chronic renal failure

I. INTRODUCTION

Chronic or irreversible, renal failure is a progressive reduction of

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

maintain the body’s internal environment. CRF can develop insidiously over

many years, or it may result from an episode of a cure renal failure from which

the client has not recovered. The incidence of CRF varies widely by state and

country. In the United States, the incidence is 268 new cases per million

populations.

Chronic renal failure affects many body systems. It can also lead to many

complications. This is the goal of health care providers, to prevent any

occurrence of complications. One of the complications of CRF is

hyperparathyroidism; this is due to the compensatory mechanism of the

parathyroid hormone once it detects any alteration in the calcium level of the

body.

It is important for clinicians to recognize the problem of

hyperparathyroidism early in the course of chronic kidney disease so that growth

of the parathyroid glands can be prevented or halted, and excessive secretion of

hyperthyroidism can be controlled to help minimize the adverse consequences

on bone and mineral metabolism, which may lead to bone pain and bone

fractures, decreased growth in children, muscle weakness, and elevations in the

calcium phosphorus product, which contributes to calcification of the heart

valves and blood vessels and contributes to the high cardiovascular mortality in

patients with advanced kidney disease.

Early detection of this complication of chronic kidney disease will provide

an opportunity to intervene to control the secretion of parathyroid hormone and,

thus, minimize the problem. Early detection will also allow for the opportunity to

prevent further growth of the parathyroid glands so that the magnitude of the

problem will be lessened as kidney function deteriorates. There is also some

evidence that the control of hyperparathyroidism may help to slow the

progression of kidney disease. Ultimately, it is hoped that with timely intervention

1

to control this complication of chronic kidney disease, improved patient outcomes

on in terms of morbidity and mortality will be achieved.

To ensure that the diagnosis of hyperparathyroidism is made early in the

course of chronic kidney disease, it is important to educate primary care

physicians, cardiologists, endocrinologists and other healthcare providers who

may see patients in the early stages of chronic kidney disease, so that they may

assess blood parathyroid hormone levels to uncover this complication and either

embark on the treatment of hyperparathyroidism or consider referral to a

nephrologist for further advice on the appropriate management strategies.

Referral to a nephrologist would appear to be preferable at the present time as

the field is advancing with new therapies being evaluated and implemented in

practice.

At the American Society of Nephrology Renal Week 2004 meeting, results

are being presented on the administration of oral paricalcitol, now in capsular

form, so that its use can be evaluated in patients with earlier stages of kidney

disease (stage III and IV), who are not yet on dialysis. The phase 3 studies of

orally administered paricalcitol showed that this strategy is effective in reducing

the degree of hyperparathyroidism, and that the administration of this vitamin D

analog is not associated with hypercalcemia, hyperphosphatemia, or

hypercalcuria. Thus, the treatment was effective and well tolerated and appeared

to be free of side effects. These studies are important because they provide a

new therapy for the complication of hyperparathyroidism in the course chronic

kidney disease, and, thus, if the diagnosis of this complication can be made

earlier in the course of chronic kidney disease, treatments such as oral

paricalcitol may be effective in managing this complication.

As nurses, we could help our patients by having a deep understanding of

the disease, that we may learn the proper interventions for the chronic kidney

disease patients. In this way, we could render quality care for them. We could as

well lead them to the proper treatment to lessen their sufferings brought by the

kidney failure, in anyhow. By having a wide understanding of the disease, we

could impart teachings on how we could prevent the occurrence of chronic

2

kidney disease. As nurses, it is our responsibility to render information and impart

health teachings to improve the condition of our patients to the best of our

abilities. One of the characteristics that we, nurses, should have is to be

informative and only through a keen study of disease such as this way for us to

gain all the information that we need to learn. May this case study served its

purpose through the help of our Lord, Jesus Christ.

II. NURSING ASSESSMENT

A. Personal Data and History (Demographic Data)

Mr. Scrooge is a 53-year-old male, married living at 21 St. Cecilia, Paula

Complex, Laguna. He was born on September 16, 1952 in Laguna. He is married

for 29 years now and has six children. He was not able to finished his desired

career during his college years because their family business was suddenly went

bankrupt. According to Mr. Scrooge, education is important that’s why he decided

to look for more affordable career. While studying he decided to work to be able

to support his education. With his perseverance and determination, he was able

to finished aircraft maintenance. But with all of this stress and difficulties

happening in his life, he learned how to smoke. According to him, smoking helps

him to be relaxed. He consumed 8 sticks/day. He was also an occasional drinker.

