Chronic Renal Failure

I. 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 body’s 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

hyperparathyroidism; this is due to the compensatory mechanism of the parathyroid hormone once it detects any alteration in the calcium level of the body. It

is

important

for

clinicians

to

recognize

the

problem

of

hyperparathyroidism early in the course of chronic kidney disease so that growth of the parathyroid glands can be prevented or halted, and excessive secretion of hyperthyroidism can be controlled to help minimize the adverse consequences on bone and mineral metabolism, which may lead to bone pain and bone fractures, decreased growth in children, muscle weakness, and elevations in the calcium phosphorus product, which contributes to calcification of the heart valves and blood vessels and contributes to the high cardiovascular mortality in patients with advanced kidney disease. Early detection of this complication of chronic kidney disease will provide an opportunity to intervene to control the secretion of parathyroid hormone and, thus, minimize the problem. Early detection will also allow for the opportunity to prevent further growth of the parathyroid glands so that the magnitude of the problem will be lessened as kidney function deteriorates. There is also some evidence that the control of hyperparathyroidism may help to slow the progression of kidney disease. Ultimately, it is hoped that with timely intervention

1

to control this complication of chronic kidney disease, improved patient outcomes on in terms of morbidity and mortality will be achieved. To ensure that the diagnosis of hyperparathyroidism is made early in the course of chronic kidney disease, it is important to educate primary care physicians, cardiologists, endocrinologists and other healthcare providers who may see patients in the early stages of chronic kidney disease, so that they may assess blood parathyroid hormone levels to uncover this complication and either embark on the treatment of hyperparathyroidism or consider referral to a nephrologist for further advice on the appropriate management strategies. Referral to a nephrologist would appear to be preferable at the present time as the field is advancing with new therapies being evaluated and implemented in practice. At the American Society of Nephrology Renal Week 2004 meeting, results are being presented on the administration of oral paricalcitol, now in capsular form, so that its use can be evaluated in patients with earlier stages of kidney disease (stage III and IV), who are not yet on dialysis. The phase 3 studies of orally administered paricalcitol showed that this strategy is effective in reducing the degree of hyperparathyroidism, and that the administration of this vitamin D analog

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

2

kidney disease. As nurses, it is our responsibility to render information and impart health teachings to improve the condition of our patients to the best of our abilities. One of the characteristics that we, nurses, should have is to be informative and only through a keen study of disease such as this way for us to gain all the information that we need to learn. May this case study served its purpose through the help of our Lord, Jesus Christ. II. NURSING ASSESSMENT A. Personal Data and History (Demographic Data) Mr. Scrooge is a 53-year-old male, married living at 21 St. Cecilia, Paula Complex, Laguna. He was born on September 16, 1952 in Laguna. He is married for 29 years now and has six children. He was not able to finished his desired career during his college years because their family business was suddenly went bankrupt. According to Mr. Scrooge, education is important that’s why he decided to look for more affordable career. While studying he decided to work to be able to support his education. With his perseverance and determination, he was able to finished aircraft maintenance. But with all of this stress and difficulties happening in his life, he learned how to smoke. According to him, smoking helps him to be relaxed. He consumed 8 sticks/day. He was also an occasional drinker. He worked as aircraft maintenance in Clark Air Base in Pampanga for more than 20 years. Mr. Scrooge said that he is fond of eating meat and poultry products. After work, he only stays at home because he feels very tired after work. At present, he still works as aircraft maintenance in Clark Air Base in Pampanga. Mr. Scrooge was admitted in Angeles University Foundation Medical Center last February 3, 2005. He was admitted due to body weakness and severe anemia. He was discharged on February 10, 2005.

3

B. Family Health-Illness History Mother Side Lola (+) DM

Father Side Lolo

Mo

Lola

Lolo (+) HPN

Po p Mr. Scrooge (+) HPN (+)Kidney Failure

C. History of Past Illness Mr. Scrooge was known for being hypertensive for 5 years now. He was diagnosed of hypertension and kidney failure last 2001. He was hospitalized in St. Luke’s Hospital because of the said health problem. According to him, his chief complain that time was only hypertension. He was discharged from the hospital after six days of confinement. After his discharge, Mr. Scrooge consistently having his blood chemistry and creatinine check-up every month in AUFMC. If the results are all normal, his check-up becomes every month. These all became routine on him. On May 2004, he was hospitalized for the second time in AUFMC. After two days of confinement in the hospital, he decided to transfer in St. Luke’s Hospital. Mr. Bean experienced difficulty of breathing and fatigability that time. He was diagnosed of Pulmonary Congestion.

