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8/3/2019 Assigment Final End Stage Renal Failure
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NURSING MANAGEMENT FOR PATIENT UNDERGOING HEMODIALYSIS
1. INTRODUCTION
Nowadays people of Malaysia are threatened with a variety of illnesses caused by life style
among the diseases that involve the kidneys of "renal failure". We know that the kidney is one of
the most important organs in the human body functions. Renal is derived from the Latin word
renes, meaning kidneys. Can be defined is a pair of kidneys are located behind the abdominal
organs. Each kidney is about 4 or 5 inches long. It is about a fist size. Right kidney is located
right below the diaphragm and behind the heart. While the left kidney is located below the
diaphragm and spleen organ behind. Above each kidney is adrenal gland also known as
(suprarenal glands), and each kidney contains about one million units, which is referred to
neurons. Irregular position in the abdominal area due to the liver causing the right kidney is
slightly lower than the left kidney.
Retro peritoneum and kidneys is approximately 9 to 13 cm in diameter, which is slightly larger
left than the right. It was around the level of T12 to L13 vertebral level. Some parts of the
kidney is protected by the bones of the eleventh rib and two twelve and each adrenal gland is
fully protected by two layers of fat (per renal and Para renal fat) and renal fascia which helps
cushion it..
1.1 KIDNEY FUNCTION
The bladder holds about 400 ml (1 / 4 pints) of urine when full. Normal urine normally produced
is around 2 liters per day. The main function of the kidney is responsible for the generation of
waste from the body, regulating electrolyte balance and blood pressure and stimulates production
of red blood cells. It cleanses the blood and makes urine from waste and they produce them.
Blood is pumped by the heart to the kidneys. Their kidneys have a drainage system that takes
urine from the kidneys to the bladder. Drainage system as a channel with a tube (ureter) that
connects the kidney to the bladder. Urine down ureter (for each kidney) into the bladder. Urine is
stored in the bladder prior to discharge from the body through another tube called the ureter
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Another kidney function helps blood pressure. Fine blood pressure is controlled by a healthy
kidney. When the kidneys fail one of their blood pressure usually rises. Although it is not really
known why. Pressure high blood pressure will not cause symptoms except for very high
pressure, but it increases the risk of stroke or heart attack.
The kidneys also help control the actual manufacture of blood cells. The kidneys help regulate
blood cells, the actual manufacturing in the bone marrow. Floating in the liquid if the blood
(plasma). Their job is to carry oxygen around the body.
The kidneys also produce certain hormones that have important functions in the body, including
the following:
Active form of vitamin D (calcitriol or 1.25 dihydroxy-vitamin D), which controls the
absorption of calcium and phosphorus from foods, promoting formation of strong bones.
Erythropoietin (EPO), which stimulates bone marrow to produce red blood cells.
Renin, which regulates blood volume and blood pressure
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2. END STAGE RENAL FAILURE
As we know, kidney failure is in various stages. Among them are the "acute renal failure",
"chronic renal failure" and the final stage is the "end stage renal failure". Based on studies in theUnited State is created by the National Kidney Foundation in 2001, a total of 370,000 person end
stage renal failure have a number of cases increased approximately 8% each year.
End-stage kidney failure (ESRF) defined by Abassi et all 2010 as a reduction in the
irreversible in kidney function , which is severe enough to be fatal in the absence of
dialysis or transplantation.
.
"End stage renal failure" can also be defined as an irreversible decline in kidney function that is
severe enough to be fatal in the absence of dialysis or transplantation. In general, end stage renal
failure occurs when there is less than 10% of the remaining kidney function. In 2000 the final
stage of kidney failure than 375,000 American affected aspects of MRE increased to 651,000 by
2010.
Stage 5 chronic kidney disease can be described as kidney failure, also known as end stage renal
failure and chronic kidney disease has developed. Renal replacement therapy, dialysis or kidney
transplant may be needed to sustain life.
2.2CAUSES OF END STAGE RENAL FAILURE
Although chronic kidney disease sometimes results from the major diseases of the kidney itself,
the main reasons for diabetes and high blood pressure.
1. Type 1 and type 2 diabetes mellitus can cause a condition called diabetic nephropathy,which is the main cause of kidney disease in the United States.
