Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

BAB 5

5. RENAL REPLACEMENT THERAPY When patients have reached and stage renal disease are gibe option to decide or decided by the nephrologists based on patient conditions for a renal replacement theraphy. The option that are available are :-

5.1 Continuous Ambulatory Peritoneal Dialysis A tenckoff catheter is inserted into the peritoneum cavity and after 10 14 days, a training is given by a nurse. Its a dialysis process that dose non stop. Its continuously cleans the blood 24 hours a day. Patient is free between 2 exchanges. Peritoneal membrane works like a semi-permeable filter.

5.2 Haemodialysis Haemodialysis is a procedure for removing dissolved waste or contaminants ( eg urea, creatinine uric acid) from the blood mainly by diffusion through a semipermeable membrane (dialyser membrane) by using dialysate as a buffer when the kidney filtration function fail. Diffusion, ultrafiltration and osmosis will be happen during haemodialysis. A permanent access is created either ateriovenous fistula or Brachiocephalic fistula or a temporary acces is inserted to the patient haemodialysis procedure done.
___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

Process A Semipermeable Membrane

(Sumber: http//www.shodor.org/master/biomed/physio/haemodialysis/fig2.jpg)

5.3 Kidney Transplant Is the transfer of a healthy from the donor to patient with end stage kidney failure. Only kidney transplant can replace all of the functions of the kidney.

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

Schedule : Anemia for year 1999 Date HB (g/dL) 9.4 8.1 8.1 11.3 13.2 Sr IRON (umol/L) 14 29 20 10 10 Sr Ferritin (g/L) Sr IPTH (pg/ml) TIBC (mmol/L) 54 45 42 45 48

25.05.99 06.07.99 12.08.99 07.10.99 22.11.99

Schedule : Anemia for year 2000 Date HB (g/dL) 8.5 8.9 9.2 10.8 Sr IRON (umol/L) 18 23 10 Sr Ferritin (g/L) Sr IPTH (pg/ml) TIBC (mmol/L) 46 49 49

07.03.00 13.04.00 08.08.00 07.09.00

Schedule : Hemoglobin 1999 & 2000

14 12 10 8 6 4 2 0 25.05.99 06.07.99 12.08.99 07.10.99 22.11.99 07.03.00 13.04.00 08.08.00 07.09.00

HB

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, Perak Name: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date Biochemistry
25.05.99 06.07.99 12.08.99 07.10.99 22.11.99

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L SGOT/SGPT Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Ca x Po4 Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS RBS HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV Blood group

21 147 4.5 911 107 302 61 37 5 101 1.96 2.06 1.0 5.2

20.2 147 4.6 856 105 443 72 42 1 91 12/13 2.40 2.12 1.1 6.6 1.9 1.7

18.7 145 4.6 994 98 401 71 43 1 90 20/19 2.43 2.05 1.4 5.6 1.5

9.4 5300 27.3 156,000 91.7 34.4 14 54

8.1 5.5 24.0 126,000 93.3 33.8 29 45

8.1 4.6 24.6 164,000 98.3 33.0 20 42

11.3 4.5 33.0 182,000 96.0 34.2 10 45

13.2 4.8 38.3 181,00 90.5 34.5 10 48

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___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, Perak Name: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date Biochemistry
07.03.00 13.04.00 08.08.00 07.09.00

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L SGOT/SGPT Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Ca x Po4 Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS RBS HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV VDRL Blood group

20.2 140 4.5

22.2 143 4.6 1150

97 453 70 41 9 129 14/15 2,37 2.14 0.9 6.0 1.4

106 591 71 39 1 104 2.29 1.22 1,1 5.9 1.5

8.5 4.1 24.2 148,000 86.7 3.51

8.9 5.4 23,7 168,000 89.4 37.6 18 46

9.2 4.3 26.0 162,000 90.6 35.4 2.87 23 49

10.8 5.7 30 225,000 89.6 36 3.35 10 49

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___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, Perak Name: Koh Kam Wah I/C No. : 590530-08-6095 I
LAB Test Date Biochemistry
03.01.08 03.04.08 10.08.08 16.10.08

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L Alanine Transminase Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Magnesium 0.7-1.10mmol/L Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS SGOT HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV VDRL Blood group

15.9 3.8 3.8 142 3.10 1014.0 99 435 75 46 15.6 83 21 2.32 1.60 1.09 3.20 1.40 1.46 1.10 2.91 3.9 12.0 12.1 5.1 36.7 173 99.6 33.0 13.4 19.10 39.40 644.7 407

22.90 5.0 5.0 139 2.6 1187.0 94 512 73 46 14.0 100 16 2.28 1.53 1.04 3.40 1.60 1.47 1.20 2.83 5.0 14.0 11.7 8.1 34.1 188 95.9 34.4 12.7 13.40 44.40 705.0 637.60

25.2 6.8 6.8 140 4.8 1227.0 92 500 79 40 10.4 74 20 2.45 2.37 1.12 4.0 4.4 0.90 1..10 3.64 4.2 10 12.2 7.6 37.5 191 101.0 32.6 3.71 14 44.0 743.7 242.8

