Capitol Medical Center

Quezon City, Philippines

Nursing Service Department

A Case Study On
Nursing Care Management of Patients with

In partial fulfillment of the requirements for the

45th Skills Training Program

Group 2:
Esposo, Bern
Erive, Robetha
Gatus, JL
Grageda, Jerome
Ignacio, Aljon
Macadangdang, Lea Mari
Maddara, Marivic
Magbanaua, Mark
Manong, Shane
Martin, Abigail
Mitra, Alyza

September 2014

Table of Contents
Introduction
Background of the Case Study
Objectives of the Case Study
Theoretical Framework
Clinical Summary
General Data
Chief Complaint
History of Present Illness
Past Medical History
Family Health History
Physical Assessment (Cephalo-Caudal)
Patterns of Functioning
Laboratory and Diagnostic Examinations
Course in the Ward
Clinical Discussion of the Disease
Anatomy and Physiology
Pathophysiology/ Schematic Diagram of the Disease
Drug Study
Nursing Process
Problem List
Nursing Care Plan
Discharge Planning
Recommendations
References

INTRODUCTION

 Background of the Study

Chronic kidney disease (CKD), also known as chronic renal disease, is a
progressive deterioration of renal function over a period of months or years. The
symptoms of worsening of the kidney function are unspecific and develop slowly, and
might include anorexia, nausea, vomiting, stomatitis, dysguesia, nocturia, lassitude,
fatigue, pruritus, decreased mental acuity, muscle twitches and cramps, water retention,
undernutrition, peripheral neuropathies, and seizures. Chronic kidney disease is
diagnosed as a result of screening of people known to be at risk of kidney problems,
such as those with hypertension, nephroangiosclerosis, glomerulopathies, diabetic
nephropathy and other genetic variables.
One cause of kidney failure is Hypertension which is one of the leading causes of
CKD due to the deleterious effects that increased BP has on kidney vasculature. Longterm, uncontrolled, high BP leads to high intraglomerular pressure, impairing glomerular
filtration. HTN has been reported to occur in 85% to 95% of patients with CKD (stages 3
5). Uncontrolled HTN is a risk factor for developing CKD, is associated with a more rapid
progression of CKD, and is the second leading cause of ESRD. Damage to the glomeruli
lead to an increase in protein filtration, resulting in abnormally increased amounts of
protein in the urine (microalbuminuria or proteinuria). Microalbuminuria is the
presentation of small amounts of albumin in the urine and is often the first sign of CKD.
Proteinuria (protein-to-creatinine ratio 200 mg/g) develops as CKD progresses, and is
associated with a poor prognosis for both kidney disease and CVD. Elevated BP leads to
damage of blood vessels within the kidney, as well as throughout the body. This damage
impairs the kidney's ability to filter fluid and waste from the blood, leading to an increase
of fluid volume in the bloodthus causing an increase in BP. Therefore the relationship of
CKD to hypertension is cyclic.
CKD is first suspected when serum creatinine rise, through a blood test, which
indicate a falling glomerular filtration rate and as a result, a decreased capability of
the kidneys to excrete waste products. In the early stages of the disease, creatinine level
may be normal but it could also be discovered later on in the urinalysis that the kidney is
releasing protein and red blood cells through the urine. To check if the cause is
reversible, various forms of imaging, blood test and renal biopsy are done. An ultrasound
examination of the kidneys is usually helpful in evaluating for obstructive uropathy and
in distinguishing acute from chronic renal failure based on kidney size. The definitive
diagnostic tool is renal biopsy, but it is not recommended when ultrasonography
indicates small, fibrotic kidneys. Recent professional guidelines classify the severity of
chronic kidney disease in five stages.

Stage 5 CKD is also called established chronic kidney disease and is synonymous
with the now outdated terms end-stage renal disease (ESRD), chronic kidney failure
(CKF) or chronic renal failure (CRF)
Progression of CKD is predicted in most cases by the degree of proteinuria.
Hypertension, acidosis, and hyperparathyroidism are associated with more rapid
progression as well. There is no specific direct treatment that will slow the progression of
the disease. If there is an underlying cause, this may be treated directly just to slow the
damage. In particular, controlling hyperglycemia in patients with diabetic nephropathy
and controlling hypertension in all patients substantially slows deterioration of GFR.
Severe CKD requires forms of renal replacement therapy such as dialysis and kidney
transplantation.

