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A. Description of the Disease
Chronic kidney disease (CKD), also known as Chronic renal disease (CRD) is a pathophysiologic process (last more than 3 months) with multiple etiologies, resulting in the inexorable attrition of nephron number and function, and frequently leading to end-stage renal disease (ESRD).
ESRD represents a clinical state or condition in which there has been an irreversible loss of endogenous renal function, of a degree sufficient to render the patient permanently dependent upon renal replacement therapy (dialysis or transplantation) in order to avoid life-threatening uremia.
Glomerular filtration rate (GFR) is the best measure of kidney function. The GFR is the number used to figure out a person’s stage of kidney disease. A math formula using the person’s age, race, gender and their serum creatinine is used to calculate a GFR. A doctor will order a blood test to measure the serum creatinine level. Creatinine is a waste product that comes from muscle activity. When kidneys are working well they remove creatinine from the blood. As kidney function slows, blood levels of creatinine rise.
CKD stagesThe stages of CKD (Chronic Kidney
Disease) are mainly based on measured or estimated GFR (Glomerular Filtration Rate).
Glomerular filtration rate (GFR) is the best measure of kidney function. The GFR is the number used to figure out a person’s stage of kidney disease. There are five stages but kidney function is normal in Stage 1, and minimally reduced in Stage 2.
Stage GFR* Description Treatment stage
1 90+ Normal kidney function but urine findings or structural abnormalities or genetic trait point to kidney disease
Observation, control of blood pressure. More on
management of Stages 1 and 2 CKD.
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. More on management of
Stages 1 and 2 CKD.
3A3B
45-5930-44
Moderately reduced kidney function
Observation, control of blood pressure and risk factors. More on management of
Stage 3 CKD.
4 15-29 Severely reduced kidney function Planning for endstage renal failure. More on
management of Stages 4 and 5 CKD.
5 <15 or on
dialysis
Very severe, or endstage kidney failure (sometimes call
established renal failure)
Treatment choices. More on management of Stages 4
and 5 CKD.
B. Statistics (Prevalence and Incidence rate)
The most recent report of the United States Renal Data System estimates that nearly one-half million patients in the United States were treated for ESRD in the year 2004, and by 2010 this figure is expected to increase by approximately 40%. The elderly are a growing segment of the population and at increased risk for renal disease. Additionally, males and African-Americans with pre-existing hypertension or diabetes and CKD are also at much higher risk for ESRD. These observations have also been confirmed throughout the developed world: Europe, Asia, Australia as well as in developing regions such as China, India and Africa.
According to the National Statistics Office (NSO), kidney disease is now no. 10 cause of mortality in the Philippines.
KIDNEY ANATOMY
The kidneys are dark-red, bean-shaped organs. One side of the kidney bulges outward (convex) and the other side is indented (concave).
Each Kidney is enclosed in a transparent membrane called the renal capsule which helps to protect them against infections and trauma. The kidney is divided into two main areas a light outer area called the renal cortex, and a darker inner area called the renal medulla.
Kidney Anatomy and Excretion
The most basic structures of the kidneys are nephrons. They are responsible for filtering the blood and removing waste products.
The renal artery delivers blood to the kidneys each day. Over 180 liters (50 gallons) of blood pass through the kidneys every day.
The process of separating wastes from the body's fluids and eliminating them is known as excretion. The body has four organ systems that are responsible for excretion. The urinary system is one of the main organ systems responsible for excretion. It excretes a broad variety of metabolic wastes, toxins, drugs, hormones, salts, hydrogen irons and water.
KIDNEY LOCATION
The normal kidney location is towards the back of the abdominal cavity, just above the waist. If you put your hands on your hips, your kidneys are located just about where your thumbs are. One kidney is normally located just below the liver, on the right side of the abdomen and the other is just below the spleen on the left side.
NORMAL KIDNEY SIZE
The normal kidney size of an adult human is about 10 to 13 cm (4 to 5 inches) long and about 5 to 7.5 cm (2 to 3 inches) wide. It is approximately the size of a conventional computer mouse.
A kidney weighs approximately 150 grams. Kidneys weigh about 0.5 percent of total body weight.
© Excretion Blood volume control Ion concentration regulation pH regulation Red blood cell concentration Vitamin D synthesis
Chronic Kidney Diseases Diabetes Mellitus Type 2 Hypertension
General ill feeling and fatigue Generalized itching (pruritus) and dry skin Loss of appetite Nausea Other symptoms may develop, including: Abnormally dark or light skin and changes in
nails Bone pain Brain and nervous system symptoms
› Drowsiness and confusion › Problems concentrating or thinking › Numbness in the hands, feet, or other areas
Swelling of the feet and hands (edema
End-stage kidney disease changes the results of many tests. Patients receiving dialysis will need these and other tests done often:potassium Sodium Albumin Phosphorous Calcium Cholesterol Magnesium Complete blood count (CBC) Electrolytes
Dialysis or kidney transplantation is the only treatment for ESRD. Your physical condition and other factors determine which treatment is used.