He worked as aircraft maintenance in Clark Air Base in Pampanga for more than

20 years.

Mr. Scrooge said that he is fond of eating meat and poultry products. After

work, he only stays at home because he feels very tired after work. At present,

he still works as aircraft maintenance in Clark Air Base in Pampanga.

Mr. Scrooge was admitted in Angeles University Foundation Medical

Center last February 3, 2005. He was admitted due to body weakness and

severe anemia. He was discharged on February 10, 2005.

3

B. Family Health-Illness History

Mother Side Father Side

C. History of Past Illness

Mr. Scrooge was known for being hypertensive for 5 years now. He was

diagnosed of hypertension and kidney failure last 2001. He was hospitalized in

St. Luke’s Hospital because of the said health problem. According to him, his

chief complain that time was only hypertension. He was discharged from the

hospital after six days of confinement. After his discharge, Mr. Scrooge

consistently having his blood chemistry and creatinine check-up every month in

AUFMC. If the results are all normal, his check-up becomes every month. These

all became routine on him.

On May 2004, he was hospitalized for the second time in AUFMC. After

two days of confinement in the hospital, he decided to transfer in St. Luke’s

Hospital. Mr. Bean experienced difficulty of breathing and fatigability that time.

He was diagnosed of Pulmonary Congestion.

4

Lola (+) DM Lolo (+) HPNLolaLolo

Moma

Pop

Mr. Scrooge(+) HPN(+)Kidney Failure

D. History of Present Illness

Four days prior to admission, Mr. Scrooge experienced easy fatigability.

No other accompanying signs and symptoms. His condition was persisted until

one day prior to admission, he already experiencing body weakness, body

malaise, pallor and fatigability that’s why he consulted AUFMC. He was advised

to have laboratory examination (Hgb and Hct), which revealed anemia and he

was advised to be admitted. His initial vital signs were as follows: T-36.8, RR- 22,

PR- 64, BP- 170/100.

E. Physical Examination

February 3, 2005

Upon Admission:

VS:

T - 36.8

RR - 22

PR - 64

BP - 170/100

Integumentary

A. Skin- pallor, brown in complexion, with good skin turgor

B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4

seconds)

Head-no mass palpated

A. Scalp- hair evenly distributed without any presence of lice and lesions

B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally

round and reactive to light and accommodation

C. Ears- symmetrical with cerumen, no discharges noted

D. Nose- without flaring of nostrils, no discharges noted

E. Mouth- with dry and pale lips

5

F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and

pain

G. Chest and Lungs- with bibasal rales

Abdomen- soft, flat, tender

GIT: loss of appetite

Renal and Urologic changes: fatigability, oliguria

Cardiovascular changes: hypertension

Hematopoietic changes: anemia

Skeletal changes: hypocalcemia and hyperphosphatemia

February 7, 2005

Vital Signs:

T - 36

RR - 22

PR - 81

BP - 170/100

Integumentary



seconds)







E. Mouth- with dry and pale lips


pain


6



Renal and urologic changes: oliguria


February 8, 2005

Vital Signs:

T - 36.2

RR - 16

PR - 80

BP - 170/100

Integumentary



seconds)







E. Mouth- (-) pallor, dry lips


pain



Renal and Urologic changes: oliguria


7

February 9, 2005

Vital Signs:

T - 36.4

RR - 20

PR - 71

BP - 160/100

Integumentary



seconds)







E. Mouth- with (-) pallor, dry lips


pain






8

February 10, 2005

Vital Signs:

T - 37

RR - 17

PR - 85

BP - 180/90

Integumentary

C. Skin- pallor, brown in complexion, with good skin turgor

D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4

seconds)


H. Scalp- hair evenly distributed without any presence of lice and lesions

I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally


J. Ears- symmetrical with cerumen, no discharges noted

K. Nose- without flaring of nostrils, no discharges noted

L. Mouth- (-) pallor

M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and

pain

N. Chest and Lungs- with bibasal rales





9

F. Diagnostic and Laboratory Procedures

Diagnostic/ Laboratory Procedure

Date Ordered

Date Result in

Indication (s)Purpose (s) Result

Normal Values used by the

hospital

Analysis and Interpretation

1. CBC

Hgb

Hct

WBCLeukocytes

Neutrophils

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythorpoietin factor is already affected

Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients

Determines any inflammation and infection

Determines any acute bacterial infection

Determines any chronic bacterial infection or viral

72103107118109

.23

.31

.33

.36

.32

7.766.019.408.589.5

.81

.75

.71

.72

.74

.1

.13

.20

120-170 g/L

.40-.50

5-10x109/L

.50-.70

.10-.40

Results were all below the normal level, thus indicating renal malfunction and thereby causing anemia

