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I. INTRODUCTION
The researcher’s exposure to the hemodialysis area last June 2005
led her to be more interested in choosing Chronic Renal Failure for her
study. A great number of population in the United States, Africa and as
well as in the Philippines are diagnosed with CRF and these people
diagnosed with this disease are also fighting and surviving with the help
of functioning transplant or through the scheduling usage of different
hemodialysis or peritoneal dialysis that helps each one of them fight this
lifetime.
As a nursing student and a future nurse in a year or less, it
is her responsibility to give efficient and effective care to her future
patients and through this study, it will give the researcher’s view a
broader knowledge and development of skills and attitude in caring for
patients especially those with CRF regardless of age if ever assigned in
the same situation in the future.
After this case study, the researcher expects to gain more facts
about the care of patients with CRF and be well understood about its
occurrence, how it affects the people, how it’s treated and prevented and
through this her knowledge will be shared to CRF patients and to their
significant others so that negative misconceptions about the disease will
be erased. This case study would allow both the researcher and clients
be well educated more as proper knowledge will pave way to a more
effective holistic care.
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Chronic renal failure is a slow insidious process of kidney
destruction. It may go unrecognized for years as nephron units are
destroyed and renal mass is reduced. When the kidneys are no longer
able to excrete metabolic wastes and regulate fluid and electrolyte
balance adequately, the client is said to have (ESRD) End stage renal
disease, the final stage of CRF.
End stage renal disease is increasing in incidence in all age
groups, with a particularly sharp increase in people over age 70. The
incidence if ESRD is highest in African Americans, followed by Native
americans. Diabetic nephropathy and hypertension are the leading
causes of chronic renal failure in the United States. Among African
Americans, hypertension is the leading cause.
The causes of CRF are numerous. Chronic glomerulonephritis,
ARF, polycystic kidney disease, obstruction, repeated episodes of
pyelonephritis, and nephrotoxins are examples of causes. Systemic
diseases, such as diabetes mellitus, hypertension, lupus erythematous,
polyarteritis, sickle cell disease and amyloidosis, may produce CRF.
Diabetes is the leading cause and accounts for more than 30% of clients
who receive dialysis. Hypertension is the second leading cause of CRF.
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II. OBJECTIVES
Student nurse-centered:
After 2 days of SN-patient car, the student-nurse will be able to:
1. discuss chronic renal s as to its:
1.1 definition
1.2
clinical manifestations
1.3
pathophysiology
1.4
disease process and effects of different organ systems
2. identify actual and potential problems of patients with CRF
3. provide the appropriate nursing care according to identified
problems anticipate the client’s needs essential to treatment
4. impart healthy teachings to patient and SO which are helpful for
patients care encourage client to participate in planned activities
and treatment regimen
5.. explain to patient and SO the importance of drug compliance
6. teach the client as well as the significant others ways to be free
from risks of infections
7. state to client the proper intake of meal and snacks given to
him
8. instruct to client the advantages of proper weight monitoring
9. impart health teachings to the client and the significant others
towards health promotion
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Patient-centered:
After 2 days of SN-patient care, the patient will be able to:
1. define CRF
2. cite clinical and classical manifestations of CRF
3. share with the SN the physiologic and psychologic problems
being encountered
4. participate in the SN plan of activities
5. adheres to treatment regimen as evidenced by taking
medications as prescribed
7. perform measures to prevent risks for infection
8. relate the importance of overall health measures (proper aseptic
technique, daily weight monitoring, adequate nutritional intake)
9. apply to daily life the things learned, gained during the client’s
hospitalization
10. demonstrate health promotion behaviors
III. NURSING ASSESSMENT
1. Personal history
1.1.
Patient’s profile
Name : Roberto Sumabong Abello
Age: 32 years old
Sex: Male
Civil status: married
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Religion: Roman Catholic
Date of Admission: June 24, 2005
Room no: M26
Complaints: fever, vomiting, loss of appetite
Impression or Diagnosis: ESRD 2º to CGN/ CRF 2º to CGN
Physician: Dr.L. Garcia; Dr. K. Licuanan; Dr. Arn. Tan
1.2
Family and individual information, social and health
history
Mr. Abello has two daughters back in Bohol who are now
currently staying with his parents. He is married to a very
caring lady, Mrs. Jenalyn Abello who stays with him in the
hospital. Mr. Abello was an alcohol drinker that could
consume about 1 Tanduay Jr. every night. He recently
stopped a month ago before admitted to Cebu Doctors’
University Hospital due to undesirable health condition felt.
1.3 Level of Growth and Development
1.3.1 Normal development at particular stage
The patient is a middle adult. In middle
adulthood,
the
individual
makes
through involvement with others.
lasting
contributions
During this period,
personal and career achievements have often already been
experienced. Many middle adults find particular joy in
assisting their children and other young people to become
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productive and responsible adults. They may also begin to
help aging parents. Using leisure time in satisfying and
creative ways is a challenge that, if met satisfactorily,
enables middle adults to prepare for retirement.
Men and women must adjust to inevitable biological
changes. As in adolescence, middle adults use considerable
energy to adapt self- concept and body image to physiological
realities and changes in physical appearance. High selfesteem, a favorable body image, and a positive attitude
toward physiological changes are fostered when adults
engage in physical exercise, balanced diets, adequate sleep,
and good hygiene practices that promote vigorous, healthy
bodies
The psychosocial changes in the middle adult may
involve expected events, such as children moving away from
home, or unexpected events, such as marital separation.
These changes may result in stress that can affect the
middle adult’s overall level of health.
