GOOD MORNING…
Chronic Kidney Diseasesecondary to
Chronic Glomerulonephritis
General Objective
The researchers want to gain knowledge about Chronic Renal Disease. It is important to researchers to have adequate knowledge about disease process, its signs and symptoms, risk factors and complications in order for the researchers to impart right information to the patients and for future profession.
Specific Objectives• To know the different risk factors that could
lead to the development of the disease.• To know specific signs and symptoms of
the disease and their causes in order to provide proper nursing interventions to the client.
• To know the disease process and the affected parts in order to have proper health teachings to the client.
• To know probable complications and their causes in order to prevent them.
Patient’s Profile
• Name: Mr. X• Age: 34 y/o• Sex: Male• Status: Single• Address: Sampaloc, Talisay Batangas• Date of Admission: July 11,2009• Time of Admission: 4:51 pm• Chief Complaint: Edema and Fever• Attending Physician: Dr. Atienza and Dr.
Martinez
Patient’s history
• Two months prior to admission, patient had been complaining of edema, consultation has done and managed a care of nephrotic syndrome and complicated UTI. Until one week prior to consult patient was admitted at Daniel Mercado Hospital due to bipedal edema fever associated with difficulty of breathing and abdominal pain. Impression then has chronic renal disease and was advised of dialysis but due to financial constrains patient did not imply here. Consulted at OPD and was advised of admission.
History of Past Illness
• Patient has no other illness since then.
History of Present Illness
• Patient has fever and edema of lower extremities which has been the reason for his hospitalization.
• Family History
He has a familial history of hypertension.
• Patient is a 34 year old, barber in Saudi Arabia.
• Non-smoker, non-drinker.
• He has a preference in fatty and salty foods.
Chronic Kidney Disease
• a condition of progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment.
• It involves the progressive loss of glomerular filtration, a process that can be slowed but is irreversible and eventually results in end stage kidney disease. The kidney cannot maintain metabolic, fluid and electrolyte balance, resulting in uremia and azotemia.
In the Philippines one of the leading causes
of mortality and
morbidity
ranked #10 among other diseases.
Stages of Chronic Kidney Disease
Stage DescriptionGFR*
mL/min/1.73m2
1Slight kidney damage with normal or increased filtration
More than 90
2Mild decrease in kidney function
60-89
3Moderate decrease in kidney function
30-59
4Severe decrease in kidney function
15-29
5Kidney failure requiring dialysis or transplantation
Less than 15
Risk Factors
• Age >55 years old
• Gender, common on men
• Familial history of diabetes melitus and hypertension.
• Nephrotoxins such as lead, mercury, chromium and cadmiun.
• Sedentary lifestyle
• Diet
LEADING Causes• diabetes mellitus (which is the leading
cause)• pyelonephritis (inflammation of the renal
pelvis)• obstruction of the urinary tract• hereditary lesions, as in polycystic kidney
disease• vascular disorders; infections
• medications or toxic agents.
• GLOMERULONEPHRITIS
Some of the patients who is diagnosed with CRF exhibits the following signs and symptoms: hypertension, pulmonary edema, pericarditis, pruritus (itching),anorexia, nausea, vomiting and hiccups. For instance, patient’s breath may have the odor of urine (uremic fetor): this condition is associated with inadequate dialysis.
Potential Complications
• hyperkalemia
• pericarditis
• pericardial effusion
• pericardial tamponade
• hypertension
• anemia
• bone diseases
• metastatic and vascular calcifications.
Management
• Conservative management
• Dialysis
• Kidney replacement
Review of
System
BODY SYSTEM METHOD OFASSESSMENT
FINDINGS ANALYSIS
GeneralAppearance
Inspection Patient was observed lying on bed with heplock noted. Pale and weak in appearance. Appears confused most of the time
Due to poor circulation and tissue perfusion
Due to excessive accumulation of nitrogenous waste.
