Abra Valley Colleges Bangued, Abra

In Partial Fulfillment of the Requirements

in

NCM 103 (RLE)

A Case Study about

END STAGE RENAL DISEASE

Presented to: The Nursing Faculty of Abra Valley Colleges

Bangued, Abra

Presented by:BSN III - Group II

Leslie Mae M. Pimentel - LeaderCreighton A. Bayongan – Asst. Leader

Christian D. AdresJosephine B. Barber

Jhennyffer L. BarcenaCristy A. Baris

Arlene A. BigorniaShielo M. Bogac

Harold John B. BunaganMarife B. Delos Reyes

Harmony Cristie V. GonzaloMediatrix G. Pasiguen

Roxan G. Siwao

October 2010

I. INTRODUCTION

Chronic Renal Failure is usually the result of a gradually progressive loss of renal function, it

occasionally results from a rapidly progressive disease of sudden onset. Few symptoms develop

until after more than 75% of glomerular filtration is lost; then the remaining normal parenchyma

deteriorates progressively, and symptoms worsen as renal function decreases.

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal

physiologic changes in all major organ systems. If the patient can tolerate it, maintenance

dialysis or kidney transplantation can sustain life.

Stages of CRF:

1. Reduced Renal Reserved- GFR of 40-70 mL/min

2. Renal Insufficiency- GFR of 20-40 mL/min

3. Renal Failure – GFR of 10-20 mL/min

4. ESRD- GFR of less than 10 mL/min

Significance of the Study

1. To discuss Chronic Renal Failure its causes, risk factors, complications and surgical

management.

2. To know the Pathophysiology of Chronic Renal Failure

3. To know the anatomy and physiology of the organ/s involved.

4. To be familiar with the medications given to our patient.

5. To effectively use the nursing process in providing holistic care to our patient.

6. To impart knowledge to fellow student nurses to help strengthen their role as health

educators in all health care settings.

Risk factors

Age

Gender

Alcoholism

Kidney diseases

DM

Hypertension

Causes: CRF arises from seven C’s

1. Chronic Glomerular Disease such as AGN and CGN

2. Chronic Infections such as pyelonephritis & TB

3. Congenital Anomalies such polycystic kidney disease

4. Calculi Obstruction

5. Collagen Disease such as SLE

6. Chronic used of Nephritic Drugs such as aminoglycosides

7. Chronic Endocrine Disease such as Diabetes Neuropathy

Signs and Symptoms: Systemic

Neurologic System:

o Listlessness

o Attention deficit

o Seizure

o Burning pain

o Irritability

o Twitching

o Confusion/ Coma

o Hiccups.

Pulmonary System:

o Difficulty of breathing

o Insufficient breath sound

o Crakles/Rales

o Kussmaul’s respiration

Cardiovascular System:

o Cardiac failure

o Hypotension/hypertension

o Anemia

o Weight gain

o Pulse irregularity

o Arrthymia.

Gastrointestinal System :

o Metallic taste

o Ammonia/acetone breath

o N/V

o Inflammation

o Constipation

o Anorexia

o GI bleeding

Integumentary System:

o Dry skin

o Uremic frost skin

o Severe itching

o Thin and brittle hair

o Yellow bronze skin

Genito-Urinary System:

o Anorea

o Changes in the urine

appearance/pattern

o Impotence/Infertility

o Diluted urine with cast and

crystals.

Musculoskeletal System :

o Gait abnormality

o Abnormal fracture

o Inability to ambulate

o Muscle cramps/spasms.

Possible Complications

Anemia

Bleeding from the stomach or intestines

Heart and blood vessel complications

o High blood pressure

o Pericarditis

o Stroke

Increased risk of infections

Malnutrition

Seizures

Weakening of the bones and increased risk of fractures

II. PATIENT’S PROFILE

Hospital #: 914104

Name: Mrs. DOB

Birthdate: March 15, 1972

Age: 38

Birthplace: Mindanao

Address: Kimpal, Lagangilang, Abra

Sex: Female

Civil Status: Married

Religion: UCCP

Nationality: Filipino

Date and Time of Admission: September 14, 2010 @ 9:35 am

Chief Complaint: DOB 1 day PTA

Ward: ICU

Admitting Diagnosis: End Stage Renal Disease (ESRD)

Final Diagnosis: End Stage Renal Disease (ESRD)

