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INTRODUCTION
Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the bodys internal environment. CRF can develop insidiously over
many years, or it may result from an episode of a cure renal failure from which
the client has not recovered. The incidence of CRF varies widely by state and
country. In the United States, the incidence is 268 new cases per million
populations.
Chronic renal failure affects many body systems. It can also lead to many
complications. This is the goal of health care providers, to prevent any
occurrence
of
complications.
One
of
the
complications
of
CRF
is
is
important
for
clinicians
to
recognize
the
problem
of
is
not
associated
with
hypercalcemia,
hyperphosphatemia,
or
hypercalcuria. Thus, the treatment was effective and well tolerated and appeared
to be free of side effects. These studies are important because they provide a
new therapy for the complication of hyperparathyroidism in the course chronic
kidney disease, and, thus, if the diagnosis of this complication can be made
earlier in the course of chronic kidney disease, treatments such as oral
paricalcitol may be effective in managing this complication.
As nurses, we could help our patients by having a deep understanding of
the disease, that we may learn the proper interventions for the chronic kidney
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 chronic
Father Side
Lolo
Mo
ma
Lola
Po
p
Mr. Scrooge
(+) HPN
(+)Kidney Failure
- 36.8
RR
- 22
PR
- 64
BP
- 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
- 36
RR
- 22
PR
- 81
BP
- 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
6
February 8, 2005
Vital Signs:
T
- 36.2
RR
- 16
PR
- 80
BP
- 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
February 9, 2005
Vital Signs:
T
- 36.4
RR
- 20
PR
- 71
BP
- 160/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
- 37
RR
- 17
PR
- 85
BP
- 180/90
Integumentary
C. Skin- pallor, brown in complexion, with good skin turgor
D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
H. Scalp- hair evenly distributed without any presence of lice and lesions
I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
J. Ears- symmetrical with cerumen, no discharges noted
K. Nose- without flaring of nostrils, no discharges noted
L. Mouth- (-) pallor
M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
N. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Date
Ordered
Date Result
in
Indication (s)
Purpose (s)
Result
Normal Values
used by the
hospital
Analysis and
Interpretation
1. CBC
Hgb
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Hct
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
WBC
Leukocytes
Ordered
2/3,4,6,8,9/
05
Usually done to a
pt. with renal
disease to
determine if the
kidneys ability to
release
erythorpoietin
factor is already
affected
72
103
107
118
109
120-170 g/L
Used to measure
RBC number and
volume. It is an
integral part of the
evaluation of
anemic patients
.23
.31
.33
.36
.32
.40-.50
Determines any
inflammation and
infection
7.76
6.01
9.40
8.58
9.5
5-10x109/L
Determines any
acute bacterial
infection
.81
.75
.71
.72
.74
.50-.70
Result:
2/3,4,6,8,9/
05
Neutrophils
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
10
Lymphocytes
Ordered
2/3,4,6,8,9/
05
Determines any
chronic bacterial
infection or viral
infection
.1
.13
.20
.15
.13
.10-.40
Determines any
acute bacterial
infection
.05
.08
.04
.09
.07
.00-.07
To determine any
allergic reaction of
the body
.04
.04
.05
.04
.06
.00-.07
Result:
2/3,4,6,8,9/
05
Monocytes
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Eosinophils
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding
11
Diagnostic/
Laboratory
Procedure
Date
Ordered
Date Result
in
2. Hepatitis Ordered:
2/3/05
Profile
Performed:
2/5/05
Indication (s)
Purpose (s)
Analysis and
Interpretation
Result
HBSAG- non-reactive
ANTI-HCV- non-reactive
ANTI-HBC- non-reactive
ANTI-HBS-reactive
HAV-IGM- non- reactive
Result revealed
that the patient
has no hepatitis
virus and was not
exposed to any of
it.
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Handle the specimen as if it were capable of transmitting hepatitis
5. Immediately discard the needle in the appropriate receptacle
6. Send the specimen to the laboratory promptly
Diagnostic/
Laboratory
Procedure
3.Urinalysis
Date
Ordered
Date Result
in
Ordered:
2/3,6,7/05
Result:
2/3,6,7/05
Indication (s)
Purpose (s)
To diagnose
and monitor
renal or
urinary tract
disease
Result
Normal
Values used
by the
hospital
Analysis and
Interpretation
Laboratory
results revealed
that there is
presence of
albumin in the
blood; this
indicates that
the glomerular
12
Specific Gravity:
1.020, 1.025, 1.020
Albumin:
3+
Sugar: negative
Pus Cells: 1-2/HPF, 02/HPF, 2-5 /HPF
Red cells: 1-3/HPF,
1-3/HPF,4-6/HPF
cannot filter
large molecules
such as that of
albumin. It also
revealed that
there is
bacterial
infection as
evidenced by
presence of
bacteria, pus
cells and red
cells in the
urine.
