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I.

INTRODUCTION
A. Brief Description

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive
loss of renal function over a period of months or years. The symptoms of worsening kidney
function are unspecific, and might include feeling generally unwell and experiencing a reduced
appetite. Often, chronic kidney disease is diagnosed as a result of screening of people known to
be at risk of kidney problems, such as those with high blood pressure or diabetes and those with
a blood relative with chronic kidney disease. Chronic kidney disease may also be identified
when it leads to one of its recognized complications, such as cardiovascular disease, anemia or
pericarditis.
Chronic kidney disease is identified by a blood test for creatinine. Higher levels of
creatinine indicate a falling glomerular filtration rate and as a result a decreased capability of the
kidneys to excrete waste products. Creatinine levels may be normal in the early stages of CKD,
and the condition is discovered if urinalysis (testing of a urine sample) shows that the kidney is
allowing the loss of protein or red blood cells into the urine. To fully investigate the underlying
cause of kidney damage, various forms of medical imaging, blood tests and often renal biopsy
(removing a small sample of kidney tissue) are employed to find out if there is a reversible
cause for the kidney malfunction. Recent professional guidelines classify the severity of chronic
kidney disease in five stages, with stage 1 being the mildest and usually causing few symptoms
and stage 5 being a severe illness with poor life expectancy if untreated. Stage 5 CKD is also
called established chronic kidney disease and is synonymous with the now outdated terms end-
stage renal disease (ESRD), chronic kidney failure (CKF) or chronic renal failure (CRF).
There is no specific treatment unequivocally shown to slow the worsening of chronic
kidney disease. If there is an underlying cause to CKD, such as vasculitis, this may be treated
directly with treatments aimed to slow the damage. In more advanced stages, treatments may
be required for anemia and bone disease. Severe CKD requires one of the forms of renal
replacement therapy; this may be a form of dialysis, but ideally constitutes a kidney transplant.
B. Statistics

a. International
An Estimated 26 Million Adults in the United States have Chronic Kidney Disease (CKD).

Among the key findings in the CDC Chronic Kidney Disease (CKD) Surveillance Report:
• In 1999–2006, among (National Health and Nutrition Examination Survey) NHANES
survey participants, <5% of those with kidney disease stages 1 or 2 (mild disease)
reported being aware of having CKD; of those with CKD stage 3 (moderate disease),
awareness was only about 7.5%; for stage 4 (severe disease), awareness was still only
less than half (about 40%).
• Among those with CKD stage 3 or 4, younger (15%) and male (13%) participants and
those who were non-Hispanic black (21%) had the greatest levels of awareness relative
to their counterparts.
• Awareness rates for CKD stage 3 or 4 were higher in those with comorbid diagnoses of
diabetes and hypertension, but still quite low (20% and 12%, respectively).
• Persons with CKD in the community are unlikely to be aware of their disease and seek
appropriate treatment.
II. OBJECTIVES

A. General Objectives

At the end of the clinical exposure, we should be able to attain and enhance our
knowledge, skills and attitude to provide nursing care to our patient with chronic kidney failure.

B. Specific Objectives
During the exposure, we should be able to:

Cognitive:
 Discover how the patient acquired the disease through the nursing health history,
physical examinations, and some other some other factors that may contribute in relation
to chronic kidney failure and be able to assess, organize and validate those data
efficiently.
 Understand chronic kidney disease, its causes and pathophysiology.
 Design a plan of care for patient with chronic kidney disease (CKD).
 To be able to formulate those data into nursing diagnoses that may aid in the patient’s
current health condition.
 To be able to set priorities and goal outcomes in collaboration with the patient.
 To be able to document patient responses to care and verbal reports, if any.

Skills:
 Conduct physical assessment and organize data efficiently.
 Perform nursing procedures effectively and correctly to attain his optimum level of
wellness.

Attitude:
 To be able to establish rapport with the patient and folks.
 To be able to develop respect and trust.
III. ANATOMY AND PHYSIOLOGY OF THE DISEASE

Your Urinary System and How It Works


The organs, tubes, muscles, and nerves that work together to create, store, and carry
urine are the urinary system. The urinary system includes two kidneys, two ureters, the bladder,
two sphincter muscles, and the urethra.
How does the urinary system work?

The urinary tract is a pathway that includes the:


• kidneys: two bean-shaped organs that filter waste from the blood and produce urine.
• ureters: two thin tubes that take pee from the kidney to the bladder.
• bladder: a sac that holds pee until it's time to go to the bathroom.
• urethra: the tube that carries urine from the bladder out of the body when you pee.
The kidneys are key players in the urinary tract. They do two important jobs — filter
waste from the blood and produce pee to get rid of it. If they didn't do this, toxins (bad stuff)
would quickly build up in your body and make you sick. That's why you hear about people
getting kidney transplants sometimes. You need at least one working kidney to be healthy.
You might wonder how your body ends up with waste it needs to get rid of. Body processes
such as digestion and metabolism (when the body turns food into energy) produce wastes, or
byproducts. The body takes what it needs, but the waste has to go somewhere. Thanks to the
kidneys and pee, it has a way to get out.
Physiology
Urine is produced by individual renal nephron units which are fundamentally similar from
fish to mammals, however, the basic structural and functional pattern of these nephrons varies
among representatives of the vertebrate classes in accordance with changing environmental
demands. Kidneys serve the general function of maintaining the chemical and physical
constancy of blood and other body fluids. The most striking modifications are associated
particularly with the relative amounts of water made available to the animal. Alterations in
degrees of glomerular development, in the structural complexity of renal tubules, and in the
architectural disposition of the various nephrons in relation to one another within the kidneys
may all represent adaptations made either to conserve or eliminate water.

Regulation of volume
Except for the primitive marine cyclostome Myxine, all modern vertebrates, whether
marine, fresh-water, or terrestrial, have concentrations of salt in their blood only one-third or
one-half that of seawater. The early development of the glomerulus can be viewed as a device
responding to the need for regulating the volume of body fluids. Hence, in a hypotonic fresh-
water environment the osmotic influx of water through gills and other permeable body surfaces
would be kept in balance by a simple autoregulatory system whereby a rising volume of blood
results in increased hydrostatic pressure which in turn elevates the rate of glomerular filtration.
Similar devices are found in fresh-water invertebrates where water may be pumped out either
as the result of work done by the heart, contractile vacuoles, or cilia found in such specialized
“kidneys” as flame bulbs, solenocytes, or nephridia that extract excess water from the body
cavity rather than from the circulatory system. Hence, these structures which maintain constant
water content for the invertebrate animal by balancing osmotic influx with hydrostatic output
have the same basic parameters as those in vertebrates that regulate the formation of lymph
across the endothelial walls of capillaries.
Electrolyte balance
A system that regulates volume by producing an ultrafiltrate of blood plasma must
conserve inorganic ions and other essential plasma constituents. The salt-conserving operation
appears to be a primary function of the renal tubules which encapsulate the glomerulus. As the
filtrate passes along their length toward the exterior, inorganic electrolytes are extracted from
them through highly specific active cellular resorptive processes which restore plasma
constituents to the circulatory system.
Movement of water
Concentration gradients of water are attained across cells of renal tubules by water
following the active movement of salt or other solute. Where water is free to follow the active
resorption of sodium and covering anions, as in the proximal tubule, an osmotic condition
prevails. Where water is not free to follow salt as in the distal segment in the absence of
antidiuretic hormone, a hypotonic tubular fluid results.
Nitrogenous end products
Of the major categories of organic foodstuffs, end products of carbohydrate and lipid
metabolism are easily eliminated mainly in the form of carbon dioxide and water. Proteins,
however, are more difficult to eliminate because the primary derivative of their metabolism,
ammonia, is a relatively toxic compound. For animals living in an aquatic environment ammonia
can be eliminated rapidly by simple diffusion through the gills. However, when ammonia is not
free to diffuse into an effectively limitless aquatic environment, its toxicity presents a problem,
particularly to embryos of terrestrial forms that develop wholly within tightly encapsulated
eggshells or cases. For these forms the detoxication of ammonia is an indispensable
requirement for survival. During evolution of the vertebrates two energy-dependent biosynthetic
pathways arose which incorporated potentially toxic ammonia into urea and uric acid molecules,
respectively. Both of these compounds are relatively harmless, even in high concentrations, but
the former needs a relatively large amount of water to ensure its elimination, and uric acid
requires a specific energy-demanding tubular secretory process to ensure its efficient excretion.
Urine concentration
The unique functional feature of the mammalian kidney is its ability to concentrate urine.
Human urine can have four times the osmotic concentration of plasma, and some desert rats
that survive on a diet of seeds without drinking any water have urine/plasma concentration
ratios as high as 17. More aquatic forms such as the beaver have correspondingly poor
concentrating ability.
The concentration operation depends on the existence of a decreasing gradient of solute
concentration that extends from the tips of the papillae in the inner medulla of the kidney
outward toward the cortex. The high concentration of medullary solute is achieved by a double
hairpin countercurrent multiplier system which is powered by the active removal of salt from
urine while it traverses the ascending limb of Henle's loop (Fig. 2). The salt is redelivered to the
tip of the medulla after it has diffused back into the descending limb of Henle's loop. In this way
a hypertonic condition is established in fluid surrounding the terminations of the collecting ducts.
Urine is concentrated by an entirely passive process as water leaves the lumen of collecting
ducts to come into equilibrium with the hypertonic fluid surrounding its terminations.
IV. VITAL INFORMATION
Name (initials): R.E.B
Age: 52 years old
Sex: Male
Address: Estonilo Subdivision, Roxas City
Civil Status: Married
Religion: Roman Catholic
Occupation: Government Employee
Date and Time admitted: September 8, 2009 at 10:45 pm
Ward: Saint Joseph Ward (SJW)
Chief Complaint: Difficulty of Breathing
Admitting Diagnosis: Acute LV dysfunction, CKD; Pneumonia – high risk
Final Diagnosis: Chronic Kidney Disease
Attending Physician/s: Dr. R. Blancaver, Dr. Obligacion

