Renal Failure...final

GOOD MORNING …

Chronic Kidney Disease secondary to Chronic Glomerulonephritis

General Objective The researchers want to gain knowledge about Chronic Renal Disease. It is important to researchers to have adequate knowledge about disease process, its signs and symptoms, risk factors and complications in order for the researchers to impart right information to the patients and for future profession.

Specific Objectives • To know the different risk factors that could lead to the development of the disease. • To know specific signs and symptoms of the disease and their causes in order to provide proper nursing interventions to the client. • To know the disease process and the affected parts in order to have proper health teachings to the client. • To know probable complications and their causes in order to prevent them.

Patient’s Profile • • • • • • • • •

Name: Mr. X Age: 34 y/o Sex: Male Status: Single Address: Sampaloc, Talisay Batangas Date of Admission: July 11,2009 Time of Admission: 4:51 pm Chief Complaint: Edema and Fever Attending Physician: Dr. Atienza and Dr. Martinez

Patient’s history • Two months prior to admission, patient had been complaining of edema, consultation has done and managed a care of nephrotic syndrome and complicated UTI. Until one week prior to consult patient was admitted at Daniel Mercado Hospital due to bipedal edema fever associated with difficulty of breathing and abdominal pain. Impression then has chronic renal disease and was advised of dialysis but due to financial constrains patient did not imply here. Consulted at OPD and was advised of admission.

History of Past Illness • Patient has no other illness since then.

History of Present Illness • Patient has fever and edema of lower extremities which has been the reason for his hospitalization.

• Family History He has a familial history of hypertension. • Patient is a 34 year old, barber in Saudi Arabia. • Non-smoker, non-drinker. • He has a preference in fatty and salty foods.

Chronic Kidney Disease • a condition of progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. • It involves the progressive loss of glomerular filtration, a process that can be slowed but is irreversible and eventually results in end stage kidney disease. The kidney cannot maintain metabolic, fluid and electrolyte balance, resulting in uremia and azotemia.

In the Philippines one of the leading causes of mortality and

morbidity ranked #10 among other diseases.

Stages of Chronic Kidney Disease GFR* mL/min/1.73m2

Stage

Description

1

Slight kidney damage with normal or increased filtration

More than 90

2

Mild decrease in kidney function

60-89

3

Moderate decrease in kidney function

30-59

4

Severe decrease in kidney function

15-29

5

Kidney failure requiring dialysis or transplantation

Less than 15

Risk Factors • Age >55 years old • Gender, common on men • Familial history of diabetes melitus and hypertension. • Nephrotoxins such as lead, mercury, chromium and cadmiun. • Sedentary lifestyle • Diet

LEADING Causes • diabetes mellitus (which is the leading cause) • pyelonephritis (inflammation of the renal pelvis) • obstruction of the urinary tract • hereditary lesions, as in polycystic kidney disease • vascular disorders; infections • medications or toxic agents.

• GLOMERULONEPHRITIS

Some of the patients who is diagnosed with CRF exhibits the following signs and symptoms: hypertension, pulmonary edema, pericarditis, pruritus (itching),anorexia, nausea, vomiting and hiccups. For instance, patient’s breath may have the odor of urine (uremic fetor): this condition is associated with inadequate dialysis.

Potential Complications • • • • • • • •

hyperkalemia pericarditis pericardial effusion pericardial tamponade hypertension anemia bone diseases metastatic and vascular calcifications.

Management • Conservative management • Dialysis • Kidney replacement

Review of System

BODY SYSTEM

METHOD OF ASSESSMENT

General Appearance

Inspection

Integumentary System

Inspection Palpation

FINDINGS •

ANALYSIS

Patient was observed lying on bed with heplock noted. Pale and weak in appearance. Appears confused most of the time

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Pallor

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Dry skin with pruritus

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Bipedal edema (grade II)

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Due to poor circulation and tissue perfusion Due to excessive accumulation of nitrogenous waste.

