ESRD-3rd yr-1st sem

TABLE OF CONTENTS

I. INTRODUCTION

A. Definition

B. Statistics

i. International

ii. Local

II. OBJECTIVES

A. General Objective

B. Specific Objectives

III. ANATOMY AND PHYSIOLOGY

IV. VITAL INFORMATION

V. CLINICAL ASSESSMENT

A. Nursing History

B. Past Health Problem/Status

C. Family History of Illness

VI. SOCIAL, CULTURAL, RELIGIOUS BACKGROUND AND PATTERN OF FUNCTIONING.

a. Educational Background

b. Occupational Background

c. Religious practices

d. Economic status

VII. CLINICAL INSPECTION

A. Vital Signs

Upon Admission

During our Care

B. Physical Assessment (Cephalocaudal)

I. General Appearance

II. Skin, hair and nails

III. Head, face, and lymphatics

IV. Eyes, ears, nose, mouth and throat

V. Neck and upper extremities

VI. Chest, breast and axilla

VII. Respiratory system

VIII. Cardiovascular system

IX. Gastrointestinal system

X. Genitor-urinary system

XI. Musculoskeletal system

C. General Appraisal

I. Speech

II. Language

III. Hearing

IV. Mental status

V. Emotional status

VIII. LABORATORY AND DIAGNOSTIC DATA

IX. PATHOPHYSIOLOGY

X. MEDICAL MANAGEMENT

A. Drug Study

B. Medi Map

XI. NURSING MANAGEMENT

A. Concept Map of Nursing Problems

B. Nursing Care Plan

XII. DISCHARGE PLANNING

XIII. JOURNALS

XIV. ACKNOWLEDGEMENT

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OBJECTIVES

A. General Objective

After the discussion of this case presentation, the students will be able to deal

and care for a patients with End – Stage Renal Disease integrally by applying their

knowledge, skills, and positive attitudes based on what they have learned out of the

discussion.

B. Specific Objectives

At the end of individual case discussion, it is expected that the students will be

able to:

Skills

1. Deal patient with ESRD.

2. Provide proper care according to the problem manifested by the patient.

3. Conduct physical assessment and organize data efficiently.

4. Perform nursing procedures effectively and correctly to attain optimum level of

wellness.

Knowledge

1. Define ESRD.

2. Have an overview about the diseases, including its causes and complications.

3. Determine the signs and symptoms and the possible symptomatic treatment of

each.

4. Review the anatomy and physiology of the organ affected.

5. Understand the pathophysiology of the disease.

6. Identify and enumerate the management needed for ESRD and its related

complications.

7. Formulate nursing care plans that will aid in the improvement of patient’s

condition.

Attitudes

1. Develop a positive attitude in caring the patient with PKD throughout the nursing

Process.

2. To be able to establish rapport with the patient and folks.

3. To be able to develop respect and trust.

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INTRODUCTION

A. Definition

End stage kidney disease is the final stage of chronic kidney disease (CKD). It is the

most severe illness with poor life expectancy if untreated. It also called established chronic

disease and occurs when GFR falls below 15 mL/min/1.73 m2. Patients with ESRD are

dependent on renal replacement therapy (RRT) to survive. The incidence of ESRD in the

developing world is difficult to estimate and ranges from 40 per million population (pmp) to 340

pmp. The prevalence of ESRD can be more accurately recorded as the number of patients

receiving RRT.

Glomerulonephritis is the main cause of ESRD worldwide (11% – 49%). Proliferative

glomerulonephritis is more common in developing countries and may be secondary to endemic

infections like streptococcus, schistosomiasis, and malaria. Focal segmental glomerulonephritis is

also common in Africa, while IgA nephropathy is common in Asia and Pacific regions. Diabetes

mellitus and hypertension remain important factors in the etiology of ESRD, but less so in the

developing world than in the USA where they account for around 65% of ESRD.

It is very important to take really good care of our kidneys because our kidneys play a

big role to our body which is to filter our body wastes. Nowadays, cases of ESRD is increasing

in continue to spread all over the world. Having discipline to ourselves regarding our health

could be a big help to prevent diseases because most of us abuse our body that’s why we had a

lot diseases which is developing in our body and most of them could lead to death. Having a

good health is one of the greatest treasures we could have; this could make us disease free of

such serious illness. Regarding ESRD, we could only say that proper nutrition and proper care

of our kidneys is one of the important ways to prevent and to eliminate this disease to occur

within us. And what we said earlier is that, one of the best way to have good health is to have a

self-discipline regarding health care because we are the one who are deciding whether to have

a disease or not. Living with a healthy lifestyle and good health is one of the achievable and

could have a satisfying life.

As student nurses, we could help our patient by having a deep understanding of the

disease, that we may learn the proper interventions for the end-stage renal disease patients. In

this way, we could render quality care for them. We could as well lead them to the proper

treatment to lessen their sufferings brought by the kidney failure, in anyhow. By having a wide

understanding of the disease, we could impart teachings on how we could prevent the

occurrence of the disease. It is our responsibility to render information and impart health

teachings to improve the condition of our patients to the best of our abilities. One of the

characteristics that we, student nurses, should have is to be informative and only through a

keen study of disease such as this way for us to gain all the information that we need to learn.

May this case study served its purpose through the help of our Lord, Jesus Christ.

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B. Statistics

International:

93,327 people commenced treatment for end-stage renal disease annually in the US 2001

(United States Renal Data System, 2003, NIDDK)

31% of cases of ESRD each year occurs in African Americans in America (Renal Data

Report, ANS, 1999)

2% of cases of ESRD each year occurs in native Americans (Renal Data Report, ANS,

1999)

31% of cases of ESRD each year occurs in Caucasians in America (Renal Data Report,

ANS, 1999)

Local:

Kidney disease is on the rise and is an important cause of death in the Philippines.

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.

The main cause of kidney disease seems to be the increasing diabetic conditions

among the Filipinos. It is seen that about 55% of Filipinos develop kidney disease when they

suffer from diabetes. The Philippine Society of Nephrology (PSN) issued the statement that

diabetes is the single most common cause of kidney failure among diabetes mellitus

nephropathy patients.

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ANATOMY AND PHYSIOLOGY

The KIDNEYS are known as

MASTER CHEMIST. Actually, they are

pair of bean shaped, brownish-red

structures located retroperitoneally on the

posterior wall of the abdomen-from the

12th thoracic vertebra to the third lumbar

vertebra in the adult.

The average adult kidney weighs

approximately 13 to 170 g (about 4.5 oz) and is 10 to 12 cm of the long, 6 cm wide and

2.5 cm thick. The right kidney is slightly lower than the left due to the location f the liver.

An adrenal gland lies on top of each kidney. The kidneys and adrenals are independent

in function, blood supply and innervation.

NEPHRONS

- from Greek word “nephros”, meaning "kidney". It is the basic structural

and functional unit of the kidney. Its functions are vital to life and are regulated by the

endocrine system by hormones such as antidiuretic hormone, aldosterone, and

parathyroid hormone. In humans, a normal kidney contains 800,000 to one million

nephrons. Its chief function is to regulate the concentration of water and soluble

substances like sodium salts by filtering the blood, reabsorbing what is needed and

excreting the rest as urine.

TWO PARTS OF RENAL PARENCHYMA:

Medulla

- (latin renes medulla = kidney middle)

which is approximately 5 cm wide. It contains

the structures of the nephrons responsible for

maintaining the salt and water balance of the

blood. These structures include the vasa

rectae (both spuria and vera), the venulae

rectae, the medullary capillary plexus, the loop

of Henle, and the collecting tubulle. The renal

medulla is hypertonic to the filtrate in the

nephron and aids in the reabsorption of water.

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Cortex

- is the outer portion of the kidney between the renal capsule and the renal medulla. In

the adult, it forms a continuous smooth outer zone with a number of projections (cortical

columns) that extend down between the pyramids. It contains the renal corpuscles and the

renal tubules except for parts of the loop of Henle which descend into the renal medulla. It

also contains blood vessels and cortical collecting ducts. The renal cortex is the part of the

kidney where ultrafiltration occurs.

MAJOR FUNCTIONS OF KIDNEY:

Regulation of water excretion

A person normally ingests about 1300 mL of oral fluids and 1000 mL of water in food per

day. Of the fluid ingested, approximately 900 mL is lost through the skin and lungs (called

insensible loss), 50 mL through sweat and 200 mL through feces.

Regulation of electrolyte excretion

When the kidneys are functioning normally, the volume of electrolytes excreted per day

is equal to the amount ingested. The regulation of sodium volume excreted depends on

aldosterone, a hormone synthesized and released from the adrenal cortex. With increased

aldosterone in the blood, less sodium is excreted in the urine, because aldosterone fosters renal

absorption of sodium.

Regulation of acid-base balance

The kidney performs two major functions to assist in this balance. 1.) To reabsorb and

return to the body’s circulation any bicarbonate from the urinary filtrate; 2.) To excrete acid in

the urine.

Autoregulation of blood pressure

Rennin converts angiotensinogen to angiotensin I, which is then converted to

angiotensin II, the most powerful vasoconstrictor known; angiotensin II causes the blood

pressure to increase.

The adrenal cortex secretes aldosterone in response to poor perfusion or increasing

serum osmolality. The result is an increase in blood pressure.

Renal clearance

It is the ability of the kidneys to clear solutes from the plasma.

Regulation of red blood cell production

When the kidneys detect to decrease in the oxygen tension in renal bllod flow, they

release erythropoietin that stimulates the bone marrow to produce RBC and carry oxygen

throughout the body.

Vitamin D synthesis6

Secretion of prostaglandins

Excretion of waste products

The kidneys eliminate the body’s metabolic waste products which is the urea that

excreted daily for about 25 to 30 mg.

Urine storage

Bladder emptying

TEXTBOOK DISCUSSION

A. Definition

End - stage renal disease, also known as chronic kidney disease (CKD), specifically

the fifth stage of CKD. It means, it is the complete or almost complete failure of the kidneys to

function. The kidneys can no longer remove wastes, concentrate urine, and regulate many other

important body functions.

ESRD almost always follows chronic kidney disease. A person may have gradual

worsening of kidney function for 10 - 20 years or more before progressing to ESRD. Patients

who have reached this stage need dialysis or a kidney transplant.

B. Risk factors

Persons with the following conditions:

Chronic glomerulonephritis

ARF

Excessive intake of drugs Changed smoker and alcoholic beverages drinker. Polycystic kidney disease

Obstruction

Repeated episodes of pyelonephritis

Diabetes mellitus

- is the leading cause & accounts for more than 30% of clients who receive dialysis.

Hypertension

Lupus erythematous

Polyarteristis

Sickle cell disease

Amyloidosis

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C. Signs/Symptoms

CLINICAL MANIFESTATION

DISTINCTIVE

GROUPING

From the textbook

Manifested

by the

patientRationale

Electrolyte

Imbalances

Hyperkalemia

Hyponatremia The salt – wasting properties of some

failing kidneys, in addition to vomiting

and diarrhea.

Hypocalcemia

Hyper-

phosphatemia

Hypercalcemia

Mildly elevated

serum Mg

Metabolic

changes

↑ serum creatinine Serum creatinine increases as waste

products of protein metabolism

accumulate in the blood. And due to

decrease GFR.

Proteinuria The metabolic function of the kidney

which includes the metabolism fails

which tends protein to be excreted via

urine.

↑ uric acid

Carbohydrate

intolerance

Elevated

triglycerides

Metabolic acidosis It occurs because of the kidneys inability

to excrete hydrogen ions, ↓ reabsorption

of NaHCO3, ↓ formation of dihydrogen

phosphate and NH3.

