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ACKNOWLEDGEMENT
First, we would like to thank God for giving us the strength and knowledge,
wisdom and perseverance to finish this study. We would like to express our
deepest gratitude to all the people who gave us the possibility to complete this
study, And to all or parents, for their financial and emotional support.
We would also recognize Mrs. Maria Celeste M. Miranda, RN, our RLE
clinical instructor for giving us enough time to prepare and finish this study.
Our group would also like to acknowledge our Nursing Care Management
lecturer, Mrs. Syrilla Joan Domingo-Valdez II, in developing our knowledge in
order to go through this study. The staff nurses of St. Cabrini Medical Center, for
helping and guiding us all throughout our clinical duty. Above all, we extend our
deepest gratitude to our Dean Ritchie Villasanta. We thank her for continuously
developing activities that are very helpful for us, nursing students. The school
curriculum is very beneficial to us as our institution is developing responsible and
excellent health care practitioners.
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INTRODUCTION
Kidney stones are painful urinary disorders that start as salt/chemical crystals
which precipitate out from urine. Under normal circumstances, the urine contains
substances that prevent crystallization but for patients with this condition, these
inhibitory substances are ineffective. Tiny crystals will pass out along with the
urinary flow without causing problems. At least 1% of people will pass a kidney
stone during their lifetime, producing some of the most severe pain possible.
Urolithiasis (urinary tract calculi or stones) and nephrolithiasis (kidney calculi or
stones) are well-documented common occurrences in the general population of
the United States. The etiology of this disorder is mutifactorial and is strongly
related to dietary lifestyle habits or practices. Proper management of calculi that
occur along the urinary tract includes investigation into causative factors in an
effort to prevent recurrences. Urinary calculi or stones are the most common
cause of acute ureteral obstruction. Approximately 1 in 1,000 adults in the United
States are hospitalized annually for treatment of urinary tract stones, resulting in
medical costs of approximately $2 billion per year
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SIGNIFICANCE OF STUDY
PURPOSE OF THE STUDY
Our study would primarily benefit the nursing students in our institution.
This paper would serve as their resource material if they are conducting research
related to ours.
It would also help the next generation of student nurses in proposing
projects that would combat health issues in their course. They can borrow our
paper and study it as they develop projects for their subordinates. The fact that
our study is accurate, it would serve as an important basis and tool.
The private and public hospitals can also use our paper as they come up
with health missions. They could analyze our data gathered; determine health
cases, what health concern to focus to and what actions to be developed to fight
health problems.
Our paper would also help the professors in our institution. They could
have this as their material in imparting learning to their students
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Related Literature
The literature reflects the incidence of kidney (renal) stone formation to be
greater among white males than black males and three times greater in males
than females. Although kidney stone disease is one-fourth to one-third more
prevalent in adult white males, black males demonstrate a higher incidence of
stones associated with urinary tract infections caused by urea-splitting bacteria.
Kidney stones are most prevalent between the ages of 20 to 40, and a
substantial number of patients report onset of the disease prior to the age of 20.
The lifetime risk for kidney stone formation in the adult white male approaches
20% and approximately 5% to 10% for women. The recurrence rate for kidney
stones is approximately 15% in year 1 and as high as 50% within 5 years of the
initial stone.
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Anatomy and Physiology of the Urinary Tract
The urinary tract is made up of the kidneys, two ureters, the bladder, and urethra.
The major components are the kidneys, a pair of bean-shaped organs located
below the ribs near the middle of one's back. The kidneys comprise a complex
filtration system made up of individual nephrons that work together to remove
waste products from the blood, which are eliminated from the body in the form of
urine. The kidneys also function to maintain a stable balance of salts and other
substances in the blood, as well as to produce a hormone erythropoietin, which
triggers the production of red blood cells in the bone marrow.
The ureters are tube-like structures that transport the urine from the kidneys to
the bladder where the urine is stored. Muscles called sphincters tighten around
the urethra to prevent urine from leaking out. There are two sphincters: the
internal is not controlled consciously, while the external sphincter is under
voluntary control. The bladder is elastic and expands as it fills with urine. When
the bladder reaches a certain capacity, which differs for each individual, the brain
sends impulses to the internal sphincter to relax and other impulses to a muscle
called the detrusor to contract and expel the urine out the urethra. This process is
under the voluntary control of the individual, who can hold the urine until social
circumstances allow for urination. (Loss of this control is urinary incontinence.)
