GOOD MORNING…

Chronic Kidney Diseasesecondary to

Chronic Glomerulonephritis

General Objective

The researchers want to gain knowledge about Chronic Renal Disease. It is important to researchers to have adequate knowledge about disease process, its signs and symptoms, risk factors and complications in order for the researchers to impart right information to the patients and for future profession.

Specific Objectives• To know the different risk factors that could

lead to the development of the disease.• To know specific signs and symptoms of

the disease and their causes in order to provide proper nursing interventions to the client.

• To know the disease process and the affected parts in order to have proper health teachings to the client.

• To know probable complications and their causes in order to prevent them.

Patient’s Profile

• Name: Mr. X• Age: 34 y/o• Sex: Male• Status: Single• Address: Sampaloc, Talisay Batangas• Date of Admission: July 11,2009• Time of Admission: 4:51 pm• Chief Complaint: Edema and Fever• Attending Physician: Dr. Atienza and Dr.

Martinez

Patient’s history

• Two months prior to admission, patient had been complaining of edema, consultation has done and managed a care of nephrotic syndrome and complicated UTI. Until one week prior to consult patient was admitted at Daniel Mercado Hospital due to bipedal edema fever associated with difficulty of breathing and abdominal pain. Impression then has chronic renal disease and was advised of dialysis but due to financial constrains patient did not imply here. Consulted at OPD and was advised of admission.

History of Past Illness

• Patient has no other illness since then.

History of Present Illness

• Patient has fever and edema of lower extremities which has been the reason for his hospitalization.

• Family History

He has a familial history of hypertension.

• Patient is a 34 year old, barber in Saudi Arabia.

• Non-smoker, non-drinker.

• He has a preference in fatty and salty foods.

Chronic Kidney Disease

• a condition of progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment.

• It involves the progressive loss of glomerular filtration, a process that can be slowed but is irreversible and eventually results in end stage kidney disease. The kidney cannot maintain metabolic, fluid and electrolyte balance, resulting in uremia and azotemia.

In the Philippines one of the leading causes

of mortality and

morbidity

ranked #10 among other diseases.

Stages of Chronic Kidney Disease

Stage DescriptionGFR*

mL/min/1.73m2

1Slight kidney damage with normal or increased filtration

More than 90

2Mild decrease in kidney function

60-89

3Moderate decrease in kidney function

30-59

4Severe decrease in kidney function

15-29

5Kidney failure requiring dialysis or transplantation

Less than 15

Risk Factors

• Age >55 years old

• Gender, common on men

• Familial history of diabetes melitus and hypertension.

• Nephrotoxins such as lead, mercury, chromium and cadmiun.

• Sedentary lifestyle

• Diet

LEADING Causes• diabetes mellitus (which is the leading

cause)• pyelonephritis (inflammation of the renal

pelvis)• obstruction of the urinary tract• hereditary lesions, as in polycystic kidney

disease• vascular disorders; infections

• medications or toxic agents.

• GLOMERULONEPHRITIS

Some of the patients who is diagnosed with CRF exhibits the following signs and symptoms: hypertension, pulmonary edema, pericarditis, pruritus (itching),anorexia, nausea, vomiting and hiccups. For instance, patient’s breath may have the odor of urine (uremic fetor): this condition is associated with inadequate dialysis.

Potential Complications

• hyperkalemia

• pericarditis

• pericardial effusion

• pericardial tamponade

• hypertension

• anemia

• bone diseases

• metastatic and vascular calcifications.

Management

• Conservative management

• Dialysis

• Kidney replacement

Review of

System

BODY SYSTEM METHOD OFASSESSMENT

FINDINGS ANALYSIS

GeneralAppearance

Inspection Patient was observed lying on bed with heplock noted. Pale and weak in appearance. Appears confused most of the time

Due to poor circulation and tissue perfusion

Due to excessive accumulation of nitrogenous waste.