Pericarditis

Hematologic

changes

Anemia It occurs because the kidneys are

unable to produce erythropoietin, a

hormone necessary for RBC production.

Iron or folate

depletion

Hemolysis &

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platelet

abnormalities

Gastro-

intestinal

changes

Transient anorexia,

nausea & vomiting

A possible cause of nausea and

vomiting is a decomposition of the urea

by the intestinal flora resulting in a high

concentration of ammonia.

Constant bitter

taste

Fetid, fishy or

ammonia-like

breath smells

Metallic or salty

taste

Stomatitis

Hiccups Due to the accumulation of toxic

substances that stimulates phrenic

nerves.

Ulcer disease

↑ serum amylase

Constipation

Immunologic

changes

Depression of

hormonal antibody

formation

Suppression of

delayed

hypersensitivity

Decreased

chemotactic

function of the

leukocytes

Changes in

medication

metabolism

Medication toxicity

Cardio-

vascular

changes

HPN Due to water retention.

Arterial

calcifications

L ventricular

hypertrophy & HF

Chest pain Due to the accumulation of toxins in the

body because the kidney is failing in

filtering it.

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Dysrhythmias

Atherosclerosis

Anasarca Due to water retention as a result of ↑

hydrostatic pressure or for activation of

renin – angiotensin aldosterone system

Respiratory

changes

Pulmonary edema

Pleuritis

Musculo-

skeletal

changes

Osteomalacia

Osteitis fibrosa

Osteoporosis

Osteosclerosis

Muscle cramps These may result from osmolar changes

in the body fluids or sometimes from

hypokalemia.

Integumentary

changes

Intractable pruritus

Brittle hair

Pallor Due to anemia wherein the presence of

hemoglobin in the blood is decreased,

resulting to a decrease oxygen

distribution throughout the body.

Nails are thin

Neurologic

changes

Forgetfulness

Confusion It occurs due to hypokalemia, as the

transmission of nerve impulses

decreases.

Peripheral

neuropathy

Inability to

concentrate

Twitching

Dysarthria

Uremic amaurosis

Reproductive

changes

Testicular atrophy

Oliguspermia

Reduced sperm

motility

Endocrine

changes

↑ growth hormone

& prolactin

Psychosocial

changes

Powerlessness

Changes in body

image

Due to edema

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D. Complications

Uremia

- If there is failure of kidney to function well, urea and other waste products,

which are normally excreted into the urine, are retained in the blood.

Shock

- Severe condition from reduced blood circulation and it occurs because of

excessive urination and edema.

Pericarditis

- Is the inflammation of the pericardium. Due to retention of toxic substances as

a result of decreased renal function or renal failure.

Seizures

- It is an intellectual deficit due to hydroxylysinuria. It is a rare syndrome

characterized by mental retardation, seizures and high levels of hydroxylysine in the

urine.

Coma

- A profound or deep state of unconsciousness. The affected individual is alive

but is not able to react or respond to life around him/her. Coma may occur as an

expected progression or complication of an underlying illness, or as a result of an event

such as head trauma.

E. Treatment

Dialysis for hyperkalemia & fluid imbalances.

Emergency pericardiocentesis or surgery for cardiac tamponade.

Intensive dialysis and thoracentesis to relieve pulmonary edema & pleural effusion.

Peritoneal or hemodialysis to help control end-stage renal disease.

Kidney transplantation

Symptomatic treatment of ESRD

Diet:

Low protein diet to limit accumulation of end-products of protein metabolism that the

kidneys can’t excrete.

High-protein diet for patients on continuous peritoneal dialysis

High-calorie diet to prevent ketoacidosis & tissue atrophy.

Sodium, potassium & phosphorus restrictions to prevent elevated levels.

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Medications:

Loop diuretics, such as furoemide to maintain fluid balances.

Cardiac glycosides, such as Digoxin to mobilze fluids causing edema.

Calcium carbonate (Caltrate) to treat renal osteodystrophy by binding phosphate &

supplementing calcium.

Antihypertensives to control blood pressure and edema.

Antiemetics to relieve nausea & vomiting.

Famotidine or ranitidine to decrease gastric irritation.

Docusate to prevent constipation.

Iron & folate supplements or RBC transfusion to treat anemia.

Synthetic erythropoietin to stimulate the bone marrow to produce RBCs; conjugated

estrogens & desmopressin to combat hematologic effects.

Antipruritics to relieve itching.

Phosphate-removing drugs to decrease serum phosphate levels.

F. Diagnostic studies

Urinalysis

- aids in diagnosis (specific gravity fixed at 1.010, proteinuria. glycosuria, RBCs,

leukocytes, casts or crystals, depending on the cause).

Blood testing levels

- reveals elevated BUN, creatinine, low sodium level & potassium levels,

increased aldosterone secretion, low hemoglobin level & hematocrit, decreased RBC

survival time, mild thrombocytopenia, platelet defects & hyperglycemia.

Renal ultrasound

- It determines the kidney size and presence of masses, cysts, obstruction

in upper urinary tract.

Computed tomographic/ Magnetic resonance imaging

- It demonstrates the vessel disorders and kidney mass.

Abdominal (KUB)radiograph

- It demonstrates the size of kidneys/ureters/bladder and presence of

obstruction (stones).

Aortorenal angiography

- It assesses renal circulation and identifies extravascularities, masses.

Retrogade pyelogram

- It outlines abnormalities of renal pelvis & ureters.

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Renal arteriogram

- Assess renal circulation and identifies extravascularities, masses.

Voiding cystourethrogram

- It shows bladder size, reflux into ureters, retention.

Renal biopsy

- This can be done endoscopically to examine tissue cells for histologic

diagnosis.

Renal endoscopy, nephroscopy

- It is done to examine renal pelvis, flush out calculi, hematuria & remove

selected tumors.

ECG

- May be abnormal, reflecting electrolyte and acid-base imbalances.

EEG

- May be performed to identify metabolic encephalopathy.

X-ray of feet, skull, spinal column & hands

- May reveal demineralization/ calcifications resulting from electrolyte shifts

associated with CRF.

G. Nursing considerations

Bathe the patient daily using superfatted soaps & skin lotion without alcohol to ease

pruritus

Provide good perineal care using mild soap & water.

Turn the patient often & use a convoluted foam mattress to prevent skin breakdown.

Provide good oral hygiene by encouraging or performing frequent brushing with a soft

brush or sponge tip to reduce breath odor & providing sugarless hard candy &

mouthwash to minimize the metallic taste in the mouth & alleviate thirst.

Offer small, nutritious & palatable meals.

Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak pulse rate.

Carefully assess the patient’s hydration status; check for jugular vein distention,

auscultate the lungs for crackles, carefully measure daily intake & output, record daily

weight & document peripheral edema.

Monitor for bone or joint complications.

Encourage deep breathing & coughing to prevent pulmonary congestion, auscultate the

lungs often, stay alert foe clinical effects of pulmonary edema & administer diuretics &

other medications as ordered.

Observe for signs of bleeding & monitor hemoglobin level & hematocrit & check stool,

urine & vomitus for blood.

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Report signs of pericarditis such as pericardial friction rub and chest pain.

VITAL INFORMATION

Name Mr. N.D.

Sex Male

Age 26 years old

Address Bito – on Ilaya, Cuartero Capiz

Civil Status Married

Religion Roman Catholic

Occupation Dicer in Black & White

Educational Attainment High Graduate

Date & Time Admitted September 15, 2010; 9:30 pm

Ward Blessed Rosalie Rendu Ward

Room – 108

Chief complaint Vomiting

Admitting Diagnosis Acute gastritis t/c CKD 2° to Nephrolithiasis

Final Diagnosis ESRD

Diet NPO x 4°, soft diet if without urinalysis

Attending Physicians Dr. H., Dr. B.

CLINICAL ASSESSMENT

A. Nursing History

1 week prior to admission, Mr. N.D. had a very low appetite wherein he only eats bread

and milk in the morning and drinks about 5-7 bottle of soft drinks a day, and experienced an

episode of nausea.

And four days prior to admission, Mr. N.D. had several episodes of vomiting associated

with epigastric discomfort. Vomiting still persisted until on the day of admission, thus brought to

ER of St. Anthony college Hospital of Roxas City and was admitted.

B. Past Health Problem

Mr. N.D is a known prohibited drugs user. He was admitted in Dao Provincial Hospital

last November 2009 due to Urinary Tract Infection but has been treated for just about a week or

more.

Mr. N.D has also experienced a burning sensation in the chest and a pain in the

epigastric area thus; he thought to have an ulcer because of that manifestation. Other health

problems than what have been mentioned were just fever and common colds.

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C. Family Genogram

PATTERNS OF FUNCTIONING

Nutritional History

a. Drinking Patterns

Mr. N.D is not fond of drinking water. And before he experienced those manifestations

before his admission, Mr. N.D is fond of drinking carbonated beverages like soft drinks for at

least 5 – 7 bottles a day. He is also a known alcoholic drinker wherein he drinks together with

his peer every afternoon.

b. Eating Patterns

Mr. N.D told that when or after taken prohibited drugs before, his appetite also

decreases. At that time, he does not eat for almost 2 days and only drinks a lot of soft drinks to

relieve his thirst. But then, when his appetite came back, he eats every food that is being served

in the table very well.

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LEGEND:

STROKE

HYPERTENSION

POOR HEARINGACUITY

ESRD

Breathing Patterns

HOME HOSPITAL

Mr. N.D does not experience any problem in

respiration before.

RR = 21 bpm

Mr. N.D had an episode of SOB during the few

days of his admission in this institution but was

relieved when in semi – or in high – fowler’s

position.

Circulation

Temperature 36°C

Pulse rate 75 bpm

Respiration rate 21 bpm

Blood pressure 120/70 mmHg

Apical rate 82 bpm

IVF

Left carpal vein # 2 PNSS 1L + 20 mEqs NaCl x 60 cc/°

Side Drip #2 D5W 500 cc + 100 mEqs NaHCO3 x 24°x 2

cycles

Right carpal vein #1 PNSS 500 cc x KVO

Daily Activity Patterns:

a. Rest and Sleeping Patterns

Home Hospital

Mr. N.D usually sleeps at night after drinking

alcoholic beverages with his peer and the time

of sleeping is depending upon to his

companion and if when are they going to finish

drinking. Thus, he sleeps at continuously

without any difficulty or deprivation in sleeping.

His usual waking up time is 6 in the morning

because he has work at 9 am.

Mr. N.D is weak and tends to sleep during day

time if not feeling well or if he wants to. He

usually sleeps at 9 in the evening and rises at

5 – 5:30 in the morning.

b. Personal Hygiene

Home Hospital

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Mr. N.D takes a bath once a day before going

to work. He is also conscious about his

personal hygiene.

Mr. N.D can perform personal hygiene by

himself like brushing his teeth at least once

every other day.

c. Elimination Patterns

Bowel Movement

FREQUENCY PROBLEMS / DIFFICULTIES

Home Hospital Home Hospital

Once or twice a day

every morning or

after lunch

Once every 2 or 3

days and there is a

time the he defecates

twice a day.

He experienced

sometimes having

constipation.

None

Urination

FREQUENCY PROBLEMS / DIFFICULTIES

Home Hospital Home Hospital

Urinates whenever

feels to urge.

Urinates whenever

feels to urge with a

urine output of 200 cc.

None Has difficulty in

urination thus foley

catheter was inserted

and drained 80 cc of

urine after insertion.

A. Educational Background

-High school graduate. He also started a course of Criminology at Filamer Christian

University, but is not able to finish it.

B. Occupational Background

-He is a dicer in Black & White.

