Med Surg ESRD

Group 5 13B

End Stage Renal Failure Secondary to Diabetes Nephropathy

CHAPTER 1INTRODUCTION

Diabetes Mellitus is the leading cause of end stage renal disease (ESRD) andrenal failure in the United States. Diabetic nephropathy affects 20%-30% ofthose with type 1 diabetes 20 years after onset. Although less than 20% ofclients with ESRD have type 2 diabetes (NIDDK,2004).There are about 6,500 yearly deaths in the country secondary to variouskidney diseases (Kidney Center)A number of underlying diseases can cause progressive renal failure. Chronicglomerulonephritis (CGN) is the most common cause (47 percent) of ESRD inFilipinos. Other causes include chronic pyelonephritis (17 percent), diabetesmellitus (13 percent), and hypertensive nephrosclerosis (5 percent) (KidneyCenter of the Philippines, Medical City 1975-1981). er of the Philippine, Medical City 1995-2001)

OBJECTIVES

• General Objective:

Within our 3-day clinical exposure at Davao Doctors Hospital, The group will be able to assess, analyze, plan for nursing intervention, implement and evaluate the case of our patient who has End Stage Renal Failure (ESRD) secondary to Diabetes Mellitus Type 2 secondary to Diabetes Nephropathy.

Specifically our objective is to:• Establish rapport with the patient and family;• Gather all important data from the patient himself, from his family

and from the chart as basis for study;• Make a comprehensive assessment of the patient;• Enumerate the necessary laboratory test undergone by the patient

for the diagnosis and treatment of the disease;

• To know the anatomy and physiology of metabolic and renal system;

• Know the pathophysiology of the disease process;• Identify the different medical/surgical treatment done for

the patient;• Identify different drugs that is used for treatment with their

specific actions, indications, dose , interactions,adverse reactions and nursing implications and responsibilities;

• Formulate a plan of care which will based on identified actual and potential health problem;

• Give recommendations and health teachings based on the identified actual and potential health problem;

DEFINITION OF TERMS

• Chronic Kidney Disease. Is long-standing, progressive deterioration of renal function.

• Dialysis. Done to the patient having chronic renal disease incapable of cleansing the blood and disposing waste in the body

• Diabetes mellitus. One of the factor why person acquire renal failure

• Edema. Is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body

• Hypertension. Cause by the malfunction of the kidney as the result of renal failure.

• Lifestyle. Precipitating factors that causes person to have chronic renal failure

CHAPTER IIPATIENT’S PROFILE

A. Personal Profile• Patient’s name: Mr. X• Age: 54 years old• Sex: Male• Nationality: Filipino• Religion: Roman Catholic• Occupation: Businessman• Civil Status: Married• Date of Admission: February 20, 2010• Attending Physician: Dr. Maglana; Dr. Isaguirre; Dr.

Coching• Discharge Diagnosis: ESRD 2˚ DM nephropathy DM type II

• B. Medical History• When Mr. X was 26 years old, he was diagnosed

with Diabetes Mellitus Type 2. Five years ago, Mr. X was admitted to St. Luke’s Medical Center and was diagnosed with benign prostatic hyperplasia. In the year 2003, Mr. X undergone 3 consecutive eye operations on the same eye, the first operation was due to a blood clot, the second and third operations were due to ocular bleeding. Last July 2009, Mr. X was admitted twice at St. Luke’s Medical Center due to edema of the lower extremities. He was diagnosed to have a nephropathy secondary to DM. On the same month and year, he was ordered to undergo hemodialysis and still continues up to present.

• C. Present Illness• Two days prior to admission (PTA), Mr. X

experienced body weakness and joint pains in the lower extremities. BP was taken at home. No consultation done because the condition was tolerable. One day PTA, the patient still experienced body weakness with headache and nausea. Consultation was done; BP was taken with medications given. Hours prior to admission, body weakness still noted and prompted admission at Davao Doctors Hospital.

• D. Comprehensive Assessment• 1.Family background• Mr. X, 54, years old, one of the six offspring of

Mr. XY and Mrs. XX. His mother has a history of hypertension and died due to complicated cardiac problem. His father has a diabetes mellitus (DM) and died due to cardiac arrest. Among his five siblings, one of them has DM and one has hypertension. Among them, Mr. X is the only one who has renal failure.

• 2.Effects / Expectations of Illness to Family and Self:

• Mr. X, his wife and his 3 children are very worried about his present condition. Even though they know that his condition is already complicated, they still hope for his recovery. They want Mr. X to be discharged from the hospital as soon as possible this is because it has been a long time that they've staying there. This situation had led his family members to become more conscious of there health. They've learned that no matter how wealthy you are, you can never escape any forms of illnesses.

• 3. History of Past Illness:• When Mr. X was 26 years old, he was diagnosed

with Diabetes Mellitus Type 2. Five years ago, Mr. X was admitted to St. Luke’s Medical Center and was diagnosed with benign prostatic hyperplasia. In the year 2003, Mr. X undergone 3 consecutive eye operations on the same eye, the first operation was due to a blood clot, the second and third operations were due to ocular bleeding. Last July 2009, Mr. X was admitted twice at St. Luke’s Medical Center due to edema of the lower extremities. He was diagnosed to have a nephropathy secondary to DM. On the same month and year, he was ordered to undergo hemodialysis and still continues up to present.

• 4. History of Present Illness:• Two days prior to admission (PTA), Mr.

