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OBECTIVES OF CASE STUDY

GENERAL OBJECTIVES:The general objective of the case study is to gain the comprehensive knowledge about the disease to
gain the practical exercise about the Adult Health Problem and also to gain Practical experience working
with a patient having chronic kidney disease and to give holistic patient care according to their need.

SPECIFIC OBJECTIVES:The specific objectives of the case study are given below: To assess the patient and find out need of patient according to nursing process.
establish a nurse-client relationship to the client, as well as to the family by rendering a
therapeutic nurse-patient relationship;
gather adequate information to be used in the development of the study
present the clients personal data;
illustrate the patients family tree and trace significant diseases which may be of relevance to the

study
trace the health history of the client and the family by collecting information both of the past and
present illnesses;
To provide holistic nursing care to the client to all ages using nursing process.
To manage promptly as necessary to built up comfort.
To provide psychological support to the patient
To apply knowledge from the science, nursing theory and other related courses to plan and
implement nursing care.
To provide continuous care till discharge and follow-up care.
Counsel and make aware the patient party about importance of continuity of medicine and
psychological support to prevent from worsens.
To provide the discharge teaching to the patient and family member.

BIOGRAPHIC DATA

1) HEALTH HISTORY
A)

DEMOGRAPHIC DATA
NAME:
AGE:
SEX:
ADDRESS:
RELIGION:
EDUCATION
DATE OF ADMISSION:
DATE OF DISCHARGE:
IP NO. :
OCCUPATION:
MARITAL STATUS:
ATTENDING DOCTOR:
INFORMATION SOURCE:
DIAGNOSIS:
BLOOD GROUP:
BED NO:
WARD:

laxman kumar pandit


68yrs
male
Permanent: nayapati -6, jorpati
Hindu
iliterate
068/4/6
068/4/17
200821/410159
farmer
married
Dr. P.K.C
patient and his son
CKD 5
A +ve
205
nephrology

B) CHIEF COMPLAINTS: Swelling of legs, face for 2 days

C) HISTORY OF PRESENT ILLNESS: According to the patients, he come for haemodialysis, due
to increased shortness of breath during dialysis he was admitted in the nephrology ward. His general
condition is ill looking and oriented with time place and person.

D) HISTORY OF PAST ILLNESS:

According to the patients party, he is undergoing regular dialysis and is under


antihypertensive medicine.

ALLERGIES
According to the patient, he doesnt have any allergic reaction to any factors.

.
PREVIOUS HOSPITALIZATION: Nepal medical college teaching hospital for the diagnosis of
CKD

OPERATIONS OR SPECIAL TREATMENT: no any

E) FAMILY HISTORY:
Type of family: joint
No. of Family Members: 8

Fig.1 Family Tree

Table 1 Family Medical history


DISEASE

FATHERS RELATION

MOTHERS RELATION

Tuberculosis
Cancer
Heart disease
Jaundice
Epilepsy
Psychological

Absent
Absent
Absent
Absent
Absent
Absent

Absent
Absent
Absent
Absent
Absent
Absent
4

Hypertension

Present

Present

HEALTH SEEKING PRACTICE: He belongs to literate family, According to laxman kumar pandit,
they were not dependent in superstitious beliefs. If someone becomes ill in their family they take
homemade medicine then some times go to hospital.

PERSONAL HISTORY:
Health Habits:
Smoker but has left 1-2 months ago, Non alcoholic,
Non vegetarian.
No food allergy.
Maintain personal hygiene
Religion belief and worship kuldeuta.
Dietry history:
Non vegetarian.
Foods like egg-curry, rice, daal etc.

SOCIO-ECONOMIC STATUS:
He belongs to middleclass family. The major source of income is
farming and business. They are the permanent residence of jorpati.
They are well satisfied with their economic status. They have very
good inter relationship in the community.

ENVIRONMENTAL FACTOR:
Housing Pattern: Well facilitated
Waste disposal: They are practicing collective approach to manage the waste
product. Such as temporary container, burning and making compost manure. The
people from nagarpalika also come to take waste from there home.
Pollution and noise: his house is near the road , so he is very much affected by the
noise of the vehicle and the air pollution caused by the vehicle.

F) DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT CLIENTS


Robert Havighursts Developmental Tasks
Developmental
Tasks

Description

Passed or
Failed

1. Adjusting to
decreasing physical
strength and health

Older adults also have


to adjust to decreasing
physical strength and
health. The prevalence
of chronic and acute
diseases increase in
old age. Thus, older
adults may be
confronted with life
situations that are
characterized by not
being in perfect
health,serious illness
and dependency on
people.

Passed

2. Adjusting to
retirement and
reduced income

A central
developmental task
that characterized the
transition into old age
is adjustment to
retirement. The period
after retirement has to
be filled with new
projects, but is
characterized by few
valid cultural
guidelines. The
achievement of this
task may be
obstructed by the
management of
another task, living in
a reduced income after
retirement.

Passed

3. Adjusting to death Older adults may


of a spouse
become caregivers to

Failed
6

their spouses. Some


older adults have to
adjust to the death of
their spouses. After
they have lived with a
spouse for many
decades, widowhood
may force older
people to adjust to
loneliness, moving to
a smaller place,and
learning about
business matters.
4. Establishing an
The development of a
explicit affiliation
large part of the
with one's aged group population into old
age is historically
recent phenomenon to
modern cities. Thus,
advancements
understanding of the
aging process may
lead to identifying
further developmental
tasks associated with
gains and purposeful
lives for adults.

Passed

5. Meeting social and Older people might


civil obligations
accumulate
knowledge about life,
and thus may
contribute to the
development of
younger people and
the society.

Passed

6. Establishing
satisfactory physical
living arrangements

Passed

Oder adults are


generally challenged
to create positive
sense of their lives as
a whole. The feeling
that life has order and
meaning results in
happiness.