Due to blood loss and decreased hgb - 55 mg/dL Due to decreased activity of oil gland Due to water retention and increase permeability of membrane that results from shifting of fluids associated with renal failure

HEENT

Inspection Palpation

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Respiratory System

Inspection Palpation Percussion Auscultation

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Head is normal in size Hair is evenly distributed Eyes are equal rounded with both pupils reactive to light, pale conjunctiva Ears are symmetrical, each auricles aligned with the outer canthus of the eyes without any secretions Nose is symmetric and straight with no discharge or flaring Lips are pale and dry

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Indicates normal findings

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Due to blood loss and decreased hgb - 55 mg/dL

Symmetrical movement of • the chest upon breathing Respiratory rate- 19 cycles per minute With normal breath sounds

Indicates normal findings

Cardiovascular System

Palpation Auscultation

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Hypervolemia Blood pressure – 150/100 mmHg With intrajugular catheter at right intrajugular vein

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Due to fluid overload

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The catheter is a temporary access for hemodialysis

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Capillary refill test delayed by 5 seconds

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Delayed capillary refill due to blood loss and with hgb of 55 mg/dL

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Pulse rate – 95 beats per minute

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Circulatory System

Inspection Palpation

Gastrointestinal System

Inspection Auscultation Percussion Palpation

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Genitourinary System

Inspection Palpation

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• Anorexia • Nausea Gastrointestinal bleeding manifested by dark stools Abdominal distention and ascites – 107 cm Uremic Fector

Due to uremic toxins Bleeding is caused by uremia

• Decreased urine output; intake- 275 ml, output – 120 ml within 8 hours Proteinuria Decreased urine sodium

Damaged Nephrons

Musculoskeletal System

Inspection Palpation

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Hematopoietic System

Inspection

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• Decrease in muscle strength with a functional mobility of +2 Muscle cramps

Anemia Defects in platelet function thrombocytopenia

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Due to dietary restrictions

Due to reduced number of RBC

Anatomy and Physiology

The Kidney The kidneys are a pair of bean-shaped organs located below the ribs near the middle of the back. They are protected by three layers of connective tissue: the renal fascia (fibrous membrane) surrounds the kidney and binds the organ to the abdominal wall; the adipose capsule (layer of fat) cushions the kidney; and the renal capsule (fibrous sac) surrounds the kidney and protects it from trauma and infection.

Parts of the Kidney • • • • • •

Renal Vein carries blood away from the kidney and back to the right hand side of the heart. Renal Artery supplies blood to the kidney from the left hand side of the heart Pelvis is the region of the kidney where urine collects Ureter carries the urine down to the bladder Medulla is the inside part of the kidney Cortex is the outer part of the kidney

Functions of the Kidney • • • • • • • • • •

Urine formation Regulation of electrolytes Regulation of acid-base balance Control of water balance Renal clearance Secretions of prostaglandins Regulation of calcium and phosphorous balance Activates growth hormone Detoxify harmful substances (e.g., free radicals, drugs) Increase the absorption of calcium by producing calcitriol (form of vitamin D) • Produce erythropoietin (hormone that stimulates red blood cell production in the bone marrow) • Secrete renin (hormone that regulates blood pressure and electrolyte balance)

Blood Supply Each kidney receives its blood supply from the renal artery, two of which branch from the abdominal aorta. Upon entering the hilum of the kidney, the renal artery divides into smaller interlobar arteries situated between the renal papillae. At the outer medulla, the interlobar arteries branch into arcuate arteries, which course along the border between the renal medulla and cortex, giving off still smaller branches, the cortical radial arteries (sometimes called interlobular arteries). Branching off these cortical arteries are the afferent arterioles supplying the glomerular capillaries, which drain into efferent arterioles. Efferent arterioles divide into peritubular capillaries that provide an extensive blood supply to the cortex. Blood from these capillaries collects in renal venules and leaves the kidney via the renal vein. Efferent arterioles of glomeruli closest to the medulla (those that belong to juxtamedullary nephrons) send branches into the medulla, forming the vasa recta. Blood supply is intimately linked to blood pressure

Renal artery → Interlobar arteries → Arcuate arteries →

Cortical radial arteries → Afferent arterioles →

Glomerulus → Efferent arterioles → Vasa recta →

Arcuate vein → Renal vein

The Nephrons • Functional and structural unit of the kidney • Each kidney has over one million nephrons Two types of Nephron 1. Cortical Nephron (80-85%) located at outermost part of cortex 2. Juxtamedullary Nephron distinguished by long loops of henle