X experienced body weakness and joint pains in the lower extremities. BP was taken at home. No consultation done because the condition was tolerable. One day PTA, the patient still experienced body weakness with headache and nausea. Consultation was done; BP was taken with medications given. Hours prior to admission, body weakness still noted and prompted admission at Davao Doctors Hospital.

GUIDELINES PATIENT DAY 1 DAY 2 DAY 3

I. Mental Status

a. state of mental

consciousness

The patient is

conscious, alert and

coherent

The patient is conscious,

and coherent


and coherent


and coherent

b. orientation The patient is oriented

to person, time, place

and events occurring in

the environment

The patient is oriented to

person, time, place and

events occurring in the

environment




environment




environment

c. intellectual capacity The patient is able to

understand and

comprehend instructions

and commands

The patient is able to

understand and


and commands


understand and


and commands


understand and


and commands

d. vocabulary level The patient is able to

speak and understand

his vernacular, the

National Language and

the Universal language



his vernacular (Visayan),

the National Language

and the Universal

language





and the Universal

language





and the Universal

language

e. attention span The patient has a long

attention span

The patient has a short

attention span with 5-7

min concentration.

The patient has a long

attention span, with 15-

20 minute concentration

The patient has a long

attention span, with 15-

20 minute concentration

f. ability to understand The patient is able to

respond to questions,

commands/ instructions

with coherence




with coherence




with coherence




with coherence

II. Status of Special

Senses

a. auditory perception The patient is able to

hear moderate to loud

sounds and interpret

auditory stimuli

appropriately




auditory stimuli

appropriately




auditory stimuli

appropriately




auditory stimuli

appropriately

b. visual perception The patient is able to

see near and far

objects, interpret the

visual stimuli

appropriately and has

visual acuity of 20/20.

The patient is

nearsighted, able to

interpret visual stimuli

clearly with the use of

eyeglasses.

The patient is




eyeglasses.

The patient is




eyeglasses.

c. speech perception The patient is able to

speak clearly with

coherence


speak clearly with

coherence


speak clearly with

coherence


speak clearly with

coherence

d. tactile perception The patient is able to

feel different textures

and temperature, able to

identify the origin of

stimuli.





stimuli.





stimuli.





stimuli.

e. olfactory perception The patient is able to

smell and identify

different aromas and

odors appropriately


smell and identify


odors appropriately


smell and identify


odors appropriately


smell and identify


odors appropriately

III. Motor Ability

a. current mobility The patient can freely

move both upper and

lower extremities, able

to walk, stand and sit

without support.

The patient can't move

freely, with easy

fatigablity, with weak

movement of upper and

lower extremities, in

complete bed rest with

out bathroom privileges.


freely, with easy



lower extremities,in


out bathroom privileges


freely, with easy



lower extremities,in


out bathroom privileges

b. posture The patient can stand

straight, sit erect and

has proper gait.

The patient is in

complete bed rest,

positioned in high back

rest.

The patient is in

complete bed rest,


rest.

The patient is in

complete bed rest,


rest.

c. range of motion The patient is able to flex

and extend both upper

and lower extremities

The patient is able to flex


and lower extremities but

with weak movements




with weak movements




with weak movements

d. muscle and nervous

status

The patient has

moderate to strong

muscular movements.

With a musculoskeletal

status score of 5 points =

ability to move

independently. With

muscular strength of 5=

active movement against

gravity without evident

fatigue.

The patient has a weak

muscular movement with

a musculoskeletal status

score of 3 points =

dependent on others,

with muscular strength of

3= active movement

against gravity with

evident fatigability




score of 3 points =



3= active movement


evident fatigability.




score of 3 points =



3= active movement


evident fatigability.

e. loss of extremities The patient has

complete extremities

The patient has


The patient has


The patient has


IV. Body Temperature

a. ranges Tympanic temperature

ranges from 37 – 37. 5

degrees centigrade

Tympanic temperature

ranges from 36.0– 36.8

degrees centigrade


ranges from 36.0-36.5

degrees centigrade


ranges from 36.0 – 36. 7

degrees centigrade

V. Respiratory Status

a. characteristics The patient has

respiratory rate range of

16-20 cpm, with equal

depth of respiration

The patient has




The patient has




The patient has




b. use of respiratory

aids

The patient has no

oxygen inhalation,

tracheostomy tube or

endotracheal tube

The patient has no

oxygen inhalation,


endotracheal tube

The patient has no

oxygen inhalation,


endotracheal tube

The patient has no

oxygen inhalation,


endotracheal tube

c. interference with

respiration

The patient has clear

breath sounds on both

lungs, without

tracheobronchial

secretions



lungs, without

tracheobronchial

secretions



lungs, without

tracheobronchial

secretions



lungs, without

tracheobronchial

secretions

VII. Nutritional Status

a. condition of the

buccal cavity

The patient has pinkish

buccal cavity with

enough moisture.

The patient has pale

buccal cavity with

dryness noted.


buccal cavity with

dryness noted.


buccal cavity with

dryness noted.

b. digestion of food The patient has appetite,

able to consume whole

amount of food served

The patient has appetite,









c. weight 54 kg 49kg 49 kg 49 kg

VIII. Elimination Status

a. bowel The patient is able to

defecate 2 times a day,

with soft stool, golden

brown in color, aromatic













b. bladder The patient is able to

urinate freely, with urine

output of 30-40 ml/hour

depending on the intake

and patient's weight, with

transparent urine

characteristics ranging

from yellow to dark

amber, with aromatic

smell


urinate freely with urine

output of 20 cc for 8

hours with a total intake

of 650 cc, with

transparent urine, dark

amber in color, with

aromatic smell





of 450 cc , with



aromatic smell





of 540 cc, with



aromatic smell

c. abnormalities The patient has proper

excretory process

The patient has

decreased urine output.

