Académique Documents
Professionnel Documents
Culture Documents
A Case Study On
Nursing Care Management of Patients with
Group 2:
Esposo, Bern
Erive, Robetha
Gatus, JL
Grageda, Jerome
Ignacio, Aljon
Macadangdang, Lea Mari
Maddara, Marivic
Magbanaua, Mark
Manong, Shane
Martin, Abigail
Mitra, Alyza
September 2014
Table of Contents
Introduction
Background of the Case Study
Objectives of the Case Study
Theoretical Framework
Clinical Summary
General Data
Chief Complaint
History of Present Illness
Past Medical History
Family Health History
Physical Assessment (Cephalo-Caudal)
Patterns of Functioning
Laboratory and Diagnostic Examinations
Course in the Ward
Clinical Discussion of the Disease
Anatomy and Physiology
Pathophysiology/ Schematic Diagram of the Disease
Drug Study
Nursing Process
Problem List
Nursing Care Plan
Discharge Planning
Recommendations
References
INTRODUCTION
Stage 5 CKD is also called established chronic kidney disease and is synonymous
with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure
(CKF) or chronic renal failure (CRF)
Progression of CKD is predicted in most cases by the degree of proteinuria.
Hypertension, acidosis, and hyperparathyroidism are associated with more rapid
progression as well. There is no specific direct treatment that will slow the progression of
the disease. If there is an underlying cause, this may be treated directly just to slow the
damage. In particular, controlling hyperglycemia in patients with diabetic nephropathy
and controlling hypertension in all patients substantially slows deterioration of GFR.
Severe CKD requires forms of renal replacement therapy such as dialysis and kidney
transplantation.
Make a thorough assessment and good clinical judgment about the patients
personal history, family background, and lifestyle.
People should be self-reliant and responsible for their own care and others
in their family needing care.
Self care and dependent care are behaviors learned within a socio-cultural
context.
Self care practice of activities that an individual initiates and performs on their
own behalf in maintaining life, health and well being.
Self care agency is a human ability which is "the ability for engaging in self care"
-conditioned by age developmental state, life experience socio-cultural orientation
health and available resources.
Therapeutic self care demand "totality of self care actions to be performed for
some duration in order to meet self care requisites by using valid methods and
related sets of operations and actions"
Describes how the patients self care needs will be met by the nurse , the patient,
or both.
Identifies 3 classifications of nursing system to meet the self care requisites of the
patient:
-
The theory of self-care deficit when applied could identify the self care requisites of
patient from various aspects. This will be helpful to provide care in a comprehensive
manner. The application of this theory will reveal how well the supportive and
educative and partly compensatory system could be used for solving the problems in
a patient with Chronic Kidney Disease.
CLINICAL SUMMARY
General Data
A. Nursing History
Demographic Data
Name: A. F. T.
DOB: 08/23/1933
Age: 80
Gender: Male
Civil Status: Widowed
Nationality: Filipino
Religion: Roman Catholic
Address: Pasay City
Educational Attainment: College graduate
Occupation: retired accountant
Date of Admission: 08/20/2014
Attending Physician: Dr. Babaran
Chief Complaint decreased appetite and shortness of breath.
Admitting Diagnosis - Uremia; Electrolyte imbalance (Hyperkalemia); Metabolic
Acidosis; Anemia of Chronic Disease, Chronic Kidney Disease Stage 5; CAD,
Paroxysmal Atrial Fibrilation.
History of Present Illness
1 week prior to admission, patient reported to have generalized body weakness,
easy fatigability and decreased appetite. Patient also complained of difficulty in sleeping
and muscle cramps. Persistence of symptoms prompted consult at ER and was
subsequently admitted.
Upon admission, initial laboratories were done with results noted; increased
potassium levels, decreased hematocrit and hemoglobin, decreased magnesium and
phosphorus. Patient was placed on oxygen support at 2 lpm via nasal cannula.
On the 1st hospital day, patient still presented with generalized body weakness,
shortness of breath and poor appetite. Patient was referred to nephrology service for
further evaluation and co-management. Furthermore, patient was referred to an
interventionist for IJ catheter insertion. Right sided IJ catheter was inserted and chest xray showed the tip of the projection of superior vena cava with no noted pneumothorax,
and atherosclerotic aorta. Present management was continued.
On the 2nd hospital day, patient still reported to be pale and weak looking with
poor appetite thus NGT was inserted and another blood transfusion of PRBC was done
during hemodialysis with no noted adverse reaction. Present management was
continued.
On the 4th hospital day, repeat 12L ECG was done which revealed sinus rhythm
with early repolarization pattern and old septal wall myocardial infarction. Patient
tolerated sitting at bedside, however, had with dizziness on standing. There was no
noted shortness of breath and had improved appetite. Intravenous hydration was
consumed and discontinued. Present management was continued.
On the 5th hospital day, patient was given hepatitis B vaccine and was referred to
Dr. Felixberto Lukban for AVF creation.
On the 6th hospital day, patient complained of abdominal pain with urge to
defecate but had difficulty in passing out stools.
On the 7th hospital day, patient reported to have black stools corollary with
epigastric pain. No nausea, no vomiting noted. Patient was given omeprazole 40 mg IV.
On the 8th hospital day, patient was comfortable and had good appetite, no
recurrence of epigastric pain and black stools. Patient underwent regular scheduled
hemodialysis which he tolerated. Present management was continued.
On the 9th hospital day, patient underwent AVF creation on right arm, patient
tolerated the procedure with no noted post-operative complications.
The rest of his hospital stay was unremarkable. Patient was comfortable with
improved appetite and was noted to have improved condition. Moreover, patient had no
subjective complaints thus patient was cleared for discharge.
Past Medical History
Patient has been diagnosed to have Hypertension for 20 years. Patient also
had Paroxysmal Atrial Fibrillation prior to admission.
Family Health History
Client was reported to have a family history of hypertension in his siblings.
Patient has a strong family history of hypertension on paternal side. Fathers cause
of death was Cardiac Arrest. Mothers history of illness is unremarkable. Genetic
factor may also contribute to the patients current medical condition.
Personal/ Social History
He started smoking when he was 20 years old and stopped at 40 (20 pack
years). Also, he was an alcoholic beverage drinker (average of 3 bottles of beer
per day 3 times per week) for 40 years.
B. Physical Assessment
ASSESSME
NT
Vital Signs
NORMAL
FINDINGS
BP: 120/80
Temp: 3637C
RR: 16-20
PR: 60100bpm
ACTUAL
FINDINGS
METHODS
USED
INTERPRETATI
ON
BP: 130-170/
70-100mmHg
Temp: 36.0
36.7C
RR: 18 25
cpm
Inspection
Palpation
Auscultatio
n
-Hypertensive
General
Survey
Chest and
lungs
Cardiovascul
ar
Body built,
height &
weight in
relation to
age lifestyle
and health
Conscious,
awake,
follows
command,
not in
respiratory
distress
Symmetrical
chest
expansion, no
retractions,
no difficulty of
breathing
Adynamic
precordium,
regular rate,
regularly
regular
rhythm,
no
murmurs
Proportionate,
varies with
life style
PR: 62 - 88
bpm
With shortness
of breath
Inspection
Symmetrical
chest
expansion, no
retractions,
complains of
difficulty of
breathing, has
cough and
yellowish thick
sputum, (+)
productive
cough with
yellowish
phlegm, (+)
occasional
rales, (+)
crackles, (+)
Shortness of
breath
Inspection
With
paroxysmal
atrial fibrillation
Palpation
Auscultatio
n
Height: 57
Weight: 145lbs
Age: 80
BMI: 22.8
Inspection
- There is an
URTI which
contributes to
his difficulty of
breathing
- Calculated
body mass
index (BMI) is
within normal
Observe
skin color
and palpate
the skin
moisture
HEENT
Moisture in
skin and the
axillae.