V. CLINICAL ASSESSMENT

A. Nursing History
Mr. R.E.B is a chronic smoker and an excessive alcohol drinker. He plays card games
for his past time activity at around 5 o’clock at the afternoon while playing cards, he experienced
sudden chest pain, and he did not mind the pain but continue playing cards. At around 8:30 pm
after dinner while smoking, he said to his wife that the pain is much more painful that it was just
recently then after an hour, Mr. R.E.B experience difficulty of breathing, and was brought in to
the hospital.

Current medications: diazepam (Valium) for anxiety disorders, tremor muscle and
muscle spasm; Erythromycin for respiratory tract infections and pneumonia; clonidine
(Catapres) for hypertension; doxofylline (Ansimar) for bronchial asthma and pulmonary
diseases; isosorbide-5-mononitrate (Angistad) for heart pain, severe weakness of the heart
muscle and high blood pressure; acetylcysteine (Fluimucil) for respiratory infections and acute
and chronic bronchitis and bronchial asthma; clopidogrel (Plavix) for preventing myocardial
infarction and acute coronary syndrome; nitroglycerin (Transderm – Nitro) for angina pectoris;
clindamycin (Clindamycin Hydrochloride) for respiratory tract infections; meloxicam (Mobic) for
flank pain.
B. Past Health Problem / Status
Past Illnesses: Mr. R.E.B is a 52 year old male suffering from hypertension, diabetes
mellitus type – 2 and base on his laboratory results, its shows that he has pneumonia on both
sides and pulmonary congestion. He also experienced chickenpox and measles during his
childhood.
Allergies: He has no known allergies to food or drugs.
Previous Hospitalization: Previous hospitalization was May 2003 due to difficulty of
breathing with a diagnosis of Pneumonia and had undergone appendectomy.

C. Family History of Illness


Both of his parents have hypertension, diabetes mellitus type -2 and a history of
bronchial asthma, eventually, he may acquire these diseases. Some of his siblings have it too,
and also to his children especially bronchial asthma.
HPN
DM-type
II
FAMILY GENOGRAM

HPN

HP
HPN,
N
BA BA,
CKDCCC
CCCCC

Legend:
Deceased male

Deceased female
BA

Indicates patient

Living male

Living female
VI. BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND

A. Educational Background
Mr. R.E.B is a college graduate.

B. Occupational Background
He is working as a Government Employee.

C. Religious Background
He is a Roman Catholic and attends mass on Sundays and prays thee rosary at
night together with his family.

D. Economic Status
They belong to a middle class type of family and most of his children are schooling.

VII. CLINICAL INSPECTION


A. Vital Signs
Upon Admission During Care
Temperature 37.8°C 36.5°C
Pulse Rate 127 bpm 95 bpm
Respiration 36 bpm 25 bpm
Blood 260/120 mmHg 140/90 mmHg
Pressure
Cardiac Rate 130 bpm 98 bpm

B. Height, Weight, BMI – no data


C. Physical Assessment
General
Mr. R.E.B is conscious and restless. He appears to
be grumpy and irritable but conversive while sitting
or lying in bed.

Skin, Hair, Nails


Dry skin, uniform in color, (+) hematoma in right
arm and warm to touch. Hair is black with visible
white hair, no lice and dandruff and dry scalp.
Experiencing alopecia. Fingernails are trimmed, (+)
cyanotic nailbeds, toenails are not trimmed and
unclean.
Head, Face, Lymphatics
(+) Headache. No head injuries, round in shape
and oily face.

HEENT
Color of the eyes is dark brown, anicteric sclera
with pale conjunctiva. He has blurred vision and
wears glasses most of the time. His right & left ear
canal are not clean, (-) discharges, brown in color,
symmetrical in shape. Hearing is good with no pain
and infections. Have frequent colds. No discharges
or secretions and nosebleeds. Lips are dry. No
bleeding of gums or dentures noted. No inflamed
pharynx and able to swallow food without difficulty.

Neck and Upper extremities


No lumps or swollen glands. No reports of neck
pain and stiffness. Arms able to move freely.
Presence of palpitation in his wrist.

Chest, Breast and Axilla


Abnormal respiration upon admission with RR of 36
bpm and 25 bpm during care. Presence of chest
pain, (+) history of bronchial asthma, (+) rales, (+)
wheezing.

Respiratory System (Chest and Lungs)


Thorax is symmetric. (+) history of bronchial
asthma, RR is above normal. (+) dyspnea, (+)
wheezing. (+) Cough with presence of whitish
phlegm.CXR results: (+) pneumonia, (+) pulmonary
congestion.
Cardiovascular System
(+) history of hypertension with blood pressure of
260/120 upon admission and during care with the
BP of 140/90 mmHg. (+) dyspnea, (+) tachycardia,
(+) chest pain with discomfort. Cardiac rate is
above normal with AR of 130 bpm and respiration
of 36 bpm.

Gastrointestinal System (+) loss of appetite

Genito – Urinary System (+) oliguria

Musculoskeletal System (+) flank pain, (+) weakness, (+) limitation of motion
or activity, (+) bipedal pitting edema at the lower
extremities.

D. General Appraisal

Speech: He speaks clearly, attentive and conversive.


Language: The patient knows how to speak English, Tagalog, Bisaya.
Hearing: The patient’s hearing is good.
Mental Status: The patient is alert and attentive when asked but sometimes he is
grumpy, depending on his mood.
Emotional status: He is worried about his condition and thinks that he brings problem
to his family due to his situation.

VIII. LABORATORY AND DIAGNOSTIC DATA


A. Hematology
Hematology or haematology is the branch of biology (physiology), pathology, clinical
laboratory, internal medicine, and pediatrics that is concerned with the study of blood, the blood
of forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis,
treatment, prognosis, and prevention of blood diseases.

