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Introduction

This is a case study of K.D, 17 years old, residing at Barangay Mambucal, Koronadal City. He was admitted at South Cotabato Provincial Hospital last July 9, 2011 at around 6:00 in the morning with the diagnosis of Anemia Secondary to End-Stage Renal Disease, under the care of Marilyn S. Abantao, M.D.

Chronic Kidney Disease, also known as Chronic Renal Disease, is a progressive loss of renal function over a period of months and years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite. Often CKD is diagnosed as a result of screening of people known to be at risk f kidney disease/problems, such as those with high blood pressure or diabetes and those with blood relative with CKD. And it will lead to Ed- Stage Renal Disease.

End-Stage Renal Disease occurs when the Glomerular Filtrate Rate (GFR) is less than 15min/min. At this point, renal replacement therapy (dialysis or transplantation) is required.

In US, there is a rising incidence and prevalence of kidney failure, with poor outcomes and high cost. Kidney Disease is the 9th leading cause of death in US. Data from the US Renal Data System (USRDS) indicated that there has been an increase of 104 % in the prevalence of Chronic Renal Failure (CRF) between the years 1990-2001. There is an even higher prevalence of the earlier stages of CKD.

In the Philippines, according to NNHcS 2003-2004 renal report prevalence of CKD in adults using predicted GFR from MDRD equation. Stages of GFR is >= 90 is 72.8 %, 60-89 is 24.6%, 30-59 is 2.2%, and 15 years and above in 2005 was 46,627,172 a prevalence rate of 2.6% means that 1, 212, 306 other Filipinos have CKD.

Anemia is a condition in which an abnormally low number of red blood cells circulate in the body. It is the most common disorder of the red blood cells, affecting about 3.5 million Americans. Anemia is not a disease. It is a condition that results from below-normal levels of hemoglobin in the red blood cells. Hemoglobin is the iron-containing pigment of the red blood cells that carries oxygen from the lungs to the tissues. The anemia of chronic kidney disease (CKD) is, in most patients, normocytic and normochromic. It is principally due to reduced renal erythropoietin production and, to a lesser degree, to shortened red cell survival and decreased responsiveness to the hormone. Anemia can develop well before the onset of uremic symptoms due to end-stage renal disease (ESRD). Although anemia due to renal dysfunction generally develops when the glomerular filtration rate (GFR) declines to less than 30 mL/min, it can also be observed in those with markedly higher GFRs (such as 60 mL/min), and tends to occur at higher levels of GFR in African Americans than whites. If left untreated, the anemia of CKD is associated with several abnormalities. These include deterioration in cardiac function, decreased cognition and mental acuity, fatigue, and other signs and symptoms. There are also associations with an increased risk of morbidity and mortality, principally due to cardiac disease and stroke.

A common occurrence of among all age groups, it is particularly prevalent among the elderly. A recent study documented the prevalence of anemia in elderly residents of skilled

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nursing facilities to be 48%. The prevalence rate of anemia from all age groups is 30.6%. this is higher than 1993 prevalence of 28.9% as in previous surveys. The most greatly affected groups are the infants, preschoolers, pregnant women, lactating women and elderly. For the rest of population groups, the anemia problem is of moderate magnitude. Among 1-5 year old children, a decline in prevalence rate was observed from 53.2% among 1 year and 18.2 % among 5 year old children.

The 7th National Nutrition Survey (NNS) conducted by the Food and Nutrition Research Institute of the Department of Science and Technology (FNRI-DOST) showed that the prevalence of anemia among Filipinos remained high. The survey showed that while the anemia problem in the country has generally eased down from 2003 to 2008, it still remains a serious concern particularly for infants 6 months to less than 1 year old and pregnant women. Infants 6 months to less than 1 year old have the highest prevalence rate among all the age groups with 56 in every 100 or 55.7 percent having iron deficiency anemia (IDA). Though the latest result showed that there is a significant decrease from the 2003 NNS of 66.2 percent, it is still higher than its 1993 prevalence rate of 49.2 percent. Among pregnant women, 43 in every 100 or 42.5 percent are anemic.

The 7th NNS results showed that overall prevalence of anemia, from 6 months to the elderly, is 19.5 percent. Generally, females are more anemic than males except for school-age children and the elderly. Among the 13-19 year olds, the prevalence of anemia for males is 10.4 percent and 18.2 of females. Among 20-39 year olds, the prevalence is 6.8 percent for males and 18.6 percent for females, while among 40-59 years old, 12.7 percent of males are anemic and 22.7 percent of females. Male and female anemia prevalence rates were similar among 6-12 years, old with 20.4 percent males and 19.2 percent females, while among elderly, with 33.4 males and 32.8 percent females. Using the 2008 Projected Population by the National Statistics Office (NSO), the estimated number of anemic children, 6 months to less than one year, 1-5 years, and 6-12 years is 0.74 million, 2.10 million and 2.77 million, respectively.

We choose this case study to serve as information and to gain knowledge about Anemia secondary to End-Stage Renal Disease. To provide us broader knowledge regarding this condition. To answers our curiosity on how the disease process occurs, including its manifestations and intervention.

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Objectives

General objectives

After a thorough analysis, the readers and the future researchers will be able to gain knowledge and further understanding about anemia secondary to End stage Renal disease.

Specific objectives

After 5-8 hours of presenting this case, the listeners and future researchers will be able to:

1. Present the introduction completely2. Know the patient’s data which includes vital information, family background, history of

past and present illness, the effect and expectation to self and family towards condition, the genogram which shows familial / hereditary disease and developmental data where patient is classified according to individual task theory.

3. Present accordingly the physical assessment and review of system in line in the general condition of the patient.

4. Discuss comprehensively the textbook discussion which includes the complete diagnosis of the disease, related Anatomy and Physiology of the systems.

5. Trace schematically the pathophysiology.6. Interpret the diagnostic and laboratory examinations which the patient underwent to help

in diagnosis and treatment of the dis case.7. Present the doctor’s order.8. List all the drugs to be administered to the patient.9. Present all the drugs administered.10. List all prioritize problem.11. Prioritize correctly the possible nursing diagnosis and intervention being applied.12. Interpret accordingly the prognosis of the disease after medical and nursing intervention.13. Enumerate all the references used through its bibliography.

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PATIENT’S DATA

I. Vital Information

Patient’s Name: KD

Age: 17 years old

Address: Brgy. Mambucal, Koronadal City

Civil Status: Single

Sex: Male

Religion: Alliance

Race: Asian

Birthplace: Brgy. Mambucal, Koronadal City

Birthdate: July 11, 1993

Occupation: Student

Educational Attainment: 2nd Year College (BS Criminology)

Chief Complaint: Difficulty of Breathing

Diagnosis: Anemia Secondary to End-Stage Renal Disease

Attending Physician: Marilyn S. Abantao, M.D

Date & Time of Admission: July 9, 2011 at 06:00 in the morning

Health Care Finance: Parent’s Income

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Name of Father: Tatay D

Age: 35 years old

Occupation: Tricycle Driver

Educational Attainment: College Undergraduate

Name of Mother: Nanay D

Age: 33 years old

Occupation: Vegetable Vendor

Educational Attainment: College Undergraduate

Patient’s Sibling

Name: Ading D

Age: 13 yrs. Old

Occupation: Student

Educational Attainment: High School Student

Sources of Information:

Patient

Patient’s chart

Patient’s father

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Family Background

KD is a 17 years old male patient who is currently residing at Brgy. Mambucal,

Koronadal City. He belongs to a nuclear type of family, which is composed of a father, mother,

and children. The family source of income is through Tatay D and Nanay D. Tatay D is a 35

years old, a driver of tricycle they owned, and Nanay D is a 33 years old, a vegetable vendor.

They eat 3 times a day and most of the meals consist of rice, vegetables, fish and dried

fish, they seldom eat meat. According to his father, Patient KD is fond of eating Junk foods and

drinking carbonated drinks such as coke and energy drinks, KD is a smoker, he started smoking

when he was 13 years old and he also drinks alcohol with his Barkada.

Families’ bloodline is embedded with genetic diseases such as Hypertension, Diabetes

Mellitus and Kidney disease. On his paternal side KD’s Lolo has a kidney disease and

hypertension while his father has a hypertension, while on his maternal side, his Lolo and Aunt

has Diabetes Mellitus.

The family utilizes different herbal medication approved by the DOH such as; Lagundi

for cough, Oregano as anti-oxidant, and Sambong to decrease uric acid. According to patient’s

father, the family also experienced common illnesses such as headache, colds, body pain, and

fever. The family also purchased over the counter drugs to relieve illnesses they experience such

as paracetamol for fever, and headache, mefenamic acid for body pain, and Bioflu for colds. In

addition to that, patient KD and his sister Ading D had receive series of immunization and

vaccination as follows; 1 dose of BCG, 3 doses of DPT, 3 doses of OPV, Measles vaccine, and

Hepa B vaccine.

As to affiliation, the family attends church gathering and participates in any activities

conducted. The family also has their recreational activities like selling vegetables, going to

market and attends to program and any activity in their barangay.

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History of Past and Present Health and Illness

History of Past Health and Illness

History of Past illness comprises the data of patient’s childhood illness and medical

history, as well as ways on how these conundrums were resolve.

According to Tatay D, patient had already passed through the childhood illness such as measles,

mumps, and chickenpox; but by not manifest the illness again.

Patient KD experience sore throat 3 times a month, then Last December 2010 he was

diagnosed with Chronic Renal Disease by their doctor and he started his dialysis at January 2011

at Pinggoy Hospital for 2-3 times a week but it would not last for long it ends at July 2011

because of financial matter. As his diet he was informed by his Doctor to limit his rice for ½ to 1

cup and 300-500 ml of water.

History of Present Health and Illness

3-5 hours prior to admission, the onset of present illness happened at their house when

the patient is walking then suddenly feel difficulty of breathing. The patient rushes to the hospital

(SCPH) by his father, he was conscious, little confuse, responsive and he is not oriented in time,

place and people around him, he was admitted last July 9, 2011 at around 06:00 in the morning

with the Chief Complaint of Difficulty of Breathing and was diagnosed of Anemia secondary to

End-stage Renal Disease under the service of Marilyn S. Abantao, M.D. his vital signs are BP:

140/ 80 mmhg, Respiratory rate: 30 cpm, Pulse rate: 98 bpm, Temperature: 36.3˚ C.

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Effects and Expectations of Illness to Self and Family

Effects

To self:

The effect of illness to patient KD was he is not comfortable on his condition because it

is difficult for him to have undergone dialysis every 2-3 times a week and when he cannot go for

dialysis, he experiencing DOB or difficulty of breathing, weakness, and fatigue. He also stops

from school because it is difficult for him to go to school and attend classes because he becomes

lethargic and weak. He also verbalized that he can’t continue to his dream to become a

policeman because of his condition.

To family:

Parents KD verbalized that it is difficult for them to see their son suffering from the said

condition, Patient’s KD is the eldest among 2 children of Tatay D and Nanay , they have more

dreams to their son but because of KD’s condition they feel disappointed and hopeless for this

matter. According also to Tatay D, the hospitalization of their son affects their work also Ading

D is affected to the condition of her Kuya.

Expectations

To self:

Patient’s KD expect that although he was suffering from a chronic condition he could

surpass and accept the things happening to him and he was praying to the Lord for the guidance

and he also pray that he could recover soon.

To Family:

The families expect that the patient will increase his faith and belief to God and still

patient’s self-esteem will be remain in a normal state and also they expect that KD will recover

soon after hospitalization in order to them not to worry and for them, they could go back to their

work and do their normal daily living.

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GENOGRAM

Paternal Side Maternal Side

Aunt UDM

35y.o

Nanay

32y.o

Uncle U1

27 y.o

Uncle U1

30 y.o

Lolo upHPN65 y.o

Lola upDM

62y.o

Lolo uDM

70 y.o

Lola u

62y.o

UDAdding

D13y.o

- 17 Y.O- Anemia 2 end stage renal disease

- Kidney Stone

- Unknown disease

- Hypertension

- Diabetes

Legend

- Male

- Female

- Patient

- Not connected by blood

- Connected by blood

- Deceased

Uncle D

40 y.o

Aunt DD

38y.o

Tatay HPN35 y.o

HPN

DM

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Growth and Developmental Data

Sigmund Freud

Freud’s Five Stages of Development

According to Freud’s theory of psychosexual development, the personality

develops in five overlapping stages from birth to adulthood.

Freudian theory asserts that the individual must meet the needs of each

stage in order to move successfully to the next developmental stage.