Pinkish
palpebral
conjuctivae,
(-) tonsillopharyngeal
hyperemia, (-)
cervical
lymphadenop
athy
36 37.6 C
Temp: 36.0C
Palpation
- within normal
findings
Eye sight
20/20
Inspection
- within normal
findings
Inspect the
teeth and
gum
Pinkish,
moist , and
firm textured
gums
-32 teeth
Inspection
- within normal
findings
Inspect the
neck
muscles
Muscles are
equal in size
and head is
centered
Inspection
Palpation
- within normal
findings
Abdomen
Flabby soft
abdomen,
normoactive
bowel sounds,
(-) masses, (-)
tenderness
No severe
varicosities,
deformities,
swelling or
severe pain
on arms
Wears eye
glasses when
reading
With dentures,
pinkish gums,
teeth slightly
yellowish, but
has no dental
carries
Muscles are
equally in size
and head is
centered.
IJ Catheter
noted at right
side, no signs
of infection
Had an episode
of (-) bowel
movement for
2 days
Has right AVF
(right arm
precaution),
with positive
signs of bruit
and thrills
Inspection
Palpation
Full equal
pulses, with
edema on both
Inspection
Palpate skin
temperature
Assessing
the Upper
Extremities
Assessing
the Lower
Extremities
No severe
varicosities,
deformities,
Inspection
Palpation
- normal skin
findings
Auscultatio
n
Palpation
- within normal
findings
swelling or
severe pain
on legs
PRIOR TO
HOSPITALIZATION
lower
extremities, no
cyanosis
DURING HOSPITALIZATION
ANALYSIS
He verbalized the
want to be strong
and healthy again
by following the
needed therapeutic
regimen instructed
by his physician
He adheres to the
medication and
treatment regimen
prescribed
He has
maintenance drugs
for hypertension
Stops smoking and
drinking alcoholic
beverage
He smokes 1 pack
per day or 20 pack
years and drinks
alcoholic beverages
approximately 3-6
bottles, 2-3 times a
week for 20 years
In terms of
traditional concept
of health and
illness, prayer helps
a lot in such crisis
He consults the
doctor only when he
experience severe
symptoms
C. Patterns of Functioning
10
There is a need to
encourage the
patient to have
regular check ups
2. NUTRITION-METABOLIC PATTERN
PRIOR TO
HOSPITALIZATION
According to him,
nutrition is an
important factor to
an individuals
health
He usually eats 3-4
times a day
including snacks in
between meals
He prefers to eat
fruits and
vegetables
His oral fluid intake
is approximately 79 glasses of water,
1200-1500 ml per
day
DURING HOSPITALIZATION
He has decreased
appetite
He can only ingest
two spoons of food
per meal
NGT was inserted
and feeding was
started (Neprocan
Q4)
His oral fluid intake
is approximately
800-1000 ml per
day
Height: 57
Weight : 145lbs
BMI: 22.8
11
ANALYSIS
An individual health
status greatly
affects eating habits
and nutritional
status
3. ELIMINATION PATTERN
PRIOR TO
HOSPITALIZATION
Patient defecates 12 times a day. Stool
is hard in
consistency and
brown in color
He urinates 2-3
times a day roughly
around 300-500 cc
per day
DURING HOSPITALIZATION
He has negative
bowel movement
for two days.
Lactulose was given
but still no
improvement.
Dulcolax
suppository was
prescribed and
resulted to (+)
bowel movement,
soft in consistency,
brown in color
ANALYSIS
Elimination is
important because
urinary and bowel
movement affects
your entire
physiology. It makes
the body pH in
balance and it
eliminates body
toxins with it
He urinates 2-3
times a day
approximately 300500 cc
DURING HOSPITALIZATION
The patient stays in
bed almost all of
the time
Can ambulate but
with assistance due
to dizziness and
general weakness
12
ANALYSIS
Individuals who
have in active
lifestyles, all who
are faced with
inactivity because
of illness or injury
are at risk for many
problems that can
He usually reads
newspaper
He spends most of
the time talking to
his children
DURING HOSPITALIZATION
He sleeps 3-5 hours
at night and take 12 afternoon naps
about 30 minutes to
1 hour
Patient spends time
lying on his bed
He has sleep
disturbance
ANALYSIS
Illness that causes
distress can result
in sleep problems.
People who are ill
requires more sleep
than normal and
normal rhythm and
wakefulness is often
disturbed
There is sleep
disturbance
Watching television,
listening to the
radio and reading
newspaper is a
form of relaxation
for him
DURING HOSPITALIZATION
Oriented to people,
time and place
Responds to stimuli
13
ANALYSIS
There was a change
in cognitive and
perceptual pattern
in terms of stimuli
verbally and
physically
No sensory deficits
but functions are
diminished due to
age
because it is limited
only to the
environment which
is within the
hospital area and
patients room
His sensory
perception is limited
to the hospital room
DURING HOSPITALIZATION
He is easily agitated
and irritated
because of his
condition and lack
of sleep
He feels anxious
and sometimes
depressed
He doesnt feel
good about himself
ANALYSIS
Events or situations
may change the
level of self-concept
Due to his present
condition, there is a
change to the level
of patient self
perception and self
concept due to his
illness on his age of
life
DURING HOSPITALIZATION
His children were
with him during
confinement
14
ANALYSIS
When illness occurs,
roles changes for
both patient and
family
They were
supportive in giving
the needs of the
patient
He socializes with
his relatives and
neighbors
They verbalized
that they wish that
their father would
be relieved and
treated
The patient
achieves his
emotional and
moral support from
his families and
friends, which will
help him to cope
with his present
condition
DURING HOSPITALIZATION
He considers
himself healthy
even though he is
not sexually active
ANALYSIS
There are no
changes in patient
sexuality and
reproductive
pattern
DURING HOSPITALIZATION
He copes with his
children
He drinks to forget
his problems
He verbalizes what
he feels to his
children
He usually pray in
He take deep
15
ANALYSIS
Coping is the
cognitive and
behavioral effort to
manage specific
external and
internal demands
that are appraised
as taxing exceeding
time of crisis
DURING HOSPITALIZATION
The patient is
Roman Catholic. He
considers this an
important aspect in
life and states that
having faith is
essential in
maintaining his
health
He seldom attends
mass during
Sundays
He believes that
everything has a
purpose or a reason
He verbalized that
God is the source of
his strength and he
believes that only
God can help him
get through this
He prays every
night before he
sleeps
16
ANALYSIS
A persons values
influence belief
about human
needs, health, and
illness, the practice
of health behaviors
and human
responses to illness
Actual Range
Normal Range
Interpretation
Total Protein
68 g/L
64-82
Normal
Albumin
39mmol/L
34-50
Normal
Globulin
35 g/L
15-35
Normal
A/G ratio
1.20
1.10-2.40
Normal
SGPT (ALT)
13 u/L
0-55
Normal
BUN
44.6
2.5-6.4
High
Uric Acid
527
155-428
High
Sodium
140
135-145
Normal
Potassium
6.2
3.5-5.1
High
Creatinine
735
53-115
High
Interpretation
17
BUN Uric Acid and Creatinine levels are high because the kidneys are unable to
excrete chemicals waste so as a result, it will be retained in the body. Metabolic acidosis
causes hyperkalemia which is a compensatory mechanism of the body.