Physician: Dr. AT

III. HISTORY OF PAST AND PRESENT ILLNESS

A. History of Past Illness

Our patient had experience mumps, chicken pox and seasonal cough and colds as

well as fever during her childhood and used to manage these illnesses by home

remedies such as using available health resources by means of using herbal plants that

they believe can treat the said illnesses. According to her she had completed her

childhood immunization. She also claims that she had no known allergies to food and

drugs. But she claims that she is hypertensive since then. Our patient was diagnosed

with CRF and with a stage of ESRD @ metro Vigan. IVP was performed and this

confirms the diagnosis of our patient. According to our patient she’s in and out of the

hospital many times. Due to her condition, our patient had been advised to have an

AV fistula @ Metrovigan on January 10, 2010 at the left hand as an access for her

dialysis.

Few months later it was damaged with unrecalled reason , and her attending

physician suggested that they must have another access for her dialysis then they

inserted a catheter on her intrajugular vein on the left side of her neck, since then

they used it every time she’s undergoing dialysis, her lasts dialysis was on September

07, 2010 @ APH.

B. History of Present Illness

Our patient with her husband went at APH because she experienced DOB. She

was given initial treatment of D5W 1L X KVO regulated @ 10 gtts/min. hooked at

the right metacarpal vein infusing well, and O2 inhalation was hooked via NC at 3-4

Lpm. She was then admitted on September 14, 2010 @ 9:35 am with an admitting

diagnosis of ESRD by Dr. AT. She was forwarded at ICU and stayed there for28

days.

C. Familial History

According to our patient, both his paternal and maternal side had no known

serious diseases such as heart attack, diabetes mellitus, and cancer but claims that her

maternal side had a history of hypertension. They also experienced common illnesses

such as cough and colds, and fever which they treated with herbal medications.

D. Social History

According to our patient she got married when she was 25 and God gave them 3

children, a girl and a twin boy. Farming is the primary source of their food and

income to support their needs. She also claims that she had a good relationship with

her neighbors. She is fund of eating salty foods and often used “bagoong” as sauce in

anything she eats she also says that she loves soft drinks.

IV. NURSING ASSESSMENT (September 23, 2010 @ 8:00 am)

A. Maslow’s Hierarchy of Needs:

1. Physiologic Needs

O2 inhalation was hooked via NC @ 3-4 Lpm. DAT was maintained.

Wasn’t able to pass out urine and stool. She remains silent when asked about her

sexual life.

2. Safety and Security

Our patient feel safe and secured in the presence her husband who is

always there to accompany her in performing activities of daily living such as

toileting, feeding, and hygiene.

3. Love and Belongingness

Aside from her husband our patient, also felt the love rendered by the

health care providers in the hospital. Rapport was established by the staffs and

students nurses in order to obtain accurate information regarding his condition.

4. Self-Esteem

“Sakno ngatan Deng, kastoy met ti kasasaad kon?” as verbalized by the

patient which is an expression of diminishing self-esteem.

5. Self-Actualization

According to our patient, she will be self-actualized if she will be treated

and to see her children finished their studies.

B. Physical Assessment

1. General Survey

Our patient is a 38 year old, female she appears weak and often complaints

difficulty of breathing. Generalized edema was seen.

Vital Signs:

BP: 130/90 mmHg Temp.: 37.5 °C

PR: 76bpm RR: 42 cpm

2. Cephalocaudal Assessment

Integumentary System:

Poor skin turgor noted and anasarca.

Head:

Round in shape.

Hair is short and brittle with white hair noted

Evenly distributed.

Eyes:

Both eyes reveals that pupils are equally round reactive to light

accommodation upon assessment.

Pale conjunctiva noted.

Ears:

Able to recognize hear and understand spoken words.

No lumps or masses and tenderness were noted on both ears upon

palpation.

(+) discharges noted

Nose:

Nose is patent upon assessment.

Upon palpation, no tenderness/masses and pain noted.

(+) nasal flaring

O2 inhalation via NC @ 3-4 Lpm.

Mouth and Lips:

No lesions were found in the mouth but dry mouth is noted.

(+) plaque noted

Incomplete set of teeth.

Neck:

Neck has strength when move from different directions with full ROM

IJ catheter @ the right side with intact dressing.

Chest:

(+) adventitious sounds upon auscultation (wheezing)

Respiratory Rate 42 breathes per minute from the normal range of 16-

20 breaths per minute.