Urine is normally "sterile," meaning that it usually contains no bacteria. The body
accomplishes this through several methods. First, the two sphincter muscles that
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prevent urine leaking from the bladder to the urethra, also prevent the bacteria
that normally colonize the skin from ascending through the meatus (the opening
in the urethra) into the bladder. Second, the length of the urethra makes it difficult
for bacteria to get to the bladder.
The fact that women have a much shorter urethra than men accounts for the five-
fold increase of UTIs among women compared to men. Finally, if bacteria do
make it to the bladder, the body is equipped with valves where the ureters empty
into the bladder, a region known as the trigone. These valves prevent the "reflux"
of urine, and any bacteria present, back up into the kidneys. Further, the bladder
almost completely empties when urination occurs, so that any bacteria present
should be excreted as well. Nevertheless, despite all these defense mechanisms,
infections sometimes occur.
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Pathophysiology of Nephrolithiasis
Escherichia coli is the most common microorganism implicated in urinary tract
infection. E. coli is an aerobic, Gram-negative bacterium and is resident flora in
the GIT. When gaining access into the urine tract (which is sterile), E. coli causes
infection. Women are particularly vulnerable due to a short urethra and close
proximity between the urethra and anus.Mechanical obstruction of the urinary
tract, such as with renal calculi or an enlarged prostate and introduction of
urinary catheters and bladder can also increase the likelihood of developing a
urinary tract infection.
Any factor that reduces urinary flow or causes obstruction, which results in
urinary stasis or reduces urine volume through dehydration and inadequate fluid
intake, increases the risk of developing kidney stones. Low urinary flow is the
most common abnormality, and most important factor to correct with kidney
stones. It is important for health practitioners to concentrate on interventions for
correcting low urinary volume in an effort to prevent recurrent stone disease.
Contributing Factors of Nephrolithiasis
Sex. Males tend to have a three times higher incidence of kidney stones than
females. Women typically excrete more citrate and less calcium than men, which
may partially explain the higher incidence of stone disease in men
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Ethnic Background. Stones are rare in Native Americans, Africans, American
Blacks, and Israelis
Family History. Patients with a family history of stone formation may produce
excess amounts of a mucoprotein in the kidney or bladder allowing crystallites to
be deposited and trapped forming calculi or stones. Twenty-five percent of stone-
formers have a family history of urolithiasis. Familial etiologies include absorptive
hypercalciuria, cystinuria, renal tubular acidosis, and primary hyperoxaluria
Medical History. Past medical history may provide vital information about the
underlying etiology of a stone's formation. A positive medical history of skeletal
fracture and peptic ulcer disease suggests a diagnosis of primary
hyperparathyroidism. Intestinal disease, which may include chronic diarrheal
states, ileal disease, or prior intestinal resection, may be a predisposition to
enteric hyperoxaluria or hypocitraturia. This may result in calcium oxalate
nephrolithiasis because of dehydration and chemical imbalances. Irritable bowel
disease or intestinal surgery may prevent the normal absorption of fat from the
intestines and alter the manner in which the intestines process calcium or
oxalate. This may also lead to calculi or stone formation. Patients with gout may
form either uric acid stones or calcium oxalate stones. Patients with a history of
urinary tract infections (UTI) may be prone to infection nephrolithiasis caused by
urea-splitting bacteria. Cystinuria is a homozygous recessive disease leading to
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stone formation. Renal tubular acidosis is a familial disorder that causes kidney
stones in most patients who have this disorder.
Dietary Habits. Fluid restriction or dehydration may cause kidney stone
formation. Dietary intake that is high in sodium, oxalate, fat, protein, sugar,
unrefined carbohydrates, and ascorbic acid (vitamin C) has been linked to stone
formation. Low intake of citrus fruits can result in hypocitraturia, which may
increase an individual's risk for developing stones.