Test
Result
Normal Values
Interpretation
FT3 (RIA)
19.68
2.5-5.8 pmol/L
HIGH
FT4 (RIA)
38.41
11.5-23.0 pmol/L
HIGH
TSH ( IRMA)
0.01
0.27-3.75 ul/ mL
LOW
Interpretation
In people with hyperthyroidism (overactive thyroid) the level of TSH will usually be
low. This is usually because the thyroid gland is making too much of its hormones. When
levels of T3 and T4 are high, the pituitary is 'turned off' and the amount of TSH produced
is less.
URINALYSIS
18
Appearances
Color:
light yellow
Transparency:
clear
Specific gravity:
pH:
6.0
NEGATIVE
Protein:
1+
( Interpretation: Approx. 30 mg/dl is loss because the kidneys are unable to reabsorb)
RBC:
WBC:
Bacteria:
NONE
Crystals:
NONE
Cast:
NONE
Parameter
s
pH
PCO2
P02
HC03
O2
Saturation
Actual
Range
7.21
28
75
11.2
92%
19
Normal
Range
7.35-7.45
36-45
mmHg
80-120
22-27
94-95%
Interpretation
PCO2 level is regulated by the lungs, while the HCO3 level is regulated by
the kidneys. The pH is 7.21 which is ACIDOTIC. PCO2 is 28 which is
ALKALOTIC which means that the lungs are able to compensate. HCO3 is
11.2 which means ACIDOTIC so the problem would be of METABOLIC
ACIDOSIS. The PO2 and O2 saturation results reflect that the patient
cannot receive oxygen adequately.
A. Acid Base Balance
Normal _____
Abnormal X Simple _Mixed
B. Primary defect
_Respiratory
X Acidosis
X Metabolic _ Alkalosis
_ Uncompensated
XPartially compensated
_Fully compensated
C. Oxygenation: Adequate
FECALYSIS
Character:
semi-formed
Color:
brownish
Blood:
Negative
Mucus:
Negative
20
PARASITES
No ova or parasites seen
CBC
Hemoglobin
Hematocrit
Erythrocytes
MCV
MCH
MCHC
Total WBC
Differential
Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Platelet Count
protozoa
Result
82 g/L
0.26
2.94
68
28
31.80
7.5
Normal Values
135-160
0.40- 0.48
4.5-5.0
80-96
27-33
33-36
5.0-10.0
Interpretation
LOW
LOW
LOW
LOW
LOW
LOW
NORMAL
0.72
0.20
0.05
0.02
NORMAL
0.55-0.65
0.25-0.40
0.02-0.06
0.01-0.05
HIGH
LOW
NORMAL
NORMAL
HEMATOLOGY
Date Ordered: Aug. 21, 2014
21
No
Interpretation
Because of damaged kidneys, it cannot secrete erythropoietin which is a hormone
needed by the bone marrow to secrete RBCs. The result, RBCs or erythrocytes are low in
number which will also result to the decrease of hematocrit, the percentage of the
volume of whole blood that is made of RBC. The MCV, MCH and MCHC, which are part of
RBC indices, will also be low. Neutrophils increased in any inflammation or tissue injury
but lowers lymphocyte count.
X-RAY
Date requested: Aug. 25, 2014
Findings:
There is no evident pneumothorax
Both lungs are hyperaerated
Heart is not enlarged
BIOCHEMISTRY
Date Ordered: Aug. 25, 2014
Glucose fasting
Cholesterol
BUN
Creatinine
Sodium
Potassium
Iron
Calcium
Result
6.1
2.1
17.9
264
139
2.8
6.1
1.75
Normal Values
3.9-6.1
0-5.2
2.5-6.4
53-115
136-145
3.5-5.1
8.8-32.4
2.10-2.60
22
Interpretation
NORMAL
NORMAL
HIGH
HIGH
NORMAL
LOW
LOW
LOW
Magnesium
Phosphorus
0.59
1.48
0.65-1.07
0.74-1.52
LOW
NORMAL
Interpretation
Aug.
21,
2014
250am
Physicians orders
23
Aug.
21,
2014
715am
- facilitate serum K
- lactulose 30 cc if no BM ODHS
Aug.
21,
2014
1140a
m
Aug.
21,
2014
140pm
Aug.
21,
2014
230pm
Aug.
21,
2014
330pm
Aug.
21,
2014
345pm
Aug.
21,
2014
350pm
Aug.
21,
2014
830pm
24
Aug.
22,
2014
620am
Aug.
22,
2014
805am
Aug.
22,
2014
10am
Aug.
22,
2014
1120a
m
Aug.
22,
2014
125pm
Aug.
22,
2014
215pm
- comfortable
- BP 140/80, CR 96, RR 22, Temp
-36.0
- no abdominal tenderness, no edema
- I 1,200, O 240
Aug.
22,
2014
845pm
Aug.
23,
2014
9am
25
Aug.
23,
2014
10am
Aug.
23,
2014
1030a
m
Aug.
23,
2014
117pm
Aug.
24,
2014
545am
Aug.
24,
2014
8am
Aug.
24,
2014
840am
Aug.
24,
2014
1030a
m
Aug.
24,
2014
1pm
Aug.
25,
2014
9am
- ongoing HD
- conscious, coherent, not in distress,
good appetite, no nausea, and vomiting
- no dizziness, no edema, clear breath
sounds
- ongoing HD, comfortable, able to finish
breakfast
- d/c IVF
- d/c CBG monitoring
Aug.
25,
2014
1120a
m
Aug.
25,
2014
1145a
m
Aug.
25,
2014
730pm
- AKI
- schedule for HD in am
- inform MROD once TIBC result
is available
Aug.
25,
2014
840pm
Aug.
26,
2014
2am
Aug.
26,
2014
6am
Aug.
26,
2014
645am
Aug.
26,
2014
720am
Aug.
26,
2014
845am
- observe succeeding
characteristics of stool
- inform MROD of next BM
Nephro notes:
- comfortable, (+) bowel movement,
black stools this bowel movement
- BP- 140/70, HR 20, RR- 20, temp
36.0
- Input vs output 710 vs 500
27
Aug.
26,
2014
1025a
m
Aug.
26,
2014
120pm
Aug.
26,
2014
220pm
Aug.
27,
2014
910am
Aug.
27,
2014
930am
Aug.
27,
2014
1120a
m
- better appetite, BP- 150/70, HR- 95, RR18, Temp- 36.0, Input vs Output 900 vs
550
- for AVF creation prior to discharge, HD
2x/week
Aug.
27,
2014
1220p
m
Aug.
27,
2014
220pm
Aug.
- GI comfortable, no melena, no
abdominal pain, stable vital signs, clear
breath sounds, no pallor, Hgb 10.5, Hct
- 0.30
27,
2014
5pm
Aug.
27,
2014
740pm
Aug.
28,
2014
650am
Aug.
28,
2014
820am
Aug.
28,
2014
255pm
Aug.
28,
2014
7pm
Aug.
28,
2014
1030p
m
- better appetite
- with dark stools, on FeSo4
Aug.
28,
2014
1120p
m
Aug.
29,
2014
725am
Aug.
29,
2014
10am
Aug.
30,
2014
8am
Aug.
30,
2014
830am
Aug.
30,
2014
9am
Aug.
30,
2014
1150a
m
Aug.
30,
2014
2pm
Aug.
31,
2014
940am
Aug.
31,
2014
1040a
m
Aug.
