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CHAPTER I INTRODUCTION Chronic kidney disease is the slow loss of kidney function over time. The main function of the kidneys is to remove wastes and excess water from the body. Chronic kidney disease (CKD) slowly gets worse over time. In the early stages, there may be no symptoms. The loss of function usually takes months or years to occur. It may be so slow that symptoms do not appear until kidney function is less than one-tenth of normal. The final stage of chronic kidney disease is called endstage renal disease (ESRD). At this stage, the kidneys are no longer able to remove enough wastes and excess fluids from the body. The patient needs dialysis or a kidney transplant. Diabetes and high blood pressure are the two most common causes and account for most cases.

Goal: Within two weeks of Hospital duty, we will be able to implement health promotion to our patient. Objectives: To develop effective communication skills that are congruent with cultural values and beliefs for us to collect data Promotion of proper hand hygiene through health education to decrease the spread of microorganisms Promotion of good nutrition by emphasizing the importance of following his diet for the betterment of health To maintain a balance of electrolytes, minerals, and fluid in our patient

LABORATORY FINDINGS

Fecalysis Date: 09-08-2012 Physical Examination: Color: Dark green Consistency: Semi-formed Microscopic Examination: No ova or cyst of any intestinal parasite seen Cellular Elements: Pus Cells: Negative Red Cells: Negative Others: Occult blood: Negative Hematology Report Date: 09-08-2012 WBC RBC Hemoglobin Hematocrit Platelet Count Result 5.7 x10 /VL 2.77 x10 /VL 74 Grams/L 0.234 L/L 223 x10/ VL Reference Value 4.0 10.0 4.00 5.50 120 160 0.400 0.500 150.0 450.0 Indication Normal Decreased Decreased Decreased Normal

This implies that RBC is decreased in patients with CKD due to the inability of the failing kidneys to secrete the hormone erythropoietin. This hormone is a necessary stimulus for normal bone marrow to produce red blood cells. Hematocrit and hemoglobin are below normal indicating the signs of anemia.

WBC Differentiated Count Date:09-08-2012 Neutrophils Result 0.78 Reference Value Indication 0.40-0.70 Increased

Neutrophils is increased in chronic kidney disease patients under hemodialysis and its relationship with resistance to recombinant human erythropoietin and to the hemodialysis procedure. Blood Type MCV MCH MCHC Prothrombin Time Date: 09-08-2012 Result: 13.8 seconds % ACTIVITY: 71.7% INR: 1.16 Reference Value: 10.3 13.1 Indication: Increased HEMODIALYSIS TREATMENT Time ON: 1:45 Time OFF: 5:45 HbsAgs: Negative Anti HCV: Negative Vascular Access: Left (AV Fistula Strong thrill) Heparin: NSS Flushing Needle Cannulation: With ease, no difficulty Result 84.5 prn 26.7 Pcg 316 g/L Reference Value 82.0 95.0 27.0 31.0 320 - 360 Indication Normal Decreased Decreased

ANATOMY AND PHYSIOLOGY URINARY SYSTEM The Urinary system is also known as excretory system of human body. It is the system of production, storage and elimination of urine. The urinary system contributes to homeostasis by altering blood composition, pH, volume and pressure; maintaining blood osmolarity; excreting

wastes and foreign substances; and producing hormones.

Components of urinary system: Human urinary system consists of two kidneys, two ureters, a urinary bladder, and a urethra. 1. KIDNEYS Kidneys are the major organs of urinary system. Formation of urine takes place in kidneys which are two bean shaped organs lying close to the lumbar spine, one on each side of the body.Functions of the kidneys include regulation of blood ionic composition, regulation of blood pH, regulation of blood volume, regulation blood pressure, maintenance of blood osmolarity, production of hormones, regulation of blood glucose level, excretion of wastes and foreign substances.

2. URETERS These are muscular tubes extending from the kidneys to the urinary bladder. Each of two ureters transports urine from renal pelvis of one kidney to the urinary bladder. Peristaltic contractions of the muscular walls of the ureters push urine toward the urinary bladder, but hydrostatic pressure and gravity also contribute. 3. URINARY BLADDER Urinary Bladder collects urine before it is excreted from the body. Urinary bladder is a hollow muscular and elastic organ sitting on the pelvic floor. In males, it is directly anterior to the rectum; in females, it is anterior to the vagina and inferior to the vagina. Urinary bladder capacity averages 700-800ml. It is smaller to the females because the uterus occupies the space just superior to the urinary bladder. Discharge of urine from the urinary bladder, called micturition is also known as urination or voiding. 4. URETHRA Urethra is a small tube leading from the internal urethral orifice in the floor of the urinary bladder to the exterior of the body. In both males and females, the urethra is the terminal portion of the urinary system and

the passageway for discharging urine from the body. In males, it discharges semen as well.