TASK REMARKS JUSTIFICATION

Genital (Puberty and after)

Separation from parents

Achievement of independence and decision making

Energy is directed toward full sexual maturity and function

Task Not Achieved

Task Not Achieved

Task Not Achieved

The patient is still living with his parents.

The patient is still living with his parents thus; he is still dependent on them in terms of living and making decision on his own.

He doesn’t have a girlfriend because he is still hesitant to start a serious relationship.

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Erik H. Erikson

Erikson’s Eight Stages of Development

Erikson’s theory proposes that life is a sequence of developmental stages or levels of achievement. Each stage signals a task that must be accomplished.

TASK REMARKS JUSTIFICATION

Identity vs. Role Confusion

career decision accepting body

changes emancipation from

parents sense of intimacy socialization

Task Partially Achieved.

The patient said that ever since he was a child he really wants to finish his study and be a policeman someday. He also verbalize that he accepted the body changes happen to his body since he already pass the puberty stage. The patient still wants to be dependent from his parents and he doesn’t want to separate from them even after he graduates. He had already established a good relationship within opposite sex but he doesn’t have a girlfriend because he is still hesitant to start a serious relationship. He has many friends in his school and community.

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Jean Piaget

Piaget Cognitive Theory

Refers to the manner in which people learned to think, reason and use of language. It involves a person’s intelligence, perceptual ability and the ability to process information.

TASK REMARKS JUSTIFICATION

Formal Operational -Use of rationale thinking and reasoning skills.

Deductive type of reasoning- abstract thinking (anticipate what could happen in the future)

Task Achieved.KD is Cebuano and uses it as his primary way of communicating to others. He is already a 2nd year college, he know how to rationalize the things around him even in simple manner. He accepted that he has a chronic illness, he keeps praying for God guidance.

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PHYSICAL ASSESSMENT

Date: July 09, 2011

Time: 09:10 in the morning

GENERAL SURVEY:

Received patient sitting on bed, conscious and coherent with IVF of D5LR iL attached on the right Metacarpal vein/ Dorsal venous art at the level of 650cc and regulated in a KVO rate, patent and infusing well, O2 inhalation via nasal cannula noted. The patient is wearing a loose shirt that is appropriate to him, he is not wearing any accessories or jewelries. He is well groomed, conscious and not oriented in time, place and people around him. He can speak well and cooperate up to the level or as he tolerated only on the assessment to be done to him.

VITAL SIGNS:

BP: 150/ 90 mmhg

PR: 98 bpm

RR: 30 cpm

Temp.: 36.4 ˚C

HEAD/ HAIR/ SCALP:

Inspection: skull is round with symmetric facial movement ( Normocephalic & symmetrical). No dandruff as well as lice noted. The hair is black with slightly odor noted, it is evenly distributed which is fixed properly.

Palpation: no nodules, lesions, and masses noted.

NECK:

Inspection: neck muscles are equal in size with no masses and lesions noted. He can able to move his neck without any discomfort but in a slight motion and jugular vein distention noted.

Palpation: no tenderness but jugular vein distended upon palpation.

EYES & VISION:

Inspection: eyes are bilateral and lateral to each other. Eyebrows are evenly distributed with skin intact, eyelashes are equally distributed with intact eyelids. No discharges noted. Eyeballs are able to move and it is round pupils are equal, round black in color and with increase reaction to light. The sclera appears unecteric.

EARS & HEARING:

Inspection: ears are symmetrical to the head, auricles are in the same color as facial skin color. No lesions, deformities. Impacted cerumen and no discharges noted.

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Palpations: no tenderness, masses or lumps upon palpation.

NOSE:

Inspection: nose is in the midline, uniform in color and no discharges noted. No lesions noted. Flaring of nostrils is noted upon breathing.

Palpation: no masses or lumps noted.

MOUTH:

Inspection: lips are pale in color and it is dry, tongue in central, uvula is located at the midline and appear as red. Teeth are incomplete yellow in color with dental carries noted in most of the teeth. The patients breathe is uremic fetor or breath that smells like urine.

CHEST/ RESPIRATORY:

Inspection: normal chest wall, able to breathe in a fowler’s position and in orthopnic position, experienced dyspnea/ difficulty of breathing when at supine/ lying position.

Palpation: no bulges noted, no tenderness and apical pulse is not observable.

Auscultation: crackles sound noted upon auscultation. No skip of resonance noted. Bronchopony is noted and no Egophony noted.

CARDIOVASCULAR:

Auscultation: no irregularities noted on pulsation of the heart, with capillary refill of 3-4 seconds. Patients Blood Pressure upon assessment is 150/ 90 mmhg. No cyanosis noted.

BREAST:

Inspection: breast engorgement is not noted. Nipples are symmetrical to each other, black in color and not increase in size. The areolas on both are black in color and no discharges noted.

Palpation: breast tenderness is not noted upon palpation. No masses or lumps palpated.

ABDOMEN:

Inspection: some bruises noted but no rashes noted upon inspection. The skin at abdomen is dry and scaly in its appearance.

PERCUSSION & AUSCULTATION:

Inspection: dull sound noted on the upper right quadrant and hallows sound noted on the lower quadrant. Gurgling sound is also noted.

Palpation: no waving of fluids noted upon palpation.

GENITOURINARY:

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Inspection: urine is dark yellow and verbalized that he experienced pain and difficulty in urinating. He only urinates for 30cc in almost 3 hours in almost 3 hours of duration.

EXTREMITIES:

Inspection: edema on the end of the fingers noted and preorbital edema noted, with shunt on left arm and bipedal edema noted on the lower extremities.

Palpation: grade 3 bipitting edema upon palpation noted, no masses noted.

SKIN/ NAILS:

Inspection: tanned skin noted and it is dry and scaly appearance noted. Skin is intact with 3-4 seconds skin turgor and fine hairs noted and evenly distributed. Nails are pale on color and it is properly cut.

Palpation: skin is slightly cold to touch and it is dry with a capillary refill of 3-4 seconds.

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REVIEW OF SYSTEMS

Date: July 09, 2011

Time: 09: 10 in the morning

GNERAL APPEARRENCE

The patient experiences period of headaches rated as 7 from the scale of 1-3 as mild, 4-7 as moderate, 8-10 as severe. He also experienced fatigue, restlessness, dizziness, weakness, lethargy, sleep disturbances and confusion. He also experienced common illness such as cough and colds, flu and fever in the past months (6). He has a chief complaint of difficulty of breathing and he also complaining of weight loss from 50 kg to 45 kg in a few months.

SKIN/ HAIR/ NAILS

The patient denies having rashes, lumps, sores, itching, but has changes in color of nails and skin, it is pale, and he has experiencing dry skin and it appears scaly. He doesn’t experience any abnormal hair growth and even skin and head injury as well as in nails.

HEAD

Patient denies of having any head injuries prior to admission, but he complained that he experiences headache, dizziness, upon admission.

EYES

Patient claims of having blurring of vision during severe headache, but denies of having eye pain and he denies of using eyeglasses.

EARS

Patient claims that he can hear words clearly. He denies injuries, and pain. He does not experience loss of hearing.

NOSE & SINISES

The patient does not experience of having injuries, trauma and obstruction but he experience runny nose most of the time and denies of nosebleeds and sinus troubles.

MOUTH/ THORAX/ PHARYNX

The patient admits of having dental carries but denies hoarsenesss of voice, no dentures and sore tongue, but experience sore throat 3 times in a month.

NECK

The patient denies of having goiter and experiencing stiff neck.

BEAST

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The patient denies of having lumps, swelling, and nipple discharges.

CARDIOVASCULAR

The patient verbalized that he experienced increase of his blood pressure but denies of having heart murmurs, visible varicosities and phlebitis.

RESPIRATORY

Patient experiencing dyspnea and comfortable at fowler’s position and orthopneic position, he also experienced cough and verbalized that he smokes for 6-10 sticks of cigarette per day.

GASTROINTESTINAL

Patient claims of nausea and vomiting especially eaten large meals.

GENITOURINARY

Patient experience difficulty of urination, frequency and changes in color.

MUSCULOSKELETAL

Patient verbalized that he experienced weakness, restlessness, lethargy, and limitations of movement.

NEUROLOGIC/ PSYCHOLOGY

Patient experience fatigue, headache, dizziness, sleep disturbances, confusions, and lethargy. He also experienced anxiety especially new on him.

HEMATOLOGIC

The patient experiences hemodialysis every week for 2-3 times. He experience having anemia.

ENDOCRINE

The patient denies thyroid problem.

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DEFINITION OF TERMS:

A) ANEMIA- is a condition in which an abnormally low number of red blood cells circulate

in the body.

B) END STAGE RENAL DISEAS – irreversible complete or almost complete destruction

of the functioning of the renal tissue such that remaining kidney mass can no longer

maintain the body’s internal environment.

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TEXTBOOK DISCUSSION

A) ANEMIA – it is a deficiency of red blood cells, or insufficient hemoglobin within the red blood cells. There are many types of anemia. a) Iron – deficiency anemia caused by lack of dietary iron, b) pernicious anemia caused by deficiency in vitamin B12 in which the RBC’s are misshapen, large, and fragile and another cause of this anemia is lack of intrinsic factor due to autoimmune destruction of the parietal cells of the stomach lining. c) sickle cell anemia- a genetic disorder of the hemoglobin in which the RBC’s are sickled, clogs capillaries, and rupture. d) aplastic anemia- the bone marrow is suppressed with decreased production of RBC’s and WBC’s and platelets due to radiation, exposure to chemicals such as benzene, or some medications. e) hemolytic anemia- in which the RBC’s rupture before the end of their normal life span, sickle cell anemia and Rh disease of the new born are examples, another example is malaria.

Scanlon, V.C., Sanders, T. (2007). Essentials of Anatomy and Physiology; Third Edition. Page 257.

B) ANEMIA – a condition characterized by a reduction in the oxygen carrying capacity of the blood due to decreased RBC’s, hypoxia produces fatigue to persons with this condition. Anemia reflects an abnormality in red cell number, structure, or function. Causes of anemia are excessive blood loss, deficiencies and abnormalities of erythrocyte production and excessive destruction of erythrocytes.

Luckmann, J., Sorensen, K.C., (1987).Medical – Surgical Nursing, A psychophysiologic approach; Third Edition. Pages 1020, 1040-1041.

C) ANEMIA - is a condition in which an abnormally low number of red blood cells circulate in the body. Anemia is not a disease. It is a condition that results from below-normal levels of hemoglobin in the red blood cells. Hemoglobin is the iron-containing pigment of the red blood cells that carries oxygen from the lungs to the tissues.

http://ehealthmd.com/content/what-anemia

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A) END STAGE RENAL DISEASE – irreversible complete or almost complete destruction of the functioning of the renal tissue such that remaining kidney mass can no longer maintains the body’s internal environment. The end result of the patients with renal disease is either uremia,and death, treatment by dialysis or transplant.

Luckmann, J., Sorensen, K.C., (1987).Medical – Surgical Nursing, A psychophysiologic approach; Third Edition. Page 1222.

B) END STAGE RENAL DISEASE – a usually complete and irreversible deterioration, is the end result of gradual tissue destruction and loss of kidney function. It may result from glomerulonephritis, pyelonephritis, tuberculosis, polycystic kidney disease, hypertension, nephrosclerosis, renal calculi, lupus erythematosus, long- term aminoglycoside therapy, and diabetic neuropathy.

Lippincott Williams and Wilkins. (2006). Pathophysiology made incredibly easy. Page 389.

C) END-STAGE KIDNEY DISEASE - is the complete, or almost complete failure of the kidneys to function. The main function of the kidneys is to remove wastes and excess water from the body. End-stage kidney disease (ESRD) occurs when the kidneys are no longer able to function at a level needed for day-to-day life. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of normal. ESRD almost always follows chronic kidney disease. A person may have gradual worsening of kidney function for 10 - 20 years or more before progressing to ESRD.

http://www.nlm.nih.gov/medlineplus/ency/article/000500.htm. (Update Date: 8/31/2010)

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Anemia secondary to End Stage Renal Disease

- common causes of Chronic Kidney Disease (End Stage Renal Disease)o Chronic glomerular disease such as glomerulonephritis.

o Chronic infections such as pyelonephritis and tuberculosis.

o Congenital anomalies such as polycystic kidney disease.

o Vascular disease such as hypertension and nephrosclerosis.

o Obstructions such as renal calculi.

o Collagen diseases such as lupus erythematosus.

o Nephrotoxic agents such as long- term therapy of NSAID’s.

o Endocrine diseases such as diabetic neuropathy.