Eric Eriksons Developmental Task


Integrity vs. Despair
Erikson felt that much of life is preparing for the middle adulthood stage and the last stage
recovering from it. Perhaps that is because as older adults we can often look back on our lives with
happiness and are contented, feeling fulfilled with a deep sense that life has meaning and we've made
contribution to life, a feeling Erikson called integrity. On the other hand, some adults may reach this
stage and despair at their experiences and perceived failure.
My patient achieved happiness and contentment in his life based on his actions and speeches.
He is faithful and devoted to his religion. He is ready to accept death completely and he has shared his
experiences to his beloved grandchildren. Even though he accepted death fully but his faith and love for
his worshipped God never changed.

Physical Assessment
8

Name: Mr.laxman kumar pandit


Bed: 205 Age: 68 yrs
Status: Married

Ward: nephrology Ward


Sex: male

Civil

Vital Signs
Axillary T=97 degree F, PR= 90/ min, RR= 22/ min, BP= 150/80 mmHg.
General survey
Height= 5 ft and 8 inches, weight= 56 kilos,. No signs of distress noted upon assessment, able to
smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show
calmness during the examination. He has no IVF infused, and was asleep at initial assessment.
Skin
Skin is brown in color, rough, dry and warm. He has good skin turgor. Brownish discolorations
that resemble wrinkles are observed on face.
Head
Skull is round in shape, symmetrical. No masses noted. Facial movement is symmetrical,
alopecia. Scalp is clear from dandruff and lice. No scars and wounds noted.
Eyes
Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color
with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and
bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings
(puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva
are pinkish in color while the pupils constricted to light, round in shape. He is able to rotate eyes and has
coordinated eye movements.
Ears
Auricle has same color with the skin, has symmetrical shape and located a little bit higher than
the eye. Pinnas are symmetrical with no lesions noted. He has wet cerumen noted on both ears when
pulled down and back for better visualization. he is able to hear on both ears.
Nose
Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is
flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration.
9

Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and
in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses
noted.
Mouth
Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with
thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light
pink in color while hard palate is lighter in color. Gums are pinkish in color. Plagues are present on his
teeth
Pharynx
Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not
inflamed.
Neck
Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. he is
able to flex and extend neck and move it laterally (L and R).
Chest and Lungs
Breathing pattern is regular. Anteroposterior diameter to transverse diameter is in 1:2. Respiratory
excursion is symmetrical (thumb separates to 2-3cm). No tenderness, lump, Presence of breath sound in
all area of lungs
Heart and Central Vessels
Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in
apical area upon auscultation.
Back and Extremities
Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have
a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted.. His hands are
a little rough. Muscle strength is equal on both sides of the upper and lower extremities. He is able to
stand and walk on both feet independently, and his movements are well coordinated. Toes point straight
ahead. And he is able to sit up straight.
Abdomen
His abdomens color is same with the rest of the part of the body. His umbilicus is coated with
blackish dirt.
Neurologic Assessment
10

Cranial Nerves: able to identify aromas by smelling with eyes closed; able to see objects; pupil
constricted to light sensation; able to move eyeball downward and laterally; able to blink eyes; able to
smile, raise eyebrows, puff cheeks and close eyes; able to respond to questions being heard;) has rough
and vibrating sound; able to shrug shoulders, elevate and flex arms and legs against resistance; able to
protrude tongue and move it side to side.

FINDINGS:

Skin is dry and rough


Alopecia of hair
wet cerumen noted on both ears
plaques are present
Nails are long and untrimmed

3) DEFINATION, CAUSE AND PATHOPHYSIOLOGY OF CLIENTS DISEASES.


Definition:
11

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal
function over a period of months or years in which the bodys ability to maintain metabolic and fluid
and electrolyte balance fails, resulting in uremia or azotemia. In this condition, the GFR falls below 10%
of the normal rate.

Causes:

Heredity
Glomerular dysfunction
Diabetic nephropathy
Hypertension
Glomerulonephritis
Polycystic kidney disease
Urinary tract obstruction
Bladder tumour
Urethral obstruction
Hypertensive nephrosclerosis (hardening of the kidney)

Other causes:
Hiv infection
Kidney stones
Chronic kidney infections and certain cancers
Regular use of anti inflammatory drugs
Vesicoureteral reflux ( a urinary tract problem in which urine travels the wrong way back
towards kidney)
Stages of chronic kidney disease
STAGE
1.
2.
3.
4.
5.

DESCRIPTION
Slight kidney damage with
normal or increased
filtration
Mild decrease in kidney
function
Moderate decrease in
kidney function
Severe decrease in kidney
disease
Kidney failure

GFR ML/MIN
More than 90
60-89
30-59
15-29
Less than 15 or dialysis

Pathophysiology:
12

Predisposing Factors
Genetics
Age >40

Decrease insulin
production/sensitivity

Precipitating
Environment(intrapartal)
Toxin/Virus
Obesity
Decrease Serum Potasium

Elevated Serum
Glucose

Increased Osmolarity
due to Glucose

Polydipsia

Polyuria

Chronic elevation of
Serum Glucose

Polyphagia

Weight loss

Diabetic
neuropathy

Small vessel
disease

Accelerated
atherosclerosis

Diabetic
retinopathy

Hypertension

Symmetrical loss
of sensation

Diabetic
nephropathy

End-stage
renal failure

Infection

Coronary artery
disease

Numbness and
paresthesia
Wasting of
intrinsic muscles

Impaired immune
function

Loss of vision

Increase
LDL levels

Delayed wound
healing

Autonomic
neuropathy
Impotence
Diabetic foot
ulceration

Charcot changes in joints

Dry, cracked
skin

4) COMPARISON OF:
Gastroparesis

Neurogenic
bladder

13

A) SIGNS AND SYMPTOMS


Neurologic
ACCORDING TO BOOK
Weakness and fatigue
Confusion
Inability to concentrate
seizures
Restlessness of legs
Burning to soles of feet
Behavior changes