The patient has


The patient has


IX. State of Skin And

Appendages

a. skin The patient has intact

and fair skin, with even

distribution of

temperature, with

proper moisture, with

normal skin turgor

The patient has pale,

cold and dry skin, with

decreased skin turgor,

with edema noted on

both lower extremities,

with round- shaped

hyperpigmentations on

both tibial area, with

small dry necrosed

tissue on the right pedal

phalange.




with edema noted on


with round- shaped



small dry necrosed


phalange.




with edema noted on


with round- shaped



small dry necrosed


phalange.

b. hair The patient has fine,

strong and silky hair,

with even distribution,

with normal porosity.

The patient has fine,

strong and dry hair, with

even distribution, with

decreased porosity.




decreased porosity.




decreased porosity.

c. nails The patient has well

trimmed nails, properly

keratinized, with pink

nail beds.

The patient has well


keratinized, with pale

nail beds.




nail beds.




nail beds.

X. State of Physical

Rest and Comfort

a. sleep/rest pattern The patient is able to

sleep 6-8 hours a day

with resting time in the

middle of the day




middle of the day




middle of the day




middle of the day

b. presence of

pain/discomfort

The patient is

comfortable.

The patient is

comfortable.

The patient is

comfortable.

The patient is

comfortable.

c. use of supportive aids No use of supportive

aids

No use of supportive

aids


aids


aids

XI. Emotional Status

a. emotional reaction The patient is able to

react appropriately to

situations, with happy

disposition

The patient has a fair

disposition. He feels

irritable,

The patient has a fair

disposition. He feels

irritable and seldom

smiles.


react appropriately to

situations, with happy

disposition

b. body image The patient has a high

self-esteem and is

confident with his body

structures

The patient has a high

self-esteem and is


structures


self-esteem and is


structures


self-esteem and is


structures

c. ability to relate to

others

The patient is

cooperative, with less

interaction to people

around him.

The patient is



around him.

The patient is



around him.

The patient is



around him.

E. Diagnosis/ ImpressionESRD 2˚ DM nephropathy DM type II

CHAPTER IIIReview of Anatomy and Physiology

• The anatomy and physiology of the human kidney, evolved over millennia, enable this organ to excrete waste, regulate homeostatic processes and produce important hormones.

• One of the most complex, beautifully “engineered” organs of the human body, the kidneys perform several essential tasks including the excretion of waste products, the maintenance of homeostatic balance in the body and the release of important hormones. To achieve this, human kidneys have a highly developed, superbly refined anatomy and physiology.

• Location and Basic Structure of the Kidneys• The kidneys are located near the vertebral column at

the small of the back; the left kidney lying a little higher than the right. Each is identical in structure and function. They are bean-shaped, about 10 cm long and 6.5 cm wide. Each kidney comprises an outer cortex and an inner medulla. The kidney is supplied with oxygenated blood via the renal artery and drained of deoxygenated blood by the renal vein. In addition, urine produced by the kidney as part of its excretory function, drains out via narrow “tubules” and the ureter, in turn connected to the bladder.

• The Nephron• The main functional unit of the kidney is the nephron.

There are approximately one million nephrons per kidney. The role of nephrons is to make urine by:

• * Filtering blood of small molecules and ions such as water, salt, glucose and other solutes including urea. Large “macromolecules” like proteins are untouched.

• * Recycling the required quantities of useful solutes which then re-enter the bloodstream. (A process called reabsorption)

• * Allowing surplus or waste molecules/ions to flow from the tubules/ureter as urine.

• Filtration and Reabsorbtion in the Kidneys• During progress through the nephron, some solutes like sodium

chloride, potassium and glucose are reabsorbed, along with water, back into the bloodstream. This maintains a correct balance of these chemicals within the blood, assisting blood pressure regulation, for example. The filtration and reabsorbtion of glucose within the kidneys also helps to maintain correct levels of vital blood sugars. When this regulation breaks down very serious health consequences can follow.

• Urea and uric acid are nitrogen containing waste products from metabolic processes in the body. These substances are potentially toxic and are partially excreted by the kidneys to maintain good health. Interestingly, of the filtrate which enters each nephron from the blood, only about 1% actually leaves the body as urine because of the various reabsorbtion mechanisms driven by osmosis, diffusion, and active transport.

• Tubular Secretion in the Kidneys• Another, less familiar, mechanism for urine production in the

kidneys is tubular secretion. Specialized cells move solutes directly from the blood into the tubular fluid. For example, hydrogen and potassium ions are secreted directly into the tubular fluid. This process is “coupled” or balanced by the re-uptake of sodium ions back into the blood.

• Tubular secretion of hydrogen ions, augmented by control of bicarbonate levels, is important in maintaining correct blood pH. When the blood is too acidic (acidosis) more hydrogen ions are secreted. If the blood becomes too alkaline (alkalosis), hydrogen secretion is reduced. In maintaining blood pH within normal limits (about 7.35–7.45) the kidney can produce urine with pH as low as that of acid rain or as alkaline as baking soda!