Integumentary System

InspectionPalpation

Pallor

Dry skin with pruritus

Bipedal edema (grade II)

Due to blood loss and decreased hgb - 55 mg/dL

Due to decreased activity of oil gland

Due to water retention and increase permeability of membrane that results from shifting of fluids associated with renal failure

HEENT InspectionPalpation

Head is normal in size Hair is evenly distributed Eyes are equal rounded

with both pupils reactive to light, pale conjunctiva

Ears are symmetrical, each auricles aligned with the outer canthus of the eyes without any secretions

Nose is symmetric and straight with no discharge or flaring

Lips are pale and dry

Indicates normal findings

Due to blood loss and decreased hgb - 55 mg/dL

RespiratorySystem

InspectionPalpationPercussionAuscultation

Symmetrical movement of the chest upon breathing

Respiratory rate- 19 cycles per minute

With normal breath sounds

Indicates normal findings

Cardiovascular System

PalpationAuscultation

Hypervolemia Blood pressure – 150/100

mmHg With intrajugular catheter

at right intrajugular vein

Due to fluid overload

The catheter is a temporary access for hemodialysis

CirculatorySystem

InspectionPalpation

Capillary refill test delayed by 5 seconds

Pulse rate – 95 beats per minute

Delayed capillary refill due to blood loss and with hgb of 55 mg/dL

Gastrointestinal System

InspectionAuscultationPercussionPalpation

Anorexia Nausea Gastrointestinal

bleeding manifested by dark stools

Abdominal distention and ascites – 107 cm

Uremic Fector

Due to uremic toxins Bleeding is caused

by uremia

Genitourinary System

InspectionPalpation

Decreased urine output; intake- 275 ml, output – 120 ml within 8 hours

Proteinuria Decreased urine

sodium

Damaged Nephrons

Musculoskeletal System

InspectionPalpation

Decrease in muscle strength with a functional mobility of +2

Muscle cramps

Due to dietary restrictions

Hematopoietic System

Inspection Anemia Defects in platelet

function thrombocytopenia

Due to reduced number of RBC

Anatomy

and

Physiology

The Kidney

The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the back. They are protected by three layers of connective tissue: the renal fascia (fibrous membrane) surrounds the kidney and binds the organ to the abdominal wall; the adipose capsule (layer of fat) cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection.

Parts of the Kidney

• Renal Vein carries blood away from the kidney and back to the right hand side of the heart.

• Renal Artery supplies blood to the kidney from the left hand side of the heart

• Pelvis is the region of the kidney where urine collects

• Ureter carries the urine down to the bladder • Medulla is the inside part of the kidney

• Cortex is the outer part of the kidney

• Urine formation• Regulation of electrolytes• Regulation of acid-base balance• Control of water balance• Renal clearance• Secretions of prostaglandins• Regulation of calcium and phosphorous balance• Activates growth hormone• Detoxify harmful substances (e.g., free radicals, drugs) • Increase the absorption of calcium by producing calcitriol

(form of vitamin D) • Produce erythropoietin (hormone that stimulates red blood cell

production in the bone marrow) • Secrete renin (hormone that regulates blood pressure and

electrolyte balance)

Functions of the Kidney

Blood Supply

Each kidney receives its blood supply from the renal artery, two of which branch from the abdominal aorta. Upon entering the hilum of the kidney, the renal artery divides into smaller interlobar arteries situated between the renal papillae. At the outer medulla, the interlobar arteries branch into arcuate arteries, which course along the border between the renal medulla and cortex, giving off still smaller branches, the cortical radial arteries (sometimes called interlobular arteries). Branching off these cortical arteries are the afferent arterioles supplying the glomerular capillaries, which drain into efferent arterioles. Efferent arterioles divide into peritubular capillaries that provide an extensive blood supply to the cortex. Blood from these capillaries collects in renal venules and leaves the kidney via the renal vein. Efferent arterioles of glomeruli closest to the medulla (those that belong to juxtamedullary nephrons) send branches into the medulla, forming the vasa recta. Blood supply is intimately linked to blood pressure

Renal artery → Interlobar arteries → Arcuate arteries →

Cortical radial arteries → Afferent arterioles →

Glomerulus → Efferent arterioles → Vasa recta →

Arcuate vein → Renal vein

The Nephrons

• Functional and structural unit of the kidney• Each kidney has over one million nephrons

Two types of Nephron

1. Cortical Nephron (80-85%)

located at outermost part of cortex

2. Juxtamedullary Nephron

distinguished by long loops of henle

Parts of the Nephron• The afferent arteriole receives blood rich in oxygen from the renal

artery. • The glomerulus is a knotted up capillary that contains small

pores.• The efferent arteriole is smaller in diameter than the afferent

arteriole and increases the pressure in the glomerulus aiding pressure filtration

• Bowman's capsule collects the filtrate• Proximal Convoluted Tubule has a brush border with many villi to

increase the surface area for selective reabsorption. • Loop of Henle dips down into the hypertonic environment of the

kidney medulla and is responsible for the reabsorption of water from the filtrate

• Distal Convoluted Tubule is the site of tubular secretion • Peritubular Capillary Network acts as the blood supply to the

nephron. • Collecting duct receives filtrate from several nephrons.