Parts of the Nephron • The afferent arteriole receives blood rich in oxygen from the renal artery. • The glomerulus is a knotted up capillary that contains small pores. • The efferent arteriole is smaller in diameter than the afferent arteriole and increases the pressure in the glomerulus aiding pressure filtration • Bowman's capsule collects the filtrate • Proximal Convoluted Tubule has a brush border with many villi to increase the surface area for selective reabsorption. • Loop of Henle dips down into the hypertonic environment of the kidney medulla and is responsible for the reabsorption of water from the filtrate • Distal Convoluted Tubule is the site of tubular secretion • Peritubular Capillary Network acts as the blood supply to the nephron. • Collecting duct receives filtrate from several nephrons.

Functions of the Nephron • Filtration • Reabsorption • Secretion

URINE FORMATION Three processes occurring in successive portions of the nephron accomplish the function of urine formation: • Filtration of water and dissolved substances out of the blood in the glomeruli and into Bowman's capsule; • Reabsorption of water and dissolved substances out of the kidney tubules back into the blood (note that this process prevents substances needed by the body from being lost in the urine); • Secretion of hydrogen ions (H+), potassium ions (K+), ammonia (NH3), and certain drugs out of the blood and into the kidney tubules, where they are eventually eliminated in the urine.

Pathophysiology

Body system Manifestation In Chronic Kidney Disease

BODY SYSTEM

CAUSES

SIGNS AND SYMPTOMS

ASSESSMENT PARAMETERS

HEMATOPOETIC

•SUPPRESSION OF RBC PRODUCTION •DECREASED SURVIVAL TIME OF RBC. •BLOOD LOSS THROUGH BLEEDING AND DIALYSIS •MILD THROMBOCYTOPENIA •DECREASED ACTIVITY OF PLATELET

•ANEMIA •LEUKOCYTOSIS •DEFECTS IN PLATELET FUNCTION •TROMBOCYTOPENIA

•HEMATOCRIT •HEMOGLOBIN •PLATELET COUNT •OBSERVE BRUISING, AND OTHER SIGNS AND SYMPTOMS OF BLEEDING

CARDIOVASCULAR

•FLUID OVERLOAD •RENIN-ANGIOTENSIN MECHANISM •ANEMIA •CHRONIC HYPERTENSION •CALCIFICATION OF SOFT TISSUES •UREMIC TOXINS IN PERICARDIAL FLUID •FIBRIN FORMATION ON EPICARDIUM

•HYPERVOLEMIA •HYPERTENSION •TACHYCARDIA •ARRYTHMIAS •CONGESTIVE HEART FAILURE •PERICARDITIS

•VITAL SIGNS •BODY WEIGHT •ECG •HEART SOUNDS •MONITOR ELECTROLYTES •ASSESS FOR PAIN

GASTROINTESTINAL

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NEUROLOGIC

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CHANGES IN PLATELET ACTIVITY SERUM UREMIC ACID ELECTROLYTE IMBALANCE UREA COVERTED TO AMMONIA BY SALIVA

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UREMIC TOXINS ELECTROLYTE IMBALANCES CEREBRAL SWELLING RESULTING FROM FLUID SHIFTING

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ANOREXIA NAUSEA AND VOMITING GASTROINTESTIN AL BLEEDING ABDOMINAL DISTENSION DIARRHEA CONSTIPATION UREMIC FECTOR

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LETHARGY CONFUSION CONVULSION STUPOR COMA SLEEP DISTURBANCE UNUSUAL BEHAVIOR ASTERIXIS MUSCLE IRRITABILITY

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MONITOR INTAKE AND OUTPUT HEMATOCRIT HEMOGLOBIN GUALAC TEST FOR STOOLS ASSESS THE QUALITY OF STOOLS ASSESS FOR ABDOMINAL PAIN LEVEL OF ORIENTATION LEVEL OF CONSCIOUSNESS REFLEXES EEG ELECTROLYTE LEVEL

MUSCULOSKELETAL

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SKIN

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UREMIC TOXINS DECREASED CALCIUM ABSORPTION DECREASED PHOSPHATE EXCRETION