Abdomen:

(-) scar noted

(+) abdominal bloating noted.

Genitourinary:

Never defecated and urinated during our shift

Upper and Lower extremities:

With an ongoing IVF of D5W1L @ 600cc level regulated @

30gtts/min @ the right metacarpal vein. Infusing well.

(+) scars and lesions were noted.

Warm to touch.

V. ANATOMY AND PHYSIOLOGY

Kidneys

The kidneys balance the urinary excretion of substances against the accumulation

within the body through ingestion or production. Consequently, they are major controller

of fluid and electrolyte homeostasis. The kidneys also have several non-excretory

metabolic and endocrine functions, including blood pressure regulation, erythropoietin

production, insulin degradation, prostaglandin synthesis, calcium and phosphorus

regulation and Vitamin D metabolism.

The kidneys are located retroperitoneally, in the posterior aspect of the abdomen,

on either side of the ventral column. They lie between the 12th thoracic and third lumbar

vertebrae. The left kidney is usually positioned slightly higher than the right. Adult

kidneys are average approximately 11 cm in length, 5 to 7.5 cm in width, and 2.5 cm in

thickness. The kidney has a characteristic curved shape, with a convex distal edge and a

concave medial boundary.

Functions of the Urinary System

The major functions of the urinary systems are performed by the kidneys and the

kidneys play the following essentials roles in controlling the composition and volume of

body fluids:

1. Excretion.

The kidneys are the major excretory organs of the body. They remove waste

products, many of which are toxic, from the blood.

Most waste products are metabolic by products of cells and substances

absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some

of these waste products, but they cannot compensate if the kidneys fail to

function.

2. Blood volume control

The kidneys play an essential role in controlling blood volume by regulating

the volume of water removed from the blood to produce urine.

3. Ion concentration regulation.

The kidneys help regulate the concentration of the major ions in the body

fluids.

4. pH regulation.

The kidneys help regulate the pH of the body fluids. Buffers in the blood and

the respiratory system also play important roles in the regulation of pH

5. Red blood cell concentration

The kidneys participate in the regulation of red blood cell production and

therefore, in controlling the concentration of red blood cells in the blood.

6. Vitamin D synthesis

The kidneys along with the skin and the liver, participate in the synthesis of

vitamin

Ureters, Urinary Bladder and Urethra

The ureters are small tubes that carry urine from the renal pelvis of the kidney to

the posterior inferior portion of the urinary bladder. The urinary bladder is a hollow

muscular container that lies in the pelvic cavity just posterior to the pubic symphysis. It

functions to store urine, and its size depends on the quantity of urine present. The urinary

bladder can hold from a few milliliters to a maximum of about 1000 mL of urine. When

the urinary bladder reaches a volume of a few hundred mL, a reflex is activated, which

causes the smooth muscle of the urinary bladder to contract and most of the urine flows

out of the urinary bladder through urethra. The urethra is a tube that exits the urinary

bladder inferiorly and anteriorly. The triangle-shaped portion of the urinary bladder

located between the opening of the ureters and the opening of the urethra is called

trigone. The urethra carries urine from the urinary bladder to the outside of the body.

Renal Blood flow and Glomerular Filtration

The kidney receive 20% to 25% of the cardiac output under resting conditions,

averaging more than 1 L of arterial blood per minute. The renal arteries branch from the

abdominal aorta at the level of he second lumbar vertebra, enter the kidney, and

progressively branch into lobar arteries. Blood flows from the interlobular arteries

through the afferent arteriole, the glomerular capillaries, the efferent arteriole and the

peritubular capillaries. Some of the peritubular capillaries carry a small amount of blood

to the renal medulla in the vasa recta before entering the venous drainage. The blood

leaves the kidney in venous system closely corresponding to the arterial system:

interlobular veins, arcuate veins, interlobar veins, and the renal vein. The renal circulation

then empties into the inferior vena cava.

Physiology Characteristics of Urine

Urine is a watery solution of nitrogenous waste an inorganic salts that are

removed from the plasma and eliminated by the kidneys. It is 5% water and 5% dissolved

solids and gases. The amount of these dissolved substances is indicated by it specific

gravity. The specific gravity of pure water, used as a standard is 1.000. Because of the

dissolved materials it contains, urine has a specific gravity that normally varies from

1.010 to 1.040. When the kidneys are diseased, they lose the ability to concentrate urine,

and the specific gravity no longer varies as it does when the kidneys function normally.