Environmental Factors. Fluid intake consisting of drinking water high in minerals
may contribute to kidney stone development. Another contributing factor may be
related to geographical variables such as tropical climates. Stone formation is
greater in mountainous, high-desert areas that are found in the United States,
British Isles, Scandinavia, Mediterranean, Northern India, Pakistan, Northern
Australia, Central Europe, Malayan Peninsula, and China. Affluent societies have
a higher rate of small upper tract stones whereas large infection stones occur
more commonly in developing countries Bladder stones are more common in
underserved countries and are likely related to dietary habits and malnutrition
Medications. Medications such as ephedrine, guaifenesin, thiazide, indinavir, and
allopurinol may be contributory factors in the development of calculi.
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Occupations. Occupations in which fluid intake is limited or restricted or those
associated with fluid loss may be at greater risk for stone development as a
result of decreased urinary volume.
Pathogenesis
For ages nephrolithiasis has been a widespread disease and clinical statistics
prove that its morbidity index is still increasing, thus it becomes a social problem.
Peak morbidity usually occurs at the age between 30 and 40, that is why many
patients professionally active and creative have to leave their jobs for a long
period. In contrast to earlier years, frequency of the disease occurrence in
females is systematically increasing and nowadays it is only slightly lower from
that in males. Etiology and pathogenesis of the disease is also not entirely
explained. It is generally accepted that urinary stone formation is determined by
multiple factors which affect first of all chemical composition and physical
features of urine. Individual properties of the kidneys and urinary tract and
infections especially with urease producing pathogens as well as environmental
factors are also taken into account. The most favourable circumstances for
nephrolithiasis occurrence is co-existence of all these factors.
Prevalence
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As much as 10% of the U.S. population will develop a kidney stone in their
lifetime. Upper urinary tract stones (kidney, upper ureter) are more common in
the United States than in the rest of the world. Researchers attribute the
incidence of nephrolithiasis in the United States to a dietary preference of foods
high in animal protein
Clinical Presentation
Symptoms may vary and depend on the location and size of the kidney stones or
calculi within the urinary collecting system. In general, symptoms may include
acute renal or ureteral colic, hematuria (microscopic or gross blood in the urine),
urinary tract infection, or vague abdominal or flank pain. A thorough history and
physical examination, along with selected laboratory and radiologic studies, are
essential to making the correct diagnosis. Small nonobstructing stones or "silent
stones" located in the calyces of the kidney are sometimes found incidentally on
x-rays or may be present with asymptomatic hematuria. Such stones often pass
without causing pain or discomfort.
Kidney Stone Symptoms
Stones in the kidneys can become lodged at the junction of the kidney and ureter
(ureteropelvic junction), resulting in acute ureteral obstruction with severe
intermittent colicky flank pain. Pain can be localized at the costovertebral angle.
Hematuria may be present intermittently or persistently and it may be
microscopic or gross.
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Kidney Stone Complications
Occasionally, stones can injure the kidneys by causing infection, resulting in
fever, chills, and loss of appetite or urinary obstruction. If a UTI accompanies the
urinary obstruction, pyelonephritis or urosepsis can occur. If stones are bilateral,
they can cause renal scarring and damage, resulting in acute or chronic renal
failure.
Causes of Nephrolithiasis
Low Urine Volume
Low urine output is defined as < 1 liter/day. The typical etiologies of
nephrolithiasis are low fluid intake and reduced urine volume. Other possible
causes of low urine volume include chronic diarrheal syndromes that result in
large fluid loses from the gastrointestinal tract and fluid loss from perspiration, or
evaporation from lungs or exposed tissue. Stone formation may be initiated by a
low urine output, providing a concentrated environment for substances such as
calcium, oxalate, uric acid, and cystine to begin crystallization.
No Pathological Disturbance
In approximately 35% of the stone-forming population, no identifiable risk factors
for stone formation can be found. This group includes individuals with normal
serum calcium and PTH, normal fasting and calcium load response, normal urine
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volumes, normal pH, calcium, oxalate, uric acid, citrate, and magnesium levels in
the presence of calcium nephrolithiasis.
RELATED DIAGNOSTIC TESTS
Urinalysis:
Color may be yellow, dark brown, bloody. Commonly shows RBCs, WBCs,
crystals (cystine, uric acid, calcium oxalate), casts, minerals, bacteria, pus; pH
may be less than 5 (promotes cystine and uric acid stones) or higher than 7.5
(promotes magnesium, struvite, phosphate, or calcium phosphate stones).
Urine (24-hr): Cr, uric acid, calcium, phosphorus, oxalate, or cystine may be
elevated.