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MUSCLE CRAMPS LOSS OF MUSCLE STRENGTH RENAL OSTEODYSTROPHY RENAL RICKETS BONE PAIN BONE FRACTURES

ANEMIA PIGMENT RETAINED DECREASED ACTIVITY OF OIL GLAND DECREASED SIZE OF SWEAT GLAND PHOSPHATE DEPOSIT

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PALLOR PIGMENTATION PRURITUS ECCYMOSIS EXCORIATION UREMIC FROST DRY SKIN

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ELECTROLYTE LEVEL REFLEXES PAIN ASSESSMENT

OBSERVE FOR BRUISING ASSESS SKIN COLOR ASSESS SKIN INTEGRITY OBSERVE FOR SCRATCHING

GENITOURINARY

•DAMAGED NEPHRONS

REPRODUCTIVE •HORMONAL ABNORMALITIES •ANEMIA •HYPERTENSION •MALNUTRTITION •MEDICATIONS

•DECREASED URINE OUTPUT •DECREASED URINE SPECIFIC GRAVITY •PROTEINURIA •CAST AND CELLS IN URINE •DECREASED URINE SODIUM

•MONITOR INTAKE AND OUTPUT •SERUM CREATININE •BUN •SERUM ELECTROLYTES •URINE SPECIFIC GRAVITY •URINE ELECTROLYTES

•INFERTILITY •DECREASED LIBIDO •IMPOTENCE •AMENORRHEA •DELAYED PUBERTY

•MONITOR INTAKE AND OUTPUT •MONITOR VITAL SIGNS •HEMATOCRIT •HEMOGLOBIN

Laboratory Results

Hematology(July 18, 2009) Actual Value

Normal Values

Significance

Hematocrit

0.16

0.42-0.52 %

Result is below normal. Decrease in level of hematocrit signifies anemia. This is cause by impaired production of erythropoietin in the kidney. Erythropoietin stimulates bone marrow to produce RBC.

Hemoglobin

55

140-170

Result is below normal. Decrease in lnumber of hemoglobin signifies anemia

RBC

1.88

4.0-6.0 x 10

Result is below normal. Decrease in number of RBC signifies anemia. This is cause by impaired production of erythropoietin in the kidney. Erythropoietin stimulates bone marrow to produce RBC.

WBC

8.9

5.0-10.0

The result is normal. No current infection.

Platelet count

142,000

150,000-350,000

Result is below normal. Decrease in number of platelets signifies risk for bleeding. This is due to excessive nitrogenous waste in the blood.

Diferrential count

Neutrophils

0.85

0.55-0.65%

Result is above normal. This indicates the presence of bone marrow suppression.

Lympocytes

0.15

0.25-0.35%

Result is below normal. This indicates the presence of bone marrow suppression.

Eosinophils

0.00

0.02-0.04%

Result is below normal. This indicates the presence of bone marrow suppression.

Interpretation The kidney produce erythropoietin the stimulates bone marrow to produce red blood cells that increase hemoglobin and hematocrit.

In chronic kidney disease, the production of erythropoietin is impaired thus decreasing the ability of the bone marrow to produce red blood cells and decreasing the number of hemoglobin and the hematocrit level resulting to anemia. There was bone marrow suppression thereby increasing the neutrophils while lympocytes and eosinophils decrease because of anemia

Blood Chemistry (July 18, 2009) TEST

RESULT

NORMAL RANGE

Significance

Creatinine

2,482.40

62.00-133.00

The result is above normal. The result shows that kidneys cannot excrete nitrogenous wastes.

Sodium

155.4

135-148

The result is above normal. The result shows the inability of the kidneys to maintain the homeostasis of the internal environment of the body.

Potassium

5.93

3.5-5.5

The result is above normal. The result shows the inability of the kidneys to maintain the homeostasis of the internal environment of the body

Phosphorous

10.8

2.5-4.5

The result is above normal. The result shows the inability of the kidneys to maintain the homeostasis of the internal environment of the body

Calcium

1.08

1.12-1.32

The result is below normal. The result shows the inability of the kidneys to maintain the homeostasis of the internal environment of the body

Interpretation Creatinine is a break-down product of creatine phosphate and a nitrogenous waste.Creatinine is excreted mainly in the urine. In CKD, excretion of the nitrogenous wastes is impaired thus resulting in an increase in level of nitrogenous wastes like creatinine.

