview of Anatomy and Physiology
• The anatomy and physiology of the human kidney, evolved over millennia, enable this organ to excrete waste, regulate homeostatic processes and produce important hormones.
• One of the most complex, beautifully “engineered” organs of the human body, the kidneys perform several essential tasks including the excretion of waste products, the maintenance of homeostatic balance in the body and the release of important hormones. To achieve this, human kidneys have a highly developed, superbly refined anatomy and physiology.
• Location and Basic Structure of the Kidneys• The kidneys are located near the vertebral column at
the small of the back; the left kidney lying a little higher than the right. Each is identical in structure and function. They are bean-shaped, about 10 cm long and 6.5 cm wide. Each kidney comprises an outer cortex and an inner medulla. The kidney is supplied with oxygenated blood via the renal artery and drained of deoxygenated blood by the renal vein. In addition, urine produced by the kidney as part of its excretory function, drains out via narrow “tubules” and the ureter, in turn connected to the bladder.
• The Nephron• The main functional unit of the kidney is the nephron.
There are approximately one million nephrons per kidney. The role of nephrons is to make urine by:
• * Filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large “macromolecules” like proteins are untouched.
• * Recycling the required quantities of useful solutes which then re-enter the bloodstream. (A process called reabsorption)
• * Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.
• Filtration and Reabsorbtion in the Kidneys• During progress through the nephron, some solutes like sodium
chloride, potassium and glucose are reabsorbed, along with water, back into the bloodstream. This maintains a correct balance of these chemicals within the blood, assisting blood pressure regulation, for example. The filtration and reabsorbtion of glucose within the kidneys also helps to maintain correct levels of vital blood sugars. When this regulation breaks down very serious health consequences can follow.
• Urea and uric acid are nitrogen containing waste products from metabolic processes in the body. These substances are potentially toxic and are partially excreted by the kidneys to maintain good health. Interestingly, of the filtrate which enters each nephron from the blood, only about 1% actually leaves the body as urine because of the various reabsorbtion mechanisms driven by osmosis, diffusion, and active transport.
• Tubular Secretion in the Kidneys• Another, less familiar, mechanism for urine production in the
kidneys is tubular secretion. Specialized cells move solutes directly from the blood into the tubular fluid. For example, hydrogen and potassium ions are secreted directly into the tubular fluid. This process is “coupled” or balanced by the re-uptake of sodium ions back into the blood.
• Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels, is important in maintaining correct blood pH. When the blood is too acidic (acidosis) more hydrogen ions are secreted. If the blood becomes too alkaline (alkalosis), hydrogen secretion is reduced. In maintaining blood pH within normal limits (about 7.35–7.45) the kidney can produce urine with pH as low as that of acid rain or as alkaline as baking soda!
• The Kidney as an Endocrine Gland• In addition to its excretory and homeostatic roles, the
kidneys also release two important hormones into the blood. These are:
• * Erythropoietin which acts on bone marrow to increase the production of red blood cells
• * Calcitriol which promotes the absorption of calcium from food in the intestine and acts directly on bones to shift calcium into the bloodstream.
• Finally the kidney produces the enzyme renin, an important regulator of blood pressure.
CHAPTER IVPATHOPHYSIOLOGY
Pre-disposing Factors Actual Rationale
Increasing Age Mr. is 54 years old. Among older adult ( 24-64 y/o) and elderly person, the
presentation and course of renal failure may be altered
because of age-related changes in the kidney and
occurrent medical conditions . Normal aging is associated
with a decline in the GFR and subsequently with reduced
homeostatic regulation under stressful conditions. This
reduction of GFR makes these persons more susceptible
to the detrimental effects of nephrotoxic drugs and other
medical conditions.( Porth, 2005)
Sex The client is a male. ESRD is more prevalent in men, 54 % of ESRD patients
are men whereas 46% are women. This also refers to the
dominance of males in the relapse of toxins (Nowak,
2005). In both study populations, males were more likely
to have ESRD due to hypertension.(
http://www.niddk.nih.gov/fund/reports/womenrd/poster/po
ster5.htm)
A.Etiology
Race Mr. is from an Asian ethnic
group( Filipino)
Renal disease is more common in patients of Asian ethnic
origin than white Caucasians in the United Kingdom. The
incidence rate of end-stage renal failure expressed for the
estimated population of pts. with diabetes Mellitus in
Asian ethnics was 486.6 cases per M person years
compared to 35.6 in white caucasians. The high incidence
of end stage renal failure had secondary to DM for most
patients in Asian ethnic group. (Bullock, 2000)
Genetics Maternal side: Hypertension (+)
Paternal side: Diabetes Mellitus 2 (+)
Diabetes Mellitus from a genetic predisposition (i.e.