23.5 5.9 5.9 144 2.8 1290 92 570 79 47 11.8 69 28 2.82 1.75 .135 3.7 2.7 1.4 1.10 3.36 4.6 16 11.7 6.5 35.7 198 102.6 32.8 3.47 21 50 641.9 104.70

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___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

DIALYSIS LABORATORY RESULTS CHART Hospital Raja Puteri Bainun, Ipoh, Perak Name: Koh Kam Wah I/C No. : 590530-08-6095
LAB Test Date Biochemistry
05.02.09 07.05.09 13.08.09

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L Alanine Transminase Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Magnesium 0.7-1.10mmol/L Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS SGOT HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV VDRL Blood group

26.0 6.2 139 143 4.0 2.8 1250 364 90/91 598 75 45 31 2.12 2.18 1.17 4.5 9.52 0.5 0.70 6.43 4.8 16 12.5 36.9 193 103.8 33.8 3.56 13 50

26.7 6.6 138 141 4.3 2.9 1275 380 90/95 611 74 44 13.9 66 39 2.45 1.49 1.27 4.5 2.86 2.4 0.80 5.63 4.1 15 13.2 40.0 169 104.0 33.0 3.04 26 46 2542.0 440.80

23.3 5.1 139 143 4.4 3.1 1266 355 95/98 503 70 47 14.5 64 20 2.55 1.37 1.49 3.4 2.30 1.5 0.70 3.78 4.4 11 12.2 5.6 35.7 183 104.5 34.2 3.41 14 33 1504.0 453.90

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___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Umum Sarawak Name: Jachin ak. Kirat
LAB Test Date Biochemistry
23.08.04 02.09.04

I/C No. : 800107-13-5235

06.10.04

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L Alanine Transminase Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Ca x Po4 Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS RBS HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV Blood group

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

MINISTRY OF HEALTH, MALAYSIA DIALYSIS LABORATORY RESULTS CHART Hospital Umum Sarawak Name: Jachin ak. Kirat
LAB Test Date Biochemistry
25.02.04 26.07.04

I/C No. : 800107-13-5235

07.06.04 10.06.04 15.08.04

Urea pre 1.7 8.3 mmol/L Urea post Sodium pre 135-145 mmol/L Sodium post Potassium pre 3.5-5.0 mmol/L Potassium post Creatinine pre 64-122 mmol/L Creatinine post Chloride pre/Co2 96-108 mmol/L Uric Acid 142-416 mmol/L Total Protein 66-87 g/L Albumin 35-50 g/L Total Bilirubin Up to 21 mmol/L Alk phosphatase 53-128 U/L Alanine Transminase Up to 42 U/L Calcium 2.0-2.6 mmol/L Inorganic Phosphate 0.8-1.6 mmol/L Ca x Po4 Total cholesterol < 5.7 mmol/L Triglyceride < 1.7 mmol/L LDL Cholesterol < 3.9 mmol/L HDL Cholesterol > 1.4 mmol/L % of HDL > 25 mmol/L FBS RBS HAEMATOLOGY HB g/dL TWDC HCT Platelets THSD/mm MCV MCHC % Hypochromic RBCRetic/Lympho Sr. IRON 10.6-28.3 mol/L TIBC 44-75 mmol/L Transferrin Ratio UIBC > 20 % Sr. Ferritin ug/L E.S.R mm/hr Serum intact PTH 13-54 pg/ml Pre DFO Serum Post DFO Aluminium Delta VIROLOGY / SEROLOGY HBs Ag Anti HBs HBc Ag Anti HCV Anti HIV CMV Blood group ___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

Schedule : Anemia for year 1999 Date HB (g/dL) 9.4 8.1 8.1 11.3 13.2 Sr IRON (umol/L) 14 29 20 10 10 Sr Ferritin (g/L) Sr IPTH (pg/ml) TIBC (mmol/L) 54 45 42 45 48

25.05.99 06.07.99 12.08.99 07.10.99 22.11.99

Schedule : Anemia for year 2000 Date HB (g/dL) 8.5 8.9 9.2 10.8 Sr IRON (umol/L) 18 23 10 Sr Ferritin (g/L) Sr IPTH (pg/ml) TIBC (mmol/L) 46 49 49

07.03.00 13.04.00 08.08.00 07.09.00

Schedule : Hemoglobin 1999 & 2000

14 12 10 8 6 4 2 0 25.05.99 06.07.99 12.08.99 07.10.99 22.11.99 07.03.00 13.04.00 08.08.00 07.09.00