4

D. History of Present Illness Four days prior to admission, Mr. Scrooge experienced easy fatigability. No other accompanying signs and symptoms. His condition was persisted until one day prior to admission, he already experiencing body weakness, body malaise, pallor and fatigability that’s why he consulted AUFMC. He was advised to have laboratory examination (Hgb and Hct), which revealed anemia and he was advised to be admitted. His initial vital signs were as follows: T-36.8, RR- 22, PR- 64, BP- 170/100. E. Physical Examination February 3, 2005 Upon Admission: VS: T

- 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

5

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 GIT: loss of appetite Renal and Urologic changes: fatigability, oliguria Cardiovascular changes: hypertension Hematopoietic changes: anemia Skeletal changes: hypocalcemia and hyperphosphatemia February 7, 2005 Vital Signs: T

- 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

Abdomen- soft, flat, tender Cardiovascular changes: hypertension Renal and urologic changes: oliguria Hematopoietic changes: anemia

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

7

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

8

February 10, 2005 Vital Signs: T

- 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

9

F. Diagnostic and Laboratory Procedures Diagnostic/ Laboratory Procedure

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 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

Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythorpoieti n factor is already affected Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients

Determines any inflammation and infection

72 103 107 118 109

.23 .31 .33 .36 .32

7.76 6.01 9.40 8.58 9.5

.81 .75 .71 .72 .74

120-170 g/L

Results were all below the normal level, thus indicating renal malfunction and thereby causing anemia

.40-.50 Result were all below the normal range thus, showing anemia and renal disease 510x109/L Results were all above normal level. This shows presence of inflammation and infection .50-.70

Results were 10

Lymphocytes

Ordered 2/3,4,6, 8,9/05

Determines any acute bacterial infection

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

Determines any chronic bacterial infection or viral infection

Determines any acute bacterial infection

Result: 2/3,4,6, 8,9/05

.1 .13 .20 .15 .13

.10-.40

.05 .08 .04 .09 .07

.00-.07

.04 .04 .05 .04 .06

.00-.07

all above normal level. This shows presence of bacterial infection

Results were all within normal level. Showing absence of chronic infection

Some of the results were all above normal Level indicating presence of bacteria.

To determine any allergic reaction of the body Results were all within the normal level. This shows no allergic reactions.

Nursing Responsibilities:

11

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

Diagnosti c/ Laborator y Procedure

Date Ordered Date Result in

2. Ordered: Hepatitis 2/3/05 Profile Performe d: 2/5/05

Indication (s) Purpose (s)

This is usually done before proceeding in hemodialysis. This is to determine if the patient was expose to the virus of if there is presence of hepatitis virus In the blood of the patient.

Result

HBSAG- non-reactive ANTI-HCV- nonreactive ANTI-HBC- nonreactive ANTI-HBS-reactive HAV-IGM- nonreactive

Analysis and Interpretatio n 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 12

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

Date Ordered Date Result in

Indication (s) Purpose (s)

3.Urinalys Ordered: To is 2/3,6,7/0 diagnose 5 and monitor Result: renal or 2/3,6,7/0 urinary 5 tract disease

Result

Color: straw, light yellow, light yellow Appearance: slightly turbid pH: 5 Specific Gravity: 1.020, 1.025, 1.020 Albumin: 3+ Sugar: negative Pus Cells: 12/HPF, 0-2/HPF, 2-5 /HPF Red cells: 13/HPF, 1-3/HPF,4-6/HPF Epithelial Cells: Rare Mucus thread: Rare, (-), (-)

Normal Values used by the hospital

Analysis and Interpretati on Laboratory results revealed that there is presence of albumin in the blood; this indicates that the glomerular 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.