diabetogenic genes), a hypothetical triggering event that
involves an environmental agent that incites an immune
response and immunologically mediated beta cell
destruction. Much evidence has focused on the inherited
major compatibility complex ( MHC) genes that encode
three human leukocyte antigens ( HLA_DP, HLA_DQ and
HLA_DR) found on the surface of body cells. Insulin gene
regulating eta cell replication and function has been
identified on chromosome 11. (Porth, 2005)
Precipitating Factors Actual Rationale
Lifestyle(diet, exercise,) Mr. loves to eat salty, fatty & sugary
foods such as
cured meats (ham, sausage, bacon,
corned beef,), chicken and pork viand,
cheese and butter, coke soda(more often
every meal) and coffee.
Mr. has sedentary lifestyle with no or
irregular .
physical activity. He is an owner of one bi
g transportation company and works only
in computer and papers.
Foods that are high in calories (saturated fats), lack of
antioxidants and fibbers as well as high in phosphorus,
potassium, and
sodium can lead to a high probability of occurrent of ma
ny a diseases such as renal failure. These foods can bui
ld up in the bloodstream and cause harm when they can
not be eliminated by the kidneys. ( Mc Cance, 1994)
A lack of physical activity is one of the leading
causes of preventable death
worldwide. It contribute to anxiety, high blood pressure
and cardiovascular disease due to reduce insulin sensiti
vity, increase blood sugar and cholesterol levels. ( McCa
nce, 1994)
Medications Client usually medicate himself with over
the counter drugs such Paracetamol,
mefenamic acid, aspirin, etc. whenever
he got fever or experience pain.
The deleterious effects of aspirin and the NSAIDS on
the kidney are thought to result from their ability to
inhibit the vasodilatory effects of prostaglandin ,
predisposing to ischemia of the renal papillae. (Porth,
2007)
Toxins At 17 year old, Mr. started to drink
alcohol beverages (beer-240ml) and
can consumed 14 bottles a day.
Toxic substances such as alcohol can damage the
kidneys by causing a decrease in renal blood flow:
obstructing urine flow, directly damaging
tubulointerstitial structures, or by producing
hypersensitivity reactions
( Porth, 2007)
Pre-existing factors Actual Rationale
Diabetes Mellitus type2 The client was diagnosed with DM type 2 at
the age of 26 years old and started inducing
insulin injection 2x a day morning &
evening). This complication was further
diagnosed into a more serious condition of
diabetic nephropathy and just last year, he
was diagnosed of ESRD.
Long term complications, which are becoming more
common as more people live longer and gradually leadt to
the disabilities of body systems. It appears that increase
level of blood glucose may play a role in micro vascular
complications certainly lad to nephropathy.
Nephropathy or renal disease secondary to diabetic
micro vascular changes in the kidney is a common
complication of diabetes. If blood glucose level are elevated
consistently for a significant period of time, the kidneys
filtration mechanism is stressed, allowing blood proteins to
leak into the urine . As a result, the pressure in the blood
vessels of the kidney increases. It is thought that this
elevated pressure serve as the stimulus for the development
of nephropathy.
Patients with type 2 diabetes develop renal ds. Within
10-15 years after diagnose of diabetes.(Smeltzer, 2008)
Hypertension Mr. has a BP of 120/110 . The kidney is an essential organ in the long term
control of pressure. Hypertension attributed to the
rennin-angiotensin mechanism within the kidney.
Continued high pressure for hypertension destroy the
arteries of the kidneys leading to kidney failure.
(Smeltzer, 2008)
Symptomatology Actual Rationale
Neurotic Manifestation
-confusion
-seizures
-agitation
-inability to concentrate
/
/
Neurotic style is the outward manifestation of the
inability to introspect, learn about one's perception of a
situation, respective role,effect on others' effect on self
for developing and engaging in more effective bahavior
(C. Porth, 2007).