Urine culture: May reveal UTI (Staphylococcus aureus, Proteus, Klebsiella,
Pseudomonas).
Biochemical survey: Elevated levels of magnesium, calcium, uric acid,
phosphates, protein, electrolytes.
Serum and urine BUN/Cr: Abnormal (high in serum/low in urine) secondary to
high obstructive stone in kidney causing ischemia/necrosis.
Serum chloride and bicarbonate levels:
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Elevation of chloride and decreased levels of bicarbonate suggest developing
renal tubular acidosis.
CBC:
Hb/Hct:
Abnormal if patient is severely dehydrated or polycythemia is present
(encourages precipitation of solids), or patient is anemic (hemorrhage, kidney
dysfunction/failure).
RBCs:
Usually normal.
WBCs:
May be increased, indicating infection/septicemia.
Parathyroid hormone (PTH):
May be increased if kidney failure is present. (PTH stimulates reabsorption of
calcium from bones, increasing circulating serum and urine calcium levels.)
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KUB x-ray:
Shows presence of calculi and/or anatomical changes in the area of the kidneys
or along the course of the ureter.
IVP:
Provides rapid confirmation of urolithiasis as a cause of abdominal or flank pain.
Shows abnormalities in anatomical structures (distended ureter) and outline of
calculi.
Cystoureteroscopy:
Direct visualization of bladder and ureter may reveal stone and/or obstructive
effects.
CT scan:
Identifies/delineates calculi and other masses; kidney, ureteral, and bladder
distension.
Ultrasound of kidney:
To determine obstructive changes, location of stone; without the risk of failure
induced by contrast medium.
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Nursing Care Management
Nursing history
Demographic data
Patient’s name: M, RA B.
Age: 21
Birth date: April 16, 1988
Address: Bukal South, Batangas City
Height: 5’1”
Weight: 48kg
Civil status: single
Religion: catholic
Occupation: factory worker
Highest educational
Attainment: high school
Father: R.M.
Mother: M.M.
Rate: 720.00
Room number: 236b
Hospital number: 73553
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Admission number: 40863
Admission date: May 27, 2009
Admission time: 1:27 pm
Attending physician:Dr. Ronald Miranda
Chief complaint:
Painful urination
History of present illness:
One week prior to admission, the patient started to experience
painful urination. She consulted their office clinic and was given Bactrim. On
Monday, she had blood in the urine. The severity of the pain is 5/10 last week
and turned to 8/10 pain scale. She consulted in this institution and was admitted.
The patient has no allergy in any medicine and food.
History of past illness:
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The patient had mild hepatitis a when she was young. She’s
complete in immunization and never undergone any surgery.
Lifestyle and health practices:
The patient does’nt has any vices hence not doing any exercise.
She’s working as a factory worker in Calamba.
Nutritional habits:
The patient is eating regular foods most of the time but she’s also
fond of eating junk foods and soft drinks.
Recent sleep:
The patient has different positions in sleeping. Her sleeping time
ranges from 11-12:00 pm and wakes up at 6 in the morning. There’s no
interruption when she sleeps.
Treatment and medication
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Solution Frequency
D5LR 1L Q8
Paracetamol Tcup IV
For temperature 38.8 Q4
Tazocin Q12
Paracetamol 500mg/tablet
For Temperature 37.8 Q4
Lactated ringers in 5% dextrose
Used for rehydration.
Intravenous paracetamol
Used to revitalize. Intravenous administration is more reliable and
reaches peak concentrations faster compared with oral routes, as proven for
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paracetamol. Since paracetamol’s side effect profile is considerably superior,
availability of an intravenous form is very useful when other routes are less
feasible.
Paracetamol
Commonly used for the relief of fever, headaches, and other minor
aches and pains, and is a major ingredient in numerous cold and flu
remedies. While generally safe for human use at recommended doses,
acute overdoses of paracetamol can cause potentially fatal liver damage
and, in rare individuals, a normal dose can do the same; the risk is
heightened by alcoholism.
Paracetamol toxicity
Foremost cause of acute liver failure.
Tazocin
Tazocin injection contains two active ingredients, piperacillin which
is a penicillin-type antibiotic, and tazobactam, which is a medicine that prevents
bacteria from inactivating piperacillin. The injection is used to treat infections with
bacteria.