Functions of the Nephron

• Filtration

• Reabsorption

• Secretion

URINE FORMATION

Three processes occurring in successive portions of the nephron accomplish the function of urine formation:

• Filtration of water and dissolved substances out of the blood in the glomeruli and into Bowman's capsule;

• Reabsorption of water and dissolved substances out of the kidney tubules back into the blood (note that this process prevents substances needed by the body from being lost in the urine);

• Secretion of hydrogen ions (H+), potassium ions (K+), ammonia (NH3), and certain drugs out of the blood and into the kidney tubules, where they are eventually eliminated in the urine.

Pathophysiology

Body system

Manifestation

In

Chronic Kidney Disease

BODY SYSTEM

CAUSES SIGNS AND SYMPTOMS ASSESSMENT PARAMETERS

HEMATO-POETIC

SUPPRESSION OF RBC PRODUCTIONDECREASED SURVIVAL TIME OF RBC.BLOOD LOSS THROUGH BLEEDING AND DIALYSISMILD THROMBOCYTOPENIADECREASED ACTIVITY OF PLATELET

ANEMIALEUKOCYTOSISDEFECTS IN PLATELET FUNCTIONTROMBOCYTOPENIA

HEMATOCRITHEMOGLOBINPLATELET COUNTOBSERVE BRUISING, AND OTHER SIGNS AND SYMPTOMS OF BLEEDING

CARDIO-VASCULAR

FLUID OVERLOADRENIN-ANGIOTENSIN MECHANISMANEMIACHRONIC HYPERTENSIONCALCIFICATION OF SOFT TISSUESUREMIC TOXINS IN PERICARDIAL FLUIDFIBRIN FORMATION ON EPICARDIUM