Increased serum level of the sodium, phosphorous and potassium is caused by loss of excretory renal function. The impaired conversion of the vitamin d to its active form causes the decreased serum level of calcium which then causes the increased serum level of phosphorous. Hyperparathyroidism also causes the decreased level of the calcium.

Urinalysis (July 18, 2009) Result

Significance

Physical Color

Light Yellow

Normal.

ph

5.0

Normal

Transparency

Turbid

The result is abnormal. The urine contains bacteria, cells, sugar traces and albumin that contribute to the transparency of it.

Specific Gravity

1.020

Normal

Albumin

+++

The result is abnormal. The result shows that the nephrons are failing to filter protein in the glomerulus.

Sugar

Trace

The result is abnormal. The result shows that the nephrons are failing to reabsorb glucose in the tubules.

Pus cells RBC Epithelial cells Bacteria

4-6/hpf 0-2/hpf Many Few

The result is abnormal. The result shows that the functions of the nephrons are Impaired.

Interpretation The increased permeability of the capillary causes the excessive passage of protein in the urine. The impaired tubular reabsorption of glucose causes the traces of sugar in the urine. The transparency of the urine is turbid. There are many substances that causes the turbidity of it.

Ultrasound Impression: • Normal size kidneys with Renal parenchymal Disease. • Normal size prostate gland with concretions. • Minimal ascites. • Normal liver, spleen, pancreas, and aorta. • Gall bladder polyp. The result from the ultrasound of the whole abdomen shows that there is a renal disease that causes some abnormalities in the different systems of the body. Excessive accumulation of nitrogenous waste in the body is one effect of the renal desease. These nitrogenous waste irritates mucosal lining that causes gastrointestinal bleeding and minimal ascites.

Medical and Surgical Management

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Medical Mangement Hemodialysis Hemodialysis is a method for removing waste products such as potassium and urea, as well as free water from the blood when the kidneys are in renal failure. The principle of hemodialysis is the same as other methods of dialysis; it involves diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes counter current flow , where the dialysate is flowing in the opposite direction to blood flow in the extracorporeal circuit. Counter-current flow maintains the concentration gradient across the membrane at a maximum and increases the efficiency of the dialysis. Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of the dialysate compartment, causing free water and some dissolved solutes to move across the membrane along a created pressure gradient. The dialysis solution that is used is a sterilized solution of mineral ions. Urea and other waste products, potassium, and phosphate diffuse into the dialysis solution. However, concentrations of sodium and chloride are similar to those of normal plasma to prevent loss. Sodium bicarbonate is added in a higher concentration than plasma to correct blood acidity. A small amount of glucose is also commonly used. Side effects caused by removing too much fluid and/or removing fluid too rapidly include low blood pressure, fatigue, chest pains, leg-cramps, nausea and headaches. These symptoms can occur during the treatment and can persist post treatment; they are sometimes collectively referred to as the dialysis hangover or dialysis washout.

• Surgical Management • Intrajugular catheter An intrajugular catheter is surgically inserted at right intrajugular vein last July 20, 2009. It is a temporary access for hemodialysis and it is functional for 4 to 6 weeks.

Nursing Care Management

ASSESSMENT

Subjective: “Nanghihina ako “, as verbalized. Objective:  Pale and weak in appearance  Dry skin  Capillary refill time 5 seconds  ( +) abdominal distention 107 cm.  Confuse most of the time  RBC- 1.88 Normal 4-6x10/L  Hemoglobin- 55 Normal 140170g/dl  IJ catheter @ intrajugular vein, dry and intact.  V/S: BP- 150/100mmHg PR-85bpm

NURSING DIAGNOSES

Ineffective Tissue Perfusion related to Inadequate oxygen carrying capacity of the blood as evidenced by decrease hemoglobin, RBC, as revealed by laboratory result.

PLANNING After 8 hrs of nursing interventio ns the patient will be able to demonstrat e behavioral lifestyle change to improve circulation.

