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1 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. 2 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. 3 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 4 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 5 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 6 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. 7 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. 8 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 6 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 9 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 10 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. 11 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 12 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 13 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. 14 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 15 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. 16 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. 17 4.2 Schematic diagram 18 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 19 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. 20 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 21 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. 22 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. 23 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. 24 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. 25 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 26 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. 27 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. 28 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