Result were all below the normal range thus, showing anemia and renal disease

Results were all above normal level. This shows presence of inflammation and infection

Results were all above normal level. This shows presence of bacterial infection

Results were all within normal level. Showing absence of

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Lymphocytes

Monocytes

Eosinophils

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

infection

Determines any acute bacterial infection

To determine any allergic reaction of the body

.15

.13

.05

.08

.04

.09

.07

.04

.04

.05

.04

.06

.00-.07

.00-.07

chronic infection

Some of the results were all above normalLevel indicating presence of bacteria.

Results were all within the normal level. This shows no allergic reactions.

Nursing Responsibilities:

1. Explain the procedure to the patient

2. Tell the patient that no fasting is required

3. Apply pressure or a pressure dressing to the venipuncture site

4. Assess the venipuncture site for bleeding

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Date Ordered

Date Result in

Indication (s)Purpose (s) Result Analysis and

Interpretation

2. Hepatitis Profile

Ordered:2/3/05

Performed:2/5/05

This is usually done before proceeding in hemodialysis. This is to determine if the patient was expose to the virus of if there is presence of hepatitis virusIn the blood of the patient.

HBSAG- non-reactiveANTI-HCV- non-reactiveANTI-HBC- non-reactiveANTI-HBS-reactiveHAV-IGM- non- reactive

Result revealed that the patient has no hepatitis virus and was not exposed to any of it.





4. Handle the specimen as if it were capable of transmitting hepatitis

5. Immediately discard the needle in the appropriate receptacle

6. Send the specimen to the laboratory promptly


Date Ordered

Date Result in


Normal Values used

by the hospital


3.Urinalysis Ordered:2/3,6,7/05

Result:2/3,6,7/05

To diagnose and monitor renal or urinary tract disease

Color: straw, light yellow, light yellow

Appearance: slightly turbid

pH: 5

Specific Gravity:1.020, 1.025, 1.020

Albumin:

Laboratory results revealed that there is presence of albumin in the blood; this indicates that the glomerular cannot filter large molecules such as that of

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3+

Sugar: negative

Pus Cells: 1-2/HPF, 0-2/HPF, 2-5 /HPF

Red cells: 1-3/HPF, 1-3/HPF,4-6/HPF

Epithelial Cells:Rare

Mucus thread:Rare, (-), (-)

Bacteria: (-), few, (-)

Amorphous urates:Moderate, moderate, few

albumin. It also revealed that there is bacterial infection as evidenced by presence of bacteria, pus cells and red cells in the urine.




3. Instruct the patient to catch the midstream urine for better result

4. Send the specimen to the laboratory promptly


Date OrderedDate Result in


Normal Values used

by the hospital


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4. Creatinine

5. Na+

6. K+

7. Calcium

8. Phosphate

Ordered:2/3,4,6,8/05

Result in:2/3,4,7,9/05

Ordered:2/3/05

Result in:2/3/05

Ordered:2/3,6/05

Result in:2/3,7/05

Ordered: 2/3/05

Result in:2/3/05

Ordered: 2/3/05

Result in:2/3/05

This test was ordered in order to evaluate renal function.

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

To evaluate muscle contraction, nerve impulse transmission, and blood clotting

To evaluate the metabolism of carbohydrates, bone formation and acid-base balance.

149914301649731

137

4.78

6.4

186

44.20-150.30 umol/L

135-150 mmol/L

3.5-5.5 mmol/L

8.5-10.5 mg/dl

30-150 u/L

Results were all above the normal level indicating renal malfunction. The kidney cannot excrete nitrogenous waste product of protein leading to its accumulation in the blood

Normal result which means there is still fluid and electrolyte balance

Normal result which means there is still fluid and electrolyte balance

Results were all above the normal level indicating renal malfunction.

Results were all above the normal level indicating renal malfunction.



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2.Tell the patient that no fasting is required


4. Assess the venipuncture site for bleeding

III. ANATOMY AND PHYSIOLOGY

Function of the Urinary System

The major functions of the urinary systems are performed by the kidneys

and the kidneys plays the following essentials roles in controlling the composition

and volume of body fluids:

1. Excretion. The kidneys are the major excretory organs of the body. They

remove waste products, many of which are toxic, from the blood. Most waste

products are metabolic by- products of cells and substances absorbed from

the intestine. The skin, liver, lungs, and intestines eliminate some of these

waste products, but they cannot compensate if the kidneys fail to function.