Integumentary System
InspectionPalpation
Pallor
Dry skin with pruritus
Bipedal edema (grade II)
Due to blood loss and decreased hgb - 55 mg/dL
Due to decreased activity of oil gland
Due to water retention and increase permeability of membrane that results from shifting of fluids associated with renal failure
HEENT InspectionPalpation
Head is normal in size Hair is evenly distributed Eyes are equal rounded
with both pupils reactive to light, pale conjunctiva
Ears are symmetrical, each auricles aligned with the outer canthus of the eyes without any secretions
Nose is symmetric and straight with no discharge or flaring
Lips are pale and dry
Indicates normal findings
Due to blood loss and decreased hgb - 55 mg/dL
RespiratorySystem
InspectionPalpationPercussionAuscultation
Symmetrical movement of the chest upon breathing
Respiratory rate- 19 cycles per minute
With normal breath sounds
Indicates normal findings
Cardiovascular System
PalpationAuscultation
Hypervolemia Blood pressure – 150/100
mmHg With intrajugular catheter
at right intrajugular vein
Due to fluid overload
The catheter is a temporary access for hemodialysis
CirculatorySystem
InspectionPalpation
Capillary refill test delayed by 5 seconds
Pulse rate – 95 beats per minute
Delayed capillary refill due to blood loss and with hgb of 55 mg/dL
Gastrointestinal System
InspectionAuscultationPercussionPalpation
Anorexia Nausea Gastrointestinal
bleeding manifested by dark stools
Abdominal distention and ascites – 107 cm
Uremic Fector
Due to uremic toxins Bleeding is caused
by uremia
Genitourinary System
InspectionPalpation
Decreased urine output; intake- 275 ml, output – 120 ml within 8 hours
Proteinuria Decreased urine
sodium
Damaged Nephrons
Musculoskeletal System
InspectionPalpation
Decrease in muscle strength with a functional mobility of +2
Muscle cramps
Due to dietary restrictions
Hematopoietic System
Inspection Anemia Defects in platelet
function thrombocytopenia
Due to reduced number of RBC
Anatomy
and
Physiology
The Kidney
The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the back. They are protected by three layers of connective tissue: the renal fascia (fibrous membrane) surrounds the kidney and binds the organ to the abdominal wall; the adipose capsule (layer of fat) cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection.
Parts of the Kidney
• Renal Vein carries blood away from the kidney and back to the right hand side of the heart.
• Renal Artery supplies blood to the kidney from the left hand side of the heart
• Pelvis is the region of the kidney where urine collects
• Ureter carries the urine down to the bladder • Medulla is the inside part of the kidney
• Cortex is the outer part of the kidney
• Urine formation• Regulation of electrolytes• Regulation of acid-base balance• Control of water balance• Renal clearance• Secretions of prostaglandins• Regulation of calcium and phosphorous balance• Activates growth hormone• Detoxify harmful substances (e.g., free radicals, drugs) • Increase the absorption of calcium by producing calcitriol
(form of vitamin D) • Produce erythropoietin (hormone that stimulates red blood cell
production in the bone marrow) • Secrete renin (hormone that regulates blood pressure and
electrolyte balance)
Functions of the Kidney
Blood Supply
Each kidney receives its blood supply from the renal artery, two of which branch from the abdominal aorta. Upon entering the hilum of the kidney, the renal artery divides into smaller interlobar arteries situated between the renal papillae. At the outer medulla, the interlobar arteries branch into arcuate arteries, which course along the border between the renal medulla and cortex, giving off still smaller branches, the cortical radial arteries (sometimes called interlobular arteries). Branching off these cortical arteries are the afferent arterioles supplying the glomerular capillaries, which drain into efferent arterioles. Efferent arterioles divide into peritubular capillaries that provide an extensive blood supply to the cortex. Blood from these capillaries collects in renal venules and leaves the kidney via the renal vein. Efferent arterioles of glomeruli closest to the medulla (those that belong to juxtamedullary nephrons) send branches into the medulla, forming the vasa recta. Blood supply is intimately linked to blood pressure
Renal artery → Interlobar arteries → Arcuate arteries →
Cortical radial arteries → Afferent arterioles →
Glomerulus → Efferent arterioles → Vasa recta →
Arcuate vein → Renal vein
The Nephrons
• Functional and structural unit of the kidney• Each kidney has over one million nephrons
Two types of Nephron
1. Cortical Nephron (80-85%)
located at outermost part of cortex
2. Juxtamedullary Nephron
distinguished by long loops of henle
Parts of the Nephron• The afferent arteriole receives blood rich in oxygen from the renal
artery. • The glomerulus is a knotted up capillary that contains small
pores.• The efferent arteriole is smaller in diameter than the afferent
arteriole and increases the pressure in the glomerulus aiding pressure filtration
• Bowman's capsule collects the filtrate• Proximal Convoluted Tubule has a brush border with many villi to
increase the surface area for selective reabsorption. • Loop of Henle dips down into the hypertonic environment of the
kidney medulla and is responsible for the reabsorption of water from the filtrate
• Distal Convoluted Tubule is the site of tubular secretion • Peritubular Capillary Network acts as the blood supply to the
nephron. • Collecting duct receives filtrate from several nephrons.