Bacteria: (-), 13

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

Diagnostic/ Laboratory Procedure

Date Ordered Date Result in

Indication (s) Purpose (s)

Result

Normal Values used by the hospital

Analysis and Interpretatio n

14

4. Creatinin e

Ordered: 2/3,4,6,8/0 5 Result in: 2/3,4,7,9/0 5

This test was ordered in order to evaluate renal function.

1499 1430 1649 731

44.20150.30 umol/L

137 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. Phosphat e

Ordered: 2/3/05 Result in: 2/3/05

To evaluate fluid and electrolyte imbalance and identify 4.78 renal dysfunctio n To evaluate fluid and electrolyte 6.4 imbalance and identify renal dysfunctio n To 186 evaluate muscle contraction , nerve impulse transmissi on, and blood clotting

135-150 mmol/L

3.5-5.5 mmol/L

8.5-10.5 mg/dl

Results were all above the normal level indicating renal malfunction. The kidney cannot excrete nitrogenous waste product of protein leading to its accumulatio n in the blood Normal result which means there is still fluid and electrolyte balance Normal result which means there is still fluid and electrolyte balance

30-150 u/L Results were all above the normal level indicating renal malfunction. 15

To evaluate the metabolis m of carbohydra tes, bone formation and acidbase balance.

Results were all above the normal level indicating renal malfunction.

Nursing Responsibilities: 1. Explain the procedure to the patient

16

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

III. ANATOMY AND PHYSIOLOGY Function of the Urinary System The major functions of the urinary systems are performed by the kidneys and the kidneys plays the following essentials roles in controlling the composition and volume of body fluids: 1. Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of which are toxic, from the blood. Most waste products are metabolic by- products of cells and substances absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some of these waste products, but they cannot compensate if the kidneys fail to function. 2. Blood volume control. The kidneys play an essential role in controlling blood volume by regulating the volume of water removed from the blood to produce urine. 3. Ion concentration regulation. The kidneys help regulate the concentration of the major ions in the body fluids. 4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the blood and the respiratory system also play important roles in the regulation of pH 5. Red blood cell concentration. The kidneys participate in the regulation of red blood cell production and therefore, in controlling the concentration of red blood cells in the blood. 6. Vitamin D synthesis. The kidneys. Along with the skin and the liver, participate in the synthesis of vitamin D.

17

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 12th 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

18

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

The path of the Formation of Urine

Blood enters the Efferent the distal To the To collecting tubule tubuleconvulated (at this about To the urinary 99% of the filtrate meatus has been

Passes through the Glomeruli

To Bowman’s capsule

Now it becomes filtrate (blood minus RBC’s and plasma

protein To the loop of Approximately Henle 1 ml of urine is formed per To the To the minute urethra bladder

Continues through the 19 proximal convulated The 1 ml of urine goestubule to the renal

To the pelvis ureter

Fluid and Electrolyte Balance Electrolyte Balance Electrolytes are important constituents of body fluids. These are compounds that separate into positively and negatively charged ions and carry an electric current in solution. The main source of electrolytes is food. A few of the most important ions are considered here. 1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid volume. It is the main positive in extracellular fluids. Sodium is required for nerve impulse conduction and is important in maintaining acid-base balance. 2. Potassium- important in the transmission of nerve impulse; a major positive ion in the intracellular fluids. It is involved in cellular enzyme activities and helps regulate the chemical reactions by which carbohydrate is converted to protein. 3. Calcium-required for bone formation, muscle contraction, nerve impulse transmission, and blood clotting 4. Phosphate- essential in the metabolism of carbohydrates, bone formation and acid-base balance. They are found in the cell membrane and in the nucleic acids. 5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.