• The Kidney as an Endocrine Gland• In addition to its excretory and homeostatic roles, the

kidneys also release two important hormones into the blood. These are:

• * Erythropoietin which acts on bone marrow to increase the production of red blood cells

• * Calcitriol which promotes the absorption of calcium from food in the intestine and acts directly on bones to shift calcium into the bloodstream.

• Finally the kidney produces the enzyme renin, an important regulator of blood pressure.

CHAPTER IVPATHOPHYSIOLOGY

Pre-disposing Factors Actual Rationale

Increasing Age Mr. is 54 years old. Among older adult ( 24-64 y/o) and elderly person, the

presentation and course of renal failure may be altered

because of age-related changes in the kidney and

occurrent medical conditions . Normal aging is associated

with a decline in the GFR and subsequently with reduced

homeostatic regulation under stressful conditions. This

reduction of GFR makes these persons more susceptible

to the detrimental effects of nephrotoxic drugs and other

medical conditions.( Porth, 2005)

Sex The client is a male. ESRD is more prevalent in men, 54 % of ESRD patients

are men whereas 46% are women. This also refers to the

dominance of males in the relapse of toxins (Nowak,

2005). In both study populations, males were more likely

to have ESRD due to hypertension.(

http://www.niddk.nih.gov/fund/reports/womenrd/poster/po

ster5.htm)

A.Etiology

Race Mr. is from an Asian ethnic

group( Filipino)

Renal disease is more common in patients of Asian ethnic

origin than white Caucasians in the United Kingdom. The

incidence rate of end-stage renal failure expressed for the

estimated population of pts. with diabetes Mellitus in

Asian ethnics was 486.6 cases per M person years

compared to 35.6 in white caucasians. The high incidence

of end stage renal failure had secondary to DM for most

patients in Asian ethnic group. (Bullock, 2000)

Genetics Maternal side: Hypertension (+)

Paternal side: Diabetes Mellitus 2 (+)

Diabetes Mellitus from a genetic predisposition (i.e.

diabetogenic genes), a hypothetical triggering event that

involves an environmental agent that incites an immune

response and immunologically mediated beta cell

destruction. Much evidence has focused on the inherited

major compatibility complex ( MHC) genes that encode

three human leukocyte antigens ( HLA_DP, HLA_DQ and

HLA_DR) found on the surface of body cells. Insulin gene

regulating eta cell replication and function has been

identified on chromosome 11. (Porth, 2005)

Precipitating Factors Actual Rationale

Lifestyle(diet, exercise,) Mr. loves to eat salty, fatty & sugary

foods such as

cured meats (ham, sausage, bacon,

corned beef,), chicken and pork viand,

cheese and butter, coke soda(more often

every meal) and coffee.

Mr. has sedentary lifestyle with no or

irregular .

physical activity. He is an owner of one bi

g transportation company and works only

in computer and papers.

Foods that are high in calories (saturated fats), lack of

antioxidants and fibbers as well as high in phosphorus,

potassium, and

sodium can lead to a high probability of occurrent of ma

ny a diseases such as renal failure. These foods can bui

ld up in the bloodstream and cause harm when they can

not be eliminated by the kidneys. ( Mc Cance, 1994)

A lack of physical activity is one of the leading

causes of preventable death

worldwide. It contribute to anxiety, high blood pressure

and cardiovascular disease due to reduce insulin sensiti

vity, increase blood sugar and cholesterol levels. ( McCa

nce, 1994)

Medications Client usually medicate himself with over

the counter drugs such Paracetamol,

mefenamic acid, aspirin, etc. whenever

he got fever or experience pain.

The deleterious effects of aspirin and the NSAIDS on

the kidney are thought to result from their ability to

inhibit the vasodilatory effects of prostaglandin ,

predisposing to ischemia of the renal papillae. (Porth,

2007)

http://en.wikipedia.org/wiki/Physical_exercise




http://www.wisegeek.com/what-is-phosphorus.htm

http://www.wisegeek.com/what-is-potassium.htm

http://www.wisegeek.com/what-is-sodium.htm







http://en.wikipedia.org/wiki/List_of_preventable_causes_of_death





Toxins At 17 year old, Mr. started to drink

alcohol beverages (beer-240ml) and

can consumed 14 bottles a day.

Toxic substances such as alcohol can damage the

kidneys by causing a decrease in renal blood flow:

obstructing urine flow, directly damaging

tubulointerstitial structures, or by producing

hypersensitivity reactions

( Porth, 2007)

Pre-existing factors Actual Rationale

Diabetes Mellitus type2 The client was diagnosed with DM type 2 at

the age of 26 years old and started inducing

insulin injection 2x a day morning &

evening). This complication was further

diagnosed into a more serious condition of

diabetic nephropathy and just last year, he

was diagnosed of ESRD.

Long term complications, which are becoming more

common as more people live longer and gradually leadt to

the disabilities of body systems. It appears that increase

level of blood glucose may play a role in micro vascular

complications certainly lad to nephropathy.

Nephropathy or renal disease secondary to diabetic

micro vascular changes in the kidney is a common

complication of diabetes. If blood glucose level are elevated

consistently for a significant period of time, the kidneys

filtration mechanism is stressed, allowing blood proteins to

leak into the urine . As a result, the pressure in the blood

vessels of the kidney increases. It is thought that this

elevated pressure serve as the stimulus for the development

of nephropathy.