IMPLEMENTATION 

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Provided for diet restrictions, as indicated, while providing adequate calories to meet the body’s needs. Restrictions of protein help limit BUN. Encouraged client to eat rich in Iron but except fatty and salty foods. Provided psychological report for client especially when progression of the disease and resultant of treatment (dialysis) may be long term. Encouraged quiet, restful atmosphere conserves energy/ lower tissue oxygen demand. Maintained head and neck in midline or neutral position to promote circulation/ venous drainage. Encouraged use of relaxation activities and exercises techniques to decrease tension level. Encouraged early ambulation to enhances venous return. Noted mentation it may be altered by increase creatinine.

EVALUATION After 8 hrs of nursing intervention s the patient was able to demonstrate behavioral lifestyle change to improve circulation

ASSESSMENT

S: “Masakit ang

opera ko sa leeg” as verbalized O:  weak  (+) facial grimace P- With IJ catheter inserted at right intrajugular vein, dry and intact Q- Lancenating pain R- Pain is localized in neck S- score of 8 on pain scale T- started last night as reported (July 20, 2009)  V/S: • T- 36.5C • P- 85bpm • R- 18cpm

NURSING DIAGNOSIS

PLANNING

Pain related to surgical incision as evidenced by verbal report

After 6 hours of nursing intervention the patient will be able to report that pain is relieve and control

INTERVENTIONS/RATIONALE

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Performed comprehensive assessment of pain to include location, characteristics, onset frequency, duration, quality, severity to assess etiology or precipitating contributory factors Monitored vital signs for baseline data Performed pain assessment each time pain occurs. Note and investigate changes from previous reports to rule out worsening of underlying condition Assessed for referred pain as appropriate to evaluate client’s response to pain Provided comfort measures, quiet environment and calm activities to promote non- pharmacological pain management Encouraged adequate rest period to prevent fatigue Encouraged diversional activities to assist client to explore

EVALUATION After 6 hours of nursing intervention the patient reported that pain is relieved and controlled as evidenced by pain scale of 3

ASSESSMENT

Subjective: “Medyo nangangati ang binti ko“, as verbalized. Objective:  Pale and weak in appearance  The skin is flaky  Poor skin turgor  Generalized dryness of the skin  With bipedal edema grade II  Serum Creatinine 2,482.40 Normal 62.00133.00 umol  Normal size kidneys with

NURSING DIAGNOSES

Impaired skin integrity related to Impaired Metabolic state as evidenced by pruritus.

PLANNING

After 8 hrs of nursing interventions the patient will be able to demonstrate behaviors techniques to prevent skin breakdown.

IMPLEMENTATION

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Noted presence of conditions/ situations that may impair skin integrity. Handled client gently and stretching of linens regularly to maintain skin integrity. Provided protection by use of pads, pillows foam mattress to increase circulation and tissue perfusion. Limited or avoided of plastic materials and removed wet/ wrinkled linens. Moisture potentiates skin breakdown Suggested use of ice, colloidal bath, and lotions to decrease irritable itching. Recommended keeping nails short to reduce risk for dermal injury when sever itching is present. Recommended elevation of lower extremities when sitting to enhance venous return and reduce edema formation. Instructed client low salt, low fat diet.

EVALUATION

After 8 hrs of nursing interventions the patient was able to demonstrate behaviors techniques to prevent skin breakdown as evidenced by keeping the nails short and elevating lower extremities and using of pads.

ASSESSMENT

S: “Namamanas ang mga paa ko” as verbalized O: (+) pitting bipedal edema Grade II Intake greater than output •Intake- 275ml •Output- 120ml Lab Result •Serum Creatinine2,482.40 (62-133N) •Na- 155.4 (1351448N) •K- 5.93 (3.5-5.5N) •Ca- 1.08 (1.121.32N) •Phosphorous- 10.8 (2.5-4.5N) V/S:

NURSING DIAGNOSIS

PLANNING

INTERVENTIONS/RATIONALE

EVALUATION

Excess fluid volume related to compromised regulatory mechanism as evidenced by edema

After 4 hours of nursing intervention the patient will be able to verbalize understanding of individual dietary and fluid restrictions

