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Manuel S. Enverga University FoundationCollege of Nursing and Allied Health Sciences
A Case Study of a Patient with
“End Stage Renal Disease secondary to Chronic Glumerulonephritis”
In Partial Fulfillment of the Requirement forNursing Enhancement Program(Related Learning Experience)
@Hemodialysis Unit, QMC (Lucena City)
Presented To:Ms. Claire E. Davila
Clinical Instructor
Presented By:Group 4 – B
Basco, ChristineLozada, Grace
Morin, AngielynPerez, Maricel
Reyes, Ralph Lawrence
December 2012
GENERAL OBJECTIVES
At the end of our duty in QMC – Hemodialysis Unit, Level IV nursing students of
MSEUF-MAIN will be able to impart acquired knowledge and effective skills towards
achieving the patient’s optimum level of functioning through promoting, providing and
maintaining, physiologic and psychological stability, and health restoration as to apply the
right attitudes of the nursing students in rendering care to the patient experiencing
hemodialysis due to health condition of END STAGE RENAL DISEASE secondary to
CHRONIC GLUMERULONEPHRITIS, its importance and implication.
The aim of this study is to provide understanding to the students as well as the
readers regarding END STAGE RENAL DISEASE secondary to CHRONIC
GLUMERULONEPHRITIS. This study will show the contributing factors, occurrence and
complication of the condition which is important in the preventive, promotive and
rehabilitative care of the patient.
SPECIFIC OBJECTIVES
Establish a trusting relationship to client and family.
Perform the assigned task efficiently and dynamically
Understand precisely what END STAGE RENAL DISEASE is.
To be able to distinguish its clinical manifestations.
To illustrate the Anatomy and Physiology of the affected organ or the part of the body
To discuss and outline its pathophysiology.
Find out how the health status of the client had been affected by the above disorders by:
Determining its predisposing factors
Determining the causative agents of the disease
Conducting physical examination
Analyzing the results of the laboratory examinations done to the client.
Determine the appropriate nursing care and management that should be provided to the
client by:
Being familiar with the various treatment done to the client;
Understanding the different drugs ordered for the client and determines its
therapeutic effects and adverse reactions.
Evaluate the effectiveness of the medical treatment and the nursing care plans
rendered to the client.
To apply right attitude by respect through providing privacy and maintaining client’s
confidentiality.
I – INTRODUCTION
End Stage Renal Disease (ESRD), also known as Chronic Kidney Disease Stage V, 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.
Incidence, race, gender, age, ratio and proportion
Kidney disease is on the rise and is an important cause of death in the Philippines. It is
the 9th leading cause of death among Filipinos today. It is said that a Filipino is having the
disease hourly or 120 Filipinos per million populations per year. Statistics show that kidney
disease among the Filipinos is shooting up every year. Almost 10,000 Filipinos requiring either
dialysis for life or a kidney transplant for survival. About 31% of them have the most advanced
stage of the disease. Unfortunately though only 73% or about 7, 267 patients received treatment.
An estimate of about a quarter of the whole population probably just died without receiving any
treatment.
According to DOH said that in the past, chronic glomerulonephritis was the most
common cause of chronic renal failure. Today, diabetes mellitus and hypertension have taken
center stage in increasing the risk of ESRD which together account for almost 60% of dialysis
patients.
The prevalence of kidney/renal diseases has been in an increasing trend, especially the
end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry (PRDR).
The rate of death due to end-stage renal disease has been in the top ten list of the mortality of the
Department of Health (DOH).
There are more males acquiring the condition with a ratio of 2:1. This particularly afflicts
children and young adolescents, (5-15 years of age) while a smaller portion, 10% occur in
patients above 40 years. It may however be acquired at any time in the lifespan.
Rational for choosing the case
The group decided to choose this case; END STAGE RENAL DISEASE secondary to
CHRONIC GLUMERULONEPHRITIS for it will be a good study because we are all aware
that this is one of the diseases that gives a largest contribution to the morbidity rate here in the
Philippines. This is an opportunity for us not just to learn more about the causes and treatments
of this disease but also an opportunity to show our role and contribution as a nursing student. The
information and learning we will gain is advantage for us, once we encounter it again in the
future.