Treatment usually includes an ACE inhibitor, angiotensin receptor blocker, or other medications for high blood pressure.
You may need to make changes in your diet.› Eat a low-protein diet › Limit fluids › Limit salt, potassium, phosphorous, and other
electrolytes › Get enough calories if you are losing weight
Other treatments may include:
Treatment for anemia, such as extra iron in the diet, iron pills, special shots of a medicine called erythropoietin, and blood transfusions.
Special medicines called phosphate binders, to help prevent phosphorous levels from becoming too high
Extra calcium and vitamin D (always talk to your doctor before taking)
Without dialysis or a kidney transplant, death will occur from the buildup of fluids and waste products in the body. Both of these treatments can have serious risks and consequences. The outcome is different for each person.
Anemia Brain dysfunction,
confusion, and dementia Changes in electrolyte
levels Changes in blood sugar
(glucose) Damage to nerves of the
legs and arms Fluid buildup around the
lungs Heart and blood vessel
complications › Congestive heart
failure › Coronary artery
disease
› High blood pressure › Pericarditis › Stroke
Malnutrition Seizures Skin dryness,
itching/scratching, leading to skin infection
Weakening of the bones, fractures, joint disorders
The best way to prevent ESRD is to prevent CKD. Diabetes and high blood pressure are the two leading causes of CKD. You can help to protect your kidneys by keeping these in control. Get your blood sugar and blood pressure checked often.
Have regular check-ups with your doctor Eat a low-fat, low-salt diet Exercise most days of the week Avoid tobacco Drink alcohol only in moderation Also, take medicines the way your doctor tells
you. Talk to your doctor before you start any new medicine or supplement.
Anyone can have ESRD. Some people are more likely to have ESRD than others. You are more at risk for ESRD if you have:
Chronic kidney disease (CKD) Injury or trauma to the
kidneys Major blood loss
Name: ……………………………………………….........................EAAge: …………………………………………………………….....55 y/oSex: …………………………………………………..………...…….MaleCivil Status: ………………………………………....................MarriedAddress: …………………....………Brgy, Atienza Roxas City CapizDate of birth: ……………………………………….....March 15, 1955Occupation: …………………………….………………….……...NoneDate of admission: …………………………......September 11, 2010Chief Complaint: ………………………………….…….…....DyspneaDx Impression: ………….............Chronic Kidney Disease Stage V
secondary to Diabetes Mellitus nephropathy, HCVD, CAP-MR
Final Diagnosis…………………….End Stage Renal Disease secondary to DM
Nephropathy, CAP-MRAttending Physicians: ………………………………………..Dr. R.B.
A. Nursing Historya) Personal Data and History
Mr. EA is a 55 y/o man living in Brgy. Atienza, Roxas City Capiz. He is the youngest child of Mr.PA and Mrs. M A. He finished his high school degree in Capiz State University but did not continue his college degree due to financial problems. Later on, he married Mrs. MA but unfortunately they were not blessed with a child and this led Mr. EA to worsen his vices such as cigarette smoking and alcohol drinking. He consumes 2 packs of cigarette a day and drinks occasionally. When he was hospitalized, he stopped smoking and lessened alcohol drinking.
b) Present Illness
› Mr. EA was admitted on September 11, 2010 at St. Anthony College Hospital at 4 pm with a chief complaint of dyspnea and was diagnosed diabetic and hypertensive.
› 5 days PTA has experienced cough production of whitish phlegm. (-) Fever.
› 2 days PTA had dyspnea and chest tightness. › A day PTA dyspnea increased hence admitted at
Capiz Doctor’s Hospital.› On the day of admission he was transferred at
St. Anthony College Hospital for further management.
c) Past Medical History
Mr. EA is known for being hypertensive and diabetic for 30 years. He was hospitalized about four times with the same diagnosis such as hypertension, diabetes mellitus and later on diagnosed with ESRD.
d) Family History
Mr. EA has four siblings; he is the youngest among the four. His father died because of stroke and her mother died because of old age. All of his siblings are married and have their own children and grand children except him.
P. A.
DM 2, CVA, HTN
M.A
E.A
50 y/o
ESRD, DM,CAP-MR
E. S.
59 y/o
P. D.
63 y/o
HTN
L. D.
64 y/o
DM, HTN
J. A.
44 y/o
Male
Female
Patient
Deceased
B. Present Medical History a. Vital signs upon admission Temperature: 36.8 °C RR: 24 bpm CR: 83 bpm BP: 160/90 mmHg
September 13, 20108 am
September 14, 20108 am
September 14, 2010
12 am
Temperature 36.3°C 36.7°C 36.5°C
Pulse Rate 79 bpm 71 bpm 74 bpm
Respiration
Rate
22 bpm 21 bpm 19 bpm
Blood
Pressure
160/90 mmHg 160/80 mmHg 140/90 mmHg
Apical Rate 82 bpm 75 bpm 78 bpm
Methods of Assessment
Actual Findings Significance
HeadHair
Inspection -Presence of alopecia.