Noted presence of medical condition that potentiate fluid excess to assess causative or precipitating factors Noted presence of edema to evaluate degree of excess Restricted sodium and fluid intake to promote mobilization and elimination of excess fluid Recorded I&O accurately for baseline data Evaluated edematous extremities, change in position frequently to reduce tissue pressure and risk of skin breakdown Set an appropriate rate of fluid intake throughout 24-hour period to prevent peaks in fluid level Reviewed dietary restrictions and safe substitutes for salt to promote wellness Reviewed laboratory data to evaluate degree of fluid and electrolyte imbalance Administered medications as ordered

After 4 hours of nursing intervention the patient verbalized understanding of individual dietary and fluid restrictions “hindi na ako masyadong kakain ng maalat at lilimitahan ko na ang pag inom ng tubig” as verbalized

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

O:  Confused most of the time  Weak in appearance  Lab Result • Serum Creatinine2,482.40 (62133N) • Hct- 0.16 (0.420.52%N) • Hgb- 55 (140170N) • RBC- 1.88 (4.06.0x10N)  V/S: • 36.5C • P- 95bpm • R- 18cpm • Bp-150/100mmHg

Risk for Injury related to altered peripheral tissue perfusion.

After 8 hours of nursing interventio n the patient will not experience injury

INTERVENTIONS/ RATIONALE 

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Ascertained knowledge of safety needs/ injury prevention and motivation to prevent injury in home, community, and work setting. Assessed muscle strength, gross and fine motor coordination to identify risk for falls. Provided information regarding disease/ condition that may result in increased risk of injury. Encouraged to eat foods rich in iron except salty and fatty foods. Encouraged adequate rest to prevent fatigue and injury. Assisted when going to comfort room. Provided protection by use of pads, pillows, foam, mattress to increase circulation and tissue perfusion

EVALUATION After 8 hours of nursing intervention the patient did not experience injury

ASSESSMENT

Objective:  Hemoglobin55 Normal 140-170 g/dl  WBC 8.9 Normal 5.010.0 x10/L  Serum Creatinine 2,482.40 Normal 62.00133.00 umol  IJ catheter @ intrajugular vein, dry and intact.  V/S: BP150/100mmH g PR-85bpm RR-19cpm T- 36.5◦C Normal M (140-

NURSING DIAGNOSES

Risk for Infection related to excessive nitrogenous waste and inadequate secondary defenses.

PLANNING After 8 hrs of nursing interventio ns the patient will be able to identify interventio ns to prevent/ reduce risk for infections.

IMPLEMENTATION 

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Assessed laboratory results for infections such as (elevated WBC and positive blood cultures) to prevent and treat infections. Assessed temperature, respiratory and urinary system changes as disease progress to provide information about presence of infection caused by progressive chronic disease and effect on system. Advised proper hygiene by all caregivers between therapies/ clients. A first line defense against healthcare associated infections. Handled client gently and stretching of linens regularly to maintain skin integrity. Covered with sterile dressings and protect the sites to prevent contamination. Cleansed incisions / insertion sites per facility protocol with appropriate solution to reduce potential for catheter related blood stream infections. Instructed client low salt, low fat diet.

EVALUATION The patient was able to identify intervention s to prevent/ reduce risk for infections after 8 hours

Name of Drugs

Action

Indication

Contraindication

Adverse Reaction

Spironolactone (Aldactone)

Antagonizes Aldosterone in the distal tubules, Increasing Na and water excretion

Short term pre-operative treatment of primary hyperaldosteronim long term, maintenance therapy for idiopathic hyperaldosteronis m manage of essential hypertensionand management of edematous condition.

Acute renal insufficiency, anuria, and hyperkalemia.

Gynecomastia,

Classification Diuretics

Agranulocytosis, headache, drowsiness, lethargy, GI disturbance, Inability to achieve or maintain erection.

Nursing consideration ►Obtain baseline data before initiation of therapy such as V/S, degree of edema present and laboratory studies. ►Monitor for manifestation of hyperkalemia; MS; fatigue, muscle weakness; CV: arrhytmias, hypotension, Neuro: parethesias, confusion, Resp.: dyspnea. ►Assess fluid volume status: I & O ratios and record, count or weight diapers as appropriate, weight, distended red veins, crackles in lung, color, quality, and specific gravity of urine, skin turgor, moist mucous membranes should be reported. ►Monitor electrolytes: K,

Name of Drugs

Sodium Bicarbonate (Na acid carbonate) Classification Fluid electrolytes

Action

Indication

Contraindication

Adverse Reaction

Increase bicarbonate, which excess buffers H ion concentrations, reverse metabolic acidosis, neutralizes gastric acid, which forms hydrogen, NaCL, and raises blood pH.