In the middle adult years, as children depart
from the household, the family enters the postparental
family stage. Time and financial demands on the parents
decrease, and the couple faces the task of redefining their
own relationship.
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According to Erikson’s developmental theory, the
primary developmental task of the middle years is to achieve
generativity. Generativity is the willingness to care for and
guide others. If middle adults fail to achieve generativity,
stagnation occurs. This is shown by excessive concern with
themselves or destructive behavior toward their children and
the community.
1.3.2 The ill person at particular stage
Illness in middle adulthood, however may take a
longer recovery period because of the slowing of recuperative
processes. As well, acute illness in middle adulthood are
more likely to become chronic conditions. For those middle
adults who are in the “sandwich generation”, stress levels
may also increase as the middle adult tries to balance
responsibilities related to employment and family life.
The client is able to accept his condition as well as its
treatment. He complies to the medical advice given to her
but is also concerned with her physical outcome and her
family condition and status as well.
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2. Diagnostic Results
DIAGNOSTIC
TESTS
NORMAL
VALUE
June 25, 2005
Glucose
99mg/dl
Urea
120Mg/dl
nitrogen
Creatinine
22.6mg/dl
Uric acid
11.9Mg/dl
Sodium
125mmol/dl
Potassium
2.9mmol/dl
Chloride
85mmol/dl
Enzymatic
16mmol/dl
CO2
Calcium
6.3mg/dl
Phosphorus 13mg/dl
Cholesterol
78mg/dl
Triglycerides 215mg/dl
ULOL
43mg/dl
Total protein 7.6g/dl
Albumin
4.1g/dl
A/G ratio
1.2
Globumin
3.5g/dl
AST
45u/L
ALT
48u/L
ALKP
74u/L
URINALYSIS
EXAM
Color
Appearance
Reaction
Specific
gravity
Protein
Glucose
Ketones
Blood
Leukocytes
Nitrite
RESULT
SIGNIFICANCE
65-110
7-20
Normal
Increased
.7-1.5
2.5-7.5
137-145
3.6-5
98-107
22-30
Increased
Increased
Decreased
Decreased
Decreased
Decreased
8.4-10.2
2.5-4.5
131-239
0-250
0-40
6-8
3.3-5.5
1.2-2.2
2.3-3.5
15-46
11-66
38-126
Decreased
Increased
Decreased
Normal
Increased
Normal
Normal
Normal
Normal
Normal
Normal
Normal
Straw
Slightly
cloudy
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1.007
4.6-8
1.016-1.022
Normal
Normal
Trace
Negative
Negative
Small
Negative
Negative
negative
negative
negative
negative
negative
negative
Normal
Normal
Normal
Normal
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Bilirubin
urobilinogen
July 1, 2005
COMPLETE
BLOOD
COUNT
Hemoglobin
Hematocrit
Red
blood
cells
White blood
cells
MCH
Mean
corpuscular
volume
MCHC
Platelet
DIFFERENTI
AL COUNTS
Neurophils
Lymphocyte
s
Monocytes
Eosinophils
Creatinine
Potassium
Sodium
Negative
.2eu/dl
negative
Normal
0.2-1.0 eu/dl Normal
9.84g/dL
29.7
3.39x10^6/ul
14.0-17.5
41.5-40.4
4.-5.9
Decreased
Decreased
Decreased
4.94x10^3/ul
4.4-11
Normal
29.0pg
87.4fl
27.5-39.2
80-96
Normal
Normal
33.2%
33.4-35.5
203000/cumm 150000450000
Decreased
Normal
56%
37%
40-70
20-40
Normal
Normal
06%
01%
0-8
0-1
Normal
Normal
11.9mg/d
3.2mmol/L
138mmol/L
.7-1.5
3.6-5.0
137-145
Increased
Decreased
Normal
3. Present profile of Functional Health Patterns
3.1. Health Perception / Health Management Pattern
Mr. Abello describes himself to be in a fair condition. He’s complete
with the immunizations needed. His complaints regarding his
intermittent fever accompanied with loss of appetite and vomiting
started two weeks prior to his admission at CDUH and upon
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consultation to a doctor, he was diagnosed of ESRD thus prompt
treatment and the use of hemodialysis machine was in great need
and so he came to Cebu together with his wife to be admitted.
Some movements are limited due to the pain felt on his left upper
extremity because of the AV shunt insertion
3.2. Nutritional – Metabolic Pattern
Mr. Abello preferably eats anything set on the table and consumes
around 8 glasses of water per day. He was prescribed by the doctor
to consume at most 4 glasses of water each day due to his present
condition. His appetite has remained the same compared to time
before admission. As of the moment, there are no complaints of
nausea and vomiting especially after eating and taking a walk from
the room to the CR. The doctor advised the patient to only eat the
food provided by the hospital. He doesn’t have any vitamin and
food supplements and has no problem with his ability to eat and
swallow food.
3.3. Elimination Pattern
Mr. Abello verbalized that there is seldom pain upon urination and
voids a little amount of urine every time he urinates. No assistive
devices for urinating as well as for his bowel movement. He
defecates once a day.
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3.4. Activity / Exercise Pattern
Mr. Abello is unemployed and spends time with his friends
drinking a lot of alcoholic beverages every night which he recently
stopped a month ago due to the illness felt. No limitations in daily
activities but feels pain upon movement and muscle twitching of
right arm.
3.5. Cognitive / Perceptual Pattern
Mr. Abello doesn’t have any defects in sensory perception. He
hasn’t
encountered
any
complaints
such
as
vertigo
and
insensitivity to tactile stimulation. He is also able to read and write
finishing the third year level in high school.