It’s either due to old age or genetic.
Eyes Inspection -Yellow sclerae.
-Pale conjunctivae.
-Yellow sclerae indicates jaundice
because of increased serum bilirubin.
-Pale conjunctivae indicates anemia
Ears Inspection -Presence of hearing aid.
-Indicates poor hearing acuity.
c. Physical Assessment
Nails Inspection -Nails are pallor.
-Capillary refill of more than 3
seconds.-Presence of Terry’s nails.
-Pallor nails indicates anemia.
-A capillary refill of more than 3 seconds may indicate hypoxia.-Presence of Terry’s
nail is associated with aging, chronic diseases
and diabetes mellitus type 2.
Neck Inspection -Distended neck veins
Indicates fluid volume excess.
Skin Inspection - Skin is bronze gray yellow skin.-Skin is dry and flaky.
- (+) Pruritus.
-Associated with ESRD.
Respiratory System Inspection and auscultation
- Dyspnea.-Respiration rate
ranges from 21 – 24 bpm.
-(+) Rales, rhonci, and wheezing on
both lungs.
Dyspnea, rales, rhonci and wheezing indicates respiratory problem. It indicates bibasal pneumonia
and pulmonary congestion as seen
in his Chest PA.
Genitourinary System
Inspection -Inadequate urine output. His output ranges from 300-
500 cc in our shift.-Presence of
glucose in the urine.
- Inadequate urine output because the
kidney does not function anymore thus
it no longer secrete wastes.
-Presence of glucose indicates Diabetes
Mellitus.
Extremities Inspection -Symmetrical- (-)Tenderness-Presence of pitting edema
Indicates fluid volume excess and it is
commonly associated with ESRD.
General Appraisal SpeechMr. EA speaks clearly, attentive and converse
and speaks in a high modulated voice. Mr. EA was able to answer all the questions during the interview and has no difficulty in speaking.
LanguageHe knows how to speak Hiligaynon, Filipino and
English. HearingHe doesn’t have a good hearing acuity. Presence
of hearing aid noted. Emotional StatusEmotionally weak. Shows signs of sadness and
hopelessness due to present medical condition. Worries also about his financial matters requiring in his treatment of his condition.
o Brief social, cultural and religious background› Educational Background
Mr. EA finished his high school in Capiz State University. › Religious Practices
Mr. EA occasionally goes to mass every Sunday.› Economic Status
His family belongs to a middle class family.
September 01, 2010Results Normal Values Significance
Glucose 8.17 mmol/L (HIGH)
3.89-5.83 mmol/L -Diabetes Mellitus.-Chronic Renal Failure.
Creatinine 1162 umol/L (HIGH)
80 -115 umol/L -Diabetes Mellitus.-Chronic Renal Failure.
-Indicates renal disease that has seriously damaged 50% or
more of the nephrons.-Indicates renal malfunction. The kidneys cannot excrete
nitrogenous waste product of protein leading to its
accumulation in the blood.
Cholesterol 3.0 mmol/l <5.18 mmol/L Normal
Triglycerides
0.44mmol/l <1.70 mmol/L Normal
HDL 1.83 mmol/l >0.90 mmol/l NormalLDL 0.97 mmol/l <3.4 mmol/l Normal
Laboratory and Diagnostic DataClinical Chemistry
September 10, 2010
Results Normal Values
Significance
Color Pale straw Pale straw Normal
Transparency Slightly hazy Slightly hazy Normal
Reaction 6.0 4.5-7.8 Normal
Sp. Gravity 1.015 1.003-1.029 Normal
Protein Negative Negative Normal
Glucose (3+) Negative Diabetes Mellitus
RBC (2+) 0-2 hpf Normal
Urinalysis
Date Test Normal Range
Results Significance
Results were all below the normal level,
thus indicating
renal malfunction and thereby
causing anemia
September 16, 2010
Hemoglobin
135-180 g/dl
90 g/dL (LOW)
September 14, 2010
70 g/dL (LOW)
September 10, 2010
79 g/dL (LOW)
Hematology
Date Test Normal Range
Results Significance
Result were all below the
normal range thus,
showing anemia and
renal disease
September 16, 2010
Hematocrit 0.42–0.52 vol.fr
0.27 vol.fr (LOW)
September 14, 2010
0.21 vol.fr (LOW)
Hematocrit
September 10, 2010
Results Normal Range Significance
Creatinine 1, 124.13 umol/L (HIGH)
Male: 80-115 umol/L
-Diabetes Mellitus.-Chronic Renal Failure.