Functions of the Nephron
• Filtration
• Reabsorption
• Secretion
URINE FORMATION
Three processes occurring in successive portions of the nephron accomplish the function of urine formation:
• Filtration of water and dissolved substances out of the blood in the glomeruli and into Bowman's capsule;
• Reabsorption of water and dissolved substances out of the kidney tubules back into the blood (note that this process prevents substances needed by the body from being lost in the urine);
• Secretion of hydrogen ions (H+), potassium ions (K+), ammonia (NH3), and certain drugs out of the blood and into the kidney tubules, where they are eventually eliminated in the urine.
Pathophysiology
Body system
Manifestation
In
Chronic Kidney Disease
BODY SYSTEM
CAUSES SIGNS AND SYMPTOMS ASSESSMENT PARAMETERS
HEMATO-POETIC
SUPPRESSION OF RBC PRODUCTIONDECREASED SURVIVAL TIME OF RBC.BLOOD LOSS THROUGH BLEEDING AND DIALYSISMILD THROMBOCYTOPENIADECREASED ACTIVITY OF PLATELET
ANEMIALEUKOCYTOSISDEFECTS IN PLATELET FUNCTIONTROMBOCYTOPENIA
HEMATOCRITHEMOGLOBINPLATELET COUNTOBSERVE BRUISING, AND OTHER SIGNS AND SYMPTOMS OF BLEEDING
CARDIO-VASCULAR
FLUID OVERLOADRENIN-ANGIOTENSIN MECHANISMANEMIACHRONIC HYPERTENSIONCALCIFICATION OF SOFT TISSUESUREMIC TOXINS IN PERICARDIAL FLUIDFIBRIN FORMATION ON EPICARDIUM
HYPERVOLEMIAHYPERTENSIONTACHYCARDIAARRYTHMIASCONGESTIVE HEART FAILUREPERICARDITIS
VITAL SIGNSBODY WEIGHTECGHEART SOUNDSMONITOR ELECTROLYTESASSESS FOR PAIN
GASTRO-INTESTINAL
CHANGES IN PLATELET ACTIVITY
SERUM UREMIC ACID
ELECTROLYTE IMBALANCE
UREA COVERTED TO AMMONIA BY SALIVA
ANOREXIA NAUSEA AND
VOMITING GASTROINTESTIN
AL BLEEDING ABDOMINAL
DISTENSION DIARRHEA CONSTIPATION UREMIC FECTOR
MONITOR INTAKE AND OUTPUT
HEMATOCRIT HEMOGLOBIN GUALAC TEST FOR
STOOLS ASSESS THE
QUALITY OF STOOLS
ASSESS FOR ABDOMINAL PAIN
NEUROLOGIC UREMIC TOXINS ELECTROLYTE
IMBALANCES CEREBRAL
SWELLING RESULTING FROM FLUID SHIFTING
LETHARGY CONFUSION CONVULSION STUPOR COMA SLEEP
DISTURBANCE UNUSUAL
BEHAVIOR ASTERIXIS MUSCLE
IRRITABILITY
LEVEL OF ORIENTATION
LEVEL OF CONSCIOUSNESS
REFLEXES EEG ELECTROLYTE
LEVEL
MUSCULO-SKELETAL
UREMIC TOXINS DECREASED
CALCIUM ABSORPTION
DECREASED PHOSPHATE EXCRETION
MUSCLE CRAMPS LOSS OF MUSCLE
STRENGTH RENAL
OSTEODYSTROPHY RENAL RICKETS BONE PAIN BONE FRACTURES
ELECTROLYTE LEVEL
REFLEXES PAIN ASSESSMENT
SKIN ANEMIA PIGMENT RETAINED DECREASED
ACTIVITY OF OIL GLAND
DECREASED SIZE OF SWEAT GLAND
PHOSPHATE DEPOSIT
PALLOR PIGMENTATION PRURITUS ECCYMOSIS EXCORIATION UREMIC FROST DRY SKIN
OBSERVE FOR BRUISING
ASSESS SKIN COLOR
ASSESS SKIN INTEGRITY
OBSERVE FOR SCRATCHING
GENITO-URINARY
DAMAGED NEPHRONS
DECREASED URINE OUTPUTDECREASED URINE SPECIFIC GRAVITYPROTEINURIACAST AND CELLS IN URINEDECREASED URINE SODIUM
MONITOR INTAKE AND OUTPUTSERUM CREATININEBUNSERUM ELECTROLYTESURINE SPECIFIC GRAVITYURINE ELECTROLYTES
REPRODUCTIVE HORMONAL ABNORMALITIESANEMIAHYPERTENSIONMALNUTRTITIONMEDICATIONS
INFERTILITYDECREASED LIBIDOIMPOTENCEAMENORRHEADELAYED PUBERTY
MONITOR INTAKE AND OUTPUTMONITOR VITAL SIGNSHEMATOCRITHEMOGLOBIN
Laboratory Results