31,
2014
1130a
m
Sept 1,
2014
530am
Sept 1,
2014
- Stable VS
- comfortable, no DOB
- BP 140/80, HR 72, clear breath
sounds, no peripheral edema
- no difficulty of breathing, no chest
pain, comfortable
- BP 130/70, Temp 36.7, PR 80, RR
20
- I 510, O 1,400
- (+) thrills on AVF R arm
- no pain, dry dressing, no steal
syndrome
- normal
30
6pm
Sept.
2, 2014
830am
Sept.
2, 2014
3pm
Sept.
3,2014
3pm
to
31
Levels of hormones secreted by the thyroid are controlled by the pituitary gland's
thyroid-stimulating hormone, which in turn is controlled by the hypothalamus.
II. Cardiovascular System
The cardiovascular system consists of the heart, blood vessels, and
approximately 5 liters of blood that the blood vessels transport. Responsible
transporting oxygen, nutrients, hormones, and cellular waste products throughout
body, the cardiovascular system is powered by the bodys hardest-working organ
heart.
the
for
the
the
The Heart
The
32
The blood returns from the systemic circulation to the right atrium and from
there goes through the tricuspid valve to the right ventricle. It is ejected from the
right ventricle through the pulmonary valve to the lungs. Oxygenated blood
returns from the lungs to the left atrium, and from there through the mitral valve
to the left ventricle. Finally blood is pumped through the aortic valve to the aorta
and the systemic circulation.
The heart functions to pump blood to the lungs and the body. In order to
pump, the heart requires an electrical impulse just like any other muscle in the
33
body. With normal electrical conduction, electricity for the heart originates from
the sinus node in the upper right corner of the right atrium. Electricity then
spreads across both atria before reaching the AV node where it momentarily
pauses. From the AV node, electricity then rapidly passes through the right and
left bundle branches to reach the ventricles. As electricity passes through the
ventricles, the muscle is stimulated to contract.
The sinus node is the pacemaker for the heart. The heart rate depends on
how fast the sinus node fires. Many things can affect the firing of the sinus node.
Adrenaline, the hormone the body releases in response to exercise, stress, or
emotion, typically causes the sinus node to fire faster and the heart rate to
increase.
A. Blood Vessels
34
Blood vessels are the bodys highways that allow blood to flow quickly and
efficiently from the heart to every region of the body and back again. The size of
blood vessels corresponds with the amount of blood that passes through the
vessel. All blood vessels contain a hollow area called the lumen through which
blood is able to flow.
There are three major types of blood vessels: arteries, capillaries and veins.
1. Arteries and Arterioles: Arteries are blood vessels that carry blood away from
the heart. Arteries face high levels of blood pressure as they carry blood being
pushed from the heart under great force. To withstand this pressure, the walls
of the arteries are thicker, more elastic, and more muscular than those of other
vessels. Arterioles are narrower arteries that branch off from the ends of
arteries and carry blood to capillaries.
2. Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the
body and also the most common. They connect to arterioles on one end and
venules on the other. Capillaries carry blood very close to the cells of the
tissues of the body in order to exchange gases, nutrients, and waste products.
3. Veins and Venules: Veins are the large return vessels of the body and act as the
blood return counterparts of arteries. To facilitate the movement of blood,
some veins contain many one-way valves that prevent blood from flowing
away from the heart. Venules are similar to arterioles as they are small vessels
that connect capillaries, but unlike arterioles, venules connect to veins instead
of arteries. Venules pick up blood from many capillaries and deposit it into
larger veins for transport back to the heart.
B. Blood
The average human body contains about 4 to 5 liters of blood. As a liquid
connective tissue, it transports many substances through the body and helps to
maintain homeostasis of nutrients, wastes, and gases. Blood is made up of red
blood cells, white blood cells, platelets, and liquid plasma.
Red Blood Cells: Red blood cells, also known as erythrocytes, are by far the most
common type of blood cell and make up about 45% of blood volume. Erythrocytes
35
are produced inside of red bone marrow from stem cells at the rate of about 2
million cells every second. Erythrocytes transport oxygen in the blood through the
red pigment hemoglobin. Hemoglobin contains iron and proteins joined to greatly
increase the oxygen carrying capacity of erythrocytes.
White Blood Cells: White blood cells, also known as leukocytes, make up a very
small percentage of the total number of cells in the bloodstream, but have
important functions in the bodys immune system.
Platelets: Also known as thrombocytes, platelets are small cell fragments
responsible for the clotting of blood and the formation of scabs.
Plasma: Plasma is the non-cellular or liquid portion of the blood that makes up
about 55% of the bloods volume. Plasma is a mixture of water, proteins, and
dissolved substances.Many different substances can be found dissolved in the
plasma, including glucose, oxygen, carbon dioxide, electrolytes, nutrients, and
cellular waste products. The plasma functions as a transportation medium for
these substances as they move throughout the body.
Functions of the Cardiovascular System
The cardiovascular system has three major functions: transportation of materials,
protection from pathogens, and regulation of the bodys homeostasis.
Protection: The cardiovascular system protects the body through its white blood
cells. White blood cells clean up cellular debris and fight pathogens that have
entered the body. Platelets and red blood cells form scabs to seal wounds and
prevent pathogens from entering the body and liquids from leaking out. Blood also
carries antibodies that provide specific immunity to pathogens that the body has
previously been exposed to or has been vaccinated against.
36
or chemicals in the blood. The volume of blood in the body also affects blood
pressure. A higher volume of blood in the body raises blood pressure by increasing
the amount of blood pumped by each heartbeat. Thicker, more viscous blood from
clotting disorders can also raise blood pressure.
III. The Kidney
The kidneys are part of the urinary system. There are 2 kidneys in the body, one
on either side of the spine under the lower ribs, deep inside the upper part of the
abdomen. The adrenal glands are found just above each kidney and are part of the
body's endocrine system.
The ureters are thin tubes about 2530 cm (1012 inches) long that connect
the kidneys to the bladder. The urethra is a small tube that connects the bladder
to the outside of the body.
Structure
The kidneys are bean-shaped organs, about 12 cm (45 inches) long, 6 cm
(23 inches) wide and 3 cm (12 inches) thick.
Each kidney is surrounded by:
a layer of fibrous tissue called the renal capsule
a layer of fatty tissue that holds the kidneys in place against the muscle at the
back of the abdomen
a thin, fibrous tissue on the outside of the fat layer called Gerota's fascia
The cortex is the tissue just under the renal capsule. The medulla is the inner part
of the kidney. The renal pelvis is a hollow collecting area in the centre of each kidney.
37
The renal artery brings blood to the kidney, and the renal vein takes blood back to
the body after it has passed through the kidney. The area where the renal artery,
renal vein and ureter enter the kidney is called the renal hilum.
Inside each kidney is a network of millions of small tubes called nephrons. Each
nephron has 2 main parts:
Tubule - are tiny tubes that collect the waste materials and chemicals from the
blood moving through the kidney.
Corpuscle - contain a clump of tiny blood vessels called glomeruli that filter the
blood.
Function
The main function of the kidneys is to filter water, impurities and wastes
from the blood.
The blood from the body enters the kidneys through the renal arteries.
Once in the kidney, the blood passes through the nephrons where waste products
and excess water are removed. The clean blood is returned to the body through
the renal veins.
The waste products filtered from the blood are then concentrated into urine.
The urine is collected in the renal pelvis. The ureters move the urine to the
bladder where it is stored. Urine is removed from the bladder through the urethra.
The kidneys also act as endocrine glands and produce certain types of hormones:
Erythropoietin (EPO) stimulates the bone marrow to make red blood cells
38
Calcitriol, a form of vitamin D, helps the colon absorb calcium from the diet.