- Most common manifestations of Chronic Kidney Disease (End Stage Renal Disease)o Anemia – Your kidneys make an important hormone called erythropoietin (EPO).

Hormones are secretions that your body makes to help your body work and keep you healthy. EPO tells your body to make red blood cells. When you have kidney disease, your kidneys cannot make enough EPO. This causes your red blood cell count to drop and anemia to develop.

o Peripheral edema – The heavy loss of protein in the urine (over 3.0 grams per

day) with its accompanying edema is termed the nephrotic syndrome. Nephrotic syndrome results in a reduction in the concentration of albumin in the blood (hypoalbuminemia). Since albumin helps to maintain blood volume in the blood vessels, a reduction of fluid in the blood vessels occurs. The kidneys then register that there is depletion of blood volume and, therefore, attempt to retain salt. Consequently, fluid moves into the interstitial spaces, thereby causing pitting edema.

o Hyperkalemia - The hormone aldosterone regulates kidney removal of sodium and

potassium. Lack of aldosterone due to Chronic Renal Failure can result in hyperkalemia with an increase in total body potassium.

o Hypocalcemia and Hyperphosphatemia- CRF has an effect in calcium and

phosphorus. Since there will be decreased production of active vitamin D in the kidneys (calcitriol), there will be a decreased reabsorption of calcium from the GI tract, the phosphate will have a retention on the body ( since there will be a vice- versa effect with the calcium), the phosphate will bind on the calcium therefore causing decreased serum calcium level. There will be release of PTH by the parathyroid glands, and there will be release in of calcium stored in the bones which causes bone demineralization and bone density loss, this will lead to increased serum calcium and will cause further metastic calcification of the vascular walls.

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o Hypervolemia - patients with renal insufficiency cannot excrete excess fluid in the

body. That’s why fluid is retained in the body causing edema (hypervolemia). o Hypertension- patients with CRF complicates into having hypertension due to

sodium retention in the boy. The RAAS (renin angiotensin aldosterone system) will be activated due to sodium retention and there will be a concurrent hypertension.

o Acidosis - in advance renal failure, kidney cannot excrete increased loads of acid.

Decreased acid secretion primarily results from inability of the kidney tubules to reabsorb sodium bicarbonate.

- Stages of Chronic Kidney Diseaseo The stages of CKD (Chronic Kidney Disease) are mainly based on measured or

estimated GFR (Glomerular Filtration Rate). There are five stages but kidney function is normal in Stage 1, and minimally reduced in Stage 2.

Stages GFR Description Treatment

1 90+ Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease

Observation, control of blood pressure.

2 60-89 Mildly reduced kidney function, and other findings (as for stage 1) point to kidney disease

Observation, control of blood pressure and risk factors.

3A3B

45-5930-44

Moderately reduced kidney function Observation, control of blood pressure and risk factors.

4 15-29 Severely reduced kidney function Planning for end stage renal failure.

5 <15 or on dialysis

Very severe, or end stage kidney failure (sometimes call established renal failure)

Permanent renal replacement therapy (Dialysis or Kidney Transplant).

- Treatment and Management for Chronic Kidney Disease (End Stage Renal Disease)

o Hemodialysis:

- Hemodialysis is a procedure that cleans and filters your blood. It rids your body of harmful wastes and extra salt and fluids. It also controls blood pressure and helps

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your body keep the proper balance of chemicals such as potassium, sodium, and chloride. Hemodialysis uses a dialyzer, or special filter, to clean your blood. The dialyzer connects to a machine. During treatment, your blood travels through tubes into the dialyzer. The dialyzer filters out wastes and extra fluids. Then the newly cleaned blood flows through another set of tubes and back into your body. Before your first treatment, an access to your bloodstream must be made. The access provides a way for blood to be carried from your body to the dialysis machine and then back into your body. The access can be internal (inside the body -- usually under your skin) or external (outside the body). Hemodialysis can be done at home or at a center. At a center, nurses or trained technicians perform the treatment. At home, you perform hemodialysis with the help of a partner, usually a family member or friend. If you decide to do home dialysis, you and your partner will receive special training. Hemodialysis usually is done three times a week. Each treatment lasts from 2 to 4 hours. During treatment, you can read, write, sleep, talk, or watch TV.

o Transplantation:

- Kidney transplantation is a procedure that places a healthy kidney from another person into your body. This one new kidney does all the work that your two failed kidneys cannot do. A surgeon places the new kidney inside your body between your upper thigh and abdomen. The surgeon connects the artery and vein of the new kidney to your artery and vein. Your blood flows through the new kidney and makes urine, just like your own kidneys did when they were healthy. The new kidney may start working right away or may take up to a few weeks to make urine. Your own kidneys are left where they are, unless they are causing infection or high blood pressure. You may receive a kidney from a member of your family. This kind of donor is called a living-related donor. You may receive a kidney from a person who has recently died. This type of donor is called a cadaver donor. Sometimes a spouse or very close friend may donate a kidney. This kind of donor is called a living-unrelated donor. It is very important for the donor's blood and tissues to closely match yours. This match will help prevent your body's immune system from fighting off, or rejecting, the new kidney. A lab will do special tests on blood cells to find out if your

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body will accept the new kidney. The time it takes to get a kidney varies. There are not enough cadaver donors for every person who needs a transplant. Because of this, you must be placed on a waiting list to receive a cadaver donor kidney. However, if a relative gives you a kidney, the transplant operation can be done sooner. The surgery takes from 3 to 6 hours. The usual hospital stay may last from 10 to 14 days.

NURSING MANAGEMENT

1. Monitor 24-hour urine volume to follow clinical course of the disease.

2. Monitor BUN, creatinine, and electrolyte.

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3. Monitor ABG levels as necessary to evaluate acid-base balance.

4. Weigh the patient to provide an index of fluid balance.

5. Measure blood pressure at various times during the day with patients in supine, sitting,

and standing positions.

6. Adjust fluid intake to avoid volume overload and dehydration.

7. Watch for cardiac dysrhythmias and heart failure from hyperkalemia, electrolyte

imbalance, or fluid overload. Have resuscitation equipment available in case of cardiac

arrest.

8. Watch for urinary tract infection, and remove bladder catheter as soon as possible.

9. Employ intensive pulmonary hygiene because incidence of pulmonary edema and

infection is high.

10. Provide meticulous wound care.

11. Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing

power and provide additional calories.

12. Institute seizure precautions. Provide padded side rails and have airway and suction

equipment at the bedside.

13. Encourage and assist the patient to turn and move because drowsiness and lethargy may

reduce activity.

14. Explain that the patient may experience residual defects in kidney function for a long

time after acute illness.

15. Encourage the patient to report routine urinalysis and follow-up examinations.

16. Recommend resuming activity gradually because muscle weakness will be present from

excessive catabolism.

Anatomy and Physiology

a) Kidneys

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The kidneys, organs with several functions, serve essential regulatory roles in most animals, including vertebrates and some invertebrates. They are essential in the urinary system and also serve homeostatic functions such as the regulation of electrolytes, maintenance of acid-base balance, and regulation of blood pressure (via maintaining salt and water balance). They serve the body as a natural filter of the blood, and remove wastes which are diverted to the urinary bladder. In producing urine, the kidneys excrete wastes such as urea and ammonium; the kidneys also are responsible for the reabsorption of water, glucose, and amino acids. The kidneys also produce hormones including calcitriol, erythropoietin, and the enzyme renin.

Located at the rear of the abdominal cavity in the retroperitoneum, the kidneys receive blood from the paired renal arteries, and drain into the paired renal veins. Each kidney excretes urine into a ureter, itself a paired structure that empties into the urinary bladder.

Renal physiology is the study of kidney function, while nephrology is the medical specialty concerned with kidney diseases. Diseases of the kidney are diverse, but individuals with kidney disease frequently display characteristic clinical features. Common clinical conditions involving the kidney include the nephritic and nephrotic syndromes, renal cysts, acute kidney injury, chronic kidney disease, urinary tract infection, nephrolithiasis, and urinary tract obstruction. Various cancers of the kidney exist; the most common adult renal cancer is renal cell carcinoma. Cancers, cysts, and some other renal conditions can be managed with removal of the kidney, or nephrectomy. When renal function, measured by glomerular filtration rate, is persistently poor, dialysis and kidney transplantation may be treatment options. Although they are not severely harmful, kidney stones can be a pain and a nuisance. The removal of kidney stones includes sound wave treatment, which breaks up the stones into smaller pieces which are then passed through the urinary tract. One common symptom of kidney stones is a sharp pain in the medial/lateral segments of the lower back.

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Location

In humans the kidneys are located in the abdominal cavity, more specifically in the paravertebral gutter and lie in a retroperitoneal position at a slightly oblique angle. There are two, one on each side of the spine. The asymmetry within the abdominal cavity caused by the liver typically results in the right kidney being slightly lower than the left, and left kidney being located slightly more medial than the right. The left kidney is approximately at the vertebral level T12 to L3, and the right slightly lower. The right kidney sits just below the diaphragm and posterior to the liver, the left below the diaphragm and posterior to the spleen. Resting on top of each kidney is an adrenal gland. The upper (cranial) parts of the kidneys are partially protected by the

eleventh and twelfth ribs, and each whole kidney and adrenal gland are surrounded by two layers of fat (the perirenal and pararenal fat) and the renal fascia. Each adult kidney weighs between 125 and 170 grams in males and between 115 and 155 grams in females. The left kidney is typically slightly larger than the right.

Structure

The kidney has a bean-shaped structure, each kidney has a convex and concave surface. The concave surface, the renal hilum, is the point at which the renal artery enters the organ, and the renal vein and ureter leave. The kidney is surrounded by tough fibrous tissue, the renal capsule, which is itself surrounded by perinephric fat, renal fascia (of Gerota) and paranephric fat. The anterior (front) border of these tissues is the peritoneum, while the posterior (rear) border is the transversalis fascia.

The superior border of the right kidney is adjacent to the liver; and the spleen, for the left border. Therefore, both move down on inhalation.

The kidney is approximately 11–14 cm in length, 6 cm wide and 4 cm thick.

The substance, or parenchyma, of the kidney is divided into two major structures: superficial is the renal cortex and deep is the renal medulla. Grossly, these structures take the shape of 8 to 18 cone-shaped renal lobes, each containing renal cortex surrounding a portion of medulla called a renal pyramid (of Malpighi). Between the renal pyramids are projections of cortex called renal

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columns (of Bertin). Nephrons, the urine-producing functional structures of the kidney, span the cortex and medulla. The initial filtering portion of a nephron is the renal corpuscle, located in the cortex, which is followed by a renal tubule that passes from the cortex deep into the medullary pyramids. Part of the renal cortex, a medullary ray is a collection of renal tubules that drain into a single collecting duct.

The tip, or papilla, of each pyramid empties urine into a minor calyx, minor calyces empty into major calyces, and major calyces empty into the renal pelvis, which becomes the ureter.

Blood supply

The kidneys receive blood from the renal arteries, left and right, which branch directly from the abdominal aorta. Despite their relatively small size, the kidneys receive approximately 20% of the cardiac output.[5]

Each renal artery branches into segmental arteries, dividing further into interlobar arteries which penetrate the renal capsule and extend through the renal columns between the renal pyramids. The interlobar arteries then supply blood to the arcuate arteries that run through the boundary of the cortex and the medulla. Each arcuate artery supplies several interlobular arteries that feed into the afferent arterioles that supply the glomeruli.

The interstitum (or interstitium) is the functional space in the kidney beneath the individual filters (glomeruli) which are rich in blood vessels. The interstitum absorbs fluid recovered from urine. Various conditions can lead to scarring and congestion of this area, which can cause kidney dysfunction and failure.

After filtration occurs the blood moves through a small network of venules that converge into interlobular veins. As with the arteriole distribution the veins follow the same pattern, the interlobular provide blood to the arcuate veins then back to the interlobar veins which come to form the renal vein exiting the kidney for transfusion for blood.

Histology

Renal histology studies the structure of the kidney as viewed under a microscope. Various distinct cell types occur in the kidney, including:

Kidney glomerulus parietal cell Kidney glomerulus podocyte Kidney proximal tubule brush border cell Loop of Henle thin segment cell Thick ascending limb cell Kidney distal tubule cell

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Kidney collecting duct cell Interstitial kidney cells

Innervation

The kidney and nervous system communicate via the renal plexus, whose fibers course along the renal arteries to reach the kidney. Input from the sympathetic nervous system triggers vasoconstriction in the kidney, thereby reducing renal blood flow. The kidney is not thought to receive input from the parasympathetic nervous system. Sensory input from the kidney travels to the T10-11 levels of the spinal cord and is sensed in the corresponding dermatome. Thus, pain in the flank region may be referred from the kidney.