C. Religious practices

-He does not attend to mass every Sunday and even praying the rosary every afternoon.

D. Economic status

-They belong in the middle class of economic level in this society.

SOCIO-CULTURAL HEALTH

A. Cultural Health

He does not believe to any superstitious beliefs. Rather, he believes on what he wanted

to do and that’s the reason why there is a conflict between his parents.

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B. Recreational Pattern

Mr. N.D’s usual recreation is just watching television and talking with their borders

because he has only a little time for recreation due to his work. But if he had time for that,

then he is having fun with his friends; wherein they drink together every evening.

C. Environmental Pattern

He lives in a complicated situation of life due to his vices. He is living near at the

roadside together with his wife, which is seven months pregnant, at his Auntie’s custody. He

is prone also to accident because of the influence of his friends.

D. Interaction Pattern

According to him, he is not closed to her parents. Instead, he wants to be with his friends

and enjoys a lot if they are hanging out. He is not sweet to his wife and seems he is ‘siga”

the way he talks.

E. Coping Pattern

Before, he was neglected by his family when they knew that he is a drug user. But then,

they gave him another chance if he will stop taking prohibited drugs.

On the first few days after his admission, he was not visited by his parents & relatives.

Only his wife is the one taking care of him throughout his admission.

A week after, his Aunt visited him and gave an assurance that she will help him related

to his financial problems.

Now, his parents are also helping in taking care of him.

CLINICAL INSPECTION

A. Vital Signs

Upon Admission

Temperature Respiratory rate Apical pulse Radial pulse Blood pressure

37.5°C 20 bpm 92 bpm 79 bpm 110/80 mmHg

During our Care

September 16, 2010

Time Temperature

(°C)

Respiratory

rate

(bpm)

Apical pulse

(bpm)

Radial pulse

(bpm)

Blood pressure

(mmHg)

8:00 36 20 82 75 140/100

12:00 36.1 20 84 78 130/90

September 17, 2010

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Time Temperature

(°C)

Respiratory

rate

(bpm)

Apical pulse

(bpm)

Radial pulse

(bpm)

Blood pressure

(mmHg)

8:00 37.5 20 92 72 140/100

12:00 37.1 20 88 80 150/100

During Blood Transfusion

1:25 36.6 21 96 90 140/90

1:45 21 94 88 140/90

September 23, 2010

Time Temperature

(°C)

Respiratory

rate

(bpm)

Apical pulse

(bpm)

Radial pulse

(bpm)

Blood pressure

(mmHg)

8:00 36 18 82 80 130/90

12:00 36.4 19 88 84 140/90

B. Physical Assessment

General Appearance:

Mr. N.D is consciously lying on bed which appears weak, fatigue, with complaints

of pain in the anterior chest and with an ongoing IVF of #2 PNSS 1L + 20 mEqs NaCl x

60 cc/U at 500 cc level and a secured side drip of #2 D5W 500 c + 100 mEqa NaHCO3 x

24U x 2 cycles infusing well on the left carpal vein, #1 PNSS 500 cc x KVO at the right

carpal vein which is used for Blood Transfusion & O2 @ 2 Lpm via nasal cannula.

He is coherent and physically and mentally conscious wherein responsiveness to

any stimulus is observed, with non – edematous lower & upper extremeties noted but

the face is edematous during our 1st week of duty. Yet, anasarca was developed during

our second duty in the ward.

Cephalocaudal

Body Parts Method of

Assessment

Findings Interpretation

Skin Inspection Skin is cold and dry, (+)

pallor, anasarca.

Fair complexion.

Skin is soft and no scar,

Due to ↑

hydrostatic

pressure; ESRD.

Normal

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bruise or petechiae noted.

Head Inspection Edematous face

Normocephalic, absence

of nodules, hair is evenly

distributed, black in color,

straight and smooth.

Symmetrical feature of

the face.

Facial grimace

Due to ↑

hydrostatic

pressure; ESRD.

Normal

(+) chest pain;

ESRD

Nails Inspection Absence of thin nails

(-) of clubbing with an

angle of about 160U.

Normal

Eyes Inspection

Palpation

Eyebrows curled slightly

outward and evenly

distributed

Both pupils are equal in

size. Size= 2

Moderately reactive to

light and accommodation.

Edema over lacrimal

gland

(-) Tenderness

Normal

ESRD

↑ hydrostatic

pressure; ESRD

Normal

Ears Inspection Color same as facial skin

Auricle aligned with outer

canthus of the eye

Responsive to moderate

voices.

Normal

Nose Inspection Symmetric with the nasal

septum at the center

Normal

Mouth Inspection With plaques

(+) dry lips

Poor oral hygiene

ESRD

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Neck Inspection Coordinated, smooth

movements with no

discomfort

No lumps or swollen

glands

(+) edema

Normal

↑ hydrostatic

pressure; ESRD

Chest and Thorax Inspection

Auscultation

RR= 21 bpm

(+) DOB

Chest movement is

symmetrical upon

respiration.

(-) tenderness, (-)

masses.

ESRD

Normal

Abdomen Inspection

Auscultation

Palpation

Uniform in color

Abdominal girt = 94 cm

(+) pain at hypogastric

area

(+) bruits at the four

abdominal quadrants.

(+) tenderness, distended

urinary bladder

Liver is not palpable

Normal

Due to fluid

accumulation.

Full bladder.

Due to fluid

accumulation;

ESRD.

Full bladder.

Normal

Extremities Right arm muscle cramps ESRD; due to

hypokalemia

Cardiovascular Inspection

Auscultation

Chest pain

Hypertensive. Bp =

140/100 mmHg

ESRD

Gastrointestinal Inspection Anorexia, nausea &

vomiting.

Due to the

decomposition of

the urea by the

intestinal flora

resulting in a high

concentration of

ammonia.

21

Hiccups.

Due to the accumulation of toxic substances that stimulates phrenic nerves.

Genitourinary Difficulty in urinating

(+) oliguria

(+) foley catheter

UO = 50 cc,

Urine is clear in color and

is aromatic

ESRD

Normal

C. General Appraisal

i. Speech

- He is oriented and converses appropriately without any problem in his speech.

ii. Language

- He knows Ilonggo, Tagalong and a little in English.

iii. Hearing

- He is able to hear moderate sounds and interpret auditory stimuli appropriately.

iv. Emotional status

- He is worried about his condition and he really wanted that his disease will be treated.

He has a low self – esteem and is no t confident with his body structures; is

cooperative and can interact to people around him.

v. Mental status

- He is conscious, alert, coherent and oriented to person, time, place and events

occurring in the environment. He is fond of asking questions about something most

especially about his condition and able to comprehend instructions and commands.

LABORATORY AND DIAGNOSTIC DATA

Date: September 15, 20103

Fluid: Serum

Test Result Normal

Values

Significance

Potassium ↓ 3.27 mmol/L 3.5-5.1 Due to prolonged vomiting.

Sodium ↓ 129.5 mmol/L 136-145 Due to the salt – wasting properties of

22

failing kidneys; vomiting.

Creatinine ↑ 1679.6 umol/L 77-133 Due to decrease glomerular filtration of the

kidneys.

Urinalysis

Test Result Normal

Values

Significance

Macroscopic

Protein 3+ 0 Due to increase creatinine which indicates renal failure,

and at that time the kidney is failing to metabolize the

protein, thus protein is being excreted via urine without

undergoing metabolism & impaired metabolism of renal

tubule.

Microscopic

RBC/hpf 3-8 0 – 2 / hpf It occurs because the kidneys are being damaged and a

presence of cyst in right kidney.

WBC/hpf 8-23 0 – 5 / hpf Infection; The body compensates to fight against

bacteria, & the dead WBC are being excreted in the urine

since the kidney cannot filter it.

Bacteria Few Invasion of pathogens in the urinary tract.

ABG Analysis

Test Result Normal Values Significance

pH 7.263 7.35-7.45 Fully compensated metabolic acidosis &

respiratory alkalosis

It occurs because of the kidneys inability to excrete

hydrogen ions, ↓ reabsorption of NaHCO3, ↓

formation of dihydrogen phosphate and NH3.

pCO2 21.1 35-45 mmHg

pO2 154.1 80-100 mmHg

HCO3 9.2 22-26 mmol/L

O2 Sat. 99% 97-100% Normal

Date: September 16. 2010

Hematology

Test Result Normal

Values

Significance

Hematocrit .15 vol.(fr) 0.42 – 0.52 It occurs because the kidneys are unable to

produce erythropoietin, a hormone necessary

for RBC production.

Hemoglobin 50 gms/L 120 – 160

RBC 1.75 X 10^12/L 4.6 – 6.2

WBC 9.5 X 10^9/L 4.5 – 11 As a compensatory mechanism of the body to

23

fight against the invasion of pathogens.Lymphocytes .06 25-30%

Monocytes .01 2-5%

Urinalysis


Macroscopic

Transparency Hazy Clear Due to presence of bacteria.

Specific gravity 1.005 .1.10 – 1.25 Due to the fluid that accumulates in the body.

Protein 2+ Negative Due to increase creatinine which indicates

renal failure, and at that time the kidney is

failing to metabolize the protein, thus protein is

being excreted via urine without undergoing

metabolism.

Microscopic

RBC/hpf 20-31 0 – 2 / hpf It occurs because the kidneys are being

damaged and a presence of cyst in right

kidney.

WBC/hpf 8-12 0 – 5 / hpf Infection; the body compensates to fight

against bacteria, & the dead WBC are being

excreted in the urine since the kidney cannot

filter it.

Bacteria Few Invasion of bacteria in the urinary tract.

Ultrasound: KUB

Significance

Kidneys:

The right kidney measures approximately:

Coronal = 110.6 x 50.7 x 43mm (LWT) with a cortical thickness of 17.1 mm.

The borders are fuzzy.

There is increased parenchymal echopattern.

A 7.1 x 6.2 x 7.0 mm (LWH) with a volume of .2 ml cystic mass is noted in the inferior

pole.

There is no caliectasia.

There is no lithiasis.

The left kidney measures approximately:

Coronal = 102 x 64.8 x 48 mm (LWT) with a cortical thickness of 16.9 mm.

The borders are fuzzy.

There is increased parenchymal echopattern.

There is no caliectasia.

There is no lithiasis.

24

Urinary Bladder:

The urinary bladder is well distended.

It has smooth walls with a thickness of 5.2 – 6.3 mm.

No intraluminal echoes seen.

The full urinary bladder has a volume of approximately 178.6 cc.

Post void scan shows no residual urine volume.

Impression:

Normal urinary bladder ultrasonically.

Diffuse renal parenchymal disease, both kidneys.

Renal cyst, inferior pole, right kidney.