Patients with type 2 diabetes develop renal ds. Within

10-15 years after diagnose of diabetes.(Smeltzer, 2008)

Hypertension Mr. has a BP of 120/110 . The kidney is an essential organ in the long term

control of pressure. Hypertension attributed to the

rennin-angiotensin mechanism within the kidney.

Continued high pressure for hypertension destroy the

arteries of the kidneys leading to kidney failure.

(Smeltzer, 2008)

Symptomatology Actual Rationale

Neurotic Manifestation

-confusion

-seizures

-agitation

-inability to concentrate

/

/

Neurotic style is the outward manifestation of the

inability to introspect, learn about one's perception of a

situation, respective role,effect on others' effect on self

for developing and engaging in more effective bahavior

(C. Porth, 2007).

•Symptomatology

Cardiovascular Manifestation

-Hypertension

-Hyperkalemia

-Edema

-Pulmonary edema

-Pericarditis

-Hyperlipidemia

/

/

Due to sodium and water retention

or for activation or renin

angiotensin aldosterone system.

Hypertension is the most

important modifiable risk factor for

end-stage renal disease,

hyperlipidemia exacerbated by

uncontrolled diabetes mellitus (C.

Porth, 2007).

Anemia

Nausea and Vomiting

Generalized itching

Muscle weakness

Weight loss

/

/

/

/

/

In renal failure, erythropoietin production usually is insufficient to

stimulate adequate RBC production by the bone marrow. The

accumulation of uremic toxins further suppresses RBC

production in the bone marrow, and the cells the are produced

have a shortened life span (C. Porth, 2007).

A possible cause of nausea and vomiting is the decomposition

of the urea by the intestinal flora, resulting in a high

concentration of ammonia. PTH increases gastric acid secretion

and contribute to gastrointestinal problems (C. Porth, 2007).

Pruritus results from the high perspiration owing to decreased

size of the sweat glands and diminished activity of the oil glands

(C. Porth, 2007).

Decreased levels of active vitamin D lead to a decrease in

intestinal absorption of calcium with a resultant increase in PTH

levels vitamin D also regulates osteoblast differentiation,

thereby affecting bone matrix formation and mineralization.

Abnormal breakdown of the nutrients in the body can cause

weight loss(C. Porth, 2007).

• D. Narrative • Chronic renal failure can result from a number of conditions that

cause permanent loss of nephrons, including diabetes and hypertension, this may also resulted from different factors both genetics and environmental agents.

• Typically, the signs and symptoms of chronic renal failure occurs gradually and do not become evident until the disease is far advanced. This is because of the amazing compensatory ability of kidneys. Thus, progression of chronic renal failure occurs in gradual deterioration of glomerular filtration, tubular reabsorption capacity and endocrine functions of the kidneys. Four stages had been identified in chronic renal failure: Diminished renal reserve, renal sufficiency, renal failure and end – stage renal disease.

• The GFR is considered the best measures of overall function of the kidneys. Its normal function for young adults is 120-130 mL/ 130 mL/min. In the first stage, Diminished Renal Reserve, GFR drops to approximately 50% of normal. At this point, the serum BUN and creatinine levels still are normal , nd no symptoms of impaired renal function are evident. Because of diminished reserve, development of azotemia increases with an additional renal insult, due to nephrotoxic drugs.

• Stage 2- Renal Insufficiency represents a reduction in the GFR to 20% to 50% of normal. The kidneys initially have tremendous adequate capabilities. As nephrons are destroyed, the remaining nephrons undergo changes to compensate for those that are lost. In this process, remaining nephrons must filter more solutes particles from blood. Thus, during this stage azotemia, anemia, and hypertension begin to appear. Furthermore, retard deterioration of renal function leads kidneys in difficulty eliminating the waste products and makes the remaining nephrons easily disrupte, after which renal failure progresses rapidly.

• Renal failure develops when the GFR is less than 20% of normal. At this point, the kidneys cannot regulate volume and solute composition , and edema, metabolic acidosis and hyperkalemia develop. Overt uremia may ensue with neurologic, gastrointestinal and cardiovascular manifestations.

• End-stage renal disease( ESRD) occurs when the GFR is less than 5% of normal.All renal functions are severely decreased, and homeostatis is significantly altered Thus, resulted from multiple organ failure.At this final phase of renal failure, treatment with dialysis or transplantation is necessary for survival.

•

CHAPTER VCOURSE IN THE WARD/TREATMENT/

INTERVENTIONS

Date/Time Order

March 3,2010 Decrease Oxygen to PRN

For chest X-ray portable AP sitting upright

May sit-up on bed

N-AC (Flumucil) 600g 1 tab + ¼

For PFI on Monday

March 5, 2010

11:45am

Please give another dose of alphanedon (xanon)

250µmg 1 tab now

March 6,2010

10:20am

May do cervical X-ray portable for request

11pm Increase Mesoperem to 500g IV q12* with

supplemental extra dose post HD

A. MedicalA.1 Doctor’s Order

March 7,2010

8am May discontinue domperidon

12:30pm Increase norgesic forte 1 tab TID RTC PC

3am MIR C- Nephro

For HD on Tuesday (prior to PPT)

March 8, 2010 Sitaglipitin (Sonuria) 50mg, 1 tab OD as lunchtime

Decrease norvomix 14u (2 pre dinner)

8am Heparin on Tuesday TID

1pm Suggest transfusion of 1 unit PRBC during HD

tomorrow if Dr. with AP

Continue norgenic forte TID x 3 days then decrease prn

3:45pm Please secure 1 unit PRBC of patients blood during

hemodialysis tomorrow

March 9, 2010 Stand by 1 unit PRBC

12pm Resume domperidone 1 tab TID

Omeprazole 40 mg 1 tab OD

Decrease novomix 18u SQ q6* (5-11-5-11)

12:15 Agreed to be reffered to Dr. isaguire for co-ngt.

