Introduction

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. II.

OBJECTIVES General objectives: This case study is designed for the student nurse to become practiced, knowledgeable and mannered in delivering holistic care for patients diagnosed with Chronic Renal Failure. Specific Objectives: Skills •

To demonstrate the vision/mission of the school which is service oriented, research motivated, technology enable and Vincentian inspired.

•

Imply appropriate medical nursing management for Chronic Renal Failure.

Knowledge •

Discuss the anatomy and physiology of the Renal system.

•

Define and familiarize Chronic Renal Failure.

•

Learn about major etiologic causes of Chronic Renal Failure.

•

Identify clinical manifestations and risk factors of Chronic Renal Failure.

•

Be familiar with the pathophysiology of Chronic Renal Failure.

•

Be acquainted with the different drugs, its actions, and perform obligatory nursing responses for each.

•

Plan for a suitable nursing care

Attitude •

Establish a nurse-patient interaction through exchanging of thoughts and information

•

Institute bond between the student nurse and the patient.

III.

ANATOMY AND PHYSIOLOGY: 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.

Kidneys The kidneys balance the urinary excretion of substances against the accumulation within the body through ingestion or production. Consequently, they are major controller of fluid and electrolyte homeostasis. The kidneys also have several non-excretory metabolic and endocrine functions, including blood pressure regulation, erythropoietin production, insulin degradation, prostaglandin synthesis, calcium and phosphorus regulation and Vitamin D metabolism. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen. On either side of the ventral column. They lie between the 12 th thoracic and third lumbar vertebrae. The left kidney is usually positioned slightly higher than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5 cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved shape, with a convex distal edge and a concave medial boundary. Ureters, Urinary Bladder and Urethra The ureters are small tubes that carry urine from the renal pelvis of the kidney to the posterior inferior portion of the urinary bladder. The urinary bladder is a hollow muscular container that lies in the pelvic cavity just posterior to the pubic symphysis. It functions to store urine, and its size depends on the quantity of urine present. The urinary bladder can hold from a few milliliters to a maximum of about 1000 mL of urine. When the urinary bladder reaches a volume of a few hundred mL, a reflex is activated, which causes the smooth muscle of the urinary bladder to contract and most of the urine flows out of the urinary bladder through urethra. The urethra is a tube that exits the urinary bladder inferiorly and anteriorly. The triangle-shaped portion of the urinary bladder located between the opening of the ureters and the opening of the urethra is called trigone. The urethra carries urine from the urinary bladder to the outside of the body. Renal Blood flow and Glomerular Filtration The kidney receive 20% to 25% of the cardiac output under resting conditions, averaging more than 1 L of arterial blood per minute. The renal arteries branch from the abdominal aorta at the level of he second lumbar 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.

IV.

VITAL INFORMATION: Name: RD Age: 63 y.o Sex: Female Address: Tapulang, Maayon Capiz Religion: Roman Catholic Occupation: Housewife-unemployed Date and time admitted: August 26, 2009; 3:30 pm Ward: Female Medical Ward Chief Complaints: Difficulty of breathing Impression/ Admitting Diagnosis: Chronic Renal Failure secondary to Hypertensive Nephrosclerosis. Final Diagnosis: Chronic Renal Failure secondary to Hypertensive Nephrosclerosis Attending Physician: Dr. R. Blancaver

V.

CLINICAL ASSESMENT A. Nursing History: Mrs. RD, has been complaining for body malaise and light headedness at home. Then 2 weeks prior to admission, she had a sudden onset of difficulty of breathing. Her family was so alarmed that they immediately consult for medical help and was admitted to Saint Anthony College Hospital, though the patient was even refusing to seek medical assistants since she is scared to be hospitalized. B. Past Health Problems/Status: Mrs. RD was a healthy person before her admission. Whenever she feels something’s not good about her health, she just ignores it, and prefers to take a rest than taking therapy. Her delivery for all 6 children was at home with a midwife’s help. Her family has a history of hypertension, and she happened to have one. She had her maintenance drug which she is not continually responding to. But on March 2009, she was convince to have a medical check-up in the city, and was later found out that she has Renal Failure. It is the first time that Mrs. RD, was admitted to a hospital.

C. Family History of Illness FAMILY GENOGRAM

SP

RD – HTN, Stroke

RD - Accident

- Old age

RD-73

RD68,HTN, CRF

RD-70

Legends: - Diseased

- Male

Produced offsprings - Female

- Pt

VI.

BRIEF SOCIAL, CULTURAL AND RELIGIOUS BACKGROUND Mr. RD is a 63-year-old female, married living at Tapulang, Maayon Capiz. She was born on October 10, 1945 in Maayon. She is married for 39 years now and has six children. She was not able to finish her studies since their family was not financially capable to send them to school. She is a dedicated Roman Catholic, who attends regular Sunday Mass, and prays novena and Rosary. Her favorite foods to eat are cooked vegetables and dried fishes. She usually stays at home and takes good care of her family instead being out and claims that she easily gets tired.