Hematology(July 18, 2009)Actual Value Normal Values Significance
Hematocrit 0.16 0.42-0.52 % Result is below normal. Decrease in level of hematocrit signifies anemia. This is cause by impaired production
of erythropoietin in the kidney. Erythropoietin stimulates bone
marrow to produce RBC.
Hemoglobin 55 140-170 Result is below normal. Decrease in lnumber of hemoglobin signifies
anemia
RBC 1.88 4.0-6.0 x 10 Result is below normal. Decrease in number of RBC signifies anemia. This
is cause by impaired production of erythropoietin in the kidney.
Erythropoietin stimulates bone marrow to produce RBC.
WBC 8.9 5.0-10.0 The result is normal. No current infection.
Platelet count 142,000 150,000-350,000 Result is below normal. Decrease in number of platelets signifies risk for bleeding. This is due to excessive
nitrogenous waste in the blood.
Diferrential count
Neutrophils 0.85 0.55-0.65% Result is above normal. This indicates the presence of
bone marrow suppression.
Lympocytes 0.15 0.25-0.35% Result is below normal. This indicates the presence of
bone marrow suppression.
Eosinophils 0.00 0.02-0.04% Result is below normal. This indicates the presence of
bone marrow suppression.
InterpretationThe kidney produce erythropoietin the stimulates
bone marrow to produce red blood cells that increase hemoglobin and hematocrit.
In chronic kidney disease, the production of erythropoietin is impaired thus decreasing the ability of the bone marrow to produce red blood cells and decreasing the number of hemoglobin and the hematocrit level resulting to anemia.
There was bone marrow suppression thereby increasing the neutrophils while lympocytes and eosinophils decrease because of anemia
Blood Chemistry (July 18, 2009)TEST RESULT NORMAL RANGE Significance
Creatinine 2,482.40 62.00-133.00 The result is above normal. The result shows that kidneys cannot excrete
nitrogenous wastes.
Sodium 155.4 135-148 The result is above normal. The result shows the inability of the kidneys to
maintain the homeostasis of the internal environment of the body.
Potassium 5.93 3.5-5.5 The result is above normal. The result shows the inability of the kidneys to
maintain the homeostasis of the internal environment of the body
Phosphorous 10.8 2.5-4.5 The result is above normal. The result shows the inability of the kidneys to
maintain the homeostasis of the internal environment of the body
Calcium 1.08 1.12-1.32 The result is below normal. The result shows the inability of the kidneys to
maintain the homeostasis of the internal environment of the body
Interpretation
Creatinine is a break-down product of creatine phosphate and a nitrogenous waste.Creatinine is excreted mainly in the urine.
In CKD, excretion of the nitrogenous wastes is impaired thus resulting in an increase in level of nitrogenous wastes like creatinine.
Increased serum level of the sodium, phosphorous and potassium is caused by loss of excretory renal function.
The impaired conversion of the vitamin d to its active form causes the decreased serum level of calcium which then causes the increased serum level of phosphorous.