Objectives of the Study

General Objective:
The nursing profession is a unique field in which one is given a chance to improve
the lives of their patients by providing them with specialized care thus promoting their
optimum wellness. With this, our purpose is to gain and apply knowledge about the
condition and treatment of a client with chronic kidney disease.
Specific Objective:
a. To provide health workers valid and reliable information on the related causes
of chronic kidney diseases in relation to decision making in the nursing practice.
b. To enhance the knowledge and critical thinking in assessing for the signs &
symptoms that could determine the presence of CKD and evaluating therapeutic
interventions in professional nursing practice.
c. To formulate all possible evidenced based treatment and individualized,
compassionate and culturally appropriate nursing care for clients with CKD.

d. To establish guidelines on health teachings regarding the disease prevention and

early detection of CKD.
e. To provide a framework of study regarding the subject that can serve as the
foundation in future studies and research in the advancement of health care.
f.

Make a thorough assessment and good clinical judgment about the patients
personal history, family background, and lifestyle.

g. Identify predisposing and precipitating factors that have contributed to the

patients present condition.
Theoretical Framework
Dorothea Orem's Self-Care Theory
This theory assumes that:

People should be self-reliant and responsible for their own care and others
in their family needing care.

People are distinct individuals.

Nursing is a form of action interaction between two or more persons.

Successfully meeting universal and development self-care requisites is an

important component of primary care prevention and ill health.

A persons knowledge of potential health problems is necessary for

promoting self-care behaviors.

Self care and dependent care are behaviors learned within a socio-cultural
context.

A. Theory of Self Care

This theory Includes:

Self care practice of activities that an individual initiates and performs on their
own behalf in maintaining life, health and well being.
Self care agency is a human ability which is "the ability for engaging in self care"
-conditioned by age developmental state, life experience socio-cultural orientation
health and available resources.
Therapeutic self care demand "totality of self care actions to be performed for
some duration in order to meet self care requisites by using valid methods and
related sets of operations and actions"

B. Theory of self care deficit

Specifies when nursing is needed.

Nursing is required when an adult (or in the case of a dependent, the parent) is
incapable or limited in the provision of continuous effective self care.

C. Theory of Nursing Systems

Describes how the patients self care needs will be met by the nurse , the patient,
or both.
Identifies 3 classifications of nursing system to meet the self care requisites of the
patient:
-

Wholly compensatory system

Partly compensatory system

Supportive educative system

Design and elements of nursing system define.

Scope of nursing responsibility in health care situations.

General and specific roles of nurses and patients.

Reasons for nurses relationship with patients.

Orem recognized that specialized technologies are usually developed by members

of the health profession.

A technology is systematized information about a process or a method for

affecting some desired result through deliberate practical endeavor, with or
without use of materials or instruments.

The theory of self-care deficit when applied could identify the self care requisites of
patient from various aspects. This will be helpful to provide care in a comprehensive
manner. The application of this theory will reveal how well the supportive and
educative and partly compensatory system could be used for solving the problems in
a patient with Chronic Kidney Disease.
CLINICAL SUMMARY
General Data
A. Nursing History
Demographic Data