PATHOPHYSIOLOGY

A. Schematic Diagram

Autoimmune Disorder

Hypertension

Decrease renal blood flow; urine out flow obstruction Glomelular filtration BUN Serum Creatinine Inability to concentrate urine Further loss of nephron function Loss of non renal excretory function Chronic Renal Failure

SIGNS AND SYMPTOMS: >asymptomatic at first >decreased fluid volume >peripheral edema >high blood pressure >fatigue and weakness >chest pain >bleeding

NSG DIAGNOSIS: >ineffective airway clearance >excess gluid volume >risk for infection >altered role performance B. Narrative Chronic kidney disease (also known as chronic renal disease) can arise from progression of acute renal failure or congenital or familial diseases, or as the result of acquired conditions affecting glomerulotubular function that have developed over a period of months or years. There are many different causes of Chronic Renal Failure includes congenital malformation of the kidneys (birth defects),chronic bacterial infection of the kidneys with or without kidney stones (pyelonephritis),high blood pressure (hypertension),diseases associated with the immune system ( glomerulonephritis, systemic lupus).Decreased renal function interferes with the kidneys' ability to maintain fluid and electrolyte homeostasis. Remaining intact nephrons undergo a compensatory hypertrophy in order to maintain function. The maladaptive mechanisms that occur as a result of nephron damage further contribute to the progressive decline in kidney function. Among the homoeostatic derangements that may

contribute to further progression are mineral imbalance, for example phosphorus retention and secondary hyperparathyroidism, and renal hypertension. For substances whose secretion is controlled mainly through distal nephron secretion, adaptation usually maintains plasma levels at normal until renal failure is advanced. K-sparing diuretics, ACE inhibitors, -blockers, NSAIDs, cyclosporine, angiotensin II receptor blockers may raise plasma K levels in patients with less advanced renal failure.Although no treatment can repair irreversible renal lesions, the clinical consequences of reduced renal function can be minmized by appropriate medical management.

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NURSING MANAGEMENT

1. Treatment Hemodialysis 3x a week 2. Drug Study DRUG Furosem ide (Divisp ec) 40 mg 1tab BID Drug Class: Loop Diureti c MODE OF ACTION Inhibits reabsorpti on of sodium and chloride form of the proximal and distal tubules and ascending limb of the loop of Henle, leading to a sodiumrich diuresis. Therapeuti c Effect: INDICATION Oral, IV: Edema associated with heart failure, cirrhosis, renal disease IV: Acute pulmonary edema Oral: Hypertensi on ADVERSE EFFECTS Dizziness , parasthes ias, weakness, headache, drowsines s, fatigue, blurred vision, tinnitus, irreversi ble hearing loss, Nausea, anorexia, vomiting, oral and gastric NURSING CONSIDERATIONS Reduce dosage if given with other antihypertensives; readjust dosage gradually as BP responds. Give early in the day so that increased urination will not disturb sleep. Measure and record weight to monitor fluid changes. Blood glucose levels ma become temporarily elevated in patients with diabetes after starting this

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Produces Diuretic Effect

irritatio n, constipat ion, diarrhea, , jaundice

drug. Arrange to monitor serum electrolytes, hydration, liver and renal function.

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MODE OF ACTION DRUG Amlodipin e (Rovasc) 10 mg 1 tab BID Drug Classes: Antiangin al, Antihyper tensive, Calcium Channel Blocker Inhibits calcium movement across cell membranes of cardiac and vascular smooth muscle Therapeutic Effect: Dilates coronary arteries, peripheral vascular resistance by vasodilation.

INDICATION Managemen t of hypertens ion, chronic stable angina, vasospast ic (Prinzmet als or variant) angina. May be used alone or with other antihyper tensive or antiangin als.

ADVERSE EFFECTS Dizziness, light headedness, headache, fatigue, lethargy, peripheral edema, arrythmias

NURSING CONSIDERATIONS >Monitor BP carefully if patient is also on nitrates. >Monitor cardiac rhythm regularly during stabilization of dosage. >Take meals if stomach upset occurs. >Report irregular heartbeat, shortness of breath, swelling of the hands or feet, pronoun dizziness,constip ation >side effects: Nausea, vomiting (eat frequent meals);headache (adjust lighting, noise and temperature; medication may be ordered)

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DRUG TUMS calcium carbonate 1 tab OD Drug Classes: Electroly te replenish er, Antacid, antihypoc alcemic

MODE OF ACTION >Calcium is essential for function, integrity of nervous, muscular, skeletal system. Important role in normal cardiac, renal function, respiration, blood coagulation, and cell membrane and capillary permeability. Assists in regulating release/storage of neurotransmitter/hor mones. >Therapeutic Effect: Replaces calcium in deficiency states, controls hyperphosphatemia in end-stage renal disease.