Hyperparathyroidism also causes the decreased level of the calcium.
Urinalysis (July 18, 2009)Result Significance
Physical Color Light Yellow Normal.
ph 5.0 Normal
Transparency Turbid The result is abnormal. The urine contains bacteria, cells, sugar traces and albumin that contribute to the transparency of it.
Specific Gravity 1.020 Normal
Albumin +++ The result is abnormal. The result shows that the nephrons are failing to filter
protein in the glomerulus.
Sugar Trace The result is abnormal. The result shows that the nephrons are failing to reabsorb
glucose in the tubules.
Pus cellsRBC
Epithelial cellsBacteria
4-6/hpf0-2/hpfManyFew
The result is abnormal. The result shows that the functions of the nephrons are
Impaired.
Interpretation
The increased permeability of the capillary causes the excessive passage of protein in the urine.
The impaired tubular reabsorption of glucose causes the traces of sugar in the urine.
The transparency of the urine is turbid. There are many substances that causes the turbidity of it.
Ultrasound
Impression:• Normal size kidneys with Renal parenchymal Disease.• Normal size prostate gland with concretions.• Minimal ascites.• Normal liver, spleen, pancreas, and aorta.• Gall bladder polyp.
The result from the ultrasound of the whole abdomen shows that there is a renal disease that causes some abnormalities in the different systems of the body. Excessive accumulation of nitrogenous waste in the body is one effect of the renal desease. These nitrogenous waste irritates mucosal lining that causes gastrointestinal bleeding and minimal ascites.
Medical
and
Surgical
Management
• Medical Mangement• Hemodialysis
Hemodialysis is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. The principle of hemodialysis is the same as other methods of dialysis; it involves diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes counter current flow, where the dialysate is flowing in the opposite direction to blood flow in the extracorporeal circuit. Counter-current flow maintains the concentration gradient across the membrane at a maximum and increases the efficiency of the dialysis. Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the dialysate compartment, causing free water and some dissolved solutes to move across the membrane along a created pressure gradient. The dialysis solution that is used is a sterilized solution of mineral ions. Urea and other waste products, potassium, and phosphate diffuse into the dialysis solution. However, concentrations of sodium and chloride are similar to those of normal plasma to prevent loss. Sodium bicarbonate is added in a higher concentration than plasma to correct blood acidity. A small amount of glucose is also commonly used. Side effects caused by removing too much fluid and/or removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-cramps, nausea and headaches. These symptoms can occur during the treatment and can persist post treatment; they are sometimes collectively referred to as the dialysis hangover or dialysis washout.
• Surgical Management• Intrajugular catheter
An intrajugular catheter is surgically inserted at right intrajugular vein last July 20, 2009. It is a temporary access for hemodialysis and it is functional for 4 to 6 weeks.
Nursing
Care
Management
ASSESSMENT NURSING DIAGNOSE
S
PLANNING IMPLEMENTATION EVALUATION
Subjective:“Nanghihina ako
“, as verbalized.
Objective: Pale and weak
in appearance Dry skin Capillary refill
time 5 seconds ( +) abdominal
distention 107 cm.
Confuse most of the time
RBC- 1.88 Normal 4-6x10/L
Hemoglobin- 55Normal 140-
170g/dl IJ catheter @
intrajugular vein, dry and intact.
V/S:BP-
150/100mmHgPR-85bpmRR-19cpmT- 36.5◦C
IneffectiveTissue
Perfusionrelated to
Inadequateoxygencarrying
capacity of the
blood asevidenced
bydecrease
hemoglobin,RBC, as
revealed bylaboratory
result.
After 8 hrs of nursing interventions the patient will be able to demonstrate behavioral lifestyle change to improve circulation.
Provided for diet restrictions, as indicated, while providing adequate calories to meet the body’s needs. Restrictions of protein help limit BUN.
Encouraged client to eat rich in Iron but except fatty and salty foods.
Provided psychological report for client especially when progression of the disease and resultant of treatment (dialysis) may be long term.
Encouraged quiet, restful atmosphere conserves energy/ lower tissue oxygen demand.
Maintained head and neck in midline or neutral position to promote circulation/ venous drainage.
Encouraged use of relaxation activities and exercises techniques to decrease tension level.