-Indicates renal disease that has seriously damaged 50%
or more of the nephrons.-Indicates renal malfunction. The kidneys cannot excrete nitrogenous waste product
of protein leading to its accumulation in the blood.
Sodium 105.0 mmol/L (LOW)
136-145 mmol/L Indicates chronic renal failure, edema and
hyperglycemia.
Potassium 4.4 mmol/L 3.5-5.1 mmol/L Normal
BUN 16.0 umol/L (HIGH)
3.2 – 7.1 umol/L Indicates renal disease.
Clinical Chemistry
Chest PA
September 10, 2010 Impression:Pulmonary CongestionFibrosis, Left Upper LobeBibasal PneumoniaAtheromatous Aorta
September 19, 2010 Impression:Mild Pulmonary CongestionFibrosis, Left Upper LobeCardiomegaly
Test Results Normal Range Significance
pH 7. 430 ↑ (7.35 – 7.45) Partially Compensated Metabolic
Acidosis.
pCO2 21.3 ↓ (35 – 45 mmHg)
HCO3 4.1 ↓ (22 – 26 mmol/L)
ABG Analysis
Generic Name Brand Name Classification Mechanism of Action
Ketoanalogues &
essential amino acids
Ketosteril
600mg; 1 tab tid PO
Drugs Acting on the Genito-Urinary
System)
Keto-Analogues: Ketosteril contains the following essential amino acids: Lysine, threonine, tryptophan, histidine and tyrosine, in the ratio of the potato-egg pattern and the α-keto or α-hydroxy acids with the C-skeleton of essential amino acids; keto; keto-leucine, keto-isoleucine, keto-phenylalanine, keto-valine as well as hydroxy-methionine as calcium salts.
The keto or hydroxy acids are enzymatically transaminated to the corresponding L-amino acids while
the urea pool is decomposed.
Indication Contraindication Adverse Effects Nursing
Responsibilities
Prevention & therapy of damages
due to faulty/deficie
nt protein metabolism in chronic
renal insufficiency
.
Hypercalcemia, disturbed amino acid
metabolism.
Hypercalcemia - Assess pt. condition before starting therapy, and monitor drug effectiveness.- Be alert for adverse reaction and drug interaction.- Should be taken with food (Swallow whole, do not chew/crush.).
Generic
Name
Brand Name Classification Mechanism of
ActionClonidine
HCLCatapres75mg/ tab
Antihypertensive
Central analgesic
Sympatholytic (centrally acting)
Stimulates CNS
alpha2 adrenergic
receptor, inhibits sympathetic
cardioaccelerator and
vasoconstrictor centers and decreases
sympathetic outflow from the
CNS.
Indication Contraindication Adverse Effects Nursing Responsibilities
- Hypertension Contraindicated with
hypersensitivity to clonidine or any adhesive
layer components of the transdermal
system
Drowsiness Dizziness headache weakness dry mouth GI upset Dreams Nightmare Impotence
- Tell pt. to change their lifestyle to reduce the blood pressure such as smoking and using alcohol.- Tell pt to use caution with alcohol because the sensitivity may increase while using this drug.- Inform pt that he may experience these side effects; drowsiness, headache, weakness, dry mouth etc.- Report urinary retention, changes in vision, blanching of fingers and rash.
Generic Name Brand Name Classification Mechanism of ActionCefuroxime Zegen
500 mg; 1 tab bid PO
Antibiotic and Cephalosporin (2nd
generation)
Cefuroxime, a semisynthetic, broad-
spectrum 2nd generation
cephalosporin antibiotic, exerts its bactericidal activity by interfering
with the synthesis of the bacterial cell wall. It binds to penicillin-binding protein 3,
responsible for the synthesis of
peptidoglycan, a heteropolymeric
structure that gives the cell wall its mechanical
stability.
Indication Contraindication Adverse Effects Nursing Responsibilities
Treatment of infections
due to cefuroxime-
sensitive organisms:
Lower respiratory
tract infections including
pneumonia.
Hypercalcemia, disturbed amino acid
metabolism.
Pruritus, urticaria and positive Coomb's test anaphylaxis, drug fever, erythema multiforme, interstitial nephritis, toxic epidermal necrolysis and Stevens-Johnson syndrome diarrhea and nausea. Pseudomembranous Seizure. Angioedema.
- Assess pt. condition before starting therapy, and monitor drug effectiveness.- Be alert for adverse reaction and drug interaction.- Should be taken with food (Take immediately after food.).
Generic Name Brand Name Classification Mechanism of Action
Furosemide
Lasix 60 mg 1tab
Loop Diuretic Inhibits reabsorption of
sodium and chloride from the
proximal and distal tubules and ascending limb of
loop of henle, lending to a sodium- rich
diuretics.