•Symptomatology
Cardiovascular Manifestation
-Hypertension
-Hyperkalemia
-Edema
-Pulmonary edema
-Pericarditis
-Hyperlipidemia
/
/
Due to sodium and water retention
or for activation or renin
angiotensin aldosterone system.
Hypertension is the most
important modifiable risk factor for
end-stage renal disease,
hyperlipidemia exacerbated by
uncontrolled diabetes mellitus (C.
Porth, 2007).
Anemia
Nausea and Vomiting
Generalized itching
Muscle weakness
Weight loss
/
/
/
/
/
In renal failure, erythropoietin production usually is insufficient to
stimulate adequate RBC production by the bone marrow. The
accumulation of uremic toxins further suppresses RBC
production in the bone marrow, and the cells the are produced
have a shortened life span (C. Porth, 2007).
A possible cause of nausea and vomiting is the decomposition
of the urea by the intestinal flora, resulting in a high
concentration of ammonia. PTH increases gastric acid secretion
and contribute to gastrointestinal problems (C. Porth, 2007).
Pruritus results from the high perspiration owing to decreased
size of the sweat glands and diminished activity of the oil glands
(C. Porth, 2007).
Decreased levels of active vitamin D lead to a decrease in
intestinal absorption of calcium with a resultant increase in PTH
levels vitamin D also regulates osteoblast differentiation,
thereby affecting bone matrix formation and mineralization.
Abnormal breakdown of the nutrients in the body can cause
weight loss(C. Porth, 2007).
• D. Narrative • Chronic renal failure can result from a number of conditions that
cause permanent loss of nephrons, including diabetes and hypertension, this may also resulted from different factors both genetics and environmental agents.
• Typically, the signs and symptoms of chronic renal failure occurs gradually and do not become evident until the disease is far advanced. This is because of the amazing compensatory ability of kidneys. Thus, progression of chronic renal failure occurs in gradual deterioration of glomerular filtration, tubular reabsorption capacity and endocrine functions of the kidneys. Four stages had been identified in chronic renal failure: Diminished renal reserve, renal sufficiency, renal failure and end – stage renal disease.
• The GFR is considered the best measures of overall function of the kidneys. Its normal function for young adults is 120-130 mL/ 130 mL/min. In the first stage, Diminished Renal Reserve, GFR drops to approximately 50% of normal. At this point, the serum BUN and creatinine levels still are normal , nd no symptoms of impaired renal function are evident. Because of diminished reserve, development of azotemia increases with an additional renal insult, due to nephrotoxic drugs.
• Stage 2- Renal Insufficiency represents a reduction in the GFR to 20% to 50% of normal. The kidneys initially have tremendous adequate capabilities. As nephrons are destroyed, the remaining nephrons undergo changes to compensate for those that are lost. In this process, remaining nephrons must filter more solutes particles from blood. Thus, during this stage azotemia, anemia, and hypertension begin to appear. Furthermore, retard deterioration of renal function leads kidneys in difficulty eliminating the waste products and makes the remaining nephrons easily disrupte, after which renal failure progresses rapidly.
• Renal failure develops when the GFR is less than 20% of normal. At this point, the kidneys cannot regulate volume and solute composition , and edema, metabolic acidosis and hyperkalemia develop. Overt uremia may ensue with neurologic, gastrointestinal and cardiovascular manifestations.
• End-stage renal disease( ESRD) occurs when the GFR is less than 5% of normal.All renal functions are severely decreased, and homeostatis is significantly altered Thus, resulted from multiple organ failure.At this final phase of renal failure, treatment with dialysis or transplantation is necessary for survival.