Test Result Normal Significance


Values
Date: 09/13/09
WBC count 20.0x10^9/L 4.5-11.0 ↑ Infection
RBC count 4.78x10^12/L 4.2-5.4 The result is Within Normal
Range.
Hemoglobin 100g/L 120-160 ↑ Anemia from Blood
loss, kidney disorder.
Hematocrit 0.27vol.fr 0.37-0.47 ↓ Acute massive blood
loss, severe anemias
Mean Corpuscular 86.0cu.u 80-96 The result is Within Normal
Volume (MCV) Range.
Mean Corpuscular 28.5uug 27-31 The result is Within Normal
Hemoglobin Range.
(MCH)
Mean Corpuscular 33.0g/dL 32-36 The result is Within Normal
Hemoglobin the Range.
Concentration
(MCHC)
RDW 12.8% 11-16 The result is Within Normal
Range.
Neutrophils 65.0% 50-70 The result is Within Normal
Range.
Eosinophils 4.0% 0-3 ↑ Allergic reactions
Basophils 0.0% 0-1 The result is Within Normal
Range.
Lymphocytes 11.0% 20-45 ↓ It signifies severe
debilitating illnesses.
Monocytes 0.0% 0-8 The result is Within Normal
Limits.
Platelet 118 150-350 ↑ Uremia, infection.

B. Blood Chemistry
The serum chemistry profile is one of the most important initial tests that are commonly
performed on sick or aging patient. A blood sample is collected from the patient. The blood is then
separated into a cell layer and serum layer by spinning the sample at high speeds in a machine
called centrifuge. The serum layer is drawn off and a variety of compounds are then measured.
These measurements aid the veterinarian in assessing the function of various organs and body
systems.
Test Result Normal Values Significance
Date: 09/13/09
Glucose 6.78 mmol/L 4.10 – 5.90 ↑ Hyperglycemia
Sodium 125.3 mmol/L 137.0 – 145.0 ↓ Renal
insufficiency,
uremia
Magnesium 1.10 mmol/L .70 – 1.00 ↑ Renal disorder,
dehydration
Creatinine 298.3 mmol/L 71.0 – 133.0 ↑ Impaired renal
function, shock
Cholesterol 8.34 mmol/L 0.00 – 5.20 ↑ Elevation
indicates increase
risk in CAD
Direct HDLC .45 mmol/L 1.00 – 1.60 ↓ Indicates risks in
CAD
LDL 6.41 1.71 – 4.60 ↑ Elevation
indicates risk in
CAD
VLDL 1.49 0.00 – 1.03 ↑ Elevation
indicates increase
risk in CAD
Potassium 5.49 3.5 – 5.10 ↑ Acute renal failure

C. ABG Analysis
It is also called arterial blood gas (ABG) analysis, is a test which measures the amounts
of oxygen and carbon dioxide in the blood, as well as the acidity (pH) of the blood. It indicates
how well the lungs and kidneys are interacting to maintain normal blood pH (acid-base balance).
It evaluates how effectively the lungs are delivering oxygen to the blood and how efficiently they
are eliminating carbon dioxide from it.

Test Result Normal Values Significance


Date: 09/13/09
pH 7.462 7.35 – 7.45 The result is Within Normal
Limits.
paCO2 32.5 mmHg 33 – 45 mmHg The result is Within Normal
Limits.
paO2 96.0 mmHg 80 – 100 mmHg The result is Within Normal
Limits.
HCO3 22.9 mmol/L 22 – 26 mmol/L The result is Within Normal
Limits.
PCO2 53.6 mmol/L 35 - 45mmol/L ↑ Respiratory distress
ABE 0.4 mmol/L -2 - +2
SBE -0.4 mmol/L
SBC 24.7 mmol/L
O2 saturation 97.6% 97 – 100% The result is Within Normal
Limits.
FIO2 4 Lpm

D. Radiology
It provides a radiographic image of the organs or tissues, to detect abnormality such as
tumor, perforation, abscess, infection, foreign body or fracture.

Test X – ray Findings Impression


Date: 09/13/09
Follow – up study done 09/13/09 without an Bilateral pleural
Chest PA endotracheal tube compared 09/09/09 shows effusion, increase in
(mobile) confluent opacities in the (R) upper lobe and amount
both bases. Pulmonary
There is an increase in the level of the (R) Congestion
and (L) level effusion. Cardiomegaly, LV
The cardiac shadow is enlarged. The lower form
borders are obliterated. Pneumonia, both
The rest of the findings are unchanged. bases and (R) upper
lobe with
consolidation.

E. Urinalysis
A urinalysis is a test performed on a patient's urine sample to diagnose conditions and
diseases such as urinary tract infection, kidney infection, kidney stones, inflammation of the
kidneys, or screen for progression of conditions such as diabetes and high blood pressure.

Test Result Normal Significance Justification


Range
Date: 09/14/09
Color Straw Straw, Amber, WNL The color of the patient’s
Transparent urine doesn’t indicate any
deviations or
abnormalities.

Transparency Turbid Clear Abnormal The patients’ urine may


results. It have the presence of pus
indicates or bacteria. This occurs
infection like maybe due to infection.
pyuria or
bacteuria
pH 7.38 7.35 – 7.45 WNL
Specific 1.025 1.010- 1.030 WNL
Gravity
Glucose Negative Negative WNL
(Microscopic)
Pus 40 –
80/hpf
RBC 240 –
310/hpf
(Crystals)
Bacteria many Infection

F. Sputum test
Sputum test is a test of secretions from the lungs and bronchi (tubes that carry air to the
lung) to look for bacteria that cause infection.

Examination/s desired Result


Date: 09/14/09
Seen on smear were occasional gram (+) cocci in singles
Sputum Gram Stain and in pairs, few gram (-) cocci, occasional gram (-) bacilli
5-14 pus cells/OIF, moderate squamous epithelial cells
and few yeast cells.

G. Serology and Immunology


It is the science that deals with the properties and reactions of serums, especially blood
serum. It analsizes the contents and properties of blood serum.

Serum Specimen Result/s


Date: 09/09/09
Troponin – 1 (-) Negative

H. Bacteriology
The science and study of bacteria, and hence a specialized branch of microbiology. It
deals with the nature and properties of the bacteria as living entities, their morphology and
developmental history, ecology, physiology and biochemistry, genetics, and classification.

Test Result/s
Date: 09/07/09
Nature of specimen: Sputum Organism identified: Very light growth of
Candida but not albicans.
IX. PATHOPHYSIOLOGY

When discussing the pathophysiology of CKD, renal structural and physiological


characteristics, as well as the principles of renal tissue injury and repair should be taken into
consideration.
Firstly, the rate of renal blood flow of approximately 400 ml/100g of tissue per minute is
much greater than that observed in other well perfused vascular beds such as heart, liver and
brain. As a consequence, renal tissue might be exposed to a significant quantity of any
potentially harmful circulating agents or substances. Secondly, glomerular filtration is dependent
on rather high intra- and transglomerular pressure (even under physiologic conditions),
rendering the glomerular capillaries vulnerable to hemodynamic injury, in contrast to other
capillary beds. In line with this, Brenner and coworkers identified glomerular hypertension and
hyperfiltration as major contributors to the progression of chronic renal disease. Thirdly,
glomerular filtration membrane has negatively charged molecules which serve as a barrier
retarding anionic macromolecules. With disruption in this electrostatic barrier, as is the case in
many forms of glomerular injury, plasma protein gains access to the glomerular filtrate. Fourthly,
the sequential organization of nephron microvasculature (glomerular convolute and the
peritubular capillary network) and the downstream position of the tubuli with respect to
glomeruli, not only maintains the glomerulo-tubular balance but also facilitates the spreading of
glomerular injury to tubulointerstitial compartment in disease, exposing tubular epithelial cells to
abnormal ultrafiltrate. As peritubular vasculature underlies glomerular circulation, some
mediators of glomerular inflammatory reaction may overflow into the peritubular circulation
contributing to the interstitial inflammatory reaction frequently recorded in glomerular disease.
Moreover, any decrease in preglomerular or glomerular perfusion leads to decrease in
peritubular blood flow, which, depending on the degree of hypoxia, entails tubulointerstitial injury
and tissue remodeling. Thus, the concept of the nephron as a functional unit applies not only to
renal physiology, but also to the pathophysiology of renal diseases. In the fifth place, the
glomerulus itself should also be regarded as a functional unit with each of its individual
constituents, i.e. endothothelial, mesangial, visceral and parietal epithelial cells - podocytes, and
their extracellular matrix representing an integral part of the normal function. Damage to one will
in part affect the other through different mechanisms,direct cell-cell connections (e.g., gap
junctions), soluble mediators such as chemokines, cytokines, growth factors, and changes in
matrix and basement membrane composition.
The main causes of renal injury are based on immunologic reactions (initiated by
immune complexes or immune cells), tissue hypoxia and ischaemia, exogenic agents like drugs,
endogenous substances like glucose or paraproteins and others, and genetic defects.
Irrespective of the underlying cause glomerulosclerosis and tubulointerstitial fibrosis are
common to CKD.