Indication Contraindication Adverse Effects Nursing Responsibilities
-Edema associated with
renal disease and
hypertension
Contraindicated with allergy to furosemide,
sulphonamide, allergy to
tartazine, anuria, severe renal failure, and
hepatic coma.
- Dizziness- Weakness-Hypertension- Drowsiness- Blurred vision
- Take with food or meals to prevent G.I upset.- You may experience these side effects: frequency of urination, drowsiness, feeling faint or arising anddizziness.- Report loss or gain if more than pounds in 1 day, fatigue, muscle weakness or cramps.
Generic Name Brand Name Classification Mechanism of ActionAmlodipine Besylate
Norvasc10 mg 1tab OD
AntianginalAntihypertensiveCalcium Channel Blocker
Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells, inhibits transmebrane calcium flow, which results in the depression of impulse formation in specialized cardiac pacemaker cells, slowing of the velocity of conduction of the cardiac impulse, depression of myocardial contractility, and dilation of coronary arteries and arterioles and peripheral arterioles.
Indication Contraindication Adverse Effects Nursing Responsibilities
For essential hypertension, alone or in combination with other antihypertensives.
Contraindicated with allergy to amlodipine, impaired hepatic or renal function, sick sinus syndrome, and heart block.
- Dizziness- Light headedness- Headache- Fatigue- Lethargy- Edema
- Take with meals if upset stomach occurs.- You may experience these side effects: nausea, vomiting, headache.- Report irregular heartbeat, SOB, swelling of the hands or feet, pronounced dizziness.
Generic Name Brand Name Classification Mechanism of Action
Haloperidol Haloperidol La 5mg 1tab OD
AntipsychoticDopamineric
Blocker
Mechanism not fully understood,
antipsychotics block postsynaptic
dopamine receptors in the brain, depress the RAS, including those parts of the brain include with wakefulness and
emesis, chemically resembles the
phenothiazines.
Indication Contraindication Adverse Effects Nursing Responsibilities
Management of
manifestation in psychotic disorders.
Contraindicated with hypersensitivity to typical antipsychotics, coma or severe CNS depression, bone marrow depression, blooddy scrasia, circulatory collapse, subcortical brain damage, liver damage, severe hypotension or hypertension.
- Drowsiness- Insomnia- Vertigo- Tachycardia- Bradycardia- Tremor
- Take this drug exactly as prescribed.- Avoid prolonged exposure to sun or use a sunscreen or covering garments.- Maintain fluid intake and use precautions against heat stroke in hot weather.
Generic Name Brand Name Classification Mechanism of ActionSulodexide 250 LSU 1cap TID
- Anticoagulant- Antithrombotics- Fibrinolytics
Sulodexide is a heparinoid consisting of 80% fast
moving heparin and 20% dermatan sulfate. It is hypolipidaemic and
antithrombotic and has been administered by
mouth and parenterally for peripheral vascular disease
and cerebrovascular disease. It is also included in topical preparations for
local vascular inflammation and soft tissue disorders. Sulodexide differs from
heparin by having a longer half-life and a decreased effect on systemic clotting
and bleeding.
Indication Contraindication Adverse Effects Nursing ResponsibilitiesUse/treatment in diabetes and kidney disease.
Contraindicated to hypersensitivity to soludexide, heparin and heparin-like products. Diathesis and hemorrhagic diseases
Oral: Nausea, vomiting, epigastric pain. Parenteral: Pain, burning and haematoma at inj site.
- Assess patients for signs bleeding and hemorrhage. Notify physician if this occur.- Monitor patient for hypersensitivity reactions. Report signs to physician.- Monitor platelet count every 2-3 days throughout therapy. May cause mild thrombocytopenia, which appears on the 4th day and resolves despite continued heparin therapy.
Generic Name Brand Name Classification Mechanism of ActionSodium bicarbonate 650mg 1 tab 2tabs TID
- Antacid - Electrolyte- Systemic alkalinizer- Urinary alkalinizer
Increases plasma bicarbonate; buffers excess hydrogen ion concentration; raises
blood pH; reverses the clinical manifestation of acidosis; increases the excretion of free base in
the urine, effectively raising the urinary pH;
neutralizes in the gastric pH, which inhibits the proteolytic activity of
pepsin.
Indication Contraindication Adverse Effects Nursing ResponsibilitiesTreatment of metabolic acidosis which can occur in severe renal disease.
Contraindicated with allergy to any components of preparations; low serum chloride; metabolic and respiratory alkalosis; hypocalcemia
Metabolic alkalosis; mood changes, tiredness, shortness of breath, muscle weakness, irregular heartbeat; muscle hypertonicity, twitching, tetany; hypernatremia, hyperosmolality, hypocalcaemia, hypokalemia; stomach cramps, flatulence
Have patient chew oral tablets thoroughly before swallowing; follow them with a full glass of water.