20

Electrolytes must be kept in the proper concentration in both intracellular and extracellular fluids. Although some electrolytes are lost in the feces and through the skin as sweat, the job of balancing electrolytes is left mainly to the kidneys. There are several hormones that are involved in this process. Aldosterone produced by the adrenal cortex promotes the reabsorption of sodium and the elimination of potassium. Hormones from parathyroid and thyroid glands regulate calcium and phosphate levels. Parathyroid hormones increases blood calcium, levels by causing the bones to release calcium and by causing the kidneys to reabsorb calcium. The thyroid hormone calcitonin lowers blood calcium by causing calcium to be deposited in the bone. IV. THE PATIENT AND HIS ILLNESS SYNTHESIS OF THE DISEASE (CLIENT CENTERED) Chronic Renal Failure Chronic or irreversible, renal failure is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. Chronic Renal failure can develop insidiously over many years, or it may result from an episode of acute renal failure from which the client has not recovered. Precipitating Factors  Chronic glomerular disease such as glomerunephritis  Chronic infections such as chronic pyelonephritis or tuberculosis  Congenital anomalities such as polycystic  Vascular diseases, such as renal nephrosclerosis or hypertension  Obstructive processes such as calculi  Collagen diseases such as systemic lupus erythematosus  nephrotoxic agents such as long-term aminoglycoside  endocrine diseases such as diabetic neuropathy

21

Such conditions gradually destroy the nephrons and eventually cause irreversible renal failure. Similarly, acute renal failure that fails to respond to treatment becomes chronic renal failure. Predisposing Factors  Sex- both sexes are affected by chronic renal failure. But in 1998, based on United States Renal Data System, a higher total number of males with ESRD was found  Age- CRF can be found in people of any age, from infants to the very old. The elderly population also is the most rapidly growing ESRD population in the United States. Note that age 30 years progressive physiological glomerulosclerosis.

Aging

also

results

in

concomitant

progressive

physiological decrease in muscle mass such that daily urinary creatinine excretion also decreases. Clinical Manifestations The clinical manifestations of CRF are present throughout the body. No organ system is spared.  Electrolyte imbalances Electrolyte balance may be upset by impaired excretion and utilization in the kidney. Although many clients maintain normal serum sodium level, the salt-wasting properties of some failing kidneys, in addition to vomiting and diarrhea, may cause hyponatremia. Because the kidneys are efficient at excreting potassium, potassium levels usually remain within normal limits until late in the disease. Several mechanisms contriburte to hypocalcemia. Conversion of 25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to absorb calcium) is decreased, which results in reduced intestinal absorption of calcium. At the same time, phosphate is not excreted, which causes hyperphosphatemia. Because calcium and phosphate are

22

inversely related, a high phosphate level results in a reduced calcium level.  Metabolic changes In advancing renal failure, BUN and serum creatinine rise as waste products of protein metabolism accumulate in the blood. The serum creatinine level is the most accurate measure of renal function. The proteinuria accompanying renal disease and sometimes inadequate dietary intake of proteins cause hypoproteinuria, which lowers the intravascular oncotic pressure. Metabolic acidosis occurs because of the kidney’s inability to excrete hydrogen ions. Decrease reabsorption of sodium bicarbonate and decreased formation of dihydrogen phosphate and

ammonia

contribute

to

this

problem.

Acidosis

accentuates

hyperkalemia and the reabsorption of calcium from the bones.  Hematologic changes The primary hematologic effect of renal failure is anemia, usually normochromic and normocytic. It occurs because the kidneys are unable to produce erythropoietin, a hormone necessary for red blood cell production. Frequently, the fatigue, weakness, and cold intolerance accompanying the anemia lead to a diagnosis of renal failure.  Gastrointestinal changes The entire gastrointestinal system is affected. Transient anorexia, nausea, vomiting are almost universal. Clients often experience a constant bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or ammonia-like. Stomatitis, parotitis and gingivitis are common problems because of poor oral hygiene and the formation of ammonia from salivary urea. Accumulations of gastro may be a major cause of ulcer disease. Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be present. Serum amylase level may be increased, although they do not necessarily indicate pancreatitis.  Immunologic changes

23

Impairment of the immune system makes the client more susceptible to infection. Several factors are involved, including depression of humoral antibody formation, suppression of delayed hypersensitivity and decreased chemotactic function of leukocytes. Immunosuppression is an important part of the medical management of renal diseaes such as glomerulonephritis.  Cardiovascular changes The most common clinical manifestation is hypertension, produced through: mechanism of volume overload, stimulation of the renin-angiotensin system, sympatheically mediated vasoconstriction, absence of prostaglandins.  Respiratory changes Some of the respiratory effects such as pulmonary edema can be attributed to fluid overload. Metabolic acidosis causes a compensatory increase in respiratory rate as the lungs try to eliminate excess hydrogen ions.  Musculoskeletal changes The etiologic mechanism involves the kidney-bone-parathyroid and calcium-phosphate-vitamin D connections. As the GRF decreases, the phosphate excretion decreases and calcium elimination increases. Abnormal levels of calcium and phosphate stimulate the release of parathyroid hormone that mobilizes calcium from the bones and facilitates phosphate excretion.  Integumentary changes The skin is also often very dry because of atrophy of the sweat glands. Severe

and

intractable

pruritus

may

result

from

secondary

hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is evident.