3.6. Rest / Sleep Pattern
Mr. Abello verbalized that he has only five hours of sleep in a day
combining the afternoon naps he takes once in awhile. His naps
taken in the afternoon makes it very hard for him to go to sleep at
night time. Back in Bohol, sleeping routine includes watching a
movie or any TV sop or etc then goes to sleep. He doesn’t have any
sleeping aids nor takes any sleeping pills.
3.7. Self-Perception Pattern
He is most concerned of being in his best condition again since he
and his wife needs to go back to Bohol for their two children whom
they left with his parents. He is hoping to get well soon to make up
for the expense he has cost his family and parents and would to
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put his parenting responsibility to a great deal of extent since he
has been a drunkard for many years.
3.8. Role Relationship Pattern
He speaks English, tagalong and bisaya. His communication skills
can be well understood and hi can directly answer the questions
addressed to him. He is very cooperative and takes initiative in
telling the health personnel attending to him about what he feels
and the things bothering him such as the muscle twitching and
pain felt on his right arm. His family lives together with her sisterin-law’s family. His being a drunkard for a long period of time pave
way to parenting difficulties and now that he is being hospitalized,
he realized the mistakes he has done and wants to change for the
family.
3.9. Sexuality – Reproductive Pattern
His being weak and ill has changed his sexual relations with his
partner but touch with care and love is still very evident between
the couple.
3.10. Coping – Stress Tolerance Pattern
He makes decisions at home with the help and guidance of his wife
whom he confides all the time. He is hoping to be out of the
hospital as soon as possible and change for the better and stop
drinking
so that the can preserve his health and specially care
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and be the breadwinner of the family. He sleeps when he is
stressed and requires a peaceful environment so he can fully relax.
3.11. Value – Belief System
He was brought up to see God as his guidance and source of
strength. He is a devoted Roman Catholic who practices going to
church on Sundays and first Fridays together with his family and
with relatives as well on special occasions like Christmas, Easter
and New Years.
4. Pathophysiology and Rationale
4.1 Normal Anatomy and Physiology of Organ or System Affected.
Renal System
The kidneys are essentially regulatory organs which maintain the
volume and composition of body fluid by filtration of the blood and
selective reabsorption or secretion of filtered solutes.
The
kidneys
are
retroperitoneal
organs
(located
behind
the
peritoneum) situated on the posterior wall of the abdomen on each
side of the vertebral column, at about the level of the twelfth rib. The
left kidney is lightly higher in the abdomen than the right, due to the
presence of the liver pushing the right kidney down.
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The kidneys take their blood supply directly from the aorta via the
renal arteries; blood is returned to the inferior vena cava via the renal
veins. Urine (the filtered product containing waste materials and
water) excreted from the kidneys passes down the fibromuscular
ureters and collects in the bladder. The bladder muscle (the detrusor
muscle) is capable of distending to accept urine without increasing
the pressure inside; this means that large volumes can be collected
(700-1000ml) without high-pressure damage to the renal system
occuring.
When urine is passed, the urethral sphincter at the base of the
bladder relaxes, the detrusor contracts, and urine is voided via the
urethra.
Structure of the kidney
On sectioning, the kidney has a pale outer region- the cortex- and a
darker inner region- the medulla.The medulla is divided into 8-18
conical regions, called the renal pyramids; the base of each pyramid
starts at the corticomedullary border, and the apex ends in the renal
papilla which merges to form the renal pelvis and then on to form the
ureter. In humans, the renal pelvis is divided into two or three spaces
-the major calyces- which in turn divide into further minor calyces.
The walls of the calyces, pelvis and ureters are lined with smooth
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muscle that can contract to force urine towards the bladder by
peristalsis.
The cortex and the medulla are made up of nephrons; these are the
functional units of the kidney, and each kidney contains about 1.3
million of them.
Structure of the Nephron
 The nephron is the unit of the kidney responsible for ultrafiltration
of the blood and reabsorption or excretion of products in the
subsequent filtrate. Each nephron is made up of:

A filtering unit- the glomerulus. 125ml/min of filtrate is formed by
the kidneys as blood is filtered through this sieve-like structure. This
filtration is uncontrolled.

The proximal convoluted tubule. Controlled absorption of glucose,
sodium, and other solutes goes on in this region.

The loop of Henle. This region is responsible for concentration and
dilution of urine by utilizing a counter-current multiplying mechanismbasically, it is water-impermeable but can pump sodium out, which in
turn affects the osmolarity of the surrounding tissues and will affect
the subsequent movement of water in or out of the water-permeable
collecting duct.
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
The distal convoluted tubule. This region is responsible, along with
the collecting duct that it joins, for absorbing water back into the
body- simple maths will tell you that the kidney doesn't produce
125ml of urine every minute. 99% of the water is normally
reabsorbed, leaving highly concentrated urine to flow into the
collecting duct and then into the renal pelvis.
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4.2 Schematic diagram
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4.3 Disease process and effects on different organs and systems
The
pathogenesis
of
CRF
involes
deterioration
and
destruction of nephrons with progressive loss of renal function. As
the total GFR decreases and clearance is reduced, serum urea
nitrogen and creatinine levels increase. Remaining functioning
nephrons hypertrophy as they filter a larger load of solutes. A
consequence is that the kidneys lose their ability to concentrate
urine adequately. To continue excreting the solute, a large volume of
dilute urine may be passed, which makes the client susceptible to
fluid depletion. The tubules gradually lose their ability to reabsorb
elcetrolyes. Occasionally, the result is salt wasting, in which urine
contains large amounts of sodium, which leads to more polyuria.