Epithelial Cells:
Rare
Mucus thread:
Rare, (-), (-)
Bacteria: (-), few, (-)
Amorphous urates:
Moderate, moderate,
few
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Instruct the patient to catch the midstream urine for better result
4. Send the specimen to the laboratory promptly
13
Diagnostic/
Laboratory
Procedure
Date Ordered
Date Result in
Indication (s)
Purpose (s)
Result
Normal
Values used
by the
hospital
Analysis and
Interpretation
14
4. Creatinine
Ordered:
2/3,4,6,8/05
Result in:
2/3,4,7,9/05
5. Na+
Ordered:
2/3/05
Result in:
2/3/05
6. K+
Ordered:
2/3,6/05
Result in:
2/3,7/05
7. Calcium
Ordered:
2/3/05
Result in:
2/3/05
8. Phosphate
Ordered:
2/3/05
Result in:
2/3/05
1499
1430
1649
731
44.20-150.30
umol/L
To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
137
135-150
mmol/L
Normal result
which means
there is still fluid
and electrolyte
balance
To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
4.78
3.5-5.5
mmol/L
Normal result
which means
there is still fluid
and electrolyte
balance
To evaluate
muscle
contraction,
nerve impulse
transmission,
and blood
clotting
6.4
8.5-10.5
mg/dl
To evaluate the
metabolism of
carbohydrates,
bone formation
and acid-base
balance.
186
30-150 u/L
Nursing Responsibilities:
1. Explain the procedure to the patient
15
16
Kidneys
The kidneys balance the urinary excretion of substances against the
accumulation within the body through ingestion or production. Consequently, they
are major controller of fluid and electrolyte homeostasis. The kidneys also have
several non-excretory metabolic and endocrine functions, including blood
pressure regulation, erythropoietin production, insulin degradation, prostaglandin
synthesis, calcium and phosphorus regulation and Vitamin D metabolism.
The kidneys are located retroperitoneally, in the posterior aspect of the
abdomen. On either side of the ventral column. They lie between the 12 th thoracic
and third lumbar vertebrae. The left kidney is usually positioned slightly higher
than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5
cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved
shape, with a convex distal edge and a concave medial boundary.
Ureters, Urinary Bladder and Urethra
The ureters are small tubes that carry urine from the renal pelvis of the
kidney to the posterior inferior portion of the urinary bladder. The urinary bladder
is a hollow muscular container that lies in the pelvic cavity just posterior to the
pubic symphysis. It functions to store urine, and its size depends on the quantity
of urine present. The urinary bladder can hold from a few milliliters to a maximum
of about 1000 mL of urine. When the urinary bladder reaches a volume of a few
hundred mL, a reflex is activated, which causes the smooth muscle of the urinary
bladder to contract and most of the urine flows out of the urinary bladder through
urethra. The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle-shaped portion of the urinary bladder located between the
opening of the ureters and the opening of the urethra is called trigone. The
urethra carries urine from the urinary bladder to the outside of the body.
Renal Blood flow and Glomerular Filtration
The kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of he second lumbar
17
vertebra, enter the kidney, and progressively branch into lobar arteries. Blood
flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the
peritubular capillaries carry a small amount of blood to the renal medulla in the
vasa recta before entering the venous drainage. The blood leaves the kidney in
venous system closely corresponding to the arterial system: interlobular veins,
arcuate veins, interlobar veins, and the renal vein. The renal circulation then
empties into the inferior vena cava.
Physiology
Characteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are
removed from the plasma and eliminated by the kidneys. It is 5% water and 5%
dissolved solids and gases. The amount of these dissolved substances is
indicated by it specific gravity. The specific gravity of pure water, used as a
standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are
diseased, they lose the ability to concentrate urine, and the specific gravity no
longer varies as it does when the kidneys function normally.
Urine formation
The chief function of the kidneys is to produce urine. Each part of the
nephrons performs a special function. There are three important processes by
which urine is formed. They are glomerular filtration, tubular reabsorption and
tubular secretion
To the distal
convulated
To the collecting
tubule
(at
this about 99% oftubule
the filtrate
the reabsorbed)
urinary
hasTobeen
meatus
To Bowmans capsule
protein
19
20
Aging
also
results
in
concomitant
progressive
21
ammonia
contribute
to
this
problem.