V. The Patient and his Care A. Medical Management Medical Date General

Indication

Client’s

Client’s 24

Manageme nt

ordered Date performed

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

3.

Subclavian catheteriz ation

Ordered: 2/7/05 Performed: 2/7/05

Ordered: 2/3/05 4.Blood Transfusi on

Performed: 2/3/05

(s) Description Purpose (s) To maintain fluid balance of the pt.

A crystallized solution that is available in a variety of concentrat ed water and calories are provided. It is hypertonic solution containing equal amounts of Na and Cl A catheter tube is inserted into vein in either your neck, chest, leg or near the groin. It has two chambers to allow

initial reaction to the treatment Patient felt discomfort

response to the treatment Patient fluid status was maintained

Patient fluid status was maintained

To maintain fluid balance of the pt.

Patient experience d bleeding and felt discomfort on incision site

Patient did not show any further bleeding

Temporary access for hemodialy sis During the blood transfusion , patient was

Patient did manifest 25

two-way flow of blood

Ordered: 2/7,8,9/05 5. Hemodial ysis

Performed: 2/7,8,10/0 5

It is intravenou s replaceme nt of loss or destroyed blood compatible citrated human blood it is also the introductio n of whole blood or blood Componen t

Medical treatment used to promote excretion of wastes materials from the blood of patient.

To immediatel y restore blood volume to treat severe anemia, to be able to maintain oxygen transport to the different parts of the body

chilling for a short period of time. There was no further adverse reaction noted upon the transfusion

Patient was slightly nervous about the treatment .

some reaction such as chilling but there was not further reaction after the treatment

There was no adverse reaction noted during and after the procedure

It is indicated for the patient because the kidneys cannot function very well to excrete the nitrogenou s waste products, thus leading to its accumulati on in the blood.

Nursing Responsibilities 26

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 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 client’s weight d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension (unless ordered otherwise) During

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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

Amlodipi ne besylate •

norvas

Date ordered Date Taken Date changed or D/C

Route of admin. Dosage and freq. Of admin.

•

neoblo c

Client’s response to medication

Ordered: 2/3/05 Taken: 2/3-10/05

PO 5 mg OD

c

Metoprol ol tartate

General action

Indication (s) Purpose(s)

Ordered: 2/3/05 Taken: 2/3-10/05

PO 50 mg OD

Calcium antagonist, antihyperte nsive

Beta blockers, antihyperte nsive drug

To decrease increase blood pressure

To decrease increase blood pressure

Patient did not show any side effects

Patient did not show any side effects

Ordered:

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2/3/05 Iberetfolic acid

Taken: 2/3-10/05

Iron PO 1 cap

deficiency

BID

For patient having anemia

changed: 2/3/05

Patient’s stool was dark green in color

Ordered: 2/3/05 furosemi de •

Taken: 2/3-10/05

Diuretic PO 40 mg

For oliguric patient

OD

lasix

Patient did not show any side effects

Ordered: 2/3/05 Taken: 2/3-10/05 calcium carbonat e

PO 1 tab. D/C: 2/3/05

Calcium supplemen t

TID

To treat hypocalce mia

Patient did not show any side effects

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. Check vital signs to obtain baseline data. 2. Monitor BP

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3. Prepare the drug and the materials 4. Observe for initial assessment. 5. Observe for any initial response to the treatment. After: 1. Observe for any intolerance and side effects on the prescribed drug.