As renal damage advances and the number of functioning
nephrons declines, the total GFR decreases further. Thus the body
becomes unable to rid itself of excess water, salt, and other waste
products through the kidneys. When the GFR is less than 10 to 20
ml/min, the effect of uremic toxins on the body becomes evident. If
the disease is not treated by dialysis or transplantation, the outcome
of CRF is uremia and death
The clinical manifestations of the early stages of renal failure depend
on the disease process and contributing factors. As nephron
destruction progresses to ESRD, the manifestations become similar
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and are described as uremic syndrome. The clinical course of
irreversible renal disease and uremic syndrome follows a pattern:

Reduced renal reserve refers to the state in which BUN is
high-normal but the client has no clinical manifestations.
Normal functioning is evident as long as the client is not
exposed to unusual physiologic and psychosocial stress.

Renal insufficiency reflects a more advanced pathologic
process with mild azotemia when the client is receiving a
general diet. Impaired urine concentration, nocturia and mild
anemia are common findings. Renal function is easily
impaired by stress.

Renal failure is indicated by severe azotemia, acidosis,
impaired urine dilution, severe anemia, and a number of
electrolyte imbalances, such as hypernatremia, hyperkalemia
and hyperphosphatemia

ESRD
is
characterized
manifestations;
deranged
by
two
groups
excretory
and
of
clinical
regulatory
mechanisms and a distinctive grouping of gastrointestinal,
cardiovascular, neuromuscular, hematologic, integumentary,
skeletal, and hormonal manifestations. The kidneys can no
longer maintain homeostasis.
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GASTROINTESTINAL CHANGES
The entire gastrointestinal system is affected. Transient anorexia,
nausea and vomiting are almost universal. Clients often experience a
constant bitter, metallic or salty taste and their breath commonly
smells fetid, fishy or ammonia-like.
Constipation
is
a
common
problem.
It
often
results from
phosphate-binding agents, restriction of fluids and high-fiber foods
(many of which are rich in potassium and phosphorus), and
decreased activity.
CARDIOVASCULAR CHANGES
The most common clinical manifestation is hypertension produced
through the following:
 Mechanisms of volume overload
 Stimulation of the rennin-angiotensin system
 Sympathetically mediated vasoconstrictions;
 Absence of prostaglandins
Artherosclerosis
carbohydrate
and
hyperthyroidism.
is
lipid
accelerated
metabolism,
because
impaired
of
abnormal
fibrinolysis
and
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RESPIRATORY CHANGES
Some of the respiratory effects, such as pulmonary edema can be
attributed to fluid overload. Pleuritis is a frequent finding, especially
when pericarditis develops. A characteristic condition called uremic
lung is a type of pneumonitis that responds well to fluid removal.
Metabolic acidosis causes a compensatory increase in respiratory rate
as the lungs work to eliminate excess hydrogen ions.
MUSCULOSKELETAL CHANGES
The musculoskeletal system is affected early in the disease
process, and up to 90% of clients with CRF experience renal
osteodystrophy. This condition develops insidiously and takes several
forms: osteomalacia, osteitis fibrosa, osteoporosis and osteosclerosis.
INTEGUMENTARY CHANGES
Integumentary problems are particularly uncomfortable for some
clients with CRF. The skin is also often very dry because of atrophy of
the sweat glands. Sever and intractable pruritis may result from
secondary hyperparathyroidism and calcium deposits in the skin.
Pruritis can lead to excoriated skin caused by continued scratching.
Hair is brittle and tends to fall out; nails are thin and brittle as well.
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REPRODUCTIVE CHANGES
Reproductive system changes can be alarming. Women commonly
experience menstrual irregularities, particularly amenorrhea, and
infertility. However some women with CRF have conceived and had
successful full-term pregnancies. Men commonly report impotence of
both physiologic and psychological causes. They may also experience
testicular
atrophy,
oligospermia
(decreased
sperm
count),
and
reduced sperm motility. Both genders report decreased libido,
possibly from both physiologic and psychological factors.
ENDOCRINE CHANGES
CRF also affects endocrine system, such as the insulin utilization
and parathyroid function discussed already. Pituitary hormones, such
as growth hormone and prolactin, may be increased in some people.
The levels of luteinizing hormone and follicle-stimulating hormone
vary greatly from client to client. Thyroid stimulating hormone is
usually normal, but it may show a blunted response to thyrotropinreleasing hormone; this commonly results in hypothyroidism.
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4.4 Classical and Clinical Symptoms
CLASSICAL
SYMPTOM
Hypertension
CLINICAL
SYMPTOM
manifested
Pulmonary
edema
Pericarditis
Not manifested
Not manifested
Pruritis (severe Not manifested
itching)
Anemia
manifested
Calcium and Not manifested
Phosporus
imbalance
RATIONALE
Due to sodium and water retention
of from activation of the rennin
angiotensin – aldosterone system
Dute to fluid overload
Due to irritation of the pericardial
lining by uremic toxins
Uremic frost, the deposit of urea
crystals on the skin.
Due to inadequate erythropoietin
production, the shortened life span
of RBCs, nutritional deficiencies and
the patient’s tendency to bleed,
particularly from the GI tract.
Fatigue, agina and shortness of
breath results from decreased
erythropoietin.
Serum calcium and phosphate levels
have a reciprocal relationship in the
body; as one rises, the other
decreases. With decreased filtration
through the glomerulus of the
kidney, there is an increase in their
serum phosphate level and a
reciprocal
or
corresponding
decreasing the serum calcium level.