INDICATION >Symptomatic relief of upset stomach associated with hyperacidity; gastritis, peptic esophagitis, gastric hyperacidity, hiatal hernia >Prophylaxis of GI bleeding, stress ulcers, and aspiration of pneumonia; possibly useful >Dietary supplement when calcium intake is adequate

ADVERSE EFFECTS Hypercalcemia, rebound hyperacidity and milk alkali syndrome, alkalosis, renal damage.

NURSING CONSIDERATIONS >Have patient chew antacid tablets thoroughly before swallowing; following with a glass of water or milk. >Give calcium carbonate antacid 1 and 3 hr after meals. >Report loss of appetite, nausea and vomiting, abdominal pain, constipation, dry mouth, thirst, increasing voiding

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Ferrous Sulfate 1 tab OD Drug Classes: Enzymatic Mineral, Iron Preparati on

Essential component in formation of Hgb, myoglobin, and enzymes. Therapeutic Effect: Necessary for effective erythropoieses and for transport and utilization of O2

Prevention and treatment of iron deficiency anemia due to inadequate diet, malabsorption, and/or blood loss.

CNS toxicity, acidosis, coma and death with overdose

Take drug on an empty stomach with water. Take after meals if GI upset is severe. Have periodic blood tests during therapy to determine appropriate dosage. You may experience theses side effects: GI upset, nausea, vomiting, diarrhea or constipation; dark or green stools.

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DRUG Isosurbide dinitrate (Isolet) 1 tab OD Drug Class: Antiangin al, Nitrate, Vasodilat or

MODE OF ACTION Stimulates intracellular cyclic GMP Therapeutic Effect: Relaxes vascular smooth muscle of both arterial and venous vasculature. Decreases preload and afterload

INDICATION Prophylaxis and treatment of angina pectoris. Unlabeled: CHF, pain relief, dysphagia, relief of esophageal spasm with GE reflux.

ADVERSE EFFECTS Drug should be discontinued if blurred vision, dry mouth occurs. Severe postural hypotension manifested by fainting, pulselessnes, cold/clammy skin, profuse sweating.

NURSING CONSIDERATIONS Give sublingual preparations under the tongue or in the buccal pouch; discourage the patient from swallowing. Monitor number of angina episodes, orthostatic episodes. Assists with ambulation if lightheadedn ess, dizziness occurs.

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DRUG Ceftriaxo ne sodium 2gms. IV OD Drug Classes: Third generatio n Cephalosp orins, Antibioti c

MODE OF ACTION Binds to bacterial membranes Therapeutic Effect: Inhibits synthesis of bacterial cell wall. Bacteriacidal.

INDICATION Treatment of respirator y and GU tracts, skin, bone, intraabdominal, biliary tract infections

ADVERSE EFFECTS Antibiotic associated colitis, other superinfections may result from altered bacterial balance. Nephrotoxicity may occur, esp. with preexisting renal disease.

NURSING CONSIDERATIONS Culture infection site, and arrange for sensitivity tests before and during therapy if expected response is not seen. Give oral drug with food to decrease GI upset. Take full course of therapy even if you are feeling better. Discontinue if hypersensiti vity reaction occurs.

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DRUG Seretide 250 gms. BID 1 Puff Drug Classes: Antiasthm atic, Beta2 selective adrenergi c agonist, Bronchodi lator, Sympathom imetic

MODE OF ACTION Stimulates beta2 adrenergic receptors in the lungs, resulting in relaxation of bronchial smooth muscle. Therapeutic Effect: Relieves bronchospasm, reduces airway resistance.

INDICATION Relief of bronchospa sm due to reversible obstructiv e airway disease, exercise induced bronchospa sm.

ADVERSE EFFECTS Excessive sympathomimetics stimulation may produce palpitations, extrasystoles, tachycardia, chest pain, slight increase in BP, followed by substantial decrease, chills, sweating, blanching of skin.

NURSING CONSIDERATIONS Monitor rate, depth, rhythm, type of respiration; quality and rate of pulse; EKG; serum potassium, ABG determinatio ns. Assess lung sounds for wheezes and rales. Instruct on proper use of inhaler. Instruct patient to increase fluid intake Avoid excessive use of caffeine derivatives.

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DRUG Levopront 10 ml 10ml TID Drug Class: Anti tussive

MODE OF ACTION Anesthetizes stretch receptors in respiratory passages, lungs, and pleura. Therapeutic Effect: Reduces cough production.

INDICATION Relief of nonproduct ive cough, including acute cough or minor throat/bro nchial irritation .

ADVERSE EFFECTS Paradoxical reaction (Restlessness, insomnia, euphoria, nervousness, tremors) has been noted.