An overview of the pathophysiology of CKD should give special consideration to mechanisms of


glomerular, tubular and vascular injury.
X. MEDICAL MANAGEMENT
A. Drug Study
Name of the
Drug with Generic Action Mechanism Indication Side Contraindicati Nursing
Dosage Name of Action s Effects ons Responsibilities

Valium Diazepam - Depresses -Anxiety - Contraindicate • Monitor


2.5 g IV x 2 Anxiolyti the CNS, disorders, Drowsiness d in patients periodic hepatic,
doses c and -Acute -Dizziness hypersensitive renal, and
OD - suppresses alcohol -GI upset to drug or soy hemtopoeitic
Antiepile the spread of withdrawal -Difficulty protein; in function studies
ptic seizure , concentrati patients in patients
- activity. -Tremor ng experiencing receiving
Benzodi Muscle , -Fatigue shock, coma, repeated or
azepine relaxant: - or acute prolonged
-Skeletal Adjunct Nervousnes alcohol therapy.
muscle for relief of s intoxication
relaxant reflex (parenteral • Monitor elderly
(centrally skeletal form). patients for
acting) muscle Diastat rectal dizziness, ataxia,
spasm gel is mental status
due to contraindicated changes.
local in patients with Patients are at
pathology acute angle- an increased risk
(inflammat closure for falls.
ion of glaucoma
muscles • Warn patient to
or joints) avoid activities
or and good
secondary coordination until
to trauma effects of drug
before are known.
endoscopi
c • Tell patient to
procedure avoid activities
s, that requires
Preoperati alertness and
ve good
sedation coordination until
effects of drug
are known.

• Tell patient to
avoid alcohol
while taking drug.

• Notify patients
that smoking
may decrease
drug’s
effectiveness.
B. Other Treatments
Hemodialysis
Hemodialysis (also haemodialysis) is a method for removing waste products such
as potassium and urea, as well as free water from the blood when the kidneys are inrenal
failure. Hemodialysis is one of three renal replacement therapies (the other two beingrenal
transplant; peritoneal dialysis).
Hemodialysis can be an outpatient or inpatient therapy. 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.

Side effects:

• Low Blood Pressure

• Fatigue

• Chest Pain

• Nausea

• Headache

• Leg Cramps

The severity of these symptoms is usually proportionate to the amount and speed of fluid
removal. These side effects can be avoided and/or their severity lessened by limiting fluid
intake between treatments or increasing the dose of dialysis

Complications of Hemodialysis

• Sepsis

• Endocarditic (an infection affecting the heart valves)

• Osteomyelitis (infection affecting the bones)


• Bleeding

Complications during Hemodialysis

• Hypotension

• Cramps

• Febrile Reaction

• Arrythmia

• Hemolysis

• Hypoxia

In hemodialysis, three primary methods are used to gain access to the blood: an intravenous
catheter, an arteriovenous (AV) fistula and a synthetic graft. The type of access is influenced by
factors such as the expected time course of a patient's renal failure and the condition of his or
her vasculature. Patients may have multiple accesses, usually because an AV fistula or graft is
maturing and a catheter is still being used.
PREPARING FOR HEMODIALYSIS
Preparations for hemodialysis should be made at least several months before it will be
needed. In particular, you will need to have a procedure to create an "access" (described below)
several weeks to months before hemodialysis begins.
Vascular access — An access creates a way for blood to be removed from the body,
circulate through the dialysis machine, and then return to the body at a rate that is higher than
can be achieved through a normal vein. There are three major types of access: primary AV
fistula, synthetic AV bridge graft, and central venous catheter. Other names for an access
include a fistula or shunt.
The access should be created before hemodialysis begins because it needs time to heal
before it can be used. Discussions about the access should begin even earlier, since you will
need to avoid injuring blood vessels that will eventually be used for access. Having an
intravenous line (IV) or frequent blood draws in the arm that will be used for access can damage
the veins, which could prevent them from being used for a hemodialysis access. The access is
usually created in the non-dominant arm; for a right-handed person this would be their left arm.
Primary AV fistula — A primary AV fistula is the preferred type of vascular access. It
requires a surgical procedure that creates a direct connection between an artery and a vein.
This is often done in the lower arm, but can be done in the upper arm as well. Sometimes a vein
that would not normally be useful for creating an AV fistula can be moved so that it is more
accessible; this is often done in the upper arm.
Regardless of its location or how it is created, the access is located under the skin.
During dialysis, two needles are inserted into the access. Blood flows out of the body through
one needle, circulates through the dialysis machine, and flows back into the access through the
other needle.
A primary AV fistula is usually created two to four months before it will be used for
dialysis. During this time, the area can heal and fully develop or "mature".
Synthetic bridge graft — Sometimes, a patient's arm veins are not suitable for creating a fistula.
In these cases, a surgeon can use a flexible rubber tube to create a path between an artery and
vein. This is called a synthetic bridge graft. The graft sits under the skin and is used in much the
same way as the fistula except that the needles used for hemodialysis are placed into the graft
material rather than the patient's own vein.
Grafts heal more quickly than fistulas and can often be used about two weeks after they
are created. However, complications such as narrowing of the blood vessels and infection are
more common with grafts than with AV fistulas.
Central venous catheter — A central venous catheter uses a thin flexible tube that is
placed into a large vein (usually in the neck). It may be recommended if dialysis must be started
immediately and the patient does not have a functioning AV fistula or graft. This type of access
is usually used only on a temporary basis. In some cases, however, there can be problems
maintaining an AV fistula or graft, and the central venous route is used for long-term access.
Catheters have the highest risk of infection and the poorest function compared to other
access types; they should be used only if a primary fistula or synthetic bridge graft cannot be
maintained.
Dietary changes — some patients, especially those who receive dialysis in a center, will
need to make changes in their diet before and during hemodialysis treatment. These changes
ensure that you do not become overloaded with fluid and that you consume the right balance of
protein, calories, vitamins, and minerals.
A diet that is low in sodium, potassium, and phosphorus may be recommended, and the
amount of fluids (in drinks and foods) may be limited. A dietitian can help you to choose foods
that are compatible with hemodialysis treatment.
Nutritionist

Members of the Health Team (CKD) A person whose professional


activity is devoted to Patient Support System
researching and advising on Dedicated central point of
Pharmacist
matters of nutrition contact who assists providers
The pharmacist may delegate
and patients
prescription-filling and
administrative tasks and
supervise their completion.
Transplant Nephrologist
The majority of kidneys that are
Mr.
transplanted come from deceased
Peritoneal Dialysis Nurse R.E.B
organ donors. Organ donors are
PD filters the patient’s blood
adults who have become critically ill
inside the body, requiring fewer
and will not live as a result of their
equipment restrictions. This
illness. Parents or spouses can also
allows our patients to dialyze at
agree to donate a relative's organs
home or at work.