The decrease serum calcium levels
causes increased secretion of the
parathormone from the parathyroid
glands. In renal failure, however the
body does not respond normally to
the increased secretion of the
parathormone; as a result, calcium
leaves the bone, often producing
bone changes and bone disease. In
addition, the active metabolite of
vitamin D normally manufactured
by the kidney decreases as renal
failure progresses.
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GI



Not manifested
Due to accumulation
waste products
of
uremic
Nausea
Vomiting
Hiccups
NEURO



ALOC
Muscle
twitching
seizure
manifested
Reduced Renal manifested
REserve
Metabolic
acidosis
Not manifested
As glomerular filtration decreases
(due to nonfunctioning glomeruli),
the creatinine clearance value
decreases, where as the serum
creatinine and BUN levels increases.
Serum creatinine is the more
sensitive indicatior of renal function
because of its constant production
in the body. The BUN is affected not
only by renal disease but also by
protein
intake
in
the
diet,
catabolism, parenteral medication
and
medications
such
as
corticosteroids.
Metabolic acidosis occurs because
the
kidney
cannot
excreate
increases loads of acid. Decreased
acid secretion primarily results from
inability of the kidney tubulues to
excrete ammonia and to reabsorb
sodium bicarbonate. There is alos
excretion of phosphates and other
organic acids.
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IV. NURSING INTERVENTION
1. Care guide of patient with disease condition
a. Collaborative care
Preventing acute renal failure is a goal in the care of all
clients, especially for those in high-risk groups. Maintaining
blood volume, cardiac output, and blood pressure is vital to
preserve kidney perfusion. Nephrotoxic drugs are avoided if
possible. When a nephrotoxic drug must be used, keeping the
client well hydrated and avoiding additional nephrotoxins help
reduce the risk of renal failure. Care for the client with
chronic renal failure focuses on eliminating factors that may
further decrease renal function and on slowing the progress of
ESRD.
b. Diet and Fluid Management
When the kidneys cannot effectively regulate fluid and
electrolyte balance and eliminate metabolic waste products,
intake of these substances must be regulated. Fluid and
sodium intake is restricted. The daily fluid intake is
calculated by allowing 500 ml of insensible losses and adding
the amount of urine during the previous 24 hours. Clients
with CRF should notify the physician of any weight gain of
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more than 5 pounds over a two day period. Sodium and
potassium intake is regulated. Salt substitutes containing
potassium are avoided.
c. Pharmocology
All nephrotoxic drugs are avoided and used with extreme
caution. Drug dosages may be adjusted because excretion is
slowed and half-life is prolonged.
Diuretics such as furosemide (lasix may be ordered to
reduce fluid volume, lower blood pressure, and lower serum
potassium levels. Other antihypertensive drugs such as ACE
inhibitors are prescribed to maintain the blood pressure with
in normal levels
Sodium bicarbonate or calcium carbonate may b used to
manage
the
electrolyte
imbalances
and
acidosis
accompanying renal failure.
Folic acid and iron supplements are used to combat
anemia.
A
multiple-vitamin
preparation
is
also
often
prescribed, because anorexia, nausea and dietary restrictions
may limit nutrient intake.
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d. Dialysis
When conservative management is no longer effective to
maintain fluid and electrolyte balance and prevent uremia,
dialysis is considered. Dialysis is diffusion of solutes across a
semi-permeable
membrane
from
an
area
of
higher
concentration to one of lower concentration. In dialysis, a
semipermeable membrane separates blood from an isotonic
dialyzing solution. Water and solutes such as urea, creatinine
and electrolytes diffuse across this membrane, but proteins
do not.
Dialysis compensates the kidneys inability to
eliminate excess water and solutes.
e. Hemodialysis
Hemodialysis, electrolytes, waste products, and excess
water are removed from the body by diffusion and filtration.
The client’s blood is pumped to a dialyzing membrane unit,
where it moves past a semipermeable membrane. Dialysate is
warmed to body temperature and passed along the other side
of the membrane. Solutes diffuse through the membrane into
the dialysate to diffuse into the blood.
Excess water is
removed from the blood by creating a higher fluid pressure on
the blood side of the membrane.
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Clients on hemodialysis may experience both systemic and
fistula complications. Hypotension is the most frequent
complication occurring during hemodialysis. Bleeding may
occur due to altered clotting and the use of heparin during
dialysis. Infection is a significant risk. Dialysis dementia is a
progressive, potentially fatal neurologic complication that may
affect clients on long-term hemodialysis
AV fistula problems include infection, and clotting or
thrombosis. These complications may cause fistula failure
and require development of a new site. AV fistula failure can
have a psychological impact resulting in depression and
altered self-concept.
2. Actual Patient Care
2.1 NCP
NEEDS /
CUES /
PROBLEMS
Physiologic
deficit
Risk for
Infection
Cues:
-patient
undergoes
hemodialysis
NURSING
DIAGNOSIS
SCIENTIFIC OBJECTIVES
BASIS
OF CARE
Risk for
infection:
hemodialysis
therapy
related to
impaired
renal
function
Renal
failure
affects the
immune
system,
increasing
the risk for
infection.