ACCORDING TO PATIENT
present
present
absent
absent
present
present
present

integumetry
ACCORDING TO BOOK
Dry, flaky skin
Thin, brittle nails
Thinning hair

ACCORDING TO PATIENT
present
present
absent

cardiovascular

ACCORDING TO BOOK
Hypertension
Pitting edema
Periorbital edema

ACCORDING TO PATIENT
present
present
present

pulmonary
ACCORDING TO BOOK
Shortness of breath
tachypnea
Kussmaul- type respiration

ACCORDING TO PATIENT
present
present
present

G.I
ACCORDING TO BOOK
Metallic taste
Anorexia, nausea
Vomiting, constipation/ diarrhea

ACCORDING TO PATIENT
Absent
Absent
present

14

Hematologic
ACCORDING TO BOOK
Anemia

ACCORDING TO PATIENT
present

Reproductive
ACCORDING TO BOOK
amenorrhea
infertility
Testicular atrophy

ACCORDING TO PATIENT
Absent
Absent
absent

Musculoskeletal
ACCORDING TO BOOK
Muscle cramps
Loss of muscle strength
Bone pain
Bone fracture

ACCORDING TO PATIENT
Present
Present
Present
absent

15

B) INVESTIGATION
ACCORDING TO BOOK
Laboratory test:

USG
biopsy
KUB film

ACCORDING TO PATIENT
Blood urea: 119.0 mg/dl
Creatinine:9.1
Na+:139.o
K+:5.2 meq/r
Serum albumin:2.8gm/dl
Hb:9.6gm%
Glucose f:120 mg/dl
Glucose pp : 141mg/dl
Done but report was not available
Done but report was not available
Not done

It is an ultrasound-based diagnostic medical


imaging technique used to visualize muscles,
tendons, and many internal organs, to capture
their size, structure and any
pathological lesions
with real time tomographic images.
Normal Size in cm:
Left Kidney
Right Kidney
10.8 +- Length
9.7 +0.8
0.7
4.2 +
Width
4.3 +-0.5
0.5
4.8 +Thick
3.9 +0.5
0.5
1.5
C. Thick
1.5

16

C) COMPARISON OF MEDICAL MANAGEMENT


The goal of management is to maintain kidney function and homeostasis for as long as possible.
Because of the great deterioration of renal function, the duration of management may vary from months
to years. Nothing can be done to prevent or delay the fatal outcome.
ACCORDING TO BOOK
ACCORDING TO PATIENT
Control of urinary volume: fluids
My patient was prescribed to drink
are forced since kidney has lessened
lee than 500 ml water in a day.Tab
ability to concentrate solids. more
lasix 40 mg, po, od, is given to my
fluids about 2litres is needed to
patient.
excrete waste. Sometimes
frusemide may be required to
increase urine production.
Control of nausea and vomiting:
Creatinine clearance rate was 10.g
anorexia, nausea and vomiting tend
mg/dl on 4/2, 8.5 mg/dl on 068/4/6,
to develop when the cretinine
9.7mg/dl on 068/4/9.
clearance falls below 5ml/min. so
reduction in protein is required to
improve nausea. Blood: 0.8-1.4
mg/dL is the normal. Due to
impaired kidney function,
creatinine in the blood elevates.
Antiseizure agents
Since my patient didnt develop any
kind of seizure. So antiseizure
agents were not used.
Antihypertensive agents:
Tab nifedipine 10 mg,tds was given
hypertension is managed by
to my patient to control
intravascular volume control and a
hypertension.
variety of anti- hypertensive agents.
Control of hyperkalaemia will be

treated with I/V glucose and insulin


in a ratio of 3 gm Glucose to 1 unit
soluble insulin.
Control of anemia: blood
Since my patient didnt develop
transfusion are frequently required.
anemia so bllod transfusion was not
done.
Accurate record of input and output
Input and output chart was
chart should be maintained
maintained.
4/6 : 200ml total input and 200ml
was total output
4/7: 350ml was total input and 250
mi was total output
4/8: 500ml total input and 350ml
17

Other therapy: dialysis


It is usually initiated when
the patient cannot maintain
a reasonable lifestyle with
conservative treatment.

total output
4/9: 530ml was total intake and 150
ml was total output
4/10: 450ml total input and 300ml
total output
4/11: 400 ml total input and 300 ml
total output
My patient is undergoing regular
dialysis, 2-3 times in a week

COMPARISON OF SURGICAL MANAGEMENT


ACCORDING TO BOOK
Kidney transplantation: it involves
transplanting a kidney from a living donor
to a recipient who has ESRD. The success
rate increases if kidney transplantation
from a living donor is performed before
dialysis is initiated.

ACCORDING TO PATIENT
Kidney transplantation cannot be
performed in my patient because of
hypertension and slow wound healing due
to diabetes mellitus.

18

D) COMPARISON OF NURSING MANAGE MENT


The patient with chronic renal failure requires astute nursing care to avoid the complications of reduced
renal failure and the stresses and anxieties of dealing with a life threatening illness.
ACCORDING TO BOOK
Nursing care is directed toward assessing
fluid status and identifying potential source
of imbalance
Implement a dietary program to ensure
proper nutritional intake within the limits
of the treatment regimen.
Promote positive feelings by encouraging
increased self care
Provide explanations and information to
the patient and family concerning ESRD,
treatment options and potential
complications
Nurse must be familiar with various drugs
and their side effects
Provide emotional support to the patient
and his family because of the numerous
changes experienced.