Functions

The kidney participates in whole-body homeostasis, regulating acid-base balance, electrolyte concentrations, extracellular fluid volume, and regulation of blood pressure. The kidney accomplishes these homeostatic functions both independently and in concert with other organs, particularly those of the endocrine system. Various endocrine hormones coordinate these endocrine functions; these include renin, angiotensin II, aldosterone, antidiuretic hormone, and atrial natriuretic peptide, among others.

Many of the kidney's functions are accomplished by relatively simple mechanisms of filtration, reabsorption, and secretion, which take place in the nephron. Filtration, which takes place at the renal corpuscle, is the process by which cells and large proteins are filtered from the blood to make an ultrafiltrate that will eventually become urine. The kidney generates 180 liters of filtrate a day, while reabsorbing a large percentage, allowing for the generation of only approximately 2 liters of urine. Reabsorption is the transport of molecules from this ultrafiltrate and into the blood. Secretion is the reverse process, in which molecules are transported in the opposite direction, from the blood into the urine.

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Excretion of wastes

The kidneys excrete a variety of waste products produced by metabolism. These include the nitrogenous wastes called "urea", from protein catabolism, as well as uric acid, from nucleic acid metabolism.

Acid-base homeostasis

Two organ systems, the kidneys and lungs, maintain acid-base homeostasis, which is the maintenance of pH around a relatively stable value. The lungs contribute to acid-base homeostasis by regulating bicarbonate (HCO3

-) concentration. The kidneys have two important roles in the maintaining of the acid-base balance: to reabsorb bicarbonate from and to excrete hydrogen ions into urine

Osmolality regulation

Any significant rise in plasma osmolality is detected by the hypothalamus, which communicates directly with the posterior pituitary gland. An increase in osmolality causes the gland to secrete antidiuretic hormone (ADH), resulting in water reabsorption by the kidney and an increase in urine concentration. The two factors work together to return the plasma osmolality to its normal levels.

ADH binds to principal cells in the collecting duct that translocate aquaporins to the membrane allowing water to leave the normally impermeable membrane and be reabsorbed into the body by the vasa recta, thus increasing the plasma volume of the body.

There are two systems that create a hyperosmotic medulla and thus increase the body plasma volume: Urea recycling and the 'single effect.'

Urea is usually excreted as a waste product from the kidneys. However, when plasma blood volume is low and ADH is released the aquaporins that are opened are also permeable to urea. This allows urea to leave the collecting duct into the medulla creating a hyperosmotic solution that 'attracts' water. Urea can then re-enter the nephron and be excreted or recycled again depending on whether ADH is still present or not.

The 'Single effect' describes the fact that the ascending thick limb of the loop of Henle is not permeable to water but is permeable to NaCl. This allows for a countercurrent exchange system whereby the medulla becomes increasingly concentrated, but at the same time setting up an osmotic gradient for water to follow should the aquaporins of the collecting duct be opened by ADH.

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Blood pressure regulation

Long-term regulation of blood pressure predominantly depends upon the kidney. This primarily occurs through maintenance of the extracellular fluid compartment, the size of which depends on the plasma sodium concentration. Although the kidney cannot directly sense blood pressure, changes in the delivery of sodium and chloride to the distal part of the nephron alter the kidney's secretion of the enzyme renin. When the extracellular fluid compartment is expanded and blood pressure is high, the delivery of these ions is increased and renin secretion is decreased. Similarly, when the extracellular fluid compartment is contracted and blood pressure is low, sodium and chloride delivery is decreased and renin secretion is increased in response.

Renin is the first in a series of important chemical messengers that comprise the renin-angiotensin system. Changes in renin ultimately alter the output of this system, principally the hormones angiotensin II and aldosterone. Each hormone acts via multiple mechanisms, but both increase the kidney's absorption of sodium chloride, thereby expanding the extracellular fluid compartment and raising blood pressure. When renin levels are elevated, the concentrations of angiotensin II and aldosterone increase, leading to increased sodium chloride reabsorption, expansion of the extracellular fluid compartment, and an increase in blood pressure. Conversely, when renin levels are low, angiotensin II and aldosterone levels decrease, contracting the extracellular fluid compartment, and decreasing blood pressure.

Hormone secretion

The kidneys secrete a variety of hormones, including erythropoietin, and the enzyme renin. Erythropoietin is released in response to hypoxia (low levels of oxygen at tissue level) in the renal circulation. It stimulates erythropoiesis (production of red blood cells) in the bone marrow. Calcitriol, the activated form of vitamin D, promotes intestinal absorption of calcium and the renal reabsorption of phosphate. Part of the renin-angiotensin-aldosterone system, renin is an enzyme involved in the regulation of aldosterone levels.

Development

The mammalian kidney develops from intermediate mesoderm. Kidney development, also called nephrogenesis, proceeds through a series of three successive phases, each marked by the development of a more advanced pair of kidneys: the pronephros, mesonephros, and metanephros.

Evolutionary adaptation

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Kidneys of various animals show evidence of evolutionary adaptation and have long been studied in ecophysiology and comparative physiology. Kidney morphology, often indexed as the relative medullary thickness, is associated with habitat aridity among species of mammals.

Etymology

Medical terms related to the kidneys commonly use terms such as renal and the prefix nephro-. The adjective renal, meaning related to the kidney, is from the Latin rēnēs, meaning kidneys; the prefix nephro- is from the Ancient Greek word for kidney, nephros (νεφρός). For example, surgical removal of the kidney is a nephrectomy, while a reduction in kidney function is called renal dysfunction.

Diseases and disorders

Congenital

Congenital hydronephrosis Congenital obstruction of urinary tract Duplex kidneys, or double kidneys, occur in approximately 1% of the population. This

occurrence normally causes no complications but can occasionally cause urine infections. Duplicated ureter occurs in approximately one in 100 live births

Horseshoe kidney occurs in approximately one in 400 live births Polycystic kidney disease

o Autosomal dominant polycystic kidney disease afflicts patients later in life. Approximately one in 1000 people will develop this condition

o Autosomal recessive polycystic kidney disease is far less common, but more severe, than the dominant condition. It is apparent in utero or at birth.

Renal agenesis. Failure of one kidney to form occurs in approximately one in 750 live births. Failure of both kidneys to form is invariably fatal.

Renal dysplasia Unilateral small kidney Multicystic dysplastic kidney occurs in approximately one in every 2400 live births Ureteropelvic Junction Obstruction or UPJO; although most cases appear congenital,

some appear to be an acquired condition

AcquiredDrawing of an enlarged kidney by John Hunter.

Diabetic nephropathy Glomerulonephritis Hydronephrosis is the enlargement of one or both of the kidneys caused by obstruction of

the flow of urine.

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Interstitial nephritis

Kidney stones (nephrolithiasis) are a relatively common and particularly painful disorder. Kidney tumors

o Wilms tumoro Renal cell carcinoma

Lupus nephritis Minimal change disease In nephrotic syndrome, the glomerulus has been damaged so that a large amount of

protein in the blood enters the urine. Other frequent features of the nephrotic syndrome include swelling, low serum albumin, and high cholesterol.

Pyelonephritis is infection of the kidneys and is frequently caused by complication of a urinary tract infection.

Renal failure o Acute renal failureo Stage 5 Chronic Kidney Disease

b) Bone marrow

is the flexible tissue found in the interior of bones. In humans, bone marrow in large bones produces new blood cells. Bone marrow is also a vital element of the lymphatic system, as it produces lymphocytes and acts to prevent the backflow of lymph. On average, bone marrow constitutes 4% of the total body mass of humans; in adults weighing 65 kg (143 lbs), bone marrow accounts for approximately 2.6 kg (5.7 lbs).

Marrow types

There are two types of bone marrow: red marrow (consisting mainly of hematopoietic tissue) and yellow marrow (consisting mainly of fat cells). Red blood cells, platelets and most white blood cells arise in red marrow. Both types of bone marrow contain numerous blood vessels and capillaries. At birth, all bone marrow is red. With age, more and more of it is converted to the yellow type; only around half of adult bone marrow is red. Red marrow is found mainly in the flat bones, such as the hip bone, breast bone, cranium, ribs, vertebrae and shoulder blades, and in the cancellous ("spongy") material at the epiphyseal ends of long bones such as the femur and humerus. Yellow marrow is found in the medullary cavity, the hollow interior of the middle portion of long bones. In cases of severe blood loss, the body can convert yellow marrow back to red marrow to increase blood cell production.

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Stroma

The stroma of the bone marrow is all tissue not directly involved in the primary function of hematopoiesis. Yellow bone marrow makes up the majority of bone marrow stroma, in addition to smaller concentrations of stromal cells located in the red bone marrow. Though not as active as parenchymal red marrow, stroma is indirectly involved in hematopoiesis, since it provides the hematopoietic microenvironment that facilitates hematopoiesis by the parenchymal cells. For instance, they generate colony stimulating factors, which have a significant effect on hematopoiesis. Cells that constitute the bone marrow stroma are:

fibroblasts (reticular connective tissue) macrophages adipocytes osteoblasts osteoclasts endothelial cells forming the sinusoids

Macrophages contribute especially to red blood cell production, as they deliver iron for hemoglobin production.

Bone marrow barrier

The blood vessels of the bone marrow constitute a barrier, inhibiting immature blood cells from leaving the marrow. Only mature blood cells contain the membrane proteins required to attach to and pass the blood vessel endothelium. Hematopoietic stem cells may also cross the bone marrow barrier, and may thus be harvested from blood.

Stem cells

The bone marrow stroma contain mesenchymal stem cells (MSCs) (also called marrow stromal cells). These cells are multipotent stem cells that can differentiate into a variety of cell types. Cell types that MSCs have been shown to differentiate into in vitro or in vivo include osteoblasts, chondrocytes, myocytes, adipocytes and beta-pancreatic islets cells. MSCs can also transdifferentiate into neuronal cells.

Compartmentalization

There is biologic compartmentalization in the bone marrow, in that certain cell types tend to aggregate in specific areas. For instance, erythrocytes, macrophages, and their precursors tend to gather around blood vessels, while granulocytes gather at the borders of the bone marrow.

Lymphatic role

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Bone marrow is a key element of the lymphatic system, being one of the primary lymphoid organs which generate lymphocytes from immature hematopoietic progenitor cells. The bone marrow and thymus constitute the primary lymphoid tissues involved in the production and early selection of lymphocytes. Bone marrow furthermore performs a valve-like function to prevent the backflow of lymphatic fluid in the lymphatic system.

Types of stem cells

Hematopoietic precursor cells: promyelocyte in the center, two metamyelocytes next to it and band cells from a bone marrow aspirate.

Bone marrow contains three types of stem cells:

Hematopoietic stem cells give rise to the three classes of blood cells that are found in the circulation: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets (thrombocytes).

Mesenchymal stem cells are found arrayed around the central sinus in the bone marrow. They have the capability to differentiate into osteoblasts, chondrocytes, myocytes, and many other types of cells. They also function as "gatekeeper" cells of the bone marrow.

Endothelial stem cells

Diseases involving the bone marrowThe normal bone marrow architecture can be displaced by malignancies, aplastic anemia, or infections such as tuberculosis, leading to a decrease in the production of blood cells and blood platelets. In addition, cancers of the hematologic progenitor cells in the bone marrow can arise; these are the leukemias.

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c) Heart Anatomy

Coronary Arteries

Because the heart is composed primarily of cardiac muscle tissue that continuously contracts and relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle tissue.

The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the beginning of the aorta, near the top of the heart.

The initial segment of the left coronary artery is called the left main coronary. This blood vessel is approximately the width of a soda straw and is less than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of the heart and is embedded in the surface of the back of the heart.

Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for disposal through the lungs, kidneys and liver.

When cholesterol plaque accumulates to the point of blocking the flow of blood through a coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.

Superior Vena Cava

The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right atrium of the heart.

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Inferior Vena Cava

The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right atrium of the heart.

Aorta

The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.

Pulmonary Artery

The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify arteries as vessels carrying blood away from the heart.

Pulmonary Vein

The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins as vessels carrying blood to the heart.

Right Atrium

The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle.

Right Ventricle

The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.

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Left Atrium

The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve into the left ventricle.

Left Ventricle

The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the body.

Papillary Muscles

The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. The contraction of the papillary muscles opens these valves. When the papillary muscles relax, the valves close.

Chordae Tendineae

The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as "heart strings."

Tricuspid Valve

The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve into the pulmonary artery.

Mitral Value

The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left ventricle

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contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.