Acidosis
accentuates
22
and
intractable
pruritus
may
result
from
secondary
Indication (s)
Clients initial
Clients
23
Management
Date performed
Description
1. D5 LRS iL x
KVO
Ordered:
2/3,7,9/05
Performed:
2/3,7,9/05
Changed:
2/3/05
D/C
2/10/05
2. D5 NaCl iL x
KVO
Ordered:
2/3/05
Performed:
2/3/05
A crystallized
solution that is
available in a
variety of
concentrated
water and
calories are
provided. It is
hypertonic
solution
containing
equal amounts
of Na and Cl
3. Subclavian
Ordered:
2/7/05
Performed:
2/7/05
A catheter tube
is inserted into
vein in either
your neck,
chest, leg or
near the groin.
It has two
chambers to
allow two-way
flow of blood
catheterization
4.Blood
Transfusion
Ordered:
2/3/05
Performed:
2/3/05
Purpose (s)
To maintain
fluid balance of
the pt.
It is intravenous
replacement of
loss or
destroyed
blood
compatible
citrated human
blood it is also
the introduction
reaction to the
treatment
response to the
treatment
Patient felt
discomfort
Patient fluid
status was
maintained
To maintain
fluid balance of
the pt.
Temporary
access for
hemodialysis
To immediately
restore blood
volume to treat
severe anemia,
to be able to
Patient fluid
status was
maintained
Patient
experienced
bleeding and
felt discomfort
on incision site
During the
blood
transfusion,
patient was
chilling for a
short period of
time. There
was no further
adverse
Patient did
manifest some
reaction such
as chilling but
there was not
further reaction
after the
24
of whole blood
or blood
Component
5.
Hemodialysis
Ordered:
2/7,8,9/05
Performed:
2/7,8,10/05
Medical
treatment used
to promote
excretion of
wastes
materials from
the blood of
patient.
maintain
oxygen
transport to the
different parts
of the body
It is indicated
for the patient
because the
kidneys cannot
function very
well to excrete
the nitrogenous
waste products,
thus leading to
its
accumulation in
the blood.
reaction noted
upon the
transfusion
Patient was
slightly nervous
about the
treatment
.
treatment
There was no
adverse
reaction noted
during and after
the procedure
Nursing Responsibilities
1. Blood transfusion
Before
a. Assess client for history of previous BT and any adverse reactions
b. Ensure that the client has an 18 to 19 gauge IV catheter in place
c. Use 0.9% sodium chloride IVF
d. Verify the ABO group, Rh type, client and blood numbers and expiration
date.
e. Take baseline vital signs before initiating BT
f. Identify the patient prior to transfusion
g. Explain the purpose of the transfusion
During
a. Start transfusion slowly
b. Maintain prescribed transfusion rate
25
c. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post
transfusion
After
a. Monitor for adverse reactions
b. Documentation
2. Hemodialysis
Before
a. Explain the purpose of the transfusion
b. Have client void
c. Chart clients weight
d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension
(unless ordered otherwise)
During
a. Obtain and record vital signs before and every 30 mins. during the
procedure
b. Ensure bedrest with frequent position changes for comfort
c. Proper heparinization must be done to prevent coagulation during the
therapy
d. Inform client that headache and nausea may occur
e. Monitor closely for bleeding since blood has been heparinized for
procedure
After
a. Weight the patient after the therapy and record
b. Monitor vital signs especially hypotension.
c. Assess for complications (hypovolemic shock, dialysis disequilibrium
syndrome)
Name of Drug
Date ordered
Date Taken
Date changed
or D/C
Route of
admin. Dosage
and freq. Of
admin.
General action
Indication (s)
Purpose(s)
Clients
response to
medication
26
Amlodipine
besylate
Ordered:
2/3/05
Taken:
2/3-10/05
PO 5 mg OD
Calcium
antagonist,
antihypertensive
To decrease
increase blood
pressure
Ordered:
2/3/05
PO 50 mg OD
Beta blockers,
antihypertensive
drug
To decrease
increase blood
pressure
PO 1 cap BID
Iron deficiency
For patient
having anemia
Patients stool
was dark green
in color
PO 40 mg OD
Diuretic
norvasc
Metoprolol
tartate
neobloc
Taken:
2/3-10/05
Iberet- folic
acid
Ordered:
2/3/05
Taken:
2/3-10/05
changed:
2/3/05
furosemide
lasix
Ordered:
2/3/05
For oliguric
patient
Taken:
2/3-10/05
calcium
carbonate
Ordered:
2/3/05
Taken:
PO 1 tab. TID
Calcium
supplement
To treat
hypocalcemia
27
2/3-10/05
D/C:
2/3/05
Nursing Responsibilities
Prior:
1. Check and determine the prescribed the drug.
2. Inform the patient about the prescribed the drug.
3. Explain the procedure, purpose, indication and side effects of the drug.
During:
1.
2.
3.
4.
5.