HYPERVOLEMIAHYPERTENSIONTACHYCARDIAARRYTHMIASCONGESTIVE HEART FAILUREPERICARDITIS

VITAL SIGNSBODY WEIGHTECGHEART SOUNDSMONITOR ELECTROLYTESASSESS FOR PAIN

GASTRO-INTESTINAL

CHANGES IN PLATELET ACTIVITY

SERUM UREMIC ACID

ELECTROLYTE IMBALANCE

UREA COVERTED TO AMMONIA BY SALIVA

ANOREXIA NAUSEA AND

VOMITING GASTROINTESTIN

AL BLEEDING ABDOMINAL

DISTENSION DIARRHEA CONSTIPATION UREMIC FECTOR

MONITOR INTAKE AND OUTPUT

HEMATOCRIT HEMOGLOBIN GUALAC TEST FOR

STOOLS ASSESS THE

QUALITY OF STOOLS

ASSESS FOR ABDOMINAL PAIN

NEUROLOGIC UREMIC TOXINS ELECTROLYTE

IMBALANCES CEREBRAL

SWELLING RESULTING FROM FLUID SHIFTING

LETHARGY CONFUSION CONVULSION STUPOR COMA SLEEP

DISTURBANCE UNUSUAL

BEHAVIOR ASTERIXIS MUSCLE

IRRITABILITY

LEVEL OF ORIENTATION

LEVEL OF CONSCIOUSNESS

REFLEXES EEG ELECTROLYTE

LEVEL

MUSCULO-SKELETAL

UREMIC TOXINS DECREASED

CALCIUM ABSORPTION

DECREASED PHOSPHATE EXCRETION

MUSCLE CRAMPS LOSS OF MUSCLE

STRENGTH RENAL

OSTEODYSTROPHY RENAL RICKETS BONE PAIN BONE FRACTURES

ELECTROLYTE LEVEL

REFLEXES PAIN ASSESSMENT

SKIN ANEMIA PIGMENT RETAINED DECREASED

ACTIVITY OF OIL GLAND

DECREASED SIZE OF SWEAT GLAND

PHOSPHATE DEPOSIT

PALLOR PIGMENTATION PRURITUS ECCYMOSIS EXCORIATION UREMIC FROST DRY SKIN

OBSERVE FOR BRUISING

ASSESS SKIN COLOR

ASSESS SKIN INTEGRITY

OBSERVE FOR SCRATCHING

GENITO-URINARY

DAMAGED NEPHRONS

DECREASED URINE OUTPUTDECREASED URINE SPECIFIC GRAVITYPROTEINURIACAST AND CELLS IN URINEDECREASED URINE SODIUM

MONITOR INTAKE AND OUTPUTSERUM CREATININEBUNSERUM ELECTROLYTESURINE SPECIFIC GRAVITYURINE ELECTROLYTES

REPRODUCTIVE HORMONAL ABNORMALITIESANEMIAHYPERTENSIONMALNUTRTITIONMEDICATIONS

INFERTILITYDECREASED LIBIDOIMPOTENCEAMENORRHEADELAYED PUBERTY

MONITOR INTAKE AND OUTPUTMONITOR VITAL SIGNSHEMATOCRITHEMOGLOBIN

Laboratory Results

Hematology(July 18, 2009)Actual Value Normal Values Significance

Hematocrit 0.16 0.42-0.52 % Result is below normal. Decrease in level of hematocrit signifies anemia. This is cause by impaired production

of erythropoietin in the kidney. Erythropoietin stimulates bone

marrow to produce RBC.

Hemoglobin 55 140-170 Result is below normal. Decrease in lnumber of hemoglobin signifies

anemia

RBC 1.88 4.0-6.0 x 10 Result is below normal. Decrease in number of RBC signifies anemia. This

is cause by impaired production of erythropoietin in the kidney.

Erythropoietin stimulates bone marrow to produce RBC.

WBC 8.9 5.0-10.0 The result is normal. No current infection.

Platelet count 142,000 150,000-350,000 Result is below normal. Decrease in number of platelets signifies risk for bleeding. This is due to excessive

nitrogenous waste in the blood.

Diferrential count

Neutrophils 0.85 0.55-0.65% Result is above normal. This indicates the presence of

bone marrow suppression.

Lympocytes 0.15 0.25-0.35% Result is below normal. This indicates the presence of

bone marrow suppression.

Eosinophils 0.00 0.02-0.04% Result is below normal. This indicates the presence of

bone marrow suppression.

InterpretationThe kidney produce erythropoietin the stimulates

bone marrow to produce red blood cells that increase hemoglobin and hematocrit.

In chronic kidney disease, the production of erythropoietin is impaired thus decreasing the ability of the bone marrow to produce red blood cells and decreasing the number of hemoglobin and the hematocrit level resulting to anemia.

There was bone marrow suppression thereby increasing the neutrophils while lympocytes and eosinophils decrease because of anemia

Blood Chemistry (July 18, 2009)TEST RESULT NORMAL RANGE Significance

Creatinine 2,482.40 62.00-133.00 The result is above normal. The result shows that kidneys cannot excrete

nitrogenous wastes.

Sodium 155.4 135-148 The result is above normal. The result shows the inability of the kidneys to

maintain the homeostasis of the internal environment of the body.

Potassium 5.93 3.5-5.5 The result is above normal. The result shows the inability of the kidneys to

maintain the homeostasis of the internal environment of the body

Phosphorous 10.8 2.5-4.5 The result is above normal. The result shows the inability of the kidneys to

maintain the homeostasis of the internal environment of the body

Calcium 1.08 1.12-1.32 The result is below normal. The result shows the inability of the kidneys to

maintain the homeostasis of the internal environment of the body

Interpretation

Creatinine is a break-down product of creatine phosphate and a nitrogenous waste.Creatinine is excreted mainly in the urine.

In CKD, excretion of the nitrogenous wastes is impaired thus resulting in an increase in level of nitrogenous wastes like creatinine.

Increased serum level of the sodium, phosphorous and potassium is caused by loss of excretory renal function.

The impaired conversion of the vitamin d to its active form causes the decreased serum level of calcium which then causes the increased serum level of phosphorous.