Significance of the Study
The significance of this study is to enhance and gain knowledge, as well as to develop
skills and to apply interventions for patient with END STAGE RENAL DISEASE secondary to
CHRONIC GLUMERULONEPHRITIS. This study will serve as guidelines in assessing and
providing nursing care.
This study also aims to educate the people about the disease of the kidneys specifically
END STAGE RENAL DISEASE to serve as their eye opener for understanding how important
our kidney is and its functions to our daily life activities.
Scope and limitation of the study
This study would focus only on END STAGE RENAL DISEASE secondary to
CHRONIC GLUMERULONEPHRITIS which indicates the disease process and client’s present
health condition and the nursing action relevant for the client’s situation within the rotation at
QMC – Dialysis Unit.
Conceptual and Nursing Theory
Imogene M. King - Theory of Goal Attainment
The concepts of self, perception, communication,
interaction, transaction, role and decision making were
selected to represent how individuals and groups in the health
care system interact to achieve goals. “This transaction model
developed to represent the process whereby individuals
interact to set goals that result in goal attainment” (King,
1981). The theory of goal attainment, developed by Imogene
M. King, is based on the “assumption that human beings are
the focus of nursing….the goal of nursing is health: its promotion, maintenance, and/or
restoration; the care of the sick or injured; and the care of the dying”. King's model consists of
three interacting systems: personal, interpersonal, and social. The three interacting relationships
involve the individual, nurse-client interaction and nursing. Nurse-client interactions are thought
to be individual perceptions which influence the process of goal attainment.
The group chose this theory because the primary nursing goal of patient having END
STAGE RENAL DISEASE is to assist the patient to achieve, preserve, and reclaim health. The
theory emphasizes the importance of knowledge and information that the nurse and the client
both bring to the relationship, working together to achieve goals. Imogene M. King’s conceptual
framework is best described as a holistic view of the complexity in nursing and multiple health
care systems.
Related Literature
Overview of the disease
End – stage renal disease is irreversible and progressive reduction of functioning renal
tissue. It occurs when the remaining kidney mass can no longer maintain the body’s internal
environment which results to renal failure. It is also called Chronic Kidney Disease (CKD) and is
labeled stage 5. ESRD can develop insidiously over many years or may result from an episode of
renal failure from which the client has not recovered. It usually occurs when chronic kidney
disease has worsened to the point at which kidney function is less than 10% of normal. ESRD
almost always follows chronic kidney disease
Causes
The causes of ESRD are numerous. Various injuries and disease process that may
result in kidney failure were Chronic Glumerulonephritis, Acute Renal Failure, Polycystic
Kidney Disease, Obstruction, repeated episodes of Pyelonephritis, and Nephrotoxins.
Systemic diseases such as Diabetes Mellitus, Hypertension, Lupus Erythematous, Sickle Cell
Disease and Amyloidosis may produce chronic kidney disease.
Diabetes Mellitus is the leading cause and accounts for more than 30% of clients who
receive dialysis. Hypertension is the second leading cause of ESRD.
Clinical Manifestations
The symptoms for acute and chronic kidney disease may be different. The following are
the most common manifestations of chronic renal failure. However, each individual may
experience symptoms differently. Symptoms may include:
poor appetite
vomiting
bone pain
headache
insomnia
itching
dry skin
malaise
fatigue with light activity
muscle cramps
high urine output or no urine output
recurrent urinary tract infections
urinary incontinence
pale skin
bad breath
hearing deficit
detectable abdominal mass
tissue swelling
irritability
poor muscle tone
change in mental alertness
metallic taste in mouth
Treatment
Dialysis or kidney transplantation is the only treatment for ESRD. A patient must prepare
for dialysis before it is absolutely necessary. The preparation includes learning about dialysis and
the types of dialysis therapies, and placement of a dialysis access.
Medications usually include an ACE inhibitor, angiotensin receptor blocker, or other
medications for high blood pressure.
Changes in DIET:
Eat a low-protein diet
Get enough calories if you are losing
weight
Limit fluids
Limit salt, potassium, phosphorous,
and other electrolytes
Other treatments may include:
Extra calcium and vitamin D
Special medicines called phosphate binders, to help prevent phosphorous levels from
becoming too high
Treatment for anemia, such as extra iron in the diet, iron pills, special shots of a medicine
called erythropoietin, and blood transfusions.
Procedures and Tests
Blood tests. Kidney function tests look for the level of waste products, such as creatinine
and urea, in your blood.