12:15 Agreed to be reffered to Dr. isaguire for co-ngt.

March 10, 2010

9:50am

MRIC – refer

Continue medications

11:20am Decrease norvomix - 14u SQ AC-BP

10u SQ AC-Soppu (give insulin just before eating)

10:50pm MRIC

Update Dr. maglana Referred AD schedule tomorrow

Will await infectious clearance and once cleared, inform cardio

service with out fail

For possible insertion of permanent pacemaker

Test Name Result

Blood Type “A”

RH Type Pos (+)

Date Test Result Normal Values Justification

February

20, 2010

Hemoglobin 110 140-170g/L >decreased Hemoglobin may lead to

anemia that can result to kidney

disease and other chronic illness.

(http://www.aabb.org).

A.2 Laboratories/ diagnostic procedure1. Hematology

Hematocrit 0.33 0.40-0.50 >Decreased Hematocrit are the

same as for Hemoglobin and may

indicate low thymus function (

http://www.wisegeek.com/what-is

-a-differential-white-cell-count.ht

m)

Erythrocytes 4.08 4.5-5.0 >Decreased Erythrocyte may due

to anemia and low Hemoglobin. A

blood test that measures the

number of RBC's (

http://www.wisegeek.com/what-is

-a-differential-white-cell-count.ht

m)

Leukocytes 10.70 5.0-10.0 10ˆ9/L High white blood cell count could

indicate Infection,

inflammation, trauma,

tissue damage,

use of certain medications, such

as corticosteroids, antibiotics or

anti-seizure drugs, and allergy

(http://www.steadyhealth.com/arti

cles/What_does_high_white_bloo

d_cells_count_indicate__a723.ht

ml).

http://www.wisegeek.com/what-is-a-differential-white-cell-count.htm






Segmenters 0.684 0.55-0.65 > An increase in value of these

cells generally indicates the

presence of an acute bacterial

infection or some inflammation

going on inside the body (

http://www.wisegeek.com/what

-is-a-differential-white-cell-coun

t.htm)

Lymphocytes 0.196 0.35-0.45 >people with a decreased

lymphocyte count may be more

susceptible to certain types of

infections

(http://www.associatedcontent.

com/article/2044911/what_cau

ses_a_decreased_lymphocyte.

html)




Eosinophils 0.022 0.02-0.04 Normal

Monocytes 0.098 0.06-0.12 Normal

Basophils 0.000 0. -0.02 Normal

MCV 84.5 80-97fL Normal

MCH 29.10 27.0-31.2 pg Normal

MCHC 340 318-354 Normal


March 8, 2010 Hemoglobin 98 140-170g/L >decreased Hemoglobin may

lead to anemia that can result

to kidney disease and other

chronic illness.

(http://www.aabb.org).

Hematocrit 0.30 0.40-0.50 >Decreased Hematocrit are the same as

for Hemoglobin and may indicate low

thymus function (

http://www.wisegeek.com/what-is-a-differ

ential-white-cell-count.htm)

Erythrocytes 3.03 4.5-5.0 >Decreased Erythrocyte may due to

anemia and low Hemoglobin. A blood

test that measures the number of RBC's (



Leukocytes 8.60 5.0-10.0 10ˆ9/L Normal

Thrombocytes 383.00 140-440 10ˆ9/L Normal

Segmenters 0.660 0.55-0.65 > An increase in value of these cells

generally indicates the presence of an

acute bacterial infection or some

inflammation going on inside the body (









Lymphocytes 0.180 0.35-0.45 >people with a decreased lymphocyte

count may be more susceptible to

certain types of infections(

http://www.associatedcontent.com/articl

e/2044911/what_causes_a_decreased_

lymphocyte.html

)

Eosinophils. 0.061 0.02-0.04 >The level of eosinophils can be too

high in response to allergies. They can

also be too high when exposed to

certain types of bacteria (

http://www.medfriendly.com/eosinop

hil.html

)

http://www.associatedcontent.com/article/2044911/what_causes_a_decreased_lymphocyte.html



http://www.medfriendly.com/eosinophil.html

http://www.medfriendly.com/eosinophil.html

Monocytes 0.099 0.06-0.12 Normal

Basophils 0.000 0. -0.02 Normal

MCV 75.40 80-97fL >The MCV relates to the

average size of the red blood

cell. MCV is decreased in Iron

deficiency (

http://www.wisegeek.com/what-i

s-a-differential-white-cell-count.

htm)

MCH 24.10 27.0-31.2 pg >The MCH is decreased in the

same conditions as the MCV (

http://www.wisegeek.com/what-i

s-a-differential-white-cell-count.

htm)

.