Urine formation

The chief function of the kidneys is to produce urine. Each part of the nephrons

performs a special function. There are three important processes by which urine is

formed. They are glomerular filtration, tubular reabsorption and tubular secretion.

The Path of the Formation of Urine

Blood enters the Efferent arterioles

Passes through the Glomeruli

To Bowman’s capsule

Now it becomes filtrate (blood minus RBC’s and plasma protein protein

Continues through the proximal convulated tubule

To the loop of Henle

To the distal convulated tubule

To the collecting tubule (at this about 99% of the filtrate has been reabsorbed)

Approximately 1 ml of urine is formed per minute and goes to the renal pelvis

To the ureter

To the bladder

To the urethra

To the urinary meatus

VI. PATHOPHYSIOLOGY

Predisposing factors Precipitating factors- Age (38) - Lifestyle- Hypertensive - Diet (salty foods)- Gender (female)

Renal Malfunction

Nephrons are permanently destroyed

Kidneys become unable to respond to excessive or decreased salt and fluid intake

Synthesis of erythropoietin diminishes, and the kidneys are unable to excrete end products of metabolism

Number of substances that are normally excreted accumulate in the body, including nitrogenous waste, electrolytes, and uremic toxins

Signs and Symptoms

Cardiovascular System Hypertension Anemia Weight gain Pulse irregularity Arrhythmia

Integumentary System Dry Skin Uremic frost skin Severe itching Thin and brittle hair Yellow bronze skin

Musculoskeletal System Gait abnormality Inability to

ambulate Loss of muscle

strength

Pulmonary System DOB Insufficient breath

sound Kussmaul’s

respiration

Neurologic System Leastlessness Attention deficit Irritability

Gastrointestinal System Ammonia breath Anorexia

Genitourinary System Changes in urine

pattern

Management Dialysis Medications

- Paracetamol 300mg IV 4˚q̄�- Hydrocortisone 100mg IV 6˚q̄�- Ranitidine 50mg IV 12˚q̄�- Furosemide 20mg IV OD- Calcium Carbonate 1 tab TID- Sodium Bicarbonate 1 tab TID- Salbutamol nebule 2.5cc q 4˚�

-

Untreated Complications may occur Anemia Bleeding from the stomach or

intestine Heart and blood vessel

complications:- High blood pressure- Pericardidits- Stroke

Increased risk in infections Malnutrition Seizures Weaking of the bones and increase

risk of fractures Possibly death

VII. DIAGNOSTICS EXAMS

A. Ideal

Urinalysis

This test detects ion concentration of the urine. Small amounts of protein or

ketoacidosis tend to elevate results of the specific gravity. Specific gravity is an

expression of the weight of a substance relative to the weight of an equal volume of

water. Water has a specific gravity of one. The specific gravity of your urine is

measured by using a urinometer. Knowing the specific gravity of your urine is very

important because the number indicates whether you are hydrated or dehydrated. If

the specific gravity of your urine is under 1.007, you are hydrated. If your urine is

above 1.010, you are dehydrated.

Renal Scan

A Renal Scan is used to help diagnosis kidney disease and certain problems

with the rest of the urinary tract. It is primarily used to evaluate the function and size

of the kidneys.

Complete Blood Count

A complete blood count (CBC), also known as full blood count (FBC) or full

blood exam (FBE) or blood panel, is a test panel requested by a doctor or other

medical professional that gives information about the cells in a patient's blood. A

scientist or lab technician performs the requested testing and provides the requesting

medical professional with the results of the CBC. Blood studies show elevated blood

urea nitrogen, serum creatinine, and potassium levels; decreased arterial pH and

bicarbonate; and low hemoglobin (Hb) level and hematocrit (HCT).

Urine Culture

A urine culture is a diagnostic laboratory test performed to detect the presence

of bacteria in the urine (bacteriuria). There are several different methods for

collection of a urine sample. The most common is the midstream clean-catch

technique. Hands should be washed before beginning. For females, the external

genitalia (sex organs) are washed two or three times with a cleansing agent and rinsed

with water. In males, the external head of the penis is similarly cleansed and rinsed.

The patient is then instructed to begin to urinate, and the urine is collected midstream

into a sterile container. In infants, a urinary collection bag (plastic bag with an

adhesive seal on one end) is attached over the labia in girls or a boy's penis to collect

the specimen.