ACCORDING TO PATIENT
As a nurse I assessed the fluid status of my patient
by monitoring input and output record closely.
My patient was prescribed to have fluid less than
500ml/day and was on renal diet. As a nurse I
closely observe the dietary pattern of my patient
I encouraged my patient to perform his activity of
daily living by himself and promoted the positive
feelings.
As a nurse I provided explanation to the patient
and his family members about his treatment
options and potential complications.
As a nurse I provided information to my patient
regarding various drugs used in it.
I provided my patient and his family emotional
support so that anxiety and tension is relieved to
some extent.

19

5) DRUGS CARD OF MEDICINES


My patient has used the following drug: Tab nifedipine 10mg, tds
Tab lasix 40mg, od
Tab pantop 40 mg
Diclofenac gel
Tab domel 1 tab
Tab haloperidol
1. Tab nifedipine
Therapeutic class: antianginal, antihypertensive, calcium channel blocker
Action :antihypertensive agent that inhibits calcium ion movement across cell membranes, depressing
contraction of cardiac and vascular smooth muscles
Therapeutic effect: decreases blood pressure
Indication: chronic stable angina, hypertension
Contra- indication: severe hypotension
Side effects: peripheral edema, headache, dizziness, (occasional): nausea, muscle cramps and pain,
dyspnea, cough (rare): hypotension, rash, constipation, sexual difficulties
Nursing management: administer on an empty stomach
Do not crush or chew sustained release dosage forms

2. Furosemide
Novosimide; PMS-Furosimide
Classification: Loop diuretics
Indications:

Edema

d/t

heart

failure,

hepatic

impairment

or renal disease. Hypertension.


Action: Inhibits the reabsorption of sodium and

chloride from

the loop of Henle and distal renal tubule. Increases

renal

20

excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in
impaired renal function. Decreased blood pressure.
Dosage: 1 tablet, 200 mg
Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur;
Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol
intolerance.
Precautions: Severe liver disease; electrolyte depression
Side effects: CNS blurred vision, dizziness, head ache, vertigo
EENT hearing loss, tinnitus
CV hypotension
GI anorexia, constipation, diarrhea, dry mouth, nausea, vomiting
GU excessive urination
Derm photosensitivity, rash
F and E dehydration
Nursing Responsibilities:
1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth,
hypotension, or oliguria occurs.
2. Monitor blood pressure and pulse before and during administration.
3. Monitor blood glucose closely; may cause increased blood glucose level.
4. Caution patient to change positions slowly to minimize orthostatic hypotension.
5. Advise patient to contact health care professional immediately if muscle weakness, cramps,
nausea, dizziness and numbness occurs.
6. Caution older patients or their caregivers about increased risk for falls.

3. tab pantop
Generic name: pantoprazole
Functional class: proton pump inhibitor
Action: it inhibits the secretion of hcl in the stomach by specific action on the proton pumps of the
patietal cells.
Dose and routes:
Adult: 40 mg/day (PO)
21

In pathological hypersecretory conditions: adult I/V 80 mg over 12 hours


Indication:
Peptic ulcer,zollinger ellison syndrome, NSAIDS associated peptic ulcer
Contraindication: lactation, hypersensitivity to drug
Side effects:
CNS: headache, insomnia, mental depression, confusion
GI system: diarrhea, abdominal pain, constipation
INTEG: rash, peripheral edema
Muscular system: myalgia( pain in the muscles)

4. diclofenac gel
therapeutic class: NSAID, antipyretic, non narcotic analgesic
action: NSAID that inhibits prostaglandin synthesis reducing the intensity of pain
therapeutic effect: produces analgesic and anti-inflammatory effects
indication: osteoarthritis, rheumatoid arthritis, pain, primary dysmennorrhea
contra indication: hypersensitivity to aspirin, diclofenac
side effects: headache, abdominal cramps, constipation, diarrhea, nausea

5. Domperidone

Motilium (1 tab, 100 mg)


Classification:

Anti-emetic

and

anti-vertigo

Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopaminereceptors in the chemo-emetic trigger zone produces an anti-emetic effect.
Interactions:

Concomitant administration of anti-cholinergic drugs may inhibit the anti-dyspeptic effects of


MOTILIUM.

Anti-muscarinic agents and opioid analgesics may antagonize the effect of MOTILIUM

MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and vomiting) of
dopaminergic agonists.

22

Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of concomitant
orally administered medicines, particularly those with sustained release or enteric coated
formulations.

As MOTILIUM interferes with serum prolactin levels, it may interfere with other
hypoprolactinaemic agents and with some diagnostic tests.

Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be
taken after meals and not before meals, i.e. they should not be taken simultaneously with
MOTILIUM.

Reduced

gastric

acidity

impairs

the

absorption

of

domperidone.

Oral bioavailability is decreased by prior administration of cimetidine or sodium bicarbonate


Side Effects:

Allergic reactions, such as rash or urticaria, have been reported.

Abdominal cramps have been reported.

Reversible raised serum prolactin levels have been observed which may lead to gynaecomastia.

Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the
possible occurrence of neurological side-effects cannot be totally excluded

Nursing Responsibilities:
1. Assess for extra-pyramidal effects such as jerking and tongue protrusion.
2. Check for hypotension.