Encouraged early ambulation to enhances venous return.
Noted mentation it may be altered by increase creatinine.
After 8 hrs of nursing interventions the patient was able to demonstrate behavioral lifestyle change to improve circulation
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTIONS/RATIONALE EVALUATION
S: “Masakit ang opera ko sa leeg” as verbalized
O: weak (+) facial
grimaceP- With IJ catheter
inserted at right intrajugular vein, dry and intact
Q- Lancenating pain
R- Pain is localized in neck
S- score of 8 on pain scale
T- started last night as reported (July 20, 2009)
V/S: T- 36.5C P- 85bpm R- 18cpm Bp-
150/100mmHg
Painrelated
tosurgicalincision
asevidence
dby
verbalreport
After 6hours ofnursing
interventionthe patientwill be able
to reportthat painis relieve
andcontrol
Performed comprehensive assessment of pain to include location, characteristics, onset frequency, duration, quality, severity to assess etiology or precipitating contributory factors
Monitored vital signs for baseline data
Performed pain assessment each time pain occurs. Note and investigate changes from previous reports to rule out worsening of underlying condition
Assessed for referred pain as appropriate to evaluate client’s response to pain
Provided comfort measures, quiet environment and calm activities to promote non- pharmacological pain management
Encouraged adequate rest period to prevent fatigue
Encouraged diversional activities to assist client to explore methods for alleviation or control of pain
Administered medications as ordered
After 6 hoursof nursing
interventionthe patientreported
that pain isrelieved andcontrolled as
evidenced bypain scale of 3
ASSESSMENT NURSINGDIAGNOSES
PLANNING IMPLEMENTATION EVALUATION
Subjective:“Medyo
nangangati ang binti ko“, as verbalized.
Objective: Pale and
weak in appearance
The skin is flaky
Poor skin turgor
Generalized dryness of the skin
With bipedal edema grade II
Serum Creatinine
2,482.40Normal 62.00-
133.00 umol Normal size
kidneys with renal parenchymal disease
Impairedskin integrity
related toImpairedMetabolicstate as
evidenced by
pruritus.
After 8 hrs of nursing interventions the patient will be able to demonstrate behaviors techniques to prevent skin breakdown.
Noted presence of conditions/ situations that may impair skin integrity.
Handled client gently and stretching of linens regularly to maintain skin integrity.
Provided protection by use of pads, pillows foam mattress to increase circulation and tissue perfusion.
Limited or avoided of plastic materials and removed wet/ wrinkled linens. Moisture potentiates skin breakdown
Suggested use of ice, colloidal bath, and lotions to decrease irritable itching.
Recommended keeping nails short to reduce risk for dermal injury when sever itching is present.
Recommended elevation of lower extremities when sitting to enhance venous return and reduce edema formation.
Instructed client low salt, low fat diet.
After 8 hrs of nursing interventions the patient was able to demonstrate behaviors techniques to prevent skin breakdown as evidenced by keeping the nails short and elevating lower extremities and using of pads.
ASSESSMENT NURSING DIAGNOSIS
PLANNING INTERVENTIONS/RATIONALE EVALUATION
S: “Namamanas ang mga paa ko” as verbalizedO:(+) pitting bipedal edema Grade IIIntake greater than outputIntake- 275mlOutput- 120mlLab ResultSerum Creatinine- 2,482.40 (62-133N)Na- 155.4 (135-1448N)K- 5.93 (3.5-5.5N)Ca- 1.08 (1.12-1.32N)Phosphorous- 10.8 (2.5-4.5N)V/S:Bp-130/100 mmHg
Excess fluid volume
related to compromised regulatory mechanism
as evidenced by edema
After 4 hours of nursing
intervention the patient
will be able to verbalize
understanding of individual
dietary and fluid
restrictions
Noted presence of medical condition that potentiate fluid excess to assess causative or precipitating factorsNoted presence of edema to evaluate degree of excessRestricted sodium and fluid intake to promote mobilization and elimination of excess fluidRecorded I&O accurately for baseline dataEvaluated edematous extremities, change in position frequently to reduce tissue pressure and risk of skin breakdownSet an appropriate rate of fluid intake throughout 24-hour period to prevent peaks in fluid levelReviewed dietary restrictions and safe substitutes for salt to promote wellnessReviewed laboratory data to evaluate degree of fluid and electrolyte imbalanceAdministered medications as ordered
After 4 hours of nursing
intervention the patient verbalized
understanding of individual dietary and
fluid restrictions
“hindi na ako masyadong kakain ng maalat at
lilimitahan ko na ang pag
inom ng tubig” as verbalized
ASSESSMENT NURSINGDIAGNOSIS
PLANNING INTERVENTIONS/RATIONALE
EVALUATION
O: Confused most of
the time Weak in
appearance Lab Result Serum
Creatinine- 2,482.40 (62-133N)
Hct- 0.16 (0.42-0.52%N)
Hgb- 55 (140-170N)
RBC- 1.88 (4.0-6.0x10N)
V/S: 36.5C P- 95bpm R- 18cpm Bp-
150/100mmHg
Risk forInjury
related toaltered
peripheraltissue
perfusion.