Do not give oral sodium bicarbonate within 1-2 hour of other oral drugs to reduce risk of drug interaction.
Generic Name Brand Name Classification Mechanism of Action
Losartan 80mg 1tab OD
Antihypertensive - ARB
Selectively blocks the binding of angiotensin
II to specific tissue receptors found in the
vascular smooth muscle and adrenal
gland; this action blocks the
vasoconstriction effect of the renin-
angiotensin system as well as the release of
aldosterone
Indication Contraindication Adverse Effects Nursing Responsibilities
Treatment of hypertension, alone or in combination with other antihypertensive.
Contraindicated with hypersensitivity to losartan.
CNS: headache, dizziness, syncope, insomniaCV: hypertensionDERMATOLOGIC: rash, urticarial, pruritus, alopecia, dry skinGI: diarrhea, abdominal pain, nausea, constipation, dry mouthRESPIRATORY: URI symptoms, cough, sinus disordersOTHER: back pain, fever, gout, muscle weakness
- Monitor patient closely in any situation that may lead to a decrease in BP secondary to reduction in fluid volume; excessive perspiration, dehydration, vomiting, diarrhea; excessive hypotension can occur.- Monitor BP at drug trough (prior to a scheduled dose).
- Monitor drug effectiveness.
Assessment: S: “Madasig ko kapuyon” as verbalized.O:- BP: 140-160/90 mmHg- RR: 21-24 bpm-Crea: 1, 124.13 umol/L (↑)-BUN: 16.0 umol/L (↑)- Hct: 0.21 – 0.27 vol.fr (↓)-Hgb: 70 – 90 g/dL (↓)-pH 7.430 (↑)-pCO2: 21.3 (↓)-HCO3: 4.1 (↓)-Glucose: 8.17 mmol/L
After 6 hrs of nursing interventions, patient will have an improvement on tissue perfusion by demonstrating v/s within client’s normal range, absence of edema, balance intake and output and free of pain.
Independent:1. Monitor vital signs especially the
blood pressure.Rationale: Decreased glomerular filtration
or GFR may increase renin release and raise BP to conserve energy.
2. Measure urine output.Rationale: Necessary for determining
renal function and fluidreplacement.
3. Provide for diet restrictions, as indicated, while providing adequate calories to meet the body’s needs.
Rationale: Restriction of protein helps limit BUN.
4. Elevate head of bed and legs.Rationale: To increase gravitational blood flow and
enhance venous return and reduce edema.
Dependent:1. Blood transfusion of Pack RBC Type O.Rationale: Replacement of loss or destroyed blood
compatible citrated human blood.
2. Administer Sulodexide 250 LSU 1cap TID.Rationale: Sulodexide is a heparinoid consisting of 80%
fast moving heparin and 20% dermatan sulfate. It is hypolipidaemic and antithrombotic.
3. Administer Lasix 60 mg 1tabRationale: Treatment for edema associated
with renal disease and hypertension.
4. Administer Norvasc 10 mg 1tab ODRationale: Inhibits the movement of calcium
ions across the membranes of cardiac and arterial muscle cells.
5. Administer Losartan 80mg 1tab ODRationale: blocks the vasoconstriction effect
of the renin-angiotensin system as well as the release of aldosterone
Evaluation:
Goal partially met.
Patient’s v/s is within his normal range and with adequate urine output of approximately 850 cc at the end of the shift but still with edema.
As evidenced by:“Gapanghubag man gyapon ang akon nga
tiil.” As verbalized.
Assessment:Subjective:“Nabudlayan ko mag ginhawa” as verbalized.
Objective:-Dyspnea-(+) rhonci, wheezing, and rales on both lungs-Pulmonary congestion-Bibasal pneumonia-Hct: 0.21-0.27 vol.fr (↓)Hgb: 70 – 90 g/dL (↓)-pH 7.430 (↑)-pCO2: 21.3 (↓)
After 30 minutes, patient will be able to demonstrate improve ventilation and adequate oxygenation.
Independent:1. Elevate head of bed/position client
appropriately, provide airway adjuncts.Rationale: To maintain airway and
enhance lung expansion.2. Encourage frequent position changes
and deep breathing exercises.Rationale: Promotes optimal chest
expansion and drainage of secretions.
3. Encourage adequate rest and limit activities within client’s tolerance.
Rationale: Helps limit oxygen needs or consumption.
4. Promote calm/ restful environment.Rationale: To decrease dyspnea.
Dependent:1. Administer Zegen 500 mg; 1 tab bid PORationale: Treatment of infections due to
cefuroxime sensitive organisms: Lower respiratory tract infections including pneumonia.