Urine tests. Analyzing a sample of your urine may reveal abnormalities that point to
chronic kidney failure and help identify the cause of chronic kidney disease.
Imaging tests. The doctor may use ultrasound to assess your kidneys' structure, size and
degree to which they reflect sound waves (echogenicity). Other imaging tests may be
used in some cases.
Removing a sample of kidney tissue for testing. The doctor may recommend a kidney
biopsy to remove a sample of kidney tissue. Kidney biopsy is often done with local
anesthesia using a long, thin needle that's inserted through your skin and into your
kidney. The biopsy sample is sent to a lab for testing to help determine what's causing
your kidney problems.
II – CLINICAL SUMMARY
General Data Profile
Name: AAA
Address: Brgy. Talipan purok Maligaya Pgbilao, Quezon
Birthday: Oct. 28, 1978
Birth Place: Lucena City
Nationality: Filipino
Religion:Roman Catholic
Occupations: Businessman
Date of admission: July 9, 2012
Admitting Diagnosis:End stage renal disease secondary to chronic glomerolunephritis
Admitting Physician: Dr. Joseph Michael Abcede, MD
Chief Complaint
Patient was admitted @ MCDGH with chief complaint of vomiting, shortness of breath,
body weakness, and elevated blood pressure.
History of present illness
2 days prior to admission patient AAA felt dizzy, loss of appetite, shortness of breath and
body weakness but he ignore it. Patient AAA has history of family hypertension. Prior to
admission, patient was brought to ER-QMC for consultation and ROD ordered laboratory
examination like CBC and urinalysis in order to know the problem and give right medication for
the patient. His blood pressure was 270/170mmHg and the doctor ordered antihypertensive
medication to decrease blood pressure, and the patient remained in the hospital for 3 days.
a. Childhood Illness - According to the patient, he only experienced simple cough and colds
b. Immunizations - The patient has complete immunizations
c. Allergies - The patient had no allergic reactions in any foods and drugs.
d. Accidents - None
e. Hospitalization - According to the patient it was his first hospitalization when the doctor diagnosed him End stage renal failure
f. Medications or currently taking
- Clonidine, Amlodipine, Losartan, Ferrous Sulfate, Carvidolol
g. Domestic Travels - Tagaytay, Cavite, Lucena
Family History – Genogram
Legends:= Male = Female = Patient
59Mild
Stroke Mother
Patient34 172432 26
2 mos.456
Brothers and sisters
Father
Siblings
55Stroke
Wife30
103
In the family genogram of our client, there are no kidney disorders in their family,
however there are diseases that could contribute to his disease. Both of his parents had a history
of stroke and experiencing hypertension. Hypertension is one of the leading causes of ESRD in
the Philippines.
Psychosocial Theory – According to Erik Erikson
According to this theory young adulthood had intimate relationship with another person
and a commitment to work and relationship. Based on our interview with the patient, we found
out that the theory of Erikson correlates with the information that we’ve gathered to the patient.
According to the patient, he really loves his wife and their 6 kids. And they help each other to
provide all the needs of the family. After the patient resigned in his previous work, he decided to
have an owned business.
Psychosexual theory – According to Sigmund Freud
According to this theory, the genital stage correlates to the patient’s age because the
patient wanted to gain independence and decision making by working and from his age the
patient wanted to be a good husband to his wife and father to their children. When it comes with
decision making, the patient is the one who make decision for his problem as long as he knows
that he can solve it with his own. The patient is in the stage of independency.
Environment / Living Condition
The patient lives in Brgy. Talipan Pagbilao, Quezon. In the surroundings of their house,
there are trees and lots of houses. Although their house is in front of the Barangay Health Center,
he didn’t even make a consultation whenever he feels ill. Since he was diagnosed with End Stage
Renal Disease, he has a maintenance medication for hypertension and currently undergoing a
hemodialysis twice a week. Unlike when he was not already diagnosed with ESRD, he is always
drinking alcohol after his work, consumed 2 packs of cigarettes a day and eats a lot of salty, and
fatty foods that he wants but now he is very strict with regards to his food and he is also a former
driver in a bank where he resigned because of his present condition.