Renin helps control blood pressure.
PATHOPHYSIOLOGY
39
40
41
DRUG STUDY
DATE
ORDERED
NAME OF
MEDICATION
August 20,
2014
Calcium
polystyren
e sulfonate
(Kalimate)
15 g
TID
CLASSIFICATI
ON
ACTION
Antipotassium
reduces serum
levels of
potassium and
removes
excess
potassium
from the body
through the
GIT
SPECIFIC
INDICATION
Since patient
has ESRD
which means
his kidneys
are unable to
perform its
function of
eliminating
waste
products, he
retains
massive
amount of
potassium in
his blood
which results
to
hyperkalemi
a
43
CONTRAINDICATI
ON
Serum potassium
< 5 mmol/litre C
Conditions
associated with
hypercalcemia
(e.g.
hyperparathyroid
ism, multiple
myeloma,
sarcoidosis or
metastic
carcinoma)
History of
hypersensitivity
to polystyrene
sulfonate resins
Obstructive
bowel disease
COMMON SIDE
EFFECTS/
ADVERSE EFFECTS
NURSING
RESPONSIBILI
TIES
Hypokalemia and
Hypercalcemia
and their related
clinical
manifestations;
nausea, vomiting,
gastric irritation,
anorexia,
constipation and
occasionally,
diarrhea; Fecal
impaction and
gastrointestinal
concretions
(bezoars),
intestinal
obstruction, acute
bronchitis and/or
bronchopneumoni
a, Gastrointestinal
tract ulceration or
necrosis which
could lead to
intestinal
perforation
Use with
caution if
patient is
taking
digitalis
because of
the possibility
of digitalis
toxicity on
the heart,
manifested
by various
ventricular
arrhythmias
and A-V nodal
dissociation,
associated
with
hypokalemia
and/or
hypercalcemi
a
Use with
caution if
patient is
taking
aluminium
hydroxide
because of
possibility of
Intestinal
obstruction
Monitor for
signs of
Hypokalemia
and
Hypercalcemi
a (malaise,
palpitations,
muscle
weakness,
mild
hyperventilati
on, metabolic
acidosis
August 20,
2014
Antihypertensive
Clonidine
(Catapres)
75 mcg 1
tab
OD
Sympatholyti
c
stimulates CNS
alpha2adrenergic
receptors,
inhibits
sympathetic
cardio
accelerator
and
Indicated for
patients
hypertension
Hypersensitivity
to clonidine or
any adhesive
layer
components of
the transdermal
system
Use cautiously
44
drowsiness,
dizziness, lightheadedness,
headache,
weakness, dry
mouth, GI upset,
dreams,
nightmares,
dizziness,
Take this
drug exactly
as prescribed
Attempt
lifestyle
changes that
will reduce
your blood
vasoconstricto
r centers, and
decreases
sympathetic
outflow from
the CNS
with severe
coronary
insufficiency,
recent MI,
cerebrovascular
disease, chronic
renal failure,
pregnancy,
lactation
decreased libido,
palpitations
Drowsiness,
sedation,
dizziness, dry
mouth,
constipation,
Transient localized
skin reactions
pressure
(Stop
smoking and
drinking
alcohol, lose
weight,
restrict intake
of salt,
exercise
regularly)
Change from
a seated or
lying position
slowly to
avoid
dizziness.
Use caution
in performing
activities
requiring
alertness.
August 20,
2014
Methimazo
le
(Tapazole)
Anti-thyroid
drug
inhibits the
synthesis of
thyroid
hormones
Since patient
has
hyperthyroidi
sm, this is
indicated to
decrease his
45
Dizziness,
weakness, vertigo,
drowsiness,
nausea, vomiting,
loss of appetite,
rash, itching
Use caution
in performing
activities
requiring
alertness.
5mg 1 tab
OD
August 20,
2014
Erythropoi
etin
(Recormon
) 5,000
units SQ
thyroid
hormones
Hematopoieti
c
Agent
a natural
glycoprotein
produced in
the kidneys
which
stimulates red
blood cell
production in
the bone
marrow
Treatment of
patients
anemia
associated
with chronic
renal failure
since one of
the kidneys
function of
producing
erythropoieti
n which is
responsible
in the
production of
RBC via
stimulation
of the bone
marrow is
lost
46
with bone
marrow
depression
Paraesthesia,
neuritis, rash,
agranulocytosis,
granulocytopenia,
thrombocytopenia,
hypoprothrombine
mia, bleeding
Uncontrolled
hypertension,
hypersensitivity
to human
albumin
Dizziness,
headache,
seizures, fatigue,
joint pain, nausea,
vomiting, diarrhea
Use cautiously
with pregnancy,
lactation, sickle
cell anemia,
myelodysplastic
syndromes,
porphyria,
hypercoagulable
disorders
Headache,
arthralgias,
fatigue, asthenia,
dizziness,
hypertension,
edema, chest
pain, nausea,
vomiting, diarrhea
Eat small
frequent
meals to
prevent GI
symptoms
Report fever,
sore throat,
unusual
bleeding or
bruising,
headache,
general
malaise
Drug must be
given three
times per
week and can
only be given
IV,
subcutaneou
sly, or into a
dialysis
access line.
Use caution
in performing
activities
requiring
alertness.
Report
difficulty
breathing,
numbness or
tingling,
chest pain,
seizures,
severe
headache
August 20,
2014
Amlodipine
(Norvasc)
10mg/tab
OD in AM
Antihypertensive,
Anti-anginal,
Calcium
channel
blocker
inhibits the
movement of
calcium ions
across the
membranes of
cardiac and
arterial muscle
cells; inhibits
trans
membrane
calcium flow
which results
in the
depression of
impulse
formation in
specialized
cardiac
pacemaker
cells, slowing
the velocity of
conduction of
the cardiac
impulse,
depression of
myocardial
contractility,
and dilatation
Indicated for
patients
hypertension
Allergy to
amlodipine,
impaired hepatic
or renal function,
sick sinus
syndrome, heart
block, lactation
Use cautiously
with heart failure
and pregnancy
Nausea, vomiting,
headache
Dizziness, lightheadedness,
headache, fatigue,
lethargy,
peripheral edema,
flushing, nausea
Monitor BP
carefully if
patient has
other antihypertensive
drugs
Attempt
lifestyle
changes that
will reduce
your blood
pressure
(Stop
smoking and
drinking
alcohol, lose
weight,
restrict intake
of salt,
exercise
regularly)
Eat frequent
small feeding
Report
irregular
47
of coronary
arteries and
arterioles and
peripheral
arterioles;
these effects
lead to
decreased
cardiac work,
decreased
cardiac oxygen
consumption,
and increased
delivery of
oxygen to
cardiac cells
August 22,
2014
Propylthio
uracil
(PTU)
50 mg 1
tab
TID
Anti-thyroid
drug
inhibits the
synthesis of
thyroid
hormones;
partially
inhibits the
peripheral
conversion of
T4 to T3, the
more potent
form of thyroid
hormone
heartbeat,
shortness of
breath,
swelling of
the hands or
feet,
pronounced
dizziness,
constipation
Since patient
has
hyperthyroidi
sm, this is
indicated to
decrease his
thyroid
hormones
48
Dizziness,
weakness, vertigo,
drowsiness,
nausea, vomiting,
loss of appetite,
rash, itching
Paresthesia,
neuritis, vertigo,
drowsiness, skin
rash, urticarial,
nausea, vomiting,
epigastric distress
Take this
drug aroundthe-clock at 8
hour intervals
This drug
must be
taken for a
prolonged
period to
achieve the
desired
effects
Report fever,
sore throat,
unusual
bleeding or
August 22,
2014
Carvedilol
(Carvid)
6.25 mg 1
tab
BID
Alpha and
beta
adrenergic
blocker,
Antihyperten
sive
Completely
blocks alpha,
beta, and
beta2
adrenergic
receptors and
has some
sympathomim
etic activity at
beta2
receptors.