NURSING CONSIDERATIONS Give with meals if GI upset occurs; give after meals if drooling or nausea occurs. Ensure patient voids before receiving each dose if urinary retention is a problem. Take this drug exactly as prescribed. Report difficult or painful urination, constipation , rapid or pounding heartbeat, confusion, eye pain.

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PRN MEDS: DRUG Clonidine (Catapres) Drug Classeses: Antiadrenergic ,Sympatholytic ,Antihypertens ive MODE OF ACTION Epidural: Prevents pain signal transmission to the brain and produces analgesia at pre- and postalpha adrenergic receptors in the spinal cord. Therapeutic Effect: Reduces peripheral resistance; decreases BP, heart rate INDICATION Treatment of hypotensio n alone or in combinatio n with other antihypert ensive agents. ADVERSE EFFECTS Overdosage produces profound hypotension, irritability, bradycardia, respiratory depression, hypothermia, milosis, arrhythmias, apnea. NURSING CONSIDERATIONS Take this drug exactly as prescribed. Do not discontinue the drug unless instructed by your healthcare provider. Attempt lifestyle changes that will reduce your BP: stop smoking and using alcohol; restrict intake of salt; exercise regularly. Report urinary retention, changes in vision,

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DRUG Metoclopr amide IV Drug Classes: Antiemeti c, Dopaminer gic blocker, GI stimulant

MODE OF ACTION Stimulates motility of upper GI tract. Decreases reflux into esophagus. Raises threshold activity of chemoreceptor trigger zone. Therapeutic Effect: Accelerates intestinal transit and gastric emptying. Produces antiemetic activity.

INDICATION To facilitate small bowel intubation; stimulate gastric emptying, intestinal transit.Relieves symptoms of acute, recurrent gastroparesis.

blanching of fingers, rash. NURSING CONSIDERATIONS Take this drug exactly as prescribed. Do not use alcohol, sleep remedies, or sedatives; serious sedation could occur. Report involuntary movement of the face, eyes, limbs, severe diarrhea. Assess for dehydration (poor skin turgor, dry mucous membranes, longitudinal furrows in tongue.

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DRUG Ipatropiu m bromide + salbutamo l Drug Classes: Anticholi nergic, Antimusca rinic, Bronchodi lator, Paramsymp atholytic

MODE OF ACTION Blocks action of acetylchol ine at parasympat hetic sites in bronchial smooth muscle. Therapeuti c Effect: Causes bronchodil ation, inhibits secretions from the glands lining the nasal mucosa.

INDICATION Bronchodi lator for maintenan ce treatment of bronchospasm associate d with COPD (solution , aerosol), chronic bronchiti s, and emphysema .

ADVERSE EFFECTS Worsening of narrowangle glaucoma, acute eye pain, hypotensi on occurs rarely.

NURSING CONSIDERATIONS Ensure adequate hydration; control environment (temperature) to prevent hyperpyrexia. Have patient void before taking medication to avoid urinary retention. Teach patient proper use of inhaler. Protect solution for inhalation from light. Store unused vials in foil pouch. Teach patient proper use of inhaler.

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3.Nursing Care Plan ASSESSMENT Subjective: Nahirapan ako huminga Objective: >Adventitious breath sounds (crackles) heard upon auscultation >Nonproductive cough noted >Restlessness >Difficulty of breathing Nursing Diagnosis: Ineffective Airway Clearance related to retained secretions in the respiratory tract EXPLANATION OF THE PROBLEM Normally the lungs are free from secretions. But with Bronchopneumonia, bacteria are invading the lung parenchyma thus, producing inflammatory process. And this response leads to filling of the alveolar sacs with exudates leading to consolidation. Due to consolidation the airway is narrowed thus wheezes is being heard, DOB in some cases orthopnea is observed OBJECTIVES STO: >Within 8 hours of effective nursing interventions, patient will be able to maintain airway patency. INTERVENTION Dx: >Monitor vital signs noting blood pressure or pulse changes >Observe for improvement in symptoms RATIONALE EVALUATION

LTO: >Within 2 days of nursing interventions, the patient will be able to demonstrate reduction of congestion with breath sounds clear.

STO: >to assess >After 8 hours changes of effective nursing interventions, patient was >to evaluate able to the maintain interventions airway done patency. >Observe for >to assess signs of changes respiratory distress LTO: Tx: >After 2 days >Position head >to open or of nursing midline with maintain open interventions, flexion airway in at- the patient appropriate rest or was able to for condition compromised demonstrate individual reduction of >Assist with >to identify congestion appropriate causative with breath testing factors sounds clear. >Auscultate >to ascertain breath sounds status and and assess air note progress movement >Keep >to maintain environment adequate

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allergen free

patent airway

>Provide >to mobilize supplemental secretions humidification Edx: >Encourage deep breathing and coughing exercises >Support cessation of smoking >Encourage patient to have adequate rest >to maximize effort >to improve lung function >to promote wellness