2. High blood pressure (hypertension), if uncontrolled, can damage the kidneys, from timeto time.
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3. Glomerulonephritis inflammation and damage to the kidney filtration system, which canlead to kidney failure. Post infectious conditions and lupus which is one source of many
Glomerulonephritis.
4. Polycystic kidney disease is an example for the children of chronic kidney disease inwhich both kidneys have multiple cysts.
5. The use of painkillers such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil)fixed on a long period of time can lead to analgesic nephropathy, another cause of kidney
disease. Some other drugs can also damage the kidneys.
6. clogging and hardening of the arteries (atherosclerosis) that lead to the kidneys causes acondition called ischemic nephropathy, which is another cause of progressive kidney
damage.
7. Obstruction of urine flow by the rocks, the restrictions (narrowing), or cancer can alsocause kidney disease.
8. Other causes of chronic kidney disease, including HIV infection, the cells sickle disease,heroin abuse, amyloidosis, kidney stones, chronic kidney infections and certain cancers.
3.0 CLINICAL FINDINGS AND EFFECTS ON PATIENTS
Patient with end stage renal failure have a variety of signs or symptoms that can be seen and
different. It can be explicit or hidden. Based on the laboratory results obtained from Madam
Wong her serum creatinine is higher than normal readings, the normal creatinine are in range
less than 97. Creatinine blood test is to find proper kidney function and is used to
determine glomerular filtration rate, by the result found her had to undergo hemodialysis
immediately.
Based on the symptoms shown, she suffered "Shortness of breath '. It is caused by fluid
accumulation in the lungs. Other signs that patient also experience fatigue and
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confusion in which the patient is in a state of uremia syndrome. In this situation can be seen
where the level of creatinine in the blood are increase. This syndrome can affect body systems
such as the intestines, nerves and heart. Another cause of fatigue maybe patient have a mild
anemia due to hemoglobin are 10.1 g/ dl. For the patient who need to go to hemodialysis
,hemoglobin should be maintain at 11 g/dl.
"Pitting edema" is one of the symptoms listed for renal patients which it occur when kidney
function has deteriorated it could no longer filter the liquid and keep the balance of salt. When
this happens, fluid and salt from the body fluid build up in body tissues and cause edema.
Other symptoms that may be identified as the patient's skin will become dark or bright, unusual
skin than the original and will be a change in the nails.
Others laboratory examination done such as taking blood for "blood urea nitrogen," in which to
look at kidney function. Urea is the main product of protein metabolism. Its formed in liver
and excreted mainly by kidney in urine. If the kidneys are unable to remove the urea in the
blood it will rise.
Besides taking full blood count is one of examination must do in patient with renal failure,
its for detect renal anemia which full blood count is a component, such as hemoglobin,
hematocrit .
Urine output are also one of symptom that can be seen in end stage renal failure was caused
when 90% of nephrons almost fails it can cause "blood urea nitrogen" and "creatinine"
increases so that it causes "polyuria" changed to "oliguria . "
Chronic disease have characteristic that lead to patient fatigue and symptoms of
depression. End stage renal failure in terms of influencing an individual's physical,
psychological, and emotional health. The impacts can be seen is that according to Morsch,
Concalus & Banis, 2006 end stage renal failure is Associated with poor quality of life,
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depression (Kimmel & Peterson, 2006), reduced physical functioning Ability (Cleary & Diennan
2005; O'Sullivan 2007 ), poor sleep quality (Elder et all, 2007) and fatigue (Mc Cann & Boore,
2008; O'Sullivan & Mc Carthy, 2007).
Having chronic condition such end stage renal disease is likely to have a impact on
patient everyday life. The concerns commonly identified among of end stage renal failure
patient are disruption of lifestyle (Devins et all.2001).Whereas Blaschek 2003 said that
suffering from continuing symptom , stress and uncertainly of life. Intervention aimed at
modifying know mortality risk factors are expected to have considerable impact in this
patient population in survival and hopefully, Qol (Lindquist& Syoden 1998, Golper 2001,
Loss- Ayau et all- 2008 ).
Other symptoms, if untreated, can cause life-threatening condition and can be formed.
1. metabolic acidosis, or increased acidity of the body due to the inability to manufacturebicarbonate, will alter enzyme and oxygen metabolism, causing organ failure.