Pulmonary Valve

The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.

Aortic Valve

The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles relax, preventing blood from returning to the heart.

The heart is a complex organ whose primary function is to pump blood through the pulmonary and systemic circulations. It is composed of four muscular chambers: the main pumping chambers, the left and right ventricles, and the left and right atria, which act like "priming pumps" responsible for the final 20–30% of ventricular filling (Figure 10–1A). Peripheral venous return from the inferior and superior venae cavae fills the right atrium and ventricle (through the open tricuspid valve) (Figure 10–1B). With atrial contraction, additional blood flows through the tricuspid valve and completes the filling of the right ventricle. Unoxygenated blood is then pumped to the pulmonary artery and lung by the right ventricle through the pulmonary valve (Figure 10–1C). Oxygenated blood returns from the lung to the left atrium via four pulmonary veins (Figure 10–1D). Sequential left atrial and ventricular contraction pumps blood back to the peripheral tissues. The mitral valve separates the left atrium and ventricle, and the aortic valve separates the left ventricle from the aorta (Figures 10–1D and 10–1E).

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Anatomy of the heart

A: Anterior view of the heart. B: View of the right heart with the right atrial wall reflected to show the right atrium. C: Anterior view of the heart with the anterior wall removed to show the right ventricular cavity. D: View of the left heart with the left ventricular wall turned back to show the mitral valve. E: View of the left heart from the left side with the left ventricular free wall and mitral valve cut away to reveal the aortic valve.

The heart lies free in the pericardial sac, attached to mediastinal structures only at the great vessels. During embryologic development, the heart invaginates into the pericardial sac like a fist pushing into a partially inflated balloon. The pericardial sac is composed of a serous inner layer (visceral pericardium) directly apposed to the myocardium and a fibrous outer layer called the parietal pericardium. Under normal conditions, approximately 40–50 mL of clear fluid, which probably is an ultrafiltrate of plasma, fills the space between pericardial sac.

The left main and right coronary arteries arise from the root of the aorta and provide the principal blood supply to the heart (Figure 10–2). The large left main coronary artery usually branches into the left anterior descending artery and the circumflex coronary artery. The left anterior descending coronary artery gives off diagonal and septal branches that supply blood to the anterior wall and septum of the heart, respectively. The circumflex coronary artery continues around the heart in the left atrioventricular groove and gives off large obtuse marginal arteries that supply blood to the left ventricular free wall. The right coronary artery travels in the right atrioventricular groove and supplies blood to the right ventricle via acute marginal branches. The posterior descending artery, which supplies blood to the posterior and inferior walls of the left

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ventricle, arises from the right coronary artery in 80% of people (right-dominant circulation) and from the

circumflex artery in the remainder (left-dominant circulation).

Contraction of the heart chambers is coordinated by several regions in the heart that are composed of myocytes with specialized automaticity (pacemaker) and conduction properties (Figure 10–3). Cells in the sinoatrial (SA) node and the atrioventricular (AV) node have fast pacemaker rates (SA node: 60–100 beats/min; AV node: 40–70 beats/min), and the His bundle and Purkinje fibers are characterized by rapid rates of conduction. Because it has the fastest intrinsic pacemaker rhythm, the SA node is usually the site of initiation of the cardiac electrical impulse during a normal heartbeat. The impulse then rapidly depolarizes both the left and right atria as it travels to the AV node. Conduction velocity slows from 1 m/s in atrial tissue to 0.05 m/s in nodal tissue. After the delay in the AV node, the impulse moves rapidly down the His bundle (1 m/s) and Purkinje fibers (4 m/s) to simultaneously depolarize the right and left ventricles. The atria and ventricles are separated by a fibrous framework that is electrically inert,

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so that under normal conditions the AV node and the contiguous His bundle form the only electrical connection between the atria and ventricles. This arrangement allows the atria and ventricles to beat in a synchronized fashion and minimizes the chance of electrical feedback between the chambers.

The electrical activity of the heart can be measured from the body surface at standardized positions by electrocardiography. On the electrocardiogram (ECG), the P wave represents depolarization of atrial tissue; the electrocardiographic wave (QRS) interval, ventricular depolarization; and the T wave, ventricular repolarization (Figure 10–3). Because normal ventricular depolarization occurs almost simultaneously in the right and left ventricles—usually within 60–100 ms—the QRS complex is narrow. Although the electrical activity of the small specialized conduction tissues cannot be measured directly from the surface, the interval between the P wave and the start of the QRS complex (PR interval) represents primarily the conduction time of the AV node and His bundle.Physiology of the Whole Heart

Because the ventricles are the primary physiologic pumps of the heart, analysis has focused on these chambers, particularly the left ventricle. Function of intact ventricles is traditionally studied by evaluating pressure-time and pressure-volume relationships.

d) RESPIRATORY SYSTEM

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Respiratory System Functions1. supplies the body with oxygen and disposes of carbon dioxide2. filters inspired air3. produces sound4. contains receptors for smell5. rids the body of some excess water and heat6. helps regulate blood Ph

Upper Respiratory Tract

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Composed of the nose and nasal cavity, paranasal sinuses, pharynx (throat), larynx. All part of the conducting portion of the respiratory system.A) Nose provides and airway for respiration

• moistens and warms entering air • filters and cleans inspired air • resonating chamber for speech

detects odors in the air stream

B) Paranasal Sinuses Four bones of the skull contain paired air spaces called the paranasal sinuses - frontal,

ethmoidal, sphenoidal, maxillary Decrease skull bone weight Warm, moisten and filter incoming air Add resonance to voice. Communicate with the nasal cavity by ducts. Lined by pseudostratified ciliated columnar epithelium.

C) Pharynx Common space used by both the respiratory and digestive systems. Commonly called the throat. Originates posterior to the nasal and oral cavities and extends inferiorly near the level of

the bifurcation of the larynx and esophagus. Common pathway for both air and food.

D) Nasopharynx Material from the oral cavity and oropharynx is typically blocked from entering the

nasopharynx by the uvula of soft palate, which elevates when we swallow. In the lateral walls of the nasopharynx, paired auditory/eustachian tubes connect the

nasopharynx to the middle ear. Posterior nasopharynx wall also houses a single pharyngeal tonsil (commonly called the

adenoids).

E) Oropharynx The middle pharyngeal region. Immediately posterior to the oral cavity. Bounded by the edge of the soft palate superiorly and the hyoid bone inferiorly. Common respiratory and digestive pathway through which both air and swallowed food

and drink pass. Contains nonkeratinized stratified squamous epithelim.

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Lymphatic organs here provide the first line of defense against ingested or inhaled foreign materials. Palatine tonsils are on the lateral wall between the arches, and the lingual tonsils are at the base of the tongue.

F) Laryngopharynx Inferior, narrowed region of the pharynx. Extends inferiorly from the hyoid bone to the larynx and esophagus. Terminates at the superior border of the esophagus and the epiglottis of the larynx. Lined with a nonkeratinized stratified squamous epithelium. Permits passage of both food and air.

Lower Respiratory Tract Conducting airways (trachea, bronchi, up to terminal bronchioles). Respiratory portion of the respiratory system (respiratory bronchioles, alveolar ducts, and

alveoli).

A) Larynx Voice box is a short, somewhat cylindrical airway ends in the trachea. Prevents swallowed materials from entering the lower respiratory tract. Conducts air into the lower respiratory tract. Produces sounds. Supported by a framework of nine pieces of cartilage (three individual pieces and three

cartilage pairs) that are held in place by ligaments and muscles.

B) Trachea

A flexible tube also called windpipe. Extends through the mediastinum and lies anterior to the esophagus and inferior to the

larynx. Anterior and lateral walls of the trachea supported by 15 to 20 C-shaped tracheal

cartilages. Cartilage rings reinforce and provide rigidity to the tracheal wall to ensure that the

trachea remains open at all times Posterior part of tube lined by trachealis muscle Lined by ciliated pseudostratified columnar epithelium.

C) Bronchial tree A highly branched system of air-conducting passages that originate from the left and

right primary bronchi. Progressively branch into narrower tubes as they diverge throughout the lungs before

terminating in terminal bronchioles.

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Incomplete rings of hyaline cartilage support the walls of the primary bronchi to ensure that they remain open.

Right primary bronchus is shorter, wider, and more vertically oriented than the left primary bronchus.

Foreign particles are more likely to lodge in the right primary bronchus.

Pre-disposing factors Rationale Justification Remarks Age -renal diseases my

affect person at any age range. According to the internet, 15 years and above in 2005 was 46,627,172 a prevalence rate of 2.6% means that 1, 212,306 other Filipinos have CKD.

-patient is 17 years of age.

Present

Sex -it can occur in both sexes (male and female). According to www.wikipedia.com, the disease is more likely to happen to a female pt.

- Our patient is a male.

Present

Race -according to the book of ignata, american-african people are

-patient is an Asian. Present

P a g e | 48

more likely to have an ESRD.

Genetic factor -it is an inherited disease that can be acquired through either line of parents.

-according to patient, his grandfather on paternal side had a history of kidney disease.

Present

Previous infection/ history of infection

-infection especially cause by a streptococcal infection can lead to glomerulonephritis.

-patient had a history of sore throat and skin infection as he reported.

Present

ETIOLOGY

Precipitating factors Rationale Justification Remarks Sedentary

lifestyle-activity in daily living focus in eating, sleeping, sitting, smoking, alcohol habits and limit exercise.

-patient verbalize that he usually engaged to activities such as cigarette smoking and alcohol drinks.

Present

Diet -foods rich or increased in sodium content can alter renal functions.

-patient is fond of eating junk foods and foods rich in sodium such as dried fish(bulad).-also patient fond of drinking caffeinated drinks such as extrajoss after he exercise.

Present

Environmental factors

-stimulation of the different factors present in the

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Lack of guidance

Peer pressure

environment causes our body to react to certain stimuli ( such as bacteria and viruses).

-parents are responsible in rearing their children which includes the guidance in proper diet, exercise and hygiene.

Activities such as cigarette smoking and alcohol drinking usually are initiated by peers.

-patients’ parents are too busy with their work in order to provide physiologic needs to their children that they forgot to perform their responsibility to guide and teach their sons the proper diet and hygiene.

Patient reported that he usually accompany his barkadas in doing such activities.

Present

Present

Hygiene Poor hygiene is more likely to attract microorganisms that can cause infections.

Patient has dental carries and skin infections

Present

Unsafe water sources

Water with chlorine content can damage the kidneys in long term.

Patient and his family gets their water from “NAWASA” which has chlorine content.

Present

Exposure to infection

Streptococcal infection can lead to glomerulonephritis which can later contribute to Chronic Renal Failure.

Patient has dental carries and skin infections which is probably infected with streptococcal microorganisms.

Present

Smoking Cigarette contains a Patient confirms that Present

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substance “nicotine” which can cause vasoconstriction that can affect normal blood flows into the kidneys.

he is smoking prior to admission.

Alcohol drinking It contains substances which are toxic to the kidneys.

Patient is fond of drinking alcoholic drinks with his friends.

Present

SYMPTOMATOLOGY

SIGNS AND SYMPTOMS RATIONALE/ JUSTIFICATION

Remarks

NEUROLOGIC Weakness and Fatigue -this is due to the decreased

tissue oxygenation brought about by the decreased RBC resulting to the tissue perfusion.

present

Confusion -this may be due to the decrease tissue oxygenation in the brain

Present

Inability to concentrate -this may be due to the accumulation of uremic waste products

Present

Disorientation -this is due to the uremic waste product accumulation

Present

Behavior changes -this is due to the irritation brought about by the uremic

present

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waste accumulationPatient appears irritable.

Tremors or Seizures -this may be associated with the uremic waste product accumulation

Not present

Restlessness of the legs

-this is associated with the decreased tissue oxygenation brought about by the decrease RBC count which may leads to decrease tissue perfusion

Not present

CARDIOVASCULAR Hypertension -this is due to sodium and

water retention in the body that contributes to the increase blood volumePatient BP is 150/90 mmHg

Present

Pitting edema -this is due to increase albumin excretion which is responsible for the oncotic pressure (pulling of blood or fluid into the extra cellular cells)-this is also because of the damage to the juxtaglomerular(JG) cells that increase the infiltration rate which result in the retention of fluid and electrolytes in the body usually in the lower extremities.

Present

Increase cardiac output -this is due to fluid and sodium retention which results to the increase volume in the body.

present

Engorged neck vein -this is due to the increased pressure brought about by the increase cardiac output and blood volume

Present

Periorbital edema -this is due to the fluid and sodium retention which increase blood volume in the body.