Hyperparathyroidism also causes the decreased level of the calcium.

Urinalysis (July 18, 2009)Result Significance

Physical Color Light Yellow Normal.

ph 5.0 Normal

Transparency Turbid The result is abnormal. The urine contains bacteria, cells, sugar traces and albumin that contribute to the transparency of it.

Specific Gravity 1.020 Normal

Albumin +++ The result is abnormal. The result shows that the nephrons are failing to filter

protein in the glomerulus.

Sugar Trace The result is abnormal. The result shows that the nephrons are failing to reabsorb

glucose in the tubules.

Pus cellsRBC

Epithelial cellsBacteria

4-6/hpf0-2/hpfManyFew

The result is abnormal. The result shows that the functions of the nephrons are

Impaired.

Interpretation

The increased permeability of the capillary causes the excessive passage of protein in the urine.

The impaired tubular reabsorption of glucose causes the traces of sugar in the urine.

The transparency of the urine is turbid. There are many substances that causes the turbidity of it.

Ultrasound

Impression:• Normal size kidneys with Renal parenchymal Disease.• Normal size prostate gland with concretions.• Minimal ascites.• Normal liver, spleen, pancreas, and aorta.• Gall bladder polyp.

The result from the ultrasound of the whole abdomen shows that there is a renal disease that causes some abnormalities in the different systems of the body. Excessive accumulation of nitrogenous waste in the body is one effect of the renal desease. These nitrogenous waste irritates mucosal lining that causes gastrointestinal bleeding and minimal ascites.

Medical

and

Surgical

Management

• Medical Mangement• Hemodialysis

Hemodialysis is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. The principle of hemodialysis is the same as other methods of dialysis; it involves diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes counter current flow, where the dialysate is flowing in the opposite direction to blood flow in the extracorporeal circuit. Counter-current flow maintains the concentration gradient across the membrane at a maximum and increases the efficiency of the dialysis. Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the dialysate compartment, causing free water and some dissolved solutes to move across the membrane along a created pressure gradient. The dialysis solution that is used is a sterilized solution of mineral ions. Urea and other waste products, potassium, and phosphate diffuse into the dialysis solution. However, concentrations of sodium and chloride are similar to those of normal plasma to prevent loss. Sodium bicarbonate is added in a higher concentration than plasma to correct blood acidity. A small amount of glucose is also commonly used. Side effects caused by removing too much fluid and/or removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-cramps, nausea and headaches. These symptoms can occur during the treatment and can persist post treatment; they are sometimes collectively referred to as the dialysis hangover or dialysis washout.

• Surgical Management• Intrajugular catheter

An intrajugular catheter is surgically inserted at right intrajugular vein last July 20, 2009. It is a temporary access for hemodialysis and it is functional for 4 to 6 weeks.

Nursing

Care

Management

ASSESSMENT NURSING DIAGNOSE

S

PLANNING IMPLEMENTATION EVALUATION

Subjective:“Nanghihina ako

“, as verbalized.

Objective: Pale and weak

in appearance Dry skin Capillary refill

time 5 seconds ( +) abdominal

distention 107 cm.

Confuse most of the time

RBC- 1.88 Normal 4-6x10/L

Hemoglobin- 55Normal 140-

170g/dl IJ catheter @

intrajugular vein, dry and intact.

V/S:BP-

150/100mmHgPR-85bpmRR-19cpmT- 36.5◦C

IneffectiveTissue

Perfusionrelated to

Inadequateoxygencarrying

capacity of the

blood asevidenced

bydecrease

hemoglobin,RBC, as

revealed bylaboratory

result.

After 8 hrs of nursing interventions the patient will be able to demonstrate behavioral lifestyle change to improve circulation.

Provided for diet restrictions, as indicated, while providing adequate calories to meet the body’s needs. Restrictions of protein help limit BUN.

Encouraged client to eat rich in Iron but except fatty and salty foods.

Provided psychological report for client especially when progression of the disease and resultant of treatment (dialysis) may be long term.

Encouraged quiet, restful atmosphere conserves energy/ lower tissue oxygen demand.

Maintained head and neck in midline or neutral position to promote circulation/ venous drainage.

Encouraged use of relaxation activities and exercises techniques to decrease tension level.

Encouraged early ambulation to enhances venous return.