2. Unable to remove potassium and increases in serum potassium levels (hyperkalemia) isAssociated with a fatal heart rhythm disturbances (arrhythmias), including ventricular
tachycardia and ventricular fibrillation.
3. Increased level of urea in the blood (uremia) can affect the function of various organs ofthe brain (encephalopathy) with alteration of thinking, inflammation of the lining of the
heart (pericarditis), decreased muscle function because of low calcium levels
(hypocalcemia).
4. The weakness may be caused by anemia in which red blood cell count decreased, because of lower levels of erythropoietin produced by the kidneys failed be able to
stimulate the bone marrow. The decrease in red cells with a decrease in the ability to
carry oxygen in the blood, resulting in decreased oxygen delivery to the cells for them to
do the work, therefore, the body tires quickly. And, with less oxygen, the cells are easier
to use anaerobic metabolism (= without aerobic = oxygen). This can lead to the total
increase in acid production which can not be handled by the kidneys that have failed
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5. As waste products build in the blood, loss of appetite, lethargy and fatigue was verystrong. This can lead to decreased mental function, and coma may occur.
4. .MANAGEMENT OF THE PATIENT UNDERGOING HEMODIALYSIS
Dialysis is a treatment that takes over the task performed by the kidneys. Once for the
last stage kidney failure (end stage renal failure), most patient requiring dialysis treatment.
This treatment is likely for life except for kidney transplants.
According to Wong et all 2007 there are approximately 3000 patient on dialysis of
whom 80% are on continuous ambulatory peritoneal dialysis and remaining 20% are
receive hemodialysis.. Hemodialysis is done where an artificial kidney (haemodialyzer)connected to a machine that filters work to remove waste impurities and excess fluid from the
body. This procedure is carried out in a special unit (hemodialysis unit) in the hospital and takes
around four hours per session to three sessions a week. The patient will require fistula of blood
from the body to flow into the artificial kidney. The surgeon will make this fistula by connecting
an artery to the venous blood vessels to become larger blood vessels. During dialysis, wasteproducts in the bloodstream are carried out of the body. At the same time, electrolytes and other
chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the
body.
In the hemodialysis treatment of several aspects of care should be taken into consideration,
including the vascular access. Patients who undergo dialysis vascular access and so requires
access sites must be protected from damage or infection. Malovrh 2005 suggests a long-term
survival and quality of life of patients on hemodialysis depend on dialysis adequacy through the
appropriate vascular access. Ateriovenous fistula and graft require subcutaneous access and, to protect their access sites from unnecessary pressure or injury, venepuncture, cannulation,
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arterial-line insertion and the use of blood-pressure cuffs must be avoided (Richard and
Engebretson 2010).
In addition of vascular access, care diet is also important for end stage renal failure patients.
Among are fluid intake and other food. The volume of urine passed by patients undergoingdialysis is too small to remove all the fluid from their food and drink. Fluid retention leads to
increased blood volume, distended blood vessels and high blood pressure, which can in turn
lead to pulmonary edema (Agar 2010).
According to Kalanter-Zadeh (2009)in a study of fluid gain in patients undergoing dialysis
found that the average patient gained between 1.5 and 2.0kg of fluid between dialysis sessions,
and that a weight gain of at least 4kg over two consecutive dialysis sessions was associated with
a 28 per cent increased risk of death. Optimal fluid management is a determinant of survival in
patients undergoing renal replacement therapy (Collins and Mujais 2002) and,Blair 2009 states
that patients with chronic kidney disease, morbidity and mortality are increased by excessive
fluid intake.
Most patients undergoing dialysis are restricting to 1 liter fluid a day and if they are given extra
fluids intravenously, they must be monitored constantly.
Hyperkalaemia in most people, about 90 per cent of potassium is excreted by the kidneys and
patients undergoing dialysis who fail to adhere to dietary advice may be at risk of
hyperkalaemia due to decreased potassium excretion (Challinor 2008). Hyperkalaemia affectsthe ability of cardiac muscle tissue to conduct electrical impulses, potentially resulting in
ventricular fibrillation and a systolic arrest (Ahee and Alexander 2000),
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NURSING PROCESS
PROBLEM GOAL INTERVENTION EVALUATION
High risk of
Arterivenous Fistula
thrombosis and
Aneurysm due to
knowledge deficit.