6. Haloperidol
Therapeutic class: antipsychotic
Action: an antipsychotics agent that competitively block postsynaptic dopamine receptors
Therapeutic effect: produces tranquilizing effect
Indication: treatment of psychotic disorders
Contra indication: CNS depression, hepatic disease
Side effects: blured vision, constipation, dry mouth, peripheral edema, difficulty urinating,
decreased thirst, dizziness, drowsiness
Nursing consideration:

take with food or milk


23

donot mix liquid formulation with coffee or tea

use a sunscreen during sun exposure to prevent burns

7. inj. Novapid 4 units


Func class: antidiabetic
Chem.. class: exogenous unmodified insulin
Action: decreases blood glucose, by transport of glucose into cells and the conversion of glucose to
glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium
Uses: DM type 1 and 2
Doses and routes:
Adult: subcut dosage individualized, give within 15 min before or 20 min after starting a meal
Side effects:
EENT: blurred vision, dry mouth
INTEG: flushing, swelling, redness
META: hypoglycemia
SYST: anaphylaxis
Contraindication: hypersensitivity to protamine
Precaution: pregnancy
Nursing Interventions:
1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet,
lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration,
drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea,.
2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid
deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst.
3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin
dose.
4. Monitor blood glucose every 6 hours during therapy.
6.

Store insulin in refrigerator. Do not use if cloudy, discolored or unusually viscous.

7.

Rotate site of infection.

8.

Instruct patient on proper techniques for administration.

9.

Explain to the patient that this medication controls hyperglycemia but does not cure

diabetes.
24

6) SUMMARY OF CLIENT DAILY PROGRESS REPORT IN HOSPITAL

DATE

TIME

04/O8/068

04/09/068

04/10/068

PULSE

2am

TEMPERATU
RE
98 degree F

80/m

RESPIR
ATION
20/m

BP

6pm

97.6 degree F

88/m

28/m

12:30p 98 degree F
m

82/m

24/m

1:20p
m

98 degree F

90/m

20/m

210/100
mm of hg

2pm

98 degree F

100/m

22/m

6pm

101.6 degree F

110/m

24/m

200/90
mm of hg
210/80
mm of hg

SUMMARY

200/80mm Pts g/c is seems


of hg
satisfactory, vital signs
monitored with rise in
210/80
blood pressure.
mm of hg Prescribed medicine
carried out. Input and
output chart maintained.
Paln for haemodialysis
tomorrow. No any
complain from the
patient side.
210/100
mm of hg
pts g/c seems
satisfactory. Vital signs
are taken and recorded
with rise in blood
pressure. haemodialysis
done. Patient in normal
diet. Prescribed
medication carried out.
No any specific
complain from patient
side.
Pts g/c is satisfactory.
Vital signs are taken and
recorded with rise in
blood pressure and
temperature. Tab
paracetamol and cold
compresses given to the
patient.All prescribed
medication was carried
out. Patient is on normal
25

diet.
04/11/068

10am

97 degree f

90/m

20/m

210/90
mm of hg

2pm

97 degree f

88/m

20/m

10 am

97 degree f

92/ min

20/min

2pm

98 degree f

88/min

20/min

04/13/068

10am

98 degree f

80/min

22/min

04/14/068

10 am

97 degree f

80/ min

20/min

210/90
Pts general condition is
mm of hg satisfactory. Vital signs
are taken with rise in
blood pressure. prescribed
medicine carried out.
Normal bowel and
bladder habit. Patient
complain is dry and
itching over skin of
hands and legs. So he is
in dermatology
consultation.
Dermatology department
prescribed him coconut
oilto apply in itching and
dry areas three times a
day.
180/80
pts g/c seems satisfactory.
mm of hg Vital signs are taken and
recorded with rise in blood
pressure. haemodialysis done
through left femoral vein. Put
the sand bag pressure at the
femoral site for 2 hours. Patient
in normal diet. Prescribed
medication carried out. No any
specific complain from patient
side.
180/70
mm of hg
150/90
Patient general condition
mm of hg seems satisfactory. Vital
signs taken with rise in
blood pressure. Prescribed
medicine carried out.
Normal bladder habit but
bowel habit is disturbed.no
any such complain from
patient side
140/80
Patient general condition seems
mm of hg satisfactory. Patient general
condition seems satisfactory.

04/12/068

26

Vital signs taken with rise in


blood pressure. Prescribed
medicine carried out. Normal
bowel and bladder habit. No
any itching on the patients skin
2pm

98 degree f

76/min

20/min

04/15/068

10am

98 degree f

78/min

22/min

04/16/068

10 am

97 degree f

80/ min

20/min

2pm

98 degree f

88/min

20/min

10am

98 degree f

90/min

22/min

04/17/068

170/70
mm of hg
190/80
mm of hg

190/70
mm of hg
180/60
mm of hg

180/70
mm of hg

pts g/c seems satisfactory.


Vital signs are taken and
recorded with rise in blood
pressure. haemodialysis
done through left femoral
vein.dialysis three times a
week that is on
Sunday,Wednesday and
Friday. Patient in normal
diet. Prescribed medication
carried out. No any specific
complain from patient side.
Pts g/c is improved. Vital
signs taken with rise in
blood pressure. All
prescribed medication was
carried out. . Discharge on
o4/17/068.
Patient general condition
seems fair. Vital signs are
taken and recorded with
rise in blood
pressure.prescribed
medicine carried
out,normal bowel and
bladder habit.dialysis three
times a week. That is on
Sunday, Wednesday and
Friday. Follow up on
medical out patient
department on Monday or
Thursday.

27

7) DIVERSIONAL THERAPY USED FOR CLIENT


Diversional therapies are used to divert ones thoughts from life stresses or to fill time.
I have used the following aspects of diversional therapy to overcome his situation.

Physical therapy : deep breathing and coughing exercise was


encouraged to perform. Proper position of the patient was maintained so that she can feel relaxed
and comfortable.

Group therapy: I gave many examples of other people having the same disease condition and
also introduced him with some of them so that he can realize that many others have and share
problems which are very similar to their own problems and that they are not alone in their
suffering.
Relaxation training: I encouraged my patient for performing yoga and meditation as relaxation
produces physiological effect that are opposite to those anxiety, that is slow heart rate, increased
peripheral blood flow.
Psychological therapy: I encourage my patient to express his feelings and attitude, and
communicate with the care takers as well as the family members. Because of this his
psychological depression can be reduced and he feels better.
Medicine therapy: I provided his medicine to relieve his pain and for his

better recovery.