Invasive
treatments
After 8 hours
of nursing
intervention,
the patient
will be able
to
demonstrate
ways to be
free from
risks of
NURSING
ACTIONS
measures to
prevent
infection:
1. use
standard
precautions
and good
washing at all
times
RATIONALE
-handwashing
and standard
precautions help
prevent spread
of infection to
and from the
client. Clients
29
-insertion of
needles
-insertion of
catheter
-possible
transfusion
for blood
and
catheters
further
increase
the risk
Medical
Surgical
Nursing by
Burke,
Lemone,
MohnBrown pg
530
infections by
maintaining
aseptic
technique at
all times
2. use strict
aseptic
technique in
handling
ports,
catheters and
incisions
3. monitor
temperature
and vital
signs at least
every 4 hours
4. monitor
WBC and
differential
on hemodialysis
have an
increased risk of
hepatitis B and
C and HIV
infections.
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-aseptic
technique is
vital to reduce
the risk of
introducing an
infectious
organism
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-an elevated
temperature or
increased pulse
rate may
indicate
infection
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-high or low
WBC counts
may indicate an
infection;
increasing
numbers of
immature WBCs
in the
30
5. culture
urine ,
peritoneal
dialysis, fluid
and other
drainage as
indicated
6. turn or
ambulate
frequently;
encourage
coughing and
deep
breathing
7. restrict
visits from
obviously ill
family
members
circulation may
indicate
infection
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-culture is used
to determine the
presence of
pathogen
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-these measures
decrease the
risk of
respiratory
infection
(Medical
Surgical
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
-teach the client
and family how
to reduce the
spread of
infection. The
client and family
need to know
and understand
how to reduce
the risk of
infection at
home and
hospital
(Medical
Surgical
31
Nursing by
Burke, Lemone,
Mohn-Brown pg
530)
NEEDS /
CUES /
PROBLEMS
Physiologic
overload
Excess fluid
volume
Cues:
-abnormal
diagnostic
results
-decrease
and
increase
electrolyte
levels
-increase
weight for
the past
months
-small urine
output
NURSING
SCIENTIFIC OBJECTIVES
DIAGNOSIS
BASIS
OF CARE
Excess fluid
volume:
decrease
and
elevated
fluid and
electrolytes
related to
impaired
kidney
function
Electrolyte
imbalances
may
develop
because of
water
retention
and
impaired
renal
function
Medical
Surgical
Nursing
byBurke,
Lemone,
MohnBrown pg
530
After 8 hours
of nursing
intervention,
the aptient
will be able
to
demonstrate
reduced fluid
volume by
weight loss
NURSING
ACTIONS
measures to
reduce fluid
volume:
1.maintain
accurate input
and output
record
RATIONALE
-helps determine
treatment,
especially fluid
restriction,
hourly urine
output
measurements
maybe done in
acute renal
failure
2. weigh daily
-weigh often
as ordered, use provides a more
consistent
accurate
technique and assessment of
timing to
fluid volume
ensure
than intake and
accuracy
output records,
particularly in
oliguric patients
3. document
-changes in the
vital signs at
vital signs may
least every 4
indicate either
hours
fluid volume
excess or deficit.
Hypertension
can further
damage kidneys
4. restrict fluid -fluid restriction
as ordered.
helps minimize
Provide
fluid retention
frequent
and the
mouth care
complications of
32
and encourage
using hard
candies to
decrease the
thirst response
5. administer
medications as
prescribed
6. administer
diuretics as
ordered and
monitor
response
7. monitor
electrolytes
and for
manifestations
of imbalance.
Report
abnormal
results
NEEDS /
NURSING
CUES /
DIAGNOSIS
PROBLEMS
Physiologic Imbalanced
deficit
nutrition:
less than
Imbalanced body
nutrition
requirements
related to
Cues:
effects of
-loss of
uremia
appetite
-patient is
diagnosed
with
chronic
renal
failure
-electrolyte
SCIENTIFIC
BASIS
OBJECTIVES
OF CARE
NURSING
ACTIONS
The
manifestations
of uremia and
dietary
restrictions
often affect
food intake.
The client may
not eat
enough to
meet
metabolic
needs.
After 8 hours
of nursing
intervention,
the patient
will be able
to eat 100%
of prescribed
diet
including
snacks
measures to
improve
nutritional
intake:
1. monitor
and
document
food intake
including the
amount and
type of food
consumed
Medical
Surgical
2. administer
anti-emetic
drugs 30-60
fluid volume
excess,
especially the
client being
manage with
dialysis
-reduces total
liquid consumed
-diuretics may
promote
urination
RATIONALE
-food intake
records help
determine the
adequacy of
nutritional
intake and
identify the
need for
nutritional
supplements
-anorexia,
nausea and
vomiting are
33
imbalance
-not all the
food on the
tray was
eaten
Nursing by
Burke,
Lemon, MohnBrown pg 530
minutes
before eating
3. provide
mouth care
prior to care
4. provide
frequent
small meals
or between
meal snack
5. arrange for
dietary
consultation.
Provide
preferred
foods to the
extent
possible and
plan with
family
6. monitor
serum and
electrolytes
and albumin
diagnostic
results
7. administer
and monitor
parenteral
nutritional
common. Antiemetic drugs
reduce nausea
and the risk of
vomiting with
food intake
-the client may
have a metallic
taste and bad
breath. Mouth
care improves
taste and
promotes
appetite
-these
measures
promote food
intake in the
fatigues or
anorexic
patient
-the client is
more likely to
eat favorite
foods.