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Tazocin is given by injection or infusion (drip) into a vein. It is used
to treat severe infections, including those caused by multiple organisms.
Use with caution in
- Decreased kidney function
- Kidney failure
- History of allergies
- Low sodium diet
- Low blood potassium levels (hypokalaemia)
Not to be used in
- Allergy to penicillin or cephalosporin type antibiotics
- Allergy to beta-lactamase inhibitors
This medicine should not be used if you are allergic to one or any of its
ingredients. Please inform your doctor or pharmacist if you have previously
experienced such an allergy. If you feel you have experienced an allergic
reaction, stop using this medicine and inform your doctor or pharmacist
immediately.
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Side effects
Medicines and their possible side effects can affect individual people in different
ways. The following are some of the side effects that are known to be associated
with this medicine. Because a side effect is stated here, it does not mean that all
people using this medicine will experience that or any side effect.
- Diarrhea
- Nausea and vomiting
- Rash
- Overgrowth of the yeast Candida, which may cause infection such as thrush
- Disturbances in the normal numbers of blood cells in the blood
- Headache
- Difficulty sleeping (insomnia)
- Low blood pressure (hypotension)
- Inflammation of the wall of a vein with a blood clot forming in the affected
segment of vein (thrombophlebitis)
- Constipation
- Indigestion
- Sore mouth
- Skin reactions such as itching, hives, flushing, eczema
- Severe allergic skin rashes
- Fever (pyrexia)
- Reactions at injection site
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- Liver or kidney disorders
- Fatigue
- Muscle pain and weakness
- Hallucinations
Abstract:
Each time we are permitted to take our journey with the patient and their
family, we treat it as an honor they have bestowed upon us. We have the
opportunity to provide care to clients and to communicate to them by and by.
As we entered at our patient’s room which is room number 236, we
greeted her and then we gave our best smiles to her. The patient that was
assigned to us seems to be very kind, she is very accommodating and has
showed willingness in participation in the interview. She is M, RA B., a 21 years
old girl. Her birthday is April 16, 1988 came from Bukal South, Batangas City.
She’s single, a catholic and a Filipino. Her highest educational attainment is High
school that’s why she’s working as a factory worker at First Philippine Industrial
Park located at Sto. Tomas, Batangas.
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She was admitted on May 27, 2009 at exactly 01:27pm. One week prior to
admission, the patient started to experience painful urination. She consulted their
office clinic and was given Bactrim. On Monday, she had blood in the urine. The
severity of the pain is 5/10 last week and turned to 8/10 pain scale. She
consulted in this institution and was admitted. The patient has no allergy in any
medicine and food. About her past illness, the patient had mild hepatitis A when
she was young. She’s complete in immunization and never undergone any
surgery. The patient does’nt has any vices hence not doing any exercise. The
patient is eating on time but fond of eating junk foods and soft drinks. The patient
has different positions in sleeping. Her sleeping time ranges from 11-12:00 pm
and wakes up at 6 in the morning. There’s no interruption when she sleeps.
Due to the diagnosis, which is Urinary Tract Infection, the Doctor
prescribed her to take medications such as D5LR 1L, Paracetamol Tcup IV,
Tazocin, and Paracetamol 500mg/tablet.
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Nursing Process
Assessment Nursing
Diagnosis
Planning Nursing
Intervention
Rationale Expected
Outcome
Subjective;
:“Masakit
angpagihi ko” as
verbalized by the
patient
Acute pain related
to biological
factors such as
trauma or activity
of disease
process
Short term:
At the end of the
shift, the patients
may relief pain
and discomfort.
Use
antispasmo
dic drugs
Encourage
patient to
To relieve
irritability
and pain
To provide
adequate
The Patient will
experience relief
pain
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Objective:
>Facialgrimace.
>Restlessness.
>V/S taken
asfollows:T:
37.3P: 82R:
19BP: 120/90
Long term;
Upon the patient
discharge, the
patient may
increase
knowledge of
preventive
measure and
treatment
modalities and
absence of
complication.
drink liberal
amount of
fluid
Instruct the
patient to
avoid
urinary
tract
irritant.