Recreational therapy: according to this therapy, I encouraged my patient to


listen songs of his choice. I also encouraged him to sing songs as he loves to listen and sing old
melody filmy songs songs. Beside these I also encouraged my patient to read magazines,
newspaper, listen radio, etc. so that it would help patient diverse his mind away from his anxiety
and depression.

28

APPLICATION OF NURSING THEORIES


Virginia Hendersons Independent Theory:
In 1955, Henderson formulated unique function of nursing, she purposed 14
components of Basic nursing care. The components are as follows:
Breathe normally.
Eat and drink adequately
Eliminate body wastes
Move and maintain desirable postures.
Sleep and rest
Select suitable clothes- dress and undress
Maintain body temperature within normal range by adjusting clothing and modifying the
environment.
Keep the body clean and well groomed and protect the integument.
Avoid danger in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fear or opinion.
Worship according to ones faith.
Play or participate in various forms of recreation.
Learn, discover or satisfy the curiosity that leads to normal developmental and health and
use of the available facilities.

29

APPLICATION OF THEORY ON MY PATIENT


Breath normally:- I encourage my patient to do deep breathing and coughing
exercise. This helps to promote lung expansion and gases extent and also help to
loosen and bring out secretion.
Eat and drink adequately:- I encourage my patient to eat and drink adequately
according to body needs and the patient food habit was well maintained.he was
prescribed to have fluid less than 500ml/day
Eliminate body waste:- My patient bowel and bladder habit was normal so his
eliminate body waste pattern was well maintained.
Move and maintain desirable posture:- I helped my patient to move and maintain
the desirable position
Sleep and rest: I encouraged patient to take a adequate rest and sleep according to
body need and disease condition for a positive health.
Select suitable clothe and dress:- Suitable clothe was selected.
Body cleanliness:- I encourage my patient to keep her body clean.
Avoid danger in the environment and avoid injuring others: sometimes my patient
shows aggressive behavior so antipsychotics drugs were prescribed to my patient
to avoid danger in the environment and also to avoid injuring others.
Communicate with others in expressing emotions, needs, fear or opinion:- As my
patient was able to communicate, his communication pattern was maintaining.
Worship according to ones faith
Play or participate in various forms of recreation:- This component help me
inspire my patient to write new poems, story and jokes.

30

9) NURSING CARE PLAN

31

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATI
ON

RATIONAL

EVALUATI
ON

Subjective data:
patient says
that, my hands
and face are
swelling

Excess fluid
volume
related to
fluid
accumulatio
n between
dialysis
treatments.

Patient
will
maintai
n fluid
volume
status
within
establis
hed
paramet
ers.

-assess weight,
lung sounds and
extremities for
presence of
edema

-weight, lung
sounds and
extremities was
assessed for
presence of
edema.
-input and
output was
monitored.

-To determine the


fluid volume so that
treatment
parameters can be
identified.

My goal
was fully
met as
patient is
free of
peripheral
edema.

objective data:
patients face
and hand was
swelling

-monitor intake
and output.
Some patient
continue to
urinate small
amounts, but it
is inadequate to
clear all waste
products.
-monitor
-laboratory data
laboratory data: was monitored
blood
urea,nitrogen,ser
um
creatinine,sodiu
m,potassium,cal
cium,hb,etc
-teach pt the
need for
maintaining
fluid restrictions
between
treatment
-teach pt the
need for
restricting
sodium intake

-fluid
restrictions
between
treatment was
maintained.
-the need for
restricting
sodium intake
was teached.

-Intake is limited
and must be
monitored to
prevent fluid
volume overload.

-nitrogenous waste
and electrolytes
accumulate
between treatments.
Anemia and blood
losses associated
with hemodialysis
are complications
associated with
kidney failure.
-to prevent excess
intake, which can
lead to
hypervolemia
-sodium intake
stimulates thirst
which can lead to
excessive fluid
intake and
subsequent
hypervolemia.

32

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATI
ON

Subjective data:
patient says
that, my hand
and face are
swelling

Risk for
skin
integrity
related to
alterations
in skin
turgor
(edema)

Patient
will
maintai
n an
intact
skin

-inspect skin
for changes in
colour,turgor,va
scularity,note
redness
-monitor fluid
intake and
hydration of
skin and
mucous
membranes
-inspect
dependent areas
for edema.
Elevate legs as
indicated.

-skin was
inspect for
changes in
colour, turgor,
vasclarity.
- fluid intake
and hydration of
skin and mucous
membranes was
monitored.

-indicates areas of
poor
circulation/breakdo
wn that may lead to
infection.
-detects presence of
dehydration or
overhydration that
affect circulation
and tissue integrity
at the cellular level.
-dependent areas -edematous tissues
for edema was
are prone to
inspected and
breakdown.
legs was
Elevation promotes
elevated as
venous return,
indicated.
limiting venous
stasis,edema
formation.
- provide
-soothing skin
-lotions and
soothing skin
care was
ointment may be
care. Restrict
provided and
desired to relieve
use of soaps.
creams,
dry,cracked skin.
Apply ointments ointments was
or creams.
applied.
-keep linens dry, -linens were
-reduces dermal
wrinkles free
kept dry and
irritation and risk of
wrinkles free.
skin breakdown.
-investigate
- reports of
-although dialysis
reports of
itching was
has largely
itching
investigated
eliminated skin
problems associated
with uremic
frost,itching can
occur because the
skin is an excretory
route for waste
products.
- suggest
- loose fitting
-prevents direct
wearing loose
cotton garments dermal irritation
fitting cotton
were suggested
and promotes
garments
to wear.
evaporation of
moisture on the
skin.

My goal
was fully
met as
patient
maintain
an intact
skin.