Physical Assessment
Parameters Normal Findings Actual Findings InterpretationGeneral Appearance - Healthy in
Appearance
- Ambulatory - With full range of motion of neck and upper and lower extremities-able to speak clearly and articulate each word being spoken without any difficulty- with good gag reflex
- With slightly weak in appearance- Ambulatory- With full range of motion of neck and upper and lower extremities- Able to speak clearly and articulate each word being spoken without any difficulty-With good gag reflex
-Due to his illness condition the patient is slightly weak in appearance
Skin - With good skin turgor
- With smooth skin and free from any type of wounds
-With slightly poor skin turgor- With smooth skin and free from any type of wounds
- Due to limited oral fluid intake
Hair - Evenly distributed hair- Thick hair
-Evenly distributed hair -Thick hair
Nails - With good capillary refill of 1-2seconds - With pinkish nail beds- Short clean cut nails
-With poor capillary refill of 3-4 seconds-With pale nail beds-With short clean cut nails
- due to decrease production of erythropoietin that leads to decrease level of oxygen in the upper and lower extremities
Skull and Face - Rounded smooth skull contour- Symmetrical facial movement
- Rounded smooth skull contour- symmetrical facial movement
Eyes - No eye discharge- Eyebrows hair evenly distributed/skin intact- (+)blink reflex- With pinkish conjunctiva
- No eye discharge- Eyebrows hair evenly distributed/skin intact- (+)blink reflex- With pale conjunctiva
-Due to ineffective tissue perfusion
Ears - Auricle color same - Auricle color same
as facial skin- Auricle are mobile firm and not tender- Able to hear on both ears- No edema and discharge
as facial skin- Auricle are mobile firm and not tender- Able to hear on both ears- No edema and discharge
Mouth - Mouth uniform consistency; absence of nodules and masses- Pinkish lips- With pink gums- With symmetrical contour
- Mouth uniform consistency; absence of nodules and masses- Dry and pale lips-with pale gums- with symmetrical contour
- Due to limited oral fluid intake
Neck - No masses -With mass on the right portion of the neck
- Due to hypersecretion of T3 and T4
Abdomen - No abdominal distention- Flat rounded abdomen- Symmetrical contour
- No abdominal distention-Flat rounded abdomen-Symmetrical contour
- Due to limited intake of food and oral fluid but still the patient has normal findings in abdomen
Musculosketal (Upper and lower extremities)
- Symmetrical- No atrophy- With full range of motion
- Symmetrical - No atrophy- With full range of motion
Patterns of Functioning
Functional Health Pattern Before Hospitalization
During Hospitalization
Interpretation
Health management Pattern
Self-medicated (over the counter drugs)
He is dependent to health care team and the medication with the prescription of M.DHemodialysis
The medications and treatments are rendered by the health care team and he usually seeks medical attention due to his condition.
Nutritional/ Metabolic
a. Number of meals per day
b. Appetite
c. Glass of water per day
d. Body built
e. Height and weight
-Five times a day with in between snacks (fast food lovers) consuming 1L of fluids
-very good
-2.5L
-he has good body built
72 kg5”4’
-during hemodialysis, he tries to eat foods that he can’t usually eat.
-good
-1L including the food and fluids
-thin than the normal body built
47.5 kg5”4’
Because of the condition of the client, he has limitation when it comes to food so as to avoid excess fluids and electrolytes. Despite of his situation he has a good appetite but he limit himself to eat.
During the dialysis he’s allowed to drink and eat but in moderate amount with strictly monitor due to his condition.
Elimination
a. Frequency of urination
b. Amount of urine per day
c. Frequency of bowel movement
d. Consistency of the feces
-10 times a day
-30-60cc/hour
-4 times a day
-formed or semi-formed
-moderate
-4 times a day
-<30 cc/hour
-once or twice a day
-formed or semi-formed
-moderate
The dialysis removes the excess fluid, electrolytes, and toxins in the body.
e. Amount defecated per day
Activity and Exercise
a. Exercise
b. Fatigability
c. ADL
-active exercise every day (jogging and basketball)
-not easily get tired
-independent
-limited movement because of the body weakness
-easily get tired due to his condition
-can do ADL but limited unlike before
The patient wasn’t able o do his usual routine before like exercise and he is easily get tired but despite of his condition is not hindrance to do some ADL but in limited time and action.