•
CHAPTER VCOURSE IN THE WARD/TREATMENT/
INTERVENTIONS
Date/Time Order
March 3,2010 Decrease Oxygen to PRN
For chest X-ray portable AP sitting upright
May sit-up on bed
N-AC (Flumucil) 600g 1 tab + ¼
For PFI on Monday
March 5, 2010
11:45am
Please give another dose of alphanedon (xanon)
250µmg 1 tab now
March 6,2010
10:20am
May do cervical X-ray portable for request
11pm Increase Mesoperem to 500g IV q12* with
supplemental extra dose post HD
A. MedicalA.1 Doctor’s Order
March 7,2010
8am May discontinue domperidon
12:30pm Increase norgesic forte 1 tab TID RTC PC
3am MIR C- Nephro
For HD on Tuesday (prior to PPT)
March 8, 2010 Sitaglipitin (Sonuria) 50mg, 1 tab OD as lunchtime
Decrease norvomix 14u (2 pre dinner)
8am Heparin on Tuesday TID
1pm Suggest transfusion of 1 unit PRBC during HD
tomorrow if Dr. with AP
Continue norgenic forte TID x 3 days then decrease prn
3:45pm Please secure 1 unit PRBC of patients blood during
hemodialysis tomorrow
March 9, 2010 Stand by 1 unit PRBC
12pm Resume domperidone 1 tab TID
Omeprazole 40 mg 1 tab OD
Decrease novomix 18u SQ q6* (5-11-5-11)
12:15 Agreed to be reffered to Dr. isaguire for co-ngt.
12:15 Agreed to be reffered to Dr. isaguire for co-ngt.
March 10, 2010
9:50am
MRIC – refer
Continue medications
11:20am Decrease norvomix - 14u SQ AC-BP
10u SQ AC-Soppu (give insulin just before eating)
10:50pm MRIC
Update Dr. maglana Referred AD schedule tomorrow
Will await infectious clearance and once cleared, inform cardio
service with out fail
For possible insertion of permanent pacemaker
Test Name Result
Blood Type “A”
RH Type Pos (+)
Date Test Result Normal Values Justification
February
20, 2010
Hemoglobin 110 140-170g/L >decreased Hemoglobin may lead to
anemia that can result to kidney
disease and other chronic illness.
(http://www.aabb.org).
A.2 Laboratories/ diagnostic procedure1. Hematology
Hematocrit 0.33 0.40-0.50 >Decreased Hematocrit are the
same as for Hemoglobin and may
indicate low thymus function (
http://www.wisegeek.com/what-is
-a-differential-white-cell-count.ht
m)
Erythrocytes 4.08 4.5-5.0 >Decreased Erythrocyte may due
to anemia and low Hemoglobin. A
blood test that measures the
number of RBC's (
http://www.wisegeek.com/what-is
-a-differential-white-cell-count.ht
m)
Leukocytes 10.70 5.0-10.0 10ˆ9/L High white blood cell count could
indicate Infection,
inflammation, trauma,
tissue damage,
use of certain medications, such
as corticosteroids, antibiotics or
anti-seizure drugs, and allergy
(http://www.steadyhealth.com/arti
cles/What_does_high_white_bloo
d_cells_count_indicate__a723.ht
ml).
Segmenters 0.684 0.55-0.65 > An increase in value of these
cells generally indicates the
presence of an acute bacterial
infection or some inflammation
going on inside the body (
http://www.wisegeek.com/what
-is-a-differential-white-cell-coun
t.htm)
Lymphocytes 0.196 0.35-0.45 >people with a decreased
lymphocyte count may be more
susceptible to certain types of
infections
(http://www.associatedcontent.
com/article/2044911/what_cau
ses_a_decreased_lymphocyte.
html)
Eosinophils 0.022 0.02-0.04 Normal
Monocytes 0.098 0.06-0.12 Normal
Basophils 0.000 0. -0.02 Normal
MCV 84.5 80-97fL Normal
MCH 29.10 27.0-31.2 pg Normal
MCHC 340 318-354 Normal
Date Test Result Normal Values Justification
March 8, 2010 Hemoglobin 98 140-170g/L >decreased Hemoglobin may
lead to anemia that can result
to kidney disease and other
chronic illness.
(http://www.aabb.org).