Hemodialysis Nurse
Social worker
The principle of hemodialysis is the same as other
It is a profession for those with a
Nephrologists
methods of dialysis; it involves diffusion of solutes
strong desire to help improve
A physician who has been trained in the diagnosis and
across a semipermeable membrane. Hemodialysis
people’s lives. Social workers assist
management of kidney disease, by regulating blood pressure,
utilizes counter current flow, where the dialysate is
people by helping them cope with
regulating electrolytes, balancing fluids in the body, and
flowing in the opposite direction to blood flow in the
issues in their everyday lives, deal
administering dialysis. Nephrologists treat many different
extracorporeal circuit. Counter-current flow
with their relationships, and solve
kidney disorders including acid-base disorders, electrolyte
maintains the concentration gradient across the
personal and family problems.
disorders, nephrolithiasis (kidney stones), hypertension (high
membrane at a maximum and increases the
blood pressure), acute kidney disease and end-stage renal
efficiency of the dialysis.
disease.
2. Ineffective airway clearance related to
presence of secretions in the
tracheobronchial tree.
XI. NURSING MANAGEMENT
Objective/s:
A. Concept Map of Nursing Problems (+) Crackles, (+) Whitish productive cough,
10. Low self-esteem Impaired gas exchange r/ t presence (+) Chest pain, (+) DOB, (+) Tachycardia, (+)
r/t loss of kidney function of secretions on both lung base Cyanotic Nails, (+) Weakness, (+) Confusion,
RR= 36 bpm, Hgb= 100 g/L, Hct= 0.27 Vol.fr
Objective/s: Objective/s: X-ray Results: Bilateral pleural effusion,
(+) indecisive nonassertive behavior, (+) (+) Restlessness, (+) DOB, (+) Crackles, (+) pulmonary congestion pneumonia in both
Weakness, Lack of eye contact, Refusal Pallor, (+) Irritability, (+) Decreased bases
to participate in hospital procedures, hemoglobin – 133 g/L (N.V. 120 – 160), RR-
increasingly dependent on her wife 36 bpm, (+) History of bronchial asthma,
X-ray Results: Pleural effusion, Pneumonia, 3. Acute Pain r/t decrease renal
both bases. function
9. Risk for impaired skin integrity
r/t altered fluid status
Objective/s:
`
Objective/s: (+) Flank pain, Pain scale of 6 out
(+) Pitting edema, (+) PD catheter, 0f 10, (+) Loss of appetite, (+)
(+) IV cut down, (+) Hematoma at Guarding at the flank area, (+)
right arm; warm to touch. CC: Difficulty of Inadequate rest, (+) Irritability, (+)
Facial grimace
Breathing
8. Activity Intolerance r/t
Medical 4. Altered thermoregulation related to
generalized body weakness Diagnosis: invasion of pathogens

Chronic Kidney Objective/s:


Temp. 37.9° C, Skin warm to touch,
Objective/s:
(+) Body weakness, Ambulatory with
Disease 5. Infection r/t invasion of bacterial Weak in appearance, WBC result -
microorganism in the lungs 20.0x10^9/L (N.V - 4.5-11.0),
assistance Irritability, (+) Weakness, Neutrophils - ↑ 65.0% (N.V - 50-70),
(+) Shortness of breath, (+) Fatigue Objective/s: Lymphocytes ↓ 11.0% (N.V - 20-45)
6. Fluid volume excess related to impaired Based on the Laboratory results: X-ray revealed:
renal function Eosinophils = 4.0% (0-3%), WBC = Bilateral pleural effusion, increase in
7. Impaired Urinary Elimination r/t
20.0X10^9/L (4.5 – 11.0 X 10 ^ 9/L), amount, Pulmonary Congestion,
altered renal function
Objective/s: Sputum: Occasional gram (+) cocci in singles Cardiomegaly, LV form, Pneumonia,
(+) Bipedal pitting edema, (+) Increase BP - & in pairs, few gram (-) bacilli 5-14 pus cells / both bases and (R) upper lobe with
Objective/s:
230/160 mmHg, (+) Tachycardia- 130 bpm, (+) OIF, moderate squamous epithelial cells & few consolidation.
(+) HD 3x a week, (+)Oliguria, Urine
Crackles yeast cells.
output of 10cc/hr, Bloated abdomen upon
(+) Tachypnea – RR – 36, Hgb 100g/L (N.V - (+) whitish productive cough, (+) temperature –
palpation, Pale in appearance,
Nursing Care Plan Weak 120-160), Hct 0.27vol.fr (N.V - 0.37-0.47), 38C
looking, Creatinine = 298.3 mmol/L
X-ray Results: Bilateral pleural effusion,
Pulmonary congestion , Pneumonia in both
bases
ASSESSMENT NURSING PLANNING NURSING RATIONALE NURSING EVALUATION
DIAGNOSIS INTERVENTION/S THEORIST/S

Subjective: Impaired gas After 4 hours of Independent: Goal partially met.


“Gina hapo ako” exchange r/ t nursing intervention, 1. Position 1. Lowers Lydia Hall’s theory
as verbalized. presence of Mr. REB will Mr. REB in semi diaphragm of Care - Nurturance After 4hours of
secretions on verbalize decrease fowler’s position and promoting chest nursing intervention.
Objective/s: both lung base in difficulty of change position every expansion and Mr. REB was able to
• (+) breathing AEB 2 hours decrease pressure re-establish normal
Restlessness decrease RR on the abdomen breathing pattern but
• (+) DOB some of the

• (+) Crackles 2. Encourage 2. To promote lung Faye Abdellah’s secretions are still

• (+) Pallor deep breathing expansion theory of 21 Nursing present.


exercise Problems (Patient
• (+) Irritability
approach to Nursing)
• (+) Decreased
hemoglobin – 133 g/L
3. Provide back 3. This will allow Virginia
(N.V. 120 – 160 g/L)
tapping to Mr. REB mobilization and Henderson’s theory
• RR- 36 bpm
expectorations of of 14 Basic Needs
• (+) History of
secretions. (Doing the for the
bronchial asthma
patient what they
• X-ray Results:
cannot do for
Pleural Effusion themselves)
Pneumonia, both
bases.
4. Suction as 4. Clears airway Faye Abdellah’s
indicated from secretions theory of 21 Nursing
Problems (Doing the
for the patient what
they cannot do for
themselves)
Dependent:
1. Administer 1. To loosen Dorothy Johnson’s
Fluimucil 600mg as secretions for theory of Human
indicated efficient Behavioral System
expectorations (Medicine focus:
Cure)

2. Administer O2 2. To relieve o2 Florence


therapy 21/msn deficit Nightingale’s theory
of Environment
(Alleviate
unnecessary source
of pain and
suffering)
3. Administer 3. To inhibit the Dorothy Johnson’s
Erythromycin 300 mg growth of bacteria theory of Human
TID (bacteriostatic) Behavioral System
(Medicine focus:
Cure)

4. Nebulization 4. To loosen and Lydia Hall’s theory


1L/m with combivent liquefy secretions. of Components of
Nursing / Caring
(Core and Cure
-shared with other
health care
providers)

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S
Subjective: Ineffective After 8 hours of Independent: Goal partially
“Nabudlayan ako mag airway nursing 1. Assist the Mr. 1. This improves Faye Abdellah’s theory met.
ginhawa” as verbalized. clearance r/t intervention, Mr. REB the productivity of of 21 Nursing Problems
presence of REB will be able to in performing cough (Problem Solving to After 8 hours of
Objective/s: secretions in the expectorate coughing and move the patients nursing
• (+) Crackles tracheobronchial secretions and breathing maneuvers. towards health.) interventions,
• (+) Whitish tree. have normal Mr. REB

productive cough respiratory rate. secretions are

• (+) Chest Pain 2. Controlled Faye Abdellah’s theory mobilized and


2. Instruct the Mr. coughing of 21 Nursing Problems cough out but
• (+) DOB
REB in the techniques help (Doing the for the the airway is
• (+)Tachycardia
following: mobilize patient what they cannot not totally free
• (+) Cyanotic
• Optimal secretions from do for themselves.) from excessive
Nails
positioning (semi smaller airways to secretions AEB
• (+) Weakness
fowlers) larger airways abnormal lung
• (+) Confusion
• Use of pillow or because coughing sounds or
• RR= 36 bpm is done at varying crackles.
hand splints when
• Hgb= 100 g/l times.
coughing.
• Hct= 0.27 Vol.fr
• Use of
• CXR- bilateral abdominal muscle
pleural effusion, for more forceful
pulmonary cough
congestion
pneumonia in both
• Temperance of
bases ambulation and
frequent position
change. 3. To loosen Virginia Henderson’s
3. Provide back secretions theory of 14
Tapping to patient. Components of Nursing
Care (Process or
movements from
dependence to
independence.)