Both alpha and
beta blocking
actions
contribute to
the BPlowering
effect; beta
blockade
prevents the
reflex
tachycardia
seen with
most alpha
blocking drugs
and decreases
plasma renin
activity.
Significantly
reduces
plasma renin
activity
Indicated for
my patients
hypertension
Decompensated
heart failure,
bronchial
asthma, heart
block,
cardiogenic
shock,
hypersensitivity
to carvedilol,
pregnancy,
lactation
Use cautiously
with hepatic
impairment,
peripheral
vascular disease,
thyrotoxicosis,
diabetes,
anesthesia,
major surgery
Depression,
dizziness, lightheadedness
Dizziness, vertigo,
tinnitus, fatigue,
bradycardia,
hypotension,
gastric pain,
flatulence,
constipation,
diarrhea, rhinitis
bruising,
headache,
general
malaise
Take drug
with meals
Do not stop
taking drug
unless
instructed to
do so by a
health care
provider
Avoid use of
over the
counter
medications
If you are
diabetic,
promptly
report
changes in
glucose level
Report
difficulty
breathing,
swelling of
extremities,
changes in
color of stool
or urine, very
slow heart
rate,
continued
49
dizziness
August 20,
2014
Oral Iron
Supplement
FeSO4
1 tab TID
Hematinic
Ferrous sulfate
replaces iron,
an essential
component in
the formation
of hemoglobin.
Treatment of
patients
anemia
Hemosiderosis,
primary
hemochromatosi
s, hemolytic
anemia unless
iron deficiency
anemia is also
present, peptic
ulceration,
ulcerative colitis,
or regional
enteritis.
Temporary
staining of teeth
(with liquid forms).
Nausea, epigastric
pain,
vomiting, constipa
tion, black
stools, diarrhea,
anorexia.
Use cautiously
on long-term
basis.
August 22,
2014
Omeprazol
e
Proton Pump
Inhibitor
It suppresses
stomach acid
secretion by
specific
inhibition of
To prevent
acid-base
disturbances
in the GI
tract
50
Atrophic
Gastritis, Liver
Problems,
Clostridium
Difficile Bacteria
Back, leg, or
stomach pain
bleeding or
crusting sores on
Drug may be
taken with
meals to
minimize GI
effects;
maximum
absorption
will occur if
drug is taken
between
meals.
Ferrous
sulfate
blackens
feces and
may interfere
with tests for
occult blood
in the stool;
the guaiac
test and
orthotoluidin
e test may
yield falsepositive
results, but
the benzidine
test is usually
not affected.
Swallow
capsules
whole with
water. Do not
take with
(Omepron)
40mg 1cap
OD
the H +/K +
ATPase system
found at the
secretory
surface of
gastric parietal
cells. Because
this enzyme
system is
regarded as
the acid
(proton, or H+)
pump within
the gastric
mucosa,
omeprazole
will inhibit the
final step of
acid
production.
Omeprazole
will also inhibit
both basal and
stimulated
acid secretion
irrespective of
the stimulus.
August 22,
2014
Ketoanalogue
s
Ketoanalo
gues
and
Essential
Amino
Acids
(Ketosteri)
Essential
Amino Acids
Normalizes
metabolic
process,
promotes
recycling
product
exchange.
Related Colitis,
Osteoporosis,
Broken Bone,
Low Amount of
Magnesium in
the Blood
the lips
blisters
bloody or cloudy
urine
chills
continuing ulcers
or sores in the
mouth
other liquids
or open
capsule and
sprinkle onto
food.
Take on an
empty
stomach at
least 1 h
before meals.
difficult, burning,
or painful urination
fever
Indicated for
patients
metabolic
acidosis
Hypercalcemia
Disturbed amino
acid metabolism
Caution use for
patietn with
Reduces ion
concentration
51
Hypercalcemia
may develop
Take drug as
prescribed
Warn the
patient about
possible side
effects and
how to
600 mg 2
tabs
TID
of potassium,
magnesium
and
phosphate.
phenylketonuria
recognize
them
Give with
food if GI
upset occurs
August 20,
2014
Moriamin
Forte
(AminoVita
)
1 tab OD
Multivitamins
Essential
Amino Acids
Folic Acid
Moriamin Forte
is a combined
amino acidsmultivitamins
preparation,
which contains
8 essential
amino acids
and 11
vitamins in
well-balanced
proportion.
Amino acids
are required
for
incorporation
into protein of
the blood and
tissues, to
replace amino
acids already
present, to
restore the
damaged
Indicated for
patients
vitamin
deficiencies
and anemia
52
Patients with
malabsorption
syndrome
Headache,
nausea, vomiting,
stomach disorder,
unpleasant taste
bud, diarrhea and
abdominal cramp
Frequently
assess for
hypercalcemi
a
Use carefully
to patients
with Diabetes
Mellitus
tissue, and to
form new
protein.
August 20,
2014
Lactulose
(Duphalac)
30cc OD at
HS if no BM
Hyperosmotic
Laxative
Produces
increased
osmotic
pressure
within colon
and acidifies
its contents,
resulting in
increased
stool water
content and
stool
softening.
Causes
migration of
ammonia
from blood
into colon,
where it is
converted to
ammonium
ion and
expelled
through
laxative
action.
Indicated for
patients
constipation
Patients who
require lowgalactose diet.
Gaseous
distention with
flatulence or
belching,
abdominal
discomfort and
cramping,
diarrhea, nausea,
vomiting.
Advise
patient that
drug can be
mixed with
fruit juice,
water, or milk
to make it
more
palatable.
Inform
patient that
drug may
cause
belching,
flatulence, or
abdominal
cramps.
Instruct
patient to
notify health
care provider
if these
symptoms
become
bothersome
or if diarrhea
occurs.
Instruct
53
patient not to
take other
laxatives
while
receiving
lactulose
therapy.
Encourage
patient to
increase
dietary fiber
and fluid
intake and
participate in
regular
exercise.
54
NURSING PROCESS
PROBLEM LIST
Date
Identified
Nursing Diagnosis
Degree
of
Priority
1st
Sept
3,2014
Ineffective Airway
Clearance
Upon
Admission
Aug 2124, 2014
Esp. Aug.
22, 2014
Ineffective Tissue
Perfusion
2nd
Upon
Admission
Aug 21
Electrolyte Imbalance
3rd
55
Justification
this homeostatic
mechanism making it
unable to filter effectively.
Thus, making the body lose
its needed electrolytes and
retain its unnecessary
waste products. This will be
our priority prior to fluid
volume excess because one
of the reasons for excess
fluid, or edema, is an
imbalance in the
electrolytes in the body.
Aug 22
O:240
Aug 22
NGT
insertion
4th
Imbalanced Nutrition:
Less than body
requirements
5th
August 25
Acute Pain
6th
Self-care Deficit
7th
56
August 21
Sleep Disturbance
8th
Aug 21,
After IJ
Cath
insertion
and AVF
creation
9th
57
Diagnosis
Ineffective
airway
clearance
related to
copious
tracheobronchial
secretions
Scientific
Rationale
A state in
which an
individual is
unable to
clear
secretions or
obstructions
from the
respiratory
tract to
maintain
airway
patency.