Hematocrit 0.30 0.40-0.50 >Decreased Hematocrit are the same as
for Hemoglobin and may indicate low
thymus function (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)
Erythrocytes 3.03 4.5-5.0 >Decreased Erythrocyte may due to
anemia and low Hemoglobin. A blood
test that measures the number of RBC's (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)
Leukocytes 8.60 5.0-10.0 10ˆ9/L Normal
Thrombocytes 383.00 140-440 10ˆ9/L Normal
Segmenters 0.660 0.55-0.65 > An increase in value of these cells
generally indicates the presence of an
acute bacterial infection or some
inflammation going on inside the body (
http://www.wisegeek.com/what-is-a-differ
ential-white-cell-count.htm)
Lymphocytes 0.180 0.35-0.45 >people with a decreased lymphocyte
count may be more susceptible to
certain types of infections(
http://www.associatedcontent.com/articl
e/2044911/what_causes_a_decreased_
lymphocyte.html
)
Eosinophils. 0.061 0.02-0.04 >The level of eosinophils can be too
high in response to allergies. They can
also be too high when exposed to
certain types of bacteria (
http://www.medfriendly.com/eosinop
hil.html
)
Monocytes 0.099 0.06-0.12 Normal
Basophils 0.000 0. -0.02 Normal
MCV 75.40 80-97fL >The MCV relates to the
average size of the red blood
cell. MCV is decreased in Iron
deficiency (
http://www.wisegeek.com/what-i
s-a-differential-white-cell-count.
htm)
MCH 24.10 27.0-31.2 pg >The MCH is decreased in the
same conditions as the MCV (
http://www.wisegeek.com/what-i
s-a-differential-white-cell-count.
htm)
.
MCHC 319 318-354 Normal
Date Test Result Normal Values Justification
February
24, 2010
Clotting Time 4'30” 2-6 min-sec Normal
Bleeding Time 2'45” 1-3 min-sec Normal
Date Test Result Normal Values Justification
March 8, 2010 Clotting time 4' 2-6 min-sec Normal
Bleeding time 1'2'” 1-3 min-sec Normal
Date Test Result Normal Values Justification
February
20, 2010
Phosphorus 3.82 0.81-1.58 mmol/L Hyperphosphatemia is common in
renal failure. Other causes include
increase intake, decrease output or a
shift from the intracellular to
extracellular space.(Brunner et al.,,
Medical Surgical Nursing, 11th ed., pg.
332)
Calcium 1.76 2.12-2.52 mmol/L Hypocalcemia is common in patients
with renal failure because this patients
frequently have elevated serum
phosphate level. Hyperphosphatemia
usually causes a reciprocal drop in the
serum calcium level. (Brunner et al.,,
Medical Surgical Nursing, 11th ed., pg.
325)
2. Serum Electrolytes
Magnesium 1.69 0.74-0.99 mmol/L > Most common cause of
hypermagnesia is renal
failure. In fact, most
patients with advanced
renal fialure have atleast
a slight elevation in serum
magnesium levels. This
condition is aggravated
when such patients
receive magnesium to
control seizures or
inadvertently take one of
the many commercial
antacids that contain
magnesium salts.
(Brunner et al.,, Medical
Surgical Nursing, 11th ed.,
pg. 330).
Potassium 7.00 3.5-5.1 mmol/L The major cause of
hyperkalemia is decreased renal
excretion of potassium. Fot this
reason, significant hyperkalemia
is commonly seen in patients
with untreated renal failure,
particularly those in whom
potassium levels increase as a
result of infection or excessive
intake of potassium in foods or
medications.(Brunner et al.,,
Medical Surgical Nursing, 11th
ed., pg. 323).
Sodium 122.00 136-145 mmol/L > Decreased sodium is
associated with parallel changes
in osmolality. Sodium has major
role in controlling water
distribution throughout the body,
because it does not easily cross
the cell wall membrane and
because of its abundance and
high concentration in the body.
(Brunner et al.,, Medical Surgical
Nursing, 11th ed., pg. 315).
Date Test Result Normal Values Justification
Februry
25, 2010
TSH (Thyroid
Stimulating
Hormone)
0.751 0.27- 42uIu/ml Normal
3. Immunologic Section
• 4. Chest Xray• March 8, 2010• A comparison with the radiograph dated March
3, 2010 discloses no change in the infiltrates and degree of pulmonary congestion in both lungs. The lateral cp sinuses are sharp.
• 5. Chest A.P. Supine Adult• March3, 2010 2:42 PM• Heart size cannot be evaluated due to the position.