2. Blood volume control. The kidneys play an essential role in controlling

blood volume by regulating the volume of water removed from the blood to

produce urine.

3. Ion concentration regulation. The kidneys help regulate the concentration

of the major ions in the body fluids.

4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in

the blood and the respiratory system also play important roles in the

regulation of pH

5. Red blood cell concentration. The kidneys participate in the regulation of

red blood cell production and therefore, in controlling the concentration of red

blood cells in the blood.

6. Vitamin D synthesis. The kidneys. Along with the skin and the liver,

participate in the synthesis of vitamin D.

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Kidneys

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently,

they are major controller of fluid and electrolyte homeostasis. The kidneys also

have several non-excretory metabolic and endocrine functions, including blood

pressure regulation, erythropoietin production, insulin degradation, prostaglandin

synthesis, calcium and phosphorus regulation and Vitamin D metabolism.

The kidneys are located retroperitoneally, in the posterior aspect of the

abdomen. On either side of the ventral column. They lie between the 12 th thoracic

and third lumbar vertebrae. The left kidney is usually positioned slightly higher

than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5

cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved

shape, with a convex distal edge and a concave medial boundary.

Ureters, Urinary Bladder and Urethra

The ureters are small tubes that carry urine from the renal pelvis of the

kidney to the posterior inferior portion of the urinary bladder. The urinary bladder

is a hollow muscular container that lies in the pelvic cavity just posterior to the

pubic symphysis. It functions to store urine, and its size depends on the quantity

of urine present. The urinary bladder can hold from a few milliliters to a maximum

of about 1000 mL of urine. When the urinary bladder reaches a volume of a few

hundred mL, a reflex is activated, which causes the smooth muscle of the urinary

bladder to contract and most of the urine flows out of the urinary bladder through

urethra. The urethra is a tube that exits the urinary bladder inferiorly and

anteriorly. The triangle-shaped portion of the urinary bladder located between the

opening of the ureters and the opening of the urethra is called trigone. The

urethra carries urine from the urinary bladder to the outside of the body.

Renal Blood flow and Glomerular Filtration

The kidney receive 20% to 25% of the cardiac output under resting

conditions, averaging more than 1 L of arterial blood per minute. The renal

arteries branch from the abdominal aorta at the level of he second lumbar

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vertebra, enter the kidney, and progressively branch into lobar arteries. Blood

flows from the interlobular arteries through the afferent arteriole, the glomerular

capillaries, the efferent arteriole and the peritubular capillaries. Some of the

peritubular capillaries carry a small amount of blood to the renal medulla in the

vasa recta before entering the venous drainage. The blood leaves the kidney in

venous system closely corresponding to the arterial system: interlobular veins,

arcuate veins, interlobar veins, and the renal vein. The renal circulation then

empties into the inferior vena cava.

Physiology

Characteristics of Urine

Urine is a watery solution of nitrogenous waste an inorganic salts that are

removed from the plasma and eliminated by the kidneys. It is 5% water and 5%

dissolved solids and gases. The amount of these dissolved substances is

indicated by it specific gravity. The specific gravity of pure water, used as a

standard is 1.000. Because of the dissolved materials it contains, urine has a

specific gravity that normally varies from 1.010 to 1.040. When the kidneys are

diseased, they lose the ability to concentrate urine, and the specific gravity no

longer varies as it does when the kidneys function normally.

Urine formation

The chief function of the kidneys is to produce urine. Each part of the

nephrons performs a special function. There are three important processes by

which urine is formed. They are glomerular filtration, tubular reabsorption and

tubular secretion

The path of the Formation of Urine

17

Blood enters theEfferent arterioles

Now it becomes filtrate (blood minus RBC’s

and plasmaprotein

To Bowman’s capsulePasses through theGlomeruli

To the distal convulated tubule

To the collecting tubule (at this about 99% of the filtrate

has been reabsorbed)

To the loop of Henle Continues through the proximal convulated tubuleApproximately 1 ml of urine is

formed per minuteThe 1 ml of urine goes to

the renal pelvisTo the ureterTo the bladderTo the urethraTo the urinary

meatus

Fluid and Electrolyte Balance

Electrolyte Balance

Electrolytes are important constituents of body fluids. These are

compounds that separate into positively and negatively charged ions and carry

an electric current in solution. The main source of electrolytes is food. A few of

the most important ions are considered here.

1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid

volume. It is the main positive in extracellular fluids. Sodium is required for

nerve impulse conduction and is important in maintaining acid-base balance.