After:
1. Observe for any intolerance and side effects on the prescribed drug.
Type of diet
Date ordered
Date started
Date changed
General
description
Indication (s)
Purpose (s)
Clients response
to the diet
DAT
Ordered:
2/3/05
Started:
2/3/05
Changed:
2/3/05
To provide
nutrients needed
by the body
Patient followed
the diet
Ordered:
2/3/05
Started:
2/3-10/05
increasing level of
creatinine in the
blood
Nursing Responsibilities
Prior:
1.
2.
3.
4.
During:
1. Check vital signs to obtain baseline data
2. Observe for initial response.
After:
1. Inform SO if it would be changed
2. Observe and monitor for changes
Type of activity
Bed rest
Date ordered
Date started
Date changed
Ordered:
2/3/05
Started:
2/3-10/05
General
description
An activity wherein
the patient is not
allowed to do any
activity. Patient
stays at bed.
Indication (s)
Purpose (s)
To decrease
consumption of
oxygen and to be
able to conserve
energy
Clients response
to the activity
Patient strictly
complied with the
prescribed activity
Nursing Responsibilities
1. Explain the procedure to patient.
2. Explain importance of activity.
3. Assist patient in doing the activity.
B. Surgical Management
Arteriovenous Fistula
29
C. Nursing management
Actual SOAPIE
30
February 3, 2005
S> madali akong mapagod
O> received patient on semi-fowlers position, with an ongoing IVF of D5 NM 1 L
X120 cc/hr @ 900 cc level, infusing well on the right hand
> Afebrile, with pink conjunctiva and lips, easy fatigability, appears weak
>VS taken and recorded as follows: T-36, PR-64, RR-18, BP-150/90
A>altered peripheral tissue perfusion r/t decrease circulating hemoglobin
P>after 6 hrs of nursing interventions, patient will have an improvement on tissue
perfusion as evidence by decrease in paleness in lips and conjunctiva, and
increase in activity tolerance
I > monitored VS and recorded
> Established rapport
> Provided adequate rest to conserve energy
> Discussed the effect of decrease hemoglobin in the body
> Instructed to eat nutritious food especially those rich in iron
> Maintained IVF regulation
> Monitored Intake and Output strictly
> Monitored patients response to blood transfusion
E >goal met as evidence by decreased in paleness and increased activity
tolerance
Actual SOAPIE
February 08. 2005
S>
31
O> received patient on supine position, awake, afebrile with pale conjunctiva,
appears weak with easy fatigability
> VS taken and recorded as follows: T-36, PR-90, RR-16, BP-170/90
A > decreased cardiac output r/t vascular resistance secondary to hypertension
P > after 6 hrs of nursing interventions, patient will improve cardiac output as
evidence by normal vital signs and decreased in paleness and fatigability
I > monitored VS and recorded
> Established rapport
> Instructed to avoid strenuous activity
> Provided calm environment
> Encourage to ambulate early
> Assisted in changing position
> Instructed SO to avoid introducing stress to the patient
> Monitored I&O strictly
E > goal met as evidence by decreased in paleness and fatigability
Admission
2/3
2
2/4
3
2/5
4
2/6
5
2/7
6
2/8
7
2/9
Discharge
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
2/10
32
4. Fatigue
5. Activity Intolerance
B. Vital Signs
T
RR
PR
BP
C. Diagnostic Procedures
1. CBC
2. Creatinine
3. Urinalysis
4. Hepatitis profile
D. Medical Management
1. D5 LRS 1 L
2.D5 NaCl
3. Blood transfusion
4. Hemodialysis
5. Subclavian catheterization
E. Drugs
1. Norvasc
2. Neobloc
3. Iberet +Folic
4. Calcium carbonate
5.furosemide
F. Diet
1. DAT
2. Low salt low protein
G. Activity / Exercise
1. Bed rest
*
*
*
*
*
*
36
18
64
36.1
20
62
36.4
20
84
36.1
20
81
36
22
81
36.2
16
80
36.4
20
71
37
17
85
150/
160/
140/
170/
170/
170/
160/
180/
90
100
80
80
110
90
100
90
B. Discharge Planning
Mr. Scrooge was discharge last February 10, 2005, Upon discharged, Mr.
Scrooges physical appearance was improved. There was absence of paleness
in the conjunctiva and lips, fatigability is decrease, and with decrease creatinine
level as compared when he was admitted in the hospital. His vital signs were as
follows: T- 36.5, PR- 85, RR-18, BP- 140/100.
M> Instructed to complied strictly with the following home medications
Norvasc 10 mg 1 tab OD
33
34
VIII. Bibliography
Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company
Philadelphia
Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation
Springhouse, Pennsylvania
Pagana (2002). Mosbys Manual of Diagnostic and Laboratory Tests.
MIMS. (2003)
www.yahoo.com
www.google.com
Homework Help
https://www.homeworkping.com/
35