Intravenous Pyelogram (IVP)

An intravenous pyelogram (also known as IVP, pyelography, intravenous

urogram or IVU) is a radiological procedure used to visualize abnormalities of

the urinary system, including the kidneys, ureters, and bladder.

An injection of x-ray contrast media is given to a patient via a needle

or cannula into the vein, typically in the arm. The contrast is excreted or removed

from the bloodstream via the kidneys, and the contrast media becomes visible on x-

rays almost immediately after injection. X-rays are taken at specific time intervals to

capture the contrast as it travels through the different parts of the urinary system. This

gives a comprehensive view of the patient's anatomy and some information on the

functioning of the renal system.

Renal function Test

Renal function test are used to determine effectiveness of the kidney’s

excretory functioning, to evaluate the severity of kidney’s disease and to follow the

patient’s progress.

ABG Analysis

Blood is taken from an artery in wrist, arm or groin. The blood is tested for the

amount of gases in it, such as oxygen, acids and carbon dioxide as well as the pH of

the blood that provides a means of assessing the adequacy of ventilation and

oxygenation.

B. Actual

URINALYSIS (September 15, 2010)

LAB TEST RESULT NORMAL VALUE SIGNIFICANCE

COLOR Straw , light yellow Amber straw significant

TRANSPARENCY Slightly turbid Clear significant

ALBUMIN +++ Negative significant

PUS CELLS 1-2/hpf 0-1hpf significant

RBC 1-3/hpf Negative significant

BACTERIA ++ Negative significant

EPITHELIAL

CELLS

+ Negative Significant

Interpretation:

Laboratory results revealed that there is the presence of albumin in the blood

which indicates that the glomerulus cannot filter large molecules such as that of albumin.

It also revealed that there is bacterial infection as evidenced by the presence of bacteria,

pus cells and red cells in the urine.

HEMATOLOGY (September 15, 2010)

RESULT NORMAL VALUES SIGNIFICANCE

WBC 7.4 103/mm3 4.0-11.0 Non-significant

RBC 2.23 L 10 6/mm3 3.80-5.80 Significant

HGB 6.8 L g/dL 12.0-17.0 Significant

HCT 18.3 L % 36.0-52.0 Significant

PLT 241 10 3/ mm3 150-450 Non-significant

PCT .179 % .100-.500 Non-significant

MCV 82 um3 80-97 Non-significant

MCH 30.3 pg 26.5-33.5 Non-significant

MCHC 36.9H g/dL 31.5-35.0 Significant

RDW 17.7H % 10.0-15.0 Significant

MPV 7.4 u m3 6.5-11.0 Non-significant

PDW 174% 100-180 Non-significant

Interpretation:

HCT and HGB were all below the normal level, thus indicating renal malfunction

and thereby, causing anemia (Decreased erythropoietin synthesis 2˚ to renal malfunction).

VIII. MANAGEMENT

A. Ideal Management

1. Medical

Erythropoietin agonists - for management of anaemia associated with chronic

renal failure

Phosphate binders - for management of hyperphosphatemia in chronic renal

failure

Calcium supplements - for hypocalcaemia associated with chronic renal

failure

Calcitriol and other Vitamin D supplements - for hypocalcaemia and

hyperparathyroidism associated with chronic renal failure

Sodium bicarbonate - for acid-base disturbance

Loop Diuretics with fluid restrictions as needed

Use of ACE inhibitors - in patients both with and without proteinuria, has

been shown to slow the progression of renal failure

2. Surgical

Dialysis

It refers to the diffusion of solute molecules through a semipermeable

membrane, passing from the side of higher concentration to that of lower

concentration. The purpose of dialysis is to maintain the life and well-being of the

patient. It is a substitute for some kidney excretory functions but does not replace

the kidney’s endocrine and metabolic functions.

Types:

1. Hemodialysis

In hemodialysis, the patient's blood is then pumped through the

blood compartment of a dialyzer, exposing it to a partially permeable

membrane. The dialyzer is composed of thousands of tiny synthetic

hollow fibers. The fiber wall acts as the semipermeable membrane.

Blood flows through the fibers, dialysis solution flows around the

outside the fibers, and water and wastes move between these two

solutions. The cleansed blood is then returned via the circuit back to

the body. Ultrafiltration occurs by increasing the hydrostatic pressure

across the dialyzer membrane. This usually is done by applying a

negative pressure to the dialysate compartment of the dialyzer. This

pressure gradient causes water and dissolved solutes to move from

blood to dialysate, and allows the removal of several litres of excess

fluid during a typical 3 to 5 hour treatment.