Dependent: 1. For Florence Nightingale’s


1. Administer 02 effective theory of Environment
therapy as ordered oxygenation (Alleviate unnecessary
4L/m source of pain and
suffering)

Dorothy Johnson’s
2. Administer 2. To loosen theory of Human
flumucil and Behavioral System
600mg ½ glass OD x liquefy secretions (Medicine focus: Cure)
5 daily

Lydia Hall’s theory of


Components of Nursing
3. Nebulization of 3. To promote Caring (Core and Cure
salbutamol 1neb x softening of -shared with other
3doses/15min secretions for health care providers.)
better
expectoration of
secretions

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S
Subjective: Acute Pain r/t After 2 hours of Independent: Goal met.
“ Ga sakit akon likod decrease renal nursing intervention, 1. Perform a 1. Pain is as subjective Florence
sa may hawak” as function Mr. REB will comprehensive experience and must Nightingale’s After 2 hours of
verbalized. verbalize decrease assessment of pain be described by the theory of nursing
of pain as evidence to include location, client in order to plan Environment intervention the
Objective/s: by decrease pain characteristics, effective treatment. (Alleviate Mr. REB,
• (+) Flank pain level. onset, duration, unnecessary source verbalized
pain scale of 6 frequency, quantity, of pain and decreased of pain
out 0f 10 Intensity, or severity suffering) as evidence by
• (+) loss of and precipitating decreased in pain
appetite factors of pain. levels from 0 out of

• (+) guarding at 10

the flank area 2. Reduce or 2. Personal factors can Florence

• (+) inadequate eliminated the influence pain and pain Nightingale’s

rest factors that tolerance. Factors that theory of

• (+) irritability precipitate or may be precipitating or Environment


increases Mr. REB’s augmenting pain (Alleviate
• (+) facial
pain experience (e.g. should be eliminated in unnecessary source
grimace
fear, fatigue, order for the pain of pain and
monotony, and lack management to be suffering)
of knowledge.) effective

3. Teach the use of 3. The use of Faye Abdellah’s


nonpharmacologic noninvasive pain relief theory of 21 Nursing
techniques (e.g. measure can increase Problems (Doing the
relaxation, guided the release of for the patient what
imagery, music endorphins and they cannot do for
therapy, distraction, enhance the themselves.)
and massage.) therapeutic effect of
pain relief medication.

4. Evaluate the 4. Research show that Florence


effectiveness of the most common reason Nightingale’s
pain control for unrelieved pain is theory of
measures used failure to routinely Environment
through ongoing assess pain and relief (Alleviate
assessment of Mr. pain. Many clients unnecessary source
REB’s pain tolerate pain if not of pain and
experience specifically talked suffering)
about.

Dependent:
1. Administer 1. To relieve pain Dorothy Johnson’s
Mobic 7.5 mg as theory of Human
ordered Behavioral System
(Medicine focus:
Cure)

2. Administer O2, 2. For effective Florence


2 Lpm therapy oxygenation Nightingale’s
as ordered theory of
Environment
(Alleviate
unnecessary source
of pain and
suffering)

ASSESSMENT NURSING PLANNING NURSING RATIONALE NURSING EVALUATION


DIAGNOSIS INTERVENTION THEORY AND
THEORIST
Subjective: Altered After 2 hours of Independent: Goal met.
“Ginalagnat siya ” thermoregulation nursing 1. Provide tepid 1. May help reduce Betty Neuman
As verbalized by the related to invasion intervention, the sponge bath fever and provide (Help the client’s Temperature is
folks. of pathogens patient’s comfort system attain, decreased from
temperature will maintain and 37.9°C to 37°C
Objective/S: decrease from regain system
• Temp. 37.9 C 37.9 C to 37.0 C stability.)
• Skin warm to within the shift.

touch 2. Provide a cool 2. Room Betty Neuman

• Weak in and calm temperature/ (On the whole

appearance environment number of person and


blankets should reaction to stress.)
• WBC result
be altered to
20.0x10^9/L
maintain near
(N.V - 4.5-11.0)
normal body
• Neutrophils H
temperature.
65.0% (N.V - 50-
70)
• Lymphocytes L
11.0% (N.V - 20-
45)

3. Monitor 3. Temperature Betty Neuman


• X-ray revealed:
patient’s elevation may (Help the client’s
Bilateral pleural
effusion, increase in temperature occur because of system attain,
amount every hour various factors maintain and
Pulmonary Congestion such as presence regain system
Cardiomegaly, LV form of infection stability.)
Pneumonia, both bases
and (R) upper lobe with Dependent:
consolidation. 1. Administer 1. To help reduce Dorothy
(September 13, 2009 ) Paracetamol fever by acting Johnson’s theory
300 mg PRN directly on the of Human
as ordered heat regulating Behavioral
system System (Medicine
focus: Cure)

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S

Objective/s: Infection r/t After 8 hours of Independent: Goal Partially Met.


Based on the invasion of bacterial nursing intervention, 1. Note for 1. Infectio Ernestine
Laboratory results: microorganism in Mr. REB is free of physical evidence ns Weidenback After 8 hours of
o Eosinophils the lungs infection as of infection must be treated to (Nurse meets nursing intervention
4.0% (0-3%) evidenced by stop the immune through Mr. REB is free of
o WBC negative culture, response and identification of pain as evidence by
20.0X10^9/L (4.5 – resolution of glomerular needs) the decrease of
11.0 X 10 ^ 9/L) symptoms, and inflammation. body temperature to

• (+) temperature within 2. Implement Dorothea Orem’s 36.8 °C


Temperature. normal limits. appropriate 2. Hand washing theory of Nursing

– 38C measures to protect by all people in Concepts

• Sputum: the patient from contact with the (Identifies what


potential infection patient is the primary Nursing Care is
Occasional gram (+)
sources. method to reduce the needed)
cocci in singles & in
risk of infection.
pairs, few gram (-)
3. Obtain a Dorothea Orem’s
bacilli 5-14 pus cells /
recent 3. Symptoms of theory of Nursing
OIF, moderate
history for signs Acute Concepts
squamous epithelial
and symptoms of glomerulonephritis (Identifies what
cells & few yeast cells.
infection or appear 10 to 14 days Nursing Care is
• (+) whitish
exposure to after initial needed.)
productive cough
infected individual. streptococcal illness.

Dependent: Dorothea Orem’s


1. Review results 1. Identification of theory of Nursing
of specimen cultures specific Concept (Self care
microorganism will – ability of the
guide selection of person to take care
appropriate of himself)
antimicrobial drugs.
Dorothy
2. Administer 2. Viral infection Johnson’s theory
Erythromycin does not respond to of Human
300mg for positive antibiotic therapy. To Behavioral System
culture findings. decrease the risk of (Medicine focus:
development of Cure)
bacterial strains
resistant to
antibiotics, drug
therapy should be
based on specific
culture and sensitivity
results.

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S

Objective/s: Fluid volume After 8 hours of Independent: Goal partially met.


• (+) Bipedal excess related to nursing intervention, 1. Note 1. Kussmaul’s Ernestine
pitting edema impaired renal Mr. REB’s respiratory respiration and Weidenback (Nurse After 8 hours of
• (+) Increase function extremities will be Pattern and work of dyspnea may be meets through nursing intervention

BP - 230/160 free of edema breathing. evident. identification of Mr. REB’s

mmHg needs) extremities was not

• (+) totally free from

Tachycardia 2. Crackles signify Ernestine edema.