2. Potassium- important in the transmission of nerve impulse; a major positive

ion in the intracellular fluids. It is involved in cellular enzyme activities and

helps regulate the chemical reactions by which carbohydrate is converted to

protein.

3. Calcium-required for bone formation, muscle contraction, nerve impulse

transmission, and blood clotting

4. Phosphate- essential in the metabolism of carbohydrates, bone formation and

acid-base balance. They are found in the cell membrane and in the nucleic

acids.

5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.

18

Electrolytes must be kept in the proper concentration in both intracellular and

extracellular fluids. Although some electrolytes are lost in the feces and through

the skin as sweat, the job of balancing electrolytes is left mainly to the kidneys.

There are several hormones that are involved in this process. Aldosterone

produced by the adrenal cortex promotes the reabsorption of sodium and the

elimination of potassium. Hormones from parathyroid and thyroid glands regulate

calcium and phosphate levels. Parathyroid hormones increases blood calcium,

levels by causing the bones to release calcium and by causing the kidneys to

reabsorb calcium. The thyroid hormone calcitonin lowers blood calcium by

causing calcium to be deposited in the bone.

IV. THE PATIENT AND HIS ILLNESS

SYNTHESIS OF THE DISEASE (CLIENT CENTERED)

Chronic Renal Failure

Chronic or irreversible, renal failure is a progressive reduction of

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

maintain the body’s internal environment. Chronic Renal failure can develop

insidiously over many years, or it may result from an episode of acute renal

failure from which the client has not recovered.

Precipitating Factors

Chronic glomerular disease such as glomerunephritis

Chronic infections such as chronic pyelonephritis or tuberculosis

Congenital anomalities such as polycystic

Vascular diseases, such as renal nephrosclerosis or hypertension

Obstructive processes such as calculi

Collagen diseases such as systemic lupus erythematosus

nephrotoxic agents such as long-term aminoglycoside

endocrine diseases such as diabetic neuropathy

19

Such conditions gradually destroy the nephrons and eventually cause

irreversible renal failure. Similarly, acute renal failure that fails to respond to

treatment becomes chronic renal failure.

Predisposing Factors

Sex- both sexes are affected by chronic renal failure. But in 1998, based on

United States Renal Data System, a higher total number of males with ESRD

was found

Age- CRF can be found in people of any age, from infants to the very old.

The elderly population also is the most rapidly growing ESRD population in

the United States. Note that age 30 years progressive physiological

glomerulosclerosis. Aging also results in concomitant progressive

physiological decrease in muscle mass such that daily urinary creatinine

excretion also decreases.

Clinical Manifestations

The clinical manifestations of CRF are present throughout the body. No

organ system is spared.

Electrolyte imbalances

Electrolyte balance may be upset by impaired excretion and

utilization in the kidney. Although many clients maintain normal serum

sodium level, the salt-wasting properties of some failing kidneys, in

addition to vomiting and diarrhea, may cause hyponatremia. Because the

kidneys are efficient at excreting potassium, potassium levels usually

remain within normal limits until late in the disease.

Several mechanisms contriburte to hypocalcemia. Conversion of

25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to

absorb calcium) is decreased, which results in reduced intestinal

absorption of calcium. At the same time, phosphate is not excreted, which

causes hyperphosphatemia. Because calcium and phosphate are

20

inversely related, a high phosphate level results in a reduced calcium

level.

Metabolic changes

In advancing renal failure, BUN and serum creatinine rise as waste

products of protein metabolism accumulate in the blood. The serum

creatinine level is the most accurate measure of renal function. The

proteinuria accompanying renal disease and sometimes inadequate

dietary intake of proteins cause hypoproteinuria, which lowers the

intravascular oncotic pressure. Metabolic acidosis occurs because of the

kidney’s inability to excrete hydrogen ions. Decrease reabsorption of

sodium bicarbonate and decreased formation of dihydrogen phosphate

and ammonia contribute to this problem. Acidosis accentuates

hyperkalemia and the reabsorption of calcium from the bones.

Hematologic changes

The primary hematologic effect of renal failure is anemia, usually

normochromic and normocytic. It occurs because the kidneys are unable to

produce erythropoietin, a hormone necessary for red blood cell production.

Frequently, the fatigue, weakness, and cold intolerance accompanying the

anemia lead to a diagnosis of renal failure.

Gastrointestinal changes

The entire gastrointestinal system is affected. Transient anorexia,

nausea, vomiting are almost universal. Clients often experience a constant

bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or

ammonia-like. Stomatitis, parotitis and gingivitis are common problems

because of poor oral hygiene and the formation of ammonia from salivary

urea. Accumulations of gastro may be a major cause of ulcer disease.

Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be

present. Serum amylase level may be increased, although they do not

necessarily indicate pancreatitis.

Immunologic changes

21

Impairment of the immune system makes the client more susceptible

to infection. Several factors are involved, including depression of humoral

antibody formation, suppression of delayed hypersensitivity and decreased

chemotactic function of leukocytes. Immunosuppression is an important part

of the medical management of renal diseaes such as glomerulonephritis.

Cardiovascular changes

The most common clinical manifestation is hypertension, produced

through:

mechanism of volume overload, stimulation of the renin-angiotensin system,

sympatheically mediated vasoconstriction, absence of prostaglandins.

Respiratory changes

Some of the respiratory effects such as pulmonary edema can be

attributed to fluid overload. Metabolic acidosis causes a compensatory

increase in respiratory rate as the lungs try to eliminate excess hydrogen

ions.

Musculoskeletal changes

The etiologic mechanism involves the kidney-bone-parathyroid and

calcium-phosphate-vitamin D connections. As the GRF decreases, the

phosphate excretion decreases and calcium elimination increases. Abnormal

levels of calcium and phosphate stimulate the release of parathyroid hormone

that mobilizes calcium from the bones and facilitates phosphate excretion.

Integumentary changes

The skin is also often very dry because of atrophy of the sweat glands.

Severe and intractable pruritus may result from secondary

hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is

evident.

V. The Patient and his Care

A. Medical Management Medical Date ordered General Indication (s) Client’s initial Client’s

22

Management Date performed Description Purpose (s) reaction to the treatment

response to the treatment

1. D5 LRS iL x KVO

2. D5 NaCl iL x KVO

3. Subclavian catheterization

4.Blood Transfusion

Ordered:2/3,7,9/05Performed:2/3,7,9/05Changed:2/3/05D/C2/10/05

Ordered:2/3/05Performed:2/3/05

Ordered:2/7/05Performed:2/7/05

Ordered:2/3/05

Performed:2/3/05

A crystallized solution that is available in a variety of concentrated water and calories are provided. It is hypertonic solution containing equal amounts of Na and Cl

A catheter tube is inserted into vein in either your neck, chest, leg or near the groin. It has two chambers to allow two-way flow of blood

It is intravenous replacement of loss or destroyed blood compatible citrated human blood it is also the introduction of whole blood or blood Component

To maintain fluid balance of the pt.

To maintain fluid balance of the pt.

Temporary access for hemodialysis

To immediately restore blood volume to treat severe anemia, to be able to maintain oxygen transport to the different parts

Patient felt discomfort

Patient experienced bleeding and felt discomfort on incision site

During the blood transfusion, patient was chilling for a short period of time. There was no further adverse reaction noted upon the transfusion

Patient fluid status was maintained

Patient fluid status was maintained

Patient did not show any further bleeding

Patient did manifest some reaction such as chilling but there was not further reaction after the treatment

23

5.Hemodialysis

Ordered:2/7,8,9/05

Performed:2/7,8,10/05

Medical treatment used to promote excretion of wastes materials from the blood of patient.

of the body

It is indicated for the patient because the kidneys cannot function very well to excrete the nitrogenous waste products, thus leading to its accumulation in the blood.

Patient was slightly nervous about the treatment.

There was no adverse reaction noted during and after the procedure

Nursing Responsibilities

1. Blood transfusion

Before

a. Assess client for history of previous BT and any adverse reactions

b. Ensure that the client has an 18 to 19 gauge IV catheter in place

c. Use 0.9% sodium chloride IVF

d. Verify the ABO group, Rh type, client and blood numbers and expiration

date.

e. Take baseline vital signs before initiating BT

f. Identify the patient prior to transfusion

g. Explain the purpose of the transfusion

During

a. Start transfusion slowly

b. Maintain prescribed transfusion rate

c. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post

transfusion

After

a. Monitor for adverse reactions

24

b. Documentation

2. Hemodialysis

Before

a. Explain the purpose of the transfusion

b. Have client void

c. Chart client’s weight

d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension

(unless ordered otherwise)

During

a. Obtain and record vital signs before and every 30 mins. during the

procedure

b. Ensure bedrest with frequent position changes for comfort

c. Proper heparinization must be done to prevent coagulation during the

therapy

d. Inform client that headache and nausea may occur

e. Monitor closely for bleeding since blood has been heparinized for

procedure

After

a. Weight the patient after the therapy and record

b. Monitor vital signs especially hypotension.

c. Assess for complications (hypovolemic shock, dialysis

disequilibrium syndrome)

Name of Drug

Date orderedDate Taken

Date changed or D/C

Route of admin. Dosage

and freq. Of admin.