Objectives
Interventions
Rationale
Evaluation
DEPENDENT
Administered
expectorants and
bronchodilators
as ordered
DEPENDENT
To facilitate
easy expulsion
of secretions
and open
airways
Demonstrate
reduction of
congestion.
Demonstrate the
use of incentive
spirometry, as
ordered
Demonstrate
behaviors to
improve or
maintain clear
airway.
Increase fluid
intake, amount
specifically
ordered by MD
(+) cough
INDEPENDENT
Monitor
respirations and
breath sounds
such as crackles,
stridor, wheezes
(+)productiv
e cough with
yellowish
phlegm
(+)
occasional
rales
Check clients
cough and gag
reflex and
swallowing
ability
(+) crackles
58
Breathing
exercises help
maximize
ventilation
Adequate
hydration can
help liquefy
secretions
INDEPENDENT
To be able to
identify
presence of
respiratory
distress and
accumulation of
secretions
To determine
the ability to
2. Demonstrate
reduction of
congestion
Clear breath
sounds
Noiseless
respiration
Improved
oxygen
exchange
Absence of
cyanosis
Oxygen
saturation
within normal
limits
Not using
accessory
muscles for
Elevate head of
bed and change
position every
two hours and as
needed
Assist patient
with self-care
activities as
needed
Monitor for
restlessness,
anxiety, and air
hunger
Support active
patient control of
condition.
Encourage warm
than cold liquids
as appropriate
Encourage to
take a deep
breath, hold for 2
seconds, and
cough two or
three times in
succession
COLLABORATIVE
59
protect the
airway
To allow the
gravity to
decrease
pressure on the
diaphragm and
enhance
drainage to
different lung
segments
breathing
3. Demonstrate
behaviors to
improve or
maintain clear
airway
Use of coughing
exercises
Reduce oxygen
demand
These are early
indicators of
hypoxia
To help in
liquefying
secretions
Controlled
coughing is
accomplished
by closure of
the glottis and
the explosive
expulsion of air
from the lungs
by the work of
abdominal and
chest muscles
Educate client
about reportable
symptoms like
restlessness,
anxiety, use of
accessory
muscles,
changes in sleep
pattern
Advise client to
monitor amount,
color and
consistency of
60
COLLABORATIVE
AND SELF CARE
MANAGEMENT
To aid in
facilitating easy
expectoration of
secretions
To maintain
adequate
airway and
improve
respiratory
function and
gas exchange
To evaluate the
progression of
disease and
monitor
response to
therapy
To provide
opportunity for
timely
evaluation and
intervention
To identify any
infectious
process and
promote timely
control of
condition
Necessary
lifestyle/behavio
ral changes
initiated.
sputum
Cues and
Clues
Subjective:
Matagalnaa
kong may
high-blood.
Objective:
Consistent
elevated BP
readings
(160/100,
170/100,
160/80)
(+) HTN for
20 years
(+) Family
history of
HTN
(+) Anemia
Low Hgb, Hct
(+)
Atherosclerot
ic aorta
Diagnosis
Ineffective
tissue
perfusion
related to
high blood
pressure
Scientific
Rationale
As blood
flows through
arteries it
pushes
against the
inside of the
artery walls.
The more
pressure the
blood exerts
on the artery
walls, the
higher the
blood
pressure will
be. If the
force of the
blood against
the artery
walls is high
enough, it
may
eventually
cause heart
problems.
intervention
Objectives
Interventions
Rationale
Evaluation
DEPENDENT
Administered
anti-hypertensive
drugs as ordered
DEPENDENT
To improve
tissue perfusion
and organ
function
Absence or
reduction of signs
and symptoms of
altered tissue
perfusion
Demonstrate
techniques to
improve circulation
Prevent
complications
Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated
INDEPENDENT
Provide calm and
restful
surroundings,
minimize
environmental
stimulation
Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted
rest
(+) Blood
Transfusion
Assist patient
with self-care
61
To promote
optimal blood
flow, organ
perfusion and
function
INDEPENDENT
Helps reduce
sympathetic
stimulation and
promotes
relaxation
Reduces
physical stress
and tension that
affect blood
pressure
To decrease
cardiac demand
7. Absence o
reduction of
signs and
symptoms of
altered tissu
perfusion,
such as:
(-) edema,
paresthesia,
intermittent
claudication
Normal
laboratory
(+) pale,
weak-looking
activities as
needed
LONG TERM GOAL
Provide
information about
disease
process/prognosis
and treatment
regimen.
Support active
patient control of
condition.
Provide comfort
measures like
elevation of head
of bed
Instruct in
relaxation
techniques like
deep breathing
exercises and
guided imagery
Apply
intermittent
compression
devices or elastic
compression
stockings to
lower extremities
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Monitor response
to medications to
control blood
pressure
Implement
62
values
Decreases
discomfort and
may reduce
sympathetic
stimulation
Can reduce
stressful stimuli,
produce
calming effect,
thereby
reducing BP
To promote
circulation and
limit
complication
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Response to
drug therapy is
important to
determine the
lowest dosage
of medications
and achieve
optimal effect
These
restrictions can
8. Demonstr
e techniques
to improve
circulation
Blood
Pressure
within norma
acceptable
limits OR a
decrease in
the systolic
BP of 20-30
mm Hg
9. Prevent
complication
(-) edema,
paresthesia,
intermittent
claudication
LONG TERM
GOAL
10. Provide
information
about diseas
process/
prognosis an
treatment
regimen.
11. Support
active patien
control of
condition
Necessary
dietary sodium,
fat, and
cholesterol
restrictions as
indicated
help manage
fluid retention
and decrease
myocardial
workload
To evaluate the
progression of
disease and
monitor
response to
therapy
Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs
Emphasize the
need for regular
exercise program
Educate client
about reportable
symptoms like
decreased in
pain sensation,
non-healing
wounds.
63
To promote
independence
and ability to
deal and
manage own
needs
To enhance
circulation and
promote wellbeing
To provide
opportunity for
timely
evaluation and
intervention
lifestyle/beha
vioral
changes
initiated.
Cues and
Clues
Objective:
(+) Uremia
(+)Hyperkale
mia
(+)Metabolic
Acidosis
(+)Anemia of
Chronic
Disease
Diagnosis
Electrolyte
Imbalance
related to
renal
dysfunction
Scientific
Rationale
The kidney
maintains the
internal
environment
of the body
by selectively
excreting or
retaining
fluids or
electrolytes
or waste
products
according to
an
individuals
specific body
needs.
However, in
renal failure,
the kidneys
become
damaged.
Thus, it
cannot
selectively
filter the
fluids,
electrolytes
and waste
products
which are to
be excreted
or retained.