MCHC 319 318-354 Normal








February

24, 2010

Clotting Time 4'30” 2-6 min-sec Normal

Bleeding Time 2'45” 1-3 min-sec Normal


March 8, 2010 Clotting time 4' 2-6 min-sec Normal

Bleeding time 1'2'” 1-3 min-sec Normal


February

20, 2010

Phosphorus 3.82 0.81-1.58 mmol/L Hyperphosphatemia is common in

renal failure. Other causes include

increase intake, decrease output or a

shift from the intracellular to

extracellular space.(Brunner et al.,,

Medical Surgical Nursing, 11th ed., pg.

332)

Calcium 1.76 2.12-2.52 mmol/L Hypocalcemia is common in patients

with renal failure because this patients

frequently have elevated serum

phosphate level. Hyperphosphatemia

usually causes a reciprocal drop in the

serum calcium level. (Brunner et al.,,

Medical Surgical Nursing, 11th ed., pg.

325)

2. Serum Electrolytes

Magnesium 1.69 0.74-0.99 mmol/L > Most common cause of

hypermagnesia is renal

failure. In fact, most

patients with advanced

renal fialure have atleast

a slight elevation in serum

magnesium levels. This

condition is aggravated

when such patients

receive magnesium to

control seizures or

inadvertently take one of

the many commercial

antacids that contain

magnesium salts.

(Brunner et al.,, Medical

Surgical Nursing, 11th ed.,

pg. 330).

Potassium 7.00 3.5-5.1 mmol/L The major cause of

hyperkalemia is decreased renal

excretion of potassium. Fot this

reason, significant hyperkalemia

is commonly seen in patients

with untreated renal failure,

particularly those in whom

potassium levels increase as a

result of infection or excessive

intake of potassium in foods or

medications.(Brunner et al.,,

Medical Surgical Nursing, 11th

ed., pg. 323).

Sodium 122.00 136-145 mmol/L > Decreased sodium is

associated with parallel changes

in osmolality. Sodium has major

role in controlling water

distribution throughout the body,

because it does not easily cross

the cell wall membrane and

because of its abundance and

high concentration in the body.

(Brunner et al.,, Medical Surgical

Nursing, 11th ed., pg. 315).


Februry

25, 2010

TSH (Thyroid

Stimulating

Hormone)

0.751 0.27- 42uIu/ml Normal

3. Immunologic Section

• 4. Chest Xray• March 8, 2010• A comparison with the radiograph dated March

3, 2010 discloses no change in the infiltrates and degree of pulmonary congestion in both lungs. The lateral cp sinuses are sharp.

• 5. Chest A.P. Supine Adult• March3, 2010 2:42 PM• Heart size cannot be evaluated due to the position.

Pulmonary vascularity is accentuatedwhich may be due to the position. Both lungs are hazy. The lateral costophrenic sinuses are sharp. Hili are not enlarged. Visualized osseus structures are normal.

• Impression:• Consider Pneumonic

• 6. Cervical Spine ADLO• March 6, 2010 1:00 PM• There is normal cervical lordosis. Anterior

spurs are seen from C4 to C5. Vertebral bodies show normal height. Disc spaces, neural foraminae + pedicles are preserved. Prevertebralsoft tissue are not thickened.

• Impression:• Degenerative Joint Disease

• A.3 Hemodialysis• • March 9, 2010• HEMODIALYSIS• In hemodialysis (HD), blood is shunted through an

artificial kidney (dialyzer) for removal of toxins/excess fluid and then returned to the venous circulation. Hemodialysis is a fast and efficient method for removing urea and other toxic products and correcting fluid and electrolyte imbalances but requires permanent arteriovenous access. Procedure is usually performed three times per week for 4 hr. HD may be done in the hospital, outpatient dialysis center, or at home.

• Nursing Management:• Evaluate reports of pain, numbness/tingling; note extremity

swelling distal to access.• Monitor temperature. Note presence of fever, chills,

hypotension.• Measure all sources of I&O. Have patient keep diary.• Weigh daily before/after dialysis run.• Monitor BP, pulse, and hemodynamic pressures if available

during dialysis.• Place patient in a supine/Trendelenburg’s position as

necessary.• Assess skin around vascular access, noting redness, swelling,

local warmth, exudate, tenderness.• Avoid contamination of access site.• Monitor serum sodium levels. Restrict sodium intake as

indicated.

Generic

Name

Brand

Name

Classificatio

n

Mechanism

of Action

Indication Contra-

Indication

Adverse

Reaction

Dosag

e

Nursing

Responsibilit

y

omeprazol

e

Prilosec Prilosec

Omeprazol

e is in a

class of

drugs called

proton

pump

inhibitors

(PPI) that

block the

production

of acid by

the

stomach.

Omeprazol

e is in a

class of

drugs called

proton

pump

inhibitors

(PPI) that

block the

production

of acid by

the

stomach.

>Contraindicate

d to those who

are

hypersensitive to

the drug.

diarrhea,

nausea,

vomiting,

headaches

, rash and

dizziness.

40 mg

(8am)

1 tablet

P.O

O.D

>Advise Pt.

To take

caution

engaging in

activities

requiring

alertness

such as

driving or

using

machinery.