General action Indication (s)Purpose(s)

Client’s response to medication

Amlodipine besylate

norvasc

Ordered:2/3/05

Taken:2/3-10/05

PO 5 mg OD Calcium antagonist, antihypertensive

To decrease increase blood pressure

Patient did not show any side effects

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Metoprolol tartate

neobloc

Iberet- folic acid

furosemide

lasix

calcium carbonate

Ordered:2/3/05

Taken:2/3-10/05

Ordered:2/3/05

Taken:2/3-10/05

changed:2/3/05

Ordered:2/3/05

Taken:2/3-10/05

Ordered:2/3/05

Taken:2/3-10/05

D/C:2/3/05

PO 50 mg OD

PO 1 cap BID

PO 40 mg OD

PO 1 tab. TID

Beta blockers, antihypertensive drug

Iron deficiency

Diuretic

Calcium supplement

To decrease increase blood pressure

For patient having anemia

For oliguric patient

To treat hypocalcemia


Patient’s stool was dark green in color



26


Prior:

1. Check and determine the prescribed the drug.2. Inform the patient about the prescribed the drug.3. Explain the procedure, purpose, indication and side effects of the drug.

During:1. Check vital signs to obtain baseline data.2. Monitor BP3. Prepare the drug and the materials4. Observe for initial assessment.5. Observe for any initial response to the treatment.

After:1. Observe for any intolerance and side effects on the prescribed drug.

Type of dietDate orderedDate started

Date changed

General description

Indication (s)Purpose (s)

Client’s response to the diet

DAT

Low salt, low protein

Ordered:2/3/05Started:2/3/05Changed:2/3/05

Ordered:2/3/05Started:2/3-10/05

Any foods and fluids that are being tolerated by the patient

Foods that has low salt and protein value

To provide nutrients needed by the body

To decrease further production of purine which can contribute in increasing level of creatinine in the blood

Patient followed the diet

Patient strictly complied with the prescribed diet


Prior:1. Check and determine the prescribed diet

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2. Inform the SO about the prescribed diet3. Explain the procedure and purpose of the prescribed diet4. Cite foods that are restricted.

During:1. Check vital signs to obtain baseline data2. Observe for initial response.

After:1. Inform SO if it would be changed2. Observe and monitor for changes

Type of activityDate orderedDate started

Date changed

General description

Indication (s)Purpose (s)

Client’s response to the activity

Bed rest Ordered:2/3/05Started:2/3-10/05

An activity wherein the patient is not allowed to do any activity. Patient stays at bed.

To decrease consumption of oxygen and to be able to conserve energy

Patient strictly complied with the prescribed activity


1. Explain the procedure to patient.

2. Explain importance of activity.

3. Assist patient in doing the activity.

B. Surgical Management

Arteriovenous Fistula

An AV fistula requires advance planning because a fistula takes a while

after surgery to develop (in rare cases, as long as 24 months). But a properly

formed fistula is less likely than other kinds of vascular accesses to form clots or

become infected. Also, fistulas tend to last many years, longer than any other

kind of vascular access.

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A surgeon creates an AV fistula by connecting an artery directly to a vein,

usually in the forearm. Connecting the artery to the vein causes more blood flow

into the vein. As a result, the vein grows larger and stronger, making repeated

insertions for hemodialysis treatment easier. For the surgery, you will be given a

local anesthetic. In most cases, the procedure can be performed on an outpatient

basis.

These fistulas require up to 6 weeks to mature before they can be used,

which makes this approach inappropriate for immediate hemodialysis. Peritoneal

dialysis or large venous access catheters may be used while the fistula is

maturing. External arteriovenous shunts are rarely used.