September 18, 2010

Hematology


Hematocrit .33 vol.(fr). .42 - .52 It occurs because the kidneys are unable to

produce erythropoietin, a hormone necessary

for RBC production.Hemoglobin 110 gms/L 12 – 160

25

PATHOPHYSIOLOGY

26

↑ Creatinine

Decrease renal blood flow

Decrease glomerular filtration (GFR)

Hypertrophy of remaining nephrons as they filter large load of solutes

Inability to concentrate urine adequately

Thickening in the amount of collagen inthe basement membranes

of the small vessels

Predisposing factors:

Family history of Hypertension

Precipitating factors:Lifestyle

-alcoholic drinker

-illegal drugs user

-carbonated drinker for about 5-7 bottles/day

Renal cyst

Specific gravity = ↓1.005

27

K = ↓ 3.27 mmol/L

Na = ↓ 129.5 mmol/L

Hypertension, blood pH =

↓7.263

Loss of nonexcretory renal function

Loss of excretory renal

function

Body becomes unable to rid itself of excess water, salt & other waste products through the

kidneys

Continuous decline in renal function

GFR falls below 15 mL/min/1.73 m2

Further loss of nephron function

Inability of the tubules to reabsorb electrolytes

END-STAGE RENAL DISEASE (ESRD)

Failure to produce

erythropoietin

Anemia

Decreased hydrogen excretion

Metabolic acidosis

Fatigue & weakness

Nausea & vomiting

Proteinuria

Anemia

oliguria

Pallor

SOB

28

Impaired function of

RAAS

Water retention

Edema

Hypertension

↑ rennin secretion

↑ rennin secretion

Vomiting

Anorexia

Muscle cramps

Decreased potassium excretion

hypokalemia

Decrease excretion of nitrogenous

waste

Chest pain

Hiccups

Anorexia

Nausea & vomiting

Facial grimacing

MEDICAL MANAGEMENT

A. Drug Study

Brand Name Norvasc

Generic Name Amlodipine

Drug class Antihypertensive, calcium – channel blocker

Dosage 5 mg 1 tab OD

Indications Hypertension

Contraindications Hypersensitivity

Adverse reaction Dizziness, lightheadedness, headache, peripheral edema,

fatigue, lethargy, flushing, nausea

Mechanism of Action Inhibits the movement of calcium ions across the membranes

of cardiac & arterial muscle cells. Inhibits transmembrane

calcium flow which results in the depression of impulse

formation in specialized cardiac peacemaker cells, slowing of

the velocity of conduction of the cardiac impulse, depression of

myocardial contractility & dilation of coronary arteries &

arterioles and peripheral arterioles lead to decreased cardiac

work, decreased cardiac oxygen consumption.

Nursing Responsibilities Administer with meals if upset stomach occurs.

Monitor the BP, cardiac rhythm & output.

Eat frequent small meals.

Report irregular heartbeat, SOB, swelling of hands & feet

Generic Name Hydrocortisone

Drug class Adrenocortical steroid, Glucocortecoids

Dosage 250mg IV every 8 hours

Indications ESRD


Adverse reaction Euphoria, insomnia, seizures, heart failure, HTN, edema,

arrhythmias, thrombo embolism. cataracts glaucoma, PUD, GI

irritation, increase appetite, pancreatitis, hypokalemia,

hyperglycemia, carbohydrate intolerance. muscle weakness,

growth suppression in children, osteoporosis.. hirsutism,

29

delayed wound healing, acne, easy bruising

Mechanism of Action May stabilize leukocyte lysosomal membranes, suppress

immune response, stimulate bone marrow and influence

nutrient metabolism. It reduces inflammation, suppress immune

function and raises adrenocorticoid hormonal levels.

Nursing Responsibilities Monitor patient’s weight, BP.

Monitor patient’s for stress. Fever, trauma, surgery and

emotional problems may increase adrenal insufficiency.

Periodically measure growth and development during high-

dose or prolonged therapy in infants and children.

Be alert for adverse reactions and drug interactions

Brand Name Micardis plus

Generic Name Telmisartan

Drug class Angiotensin II receptor anatagonist

Dosage 40 mg 1 tab OD

Indications Treatment for hypertension


Use cautiously with hepatic or biliary impairment,

hypovelemia

Adverse reaction Lightheadedness, headache, muscle weakness, hypotension,

palpitations, constipation, flatulence, gastritis, dry mouth,

dyspnea, cough, back pain, gout

Mechanism of Action Selectively blocks the binding of angiotensin II to specific tissue

receptors found in the vascular smooth muscle and adrenal

gland; this action blocks the vasoconstriction effects of the

rennin-angiotensin system as well as the release of

aldosterone, leading to decrease BP

Nursing Responsibilities Administer without regard to meals.

If BP control does both reach desired levels, diuretics or

other antihypertensive may be added to telemesartan.

Monitor BP carefully.

Note chills, dizziness and pregnancy.

Brand Name Renogen

Generic Name Epoetin alfa recombinant

Drug class Erythropoietin

Dosage 2,000 units 3x / week

Indications ESRD, anemia

Contraindications Uncontrolled hypertension

30

Hypersensitivity

Use in chronic renal failure clients who need severe anemia

corrected

Adverse reaction Hypertension, headache, fatigue, N and V, diarrhea, edema,

asthenia, respiratory congestion, cough, pyrexia, rash, SOB,

insomnia, pruritus, DVT (in surgery clients), hyperkalemia

Mechanism of Action Made by recombinant DNA Technology; it has the identical

amino acid sequence and same biologic effects as

endogenous erythropoietin (which is normally synthesized in

the kidney and stimulates RBC production). Epoetin alfa will

stimulate RBC production and thus elevate or maintain The

RBC level, decreasing the need for blood transfusion.

Nursing Responsibilities Do not give with any other drug solutions.

Do not dilute or give in conjunction with other drug

solutions.

Note any sensitivity to mammalian cell-derived products or

human albumin.

Determine CBC and iron stores.

Assess BP, control hypertension. Assess for seizures with

any significant hematocrit increase.

Regularly monitor CBC, renal function studies, I and O,

electrolytes, phosphorus and uric acid levels.

Generic Name Chlorpromazine hydrochloride

Drug class Antipsychotic, phenothiazine

Dosage 50 mg ¼ tab HS

Indications Positive intake of prohibited drugs and ESRD,

Adverse reaction Constipation, drowsiness, blurred vision, decreased sweating,

tremor, difficulty urinating, dark urine, dizziness, increased

appetite, menstrual iirigularities, swollen breast

Mechanism of Action Has significant antiemetic, hypotensive, and sedative effects;

moderated anticholinergic and extrapyramidal effects

Nursing Responsibilities Solutions may cause contact dermatitis; avoid contact with

hands or clothing.

Monitor vital signs, I&O, CBC, liver and renal function

studies. Ocular exams and ECG with prolonged activity.

Assess male clients for S&S of prostatic hypertrophy

Generic Name Ranitidine hydrochloride

Drug class Histamine H2 receptor blocking drug

Dosage 50 mg IV every 8 hours

31

Indications Gastric Ulcer

Contraindications Cirrhosis of the liver, impaired renal or hepatic function

Adverse reaction Headache, abdominal pain, constipation, diarrhea, nausea and

vomiting

Mechanism of Action Competitively inhibits gastric acid secretion by blocking the

effect of histamine H2 receptors. Both daytime and nocturnal

basal gastric acid secretion, as well as food-and penetagastrin-

stimulated gastric acid are inhibited. Weak inhibitor of

cytochrome P-45 (drug-matabolizing enzymes); thus, drug

interactions involving inhibition of hepatic metabolism are not

expected to occur

Nursing Responsibilities Visually inspect parenteral drug product for particulate

matter, and discoloration before administration.

Monitor CBC, B12, RENAL, LFT’s. Asses for infections.

Teach client to avoid alcohol, aspirin-containing products,

and beverages that contain caffeine (tea, cola, coffee);

these increase stomach acid.

Tell client not to smoke; interferes with healing and drug’s

effectiveness

Brand Name Plasil

Generic Name Metoclopramide

Drug class Gastrointestinal Stimulant

Dosage 10 mg IV every 8 hours

Indications Anorexia and vomiting

Contraindications Pheochromocytoma ,gastrointestinal hemorrhage, obstruction,

or perforation, epilepsy,clients taking drugs likely to cause

extrapyramidal symptoms, such as phenothiazines

Adverse reaction Extrapyramidal symptoms, restlessness, drowsiness, fatigue,

lassitude, akathasia, dizziness, nausea, diarrhea

Mechanism of Action Dopamine antagonist that acts by increasing sensitivity to

acetylcholine; results in increased motility of upper GI tract and

relaxation of the pyloric sphincter and duodenal bulb

Nursing Responsibilities Assess abdomen for bowel sounds, distention, N&V.

Inject slowly IV over 1-2 minutes to prevent transient

feelings of anxiety and restlessness.

Teach client that this drug increases movement/

concentrations of the stomach and intestine.

Tell patient to avoid alcohol and CNS depressant.

Brand Name Cellcept

32

Generic Name Micophenolate mofeyil

Drug class Immunosuppressant

Dosage 500 mg 1 tab TID

Indications ESRD


Adverse reaction Chest pain, edema, hypertension, hemorrhage, kidney tubular

necrosis, anemie, leukopenia, thrombocytopenia,

hypercholesterolemia, hyperglycemia, hyper & hypokalemia,

hypophosphatemia, back pain, cough, dyspnea, acne, rash,

sepsis.

Mechanism of Action Inhibits proliferative responses of T – and B – lymphocytes,

suppresses antibody formation by B- lymphocytes, and may

inhibit recruitment of leukocytes into sites of inflammation and

graft ejection.

Nursing Responsibilities Obtain a serum or urine pregnancy test within one week of

beginning therapy and provide contraception counceling.

Obtain history of kidney transplant.

Monitor CBC regularly.

Monitor serum potassium and phosphate, glucose level,

and cholesterol level.

Brand Name Aldazide

Generic Name Spironolactone

Drug class K – sparing diuretics

Dosage 25 mg 1 tab BID

Indications Edema

Contraindications Acute renal insufficiency, anuria, hyperkalemia, pregnancy.

Adverse reaction Gynaecomastia, drowsiness, lethargy, rash, headache, mental

confusion, ataxia, impotence, menstrual irregularities,

agranulocytosis.

Mechanism of Action Promotes water and Na excretion and hinders potassium

excretion by antagonizing aldosterone in distal tubule.

Nursing Responsibilities Monitor electrolyte level, fluid intake and output, weight and

blood pressure.

Assess patient’s condition before starting therapy and

regularly thereafter to monitor drug’s effectiveness.

Maximum antihypertensive response may be delayed up to

2 weeks.

Be alert for adverse reactions and drug interactions.

Brand Name Benadryl

33

Generic Name Diphenhydramine hydrochloride

Drug class Antihistamine

Dosage 50 mg 1 cap HS

Indications Allergy symptoms

Contraindications Contraindicated in patients with hypersensitivity and asthma

attack.

Adverse reaction Dizziness, drowsiness, sedation, seizures, sleepiness, dry

mouth, epigastric distress, nausea, vomiting, agranulocytosis,

thrombocytopenia, anaphylactic shock.

Mechanism of Action Competes with histamine for H1 – receptor sites on effector

cells. Prevents but doesn’t reverse histamine- mediated

responses, particularly histamine’s effect on smooth muscle of

bronchial tubes, GI tract, uterus, and blood vessels. Provides

local anesthesia by peventing initiation and transmission of

nerve impulses, and suppresses cough reflex by direct effect in

medulla of brain.

Nursing Responsibilities Take the drug 30 minutes before travel, to avoid motion

sickness.

Avoid alcohol and refrain from driving or performing other

hazardous activities that require alertness.

Tell pt. That coffee or tea may reduce drowsiness.

Obtain history of patient’s underlying condition before

therapy, and reassess regularly thereafter.

Brand Name Sodium Bicarbonate (NaHCO3)

Drug class Ion buffer, oral antacid

Dosage 650 mg 2 tabs BID

Indications Metabolic acidosis

Contraindications In pt. With metabolic and respiratory alkalosis, patients who are

losing chlorides from vomiting or continuous GI suction,

patients taking diuretics known to produce hypochloremic

alkalosis, patients with hypocalcemia in which alkalosis may

produce tetany, hypertension, seizures or heart failure; and

patients with acute ingestion of strong mineral acids.

Adverse reaction Belching, flatulence, gastric distension, hypernatremia,

hyperosmolaity, hypokalemia, metabolic alkalosis, iiritation and

pain in injection site.

Mechanism of Action Restore body’s buffering capacity and neutralizes excess acid.