Objectives
Interventions
Rationale
Evaluation
DEPENDENT
Review clients
medications
DEPENDENT
To improve
tissue perfusion
and organ
function
Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated
Collaborate in
the treatment of
the underlying
conditions
64
Instruct patient
in use of
potassiumcontaining salts
(salts
substitutes),
taking potassium
supplements
safely
INDEPENDENT
Monitor heart
To promote
optimal blood
flow, organ
perfusion and
function
To prevent or
limit effects of
electrolyte
imbalances
caused by
organ
dysfunction
Utilizing
electrolytes
depends on the
client regularly
receiving it in a
more readily
available form
INDEPENDENT
Dysrhythmias
are often
associated with
lifestyle changes
to prevent and
reduce frequency
of electrolyte
imbalances
problems in
potassium
levels
To monitor the
effect of high or
low potassium
levels in the
body and
promote timely
intervention
Fluid imbalance
usually disrupt
electrolyte
transport,
function and
excretion
Monitoring of
these signs of
excess
potassium in
the blood will
promote timely
intervention
Monitoring
these signs of
low potassium
in the blood will
facilitate timely
intervention
lifestyle
changes to
prevent and
reduce
frequency of
electrolyte
imbalances
paralysis
Measure and
report all fluid
losses including
emesis, diarrhea
66
Loss of fluids
rich in
electrolytes can
lead to an
imbalance
Maintain fluid
balance
To prevent
dehydration and
shifts of
electrolytes
COLLABORATIVE
AND SELF CARE
MANAGEMENT
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Monitor response
to medications to
control blood
pressure
Response to
drug therapy is
important to
determine the
lowest dosage
of medications
and achieve
optimal effect
To evaluate the
progression of
disease and
monitor
response to
therapy
Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs
Cues and
Clues
Subjective:
Verbalization
of shortness
of breath and
coughing
episodes
Reported
inability to
pass out
urine
Objective:
(+) Difficulty
of breathing
(+)
Hemodialysis
(8/22/14)
I 1200,
O 240
(+)mild
Diagnosis
Fluid
volume
excess
related to
compromise
d regulatory
mechanism
(kidney
failure)
Scientific
Rationale
Fluid volume
excess, or
hypervolemia
, occurs from
an increase
in total body
sodium
content and
an increase
in total body
water.
To promote
independence
and ability to
deal and
manage own
needs
Objectives
Interventions
Rationale
Evaluation
DEPENDENT
Restrict sodium
and fluid intake
as indicated
DEPENDENT
To prevent
further fluid
excess
Verbalize
understanding of
individual dietary
and fluid
restrictions
In renal
failure, the
glomeruli are
damaged
resulting in
fluid
overload.
Thus, this
increases the
hydrostatic
pressure
thereby
Administered
anti-hypertensive
drugs as ordered
Maintain rate of
IV fluid
administration as
ordered
Administer
diuretics as
prescribed
INDEPENDENT
Monitor input
and output every
shift
67
To improve
tissue perfusion
and organ
function
To prevent
peaks and
valleys in fluid
level and thirst
To prevent fluid
overload
INDEPENDENT
To obtain an
accurate fluid
volume status
swelling of
the hands
and feet
(+) oliguria
(+) HTN
causing fluid
to be pushed
into the
interstitial
spaces. Since
fluids are not
reabsorbed
at the venous
end, fluid
volume
overloads the
lymph
system and
stays in the
interstitial
spaces
leading the
patient to
have edema,
pulmonary
congestion.
Measure
abdominal girth
daily
Elevate
edematous
extremities
Change positions
frequently
Place in semifowlers position
68
Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted
To evaluate the
effectiveness of
diuretic therapy
used
To monitor signs
of fluid
retention
To reduce tissue
pressure
To reduce
likelihood of
skin breakdown
To facilitate
movement of
diaphragm and
improve
respiratory
effort
To promote
relaxation and
reduce tension
To conserve
energy and
lower tissue
oxygen demand
To decrease
g about fluid
restrictions
and diet
modification
disease
process/prognosis
and treatment
regimen.
Support active
patient control of
condition.
rest
Assist patient
with self-care
activities as
needed
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Monitor response
to medications
and diuretic
therapy
Implement
dietary sodium,
fat, and
cholesterol
restrictions as
indicated
Stress the need
for regular
medical and
laboratory followup
Identify
necessary
lifestyle changes
and assist client
69
oxygen demand
in tissues
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Response to
drug therapy is
important to
determine the
effectiveness of
therapy
These
restrictions can
help manage
fluid retention
and
To evaluate the
progression of
disease and
monitor
response to
therapy
To promote
independence
and ability to
deal and
manage own
needs
LONG TERM
GOAL
17. Provide
information
about diseas
process/
prognosis an
treatment
regimen.
18. Support
active patien
control of
condition
Necessary
lifestyle/beha
vioral
changes
initiated.
to incorporate
disease
management
into ADLs
Emphasize the
need for regular
exercise program
Educate client
about
Hemodialysis
and care for the
AVF
Cues and
Clues
Subjective:
Walangwalatalagaak
ongganangk
umain.
Objective:
(+)
decreased
appetite
(+) NGT
insertion
(+) pale
and weaklooking
Diagnosis
Altered
nutrition:
less than
body
requirement
s related to
decrease in
appetite
Scientific
Rationale
The state in
which an
individual
experiences
an intake of
nutrients
insufficient to
meet
metabolic
needs
To enhance
circulation and
promote wellbeing
To provide
adequate
knowledge to
facilitate selfcare
management
Objectives
Interventions
Rationale
Evaluation
DEPENDENT
Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated
DEPENDENT
To promote
optimal blood
flow, organ
perfusion and
function
INDEPENDENT
Provide oral
hygiene daily
Observe for
absence of
subcutaneous fat
and muscle
wasting, loss of
hair, fissuring of
nails, delayed
INDEPENDENT
To improve
taste
To assess
degree of
malnutrition
Height: 57
healing
Weight:
145lbs
BMI: 22.8
Use flavoring
agents like
lemons as
indicated
To enhance food
satisfaction and
stimulate
appetite
Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted
rest
To conserve
energy
Assist patient
with self-care
activities as
needed
Encourage client
to choose foods,
or have family
bring foods that
seem appealing,
if not
contraindicated
Promote
adequate and
timely fluid
intake and limit
fluids 1 hour pre
meals
COLLABORATIVE
AND SELF CARE
MANAGEMENT
71
To reduce
anxiety and
tension
To enhance food
satisfaction and
stimulate
appetite
To reduce
possibility of
early satiety
COLLABORATIVE
AND SELF CARE
MANAGEMENT
To implement
interdisciplinary
within
normal
range for
client
Normal
BUN and
serum
albumin,
Hct, Hgb,
and
lymphocy
levels
No further
decline in
strength
and activi
tolerance
Healthy
oral
mucous
membran
21.Demonstr
ed change
in behavio
and
lifestyle
changes
Consult dietitian
or nutritional
team, as
indicated
Stress the need
for regular
medical and
laboratory followup
Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs
72
team
management
To evaluate the
progression of
disease and
monitor
response to
therapy
To promote
independence
and ability to
deal and
manage own
needs
DISCHARGE PLANNING
Medicines
Instruct patient to take medications as directed:
1.
2.
3.
4.
5.
6.
7.
8.
Exercises
Treatment
Health Teachings
73
Out-Patient Follow-Up:
Diet:
Sexual Activity:
Spiritual Activity:
74
RECOMMENDATION
75
REFERENCES
Books:
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
19th Edition, the Merck Manual of Diagnosis and Therapy Merck, July 20, 2011
Doenges, M., Moorhouse, M., Murr, A. (2011). Nurse's pocket guide: diagnosis, prioritized
interventions and rationales. 12th edition. iGroup press co. Ltd: Thailand.
Berman, A., Snyder, S., Kozier, B., Erb, G. (2008). Fundamentals of nursing. 8th edition.
Pearson education south asia: Singapore.
Rod. R. Seeley, Trent D. Stephens, & Philip Tate, Essentials of Anatomy and Physiology,
6th edition by McGraw-Hill International Edition, 2007
MediMarketing, MIMS Philippines, 136th Edition 2014
Internet:
http://nurseslabs.com/nursing-nursing-related-theories-theorists-an-ultimate-guide/
http://www.simplypsychology.org/maslow.html
76