2. Peritoneal Dialysis

In peritoneal dialysis, a sterile solution containing glucose is run

through a tube into the peritoneal cavity, the abdominal body cavity

around the intestine, where the peritoneal membrane acts as a

semipermeable membrane.

Continuous Renal Replacement Therapy (CRRT)

CRRT is a mode of renal replacement therapy for hemodynamically

unstable, fluid overloaded patients and patients with sepsis and septic shock in

management of acute renal failure especially in the intensive care unit setting.

The popularity of ‘slow continuous therapies’ for the treatment of critically ill

patients with renal failure is increasing. The techniques which are most

commonly used are slow continuous hemodialysis and hemodiafiltration.

Slow continuous hemofiltration and slow continuous ultrafiltration also are

commonly used. Management in initial hours to counter the derangements in

critically ill patients is the most vital thing in the therapy. CRRT initiated for

ARF in critically ill patients should serve as a renal ‘replacement’ therapy

mimicking as artificial kidney support. It should enhance recovery of the

native kidneys with prevention of hyperkalemia, hyper/hyponatremia,

acidosis/alkalosis and rapid correction of pulmonary/peripheral edema by

gradual and consistent removal of extra fluid retained in the body.

Kidney transplant

Kidney transplantation or renal transplantation is the organ transplant of

a kidney into a patient with end-stage renal disease. Kidney transplantation is

typically classified as deceased-donor (formerly known as cadaveric) or

living-donor transplantation depending on the source of the donor organ.

Living-donor renal transplants are further characterized as genetically related

(living-related) or non-related (living-unrelated) transplants, depending on

whether a biological relationship exists between the donor and recipient.

Arteriovenous Fistula

An AV fistula requires advance planning because a fistula takes a while

after surgery to develop (in rare cases, as long as 24 months). But a properly

formed fistula is less likely than other kinds of vascular accesses to form clots

or become infected. Also, fistulas tend to last many years, longer than any

other kind of vascular access. A surgeon creates an AV fistula by connecting

an artery directly to a vein, usually in the forearm. Connecting the artery to the

vein causes more blood flow into the vein. As a result, the vein grows larger

and stronger, making repeated insertions for hemodialysis treatment easier.

For the surgery, you will be given a local anesthetic. In most cases, the

procedure can be performed on an outpatient basis.

These fistulas require up to 6 weeks to mature before they can be used,

which makes this approach inappropriate for immediate hemodialysis.

Peritoneal dialysis or large venous access catheters may be used while the

fistula is maturing. External arteriovenous shunts are rarely used.

B. Actual

1. Medical Management

D5W1L x 8° @ 30gtts/min @ the right metacarpal vein

O2 inhalation was hooked via NC @ 3-4 Lpm

Meds.

Ranitidine HCl 50 mg IV qˉ 8°

Hydrocortisone 50 mg qˉ 8°

Salbutamol nebule 2.5cc qˉ 4°

Furosemide 25 mg IV OD

Paracetamol 300 mg IV PRN

Calcium Carbonate 1 tab TID

Sodium Bicarbonate 1 tab TID

2. Nursing Management

Recognize the patient for risk of recurrence for infection

Monitored Intake &output

Monitored V/S every hour to serve as baseline data

Encouraged to avoid high protein, sodium and potassium rich foods to prevent

further complications.

Instructed to do deep breathing relaxation to promote generalized relaxation

Positioned in semi-fowlers to promote comfort.

Administered medications as ordered.

XI. HEALTH TEACHINGS

Encouraged patient to do deep breathing to facilitate lung expansion.

Instructed patient to have enough rest to gain strength.

Instructed to avoid rich in protein, sodium and potassium foods to prevent further

complication and may slow the progress of renal failure.

Instructed to eat nutritious foods (high in calorie diet) to strengthen the immune

system.

Advised to drink limited amounts only when thirsty.

Advised to eat food before drinking fluids to alleviate dry mouth.

Advised to use hard candy, chewing gum to moisten mouth.

Emphasized the importance of proper hygiene to promote comfort.

Reinforced SO and patient the importance of treatment because lack of cooperation

may lead to failure of therapy.

Advised patient not to see things complicatedly regarding her condition but rather

take it as a challenge to strengthen her faith in God.