Pulmonary vascularity is accentuatedwhich may be due to the position. Both lungs are hazy. The lateral costophrenic sinuses are sharp. Hili are not enlarged. Visualized osseus structures are normal.
• Impression:• Consider Pneumonic
• 6. Cervical Spine ADLO• March 6, 2010 1:00 PM• There is normal cervical lordosis. Anterior
spurs are seen from C4 to C5. Vertebral bodies show normal height. Disc spaces, neural foraminae + pedicles are preserved. Prevertebralsoft tissue are not thickened.
• Impression:• Degenerative Joint Disease
• A.3 Hemodialysis• • March 9, 2010• HEMODIALYSIS• In hemodialysis (HD), blood is shunted through an
artificial kidney (dialyzer) for removal of toxins/excess fluid and then returned to the venous circulation. Hemodialysis is a fast and efficient method for removing urea and other toxic products and correcting fluid and electrolyte imbalances but requires permanent arteriovenous access. Procedure is usually performed three times per week for 4 hr. HD may be done in the hospital, outpatient dialysis center, or at home.
• Nursing Management:• Evaluate reports of pain, numbness/tingling; note extremity
swelling distal to access.• Monitor temperature. Note presence of fever, chills,
hypotension.• Measure all sources of I&O. Have patient keep diary.• Weigh daily before/after dialysis run.• Monitor BP, pulse, and hemodynamic pressures if available
during dialysis.• Place patient in a supine/Trendelenburg’s position as
necessary.• Assess skin around vascular access, noting redness, swelling,
local warmth, exudate, tenderness.• Avoid contamination of access site.• Monitor serum sodium levels. Restrict sodium intake as
indicated.
Generic
Name
Brand
Name
Classificatio
n
Mechanism
of Action
Indication Contra-
Indication
Adverse
Reaction
Dosag
e
Nursing
Responsibilit
y
omeprazol
e
Prilosec Prilosec
Omeprazol
e is in a
class of
drugs called
proton
pump
inhibitors
(PPI) that
block the
production
of acid by
the
stomach.
Omeprazol
e is in a
class of
drugs called
proton
pump
inhibitors
(PPI) that
block the
production
of acid by
the
stomach.
>Contraindicate
d to those who
are
hypersensitive to
the drug.
diarrhea,
nausea,
vomiting,
headaches
, rash and
dizziness.
40 mg
(8am)
1 tablet
P.O
O.D
>Advise Pt.
To take
caution
engaging in
activities
requiring
alertness
such as
driving or
using
machinery.
B. Pharmacological
Generic Name
Brand Name
Classification Mechanism of Action
Indication Contra-Indication Adverse Reaction
Dosage Nursing Responsibility
desloratadineAcnius antihistamine It is used to
treat the symptoms caused by histamine. Histamine is a chemical that is responsible for many of the signs and symptoms of allergic reactions
.>treatment of allergies. Provides relief of seasonal allergy symptoms and allergic nasal conditions (rhinitis) such as runny nose, sneezing, and watery/itching eyes
>Contraindicated to those who are hypersensitive to the drug and its components
>dizziness, fatigue, heache, tachycardia, dry mouth
5mg(8am)1 tablet P.OO.D
>Advise Pt. To take caution engaging in activities requiring alertness such as driving or using machinery. >pt. May report Adverse Reaction to the drug.>instruct pt. To immediately place the tablet on hius tongue after open ing
Generic
Name
Brand
Name
Classificatio
n
Mechanis
m of Action
Indication Contra-
Indication
Adverse
Reaction
Dosag
e
Nursing
Responsibilit
y
Ketoprofen Fastu
m Gel
Analgesic Relieves
pain, fever
and
inflammati
on. It
inhibits
prostaglan
din
synthesis
Mild to
moderate
pain
minor aches
and pain or
fever
Hypersensitivity
to the drug
headache,
dizziness,
nervousne
ss, skin
rashes,
pruritus,
tinnitus,
blurred
vision
As
ordere
d
>tell patient
to report any
allergic
reaction
Brand
Name
Classification Mechanism
of Action
Indication Contra-Indication Adverse
Reaction
Dosage Nursing
Responsibility
Caltrate
Plus
Cacium
Supplement
Replaces
and
maintains
calcium;
raises
calcium level
Supplement
for Ca
deficiency &
conditions that
require
increased Ca
intake; may
reduce the
risk of
osteoporosis
later in life.