Teach
patient to
cleanse
hydration to
patients at
risk for
hydration
To reduce
concentrati
on of
pathogens
of the
Vaginal
The Patient will
understand UTI”s
and their
treatment.
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around
perineum
and
urethral
meatus
after bowel
movement
with front to
back
motion
opening.
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Nutritional Assessment
Renal Diet
You will be advised to stick to a renal diet if your kidneys have failed meaning
that your kidneys are not able to remove the wastes from your body which are
usually produced from the foods that you eat and the liquids that you drink.
The main purpose of a renal diet is to control the amount of protein, sodium and
phosphorous. Along with this, a renal diet will also help reduce the amount of
wastes present in the body thereby helping the kidney work better and avoiding a
total renal failure.
Renal Diet
In learning about the renal diet, we will focus more on what food is to be avoided
because of what they may contain:
Protein: Unless you are on haemodialysis, you should limit the protein in
your diet to 0.75g per kilogram of your body weight. Ensure that you are
taking in sufficient calories else you will have to increase the intake of
protein. The richest sources of protein are meat, fish, cheese, eggs, milk,
pulses and nuts.
Sodium: has to be controlled in the diet of renal patients as this helps in
maintaining the fluid balance in the body along with avoiding fluid retention
and high blood pressure. A high content of sodium is found in table salt,
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soups, processed cheese, canned food, junk food and pickles. All of us
know that we cannot avoid the normal table salt in our diet completely as
food would be completely tasteless and inedible. Fortunately, the quantity
of the salt that we use can be controlled with the help of using garlic,
mustard and pepper that helps in making the food tastier when very little
salt is used. Also, be wary of salt substitutes like ‘Lo-Salt’. No doubt these
substitutes are low in sodium but they are very high in potassium which
makes them equally dangerous in your diet.
Potassium: The intake of potassium should be restricted only if the tests
reveal high potassium levels in the blood. The main reason for this is that
many healthy foods that form an important part of the diet contain
potassium. If you do have to restrict the intake of potassium then avoid
leafy vegetables, fruit and fruit juices. Also, potatoes contain a high level
of potassium especially if they are fried or baked.
Phosphate: Excess of phosphate in the blood becomes a problem during
the 4th and 5th stage of the chronic kidney failure wherein the kidney
works at about 20% of its maximum capacity. A high level of phosphate
makes the patient itch very badly and has an adverse effect on the
arteries too. A good diet in not sufficient to control the level of diets in most
cases and additional medications known as phosphate binders too have to
be taken along with the food which keep the phosphate in the gut and
prevent its absorption into the blood. These medicines have to be taken
just before eating or along with food else they will not be effective.
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Phosphates are usually associated with proteins and are found in high
content in milk, cheese, baking powder, shellfish and wholegrain cereals.
It is also found in convenience foods which are added by their
manufacturers.
With so many limitations on the food that you can consume, it is not uncommon
that kidney patients start to lose weight. You have to maintain your weight at a
healthy level and here are some food tips that you can use which will fit your diet
plan and help you maintain your weight:
All breads, tortillas and cereals except bran breads and cereals can be
consumed.
Add a measured quantity of margarine, mayonnaise and vegetable oils
like olive oil or canola oil in your diet.
If you are not diabetic, then you can add honey and sugar to add calories.
Lastly, remember that you must eat snacks and meals at regular intervals
and should not miss any meal.
No matter how much of information you can gather on the internet, it is vital that
you consult a dietitian and work out a diet plan for you which will be based on
your weight, food habits and renal history. A good diet plan will ensure that you
can move forward beyond your kidney failure and lead a healthy and fulfilling life.
All it will take is a little self control. All the best!
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Sample Renal Diet
Breakfast
1/2 cup cranberry juice
1 egg
2 slices toast
2 teaspoons jelly
2 tablespoons non-milk creamer
1 cup coffee
Lunch
3 ounces sliced turkey
2 slices bread
1 lettuce leaf
2 teaspoons mayonnaise
1/2 cup cucumber salad
1 tablespoon oil and vinegar dressing
1 medium apple
1 cup lemonade
Evening Meal
3 ounces broiled fish
1/2 cup rice
1/2 cup green beans
1 cup lettuce salad
1 tablespoon oil and vinegar dressing
1 dinner roll
2 teaspoons margarine
1/2 cup canned peaches
1 cup lemon water
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