Not present

Pericardial effusion -this is due to the accumulation of fluid in the pericardial cavity.

Not present

Hyperkalemia Patients with CRF has high Not Assessed

P a g e | 52

potassium level because the kidneys cannot excrete the excess potassium.

Hyperlipidemia In CRF, there is a loss of plasma protein or albumin, there will be stimulation of synthesis of lipoproteins in the liver which causes hyperlipidemia.

Not Assessed

RESPIRATORY Difficulty of breathing -This is due to the fluid

accumulation in the lungsPresent

Crackles -this is due to the increase mucus production

Present

Tachypnea -a compensatory mechanism of the respiratory tract to maintain the normal pH.

Present

Kussmaul type of breathing

-this is due to compensatory mechanism of the respiratory tract to maintain the normal pH.

Present

Hypoxia -this is due to the decrease which is responsible for the oxygen transport to the muscle tissue of the respiratory tract.

Present

Pleuritic pain -this may be associated with the nitrogenous waste product accumulation which vary irritate the pleura.

Not present

Uremic pnuemonitis -this way is associated with the uremic waste product accumulation.

Not present

RENAL Proteinuria &

Hematuria

-this is due to the increase filtration rate which increases the permeability of the glumeruli that enables the large molecules such as CHON, RBC to pass through it.

Not present

Increase level of BUN and Serum Creatinine

-this is due to decrease renal functional to excrete

Not present

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nitrogenous waste products such as urea/ uric acid and creatinine.

Hyperphosphatemia -this maybe due to the decrease filtration through the glomerulus of the kidneys.

Not Present

Hypocalcemia -this maybe due to the increased secretion of parathormone from the parathyroid gland.

Not present

Nausea and vomiting -this may be associated with the waste product accumulation.

Present

Metallic taste -this is also associated with the accumulation of nitrogenous waste products.

Present

Ascites -this is due to accumulation of fluid in the abdomen

Not present

HEMATOLOGIC Anemia and Hgb count

-this is due to the decrease of erythropoietin in the kidneys which is responsible for the stimulation of bone marrow to produce RBC.

Present

INTEGUMENTARY Pruritus

-disposition of uremic waste products or the skin.

Present

Dry scaly skin -accumulation of nitrogenous waste production in the skin

since there is a decrease renal function to excrete waste

product.

Present

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Hematology

Name of patient: KD Date: July 9, 2011

Diagnosis: Anemia 2 0 to end stage renal Disease Hospital: SCPH

A medical specialty which concern itself with the blood and the generation of the

blood in the bone marrow. Hematology studies the red and white blood cells,

their relatives proportions and general cell health and the diseases that are caused

by imbalances between them notably leukemia and anemia.

ChemicalComponent

Normal value

Result Interpretation Nursing responsibilities

Hemoglobin mass

140-160g/l 43 Decreased Indicates

anemia

- Check for the doctor’s order to perform BT to the patient, explain the purpose and

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the procedure to the patient and follow protocol in performing blood transfusion.

Leukocyte number concentration

5.1-10x103g/l

12.8 Increased indicates acute

infection

- Instruct patient to avoid exposure to persons with active infections to avoid acquiring the infection. (no antibiotics ordered by the physician).

Segmenters 0.55-0.65 0.84 Increased indicates viral

infection

- Instruct patient to avoid exposure to persons with active infections to avoid acquiring the infection. (no antibiotics ordered by the physician).

Lymphocytes 0.25-0.35 0.07 Decreased

Commonly seen in patients with:

Steroid exposure Some cancers Immunodeficiency Renal failure Lupus

- Encourage patient to strictly comply with the therapeutic regimens ordered by the physician for fast improvement of his condition. Administer the drugs as ordered by the physician.

Eosinophils 0.02-0.04 0.01 Decreased

Decreases in eosinophil counts are associated with:

Stress Steroid exposure

- Encourage patient to avoid stressful events, provide rest periods.

Monocyte 0.03-0.06 0.07 Increased Indicates chronic

inflammatory disease and parasitic

- Instruct patient to avoid exposure to persons with active infections to avoid acquiring

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infection. the infection. (no antibiotics ordered by the physician). Teach patient how to perform proper hygiene.

Basophils 0.0-0.01 0.01 Normal - Encourage pt. to maintain balanced nutrition and strict compliance to the medical regimens ordered by the physician.

DOCTORS ORDER

Patient’s Name: K.D Physician: Marylin Abantao, MDDiagnosis:Anemia secondary to end stage secondarydisease Date: July 9, 2011

DATE/TIME ORDER REMARKS RATIONALE

7-9-116 pm

- Pls admit

- Diet law salt

- Temperature, pulse, rate monitor

Admitted

Instructed

Monitored & Recorded

- The patient is admitted for proper management and treatment

- Patient has Chronic Kidney disease; Sodium could further complicate hypertension and edema of patient. It is highly contraindicated to the patient.

- TPR is use to determine the pt’s current condition and to note significant changes. This is also for baseline data to help

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- CBC, BT

- UA

- Serum Na -

Done

Requested but not secured

Done

physician to further assess the improvement and condition of the patient.

- A complete blood count (CBC) is a series of tests used to evaluate the composition and concentration of the cellular components of blood. It consists of the following tests: red blood cell (RBC) count, white blood cell (WBC) count, and platelet count; measurement of hemoglobin and mean red cell volume; classification of white blood cells (WBC differential); and calculation of hematocrit and red blood cell indices .-Blood typing – it is needed to identify the blood type of the patient, in case of emergency blood transfusion.

- Routine urinalyses are performed for several reasons:

general health screening to detect renal and metabolic diseases

diagnosis of diseases or disorders of the kidneys or urinary tract

monitoring of patients with diabetes

- Potassium testing is frequently ordered, along with other electrolytes, as part of a routine physical. It is used to detect concentrations that are too high (hyperkalemia) or too low (hypokalemia). This test is necessary for our patients because he has kidney disease.

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- ECG

- Chest X-ray

Done

Done

- To assess for the heart function. patient is risk for having tachycardia and other heart dysrhythmias due to increased potassium in the body caused by Chronic renal failure.

- To assess for presence of cardiomegaly and pleural effusion.

DATE/TIME ORDER REMARKS RATIONALE

- scrum creatine, lipid profile

-D5LR @ KVO

- Medication1. Captopril 25g SL PRN for Br ≥140/90

Ordered but not secured

Hooked and regulated

Given

-serum creatinine test will help identify for the presence of kidney failure, lipid profile is also indicated for CRF patients because in patients with kidney diseases there is a high tendency of having hyperlipidemia. Because of the decreased albumin in the body, there will be stimulation of synthesis of lipoproteins in the liver which can cause hyperlipidemia in CRF patients.

-It is hypertonic solution. IVF is for administration of IVTT medications, and regulating it in KVO will help prevent system overload for patient since he is already edematous and has excess fluid in the body. This will prevent further progression of Edema and cardiac overload.

This drug inhibits ACE preventing.-Conversion of angiotension I to angiotensin II, a potent vasocous trictors less angiotension II

P a g e | 62

mmhg q50

2. Amlodipine 10mg POBID

3. Ranitidine 50mg IVTT q 80

4. Erythropocitin 4,000 “U” (Eprex) SC 2x a week

5. Omeprazole 40mg IVTT now

- Monitor I&O q shift

Given

Given

Given

Given

Monitored

to perpher al conterial resistance, I aldosterone aterial resistance, which reduces sodium & H2O retention & lower BP.- The patient experiences hypertension as a complication of CRF, controlling his blood pressure is needed.

-This drug reduces peripheral vascular resistance & BP, producing antiangina effects by reducing after load & mycadial or demand, blocking contriction & restoring blood flow.- The patient experiences hypertension as a complication of CRF, controlling his blood pressure is needed.

- Conpetitively inhibits action of his tamine on the H2 @ receptor sites of paristal cells, gastic acid secretion.- in patiens with CRF, the kidneys cannot excrete acids, ranitidine is given to decrease acid production in the stomach to prevent ulcers.-Mimics effects of erytropoistin functions as a growth factors & as a differentiating factor enfancing RBC production.-patient experiences anemia as a complication of CRF, giving this drug would help increase his hemoglobin count.

- An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells.- in patiens with CRF, the kidneys cannot excrete acids, omeprazole is given to decrease acid production in the stomach to prevent ulcers.

-to assess for kidney function.

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List of Drugs

NAME OF DRUGS DOSAGE ROUTE FREQUENCY

1) CAPTOPRIL(Capoten)

25 mg tablet Sublingualq60 for BP – 140/90

mmHg2) AMLODIPINE

BESYLATE(Norvasc)

10 mg tablet Oral BID

3) RANITIDINE HYDROCHLORIDE(Ranitac)

50 mg IVTT q80

4) OMEPRAZOLE(Prilosec)

40 mg IVTT NOW

5) ERYTHROPOIETIN(Eprex)

4000 “u”/ml Subcutaneous 2 x a week.

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NOTRE DAME OF TACURONG COLLEGECOLLEGE OF NURSING

DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

GENERIC: Captopril

BRAND: Capoten

CLASSIFICATION:

Antihypertensive; ACE inhibitor

MODE OF ADMINISTRATION

Route: Sublingual

Dosage: 25 mg tablet

Time: q60 for BP – 140/90 mmHg

Mechanism of Action:

Inhibits ACE, preventing conversion of angiotenin I to Angiotensin II, a potent vasoconstrictor, less angiotesin II, decreases Peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention & lowers BP.

Bibliography:

Karch, A.M. (2007). Lippincott’s Nursing Drug Guide.

Dizziness, fainting, Headache, malaise, fatigueTachycardia, hypertension, Angina pectoris Abdominal pain, anorexia, Constipation, diarrhea, dry-Mouth, nausea, vomiting Hyperkalemia Dyspnea,

ADVERSE EFFECT

Leukopenia Agranulocytosis thrombocytopenia Angioedema

Patients hypertensiveTo drug or other ACEinhibors

SPECIAL PRECAUTION

Use cautiously in patients with impaired renal function, CHF, salt or volume depletion.

DRUG INTERACTION

Drug-drug: Increased risk of

hypersensitivity reactions with allopurinol. Decreased antihypertensive effects with indomethacin. Increased captoptril effects with probenecid.

1. Assess the patient for the history of hypersensitive to drug or other ACE inhibitors

To prevent reoccurrence of hypersensitivity reactions to drug.

2. Check the patient’s BP before administering the drug

To have a baseline data and this drug is given to lower the blood pressure of the patient thus; evaluating its drug effectiveness.

3. Instruct the patient not to crush nor swallow the drug.

Crushing or swallowing the drug may interfere its effect.

4. Monitor the patient’s blood pressure.

Hypotension may occur.5. Monitor the heart rate of

the patient.

Captopril25 mg tablet

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Indication: Hypertension Hypertension in

chronic Renal failures

occur due to Sodium retention or from activation of renin-angiotensin-Aldosterone – system.

Captopril can cause tachycardia.

6. Assess the patient respiration.

Dyspnea and cough may occur.

7. Monitor patient’s body temperature.

To anticipate fever that may occur.

8. Instruct pt. to include Fiber in the Diet.

To aid if constipated as possibly cause by drug side effect.

9. Stay at bedside after giving the drug.

The pt. may become dizzy, and faint. Provide adequate protection.

10. Observe the patient for the occurrence of untoward reactions to drug.

To render prompt treatment and interventions

11. Document the drug given.

For continuity of care.

NOTRE DAME OF TACURONG COLLEGEAmlodipine10 mg tablet

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COLLEGE OF NURSING

DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

GENERIC: Amlodipine

Besylate

BRAND: Norvasc

CLASSIFICATION:

Calcium- channel blocker

Anti- angina Antihypertensive

MODE OF ADMINISTRATION

Route: PO

Dosage: 10 mg

Time: BID

Mechanism of Action: Inhibits the movement

of calcium ions across the membrane of cardiac and arterial muscle cells, inhibits trans membrane calcium flow, which results in depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of cardiac contractility, and dilation of coronary arteries and arterioles and peripheral arterioles; these effects lead to decreased cardiac work, decreased cardiac oxygen consumption and in patients with vasospastic (Prinzmetal’s) angina, increased delivery of oxygen to cardiac cells.

Bibliography:

Dizziness Light headedness Headache Fatigue Flushing Nausea

ADVERSE EFFECT

Arrhythmias Peripheral edema

Contraindicated in patients hypersensitive to amlodipine, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third)

SPECIAL PRECAUTION

Use cautiously with CHF

DRUG INTERACTION

Drug-drug: Possible

increased serum level toxicity of cyclosporine if taken concurrently.