>Contraidicated
in patients with
hypecalcemia,
and renal calculi
Pain,
bradycardia,
cardiac
arrest,
nausea and
vomiting
1 tab
PO od
>Should be
taken with food
>instruct
patient to
report any sign
of its adverse
reaction
Generic
Name
Brand
Name
Classificati
on
Mechanism
of Action
Indication Contra-
Indication
Adverse
Reaction
Dosage Nursing
Responsibility
MeropenemMeronem anxiolytics Readily
penetrates
the cell wall
of most
gram
positive
and gram
negative
bacteria to
reach
penicillin-
binding
protein
targets,
where it
inhibits cell
wall
synthesis.
Complicated
skin and skin
structure
infection
cause by
Staphylococc
us aureus
>Hypersensitivit
y to the drug
>Use cautiously
to patient with
renal
impairment
Headache,
insomnia,
confusion,
tachycardia,
diarrhea.
1 vial IV
infusion
>warn patient
to avoid
hazardous
activities that
require
alertness and
motor
cooordination
until CNS
affects are
known.
>advise pt. To
report any
signs of
Adverse
effects of the
drug.
CHAPTER VIDISCHARGE PLANNING
Basic health teaching is the greatest need of a patient after admission. The nurse should clearly teach the patient and family on how to comply with medications and other regimen to facilitate improvement of the patient health status thus providing also continuity of care to the patient.
• M – Medication• Explained the importance of the prescription including the name of the
drug (GENERIC AND BRAND NAME), purpose of medication, duration of administration, appropriate dosage, the adverse effect, side effect, formulation of medications.
• Informed the patient and the family about the medication prescribed by the physician including the purpose, dose, schedule and the side effect of the drugs.
• Instructed the patient and the family that the compliance of the regimen is really needed and may discontinue if ordered by the physician.
• Encouraged the patient and the family to report any unusualities regarding the administration of drugs.
• E – Exercise• Informed the patient and the family to have a moderate exercise to
promote physiological well-being, reducing the risk and strengthening the immune system.
• Encouraged the patient to have a deep breathing exercise.• Light exercise on both arms and legs to promote circulation in the
heart.• T – Treatment• Encouraged the patient to keep follow-up appointment.• Medications are recommended for this aim to improve the proper
blood flow and proper circulation in our body. This promotes healing and reduces pain and discomfort.
• Nutritional management-nutrition, proper diet and weight control• Prompt exercise• Health teachings to facilitate awareness an knowledge to the
patient regarding his illness.
• H – Hygiene• Encouraged the patient to have a proper hand washing with soap and
water before and after eating and whenever they spend time around people with cold or other illness.
• Encouraged patient to brush teeth properly.• Encouraged patient to keep hands away from his nose and mouth.• Educate the patient on proper hygiene by instructing to wear cotton
clothes and changing underwear to avoid irritation and provide comfort.• Educate the patient properly initiate the regular hygiene with assistance as
necessary.• O – Outpatient order• Encouraged patient to stay indoors with the doors and windows closed if
air pollution levels are high.• Encouraged patient to keep himself away from smoke.• Encouraged patient to have enough sleep and rest everyday.• Encouraged the significant other to monitor the temperature of the
patient.• Provided patient information regarding his condition and instruct to follow
why the doctor instructed.
• D – Diet• Encouraged patient to eat healthy and well-balanced diet.• Encouraged patient to avoid foods that are high in carbohydrates,
fatty foods, and salty foods.• Provided all the essential food constitutes (vitamins and minerals).• Patient must maintain the reasonable weight.• Instructed the patient to eat nutritious food such as fruits and
vegetables and in strict diabetic diet low salt and low fat diet.• Increased oral fluid intake.• S – Spiritual• Encourage patient and the family to maintain realistic hope over the
course of the illness.• Encourage the patient and the family to take time to be introspective
in the search for peace and harmony.• Help patient and the family obtain spiritual help.• Encourage patient to pray everyday and ask for God’s guidance and
strength in order to lighten up his feelings towards his condition.