Goal met. Patient was able to demonstrate
improve ventilation and adequate oxygenation as evidenced by
“Kaginhawa man ako maayo” as verbalized.
-RR of 19-20 bpm.
AssessmentSubjective:“Magamay lang ang akon ihi” as verbalized Objectve:- Urine output ranges from 300-500 cc.-Distention of neck veins-Presence of pitting edema in the extremities-BP of 140 – 160/90 mmHg-Dyspnea (21-24 bpm)-Pulmonary congestion-Hgb: 70 – 90 g/dL (↓)-Sodium: 105.0 mmol/L (↓)-pH 7.430 (↑)-pCO2: 21.3 (↓)-HCO3: 4.1 (↓)
After 8 hours of nursing intervention, the patient will display appropriate urinary output, vital signs within patient’s normal range, absence of edema and will understand the importance of fluid restriction.
Independent:1. Monitor and record accurate intake and
output.Rationale: Accurate I&O is necessary for
determining renal function and fluid replacement needs and reducing risk of fluid overload.
2. Instruct patient to limit sodium and fluid intake.
Rationale: To prevent accumulation of fluid in the body.
3. Elevate edematous extremities, change position frequently.
Rationale: To reduce tissue pressure and risk of skin breakdown.
4. Explain to the patient and family the rationale for fluid restriction.
Rationale: Understanding promotes patient and family cooperation with fluid restriction.
Dependent:1. Administer Catapres 75mg/ tab.Rationale: May be given to treat hypertension
by counteracting effects of decreased renal blood flow and/or circulating volume overload.
2. Administer Lasix 60 mg 1tab.Rationale: For treatment of edema associated
with renal disease and hypertension.
3. Administer Ketosteril 600mg; 1 tab tid PO.Rationale: Prevention & therapy of damages due
to faulty/deficient protein metabolism in chronic renal insufficiency.
Evaluation:Goal partially met. Client was able to demonstrate understanding of
importance of fluid restriction, v/s were within the patient’s normal range with an accurate urine output of approximately 850 cc at the end of the shift but still edema is noted.
Assessment Subjective:“Wala ko gana magkaon” as verbalized.
Objective:- Crea: 1, 124.13 umol/L (↑)- BUN: 16.0 umol/L (↑)-Hgb: 70 – 90 g/dL (↓)-Hct: 0.21-0.27 vol.fr (↓)-Sodium: 105.0 mmol/L (↓)- (+) pitting edema-pH 7.430 (↑)-pCO2: 21.3 (↓)-HCO3: 4.1 (↓)(Metabolic acidosis)
After 3 hrs, patient will be able to maintain adequate nutritional intake and will fully understand the importance of dietary restrictions.
Independent:1. Provide patient’s food preferences and lists
of food that are restricted in his diet.Rationale: Increased dietary intake is
encouraged.2. Encourage high-calorie, low-protein, low-
sodium, and low potassium snacks between meals.
Rationale: Reduces source of restricted foods and proteins and provides calories for energy, sparing protein for tissue growth and healing.
3. Explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels.
Rationale: Promotes patient understanding of relationships between diet and urea and creatinine levels to renal disease.
Dependent:1. Administer Sodium bicarbonate 650mg 1
tab 2tabs TIDRationale: Treatment of metabolic acidosis
which can occur in severe renal disease.
Assessment: Subjective” Daw lain na iya nahambal kag naubra, daw naglain siya
halin nga wala siya katulog” as verbalized by the wife. Objective-restlessness-irritable-BP: 160/90 mmHg- has violent tendencies-inaccurate interpretation of env’t-shouts & desires to go out of the ward-For hemodialysis: Hgb: 90 g/dL, crea: 1,124 umol/L (↑),
urinalysis (3+)- BUN: 16.0 umol/L (↑)
To improve thought process within the shift and prevent rapid deterioration of client’s condition during hospitalization.
Independent:1. Remain with the client and accompany
wherever he goes.Rationale: The client’s safety is a priority. A
highly anxious client should not be left alone.
2. Remain calm in your approach to the client.Rationale: The client will feel more secure if
you are calm and if the client feels you are in control of the situation.
3. Reduce environmental noise with minimal or decreased stimuli.
Rationale: To provide rest and relaxation to the client.
4. Provide safety measures, such as keeping away any sharp materials beside him and other objects that may used for harming others or himself.
Rationale: Clients with impaired thought process may have violent tendencies.
Dependent:1. Administer Haloperidol 5mg 1tab OD.Rationale: Management of manifestation in
psychotic disorders.
Assessment Subjective:“ Nakapoy ako pirme kag nabudlayan ko
maghinulag”as verbalized. Objective:-BP of 140 – 160/90 mmHg-Hgb: 70 – 90 g/dL (↓)-Hct: 0.21-0.27 vol.fr (↓)-Pale conjunctivae-Dyspnea - RR: 21-24 bpm-pH 7.430 (↑)-pCO2: 21.3 (↓)-HCO3: 4.1 (↓)(Metabolic acidosis)
After 1 hour, patient will be able to identify techniques to enhance activity tolerance.