B. Pharmacological

Generic Name

Brand Name

Classification Mechanism of Action

Indication Contra-Indication Adverse Reaction

Dosage Nursing Responsibility

desloratadineAcnius antihistamine It is used to

treat the symptoms caused by histamine. Histamine is a chemical that is responsible for many of the signs and symptoms of allergic reactions

.>treatment of allergies. Provides relief of seasonal allergy symptoms and allergic nasal conditions (rhinitis) such as runny nose, sneezing, and watery/itching eyes

>Contraindicated to those who are hypersensitive to the drug and its components

>dizziness, fatigue, heache, tachycardia, dry mouth

5mg(8am)1 tablet P.OO.D

>Advise Pt. To take caution engaging in activities requiring alertness such as driving or using machinery. >pt. May report Adverse Reaction to the drug.>instruct pt. To immediately place the tablet on hius tongue after open ing

Generic

Name

Brand

Name

Classificatio

n

Mechanis

m of Action

Indication Contra-

Indication

Adverse

Reaction

Dosag

e

Nursing

Responsibilit

y

Ketoprofen Fastu

m Gel

Analgesic Relieves

pain, fever

and

inflammati

on. It

inhibits

prostaglan

din

synthesis

Mild to

moderate

pain

minor aches

and pain or

fever

Hypersensitivity

to the drug

headache,

dizziness,

nervousne

ss, skin

rashes,

pruritus,

tinnitus,

blurred

vision

As

ordere

d

>tell patient

to report any

allergic

reaction

Brand

Name

Classification Mechanism

of Action

Indication Contra-Indication Adverse

Reaction

Dosage Nursing

Responsibility

Caltrate

Plus

Cacium

Supplement

Replaces

and

maintains

calcium;

raises

calcium level

Supplement

for Ca

deficiency &

conditions that

require

increased Ca

intake; may

reduce the

risk of

osteoporosis

later in life.

>Contraidicated

in patients with

hypecalcemia,

and renal calculi

Pain,

bradycardia,

cardiac

arrest,

nausea and

vomiting

1 tab

PO od

>Should be

taken with food

>instruct

patient to

report any sign

of its adverse

reaction

Generic

Name

Brand

Name

Classificati

on

Mechanism

of Action

Indication Contra-

Indication

Adverse

Reaction

Dosage Nursing

Responsibility

MeropenemMeronem anxiolytics Readily

penetrates

the cell wall

of most

gram

positive

and gram

negative

bacteria to

reach

penicillin-

binding

protein

targets,

where it

inhibits cell

wall

synthesis.

Complicated

skin and skin

structure

infection

cause by

Staphylococc

us aureus

>Hypersensitivit

y to the drug

>Use cautiously

to patient with

renal

impairment

Headache,

insomnia,

confusion,

tachycardia,

diarrhea.

1 vial IV

infusion

>warn patient

to avoid

hazardous

activities that

require

alertness and

motor

cooordination

until CNS

affects are

known.

>advise pt. To

report any

signs of

Adverse

effects of the

drug.

CHAPTER VIDISCHARGE PLANNING

Basic health teaching is the greatest need of a patient after admission. The nurse should clearly teach the patient and family on how to comply with medications and other regimen to facilitate improvement of the patient health status thus providing also continuity of care to the patient.

• M – Medication• Explained the importance of the prescription including the name of the

drug (GENERIC AND BRAND NAME), purpose of medication, duration of administration, appropriate dosage, the adverse effect, side effect, formulation of medications.

• Informed the patient and the family about the medication prescribed by the physician including the purpose, dose, schedule and the side effect of the drugs.

• Instructed the patient and the family that the compliance of the regimen is really needed and may discontinue if ordered by the physician.

• Encouraged the patient and the family to report any unusualities regarding the administration of drugs.

• E – Exercise• Informed the patient and the family to have a moderate exercise to

promote physiological well-being, reducing the risk and strengthening the immune system.

• Encouraged the patient to have a deep breathing exercise.• Light exercise on both arms and legs to promote circulation in the

heart.• T – Treatment• Encouraged the patient to keep follow-up appointment.• Medications are recommended for this aim to improve the proper

blood flow and proper circulation in our body. This promotes healing and reduces pain and discomfort.

• Nutritional management-nutrition, proper diet and weight control• Prompt exercise• Health teachings to facilitate awareness an knowledge to the

patient regarding his illness.

• H – Hygiene• Encouraged the patient to have a proper hand washing with soap and

water before and after eating and whenever they spend time around people with cold or other illness.

• Encouraged patient to brush teeth properly.• Encouraged patient to keep hands away from his nose and mouth.• Educate the patient on proper hygiene by instructing to wear cotton

clothes and changing underwear to avoid irritation and provide comfort.• Educate the patient properly initiate the regular hygiene with assistance as

necessary.• O – Outpatient order• Encouraged patient to stay indoors with the doors and windows closed if

air pollution levels are high.• Encouraged patient to keep himself away from smoke.• Encouraged patient to have enough sleep and rest everyday.• Encouraged the significant other to monitor the temperature of the

patient.• Provided patient information regarding his condition and instruct to follow

why the doctor instructed.

• D – Diet• Encouraged patient to eat healthy and well-balanced diet.• Encouraged patient to avoid foods that are high in carbohydrates,

fatty foods, and salty foods.• Provided all the essential food constitutes (vitamins and minerals).• Patient must maintain the reasonable weight.• Instructed the patient to eat nutritious food such as fruits and

vegetables and in strict diabetic diet low salt and low fat diet.• Increased oral fluid intake.• S – Spiritual• Encourage patient and the family to maintain realistic hope over the

course of the illness.• Encourage the patient and the family to take time to be introspective

in the search for peace and harmony.• Help patient and the family obtain spiritual help.• Encourage patient to pray everyday and ask for God’s guidance and

strength in order to lighten up his feelings towards his condition.

Documents

Med Surg ESRD