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