Involving the
client in
planning
promotes a
sense of
control and
learning about
dietary
restrictions
-changes in
values may
indicate either
improving or
declining
nutritional
status
-parenteral
nutrition
maybe
necessary to
34
intake as
ordered
prevent
catabolism in
the client with
renal failure
2.2 DRUG THERAPEUTIC RECORD
DRUG/
DOSE/
FREQUENC
Y/ ROUTE
NaHCO3
650 mg
1 tab TID PO
8–1–6
CLASSIFICATION/
MECHANISM
Electrolyte
Systemic
Alkalinizer
Urinary
Alkalinizer
Antacid
-Increases plasma
bicarbonate,
buffers excess
hydrogen ion
concentration,
raises blood pH;
reverses the
clinical
manifestations of
acidosis; increases
the excretion of
free base in the
urine, effectively
raising the urinary
pH; neutralizes or
reduces gastric
acidity resulting in
an increase in the
gastric pH which
inhibits proteolytic
activity of pepsin
Herax
25 mg
1 tab BID
PO
8–6
Gout preparations
Anti-anxiety
Antihistamine
Antiemetic
-Actions maybe
due to
suppression of
subcortical areas
of the CNS; has
clinically
INDICATIONS/
CONTRAINDICATION
S/ SIDE EFFECTS
INDICATIONS:
-treatment of
metabolic acidosis,
severe diarrhea,
minimization of uric
acid crystalluria in
gout; symptomatic
relief of upset
stomach from
hyperacidity
CONTRAINDICAITON
S:
-allergy to
components of
preparation, low
serum chloride,
secondary to vomiting
PRINCIPLES
OF CARE
TREATMENT
EVALUATION
1. parenteral
medications
by IV route
2. patient
should chew
oral tablets
thoroughly
before
swallowing
with a glass of
water
3. report andy
side effects
such as
irritability,
headache,
tremors and
confusion
1. monitor
patient’s input
and output
2. monitor
vital signs
2. increase
fluid intake
1. reversal of
metabolic
acidosis
2. increase
urinary and
serum pH
3. decrease
gastric
discomfort
1. take drugs
as prescribed
2. avoid
excessive
dosage
report
difficulty in
breathing,
tremors, loss
of
coordination
1. encourage
verbalization
2. give drugs
as prescribed
3. maintain
eye to eye
contact with
patient
1.
improvement
in symptoms
of CHF
2. decrease BP
SIDE EFFECTS:
-irritability, headache,
tremors, confusion,
swelling of extremity,
black or tarry stools,
pain at injection site
INDICATIONS:
-symptomatic
treatment of anxiety,
GAD, symptomatic
treatment of allergic
origin
CONTRAINDICATION
-previous
hypersensitivity,
pregnancy, lactation,
35
Calcium
Carbonate
(Calci-acid)
1 cap TID
PO
8–1–6
Alu-Tab
1 tab TID PO
8–1–6
demonstrated
antihistamine,
analgesic,
antiposmodic and
bronhodilator
action
intermittent acute
porphyria
Vitamins and
Calcium
Electrolyte
Antacid
INDICAITONS:
-osteoporosis, calcium
malabsorption and
deficiency conditions
-Essential
elements of the
body, helps
maintain
functional
integrity of the
nervous system
and muscular
system, helps
maintain cardiac
function, blood
coagulation; is an
enzyme co-factor
and affects
secretory activity
of endocrine and
exocrine gland
CONTRAINDICATION
S:
-hypercalcemia,
severe renal failure
Antacid and
Antiulcerants
INDICATIONS:
-uncomplicated peptic
ulcer, and gastric
hyperacidity;
phosphate binding in
renal dysfunction
-Nuetralizes or
reduces gastric
acid resulting in
an increase in the
pH of the stomach
and duodenal
bulb and inhibitng
proteolytic activity
of pepsin which
protects the lining
of the stomach
and duodenum;
binds with
phosphate ions in
the intestine to
from insoluble
aluminum
SIDE EFFECTS:
-sedation,
somnolence,
dizziness, dry mouth,
urinary retention,
rarely tremors and
convulsion
SIDE EFFECTS:
-constipation
CONTRAINDICATION
S:
-hypophosphatemia
SIDE EFFECTS:
-constipation
1. in large
doses, serum
calcium
concentration
and kidney
function
should be
monitored
2. do not
administer
oral drug
within 1-2
hour or
antacid
solution
3. let patient
chew antacid
tablet
1. monitor
serum levels
2. monitor
vital signs
1. special
precautions on
patients with
hypophosphatemia
and CRF may
cuase
phosphate
depletion
1. monitor
input and
output
2. monitor
vital signs
36
2.3 SOAPIE
SOAPIE # 1
S – “Nagkawala man iya gana sa pagkaon” as verbalized by his wife.
O – Received patient on bed, conscious, awake, coherent, with weight of 48
kgs and D5LR 1L infusing well on left arm at KVO rate; complaints of
decreased appetite as evidenced by left overs on plate and chief
complaint upon admission; electrolyte imbalance noted on chart; patient
diagnosed with chronic renal failure
A - Physiologic deficit: Altered nutrition, less than body requirements: loss of
appetite related to effects of uremia
P - to improve nutritional intake
I -
monitored and documented food intake; let patient do mouth care;
provided frequent small meals was advised to significant other; provided
snacks prior to patient’s preference as long as not restricted on diet and
provided ample time to chew food; monitored and charted vital signs and
patient’s intake and output
E – patient was able to eat his whole meal for lunch
37
SOAPIE # 2
S - “nagkadako man iyang timbang kumpara sa mga ni agi na bulan.” As
verbalized by his wife
O – patient received on bed, conscious, awake, coherent, with a weight of
48.35 Kgs noted the night before; urine output of patient yesterday
during 3-11 pm shift was only 30 cc having an intake of 340 cc of water;
no signs of sweating and stays in bed all the time; imbalanced electrolyte
levels; patient diagnosed with CRF
A- Excess fluid volume: Imbalanced electrolyte levels related to impaired
kidney function
P - to reduce fluid volume by weight loss
I - maintained accurate I & O records; weighed daily as ordered; documented
vital signs; restricted fluids as ordered by the physician; provided mouth
care; advised eating of hard candies to decrease thirst response;
administered medications with meals and as ordered; monitored serum
electrolytes and for maintenance of imbalances
E – patient decreased his weight from 48.35 of yesterday’s weight and 47 kgs
today
38
2.4 Health Teaching Plan
OBJECTIVES
General objectives:
After 8 hours of
nursing intervention,
the patient will be able
to acquire skills,
positive attitude and
knowledge in caring
for patients
undergoing
hemodialysis.