Cognitive/Perceptual
a. Orientation
b. Responsiveness
-aware to time, place and person
-he is appropriately responds to verbal and physical stimuli
-aware to time, place and person
- he is appropriately responds to verbal and physical stimuli
The client is oriented and the cognitive and perceptual status is totally intact and appropriately responds to the questions given.
Coping/Stress-Socialize with his friends
-He always speak out to his wife and he want to take care of his children
He has a good coping techniques despite of his condition
Values and Beliefs He is aware that GOD really exists
He is aware that GOD really exists, and his faith is more strengthened than before.
He never blames the Lord about his condition instead His faith becomes stronger than before.
Roles / Relationship
a. As a son He has a good relationship with his parents
He has a good relationship with his parents and they are one of the reason why is more strong despite of his condition.
Despite of his condition he has still a good relationship with his family and became more bonded and intact with each
b. As a brother
c. As a husband
As a father
With good relationship to his siblings
With a very good relationship with his wife and a good provider as a husband
With a very good relationship to his children and good provider to his children as a father
With good relationship to his siblings became more bonded due to his condition.
Become more stronger and bonded with each other despite of his condition.
He has more time to take care of his children due to his condition but still good provider to them.
other. He became stronger to face his situation because of his family.
Course in the Ward
Date Doctor’s Order
June 6, 2012
July 4, 2012
July 9, 2012
July 14, 2012
October 2, 2012
(+) Headache when taking AtenololShift Atenolol to Lozartan (Lifezar) 100mg/tab 1 tab OD
For pH CBC, serum crreatinine, calcium, phosphorus
To: QMC Hemodialysis UnitPlease accommodate patient for 2x/ week hemodialysis
ESRD secondary to Chronic Glomerulonephritis
For referral to Dr. Dayahan for EndoscopyFor TSH, T3, T4
For CBC, Creatinine, Calcium, Phosporus
Laboratory / Diagnostic Exam
October 3, 2012
Parameter Results Units Normal Range InterpretationRBC - 10 ^12/L 4 - 4.5 -WBC - 10^9/L 5 – 10 -Segmenters - 0.55 - 0.65 -
Lymphocytes - 0.25 - 0.35 -Eosinophils - 0.01 0.05 -
Monocytes - 0.01 0.1 -
Basophils - 0.01 0.08 -
MCV - fL 82 – 92 -MCH - Pg 27 – 32 -MCHC - % 32 - 36 -HGB 9.5 g/Dl 12 – 16 LOW
the patient has anemiaHCT - % 37-45 -Platelet - 10^9/L 150-400 -
IMPLICATIONS:
A low hemoglobin count is a below average concentration of the oxygen – carrying
hemoglobin proteins in your blood. In many cases, a low hemoglobin count is only
slightly lower than normal, isn't considered significant and causes no symptoms. A low
hemoglobin count can also be caused by an abnormality or disease. In these situations, a
low hemoglobin count is referred to as anemia.
July 15, 2009
Pt. count Cut-off RemarksAnti-HBS 2.00 10.00 Non- reactive
July 10, 2009
Pt. count Cut- off RemarksHBSAG 0.018 0.075 Non-reactive
Hepa.C Virus 0.055 0.392 Non-reactive
III – CLINICAL DISCUSSION OF THE DISEASE
Anatomy and Physiology
Kidneys
are solid organs found in the middle back that are responsible for removing water and water
soluble waste from the blood. And a kidney plays the following essential roles in controlling the
composition and volume of body fluids:
Excretion
Regulation of blood volume and pressure
Regulation of the concentration of solutes in the blood
Regulation of extracellular fluid ph
Regulation of the red blood cell synthesis
Vitamin D synthesis
Structures of the kidney:
Renal pyramid - One of multiple cone-shaped portions of the kidney where urine
is removed from blood and drained into the renal calices.
Renal artery - The main blood vessel that brings blood to the kidney from the aorta.
Renal vein - The main blood vessel that brings blood away from the kidney back to the
inferior vena cava
Renal capsule- This is the outer covering of the kidney.
Nephron- This is the working unit of the kidney.
Renal column- This is a solid portion of the kidney where blood vessels travel to and
from the nephron.
Ureter
Are small tubes that carry urine from the renal pelvis of the kidney to the posterior
inferior portion of the urinary bladder
Bladder
its functions is to store urine, and its size depend on the quantity urine present.