HB

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

5.4

KT / V Regular measurement of the delivered dose of haemodialysis. The dialysis care team should routinely measure and monitor the delivered dose of haemodialysis at last 3 monthly. The single pool Kt/V is a dimensionless ratio representing fractional urea clearance. a) K is the dialysis blood water urea clearance by using the diayzer and speed the blood pump and dialysate flow for

clearance the urea from the patient blood to dialysate.by using principle diffusion, ultrafiltration, convection and osmosis. b) T is dialysis session length (hours).The longer hours (4

hours) patient diaysis, patient will better urea clearance. c) V is the total volume of blood cleared during the dialysis session. ( the urea distribution volume ) Schedule : Haemodialysis urea modeling Date Dialyzer Blood flow (ml/min) Dialysate flow (ml/min) Urea clearance (ml/min) 238 241 239 237 Kt/v

21.11.03 07.01.04 05.04.04 12.08.04

F8 F8 F8 F8

350 350 350 350

500 500 500 500

1.45 1.65 1.54 1.44

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

Schedule : Haemodilysis urea modeling Date BUN (mg/dl) Pre dialysis Post dialysis 21.11.03 07.01.04 05.04.04 12.08.04 37 53 61 47 10 14 16 13 Berat badan (kg) Pre dialysis Post dialysis 50.0 52.5 52.0 53.0 49.0 49.0 50.6 52.6

Graf : Kt/v Level

3 2.5 2 1.5 1 0.5 0 21.11.03 07.01.04 05.04.04 12.08.04 1.2 1.2 1.2 1.2 Kt/v pesakit Normal Kt/v 1.45 1.65

1.54

1.44

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

5.5

Nursing intervention for anaemia a) Monitor blood status for maintain adequate iron store in blood. Serum ferritin Iron store in the body Serum Iron - To maintain target hemoglobin and iron levels in haemodialysis patients. Oral iron given (100mg 200mg ) or intravenous (IV Dextran 100 mg every week for 10 doses) Transferrin Saturation ( TSAT) - Reflects availability of iron. Minimum target TSAT is >20%. b) Give epoetin eg injection eprex after iron difficiency treated . Maximum dose 1200ii/week or 4000ii/day for maintain

hemoglobin. c) Adequate haemodialysis - Time dialysis should be 4 hours for every treatment, 3 times per week, blood pump high (300 400cc/min), diaylsate flow 500 800 cc/min and using high flux diayser for good clearance. d) Prevent blood loss - Minimize the volume of blood samplings taken. Return blood after complete haemodialysis as Monitor heparin dose

completely and as soon as possible.

during haemodialysis to prevent clotting during dialysis. Pre test the diayser to prevent leakage. e) Health Education - Take food contain high in iron eg internal organ, egg ect. Iron tablet should not taken with phostphate binder ( Calcium carbonate ) because calcium carbonate can

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

bind iron together. Iron tablet take with citrus fruit and avoid drink with caffeine eg coffee and tea. f) Monitor FBC and Serum Iron, TIBC and Serum Ferrittin every 3 monthly To know status of hemoglobin patient.

5.6

Nursing Intervention For Reduce Phosphate In Patient Diet. Limit intake of phosphate to less then 1000 mg/day. This will also help phosphate binders to work more efficiently. Avoid eating very large servings of meat, if possible, unless advised otherwise by dietitian or doctor. Eat your phosphate binders with meals which contain high protein foods such as fish, chicken, meat or with complet meals such as nasi lemak. Avoid eating the cartilage and soft bones of fish, shellfish and meat. Reduce intake of cocoa, chocolate-based beverages and cola drinks. Limit dairy food products such as milk, curd/yogurt and cheese. Use non-dairy creamer to replace milk in your beverages. Always choose foods with low phosphate. If your blood phosphate level is high, avoid foods that have high phosphate content. or moderate content of

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

Increasing the portion size of the food will increase the amount of phosphate you are eating. While 1 piece of kuih may have low phosphate content, taking many pieces will increase your phosphate intake.

Controlling PTH levels prevents calcium from being

withdrawn from the

bones. Usually, overactive parathyroid glands are controllable with a change in diet, dialysis treatment or medication. If PTH levels cannot be controlled, the parathyroid glands may need to be removed surgically. If your kidneys are not making adequate amounts of active vitamin D, you can take synthetic vitamin D (eg alfacalcidol) as a pill or in an injectable form. Renal

osteodystrophy can also be treated with changes in diet. Reducing dietary intake of phosphorus is on of the most important steps in preventing bone disease.

5.7

Health Education How to care of his AVF.. Exercise Advice patient to exercise his AVF hand regularly with a rubber ball to stimulate the development of his AVF Do Not Wear Tight long sleeves shirt with tight button. Not to sleep with the AVF hand under the pillow.

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman

Kajian Kes ( Case Study )

Post Basic Renal Nursing 2/2009

No BP or blood taking on the AVF hand. Avoid heavy lifting - Never use the AVF hand to carry heavy things, it can spoilt the AVF.

Monitor for Thrill - Advice patient to feel for the thrill all the time especially in the earlier part. If no more thrill felt, ask the patient to come quickly to hospital and refer him to the surgeon. The surgeon will remove any blood clot and the AVF might works again after that.

Cleanliness -

Advise patient to keep his AVF hand

clean at all times to prevent infection.

___________________________________________________________________________________________ _ SN Ramlah Bt Hj. Saliman