Nursing Responsibilities To avoid risk of alkalosis, obtain blood pH, PaO2, PaCO2,

and electrolyte level.

If NaHCOe3 is being used to produce alkaline urine,

34

monitor urine pH every 4 – 6 hours.

Give drug with water, not milk; drug may cause

hypercalcemia, alkalosis or possibly renal calculi.

Generic Name Furosemide

Drug class Loop diuretic

Dosage 20 mg IVTT every 6 hours

Indications Hypertension, edema (anasarca)


Drug Interactions Increased risk of cardiac arrhythmias with digitalis

glycosides.

Increased riskof ototoxicity with aminoglycoside antibiotics,

ciplastin.

Decreased absorption of furosemide with phenytoin.

Decreased GI absorption with charcoal.

Adverse reaction Dizziness, vertigo, paresthesias, xanthopsia, weakness,

orthostatic hypotension

Mechanism of Action Inhibits reabsorption of Na & Cl from the proximal and distal

tubules & ascending limb of the loop of Henle, leading to a Na-

rich diuresis.

Nursing Responsibilities Administer with food or milk to prevent GI upset.

Give early in the day so that increased urination will not

disturb sleep.

Monitor I & O.

Measure & record weight.

Avoid rapid position changes & hazardous activities.

Use frequent mouth care.

35

B. Medi Map

37

Pathophysiology:In end stage renal disease (ESRD), the

blood flow to the kidneys may be drastically reduced due to all the damage to the filtering structures in the kidney (the glomeruli). Urine output decreases as a result, and toxic substances build up in the blood. The sum effect of this is "uremia," a complex biochemical syndrome that results from this toxic buildup. Blood urea nitrogen and creatinine are two blood markers that rise in renal disease. Electrolyte levels can also become deranged in renal disease.

Pathophysiology:In end stage renal disease (ESRD), the

blood flow to the kidneys may be drastically reduced due to all the damage to the filtering structures in the kidney (the glomeruli). Urine output decreases as a result, and toxic substances build up in the blood. The sum effect of this is "uremia," a complex biochemical syndrome that results from this toxic buildup. Blood urea nitrogen and creatinine are two blood markers that rise in renal disease. Electrolyte levels can also become deranged in renal disease.

Risk factors:

Excessive intake of illegal drugs

Excessive alcoholic and carbonated drinker for about 5-7 bottles/day

Risk factors:

Excessive intake of illegal drugs

Excessive alcoholic and carbonated drinker for about 5-7 bottles/day

Signs & symptoms:Hyponatremia↑ serum creatinineProteinuriaMetabolic acidosisAnemiaAnorexia, nausea & vomitingHypertensionChest painMuscle crampsConfusionAnasarcaPallor

Signs & symptoms:Hyponatremia↑ serum creatinineProteinuriaMetabolic acidosisAnemiaAnorexia, nausea & vomitingHypertensionChest painMuscle crampsConfusionAnasarcaPallor

Prevention:Low protein diet.Sodium, potassium & phosphorus restrictions.Restriction of fluid intake.Encourage cessation of toxic substances such as alcohol and illegal drugs.

Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables.

Prevention:Low protein diet.Sodium, potassium & phosphorus restrictions.Restriction of fluid intake.Encourage cessation of toxic substances such as alcohol and illegal drugs.

Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables.

Nursing interventions:

Turn the patient often & use a convoluted foam mattress to prevent skin

breakdown.

Provide good oral hygiene by encouraging or performing frequent brushing

with a soft brush or sponge tip to reduce breath odor & providing

sugarless hard candy & mouthwash to minimize the metallic taste in the

mouth & alleviate thirst.


Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak

pulse rate.

Carefully assess the patient’s hydration status; check for jugular vein

distention, auscultate the lungs for crackles, carefully measure daily

intake & output, record

Encourage deep breathing & coughing to prevent pulmonary congestion,

auscultate the lungs often, stay alert foe clinical effects of pulmonary

edema & administer diuretics & other medications as ordered.

Observe for signs of bleeding & monitor haemoglobin level & hematocrit &

check stool, urine & vomitus for blood.


Nursing interventions:

Turn the patient often & use a convoluted foam mattress to prevent skin

breakdown.

Provide good oral hygiene by encouraging or performing frequent brushing

with a soft brush or sponge tip to reduce breath odor & providing

sugarless hard candy & mouthwash to minimize the metallic taste in the

mouth & alleviate thirst.


Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak

pulse rate.

Carefully assess the patient’s hydration status; check for jugular vein

distention, auscultate the lungs for crackles, carefully measure daily

intake & output, record

Encourage deep breathing & coughing to prevent pulmonary congestion,

auscultate the lungs often, stay alert foe clinical effects of pulmonary

edema & administer diuretics & other medications as ordered.

Observe for signs of bleeding & monitor haemoglobin level & hematocrit &

check stool, urine & vomitus for blood.


Medical ManagementDrugs;

Amlodipine (Norvasc) 5 mg 1 tab ODHydrocortisone 250 mg IV q8hTelmisartan (Micardis plus) 40 mg 1 tab ODEpoetin alfa recombinant (Renogen) 2,000 units 3x/weekChlorpromazine hydrochloride 50 mg ¼ tab HSRanitidine hydrochloride 50 mg IV q8hMetoclopramide (Plasil) 10 mg IV q8hMycophenolate mofetil (Cell cept) 500 mg 1 tab TID(Aldazide) 25 mg 1 tab BIDDiphenhydramine hydrochloride (Benadryl) 50 mg 1 cap HSSodium Bicarbonate 650 mg 2 tab BIDFurosemide 20 mg IVTT q8h

IVF Left carpal vein - PNSS 1L + 20 mEqs NaCl x 60 cc/° Side drip - D5W 500 c + 100 mEqa NaHCO3x24°x 2Right carpal vein - PNSS 500 cc x KVO O2 @ 2 Lpm via nasal cannula

Medical ManagementDrugs;

Amlodipine (Norvasc) 5 mg 1 tab ODHydrocortisone 250 mg IV q8hTelmisartan (Micardis plus) 40 mg 1 tab ODEpoetin alfa recombinant (Renogen) 2,000 units 3x/weekChlorpromazine hydrochloride 50 mg ¼ tab HSRanitidine hydrochloride 50 mg IV q8hMetoclopramide (Plasil) 10 mg IV q8hMycophenolate mofetil (Cell cept) 500 mg 1 tab TID(Aldazide) 25 mg 1 tab BIDDiphenhydramine hydrochloride (Benadryl) 50 mg 1 cap HSSodium Bicarbonate 650 mg 2 tab BIDFurosemide 20 mg IVTT q8h

IVF Left carpal vein - PNSS 1L + 20 mEqs NaCl x 60 cc/° Side drip - D5W 500 c + 100 mEqa NaHCO3x24°x 2Right carpal vein - PNSS 500 cc x KVO O2 @ 2 Lpm via nasal cannula

Laboratory and Diagnostic TestUrinalysisHematologySerum electrolytes test: Potassium, chlorideSerum creatinieABG analysisUltrasound: KUB

Laboratory and Diagnostic TestUrinalysisHematologySerum electrolytes test: Potassium, chlorideSerum creatinieABG analysisUltrasound: KUB

END-STAGE RENAL DISEASEEND-STAGE RENAL DISEASE

NURSING MANAGEMENT

38

A. Concept Map of Nursing Problems

39

Impaired gas exchange r/t decreased O2

carrying capacity of the blood

End – Stage Renal FailureCc : vomiting

7. Altered comfort r/t persistent hiccup.

6. Pain r/t the accumulation of

toxic substances 2° impaired

renal function.

5. Fluid volume excess r/t the excessive accumulation of

fluid in the interstitial space 2° to ↑ hydrostatic pressure.

4. Impaired urinary elimination r/t diminished

renal function.

3. Imbalance nutrition: less than body requirements r/t

loss of appetite and vomiting.

Ineffective renal tissue perfusion r/t decreased

hemoglobin concentration in blood.

8. Risk for impaired skin integrity r/t the accumulation

of fluid in the interstitial space 2° imbalanced

nutritional state.

40

Impaired gas exchange r/t decreased oxygen carrying capacity of the blood.

Subjective:

“Daw nabudlayan pa guid ko gyapon

magginhawa”, as verbalized.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

(+) fatigue

(+) weakness

(+) pallor

(+) anemia

(+) confusion

Hematology:

Hct = ↓ 15 vol.(fr)

Hgb = ↓50 gms/L

RBC = ↓1.75 X 10^12/L

ABG:

pCO2 = ↓21.1 mmHg

pO2 = ↑154.1 mmHg

Renogen 2,000 units 3x/week

O2 @ 2 Lpm via nasal cannula

4. Impaired urinary elimination r/t

diminished renal function.

Subjective:

“Indi ako kaihi”, as verbalized.

Objective:

Bp = 140/100 mmHg

(+) anasarca

Distended urinary bladder

(+) Oliguria

(+) fatigue

(+) weakness

Pain @ hypogastric area

No urine output for 7 hours

(+) tenderness

Intake exceeds output. I = 230 cc, O =

120 cc

Difficulty upon urination

Adm. Dx: CKD 2° to nepholithiasis

Urinalysis:

RBC/hpf = ↑3 – 8 / hpf (hematuria)

WBC/hpf = ↑8 – 23 / hpf (pyuria)

KUB:

Diffuse renal parenchymal disease, both

kidneys.

Renal cyst, inferior pole, right kidney

Furosemide 20 mg IVTT q8h

Aldazide 25 mg 1 tab BID

3. Imbalance nutrition: less than

body requirements r/t loss of

appetite and vomiting.

Subjective:

“Wala ako gana magkaon”, as

verbalized.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

(+) fatigue

(+) weakness

(+) anorexia

(+) nausea & vomiting.

(+) anasarca

(+) right arm muscle cramps

(+) dry skin & lips

Serum electrolytes:

K = ↓ 3.27 mmol/L

Na = ↓ 129.5 mmol/L


Chlorpromazine hydrochloride 50

mg ¼ tab HS

2. Ineffective renal tissue perfusion r/t decreased hemoglobin concentration in

blood.

Objective:

Bp = 140/100 mmHg

(+) DOB

(+) anemia

(+) oliguria

Serum creatinine = ↑1679.6 umol/L

Serum electrolytes:

K = ↓ 3.27 mmol/L

Na = ↓ 129.5 mmol/L

Hematology:


Hgb = ↓50 gms/L

RBC = ↓1.75 X 10^12/L

ABG:

pCO2 = ↓21.1 mmHg

pO2 = ↑154.1 mmHg

Urinalysis:

Protein = +3

RBC/hpf = ↑3 – 8 / hpf (hematuria)

WBC/hpf = ↑8 – 23 / hpf (pyuria)

KUB:

Diffuse renal parenchymal disease, both kidneys.

Renal cyst, inferior pole, right kidney.


Amlodipine (Norvasc) 5 mg 1 tab OD

Telmisartan (Micardis plus) 40 mg 1 tab OD



O2 @ 2 Lpm via nasal cannula.

41

8. Risk for impaired skin integrity

r/t the accumulation of fluid in the

interstitial space 2° imbalanced

nutritional state.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) anasarca

(+) anemia

(+) dry skin

Serum electrolytes:

K = ↓3.27 mmol/L

Na = ↓ 129.5 mmol/L

Creatinine = ↑1679.6 umol/L

Hematology:


Hgb = ↓50 gms/L

RBC = ↓1.75 X 10^12/L

ABG:

pH =↓ 7.263

pCO2 = ↓21.1 mmHg

pO2 = ↑154.1 mmHg

NaCO3 = ↓9.2 mmol/L

7. Altered comfort r/t

persistent hiccup

Subjective:

“Ginasinidoh ako”, as

verbalized.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

(+) facial grimace

(+) persistent hiccup

(+) weakness

(+) fatigue

Chest pain progresses

during hiccups.