Independent:1. Encourage alternating activity with rest.Rationale: Promotes activity and exercise
within limits and adequate rest.2. Promote independence in self care
activities as tolerated; assist if fatigued.Rationale: Promotes improved self-esteem.3. Note client reports of weakness, fatigue,
pain, and difficulty accomplishing tasks.Rationale: Symptoms may be result of/ or
contribute to intolerance of activity.
4. Increase exercise/activity levels gradually; teach methods to conserve energy, such as stopping to rest for 3 minutes during 5 minute walk or sitting down to brush hair instead of standing.
Rationale: To reduce fatigue and prevent over exertion.
Goal met.
Patient was able to identify techniques in enhancing activity tolerance.
Assessment Subjective: “Wala kami nagpa-dialysis kay masyado
kamahal kag isa pa wala kami kwarta.” As verbalized by the wife.
Objective:- (+) poor eye contact- (+) Irritability- (+) impaired attention-BP: 140/90 mmHg-RR: 23 bpm
After 30 minutes, we should be able to provide information to aid in understanding the value of the treatment program.
Independent1. Help family identify criteria to promote
ongoing self evaluation of situation/ effectiveness and family progress.
Rationale: Provides opportunity to be proactive in meeting needs.
2. Verify client’s level of knowledge/ understanding of therapeutic regimen.
Rationale: Provides opportunity to assure accuracy and completeness of knowledge.
3. Acknowledge individual efforts/ capabilities to reinforce movement toward attainment of desired outcomes.
Rationale: Provides positive reinforcement.
Goal met.
Patient was provided information to aid in understanding the value of the treatment program.
Assessment Subjective:“Waay na ako gaasa nga mag-ayo ako, ginahulat
ko na lang gid na kwaun niya ako.” As verbalized.
Objective:- Irritability- sighing- restlessness- impaired attention-difficulty of concentrating
Within the shift client will identify coping mechanisms to counteract feelings of hopelessness.
Independent1. Establish a therapeutic/ facilitative
relationship showing positive regard for the client.
Rationale: Client may then feel safe to disclose feelings and feel understood and listen to.
2. Help client begin to develop coping mechanisms that can be learned and used effectively.
Rationale: To counteract hopelessness.
3. Assist client or family to become aware of factors or situations leading to feelings of hopelessness.
Rationale: Provides opportunity to avoid or modify situation.
Goal met.
Client identified coping mechanisms to counteract feelings of hopelessness.
MEDICATIONSSoludexide 250 LSU 1 cap TIDAmlodipine 1 tab OD 5 mgSodium BicarbonateKetosteril 600 mg 1 tab TIDLosartan 50 mg 1 tab TIDCefuroxime 500 mg 1 tab BIDHaloperidol 5 mg 1 tab ODFurosemide (Lasix) 60 mg 1 tabCatapres 75 mg 1 tab (PRN for systolic BP of
150 and above)
Encourage to ambulate and assume his normal activities as long as there will be no problems.
· Educate the client on proper body mechanics to enable him to relax, be comfortable and prevent strains.
· Instruct the client to balance activities with adequate rest periods.
· Educate the client on the importance of drug and money compliance.
· Discuss to the client the complication of the condition because knowledge about the condition supports learning that will decrease anxiety.
· Inform or discuss to the client the importance of dialysis.
· Instruct the client to do proper personal hygiene such as taking a bath daily, brushing of teeth after eating and proper grooming.
· Stress out to the client the importance of hand washing before and after using the comfort room and eating to deter the spread of microorganisms.
· Encourage the client as well as the significant others to follow physician’s instructions regarding personal hygiene and self care.
· Instruct the patient to comply with the scheduled follow up check up to enable the physician to have continuous record on the client’s condition.
· Advice the client to report any abnormalities observed to provide immediate medical intervention.
· Review signs and symptoms with the client.
· Instruct the client to follow physician’s order regarding proper food intake and tell him about its importance.
· Encourage the client to avoid fatty foods and increase intake of vegetables and fruits.
·Instruct client to follow restrictions of his diet such as limiting fluid intake about 1 liter a day and teach client to avoid foods that are rich in potassium as much as possible make a list of food that are restricted to his diet.
· Encourage client to strengthen his faith with Almighty Father to provide spiritual growth and promote healing.
· Advice client never to forget God, to ask for Jesus’ help and to\ believe in the healing power of the Holy Spirit to promote peace of mind and relaxation, thus promoting comfort and healing not just to the mind but also to avoid harm and promote a soothing and pleasant atmosphere with everyone.