Name: A. F. T.
DOB: 08/23/1933
Age: 80
Gender: Male
Civil Status: Widowed
Nationality: Filipino
Religion: Roman Catholic
Address: Pasay City
Educational Attainment: College graduate
Occupation: retired accountant
Date of Admission: 08/20/2014
Attending Physician: Dr. Babaran
Chief Complaint decreased appetite and shortness of breath.
Admitting Diagnosis - Uremia; Electrolyte imbalance (Hyperkalemia); Metabolic
Acidosis; Anemia of Chronic Disease, Chronic Kidney Disease Stage 5; CAD,
Paroxysmal Atrial Fibrilation.
History of Present Illness
1 week prior to admission, patient reported to have generalized body weakness,
easy fatigability and decreased appetite. Patient also complained of difficulty in sleeping
and muscle cramps. Persistence of symptoms prompted consult at ER and was
subsequently admitted.
Upon admission, initial laboratories were done with results noted; increased
potassium levels, decreased hematocrit and hemoglobin, decreased magnesium and
phosphorus. Patient was placed on oxygen support at 2 lpm via nasal cannula.
On the 1st hospital day, patient still presented with generalized body weakness,
shortness of breath and poor appetite. Patient was referred to nephrology service for
further evaluation and co-management. Furthermore, patient was referred to an
interventionist for IJ catheter insertion. Right sided IJ catheter was inserted and chest xray showed the tip of the projection of superior vena cava with no noted pneumothorax,
and atherosclerotic aorta. Present management was continued.
On the 2nd hospital day, patient still reported to be pale and weak looking with
poor appetite thus NGT was inserted and another blood transfusion of PRBC was done
during hemodialysis with no noted adverse reaction. Present management was
continued.
On the 4th hospital day, repeat 12L ECG was done which revealed sinus rhythm
with early repolarization pattern and old septal wall myocardial infarction. Patient
tolerated sitting at bedside, however, had with dizziness on standing. There was no
noted shortness of breath and had improved appetite. Intravenous hydration was
consumed and discontinued. Present management was continued.

On the 5th hospital day, patient was given hepatitis B vaccine and was referred to
Dr. Felixberto Lukban for AVF creation.
On the 6th hospital day, patient complained of abdominal pain with urge to
defecate but had difficulty in passing out stools.
On the 7th hospital day, patient reported to have black stools corollary with
epigastric pain. No nausea, no vomiting noted. Patient was given omeprazole 40 mg IV.
On the 8th hospital day, patient was comfortable and had good appetite, no
recurrence of epigastric pain and black stools. Patient underwent regular scheduled
hemodialysis which he tolerated. Present management was continued.
On the 9th hospital day, patient underwent AVF creation on right arm, patient
tolerated the procedure with no noted post-operative complications.
The rest of his hospital stay was unremarkable. Patient was comfortable with
improved appetite and was noted to have improved condition. Moreover, patient had no
subjective complaints thus patient was cleared for discharge.
Past Medical History
Patient has been diagnosed to have Hypertension for 20 years. Patient also
had Paroxysmal Atrial Fibrillation prior to admission.
Family Health History
Client was reported to have a family history of hypertension in his siblings.
Patient has a strong family history of hypertension on paternal side. Fathers cause
of death was Cardiac Arrest. Mothers history of illness is unremarkable. Genetic
factor may also contribute to the patients current medical condition.
Personal/ Social History
He started smoking when he was 20 years old and stopped at 40 (20 pack
years). Also, he was an alcoholic beverage drinker (average of 3 bottles of beer
per day 3 times per week) for 40 years.

B. Physical Assessment
ASSESSME
NT
Vital Signs

NORMAL
FINDINGS
BP: 120/80
Temp: 3637C
RR: 16-20
PR: 60100bpm

ACTUAL
FINDINGS

METHODS
USED

INTERPRETATI
ON

BP: 130-170/
70-100mmHg
Temp: 36.0
36.7C
RR: 18 25
cpm

Inspection
Palpation
Auscultatio
n

-Hypertensive

General
Survey

Chest and
lungs

Cardiovascul
ar

Body built,
height &
weight in
relation to
age lifestyle
and health

Conscious,
awake,
follows
command,
not in
respiratory
distress
Symmetrical
chest
expansion, no
retractions,
no difficulty of
breathing

Adynamic
precordium,
regular rate,
regularly
regular
rhythm,
no
murmurs
Proportionate,
varies with
life style

PR: 62 - 88
bpm
With shortness
of breath

Inspection

Symmetrical
chest
expansion, no
retractions,
complains of
difficulty of
breathing, has
cough and
yellowish thick
sputum, (+)
productive
cough with
yellowish
phlegm, (+)
occasional
rales, (+)
crackles, (+)
Shortness of
breath

Inspection

With
paroxysmal
atrial fibrillation

Palpation
Auscultatio
n

Height: 57
Weight: 145lbs
Age: 80
BMI: 22.8

Inspection

- There is an
URTI which
contributes to
his difficulty of
breathing

- Calculated
body mass
index (BMI) is
within normal

Observe
skin color
and palpate
the skin
moisture
HEENT

Moisture in
skin and the
axillae.