- 130 bpm 2. Auscultate for presence of fluid in Weidenback (Nurse

• (+) Crackles Crackles. the small airways. meets through


identification of
• (+)
needs)
Tachypnea
– RR – 36
3. Dependent areas Ernestine
• Hgb
3. Note the often exhibit signs Weidenback (Nurse
100g/L (N.V -
amount of of edema. meets through
120-160)
peripheral identification of
• Hct
edema by needs)
0.27vol.fr (N.V
palpating area
- 0.37-0.47)
over the tibia,
• CXR- bilateral
ankles, sacrum
pleural effusion,
and back; and by
pulmonary
assessing
congestion
appearance on
pneumonia in both
the face. 4.Excess and of Ernestine
bases
sodium intake can Weidenback (Nurse
4. Note Mr. lead to fluid meets through
REB’s volume excess in identification of
compliance with ESRD patient. needs.)
dietary and fluid
restriction at home. 5. This maintains Lydia Hall’s theory
optimal of Care - Nurturance
positioning for air
5. Have Mr. REB exchange.
sit up if he
complains of 6.This prevents Lydia Hall’s theory
shortness of breath. fluid accumulation of Care - Nurturance
in the lower
6. Elevate the extremities
Mr. REB’s feet when
sitting down. 1. To Dorothy Johnson’s
lower down theory of Human
7. Independent: blood pressure Behavioral System
1. Administer (Medicine focus:
Catapres Cure)
75 mg 1 tab as
prescribed. 2. For the Dorothy Johnson’s
elimination of theory of Human
excess fluids Behavioral System
2. Administer Lasix (Medicine focus:
40mg as prescribed Cure)

3.Patients on Callista Roy’s


dialysis need to theory of Adaptive
importance of Mode (Physiological)
3. Restrict fluid maintaining fluid
Intake as required balance between
by the doctor to dialysis.
patient’s condition.

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S
Subjective: Impaired Urinary After 4 hours of Independent: Goal not met.
“Gamay lang siya Elimination r/t nursing 1. Provide an 1. Insufficient Florence
mangihi” as altered renal intervention, Mr. environment that toileting and Nightingale’s theory Patient was not able
verbalized by the function REB will able to encourages toileting environmental factors of Environment to demonstrate an
folks demonstrate an may contribute to (Organizing and adequate urine
adequate urine functional incontinence manipulating the output about 30 cc.
Objective/s: output about 30 or exacerbate other environment
• (+) HD 3x a cc. forms of urinary leakage physical, social, and
week psychological in
• (+)Oliguria order to put the

• Urine output person in the best

of possible conditions

10cc/hr for nature to act)

• Bloated
2. Encouraged 2. Maintains Ernestine
abdomen upon
increase fluids and hydration and good Weidenback (Nurse
palpation
maintain accurate urine flow meets through
• Pale in
intake identification of
appearance
needs)
• Weak looking
• Creatinine:
298.3 mmol/L

3. Ensure Mr. REB’s 3. These will alleviate Dorothy Johnson’s


Compliance on the anxiety and fear of theory of Human
hemodialysis the patient when doing Behavioral System
procedure. the procedure. (Medicine focus:
Cure)

4. Monitor laboratory 4. Specific gravity Faye Abdellah’s


results that are specific measures the activity theory of 21 Nursing
to renal dysfunction for the kidneys to Problems (Problem
such as: Creatinine and concentrate urine Solving to move the
specific gravity. (1.006 – 1.030) and patients towards
creatinine measures health.)
kidney damage (>0.5 –
1 mg/dl) which
indicates renal failure

Dependent:
1. Administer PNSS 1.Assist in Dorothy Johnson’s
1L at 40 cc/hour maintaining theory of Human
as indicated hydration and Behavioral System
good urine flow (Medicine focus:
Cure)
Collaborative 1.Creatinine Lydia Hall’s theory
1. Monitor measures kidney of Components of
electrolytes level damage (>0.5 – 1 Nursing Caring (Core
particularly creatinine mg/dl) which and Cure -shared
indicates renal with other health
failure. care providers.)
ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION
DIAGNOSIS THEORIST/S

Subjective: Activity After 6 hours of Independent: Goal Partially met.


“Nabudlayan ko Intolerance r/t nursing 1. Determine 1. This Ernestine Weidenback
magtindog kung generalized body interventions, Mr. Mr. REB’s perception maybe (Nurse meets through After 6 hours of
wala may ga bulig weakness REB will improve of causes of fatigue or temporary or identification of needs) nursing intervention
sakun” as mobility and activity intolerance permanent, the patient was able
verbalized positively respond physical to positively respond
to medical assessment guides to medical
Objective/s: intervention treatment intervention without
• (+) Body without any 2. Encourage Faye Abdellah’s theory any hesitation and
weakness hesitation and adequate rest periods 2. Rest of 21 Nursing Problems refusal but there is
• Ambulatory refusal. especially before between (Patient approach to still sign of shortness

with assistance meals and ambulation activities provides Nursing) of breath, weakness,

• Irritability conservation and and fatigue


recovery
• (+)weaknes
3. Encourage Faye Abdellah’s theory
s
active of 21 Nursing Problems
• (+)shortness
range of motion 3. Exerci (Patient approach to
of breath
exercises daily. ses Nursing)
• (+)fatigue
maintain muscle
strength.
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE NURSING EVALUATION
INTERVENTION THEORY AND
THEORIST

Objective/s: Risk for impaired After 8 hours of Independent: Goal met.


• (+) Pitting skin integrity r/t nursing intervention, 1. Note skin 1. Chronic fluid excess Ernestine
edema altered fluid status MR. REB’s optimal Integrity for pitting can result in skin Weidenback There is no
• (+) PD skin integrity is of extremities on breakdown. (Nurse meets presence of skin

catheter maintained as manipulation, and through breakdown.

• (+) IV cut evidenced by demarcation of identification of

down absence of clothing and shoes needs)


breakdown. on the patient’s
• (+) Hematoma
body.
At right arm,
warm to touch.
2. Note for the 2. This result in Ernestine
presence of changes in sensation Weidenback
peripheral such as paresthesias (Nurse meets
neuropathy. (burning), weakness, and through
twitching. identification of
needs)
3. Instruct Mr. REB 3. Restrictive clothing HildergardePeplau
to wear loose-fitting can increase risk of skin (Orientation,
clothing when breakdown. Identification)
edema is present.

4. Teach factors 4. Each factor plays a Betty Neuman


important to skin role in preventing skin (Help the client’s
integrity: nutrition, breakdown or system attain,
mobility, hygiene, contributes to successful maintain and regain
early recognition of skin healing if system stability.)
skin breakdown. breakdown has
occurred.

5. Instruct the 5. The peripheral HildergardePeplau


patient regarding neuropathy can impair (Orientation,
dangers when sensation, especially in Identification)
heating or cooling the lower extremities.
devices are used.
6. Stress the 6. Scratching can Betty Neuman (On
importance of not cause lesions and open the whole person
scratching skin and sores. and reaction to
of keeping finger stress.)
nails short.

7. Suggest use of 7. Increase warmth Ernestine


tepid water for can increase the itch. Weidenback
bathing (Nurse meets
through
identification of
needs)

ASSESSMENT NURSING PLANNING INTERVENTION/S RATIONALE NURSING EVALUATION


DIAGNOSIS THEORIST/S
Objective/s: Low self-esteem After 8 hours of Independent: Goal met.
• (+)indecisive r/t loss of kidney nursing 1. Note for signs of 1.The long term Imogene King’s
nonassertive function intervention, Mr. Low self-esteem: self- dialysis patient is faced theory of Nurse – After 8 hours of
behavior REB will negating verbalization, with long-term changes Patient interactions nursing intervention
• (+) manifests more depression, expressed in lifestyle, occupation, (Integrating personal Mr. REB was able to

Weakness positive self- anger, withdrawal, and financial status system; interpersonal participate in all the

• Lack of eye esteem and expressions of system; social nursing procedure

contact positively respond shame/guilt, or system) without any refusal


to medical and evaluation of self as as evidence by
• Refusal to
nursing unable to deal with presence of smile on
participate in
interventions events. his face and
hospital
without any conversant attitude
procedures
refusal. 2. Assist Mr. REB 2. The nurse patient Hildegard Peplau’s towards the health
• Increasingly
in relationship can provide theory of care provider.
dependent on
Identifying the major a strong basis for Interpersonal /
her wife
areas of concern r/t implementing other Interactive
altered self-esteem. strategies to assist the (therapeutic
patient and family with interaction between
adaptation. Nurse and Patient)

3. As Mr. REB’s Hildegard Peplau’s


3. Assist Mr. REB condition worsen with theory of
in CKD, it is more difficult Interpersonal /
Incorporating changes to engage in even Interactive
in health status into routing activities. (Orientation,
activities of daily living, Identification)
social life, interpersonal
relationships, and
occupational activities. 4.Denial and Jean Watson’s
anger theory of
4. Allow Mr. REB’s are anticipated Interpersonal nature
time to voice concerns responses to the of caring (Help
and express anger diagnosis of a chronic persons / patients
related to having a illness. achieve a degree of
chronic condition. harmony within
themselves.)