Urethra
Is a tube that exits the urinary bladder inferiorly and anteriorly.
Pathophysiology
Book based
INITIATING EVENT (infection, antigen – antibody formation,
systemic disease) DM CGN HPN LSE ARF Nephrotoxins Pyelonephritis Polycystic
Kidney Disease
Glomerular – Capillary Membrane Inflammation
Decreased renal blood flow
Glomerular Permeability
Activation of Renin – Angiotensin Aldosterone
Sysstem
HEMATURIA PROTEINURIA INCREASED
BUN AND CREATININE
Decreased GFR
Decreased Na and water
Glomerular Sclerosis
Decreased Na and water
Progressive deterioration of GF, tubular secretion and reabsorption
Kidney attempt to maintain GFR
Glomerular hyperfiltration
Decreased renal mass, nephrons are destroyed
Further loss of functional nephrons
(ESRD)END STAGE RENAL DISEASE
Client based
Develops Urinary Tract Infection (UTI)
Initiating event (infection, antigen-antibody formation, systemic disease)
Renal blood flow and glomerular filtration are decreased
Renal insufficiency; retention of sodium, water and waste
Rapidly progressive glomerulonephritis
Severe glomerular injury (chronic glomerulonephritis)
Chronic Renal Failure
(ESRD)END-STAGE RENAL DISEASE
Modifiable Risk factorso Cigarette smoking
o Drinking alcohol
o Fast food lovers
o High intake of food rich in
sodiumo Over use of over the
counter drugso Lifestyle (eating processed
foods, junk foods, salty and fatty foods)
Non-modifiable Risk factorso Family history of
Hypertension
IV – NURSING PROCESS
Long Term Objectives
The study aims to restore and maintain the patient’s body weight, strict adherence
to his diet and to prevent further complications through collaborative management of the
health care team. The patient should adhere to his scheduled hemodialysis to excrete the
metabolic waste that the kidneys cannot excrete. Kidney transplantation is needed to
attain the patient’s optimum wellness.
Prioritized List Nursing Problem
DIAGNOSIS RANK REASON
Decreased Tissue Perfusion r/t to constricted peripheral blood
vessels as manifested by increase blood pressure of
200/130
1The group decided to prioritize first the decreased tissue perfusion due to decrease circulating RBCs in the blood therefore decrease oxygen level; Circulation should be prioritized first among the problems.
Fluid Volume Excess r/t decrease Glomerular filtration Rate and sodium retention as manifested by increase BP of
200/130
2The group ranked the Fluid volume excess as number two because it is the presenting problem in our patient, to prevent further deteriorating his ill condition.
Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute
secondary defense
3We ranked it as our least priority because in the case of the patient frequent IV cannula will introduce microorganism in the blood circulation that would trigger systemic infection since there is only a risk and problems the first thing that should be managed since this problem can be fatal if left untreated.
Discharge Plan (METHOD)
Clients with Renal Disease are instructed to take the following plan for
discharge:
Medication
Medications should be taken regularly as prescribed, on exact dosage,
time, & frequency, making sure that the purpose of the medications d i sc losed
by the health care provider.
Advise patient to take the prescribed medicines continuously at home.
Medication as follows:
o – Amlodipine 5mg/tab 1tab OD (7pm)
o – Lozartan (Lifezar) 100mg 1 tab OD (7am)
o – Clonidine (Catapres) 150 mg/tab 1 tab BID (10am-10pm)
o – Carvedilol 25mg 1 tab OD (12nn)
Environment
Maintain quiet, clean and calm environment for alleviating the patient’s
discomfort
o Provide safety measure to promote safe environment and individual safety
Exercise should be promoted in a way by stretching hand and feet every
morning. Encourage the patient to keep active to adhere to exercise
program and to remain as self –sufficient as possible. But if there is presence of
pain rest should be provided.
Assist patient in doing ADLs.
Treatment
Instructed the patient to continue medication and compliance to strict regimen.
Health teaching
Encouraged a diet high in carbohydrates within the prescribed sodium,
potassium, phosphorus and protein limits.
Encouraged patient to avoid salty and fatty foods
Encouraged patient to have enough rest
Instructed the patient to do exercise as tolerated such as walking.
Encouraged activity within prescribed limits but avoid fatigue.