6. Pain r/t the accumulation of toxic

substances 2° impaired renal

function.

Subjective:

“Gasakit man gyapon akon dughan”,

as verbalized.

Objectives:

Bp = 140/100 mmHg

RR = 21

(+) DOB

(+) weakness

(+) fatigue

(+) pallor

(+) hiccups

(+) facial grimace

(+) anterior chest pain with a pain scale

of 5.

(+) anorexia

Adm. Dx: CKD 2° to Nephrolithiasis.

Serum creatinine = 1679.6 umol/L


5. Fluid volume excess r/t the excessive

accumulation of fluid in the interstitial

space 2° to ↑ hydrostatic pressure.

Subjective:

“Nagpalanghabok gidman sa”, as

verbalized by the folks.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

Abdominal girth = 94 cm

(+) anasarca

(+) anorexia

Distended urinary bladder

(+) of bruits in 4 abdominal quadrants upon

auscultation.

(+) weight gain over a short period of time.

Weight before admission = 68 kg, current

weight = 72 kg.

Fluid intake exceeds output. Intake = 230

cc, output = 120 cc.

(+) fatigue

(+) weakness




B. Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective:

“Daw nabudlayan pa gid

ko gyapon magginhawa”,

as verbalized.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

(+) SOB

(+) fatigue

(+) weakness

(+) pallor

(+) anemia

(+) confusion

Hematology:

-Hct = ↓ 15 vol.(fr)

-Hgb = ↓50 gms/L

-RBC = ↓1.75 X

10^12/L

1. Impaired gas

exchange r/t

decreased oxygen

carrying capacity of

the blood.

To provide adequate

oxygenation within the

shift.

Dependent:

Administered Renogen

2,000 units 3x/week

Provided O2 @ 2 Lpm

via nasal cannula.

Independent:

Monitored VS.

Positioned with HOB

elevated.

It has the same biologic

effects as endogenous

erythropoietin that

stimulate RBC

production and thus

elevate or maintain The

RBC level.

To provide oxygen

needed by the body for

functioning.

To determine alteration in the vital signs which includes the RR, BP,

CR.

Promotes better lung

expansion & improve

gas exchange

Goal met.

Bp = 130/90 mmHg

RR = 20 bpm

No any complaints of

DOB.

42

ABG:

-pCO2 = ↓21.1

mmHg

-pO2 = ↑154.1

mmHg

Provided rest periods to

prevent fatigue.

Recommended quietatmosphere and

bed rest if indicated.

Encouraged toperform foot exercises

every hour whenawake.

Encouraged a deep breathing exercise.

Even simple activities such as bathing can

increase oxygen consumption & cause

fatigue

This enhancesrest to lower

body’s oxygenrequirements andreduces strain on

the heart andlungs.

This will promotevenous return andbetter circulation.

Promotes optimal lung expansion.

43


Objective:

Bp = 140/100 mmHg

(+) DOB

(+) anemia

(+) oliguria

Serum creatinine =

↑1679.6 umol/L

Serum electrolytes:

-K = ↓ 3.27

mmol/L

-Na = ↓ 129.5

mmol/L

Hematology:

-Hct = ↓ 15 vol.(fr)

-Hgb = ↓50 gms/L

-RBC = ↓1.75 X

10^12/L

ABG:

-pCO2 = ↓21.1

mmHg

-pO2 = ↑154.1

2. Ineffective renal

tissue perfusion r/t

decreased hemoglobin

concentration in blood.

To demonstrate

adequate oxygenation

and perfusion within the

shift

Dependent:


2,000 units 3x/week

Adminitered Amlodipine

(Norvasc) 5 mg 1 tab OD

Administered Telmisartan (Micardis plus) 40 mg 1 tab OD



erythropoietin that

stimulate RBC

production and thus


RBC level.

Inhibits transmembrane

calcium flow which

slowing of the velocity of

conduction of the cardiac

impulse, depression of

myocardial contractility &

dilation of coronary

arteries & arterioles and

peripheral arterioles lead

to decreased cardiac

work.

Selectively blocks the

binding of angiotensin II

Goal met.

Bp = 130/90 mmHg

RR = 20 bpm

(-) DOB

44

mmHg

Urinalysis:

-Protein = +3

-RBC/hpf = ↑3 – 8

/ hpf

(hematuria)

-WBC/hpf = ↑8 –

23 / hpf

(pyuria)

KUB:

-Diffuse renal

parenchymal

disease, both

kidneys.

-Renal cyst,

inferior pole,

right kidney.

Administered Aldazide

25 mg 1 tab BID

Administered Furosemide 20 mg IVTT

q8h

Provided O2 @ 2 Lpm via nasal cannula.

to specific tissue

receptors found in the

vascular smooth muscle

and adrenal gland

leading to decrease BP.

Promotes water and Na

excretion and hinders

potassium excretion by

antagonizing aldosterone

in distal tubule that leads

to decrease Bp.

Inhibits reabsorption of

Na & Cl from the

proximal and distal

tubules & ascending limb

of the loop of Henle,

leading to a Na-rich

dieresis that leads to

decrease Bp.

To provide oxygen needed by the body for

functioning.

45

Independent:

Monitored VS.

Maintained bed rest, provide quiet environment,

To monitor patient from any changes in his

status. Elevated VS may indicate poor circulation

and oxygenation.

To decrease oxygen and blood demand.


Subjective:

“Wala ako gana

magkaon”, as verbalized.

Objective:

Bp = 140/100 mmHg

RR = 21 bpm

(+) DOB

(+) fatigue

(+) weakness

(+) anorexia

(+) nausea &

3. Imbalance nutrition:

less than body

requirements r/t loss of

appetite and vomiting.

To be able to

demonstrate selection of

food necessary for

weight gain and

consume adequate

nourishment within the

shift.

Dependent:


2,000 units 3x/week

Administered

Chlorpromazine

hydrochloride 50 mg ¼



erythropoietin that

stimulate RBC

production and thus


RBC level.

Has significant

antiemetic, hypotensive,

and sedative effects;

Goal partially met,

Consumed 50% of

served foods.

(-) nausea & vomiting

(+) anorexia

46

vomiting.

(+) anasarca

(+) right arm muscle

cramps

(+) dry skin & lips

Serum electrolytes:

-K = ↓ 3.27

mmol/L

-Na = ↓ 129.5

mmol/L

tab HS

Independent:

Discouraged beverages

that are caffeinated or

carbonated.

Encouraged range of

motion exercise.

Ensured a pleasant

environment.

Facilitated proper

position by elevating

HOB.

Provided good oral

hygiene and dentition.

moderated

anticholinergic and

extrapyramidal effects.

These may decrease

appetite and lead to

early satiety and will

make the client feel

full easily.

Metabolism and

utilization of nutrients are

enhanced by activity.

It gives a relaxed

feeling and will not

spoil her appetite.

Aids in swallowing and

reduces risk of aspiration

Noxious tastes, smells, and sight

are prime deterrents to

47

Eliminated smells from

the environment.

Instructed to avoid gas-

producer, very hot & very

cold foods

Instructed toavoid junk foods.

Educated regarding the importance of healthy

foods and it’s benefits to his body.

Encouraged to eat.

Taught about foods what & not what to eat

appetite and can produce nausea and

vomiting with increasedrespiratory difficulty.

Reduces gastric stimulation & vomiting

response

To prevent abdominal

distention

Junk foods have

empty calories thatprovide no nutritional

help to the client.

To provide ampleinformation and

awareness.

To provide nourishment

needed by the body for

metabolic demand.

To make him aware about his diet that is

needed for his nourishment.

48


Subjective:“Indi ako kaihi”, as verbalized.

Objective: Bp = 140/100 mmHg (+) anasarca Distended urinary

bladder (+) Oliguria (+) fatigue (+) weakness Pain @ hypogastric

area No urine output for 7

hours (+) tenderness Intake exceeds

output. I = 230 cc, O = 120 cc

Difficulty upon urination

Adm. Dx: CKD 2° to nepholithiasis

Urinalysis:-RBC/hpf = ↑3 – 8

/ hpf (hematuria)

-WBC/hpf = ↑8 – 23 / hpf (pyuria)

4.Impaired urinary elimination r/t

diminished renal function.

To relieve abdominal discomfort & eliminate

retention of urine after 30 mins of nursing

intervention.

Dependent:Administered


Administered Aldazide 25 mg 1 tab BID

Independent:Monitored VS.

Monitored I & O.

Maintained clienton semi-fowler’s orposition of comfort

Inhibits reabsorption of Na & Cl from the

proximal and distal tubules & ascending limb

of the loop of Henle, leading to a Na-rich

dieresis.

Promotes water and Na excretion and hinders

potassium excretion by antagonizing aldosterone

in distal tubule.

To evaluate any manifestation caused by abdominal discomfort &

bladder retention like BP, RR, AR.

Provides information about kidney function

and presence of complications.

Allows relaxation of abdominal & perineal muscles to promote bladder emptying.

Goal met.

Obtained 80 cc of clear urine after

catheterization.

Reported relief of hypogastric area.

Total urine output within the shift = 210 cc.

49

KUB:-Diffuse renal

parenchymal disease, both kidneys.

-Renal cyst, inferior pole, right kidney.

Foley catheter inserted & secured as order.

Demonstrated proper positioning of catheter

drainage tubing and bag.

Provide catheter care.

Instructed to limit Na & fluid intake.

Maintained acidic environment of the

bladder by the use of agents, or vit. C from fruits and buko juice.

Instructed to avoid caffeinated and

carbonated beverages.

To facilitate elimination of urine that can

decrease abdominal discomfort.

To facilitate drainage and prevent reflux.

To prevent ascending UTI which may

aggravate the condition

To prevent further water retention that causes

edema.

To discourage bacterial growth.

To prevent bladder irritation.

50


Subjective:“Nagpalanghabok gidman sa”, as verbalized by the folks.

Objective: Bp = 140/100 mmHg RR = 21 bpm (+) DOB Abdominal girth = 94

cm (+) anasarca (+) anorexia Distended urinary

bladder (+) of bruits in 4

abdominal quadrants upon auscultation.

(+) weight gain over a short period of time. Weight before admission = 68 kg, current weight = 72 kg.

Fluid intake exceeds output. Intake = 230 cc, output = 120 cc.

(+) fatigue (+) weakness

5. Fluid volume excess r/t the excessive

accumulation of fluid in the interstitial space

2° to ↑ hydrostatic pressure.

To stabilize fluid volume within the shift.

Dependent:Administered


Administered Aldazide 25 mg 1 tab BID

Provided O2 @ 2 Lpm via nasal cannula.

Independent:Monitored & recorded

vital signs

Instructed to limit fluid & Na intake.

Elevated edematous extremities.

Inhibits reabsorption of Na & Cl from the

proximal and distal tubules & ascending limb

of the loop of Henle, leading to a Na-rich

dieresis.

Promotes water and Na excretion and hinders

potassium excretion by antagonizing aldosterone

in distal tubule.

To provide oxygen needed by the body for

functioning.

To obtain baseline data

To monitor kidney function and fluid

retention

This increases venous return and, in turn, decreases edema.

Goal met.

Bp = 130/90mmHg

RR = 20 bpm

(-) DOB

Total urine output within the shift = 210 cc.

Total fluid intake = 190 cc.

51

Reduced constriction of vessels by avoiding crossing of legs or

ankles

Encouraged quiet, restful atmosphere.