After 8 hours of nursing intervention the patient will not experience injury
Ascertained knowledge of safety needs/ injury prevention and motivation to prevent injury in home, community, and work setting.
Assessed muscle strength, gross and fine motor coordination to identify risk for falls.
Provided information regarding disease/ condition that may result in increased risk of injury.
Encouraged to eat foods rich in iron except salty and fatty foods.
Encouraged adequate rest to prevent fatigue and injury.
Assisted when going to comfort room.
Provided protection by use of pads, pillows, foam, mattress to increase circulation and tissue perfusion
After 8 hours of nursing intervention the patient did not experience injury
ASSESSMENT NURSING DIAGNOSES
PLANNING IMPLEMENTATION EVALUATION
Objective: Hemoglobin-
55 Normal 140-170 g/dl
WBC 8.9 Normal 5.0-
10.0 x10/L Serum
Creatinine2,482.40 Normal 62.00-
133.00 umol IJ catheter @
intrajugular vein, dry and intact.
V/S:BP-
150/100mmHg
PR-85bpmRR-19cpmT- 36.5◦CNormal M (140-
180 g/L)
Risk forInfectionrelated toexcessive
nitrogenouswaste and
inadequate secondarydefenses.
After 8 hrs of nursing interventions the patient will be able to identify interventions to prevent/ reduce risk for infections.
Assessed laboratory results for infections such as (elevated WBC and positive blood cultures) to prevent and treat infections.
Assessed temperature, respiratory and urinary system changes as disease progress to provide information about presence of infection caused by progressive chronic disease and effect on system.
Advised proper hygiene by all caregivers between therapies/ clients. A first line defense against healthcare associated infections.
Handled client gently and stretching of linens regularly to maintain skin integrity.
Covered with sterile dressings and protect the sites to prevent contamination.
Cleansed incisions / insertion sites per facility protocol with appropriate solution to reduce potential for catheter related blood stream infections.
Instructed client low salt, low fat diet.
The patient was able to identify interventions to prevent/ reduce risk for infections after 8 hours
Name of Drugs
Action IndicationContraindicati
onAdverse
ReactionNursing consideration
Spironolactone
(Aldactone)
Classification
Diuretics
Antagonizes
Aldosterone
in the distal
tubules,Increasing
Na andwater
excretion
Short termpre-operativetreatment of
primaryhyperaldosteroni
mlong term,
maintenancetherapy foridiopathic
hyperaldosteronism
manage ofessential
hypertensionandmanagement of
edematouscondition.
Acute renalinsufficiency,
anuria,and
hyperkalemia.
Gynecomastia,
Agranulocytosis,
headache,
drowsiness,
lethargy,
GI disturbance,
Inability toachieveor maintainerection.
►Obtain baseline data before initiation of therapy such as V/S, degree of edema present and laboratory studies.
►Monitor for manifestation of hyperkalemia; MS; fatigue, muscle weakness; CV: arrhytmias, hypotension, Neuro: parethesias, confusion, Resp.: dyspnea.
►Assess fluid volume status: I & O ratios and record, count or weight diapers as appropriate, weight, distended red veins, crackles in lung, color, quality, and specific gravity of urine, skin turgor, moist mucous membranes should be reported.
►Monitor electrolytes: K, Na, Mg, ABG’s,
uric acid, CBC.►Observe for the 12
rights in administering medication.