Emphasized the importance of practicing proper hand washing
Instructed to do deep breathing and coughing exercises
Encouraged patient to eat nutritious foods.
Protect the client from exposure to infectious agents.
Out –patient check-up
Instructed to comeback for the next hemodialysis on November 30, 2012 Friday
at Dialysis Unit at Quezon Medical Center Lucena, City
Diet
Advised the patient to follow the Doctors Order regarding her diet with strict 1L
of fluids per day including the food fluid.
Advised the patient to a renal diet.
Drug Study
NAME OF THE DRUG
DOSAGE ACTION INDICATION CONTRA -INDICATION
ADVERSE EFFECT
NURSING RESPONSIBILITY
Amlodipine(AMVASC)Therapeutic Classification:
Antihypertensiv
Calcium Channel Blocker
Doctor’s Order:10mg/tab 1 OD 7PM
Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle and peripheral vascular smooth muscle; dilates coronary arteries;increasing myocardial oxygen delivery in patient with vasospastic angina.
hypertension, may co-administer with other antihypertensives.
Sick sinus syndrome, second or third degree heart block, hypertensivity, severe aortic stenosis, severe obstructive coronary artery disease.
CNS: headache, fatigue, dizziness
CV: dysrhythmia, peripheral edema, hypotension, palpitations, syncope, chest pain
GI: nausea, vomiting, diarrhea, gastric upset, constipation, flatulence, anorexia, gingival
Exercise the ten rights of giving medication upon administering.
Assess fluid volume status
Monitor blood pressure and pulse; if blood pressure drops call prescriber
Monitor platelet count.
Monitor cardiac status: blood pressure, ECG, PR,RR
NAME OF THE DRUG
DOSAGE ACTION INDICATION CONTRA -INDICATION
ADVERSE EFFECT
NURSING RESPONSIBILITY
Generic name:Carvedilol
Classifications: Antihyper -tensive
Doctor’s Order:
25 mg 1 tab OD 12nn
A mixture of non- selective B- blocking and a- blocking activity; decreases cardiac output, exercise induced- tachycardia, reflex orthostatic tachycardia; causes reduction in peripheral vascular resistance and vasodilatation
Essential hypertension alone or in combination with other antihypertensive
Hypersensitivity, bronchial asthma, class IV decompensated cardiac failure, 2nd, or 3rd degree heart block, cardiogeneric shock, severe bradycardia, pulmonary edema.
CNS: seizures, dizziness, headache
GI: abdominal pain, diarrhea, increased AST/ ALT, increased alkaline phosphatase
CV: bradycardia, postural hypotension, dependent edema, peripheral edema
GU: UTI Resp: rhinitis,
pharyngitis, dyspnea
Exercise the ten rights of giving medication upon administering.
Monitor renal studies including protein, BUN, creatinine.
Monitor input and output and weight daily.
Monitor blood pressure Monitor apical or pulse
ratebefore administration
Assess for edema in feet and legs daily, fluid overload.
NAME OF THE DRUG
DOSAGE ACTION INDICATION CONTRA -INDICATION
ADVERSE EFFECT
NURSING RESPONSIBILITIES
Generic Name:Epoetin Alfa(Renogen)-Human Recombinant Erythropoietin
Therapeutic Classification:
Blood formers Hematopoietic
growth factor
Doctor’s Order: 4000u
2x a week
Glycoprotein that stimulates RBC production. Hypoxia and anemia generally increase the production of erythropoietin.
Elevates the hematocrit of patients with anemia secondary to chronic kidney failure (CRF); patients may or may not be on dialysis; other anemias related to malignancies and AIDS. Autologous blood donations for anticipated transfusions. Reduces need for blood in anemic surgical patients.
Uncontrolled hypertension and known hypersensitivity to mammalian cell–derived products and albumin (human)
CNS: Seizures, headache.
CV: Hypertension
GI: Nausea, diarrhea.
Hematologic: Iron deficiency, thrombocytosis, clotting of AV fistula.
Other: Sweating, bone pain, arthralgias.
Control BP adequately prior to initiation of therapy and closely monitor and control during therapy. Hypertension is an adverse effect that must be controlled.
Monitor for hypertensive encephalopathy in patients with CRF during period of increasing Hct.
Monitor for premonitory neurological symptoms. The potential for seizures exists during periods of rapid Hct increase
Important to comply with antihypertensive medication and dietary restrictions.