Implemented comfort measures& safety

precautions to prevent skin breakdown.

Encouraged not to lie on bed all the time.

Assisted to a semi – fowler’s position.

This prevents venous pooling.

To conserve energy & lower tissue oxygen

demand.

Edema can cause skin to breakdown faster.

To reduce tissue breakdown & risk of skin

breakdown.

To facilitate movement of diaphragm, thus

improving respiratory effort.


Subjective:“Gasakit man gyapon

akon dughan”, as verbalized.

Objectives: Bp = 140/100 mmHg RR = 21 (+) DOB (+) weakness (+) fatigue

6.Pain r/t the accumulation of toxic

substances 2° impaired renal function.

To demonstrate a relief of pain as evidenced by decreased pain scale of 2 or 3 after 4 hours of nursing intervention.

Dependent:Provided O2 @ 2 Lpm via nasal cannula as

ordered.

Independent:Provided comfort measures & an

environment conducive for rest.

To provide an oxygen needed by the body for

compensation.

Promotes relaxation, reduces muscle tension, and enhances coping.

Goal met as evidenced by a decreased in pain

scale of 2.

RR = 20 bpm

(-) DOB

(-) facial grimace

52

(+) pallor (+) hiccups (+) facial grimace (+) anterior chest

pain with a pain scale of 5.

(+) anorexia Adm. Dx: CKD 2° to

Nephrolithiasis. Serum creatinine =

1679.6 umol/L

Monitored V/S.

Assisted to sit on chair.

Encouraged to limit intake of fluid & Na – rich

foods.

Encouraged a deep breathing exercises & relaxation techniques.

Provided diversional activities like watching

TV & talking with others.

Elevated the head of bed.

To monitor client’s pain status. Pain can cause

elevation of VS.

This position makes patient comfortable &

helps in relieving client’s pain.

Water and Na retention in the body may

contribute to the chest pain & discomfort as the fluids accumulate in the

chest cavity.

Promotes relaxation and reduces muscle tension.

Promotes relaxation and helps client refocus

attention on something besides discomfort.

This position makes patient comfortable &

helps in relieving client’s pain.

53


Subjective:“Ginasinidoh ako”, as verbalized.

Objective: Bp = 140/100 mmHg RR = 21 bpm (+) DOB (+) facial grimace (+) persistent hiccup (+) weakness (+) fatigue Chest pain

progresses during hiccups.

7. Altered comfort r/t persistent hiccup.

To provide pt’s comfort within the shift.

Independent:Provided rest periods.

Provided diversional activities like watching TV

and talking with others.

Provided relaxation techniques and cheerful

conversations.

Maintained a calm & quiet environment.

Provided a dim and light but providing good

Ventilation.

To facilitate comfort, sleep, and relaxation.

Distraction techniques heighten one’s

concentration upon non-painful stimuli

to decrease one’s awareness

Relaxation exercises Techniques are used

to bring about a state of physical and

mental awareness and tranquility.

To minimize stimulus that could

aggravate the condition.

To add comfort to the pt.

Goal partially met.

Still have a complaint of discomfort but the

episodes had lessen.

“Nag-ayo-ayo na yanda‘, as verbalized.


Objective: Bp = 140/100 mmHg RR = 21 bpm (+) anasarca (+) anemia

8.Risk for impaired skin integrity r/t the

accumulation of fluid in the interstitial space

2° imbalanced nutritional state.

To maintain skin integrity & prevent skin

breakdown within the shift.

Independent:VS monitored &

recorded.Changes in vital signs may indicate infection

caused by skin breakdown

Goal met.

No signs of skin breakdown or complaints

54

(+) dry skin

Serum electrolytes:-K = ↓3.27 mmol/L-Na = ↓ 129.5

mmol/L-Creatinine =

↑1679.6 umol/L

Hematology:-Hct = ↓ 15 vol.(fr)-Hgb = ↓50 gms/L-RBC = ↓1.75 X

10^12/L ABG:

-pH =↓ 7.263-pCO2 = ↓21.1

mmHg-pO2 = ↑154.1

mmHg-NaCO3 = ↓9.2

mmol/L

Use safety measures in changing the position.Encouraged use of lift

sheets to move patient in bed and discourage

patient or caregiver from elevating HOB

repeatedly.

Demonstrated good skin hygiene by washing

thoroughly and pat dry carefully.

Instructed to maintain clean & dry clothes,

preferably cotton fabric.

Encouraged not to lie on bed all the time and

provide range of motion exercise.

Recommended elevation of lower extremities

when sitting.

These measures reduce shearing forces on the

skin.

Maintaining clean & dry skin provides barrier to

infection. Patting skin dry instead of rubbing

reduces risk of dermal trauma to fragile skin.

Skin friction can cause by stiff or rough clothes

leads to irritation of fragile skin & increase

risk for infection.

Lying on bed all the time can increase risk of skin

integrity wherein a pressure is being applied

in the tissue. ROM exercise facilitates

circulation.

To enhance venous return & & reduce edema

formation.

of discomfort in the bony prominences.

55

DISCHARGE PLANNING

edications

Encourage the patient to have a strict compliance with regards to the medication to

attain therapeutic effects.

Explain to the patient the use and side effects of the medications so that he will be

aware of its effects.

Give adequate instructions to the significant others about the importance of the following

medications and dietary regimens so that the patient’s condition can remain stable as

soon as possible.

1. Renogen 2, 000 units 3x a week

2. NaHCO3 650 mg 2 tabs TID

3. Cellcept 500 mg 1 tab TID

4. Micardis plus 50 mg 1 tab OD

5. Amlodipine (Norvasc) 5 mg 1 tab OD

6. Aldazide 25 mg 1 tab BID

7. Chlopromazine 50 mg ¼ tab HS

xercise

Instruct the patient to practice moving his lower extremities to promote blood circulation

and even to improve the range of motion of his foot or feet so that he could somehow,

able to ambulate with himself in later times.

Educate the patient about bed exercises such as leg exercise, since patient is always on

bed and have limitations on his physical activity because his still weak.

Teach how to perform range-of-motion exercises because it helps reduce stiffness and

maintain or increase proper joint movement and flexibility.

reatment

Aware the patient to avoid over work for the following days and must have adequate bed

rest to regain energy or strength.

By means of anticipating the needs on the course of healing and curing process,

train the patient to focused to himself by not always depending on the interventions that

are not highly needed just to ease or prevent any health problem regarding his condition.

ome teaching

To promote adherence to the therapeutic programs. Teach the following:

Weighed self every morning to avoid fluid overload.

Drink limited amounts of fluid only when thirsty.

Measure alloted fluids and save some for ice cubes, sucking on ice is thirst quenching.

Eat food before drinking fluids to alleviate dry mouth.

56

Use hard candy or chewing gum to moisten the mouth.

Environmental sanitation is needed to provide a therapeutic way of curing himself.

Teach the patient and family how to measure blood pressure.

Teach the patient the importance of hand washing to avoid the spread of

infection.

ut-patient

Remind the patient that he must come back to the hospital one week after, for the follow-

up check-up to confirm if the patient’s condition is really restored. Also to know if there

are complications sited during the check up to know if patients condition have worsen or

not.

Advise patient and the family to report to the physician if any recurrence or severity of

symptoms, any adverse effects to the medication, and any development of

complications.

iet

Instruct him to avoid foods high in phosphorus, potassium & sodium because it can lead

to high probability of current of many diseases. These foods also can build up in the

bloodstream & can cause harm when they cannot eliminate by the kidneys.

Encourage cessation of toxic substances such as alcohol and illegal drugs in order to

prevent totally the worsening again of the problem and it can damage the kidneys by

causing a decrease in renal blood flow, obstructing urine flow, directly damaging

tubulointestinal structures or by producing hypersensitivity reaction.

Advise to eat nutritious food would somehow help the patient on regaining some

strengths or energy to his body, such as green leafy vegetables

Inform the client and the client’s relatives on the specific types of food that may help

speed up the recovery from the condition.

pirituality

Encourage the patient to read the Bible and pray to God always, ask for guidance and

pray for the healing and restoration of health.

Ask the patient to reflect on the Bible Scripture, “For I will restore health to you and heal

you on your wounds.” says the Lord. (Jeremiah 30:17).

Always seek spiritual advice and go on Sunday masses.

57

MY JOURNAL

Experiencing a duty in RENDU ward was all worth it because it enhances your skills and

knowledge in clinical area. In my first week of duty in RENDU ward I handle a seriously ill

patient with a medical diagnosis of prostate cancer. I was scared that moment because I never

handle a patient with a serious illness like him. It was my first time to do suctioning and my

second time to do an NGT. I admit that I am so nervous that moment and I don’t know what I

am going to do. My hands were shaking and I can’t perform well the said procedures. Ma’am

Bengan continue the suctioning because I can’t do it and in NGT feeding, I also failed because

the septo syringe was dislodge when I instill 30cc of water for flushing. I was so disappointed to

myself because I didn’t apply what I have learned during our OSCE in doing the procedure. I

guess I need to change my attitude being nervous every time I do nursing procedure as what

Ma’am Bengan said to me.

In my 2 weeks of duty in RENDU, I also learned things such as making nurses notes. It

is much easier for us to do a sample charting because Ma’am Bengan helped and corrected our

mistakes in doing a sample charting. Unfortunately, I was not able to administer more drugs

unlike my other group mates.

They said Ma’am Bengan was so strict, but I guess it’s wrong because Ma’am was so

nice to her students and she helps the student to become a competent nurse someday. She is

strict in a right way and she always makes us feel that we should be serious to our studies. I am

thankful because I have the time to be with her, and become our clinical instructor in clinical

area. I will never forget what Ma’am Bengan said to me “Ms. Adricula daw sobra ka pa bla sa

my Alzheimer’s”. Thank you Ma’am for sharing your knowledge to us, the enjoyment that we

have experience and the laugh trip ……LAUGH, LAUGH, LAUGH..

Kris Joy D. Adricula, S.N

58

MY JOURNAL

Being exposed in the clinical setting or having our duty at the hospital is indeed

to be one of the most unforgettable experiences being a student nurse; it is a step towards my

goal of becoming a nurse.

Taking care of my client is my responsibility being a nursing student; I am there

to meet the needs of my client and to make sure that they are safe. As I take good care of my

patient, I could hardly say that it was worth it to work on them because they are the ones who

really give meaning to my chosen profession. I can’t deny that it’s really hard at first for me to

deal with them because there is still a phase of getting to know each other before I can have

their sympathy; they have doubts on my capacity to take good care of them because I am just a

student nurse, but despite of those criticisms I still managed to have a positive outlook and I am

glad that their impression to me at first was changed after our shift.

Within our two weeks of duty in Rendu Ward we have encounter different patient

having different problem. Some of them are what they say “toxic”, imagine in our last week of

duty two of our handled patient was intubated! But I am unfortunate because I am not the one

who was assigned to them.

Their are a lot of things that I have learned through this exposure the value of

time management, and trying my best not to commit any errors for it can make my patients life

be at risk, specially that we being the healthcare provider is dealing with their lives every step or

nursing care we make has a lot of contributions to the patients condition. A mistake must be

corrected and I must learn how to be flexible enough to manage all things like the personal

problem or anything that can affect my work.

I have learned a lot in the whole hospital exposure which I can treasure and use

in dealing different patients in the next exposure. This hospital exposure serves as a challenge

to me to face patients with different conditions and it serves also as a stepping stone to enhance

my skills, attitude, and knowledge in handling different clients. And I owe this experience to our

CI’s who understand and patiently shared their knowledge without hesitation.