C. Nursing management

Actual SOAPIE

February 3, 2005

S> “madali akong mapagod”

O> received patient on semi-fowler’s position, with an ongoing IVF of D5 NM 1 L

X120 cc/hr @ 900 cc level, infusing well on the right hand

> Afebrile, with pink conjunctiva and lips, easy fatigability, appears weak

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>VS taken and recorded as follows: T-36, PR-64, RR-18, BP-150/90

A>altered peripheral tissue perfusion r/t decrease circulating hemoglobin

P>after 6 hrs of nursing interventions, patient will have an improvement on tissue

perfusion as evidence by decrease in paleness in lips and conjunctiva, and

increase in activity tolerance

I > monitored VS and recorded

> Established rapport

> Provided adequate rest to conserve energy

> Discussed the effect of decrease hemoglobin in the body

> Instructed to eat nutritious food especially those rich in iron

> Maintained IVF regulation

> Monitored Intake and Output strictly

> Monitored patient’s response to blood transfusion

E >goal met as evidence by decreased in paleness and increased activity

tolerance

Actual SOAPIE

February 08. 2005

S >

O> received patient on supine position, awake, afebrile with pale conjunctiva,

appears weak with easy fatigability

> VS taken and recorded as follows: T-36, PR-90, RR-16, BP-170/90

A > decreased cardiac output r/t vascular resistance secondary to hypertension

30

P > after 6 hrs of nursing interventions, patient will improve cardiac output as

evidence by normal vital signs and decreased in paleness and fatigability

I > monitored VS and recorded

> Established rapport

> Instructed to avoid strenuous activity

> Provided calm environment

> Encourage to ambulate early

> Assisted in changing position

> Instructed SO to avoid introducing stress to the patient

> Monitored I&O strictly

E > goal met as evidence by decreased in paleness and fatigability

VI. Patient’s Daily Progress in the Hospital

A. Patient’s Daily Progress Chart (from admission to discharge)

Days Admission 2 3 4 5 6 7 Discharge

2/3 2/4 2/5 2/6 2/7 2/8 2/9 2/10

A. Nursing Problems

1. Altered tissue perfusion * * * * * * * *

2.Decreased cardiac output * * * * * * * *

3. Fluid volume excess * *

4. Fatigue * * *

5. Activity Intolerance * * * *

B. Vital Signs

T 36 36.1 36.4 36.1 36 36.2 36.4 37

RR 18 20 20 20 22 16 20 17

31

PR 64 62 84 81 81 80 71 85

BP 150/

90

160/

100

140/

80

170/

80

170/

110

170/

90

160/

100

180/

90

C. Diagnostic Procedures

1. CBC

2. Creatinine

3. Urinalysis

4. Hepatitis profile

D. Medical Management

1. D5 LRS 1 L

2.D5 NaCl

3. Blood transfusion

4. Hemodialysis

5. Subclavian catheterization

E. Drugs

1. Norvasc

2. Neobloc

3. Iberet +Folic

4. Calcium carbonate

5.furosemide

F. Diet

1. DAT

2. Low salt low protein

G. Activity / Exercise

1. Bed rest

B. Discharge Planning

Mr. Scrooge was discharge last February 10, 2005, Upon discharged, Mr.

Scrooge’s physical appearance was improved. There was absence of paleness

in the conjunctiva and lips, fatigability is decrease, and with decrease creatinine

level as compared when he was admitted in the hospital. His vital signs were as

follows: T- 36.5, PR- 85, RR-18, BP- 140/100.

32

M> Instructed to complied strictly with the following home medications

Norvasc 10 mg 1 tab OD

Iberet+FA 1 tab BID

Ketosteril 1 tab TID after meals

Alutab 1 tab TID during meals

Furosemide 40 mg 1 tab OD for edema or oliguria

Mucosolvan 1 tsp. TID

Augmentin 375 mg 1 tab TID

Nifedipine lozenges QID

>For twice a week hemodialysis

E>Bed rest

T>proper wound care (subclavian and fistula)

H>strict compliance to the medications and in hemodialysis

O>follow-up check up on February 15, 2005

D>avoid foods rich in salt and protein

>Limit fluid intake

VII. Conclusion and Recommendations

Chronic renal failure is an irreversible and progressive disease. It is cause

by many factors. Knowing the precipitating factors leading to the development of

this health problem, people should have an extra care when it comes to health.

Giving care to a patient whether pediatric, geriatric, a medical case or

surgical case makes no difference. Rendering care to everyone who needs it is a

real sense of responsibility. In making this case study, I was able to work well

because I know for myself that I did my best for my patient.

We can say that nursing is significant therapeutic and dynamic process. It

is therefore significant for the nurse caring for the patient to wholeheartedly

33

understand what she is doing like in carrying out some basic skills in relation to

identified goals, comfort and care, interventions and prevention of illness.

VIII. Bibliography

Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company

Philadelphia

Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation

Springhouse, Pennsylvania

Pagana (2002). Mosby’s Manual of Diagnostic and Laboratory Tests.

MIMS. (2003)

www.yahoo.com

www.google.com

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http://www.yahoo.com/

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chronic renal failure