Name of Drugs
Action Indication ContraindicationAdverse
ReactionNursing
consideration
SodiumBicarbonate
(Na acid carbonat
e)
Classification
Fluidelectrolytes
Increasebicarbonate,which excessbuffers H ionconcentrations
,reversemetabolicacidosis,neutralizesgastric acid,which formshydrogen,NaCL, andraises blood
pH.
Treatment for metabolic acidosis; promotion of gastric and urine alkalinization in the case of ion toxication with weak organic acids.
Hypoventilation, hypocalcemia, further in all situations where Na intake must be restricted like cardiac insufficiency, edema, hypertension, severe kidney insufficiency.
Hypernatraemiaand serum
hyperosmolarity.
►Obtain patient history, including drug history and any hypersensitivity
►Assess respiratory and pulse rate, rhythm, depth, lung sounds.
►Monitor fluid balance (I&O ratio, edema) notify physician of fluid overload.
►Monitor for manifestation by hyponatermia: increase BP, cold, clammy skin, anorexia nausea and vomiting.
►If the patient is vomiting withhold medication and immediately inform
physician.
►Observe for the 12 rights in administering medication.
Name of Drugs Action IndicationContraindicatio
nAdverse Reaction
Nursing consideration
Nifedipine(Calciblock)
ClassificationAntagonist
Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces relaxation of coronary and peripheral vascular muscle and it dilates coronary vascular arteries.
Treatment of vasospastic angina, chronic stable angina, hypertension.
Hypersensitivity, immediate release nifedipine contraindicated in unstable angina and after recent MI, severe aortic stenosis, severe hypotension and decompensate heart failure.
Dizziness,
flushing,
headache,
hypotension,
peripheral edema,
tachycardia and palpitations.
Nausea and other GI disturbance,
rashes, pain, fever and
abnormalities liver function.
►Monitor BP, pulse before therapy.
►Assess therapeutic effectiveness and adverse reaction
►Assess knowledge and teach patient proper use of the medication; possible side effects and adverse symptoms to report.
►Observe for the 12 rights in administering medication.
Name of Drugs Action IndicationContraindicatio
nAdverse
Reaction
Nursing considerati
on
Etoricoxid(Arcoxia)
ClassificationAnalgesic
Inhibitsprostaglandinsynthesis bydecreasingenzymes.
Relief of acute pain.
Active peptic ulceration. Patient experienced bronchospasm, nasal polyps, acute rhinitis, angioneurotic edema. Patient with hypertension, established ischemic heart disease and cerebrovascular disorders.
Immune system disorders, nervous system, cardiac, respiratory, skin, renal and urinary disorders.
►Assess for pain of inflammation, characteristics of pain.
►Monitor blood counts before therapy
►Assess for hypersensitivity to medication.
►Monitor kidney
Observe for the 12 rights in administering medication.and liver function tests.
Name of Drugs Action IndicationContraindicati
onAdverse
Reaction
Nursing considerati
on
Clonidine(Catapres)
ClassificationAntihypertensiv
e
Stimulatescentral alphaAdrenergicreceptors toInhibitSympatheticCardioaccelerator
andvasoconstrictor
center.
Management of all grades of hypertension with the expectation of hypertension due to phaeochromocytoma
Hypersensitivity to Clonidine, sick syndrome.
Local skin irritation,
drowsiness, dry mouth,dizziness,headache.Anxiety fatigue sleep
disturbances,urinary retention,
burning and itching sensation of eye.
►Perform blood studies
►Assess BP before medication
►Monitor baseline for
renal, liver function before medication.
►Observe for the 12 rights in administering medication.
Name of Drugs Action Indication Contraindication
Adverse Reaction
Nursing consideration
Calcium Carbonate(Calci-aid)
ClassificationAntacid
Decrease total acid load of GI tract. Increase esophageal sphincter tone, strengthens gastric mucosal barrier and reduce pepsin activity by elevating gastric pH.
Antacid, calcium supplement, osteoporosis and hyperthyroidism.
Hypercalcemia, bone tumors, severe renal failure,.
Constipation, inflatulence, diarrhea, renal dysfunction, acid rebound.
►Assess for adverse reaction
►Assess for hypercalcemia
►Advice to increase fluid intake.
►Observe for the 12 rights in administering medication.