Lydia Hall’s theory


Collaborative: 1.They can of Components of
1. Use case provide Nursing Caring (Core
managers psychological support and Cure -shared
and social workers as and assist in financial with other health
necessary. arrangement. care providers.)
Dorothy Johnson’s
theory of Human
2.Most dialysis Behavioral System
2. Refer to patient experiences (Nursing focus: The
psychiatric some degree of behavior of the
consultant as emotional imbalance. person threatened
necessary With professional with illness or is ill.)
psychiatric
consultation, most
patients can gradually
accept changed self-
esteem Lydia Hall’s theory
of Components of
3.Groups that Nursing Caring (Core
come and Cure -shared
3. Encourage use together for mutual with other health
of goals can be most care providers.)
support groups. helpful.
XII. DISCHARGE PLANNING

M – edications
Medications prescribed by the physician should be taken properly, to help the patient lessen
unusual condition.
The following are take home medications prescribed by the physician:
• Angistad 40mg/tab OD
• Coralan 5mg/tab I tablet OD
• Catapres 75mg/tab TID
• Clopidogrel 75mg/tab OD
• Carcinor 1 tablet OD
• Exforge 5/160 mg OD

E – xercise and Activity


Encourage Mr. R.E.B to have an active range of motion exercises thrice daily to maintain his
muscle strength.

T – reatment
Continue monitoring blood pressure, hemodialysis thrice a week and comply with the
medications given prescribed by the attending physician to prevent further complications that
may occur and to have a faster recovery.

H – ome Teaching/s
1. Instruct the client/folks on how to monitor fluid status, as well as, the signs and
symptoms in order to determine existing problems and to prevent further complications.
2. Teach/ educate the client and folks on infection prevention.
3. Explain the need for meticulous skin and oral care.
4. Instruct the client on how to delay weights and how to interpret the relationship of weight
loss/gain to need for sodium and water.
5. Instruct the client and folks about the medication metabolism.
6. Teach the client and folks about the dietary regimens such as low salt, low fat and high
fiber.
7. Importance of follow-up and physician appointment.

O – ut patient follow up
After discharge, Mr. R.E.B will have a regular follow-up check up with the physician to check
and monitor the patient’s medical condition and have a dialysis thrice a week to remove waste
products from the body and to prevent future complications.
D – iet
Maintain a low salt, low fat, and high fiber diet as prescribed by the attending physician. Advice
the patient not to eat foods that is high in cholesterol such as the fatty portion of the pork that
may increase the level of his blood pressure but to eat more green and leafy vegetables.

S – pirituality and Sexuality


In order to improve his spiritual aspects, he may attend holy masses or listen to gospel readings
and pray the holy rosary or he may seek for divine providence to the Lord. Assist the patient that
may include spiritual resources to help him deal with it.
ACKNOWLEDGEMENT

We, the group 1 of BSN – 3A would like to express our genuine gratitude to the
following persons who have helped and supported us in making this case study very successful.
Without them, the success of this study would be impossible.

Above everybody else, to our good Lord, our energy source, our Almighty king and
Father, for the strength, knowledge, guidance and the values that He provided us while doing
this case study. Without Him, everything that we’ve done is not possible.

To Sr. Editha A. Bagayaua DC, RN, MAN, Dean of the College of Nursing, for her full
support and willingness to help the students for without her this activity will not be
accomplished.

To Mrs. Katherine Conlu – Bengan, RN, our Level III Clinical Coordinator/Instructor for
her support, teachings and knowledge she shared to us. She has been a good educator,
facilitator, and cool clinical instructor. Pathophysiology would not be the same without her.

To Ms. Maureen Patricio, RN, our skillful clinical instructor for taking part in educating
us in the different nursing techniques and procedures we learn in the ward and for the
knowledge you’ve shared to the group. We learned a lot!

To Mrs. Pearl Joy Degoma, RN, our ever patient and understanding clinical instructor
for she has taught us some alternative techniques that would be helpful in the ward and some
significant and important facts/contributions that she impart to us in what she knows.

To Mrs. Rubilyn Sumaylo, RN, our humorous and witty clinical instructor for you had
made us laugh during the exposure, without you, life in the ward would be boring. Thank you for
the knowledge you’ve shared to the group although it’s only for a while.

And to all our teachers and mentors, who influenced, inspired, and shared their
knowledge and expertise to us to this activity. Thank you very much.

To St. Anthony Hospital staff nurses at the St. Joseph ward and to the other wards
as well, thank you for helping, guiding and teaching us during our exposure on your area.

To our patient with the initials of R.E.B and family, thank you for your warm acceptance,
trust and for allowing us to get some information’s and a one-on-one interview in just a speck of
time for the success of our case study.
To our beloved parents, for their never-ending moral support all throughout the study.
We love you so much!

To the Family of Mr. Jose Ian Kit Macato, for their warm accommodation in letting us,
use their house in making our case study from the beginning until now. Thank you so much!

To the BSN 3A students, for the support and the never-ending bond we’ve shared from
st
1 year until up to now.

To the Group 1 of BSN 3A, for the tireless effort, knowledge, wisdom, patience,
support, cooperation and teamwork for the success of this case study.

And lastly, to those whom we failed to mention who in one way or another helped us in
this undertaking, Thank You Very Much.

The Group 1 of BSN 3A

LIMITATIONS OF THE STUDY

This study is limited due to lack of time spent with the patient because we are only
scheduled for duty twice a week, within eight hours. Sometimes, duty hours are spent with other
school activities. This is why the attention, time and communication that are supposed to be
spent by the student nurse gathering data and working with interventions to the patient are
affected.

This study is limited to one person/patient only so that we can give enough attention and
proper nursing interventions to the problems being manifested, and for us to give our optimum
level of quality care for the patient.
TABLE OF CONTENTS

PAGE

I. Introduction
Brief Description of the Disease------------------------------------------
Statistics (International)----------------------------------------------------
II. Objectives
General and Specific Objectives----------------------------------------------
III. Anatomy and Physiology of Chronic Kidney Disease-------------------
IV. Vital Information------------------------------------------------------------------
V. Clinical Assessment
Nursing History----------------------------------------------------------------
Past Health Problem/Status-----------------------------------------------
Family History of Illness----------------------------------------------------
Family Genogram------------------------------------------------------------
VI. Brief Social, Cultural and Religious Background
Educational Background----------------------------------------------------
Occupational Background--------------------------------------------------
Religious Practices-----------------------------------------------------------
Economic Status--------------------------------------------------------------
VII. Clinical Inspection
Vital Signs----------------------------------------------------------------------
Physical Assessment--------------------------------------------------------
General Appraisal------------------------------------------------------------
VIII. Laboratory and Diagnostic Data----------------------------------------------
IX. Pathophysiology------------------------------------------------------------------
X. Medical Management
Drug Tabulation--------------------------------------------------------------
Hemodialysis-----------------------------------------------------------------
Members of the Health Team (CKD)-----------------------------------
XI. Nursing Management
Concept Map of Nursing Problems-------------------------------------
Nursing Care Plan--------------------------------------------------------- -
XII. Discharge Planning-------------------------------------------------------------
XIII. Journey---------------------------------------------------------------------------
XIV. Bibliography/References-----------------------------------------------------

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