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATI
ON

RATIONAL

EVALUATI
ON

Subjective data:
patient says
that, I have
itching in my
neck

Risk for
injury
related to
infection

Patient
will be
free of
infectio
n

-assess skin ,
nothing
redness,swelling
,local
warmth,tendern
ess
-avoid
contamination
of assess site.

-nothing
redness,local
warmth,tenderne
ss and skin was
assessed

-signs of local
infection, which
can progress to
sepsis if untreated

-Aseptic
technique and
masks were

-prevents
introduction of
organisms that can

My goal
was fully
met as
patient did
not
33
develop
any sign
of
infection

objective data:
patients hand
and face was
swelling

objective data:
patients neck
was red.

RATIONAL

EVALUATI
ON

34

ASSESSMENT

DIAGNOSIS

GOAL

Subjective data: Situational


Patient
patient says
low self
will
that, I cant do esteem
mainati
anything,
I am
related
to
n
DISCHARGE
TEACHING:useless
chronic
positive
kidney
body
objective data:
failure
image
patient looks
requiring
depressed
machine
dependency

PLANNING

IMPLEMENTATI
ON

RATIONAL

EVALUATI
ON

- monitor
patients
response to
illness and
treatments

-patients
response to
illness and
treatments were
monitored.

-to determine the


effect of health
status changes so
that appropriate
interventions can be
planned
-grieving is a
necessary part of
recovery

My goal
was fully
met as
patient
verbalizes
acceptance
of
treatment
regimen as
part of
lifestyle

-allow patient to
grieve over his
losses

-patient was
allowed to
grieve over his
losses
-acknowledge
-patient grief
patients grief
about being
about being
dependent on a
dependent on a
machine was
machine
acknowledged
-support
-strengths,self
strengths,self
confidence,
confidence,deter determination
mination and
and motivation
motivation to
to live was
live
supported.
-help pt to
develop or
continue
interests beyond
dialysis and
return to as near
normal life as
possible

-pt was helped


to develop
interest beyond
dialysis and
return to as near
normal life as
possible

-monitor for
excessive
concerns about
losses,depressio
n

-excessive
concerns about
losses,
depression was
monitored

-demonstrate
empathy and
validates the
patients feeling
-Patients
undergoing dialysis
are not disabled in
all aspects of life.
Many live nearly
normal lives while
maintaining
treatment schedule
-pt may tend to
withdraw from
social activities
because of their
new schedule and
feelings of
loss,focusing on
other interests will
help the pt place
less focus on his
dependency
-there may be
indications of
suicidal
ideation,which
needs to be
identified and
treated quickly

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATI
ON

RATIONAL

EVALUATI
ON

Subjective data:
patient says
that, I cant do
anything, I am
useless

Disturbed
thought
processes
related to
accumulatio
n of toxins

Patient
will
mainati
n
optimal
level of
mentati
on

- assess extent
of impairment
in thinking
ability, memory
and orientation
-provide
quiet/calm
environment

- impairment in
thinking ability,
memory and
orientation was
assessed
-quiet/calm
environment
was provided

-uremic syndromes
effect can begin
with minor
confusion,
irritability
-minimizes
environmental
stimuli and reduces
confusion

My goal
was fully
met as
patient
35

objective data:
patient looks
depressed

Exercise

Explain to patient the significance of

-Exercises promote proper blood

and

circulation and prevent arterial and

stretching. If unable to mobilize alone,

venous stasis thus lessens platelet

instruct the watcher to give assistance

coagulation to aged people. Older

all the time. Encourage to use crutches

people have weakened blood

or any device for support. Stretching

vessel walls which can cause any

upper extremities also promote healthy

alteration in blood flow.

living. Also instruct patient to perform

Also exercise prevents atrophy of

passive range of motion.

the muscles.

-Older people has slower digestion

regular

exercise

like

walking

Teach patient to wait for 1 to 2 hours

after

eating

before

performing

any

physical activities.

rate, thus they need to conserve


more oxygen which will be
necessary for digestion of food.
Activities must be limited to
decrease oxygen demand by
organs and tissues other than the
digestive system.

Instruct the patient to practice deep


breathing exercise.

-Deep breathing exercises promote


thoracic expansion which allows air
to enter the respiratory tract and
provide oxygen to the alveoli to
avoid atelectasis or lung collapse
due to increase fluid pressure in

Treatment

Instruct patient to comply with his

the pleural space.


-Maintenance meds should not be

medication treatment like the continuous

forgotten to achieve highest

use of beta blocker Metoprolol for

therapeutic effect.

control of hypertension and Insulin for


diabetes mellitus.

Instruct client to seek medical help if

any unusualties are felt such as tingling

-These unusualties may be


indicative of worsening condition.

sensation or paresthesia, fatigue and


body malaise, dizziness, headaches,
irritability, tremors, diaphoresis, etc.

As

part

of long-time treatment,

-Medical alert bracelet provides

36

advise patient to wear medical alert

basic information about the client in

bracelet all the time and wherever he

case of accidents.

goes. It contains the patients name,


disease condition, address and contact
person.

Advise to have a family member

-Monitor of blood pressure is

take your blood pressure to check if

significant for evaluating the

youre

medications effectiveness.

maintaining

stable

blood

-Glucose monitoring is a big factor

pressure.

in the management of diabetes

Since the client has his own glucose

mellitus.

monitor, tell client to continue monitoring


blood glucose level, and immediately
seek
Hygiene

for

medical

help

if

level

is

abnormally high.
Instruct patient to practice foot care

-Proper foot care prevents injury to

to prevent ulceration and formation of

feet and toes.

gangrenous

tissues

to

the

lower

extremities.
- Check and carefully wash your feet
every day.
-Do not wear shoes that are too small or
socks that do not fit right inside your
shoes.
-Soak your feet in warm soapy water for
10 minutes before cutting your nails.
Trim your toenails straight across to
prevent ingrown toenails. You may also
file down your toenails. Do not cut your
nails into the corners or close to the skin.
You should not dig under or around the
nail.