To reduce
Arteriovenous Fistula
Complication
1.Educate her on the
care of Arteriovenous
Fistula
2.Avoid repeated
cannulation at the
same site
3.Treat infection if
Her arteriovenousFistula is still in good
condition andfuctioning well
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present
4.Cannulate carefully
try not to puncture the
fistula
5.Refer to Doctor if
there is bad aneurysm
6.Keep fistula clean
and dry
NURSING
PROBLEM
OBJECTIVE NURSING
INTERVENTION
EVALUATION
Fluid volume excess
related to failure or
comprised renal
regulatory mechanism
Patient will not show
signs and symptoms
of excess fluid.
1. Assist in dialysis
and monitor patient
progress.
2 .Administer
intravenous or oral
fluids as prescribed.
3. Monitor intake and
output chart .Strict
fluid intake to patient.
4. Use small cup to
drink ,so that patient
cannot take a lot of
water.
5. Do daily weight
and chart.
Patient not show sign
and symptoms of
excess fluid.
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6. Monitor vital sign
.Sign and symptom
Short of breath(SOB)
Early sign of fluid
overload
7. Offer ice chips or
flavored ice pops.
Record intake. Helps
minimizes thirst.
Provide frequent
mouth care. Helps
minimize thirst.
NURSING
PROBLEM
OBJECTIVE NURSING
INTERVENTION
EVALUATION
Pedal edema To reduce pedaledema
1 .Evaluate the
extended of edema
and its location ,so
that action could be
taken to relief the
condition.
2.Advice patient to
elevate his leg during
lying down to reduce
Pedal edema reduce
after intervention
given.
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swelling
3. Restricted fluid 500
ml POD (Previous
Day Output) and take
low salt diet to avoid
fluid retention.
4.Medication strictly
follow Doctors
ordered
5. Monitor the
condition of patient
during treatment and
inform doctor about
the changes
NURSING
PROBLEM
OBJECTIVE NURSING
INTERVENTION
EVALUATION
Impaired skin
integrity related to
pruritus and dry skin
secondary to uremia
and edema
Patient's skin remains
intact and free of
erythema and
abrasions.
1. Encourage use of
prescribed phosphate
binders when serum
phosphorus level is
elevated. Excess
phosphorus binds with
free calcium in the
serum. The resulting
calcium-phosphate
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complex is deposited
in soft tissues and can
cause necrotic patches
in the skin. In
addition, elevation in
calcium-phosphate
product is associated
with increased risk of
death, aortic
calcification, mitral
valve calcification,
and coronary artery
calcification.
Phosphate binders
help prevent elevation
in calcium-phosphate
product.
2. Administer
antihistamines as prescribed if needed.
Because accumulating
nitrogenous wastes
are excreted through
the skin, pruritus is
common in patients
with uremia and
causes frequent and
intense scratching.
Pruritus often
decreases with a
reduction in BUN and
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improved phosphorus
control. Decreases
itching and
subsequent scratching
that can result in
abrasions and/or
infection.
3. Keep patient's
fingernails cut short.
Prevents skin
abrasions when
scratching.
4. Teach patient
to monitor scratches
for evidence of
infection and to seek
medical attention
early if signs and
symptoms of infectionappear. Uremia
retards wound healing
and thus increases the
risk for infection.
5. Encourage use
of skin emollients and
soaps with high fat
content. Uremic skin
is often dry and scaly
because of reduction
in oil gland activity.
Skin emollients and
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soaps with high fat
content replace oils
and help reduce
itching from dryness.
6. Advise patient to
bathe every other day
and to apply skin
lotion immediately
upon exiting
bath/shower. Patients
should avoid harsh
soaps, soaps or skin
products containing
alcohol, and excessive
bathing, to prevent
skin dryness and
itching.
7. Advise patient and
significant othersabout increased risk
for bruising. Clotting
abnormalities and
capillary fragility
place patient with
uremia at increased
risk for bruising.
8. Provide
scheduled skin care
and position changes
for patients with
edema. Helps
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prevents skin
breakdown from
pressure.
PROBLEM OBJECTIVE INTERVENTION EVALUATION
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