1. Assess the patient for the history of hypersensitive to drug.

To prevent reoccurrence of hypersensitivity reactions to drug.

2. Check the patient’s BP before administering the drug

To have a baseline data and this drug is given to lower the blood pressure of the patient thus; evaluating its drug effectiveness.

3. Monitor the blood pressure during the initiation of therapy.

Drug induced vasodilation and has a gradual onset, acute hypertension is rare.

4. Assess patient’s respirations.

Drug causes dyspnea.5. Instruct patient and SO

to avoid drinking

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Karch, A.M. (2007). Lippincott’s Nursing Drug Guide.

Indication: Angina

(prinzmetal’s) Chronic stable angina Essential

hypertension

grapefruit juices. May increase drug level

and worsen the side effects.

6. Raise the side rails of bed, assist when ambulating and stay at the bedside after giving the drug.

Headache, fatigue, dizziness, lightheadedness, paresthesia and asthenia may occur thus; preventing fall accidents/injuries and promoting safety.

7. Instruct patient to avoid activities that require alertness.

This drug can cause somnolence.

8. Assess patient’s extremities for edema, rash and pruritus and notify the physician.

To give prompt treatment.

9. Observe the patient for any untoward reactions to the drug.

To render immediate

P a g e | 69

care and interventions.10. Document the drug

given. For continuity of care.

NOTRE DAME OF TACURONG COLLEGECOLLEGE OF NURSING

Ranitidine25 mg/ml in

a 2ml ampule

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DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

GENERIC: Ranitidine

Hydrochloride

BRAND: Zantac

CLASSIFICATION:

Histamine (H2) receptor antagonist

MODE OF ADMINISTRATION

Route: IVTT

Dosage: 50 mg

Time: q80

Mechanism of Action: Competitively inhibits

the action of histamine at the H2 receptors of the parietal cells of the stomach lining, inhibiting basal gastric acid secretion that is stimulated by food, insulin, histamine, cholinergic agonists, gastrin, and pentagastrin.

Bibliography:

Karch, A.M. (2007). Lippincott’s Nursing Drug Guide.

Indication: Short term

management of active duodenal ulcer

Benign gastric ulcer Short term

management of GERD

Constipation Diarrhea Vomiting Abdominal pain Local burning or

itching on the injection site.

ADVERSE EFFECT

PVC’s Leukopenia Granulocytopenia Thrombocytopenia Pancytopenia

Contraindicated in patients with allergy to ranitidine

SPECIAL PRECAUTION

Use cautiously with impaired renal or hepatic function.

DRUG INTERACTION

Drug-drug: Increased effects

of warfarin, TCA’s; monitor patient closely and adjust dosage as needed.

1. Assess the patient for the history of hypersensitive to drug.

To prevent reoccurrence of hypersensitivity reactions to drug.

2. Use cautiously to the patient.

Patient has a renal failure and may experience toxicity.

3. Monitor the heart rate of the patient.

Ranitidine can cause bachycardia and tachycardia.

4. Raise the side rails of bed, assist when ambulating and stay at the bedside after giving the drug.

Headache, vertigo, malaise and blurring of vision may occur thus; preventing fall accidents/injuries and promoting safety.

5. Monitor and regulate the

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IV infusion rate. Rapid administration

may cause PVC and further edema.

6. Assess patient’s sclera. This drug can cause

jaundice and sclera is most suitable site for assessing jaundice.

7. Administer the drug slowly.

Ranitidine can cause burning and itching at the injection site.

8. Observe the patient for any untoward reactions to the drug.

To render immediate care and interventions.

9. Document the drug given.

For continuity of care.

NOTRE DAME OF TACURONG COLLEGECOLLEGE OF NURSING

Omeprazole40 mg

ampuleampule

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DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATION NURSING RESPONSIBILITIES

GENERIC: Omeprazole

BRAND: Prilosec

CLASSIFICATION:

Proton Pump Inhibitor

MODE OF ADMINISTRATION

Route: IVTT

Dosage: 40 mg

Time: now

Mechanism of Action: An antisecretory

compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells.

Bibliography:

Karch, A.M. (2007). Lippincott’s Nursing Drug Guide.

Indication: Duodenal and gastric

ulcer. Gastroesophageal

reflux disease including severe erosive esophagitis (4 to 8 wk treatment).

Long-term treatment of pathologic hypersecretory conditions such as Zollinger-Ellison

Headache dizziness fatigue Diarrhea abdominal pain nausea mild

ADVERSE EFFECT

Hematuria proteinuria

Long-term use for gastroesophageal reflux disease (GERD), duodenal ulcers; proton pump inhibitors (PPIs), hypersensitivity; children <2 y; use of OTC formulation in children <18 y or GI bleeding; use of Zegerid in metabolic alkalosis, hypocalcemia, vomiting, GI bleeding;

SPECIAL PRECAUTION

Use cautiously with metabolic or respiratory alkalosis; hepatic disease.

DRUG INTERACTION

Drug-drug:

1. Assess the patient for the history of hypersensitive to drug.

To prevent reoccurrence of hypersensitivity reactions to drug.

2. Monitor the heart rate of the patient.

Omeprazole can cause bradycardia and tachycardia.

3. Raise the side rails of bed, assist when ambulating and stay at the bedside after giving the drug.

Headache, fatigue, dizziness and vertigo may occur thus; preventing fall accidents/injuries and promoting safety.

4. Instruct the patient to avoid activities that require alertness.

Asthenia may occur thus; preventing fall accidents/injuries and

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syndrome, multiple endocrine adenomas, and systemic mastocytosis.

In combination with clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.

Concomitant administration of diazepam and omeprazole may increase diazepam concentrations. Concomitant administration of phenytoin and omeprazole may increase phenytoin level. Concomitant administration of warfarin and omeprazole may increase warfarin levels.

promoting safety.5. Administer the drug in

the morning or 6 hours before bedtime.

Insomnia may occur thus; promoting sleep to the patient.

6. Promote comfort by proper positioning and offering a back massage.

Back pain may occur.7. Assess the patient’s skin

for the presence of rash, urticarial and pruritus. Notify the physician immediately if present.

To render prompt treatment.

8. Offer a container and ice chips to the patient if he has an urge to vomit.

Offering an ice chips can allay nausea and vomiting. Offering a containing can prevent spilling of the vomitus to the floor thus; preventing contaminations.

9. Observe the patient for any untoward reactions

P a g e | 74

to the drug. To render immediate

care and interventions.10. Document the drug

given. For continuity of care.

NOTRE DAME OF TACURONG COLLEGEErythropoietin

4000 units prepared syringe for injection

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COLLEGE OF NURSING

DRUG STUDY

NAME DRUG ACTION SIDE EFFECT CONTRAINDICATIONNURSING

RESPONSIBILITIESGENERIC:

Erythropoietin(epoietin alfa)

BRAND: Eprex

CLASSIFICATION:

blood former; hematopoietic growth factor;

MODE OF ADMINISTRATION

Route: SCDosage: 4000 unitsTime: 2 x a week

Mechanism of Action: Human

erythropoietin is produced in the kidney and stimulates bone marrow production of RBCs (erythropoiesis). Hypoxia and anemia generally increase the production of erythropoietin. Epoetin alpha is a glycoprotein that stimulates RBC production.

Bibliography:

Karch, A.M. (2007). Lippincott’s Nursing Drug Guide.

Indication: Elevates the

hematocrit of patients with anemia secondary to chronic

Headache Iron deficiency thrombocytosis pure red cell aplasia clotting of AV

fistula Sweating bone pain

ADVERSE EFFECT

Hypertension arthralgias

Uncontrolled hypertension and known hypersensitivity to mammalian cell–derived products and albumin (human); hamster protein hypersensitivity; iron-deficiency anemia

SPECIAL PRECAUTION

Use cautiously with Leukemia, sickle cell disease; coagulopathy; seizure disorders.

DRUG INTERACTION

Drug-drug:

1. Assess the patient for the history of hypersensitive to drug and uncontrolled hypertension.

To prevent reoccurrence of hypersensitivity reactions to drug and in those with uncolled hypertension.

2. Monitor the blood pressure of the patient.

Erythropoietin can cause hypertension.

3. Raise the side rails of bed, assist when ambulating and stay at the bedside after giving the drug.

Seizure, headache, fatigue, and dizziness may occur thus; preventing fall accidents/injuries and promoting safety.

4. Assess for the respirations rate of the

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kidney failure (CRF); patients may or may not be on dialysis

other anemias related to malignancies and AIDS.

Autologous blood donations for anticipated transfusions.

Reduces need for blood in anemic surgical patients.

No clinically significant interactions established.

patient. Cough and shortness of

breath may occur.5. Instruct the patient to

avoid activities that require alertness.

Paraesthesia may occur thus; preventing fall accidents/injuries and promoting safety.

6. Monitor and regulate the IV infusion rate.

Rapid administration may cause further edema.

7. Assess the patient’s extremities and refer to the physician immediately for any changes on the extremities.

Further development of edema can occur. Referring any changes to the physician can render immediate care.

8. Offer a container and ice chips to the patient if he has an urge to vomit.

Offering an ice chips can allay nausea and vomiting. Offering a

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containing can prevent spilling of the vomitus to the floor thus; preventing contaminations.

9. Observe the patient for any untoward reactions to the drug.

To render immediate care and interventions.

10. Document the drug given.

For continuity of care.

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List of Prioritized Nursing Problem

Impaired Gas Exchange related to Fluid accumulation in the lungs, edema of lungs as evidenced by cyanosis (hypoxia), dyspnea, use of accessory muscle and tachycardia.

Excess Fluid Volume related to increase secretion plasma protein as evidenced by jugular vein distension and grade 3 pitting edema.

Ineffective Tissue Perfusion related to decrease haemoglobin mass concentration as evidenced by the laboratory result of 43 g/l.

Activity Intolerance related to body weakness and dialysis procedure as manifested by decrease ADL’s and inability to balance one-self due to decrease in body strength and easy exhaustion.

Imbalanced Nutrition; less than body requirements related to dietary restriction as evidenced by dry itching skin, uremic and metallic mouth taste.

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NOTRE DAME OF TACURONG COLLEGECollege of Nursing

CITY OF TACURONGNURSING CARE PLAN

Patient’s Name: KD Date: July 9, 2011 Diagnosis: Anemia secondary to End Stage Renal Disease Hospital: SCPH

ASSESSEMENT NEEDSNSG.

DIAGNOSISOBJECTIVES INTERVENTIONS RATIONALE EVALUATION

July 9, 2011

SUBJECTIVE:

“lisod kayo ko mag ginhawa” as evidenced by the patient.

OBJECTIVE: crackles noted pallor noted orthopnea noted restlessness

noted body weakness

noted cyanosis

(hypoxia) noted

ACTIVITYEXERCISE PATTERN

by: Gordon’s Functional Health Pattern

REFERENCE: Nursing Care Plans (Guidelines for Individualizing Client Care Across the Life Span) by: Marilynn E. Doenges, Mary

Impaired Gas Exchange related to Fluid accumulation in the lungs, edema of lungs as evidenced by cyanosis (hypoxia), dyspnea, use of accessory muscle and tachycardia.

RATIONALE: Deficit in oxygenation and/ carbon dioxide elimination at the alveoli-capillary membrane.

GENERAL:The patient will be able to demonstrate gas exchange and absence of peripheral pallor as evidenced by absence of crackles and absence of cyanosis.

SPECIFIC: After 8 hours of rendering nursing intervention patient will be able to: Demonstrate

improved ventilation/

Independent: Monitor respiratory

rate/depth, use of accessory muscles, areas of cyanosis

Auscultate breath sounds, noting presence/absence, and adventitious sounds.

Investigate reports of chest pain and increasing fatigue. Observe for signs of increased fever, cough, adventitious breath sounds.

Encourage client to alternate periods of rest and activity. Make a schedule

R- indicators of adequacy of respiratory function or degree of compromise and therapy needs/ effectiveness.

R- development of atelectasis and stasis of secretions can impaired gas exchange.

R- reflective of developing acute chest syndrome which increases the workload of the heart and oxygen demand.

R- avoids excessive fatigue reduces oxygen demands/degree of hypoxia.

DATE: July 9, 2011

Goal partially met, patient was able to demonstrate as exchange as evidenced by absence of crackles but still cyanotic.

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use of accessory muscles

tachycardia noted

productive cough noted

V/S:RR- 30 cpmBP- 150/90mmHg

Frances Moorhouse, Alice C. Murr; 7th edition

Since the patients hemoglobin is decrease, there is lack of oxygen circulation in the blood. And since the patient having 1an edema, there is difficulty in oxygen and carbon dioxide exchange

oxygenation Participate in

ADL’s without weakness and fatigue.