Emphasize

the

importance

of

bathing everyday. Wash genitals with

-Proper bathing eliminates


proliferation of germs and bacteria
in the body. Mild soap does not

37

irritate the skin and the genitals.


mild soap.
-Tooth brushing prevents build up
of plaques and cavities.

Instruct client to maintain good oral

hygiene.

Instruct to wear clean clothes and

underwear.

-Dirty or improperly washed


underwear may become a
sanctuary for microbial growth.
Microbes may enter the genitals
and might worsen the clients
UTI/Cystitis.

Out-Patient
Referral

Encourage patient to undergo physical


therapy sessions.

-A Physical Therapist is a source of


information to understand agerelated changes and offer
assistance for regaining lost
abilities or develop new ones.
Physical therapy can be applied to
the clients condition: arthritis,
urinary and fecal incontinence,
amputation, and cardiac and
pulmonary disorders. It can :
a). increase, restore or maintain
range of motion, physical strength,
flexibility, coordination, balance
and endurance
b.) aids adaptations to make the
home accessible and safe
teach positioning, transfers, and
walking skills
c.) promote maximum function and
independence within an individual's
capability
d.) increase overall fitness through
exercise programs
e.) prevent further decline in
functional abilities through
education, energy conservation
techniques, joint protection, and

38

use of assistive devices to promote


independence
f.) improve sensation, joint
proprioception
g.) reduce pain
Advise to have check-ups after discharge.

-Serves as an evaluation process


to note if condition has progressed
to better or worse.

Advise to have regular laboratory exams

-To assess for renal function.

for creatinine, albumin, sodium,


potassium and calcium.
Encourage to undergo ABG Test every
Diet

month or once every 2 months.


Instruct client to avoid simple sugars.

-Simple sugars easily break down

Take energy from complex carbohydrates

and enter the blood stream.

like unpolished rice, bread and

Complex carbohydrates can

vegetables.

sustain the bodys energy


requirement for a longer time
because they are not broken down
easily.

Encourage patient to eat fibrous foods

-A diet rich in fiber relieves

like fruits and vegetables. But do not eat

constipation. It adds bulk to the

too much as it can irritate the GI tract and

excreta and facilities expulsion.

causes bleeding. Other examples of


sources of fiber are: whole grains, cereals
and legumes.
Limit intake of purine rich foods such as

-Accumulation of uric acid in the

liver, beef kidneys, brains and meat

joints causes arthritis. Uric acid is

extracts. Encourage to eat in moderate

the by product of purine break

amount: asparagus, cauliflower, spinach,

down in the liver. Because of renal

mushrooms, green peas, dried peas and

malfunction, uric acid is retained in

beans.

the blood stream and is shunted to


connective tissues.

WHAT I LEARNED FROM THIS CASE STUDY:-

39

Case study is the comprehensive study of one selected patient and comparative study with books. During
my case study, I learned the following things.
i. About the disease:I got opportunity to read and gain comprehensive knowledge through various books, literatures,
teachers, doctors, ward staffs, colleagues and via. Secondary internet. I also obtained a comprehensive
knowledge on the disease its treatment and management.
ii. About the patient:My patient was a open book to learn for me, as I got an opportunity in learning through
involving patients care, treatment, diversional therapy and teaching not only from patient but also from
his family member. I learned personal quality of patient and use the information in treating her. I also
taught the families, socio cultural, economical, religious and traditional beliefs of the patient which
influence her health.
iii. About nursing care:I applied holistic approach while giving nursing care to the patient. I followed the theorie of
Henderson in providing nursing care and I gained more knowledge and skill.
iv. About documentation.

12) CONCLUSIONS AND SUMMARY OF CASE STUDY

40

My patient name is mr. laxman pandit , 68yrs old, male with the diagnosis of Chronic kidney
disease.
Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal
function over a period of months or years

Heredity
Glomerular dysfunction
Diabetic nephropathy
Hypertension
Glomerulonephritis
Polycystic kidney disease
Urinary tract obstruction
Bladder tumour
Urethral obstruction
Hypertensive nephrosclerosis (hardening of the kidney) are some of the causes of chronic kidney
disease
The clinical features of ESRD are: weakness and fatigue, confusion, seizures, burning soles of
feet, thin, brittle nails, hypertension,periorbital oedema,etc

It can be investigate through laboratory test such as cbc, urinalysis, blood urea ,ultrasonography,
kub film etc.
During my case study, I provided health education, applied different diversional measures, treatment,
investigation, diet, personnel hygiene etc. I feel great pleasure whenever patient and his family get
treatment satisfaction and getting better. His general condition was improved so he was discharged.

41

13) REFERENCES
Nursing care plan, Marilynn E. Doengs, Mary. Francesmoorhoose, Alice C. Geissles. Murs 6th
edition
Rai lalita nursing concept theories and principles; 1st edition
Helth learning materials centre Tu, institute of medicine, maharajgunj, ktm, textbook of adult
helath nursing
Mosbys nursing drug reference,2007
Phipps Monahan and sands marek neighborsmedical surgical nursing health and illness
perspectives 7th edition, page 1260 to 1271
A Lippincott manual the Washington manual of medical therapeutics,33rd edition, page 430 to
433
http://www.emedicinehealth.com/chronic_kidney_disease/page2_em.htm
http://www.ehttp://www.emedicinehealth.com/chronic_kidney_disease/page4_em.htmmedicineh
ealth.com/chronic_kidney_disease/article_em.htm
http://en.wikipedia.org/wiki/Chronic_kidney_disease

42