VII. CLINICAL INSPECTION A. Vital Signs Admitting V/S: BP= 100/70 mmHg

V/S taken during care: BP= 140/100 mmHg

CR=40 bpm

CR=57 bpm

RR=25 bpm

RR=24 bpm PR=60 bpm

T= 36OC

T=37.2OC B. Anthropometric Measurements: Height= 58 inches Weight= 42 kilos BMI= 19.309 C. Physical Assessment I. General Appearance Mrs. RD appears to be uncomfortable and weak. She is very conscious and coherent and even answers to questions attentively. She lies on the bed uncomfortably. She is not well groomed, has messy hair but has clean clothes. II. Skin, Hair and Nails Skin- pallor, brown in complexion, with good skin turgor. Hair- short, thin and coarse. Nail- long-uncut, dirty nails; pallor nailbed, with weak

capillary refill (approximately within 3 seconds). III. Head and Face

Head-no mass palpated. Skull is normocephalic. Face- both cheeks are swelling. IV. Eyes, Ears, Nose, Mouth and Throat Eyes-White sclera, pale conjunctiva, no discharges noted,

pupils are equally round and reactive to light and accommodation Ears- symmetrical, no discharges noted; acuity poor to whispered voice. Nose-nasal mucosa pink, no sinus tenderness; without flaring of

nostrils Mouth- with dry and pale lips V. Neck and Upper Extremities

Neck- no mass palpated, without lesions, no enlargement of lymph nodes and pain. Hands- has numerous bruises on both hands, mostly on forearms. VI.

Chest, Breast and Axilla Chest- is flat and symmetrical. Breast- no mass or lump palpated. Axilla-is clean and but with few hair.

VII.

Respiratory System Thorax is symmetric. Lungs are resonant. Breath sound vesicular. No crackles, no wheezes, no rales heard.

VIII.

Cardiovascular System Heart is bradycardia. No murmurs or any abnormal sound heard.

IX. Gastrointestinal System Abdomen is soft, flat, tender. X. Musculoskeletal System Poor range of motion in some joints. No evidences of swelling or deformity. D. General Appraisal I.

Speech

Speaks clear and coherent. II.

Language Uses Hiligaynon as language.

III.

Hearing Has poor hearing sense.

IV.

Mental Status Mentally

healthy,

very

conscious

and

responds

appropriately when asks. V. Emotional Status Emotionally weak. Shows signs of anxiety and fear at certain times.

VIII. LABORATORY AND DIAGNOSTIC DATA A. Hematology August 26, 2009 TEST

RESULT

NORMAL VALUES

SIGNIFICANCE

WBC

7.4 109/L

4.5-11.0

Normal

RBC

1.63 1012/L

RBC Male: 4.66.2 RBC Female: 4.2-5.4 Hgb Male:

Hemoglobin

46 g/L

135-180 Hgb Female: 120-160

Hematocrit

0.14 vol

Hct Male: 0.40-0.54

Results is below the normal level, thus indicating renal malfunction and thereby causing anemia Results is below the normal level, thus indicating renal malfunction and thereby causing anemia Result is below the normal range thus, showing anemia and renal

Hct Female: 0.37-0.47

disease

Neutrophils

73.0 %

50-70

High

Eosinophils

1.0 %

0-3

Normal

Basophils

0.0 %

0-1

Normal

Lymphocytes

25.0 %

25-30

Normal

Monocytes

0.0 %

0-8

Normal

Platelets

156 109/L

150-130

Normal

B. Urinalysis August 26, 2009 TEST Physical Exam: Color Transparency Macroscopic Exam: pH: Specific Gravity: Protein: Glucose: Microscopic Exam: Amorphous U/P RBC: WBC: Epithelial cells: Bacteria

RESULT

NORMAL VALUE

SIGNIFICANCE

4.5-8 1.005-1.035

Normal Normal

Pale straw Slightly Hazy 5.0 1.015 Positive (+) negative (-)

occasional 1-3 /hpf 15 % Few Occasional

0-2 0-5

Laboratory results revealed that there is presence of albumin; 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

C. ABG Analysis August 26, 2009 TEST pH pCO2

7.180 20.3

NORMAL VALUE 7.35-7.45 35-45 mmHg

pO2

141.5

80-100 mmHg

HCO3

7.3

22-26 mmol/L

TCO2

17.7

ABE

-20.1

SBE

-19.6

SBC

10.5

O2 Sat

RESULT

98.6 %

97-100 %

SIGNIFICANCE

Low pH value and low pCO2 but high value of pO2 and low value of HCO3 indicates METABOLIC ACIDOSIS. Normal

D. Cross Matching Result Slip August 27, 2009 Blood Type Serial no. Cross Matching Note Blood Type Serial no. Cross Matching Note

“O” Rh (+) # 006459, # 006461, # 016093 COMPATIBLE 450 cc, WB; secured at PNC “O” Rh (+) # 006460 COMPATIBLE 450 cc, WB; secured at PNC

IX. PATHOPHYSIOLOGY

XI.

NURSING MANAGEMENT CONCEPT MAP

XII. DISCHARGE PLANNING

On the night of August 27, 2009, Mrs. RD suffered from a sudden and severe seizure. Patient was restless. Due to complications that occurred from her disease…Mrs. RD passed away. Thus, the usual and accepted discharge plan format is inapplicable. Nonetheless, proper post-mortem care was done by Nurses on duty. Spiritual aides were given. She received holy communion and was anointed. Family was also instructed to give due Necrological service.

XII.

BIBLIOGRAPHY Websites:

♂www.pdfcoke.com ♂www.wikipedia.org ♂www.nursingcrib.com Books:

♀Karch, Amy M. Lippincott’s Nursing Drug Guide, 2009 ♀Braunwald, Eugene et al. Harrison’s Principle of Internal Medicine. 15th Ed. 2001

♀Doenges, et al. Nurse’s Pocket Guide. 10 ed. ♀Ackley, Betty J et al. Nursing Diagnosis Handbook. 7 ed.2006 ♀Muscari, Mary E. Lippincott’s Pediatric Nursing. 4 ed. 2005 ♀Huether, Sue E, et al. Understanding Pathophysiology. 2 th

th

th

nd

Ed.2009

♀Larsen,Hal. Diagnostic Test Made Incredibly Easy.2006 ♀MIMS 109 ed. 2006 th