CONTENT
METHODOLOGY
Specific objectives:
After 45 minutes of
student nurse-patient
and significant other
interaction, the client
will be able to:
1. define the following
term in their own level
of understanding
1.1 hemodialysis
1. TERM
a. hemodialysis - most common used
method of dialysis
Informal discussion
2. explain the pathway
for hemodialysis
2. PATHWAY FOR HEMODIALYSIS
Informal discussion
-In hemodialysis, electrolytes and waste products Visual aids
and excess water are removed from the body by
diffusion and filtration. The client’s blood is
pumped to a dialyzing membrane unit, where it
moves past a semi-permeable membrane.
Dialysate is warmed to body temperature and
passed along the other side of the membrane,
solutes diffuse through the membrane into the
dialysate. Medications can be added to the
dialysate to diffuse into the blood. Excess water is
removed by eradicating a higher fluid pressure on
the blood side of the membrane. Clients typically
undergo 2 or 3 sessions of hemodialysis per week
for a total of 12 hours. Hemodialysis can be done
at home but usually occurs in an out-patient
dialysis center
39
3. enumerate different
possible complications
for patients
undergoing
hemodialysis
3. COMPLICATIONS
-clients on hemodiaylsis may experience both
systemic and fistula complications. hypertension
is the most frequent complication occurring
during hemodialysis. Bleeding may occur due to
altered clotting and the use of heparin during
dialysis, infection is a significant risk
Informal discussion
4. site important things 4. IMPORTANT THINGS TO BE DONE
to be done before and
after hemodialysis
BEFORE DIALYSIS
a. use standard precaution at all times
b. document vital signs, lung sounds and
weight
c. taking of blood pressure on vascular site
should be avoided
AFTER DIALYSIS
a. document vital signs, weight and vascular
access site
b. monitor possible adverse effects of
dialysis such as muscle cramping,
headache, nausea and vomiting, seizure
and hypertension
c. provide psychological support; listen
actively for feelings of grief, hopelessness
or anger
Informal discussion
Visual aids
5. demonstrate ways to 5. WAYS TO PREVENT INFECTION
prevent infection
a. proper medical handwashing
b. dress site aseptically
c. disposed needles properly
Informal discussion
Demonstration
Return demonstration
V. EVALUATION AND RECOMMENDATION
The survival rate of people with CRF has improved with the advent
and improvement of dialysis and transplantation. At 1 year after dialysis
begins, the survival rate is about 79%. After 5 years, the rate decreases
to 33%.
40
The client must comply with dietary and fluid intake modifications
and take prescribed medications as ordered.
They must monitor and
record weight and blood pressure daily and care for the vascular access
or peritoneal catheter as ordered. Noncompliance with the regimen leads
to complications. The client or family must perform dialysis at home or
keep scheduled dialysis appointments and attend to it regularly.
VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO:
NURSING PRACTICE
The study is one tool in giving way to a more holistic
and effective care in patients with CRF. Preventive measures will
then be well emphasized thus stop worsening the lives of the
people prone to this disease. Having a good outlook and positive
attitudes is another thing we can get out of this case study. Being
positive and confident in dealing with these patients will make the
patients feel at ease and trust their nurses more which aids in
giving effective and better care.
NURSING EDUCATION
This study will make a contribution to nursing
education as it would help future nurses and student nursed be
more knowledgeable regarding this disease, equipped in their
41
nursing care and be able to correct misconceptions regarding the
disease
NURSING RESEARCH
Research is a vital part to every theory, formula and
newly concept rendered to the society. This study can be a good
basis for the future researchers and professionals so that better
interventions and knowledge will soon be made and imparted to all
patients, their significant others and professionals dealing that will
deal with this disease.
This study will aid as basis for future researchers of this
kind of disease and broaden knowledge of the researcher. This will
also add information needed by other students that will help them
understand this disease condition and its other facts that is
essential when dealing with CRF patients
42
VII. BIBLIOGRAPHY
The Lippincott Manual of Nursing Practice
4th edition by Lilian Shaltis Brunner and Doris Smith Suddarth
Medical Surgical Nursing
Vol. 1&2, 10th edition by Brunner and Suddarth
Nursing Care plan Guide
by Ulrich and Canore 6th edition
Nursing Pocket Guide
8th edition by Doonges and Moorhouse
Maternal and Child Health Nursing
Vol. 1, 4th edition by Adelle Pilliteri
Dictionary of Medical Terms
Rothenberg and Chapman
3rd ed
2003 Lippincotts Nursing Drug Guide
by Amy M. Karch
MIMS
Vol. 32 Number 4 2003
Fundamentals of Nursing
Vol. 2, 5th edition by Potter and Perry
Medical Surgical Nursing
by Burke, Lemone, Mohn-Brown pg 530
http://www.le.ac.uk/pathology/teach/va/anatomy/case4/frmst4a.html