Treatment for metabolic acidosis; promotion of gastric and urine alkalinizati on in the case of ion toxication with weak organic acids.

Hypoventilation, hypocalcemia, further in all situations where Na intake must be restricted like cardiac insufficiency, edema, hypertension, severe kidney insufficiency.

Hypernatraemia and serum hyperosmolarity.

Nursing consideration ►Obtain patient history, including drug history and any hypersensitivity ►Assess respiratory and pulse rate, rhythm, depth, lung sounds. ►Monitor fluid balance (I&O ratio, edema) notify physician of fluid overload. ►Monitor for manifestation by hyponatermia: increase BP, cold, clammy skin, anorexia nausea and vomiting. ►If the patient is vomiting withhold medication and immediately inform physician.

Name of Drugs

Nifedipine (Calciblock) Classification Antagonist

Action Inhibits calcium ion influx across cell membrane during cardiac depolarization, produces relaxation of coronary and peripheral vascular muscle and it dilates coronary vascular arteries.

Indication

Contraindication

Treatment of vasospastic angina, chronic stable angina, hypertension.

Hypersensitivity, immediate release nifedipine contraindicated in unstable angina and after recent MI, severe aortic stenosis, severe hypotension and decompensate heart failure.

Adverse Reaction Dizziness, flushing, headache, hypotension, peripheral edema, tachycardia and palpitations. Nausea and other GI disturbance, rashes, pain, fever and abnormalities liver function.

Nursing consideration ►Monitor BP, pulse before therapy. ►Assess therapeutic effectiveness and adverse reaction ►Assess knowledge and teach patient proper use of the medication; possible side effects and adverse symptoms to report. ►Observe for the 12 rights in administering medication.

Name of Drugs

Action

Etoricoxid (Arcoxia)

Inhibits prostaglandin synthesis by decreasing enzymes.

Classification Analgesic

Indication Relief of acute pain.

Contraindication Active peptic ulceration. Patient experienced bronchospasm , nasal polyps, acute rhinitis, angioneurotic edema. Patient with hypertension, established ischemic heart disease and cerebrovascul ar disorders.

Adverse Reaction Immune system disorders, nervous system, cardiac, respiratory, skin, renal and urinary disorders.

Nursing consideration ►Assess for pain of inflammation, characteristi cs of pain. ►Monitor blood counts before therapy ►Assess for hypersensitivi ty to medication. ►Monitor kidney Observe for the 12 rights in administering medication.an d liver function tests.

Name of Drugs

Action

Indication

Contraindication

Adverse Reaction

Clonidine (Catapres)

Stimulates central alpha Adrenergic receptors to Inhibit Sympathetic Cardio accelerator and vasoconstrictor center.

Management of all grades of hypertension with the expectation of hypertension due to phaeochromo cytoma

Hypersensitivity to Clonidine, sick syndrome.

Local skin irritation, drowsiness, dry mouth, dizziness, headache. Anxiety fatigue sleep disturbances, urinary retention, burning and itching sensation of eye.

Classification Antihypertensive

Nursing consideration ►Perform blood studies ►Assess BP before medication ►Monitor baseline for renal, liver function before medication. ►Observe for the 12 rights in administering medication.

Name of Drugs

Action

Calcium Carbonate (Calci-aid)

Decrease total acid load of GI tract. Increase esophageal sphincter tone, strengthens gastric mucosal barrier and reduce pepsin activity by elevating gastric pH.

Classification Antacid

Indication Antacid, calcium supplement, osteoporosis and hyperthyroidism.

Contraindication

Adverse Reaction

Hypercalcemia, bone tumors, severe renal failure,.

Constipation, inflatulence, diarrhea, renal dysfunction, acid rebound.

Nursing consideration ►Assess for adverse reaction ►Assess for hypercalcemia ►Advice to increase fluid intake. ►Observe for the 12 rights in administering medication.