Display improved and normal pulmonary function tests.

(time for rest period of the patient).

Evaluate activity tolerance; limit activities to those within client tolerance or place client on bed rest. Assist with ADL’s and mobility as needed.

Monitor vital signs, no changes in cardiac rhythm.

Collaborative: Administer

supplemental humidified oxygen as indicated.

Monitor laboratory studies such as; CBC, Chest X-ray

R-sufficient intake is necessary to provide for mobilization of secretions and to prevent hyper viscosity of blood/capillary occlusion.

R-reduction of the metabolic requirements of the body, reduces the oxygen requirements. Degree of hypoxia.

R-maximizes oxygen transport to tissues, particularly in presence of pulmonary pneumonia. O2 should be given be only in presence of confirmed hypoxemia because O2 can suppress erythropoietin level, further reducing the production of RBC’.

R-Client is particularly prone to pneumonia, which is potentially fatal because of its hypoxemic effect of increasing

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Administer packed RBC’s on exchange transfusion as indicated.

Administer medications as indicated:Antibiotics

sickling.

R-Increases number of oxygen-carrying cells, dilutes the percentage of HBs to prevent sickling, improves circulation, and removes/decreases number of sickled cells.

R-a broad- spectrum antibiotic is started immediately pending culture result of suspected infections then may be change when the specific pathogen is identified.

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NOTRE DAME OF TACURONG COLLEGECollege of Nursing

CITY OF TACURONGNURSING CARE PLAN

Patient’s Name: KD Date: July 9, 2011 Diagnosis: Anemia secondary to End Stage Renal Disease Hospital: SCPH

ASSESSEMENT NEEDSNSG.

DIAGNOSISOBJECTIVES INTERVENTIONS RATIONALE EVALUATION

July 9, 2011

SUBJECTIVE:

”NO VERBAL CUES”

OBJECTIVES: Orthopnea

noted

Grade3 pitting edema

Jugular vein distension noted

Increase

ACTIVITY EXERCISE PATTERN

by: Gordon’s Functional Health Pattern

REFERENCE: Nursing Care Plans (Guidelines for Individualizing Client Care Across the Life Span) by: Marilynn E. Doenges, Mary Frances

Excess Fluid Volume related to increase secretion plasma protein as evidenced by jugular vein distension and grade 3 pitting edema.

RATIONALE: Increase

isotonic fluid retention

The patients kidney is already damaged, therefore the kidneys are

GENERAL:The patient will be able to maintain of ideal body weight without excess fluid as evidenced by exhibits normal skin turgor without edema.

SPECIFIC: After 8 hours of rendering nursing intervention patient will be able to: Demonstrate no

rapid weight changes.

Maintains dietary and fluid

Independent: Assess fluid status:

daily weight; intake and output balance; skin turgor and presence of edema; distention of neck vein; blood pressure; pulse rate and rhythm and; respiratory rate and effort.

Limit fluid intake to prescribed volume.

Identify potential sources of fluid: medications; oral and intravenous; foods.

R- assessment provides baseline and ongoing database for monitoring changes and evaluating interventions.

R- fluid restriction will be determined on basis of weight, urine output and responsive to therapy.

R-unrecognized sources of excess fluids may be identified.

DATE: July 9,2011

Goal Partially Met the patient was able to maintain of ideal body weight without excess fluid as evidenced by partially exhibits normal skin turgor without edema.

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blood pressure of 150/90 mmHg

Crackles noted upon auscultation

V/S:RR- 30 cpmBP- 150/90mmHg

Moorhouse, Alice C. Murr; 7th

edition

not properly excretes water because there is water and sodium retention, and is causes an edema.

restrictions.

Exhibits normal skin turgor without edema.

Exhibits normal vital signs.

Exhibits no neck vein distention.

Reports no difficulty of breathing and shortness of breath.

Performs oral hygiene frequently.

Reportsdecreased thirst

Reports decreased dryness of oral mucous membranes.

Monitor urine output, noting amount and color, as well as time of day when diuresis occurs.

Monitor and calculate 24 hours intake and output (I & O) balance of the patient.

Explains to patient and family rationale for restriction.

Assist patient to cope with the discomfort resulting from fluid restriction.

Auscultate breath sounds, noting decreased and or adventitious sounds; e.g. crackles, wheezes. Note presence of increased

R-urine output may be scanty and concentrated (especially during the day) because of renal perfusion.

R- diuretic therapy may result in sudden/excessive fluid loss (circulating hypovolemia), even though edema/ascites remains.

R- understanding promotes patient and family cooperation with fluid restriction.

R- increasing patient comfort promotes compliance with dietary restrictions.

R- excess fluid volume often leads to pulmonary congestion.

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dyspnea, tachypnea, orthopnea.

Change position frequently. Elevate feet when sitting. Inspect skin surface, keep dry, and provide padding as indicated.

R- edema formation, slowed circulation, altered nutritional intake, and prolonged immobility/bed rest are cumulative stressors that affects skin integrity and require close supervision/preventive interventions.

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NOTRE DAME OF TACURONG COLLEGECollege of Nursing

CITY OF TACURONGNURSING CARE PLAN

Patient’s Name: KD Date: July 9, 2011 Diagnosis: Anemia secondary to End Stage Renal Disease Hospital: SCPH

ASSESSEMENT NEEDSNSG.

DIAGNOSISOBJECTIVES INTERVENTIONS RATIONALE EVALUATION

July 9, 2011

SUBJECTIVE:“ galingin akuang ulo, ug murag blurred akuang panan- aw. Di pa jud ko ka lihok ug tarong kay murag hina pa gud akuang lawas” as verbalized by the patient.

OBJECTIVES: Grade3 pitting

edema

Pallor noted

Delayed capillary refill of 3-4 seconds

Restlessness

ACTIVITY-EXERCISE PATTERN

by: Gordon’s Functional Health Pattern

REFERENCE: Nursing Care Plans (Guidelines for Individualizing Client Care Across the Life Span) by: Marilynn E. Doenges, Mary Frances

Ineffective Tissue Perfusion related to decrease hemoglobin mass concentration as evidenced by laboratory result of 43 g/l.

RATIONALE:Ineffective Tissue Perfusion related to hemoglobin mass concentration results of 43 g/L secondary to Anemia

GENERAL: The patient will

be able to regain normal perfusion as evidenced by increase hemoglobin mass concentration within normal range.

SPECIFIC:After 8hours of rendering nursing intervention patient will be able to:

Demonstrate of condition, therapy regimen, side

Independent: Monitor V/S.

Assess pulses for rate, rhythm, and volume.

Assess skin for coolness, pallor, cyanosis, diaphoresis, delayed capillary refill.

Note changes in level of consciousness; reports of headaches, dizziness; development of sensory/ motor

R-for baseline data slugging and sickling in peripheral vessels may lead to complete or partial obliteration of a vessel.

R-Changes reflect diminished circulation/ hypoxia potentiating capillary occlusion.

R-Changes may reflect diminished perfusion to the central nervous system (CNS) due to ischemia or infarction.

DATE: July 9, 2011

Goal Not Met, patient was not able to maintain and regain normal tissue perfusion as evidenced by decreased hemoglobin mass concentration because Blood Transfusion is not done.

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noted

Body weakness Lethargic

appearance

Pale conjunctiva noted

Hemoglobin mass concentration result of 43 g/L

V/S:T-36.5 celsius RR- 30 cpmPR-98 bpmBP- 150/90mmHg

Moorhouse, Alice C. Murr; 7th edition

effects of medication and when to contact healthcare provider.

Demonstrate behavior/ lifestyle changes to improve circulation.

Demonstrate increase perfusion as individually appropriate (e.g., skin, warm/ dry, V/S within normal range, absence of edema).

deficits; seizure activity.

Maintain adequate fluid intake and also monitor urine output.

Assess lower extremities for skin texture, edema.

Maintain environmental temperature and body warmth without overheating. Avoid hypothermia.

Evaluate for presence edema.

R-Dehydration not only causes hypervolemia but increase sickling and occlusion of capillaries. Decreased renal perfusion/ failure may occur because of vascular occlusion.

R-Reduces peripheral circulation often leads to dermal changes.

R-to prevent vasoconstriction, aids in maintaining circulation and perfusion. Hypothermia may exacerbate cardiovascular compromise with severe anemia.

R-Vaso-occlusion/ circulatory stasis may lead to edema

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COLLABORATIVE: Monitor laboratory

examination such as; CBC, BUN, CREATININE.

Administer medication as indicated: ERYTHROPOETIN (Epoetin Alfa).

of extremities, potentiating risk of tissue ischemia/ necrosis.

R-Decreased tissue perfusion may lead to gradual infarction of organ tissues, such as the brain, liver, spleen, kidney.

R-It is indicated for Anemia and enhances RBC production.

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Prognosis

CRITERIA GOOD FAIR POOR RATIONALE

Duration of

illness

The duration of illness of Ms. RI is poor because the patient is always admitted at the hospital and stayed for 6-10 days.

Onset of Illness

3-5 hours prior to admission, the onset of present illness happened at their house. The patient was walking then suddenly he feels difficulty of breathing. The patient was rushed to the hospital by his father and he was conscious, little confuse, responsive and not oriented to time, place and people around him. The client was diagnosed last December 2010 at the age of 16 with End-Stage Renal Disease and he submits himself for dialysis last January 2011 but he stops the treatment last July 2011.

Hygiene

The patient has good and proper grooming in spite of his condition as evidenced by well-fixed hair, wears clean and appropriate clothing and trimmed nails.

AgeThe patient is 17 years old. This age is not appropriate to experience this kind of condition.

Diet

Although that the patient follows what the doctor’s order for his diet (a low salt diet and rise is limited for ½ to 1 cup only and he also limit his fluid intake to 300-500 mL) but, prior to the admission, he eats junk foods and drinks carbonated and alcoholic drinks.

Performance

LevelThe patient is trying to perform his daily activities but still in a limited range of motion.

Willingness to

Undergo

Treatment

The patient is willing to take his medication and follow what are the instructed to him by his physician but, he stops his dialysis last July 2011.

Family Support His family is very supportive to the patient most especially his father that accompanied him to the hospital, guide him in all the needs

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and procedures. His father attended all the needs of his son. His mother also visited him at the hospital. His younger sibling also visits him after his class.

Total 2 2 4

Computation:

Good: 2/8 *100= 25%

Fair: 2/8 *100 = 25%

Poor: 4/8 * 100= 50%

Interpretation:

According to the computation, the prognosis of the patient is poor because he got 50% out of 100 %. 3-5 hours prior to admission, the onset of present illness happened at their house. The patient was walking then suddenly he feels difficulty of breathing. The patient was rushed to the hospital by his father and he was conscious, little confuse, responsive and not oriented to time, place and people around him, and also the patient is always admitted at the hospital and stayed for 6-10 days . The client was diagnosed last December 2010 at the age of 16 with End-Stage Renal Disease and he submits himself for dialysis last January 2011 but he stops the treatment last July 2011, patient is 17 years old. His age is not appropriate to experience this kind of condition. Although the patient follows what the doctor’s order for his diet (a low salt diet and rise is limited for ½ to 1 cup only and he also limit his fluid intake to 300-500 mL) but, prior to the admission, and he eats junk foods and drinks carbonated and alcoholic drinks.

Bibliography

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Smith A.L. (1990). Microbiology and Pathology 12th edition the c.u. Mosby company

Igna tavicius, d.D, worman M.I (2006) Medical Surgical Nursing 2nd reprinted copy right

2006 Elsevier (Singapore ) Original Edition copyright 2006 Elsevier (USA)

Potter, P.A., Perry,A.G. (1989-1989)Fundamental of Nursing concept process and practice 3rd

Edition Mosby company

Forbes B. Sahm D Weissfeld A. (2007) Balley and scott diagnostic microbiology 12 th edition

Elvvier Singapore.

Lippincott Williams and Wilkins. (2006). Pathophysiology made incredibly easy.

Scanlon, V.C., Sanders, T. (2008). Essentials of Anatomy and Physiology; Fifth Edition.

Doenges, M.E., et. Al. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions and

Rationales.

http://nursingcrib.com/nursing-notes-reviewer/acute-renal-failure/

http://www.kidneypatientguide.org.uk/site/fluid.php

http://www.kidneypatientguide.org.uk/site/fluid.php

http://living.oneindia.in/pregnancy-parenting/basics/2006/electra-complex-oedipus-

complex.html