Noted mentation it may be altered by increase creatinine.

After 8 hrs of nursing interventions the patient was able to demonstrate behavioral lifestyle change to improve circulation

ASSESSMENT NURSINGDIAGNOSIS

PLANNING INTERVENTIONS/RATIONALE EVALUATION

S: “Masakit ang opera ko sa leeg” as verbalized

O: weak (+) facial

grimaceP- With IJ catheter

inserted at right intrajugular vein, dry and intact

Q- Lancenating pain

R- Pain is localized in neck

S- score of 8 on pain scale

T- started last night as reported (July 20, 2009)

V/S: T- 36.5C P- 85bpm R- 18cpm Bp-

150/100mmHg

Painrelated

tosurgicalincision

asevidence

dby

verbalreport

After 6hours ofnursing

interventionthe patientwill be able

to reportthat painis relieve

andcontrol

Performed comprehensive assessment of pain to include location, characteristics, onset frequency, duration, quality, severity to assess etiology or precipitating contributory factors

Monitored vital signs for baseline data

Performed pain assessment each time pain occurs. Note and investigate changes from previous reports to rule out worsening of underlying condition

Assessed for referred pain as appropriate to evaluate client’s response to pain

Provided comfort measures, quiet environment and calm activities to promote non- pharmacological pain management

Encouraged adequate rest period to prevent fatigue

Encouraged diversional activities to assist client to explore methods for alleviation or control of pain

Administered medications as ordered

After 6 hoursof nursing

interventionthe patientreported

that pain isrelieved andcontrolled as

evidenced bypain scale of 3

ASSESSMENT NURSINGDIAGNOSES

PLANNING IMPLEMENTATION EVALUATION

Subjective:“Medyo

nangangati ang binti ko“, as verbalized.

Objective: Pale and

weak in appearance

The skin is flaky

Poor skin turgor

Generalized dryness of the skin

With bipedal edema grade II

Serum Creatinine

2,482.40Normal 62.00-

133.00 umol Normal size

kidneys with renal parenchymal disease

Impairedskin integrity

related toImpairedMetabolicstate as

evidenced by

pruritus.

After 8 hrs of nursing interventions the patient will be able to demonstrate behaviors techniques to prevent skin breakdown.

Noted presence of conditions/ situations that may impair skin integrity.

Handled client gently and stretching of linens regularly to maintain skin integrity.

Provided protection by use of pads, pillows foam mattress to increase circulation and tissue perfusion.

Limited or avoided of plastic materials and removed wet/ wrinkled linens. Moisture potentiates skin breakdown

Suggested use of ice, colloidal bath, and lotions to decrease irritable itching.

Recommended keeping nails short to reduce risk for dermal injury when sever itching is present.

Recommended elevation of lower extremities when sitting to enhance venous return and reduce edema formation.

Instructed client low salt, low fat diet.

After 8 hrs of nursing interventions the patient was able to demonstrate behaviors techniques to prevent skin breakdown as evidenced by keeping the nails short and elevating lower extremities and using of pads.

ASSESSMENT NURSING DIAGNOSIS

PLANNING INTERVENTIONS/RATIONALE EVALUATION

S: “Namamanas ang mga paa ko” as verbalizedO:(+) pitting bipedal edema Grade IIIntake greater than outputIntake- 275mlOutput- 120mlLab ResultSerum Creatinine- 2,482.40 (62-133N)Na- 155.4 (135-1448N)K- 5.93 (3.5-5.5N)Ca- 1.08 (1.12-1.32N)Phosphorous- 10.8 (2.5-4.5N)V/S:Bp-130/100 mmHg

Excess fluid volume

related to compromised regulatory mechanism

as evidenced by edema

After 4 hours of nursing

intervention the patient

will be able to verbalize

understanding of individual

dietary and fluid

restrictions

Noted presence of medical condition that potentiate fluid excess to assess causative or precipitating factorsNoted presence of edema to evaluate degree of excessRestricted sodium and fluid intake to promote mobilization and elimination of excess fluidRecorded I&O accurately for baseline dataEvaluated edematous extremities, change in position frequently to reduce tissue pressure and risk of skin breakdownSet an appropriate rate of fluid intake throughout 24-hour period to prevent peaks in fluid levelReviewed dietary restrictions and safe substitutes for salt to promote wellnessReviewed laboratory data to evaluate degree of fluid and electrolyte imbalanceAdministered medications as ordered