Type of diet

Date ordered Date started Date changed

DAT

Ordered: 2/3/05 Started: 2/3/05 Changed: 2/3/05

Low salt, low protein

Ordered: 2/3/05 Started: 2/3-10/05

General description

Any foods and fluids that are being tolerated by the patient

Foods that has low salt and protein value

Indication (s) Purpose (s)

Client’s response to the diet

To provide nutrients needed by the body

Patient followed the diet

To decrease further production of purine which can contribute in increasing level of creatinine in the blood

Patient strictly complied with the prescribed diet

Nursing Responsibilities Prior: 1. 2. 3. 4.

Check and determine the prescribed diet Inform the SO about the prescribed diet Explain the procedure and purpose of the prescribed diet Cite foods that are restricted.

During:

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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

Client’s 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 An AV fistula requires advance planning because a fistula takes a while after surgery to develop (in rare cases, as long as 24 months). But a properly formed fistula is less likely than other kinds of vascular accesses to form clots or become infected. Also, fistulas tend to last many years, longer than any other kind of vascular access.

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A surgeon creates an AV fistula by connecting an artery directly to a vein, usually in the forearm. Connecting the artery to the vein causes more blood flow into the vein. As a result, the vein grows larger and stronger, making repeated insertions for hemodialysis treatment easier. For the surgery, you will be given a local anesthetic. In most cases, the procedure can be performed on an outpatient basis. These fistulas require up to 6 weeks to mature before they can be used, which makes this approach inappropriate for immediate hemodialysis. Peritoneal dialysis or large venous access catheters may be used while the fistula is maturing. External arteriovenous shunts are rarely used.

C. Nursing management Actual SOAPIE February 3, 2005 S> “madali akong mapagod” O> received patient on semi-fowler’s 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

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>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 patient’s response to blood transfusion E >goal met as evidence by decreased in paleness and increased activity tolerance Actual SOAPIE February 08. 2005 S> 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

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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

VI. Patient’s Daily Progress in the Hospital A. Patient’s Daily Progress Chart (from admission to discharge) Days

Admissi on 2/3

Discharg

2

3

4

5

6

7

2/4

2/5

2/6

2/

2/8

2/9

2/10

* *

* *

* *

e

7 A. Nursing Problems 1. Altered tissue perfusion 2.Decreased cardiac output 3. Fluid volume excess 4. Fatigue 5. Activity Intolerance B. Vital Signs T RR PR

* * * * *

* * * * *

* *

* *

* *

*

* *

36

3

3

3

36

3

3

37

18 64

6.1 20 62

6.4 20 84

6.1 20 81

22 81

6.2 16 80

6.4 20 71

17 85

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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

150/

1

1

1

17

1

1

180/

90

60/

40/

70/

0/1

70/

60/

90

100

80

80

10

90

100

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B. Discharge Planning Mr. Scrooge was discharge last February 10, 2005, Upon discharged, Mr. Scrooge’s 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  Iberet+FA 1 tab BID  Ketosteril 1 tab TID after meals  Alutab 1 tab TID during meals  Furosemide 40 mg 1 tab OD for edema or oliguria 35

 Mucosolvan 1 tsp. TID  Augmentin 375 mg 1 tab TID  Nifedipine lozenges QID >For twice a week hemodialysis E>Bed rest T>proper wound care (subclavian and fistula) H>strict compliance to the medications and in hemodialysis O>follow-up check up on February 15, 2005 D>avoid foods rich in salt and protein >Limit fluid intake VII. Conclusion and Recommendations Chronic renal failure is an irreversible and progressive disease. It is cause by many factors. Knowing the precipitating factors leading to the development of this health problem, people should have an extra care when it comes to health. Giving care to a patient whether pediatric, geriatric, a medical case or surgical case makes no difference. Rendering care to everyone who needs it is a real sense of responsibility. In making this case study, I was able to work well because I know for myself that I did my best for my patient. We can say that nursing is significant therapeutic and dynamic process. It is therefore significant for the nurse caring for the patient to wholeheartedly understand what she is doing like in carrying out some basic skills in relation to identified goals, comfort and care, interventions and prevention of illness.

VIII. Bibliography Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company 36

Philadelphia Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation Springhouse, Pennsylvania Pagana (2002). Mosby’s Manual of Diagnostic and Laboratory Tests. MIMS. (2003) www.yahoo.com www.google.com

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