Do not drive or engage in other potentially hazardous activity during the first 90 d of therapy because of possible seizure activity.
NCP Based on the sequence of Prioritized problems
Assessment Nursing Diagnosis
Planning Intervention Rationale Evaluation
Subjective:
Objective: Oliguria Hyper-
tensive Cold and
clammy skin Hgb 9.5 g/dL
Decrease tissue perfusion related to peripheral vasoconstriction as manifested by high blood pressure. 200/130mmhg
After 4 hours of nursing intervention the patient will demonstrate increase perfusion as individually appropriate
Nurse patient interaction.
Measure and recorded blood pressure
Observe skin color, moisture, temperature and capillary refill time
Note presence, quality of central and peripheral pulses.
Explain the importance of providing calm, restful
To establish rapport
Provide objective data for monitoring
Presence of pallor, cool moist skin and delays capillary time may be due to peripheral vasoconstriction
Bounding carotid, jugular, radial, and femoral pulses may be observed/ palpated.Pulses in the legs/ feet may be diminished, reflecting effects of vasoconstriction and venous congestion.
Goal met
After 4 hours of nursing intervention the patient was able to demonstrate increase tissue perfusion as manifested seen patient cooperative and interested, and his blood pressure became 160/100.
surroundings, minimize environmental activity and noise
Provide adequate rest period of time and limit the number of visitor and the length of stay
Encourage compliance with dietary and fluid restrictions therapy
Monitor response to medications to control blood pressure.
It helps reduce sympathetic stimulation, promotes relaxation and reduces physical stress and tension that affect blood pressure.
It decrease discomfort and may reduce sympathetic stimulation
Adherence to diet and fluid restrictions and dialysis schedule prevents excess fluid and sodium accumulation
Responseto drug therapy is dependent on both individual as well as the synergisticeffects of the drug
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective (none)
Objectives
Excess fluid volume r/t decrease Glomerular filtration Rate and sodium
After 4 hours of nursing interventions, patient will demonstrate
1. Establish rapport To gain trust and rapport Goal met
The patient demonstrated behaviors
Blood pressure of 200/130 mmHg
Oliguria noted
retention as manifested by increase blood pressure of 200/130
behaviors to monitor fluid status and reduce recurrence of fluid excess
2. Monitor and record vital signs
3. Assess possible risk factors
4. Assess patient’s appetite
5. Note amount/rate of fluid intake from all sources
6. Compare current weight gain with admission or previous stated weight
7. Auscultate breath sounds
8. Note presence of edema.
9. Measure abdominal girth for changes.
10. Evaluate mentation for confusion and personality changes.
11. Change position of client
To obtain baseline data
To assess precipitating and causative factors.
To note for presence of nausea and vomiting
To prevent fluid overload and monitor intake and output
To monitor fluid retention and evaluate degree of excess
For presence of crackles or congestion
To determine fluid retention
May indicate increase in fluid retention
May indicate cerebral edema.
To prevent pressure ulcers.
to monitor fluid status and reduce recurrence of fluid excess
timely.
12. Review lab data like BUN, Creatinine, Serum electrolyte.
13. Restrict sodium and fluid intake if indicated
14. Weigh client
15. Encourage quiet, restful atmosphere.
To monitor fluid and electrolyte imbalances
To lessen fluid retention and overload.
.
Weight gain may indicate fluid retention and edema.
To conserve energy and lower tissue oxygen demand.
.
Assessment Nursing Diagnosis
Planning Intervention Rationale Evaluation
Subjective (none)
Objectives
Decrease
hemoglobin
Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute secondary defense
After 4 hours of nursing intervention the patient will not experience sign and symptom of infection
NPI established and maintained
Promoted good hand washing
To gain trust
Reduce risk of cross contamination
Goal met
After 4 hours of nursing intervention the patient did not experienced any sign and symptom of infection.
9.5g Use aseptic technique when manipulating/IV invasive lines
Explain the importance of deep breathing, coughing frequent position changes
Asses skin integrity
Monitor vital signs
Reduces bacterial colonization
It Prevents atelectasis and mobilizes secretion to reduce risk of pulmonary infections
Excoriations from scratching may become secondarily infected
Fever and increase pulse and respiration is typical increase metabolic rate resulting from inflamatory process
Recommended