After 4 hours of nursing

intervention the patient verbalized

understanding of individual dietary and

fluid restrictions

“hindi na ako masyadong kakain ng maalat at

lilimitahan ko na ang pag

inom ng tubig” as verbalized

ASSESSMENT NURSINGDIAGNOSIS

PLANNING INTERVENTIONS/RATIONALE

EVALUATION

O: Confused most of

the time Weak in

appearance Lab Result Serum

Creatinine- 2,482.40 (62-133N)

Hct- 0.16 (0.42-0.52%N)

Hgb- 55 (140-170N)

RBC- 1.88 (4.0-6.0x10N)

V/S: 36.5C P- 95bpm R- 18cpm Bp-

150/100mmHg

Risk forInjury

related toaltered

peripheraltissue

perfusion.

After 8 hours of nursing intervention the patient will not experience injury

Ascertained knowledge of safety needs/ injury prevention and motivation to prevent injury in home, community, and work setting.

Assessed muscle strength, gross and fine motor coordination to identify risk for falls.

Provided information regarding disease/ condition that may result in increased risk of injury.

Encouraged to eat foods rich in iron except salty and fatty foods.

Encouraged adequate rest to prevent fatigue and injury.

Assisted when going to comfort room.

Provided protection by use of pads, pillows, foam, mattress to increase circulation and tissue perfusion

After 8 hours of nursing intervention the patient did not experience injury

ASSESSMENT NURSING DIAGNOSES

PLANNING IMPLEMENTATION EVALUATION

Objective: Hemoglobin-

55 Normal 140-170 g/dl

WBC 8.9 Normal 5.0-

10.0 x10/L Serum

Creatinine2,482.40 Normal 62.00-

133.00 umol IJ catheter @

intrajugular vein, dry and intact.

V/S:BP-

150/100mmHg

PR-85bpmRR-19cpmT- 36.5◦CNormal M (140-

180 g/L)

Risk forInfectionrelated toexcessive

nitrogenouswaste and

inadequate secondarydefenses.

After 8 hrs of nursing interventions the patient will be able to identify interventions to prevent/ reduce risk for infections.

Assessed laboratory results for infections such as (elevated WBC and positive blood cultures) to prevent and treat infections.

Assessed temperature, respiratory and urinary system changes as disease progress to provide information about presence of infection caused by progressive chronic disease and effect on system.

Advised proper hygiene by all caregivers between therapies/ clients. A first line defense against healthcare associated infections.

Handled client gently and stretching of linens regularly to maintain skin integrity.

Covered with sterile dressings and protect the sites to prevent contamination.

Cleansed incisions / insertion sites per facility protocol with appropriate solution to reduce potential for catheter related blood stream infections.

Instructed client low salt, low fat diet.

The patient was able to identify interventions to prevent/ reduce risk for infections after 8 hours

Name of Drugs

Action IndicationContraindicati

onAdverse

ReactionNursing consideration

Spironolactone

(Aldactone)

Classification

Diuretics

Antagonizes

Aldosterone

in the distal

tubules,Increasing

Na andwater

excretion

Short termpre-operativetreatment of

primaryhyperaldosteroni

mlong term,

maintenancetherapy foridiopathic

hyperaldosteronism

manage ofessential

hypertensionandmanagement of

edematouscondition.

Acute renalinsufficiency,

anuria,and

hyperkalemia.

Gynecomastia,

Agranulocytosis,

headache,

drowsiness,

lethargy,

GI disturbance,

Inability toachieveor maintainerection.

►Obtain baseline data before initiation of therapy such as V/S, degree of edema present and laboratory studies.

►Monitor for manifestation of hyperkalemia; MS; fatigue, muscle weakness; CV: arrhytmias, hypotension, Neuro: parethesias, confusion, Resp.: dyspnea.

►Assess fluid volume status: I & O ratios and record, count or weight diapers as appropriate, weight, distended red veins, crackles in lung, color, quality, and specific gravity of urine, skin turgor, moist mucous membranes should be reported.

►Monitor electrolytes: K, Na, Mg, ABG’s,

uric acid, CBC.►Observe for the 12

rights in administering medication.