Carol Ann D. Dela Cruz, S.N

59

MY JOURNAL

When I was a child, I wander myself working in a hospital as a nurse. I thought giving

care is easy as that but as a student nurse it wasn’t. Working in a hospital is just like a

battlefield. You have to be God-fearing, strong, confident, alert mind, carry with yourself the core

values and be ready to face different encounters. I’m on third year now. I encountered so many

things in the ward. I’m glad to have mistakes because I learned to know what should be done

correctly. I may learn new things during our duties but still there are lots of things I should be

focusing on. Just like rendering my care to my patient. Carrying my critical thinking skills all

throughout the shift which I am always reminded by my clinical instructor, is very useful. Not all

the time, we should just depend on what we see in textbooks or by just looking the charts

without even knowing its significance. Sometimes you have to go deeper for you to understand

the existence of the disease present in the patient as well as to render care accordingly. Thank

you to my dear clinical instructor for giving us activities every duty. I’ve learned different medical

terms, the responsibilities should be done and knotting them all to understand well. In charting,

I enjoyed making them because through the corrections made I was able to do better one the

next time. In giving medicine, now I can say I learned from my mistake before. I always assure

to check the physicians order and if things which I did not understand I ask my clinical instructor.

All those helped me a lot to be a responsible and effective nurse.

During my 1st and 2nd day duty at Blessed Rosalie Rendu Ward, I had a pt. named M.L,

female, 52 y.o. She had a gouty arthritis. Upon my care, I have already an idea in my mind

because I had a background of it. I was able to apply my nursing intervention well but I cannot

control her irritability. I understand because she is in pain. To maintain my care, what I did, I

gave her more patience. I respect her by not disturbing her when she is about to sleep. She

might not follow me to do warm compress but I’m still encouraging and providing her the health

teaching about the disease. I also establish rapport so that she trust me at the same time.

During my 3rd and 4th day of duty, I had E.C. as my patient. He is 65 y.o and had a DM

Type II. He undergone debridement on the left leg because the doctor should prevent the

progression of pathogens on the affected area caused by the TALABA. During the dressing

done by Dr. T., I was so amazed to see his left leg. I observed the incision. There is a

seropurulent drainage coming out. It is scary to look at because it’s my first time to see such

wound. As doctor cleaned, he told me not to put betadine inside the wound especially the meat-

like part of the skin because the cell inside will die. Imagine the talaba could really be a factor to

introduce pathogens inside the skin and its invasion will progress if not treated immediately. It

will cause much damage to the skin. During my care, I also advised my patient to include

malunggay in his diet. I just read it from a magazine in the library that malunggay is a miracle

tree and it decreases blood glucose. So I shared it to him. In administering humulin “R” since it

was my first time, I’m nervous at first but as I always remember not to panic and have presence

of mind. Everything will go easy.

Ma. Rica Gracia Bulaso, S.N

60

MY JOURNAL

During our Duty at Blessed Rosalie Rendu Ward, I have encountered

some of the rarest diseases of the critically ill patients, I have widened my

knowledge about there disease process and enhanced my skills in caring for the

sick. I have also develop my intrapersonal skills in relation to interacting with the

staff nurses in the ward and in caring for my patient. I have learned how to

interact with my patient and how to deal with their problem regarding their

condition. As the days past by I have I wider and better understanding of the

medication that we are giving to our patient and what are the signs and

symptoms that we should observe and watch out for as we are giving our

medication, and as a student or even the staff nurse’s should always observe the

13 rights of administering medication, as a student if you are in doubt in

administering your medication always and foremost consult your clinical

instructor and consult the staff nurses in the ward. I have also learned how to

manage my time well in managing for the sick.

Daniel Delid,S.N

61

MY JOURNAL

During our fourth rotation with ma'am katz we are all having so much fun,

even though we are all busy doing our duties as a student nurses we still have

time to bond with the group and also with ma'am katz. I was able to learn more

things during our duty because we are having our ward class we would discuss

the things regarding some of the procedures that we are performing in the clinical

area for example how to instruct our patient in collecting urine. Some of the

disease that our patients manifest and a lot more. The last day of our duty is the

most memorable day because ma'am would share us some stories and we would

all laugh at it. It also funny how ma'am gives us some advices especially when

ma'am gives advice to Mr. Rufino. Sometimes im scared when ma'am calls out

my attention because im laughing very loud im scared that ma'am katz might get

angry with me and now im trying so hard not to laugh very loud. HAHAHA.

Krizia Allison Basas, S.N

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MY JOURNAL

Interns are provided with introductory experiences and close staff supervision in counseling

patients. This is typically a fourth week rotation. Common patient diagnoses are

hypertension,CVA,Dengue fever,ESRD and ect. The focus of this experience is on developing

skills in planning care, counseling, and documenting care provided. This includes setting

priorities, long-term goals, and behavioral objectives for patients.

The last two weeks of our exposure here in the rendu ward there are lots of happy and

sad happenings happened. There are times that Ma’am Bengan always reminding us about our

medications and our vital signs. There are also bloopers in our charting. There are also sad

things that we’ve experience especially if Ma’am Bengan is not in mood and she is always

telling that we should be serious to our duty and we should have our commonsense also the

presence of mind.

I have experience that Ma’am Bengan was telling me if I have any problem because my

charting is wrong and she don’t know what she should do to me, but I was only listening to her

because I know that it is for my own good and she is only reminding me that I should be

attentive and I should be focused of the things that I was doing. Everytime that the doctors are

doing their rounds it is important for us to go with them because there are many things that we

can learn from them.

We’ve learned lots of things here in the Rendu Ward especially the five rights of giving

medications, the do’s and dont’s of medications used the proper charting and procedures that

we can be seen in the actual

We are very thankful because we have a clinical instructor that is always there for us to

reminding us of our duty in rendering of care to our patient.Clinical experience is very important!

Students must get experience in a medical environment in order to make an informed decision

to pursue a career in medicine. we should not think of clinical experiences simply in terms of

putting in a requisite number of hours to meet a minimal requirement for admission to medical

school. As important as devoting the time to gaining this experience is what you learn through it.

Clinical experience can have an added benefit for premed students.Nurses dispense comfort,

compassion, and caring without even a prescription.

Akemie C. Campos, S.N

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MY JOURNAL

After 2 weeks of my exposure again in the Blessed Rosalie Rendu Ward with Mrs.

Katherine Conlu-Bengan, I have learned and experienced a lot of things, things that I am only

lucky enough to see and learn because of my chosen career.

On the first day, I was assigned to a patient who for proctosigmoidoscopy or the

endoscopic viewing of the rectum and the sigmoid colon and hemorrhoidectomy or a surgical

procedure to repair hemorrhoids. I was also assigned to a patient who was diagnosed to have

Myocardial Infarction but she was for discharge that morning so I wasn’t able to handle her for

the whole shift.

On the second day, I was still assigned to a same patient and that day was the day

before her operation. She was advised to have a clear liquid diet, in preparation for her

operation. I was able to apply the necessary preoperative care for her based from what I have

seen and experienced when my mother had also a surgery. On that day, Dr. B. made her

rounds to check if the patient is ready and if there are no contraindications for the surgery,

fortunately there was none.

I assessed also my patient’s emotional status, if she is anxious about what’s going to

happen to her and she said to me that yes, she is a little bit nervous but it helps her a lot,

thinking that she waited for this surgery to happen long time ago.

On our second week of exposure, I was assigned to an 8 year old girl who was

diagnosed to have UTI v/s Dengue Fever. During my care, I assessed her for signs of bleeding

especially when her platelet count dropped to 74 x 109/L (150-450 x 109/L), there was also a

request for 2 packs of platelet concentration to be transfused to her.

On our second day of the week, my patient had successfully undergone a blood

transfusion. Her platelet and CBC was to be monitored that day. There was still no presence of

bleeding tendencies.

During this day also, one of our patients suffered from multiple injuries and he have a

Chest Tube Thoracostomy. Ma’am Bengan showed us how to assess for patients with this and

also she showed us what an oscillation in the tube looks like and also we assisted during the

ECG tracing. We’re lucky enough that we had actually seen those things after the recent

discussion in our OSCE.

Lucijane B. Bernas, S.N

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MY JOURNAL

Clinical experience has been always an integral part of nursing

education. It prepares student nurses to be able of "doing" as well as

"knowing" the clinical principles in practice. The clinical practice stimulates

students to use their critical thinking skills for problem solving. Awareness

of the Existence of stress in nursing students by nurse educators and

responding to it will help to diminish student nurses experience of stress.

What I have learned for the 4 months of our clinical duty is to be more

responsible to handle my patient condition and the aims to work toward

better quality. I’ am very thankful to our CI’s who are not tired teaching us

when we are not sure in what we are doing in clinical area. I’m looking

forward to many things that I’m very eager and ecstatic to know about. I’m

hoping my nursing life will awaken my curiosity regarding other people’s

condition.

Joerez Ivan Rufino, S.N

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MY JOURNAL

In our last two weeks of rotation of duty in the Blessed Rosalie Rendu Ward had

left me with so many experiences that thought me a lot of things to remember.

Experiencing in the clinical setting makes me feel excited of my future job as a nurse

someday but sometimes there are things that bothers me that makes me feel nervous.

In doing our charting it enhances my skill and ability in doing it. I always instilled on my

mind that I must be relaxed and do the things that is necessary to correct every time I’m

in the clinical area. I must do everything correctly for the benefit of my patients. It is

good and relieving feeling that the patient that I handled will be discharges immediately.

I’ve learned how to be responsible nurses especially in doing our works and I’ve

challenged to perform my task well as a student nurse and to be able to perform correct

and effective nursing care to my patient.

Christine Joy Dunton, S.N

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ACKNOWLEDGEMENT

It’s certainly been weeks of demanding and challenging coursework and

activities. Yet instead of tearing many apart, we managed to work and be able to

present ourselves today in front of those who took so many risks just by teaching us and

moulding us as competent future nurses.

We would forever be grateful to them. We can say that they are our angels who

walk with us during our journey. And who are they? They are our adored and honored

clinical instructors. Starting with the most glowing and cheerful CI, Mrs. Edrelyn

Venturanza, who taught us how to manage our hectic days and works with radiant

attitudes. To the ever charming and smart CI, Ms. Maureen Patricio who taught us that

we should have the focus even in the smallest things that we do in the ward. And last

but certainly not the least, our clinical instructor for the past 2 weeks, the ever

sophisticated and our dearly loved Mrs. Katherine Conlu-Bengan.

“We can all heal, we can all save lives: we should just start to care about what

we have yet to do, rather than waste our time to do pointless things and focusing on

what we have failed to achieve”, that is what Ma’am Bengan has taught us. That is what

her criticisms have instilled in our minds and hearts. Without her looking out for us,

making sure that we don’t get into any messes, without her uplifting words and advices,

that in this point forward, we should start to become matured individuals and improve

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our performance, we wonder if we can still be able to manage everything around us

especially those things that we should prioritize.

With countless reasons, our group would like to personally thank her for staying

with us, sharing laughs with us, for being patient with us and most especially, for

sharing her wisdom with us.

After several days of our duty with her in the BRRW, we already felt a sense of

accomplishment, because we have faced challenges that we never expected to have.

Her efforts to teach us made us realize that we wanted to be able to do things even as

not perfect as they should be, but enough to make her smile and lessen her worries for

us.

Whoever we are right now, in the field of nursing, are direct results of all the

teachings and flaws. We were also inspired by the saying: “Diamonds need pressure to

come into beings”, and so maybe, it would help if we think about it that way.

We will always try to remember patience and grace and hold on to the words that

our dear clinical instructors held on to when we tried their patience and grace once upon

our lives.

BSN III-B

Group I

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ESRD-3rd yr-1st sem

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