Name of Drugs

Action Indication ContraindicationAdverse

ReactionNursing

consideration

SodiumBicarbonate

(Na acid carbonat

e)

Classification

Fluidelectrolytes

Increasebicarbonate,which excessbuffers H ionconcentrations

,reversemetabolicacidosis,neutralizesgastric acid,which formshydrogen,NaCL, andraises blood

pH.

Treatment for metabolic acidosis; promotion of gastric and urine alkalinization in the case of ion toxication with weak organic acids.

Hypoventilation, hypocalcemia, further in all situations where Na intake must be restricted like cardiac insufficiency, edema, hypertension, severe kidney insufficiency.

Hypernatraemiaand serum

hyperosmolarity.

►Obtain patient history, including drug history and any hypersensitivity

►Assess respiratory and pulse rate, rhythm, depth, lung sounds.

►Monitor fluid balance (I&O ratio, edema) notify physician of fluid overload.

►Monitor for manifestation by hyponatermia: increase BP, cold, clammy skin, anorexia nausea and vomiting.

►If the patient is vomiting withhold medication and immediately inform

physician.

►Observe for the 12 rights in administering medication.

Name of Drugs Action IndicationContraindicatio

nAdverse Reaction

Nursing consideration

Nifedipine(Calciblock)

ClassificationAntagonist

Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces relaxation of coronary and peripheral vascular muscle and it dilates coronary vascular arteries.

Treatment of vasospastic angina, chronic stable angina, hypertension.

Hypersensitivity, immediate release nifedipine contraindicated in unstable angina and after recent MI, severe aortic stenosis, severe hypotension and decompensate heart failure.

Dizziness,

flushing,

headache,

hypotension,

peripheral edema,

tachycardia and palpitations.

Nausea and other GI disturbance,

rashes, pain, fever and

abnormalities liver function.

►Monitor BP, pulse before therapy.

►Assess therapeutic effectiveness and adverse reaction

►Assess knowledge and teach patient proper use of the medication; possible side effects and adverse symptoms to report.

►Observe for the 12 rights in administering medication.

Name of Drugs Action IndicationContraindicatio

nAdverse

Reaction

Nursing considerati

on

Etoricoxid(Arcoxia)

ClassificationAnalgesic

Inhibitsprostaglandinsynthesis bydecreasingenzymes.

Relief of acute pain.

Active peptic ulceration. Patient experienced bronchospasm, nasal polyps, acute rhinitis, angioneurotic edema. Patient with hypertension, established ischemic heart disease and cerebrovascular disorders.

Immune system disorders, nervous system, cardiac, respiratory, skin, renal and urinary disorders.

►Assess for pain of inflammation, characteristics of pain.

►Monitor blood counts before therapy

►Assess for hypersensitivity to medication.

►Monitor kidney

Observe for the 12 rights in administering medication.and liver function tests.

Name of Drugs Action IndicationContraindicati

onAdverse

Reaction

Nursing considerati

on

Clonidine(Catapres)

ClassificationAntihypertensiv

e

Stimulatescentral alphaAdrenergicreceptors toInhibitSympatheticCardioaccelerator

andvasoconstrictor

center.

Management of all grades of hypertension with the expectation of hypertension due to phaeochromocytoma

Hypersensitivity to Clonidine, sick syndrome.

Local skin irritation,

drowsiness, dry mouth,dizziness,headache.Anxiety fatigue sleep

disturbances,urinary retention,

burning and itching sensation of eye.

►Perform blood studies

►Assess BP before medication

►Monitor baseline for

renal, liver function before medication.

►Observe for the 12 rights in administering medication.

Name of Drugs Action Indication Contraindication

Adverse Reaction

Nursing consideration

Calcium Carbonate(Calci-aid)

ClassificationAntacid

Decrease total acid load of GI tract. Increase esophageal sphincter tone, strengthens gastric mucosal barrier and reduce pepsin activity by elevating gastric pH.

Antacid, calcium supplement, osteoporosis and hyperthyroidism.

Hypercalcemia, bone tumors, severe renal failure,.

Constipation, inflatulence, diarrhea, renal dysfunction, acid rebound.

►Assess for adverse reaction

►Assess for hypercalcemia

►Advice to increase fluid intake.

►Observe for the 12 rights in administering medication.