Warm, dry skin,

no active
dermatoses

Pinkish
palpebral
conjuctivae,
(-) tonsillopharyngeal
hyperemia, (-)
cervical
lymphadenop
athy
36 37.6 C

Within normal Inspection

findings

Temp: 36.0C

Palpation

- within normal
findings

Eye sight

20/20

Inspection

- within normal
findings

Inspect the
teeth and
gum

Pinkish,
moist , and
firm textured
gums
-32 teeth

Inspection

- within normal
findings

Inspect the
neck
muscles

Muscles are
equal in size
and head is
centered

Inspection
Palpation

- within normal
findings

Abdomen

Flabby soft
abdomen,
normoactive
bowel sounds,
(-) masses, (-)
tenderness
No severe
varicosities,
deformities,
swelling or
severe pain
on arms

Wears eye
glasses when
reading
With dentures,
pinkish gums,
teeth slightly
yellowish, but
has no dental
carries
Muscles are
equally in size
and head is
centered.
IJ Catheter
noted at right
side, no signs
of infection
Had an episode
of (-) bowel
movement for
2 days
Has right AVF
(right arm
precaution),
with positive
signs of bruit
and thrills

Inspection
Palpation

Full equal
pulses, with
edema on both

Inspection

Palpate skin
temperature

Assessing
the Upper
Extremities

Assessing
the Lower
Extremities

No severe
varicosities,
deformities,

Inspection
Palpation

- normal skin
findings

Auscultatio
n
Palpation

- within normal
findings

swelling or
severe pain
on legs

PRIOR TO
HOSPITALIZATION

lower
extremities, no
cyanosis

DURING HOSPITALIZATION

Patient rated his

general health 5/10
(10 being the
highest and 1 being
the lowest) because
of his condition
hypertension
He verbalized that
being healthy is
very essential to
him
Walking every
morning for 15-20
minutes is his form
of exercise
He takes Moriamin
Forte

ANALYSIS

Patient rated his

general health 3/10

The patient is aware

of his condition

He verbalized the
want to be strong
and healthy again
by following the
needed therapeutic
regimen instructed
by his physician

He adheres to the
medication and
treatment regimen
prescribed

He has
maintenance drugs
for hypertension
Stops smoking and
drinking alcoholic
beverage

He smokes 1 pack
per day or 20 pack
years and drinks
alcoholic beverages
approximately 3-6
bottles, 2-3 times a
week for 20 years
In terms of
traditional concept
of health and
illness, prayer helps
a lot in such crisis
He consults the
doctor only when he
experience severe
symptoms
C. Patterns of Functioning

10

There is a need to
encourage the
patient to have
regular check ups

1. HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

2. NUTRITION-METABOLIC PATTERN

PRIOR TO
HOSPITALIZATION
According to him,
nutrition is an
important factor to
an individuals
health
He usually eats 3-4
times a day
including snacks in
between meals
He prefers to eat
fruits and
vegetables
His oral fluid intake
is approximately 79 glasses of water,
1200-1500 ml per
day

DURING HOSPITALIZATION
He has decreased
appetite
He can only ingest
two spoons of food
per meal
NGT was inserted
and feeding was
started (Neprocan
Q4)
His oral fluid intake
is approximately
800-1000 ml per
day

Height: 57
Weight : 145lbs
BMI: 22.8

11

ANALYSIS
An individual health
status greatly
affects eating habits
and nutritional
status

3. ELIMINATION PATTERN

PRIOR TO
HOSPITALIZATION
Patient defecates 12 times a day. Stool
is hard in
consistency and
brown in color
He urinates 2-3
times a day roughly
around 300-500 cc
per day

DURING HOSPITALIZATION
He has negative
bowel movement
for two days.
Lactulose was given
but still no
improvement.
Dulcolax
suppository was
prescribed and
resulted to (+)
bowel movement,
soft in consistency,
brown in color

ANALYSIS
Elimination is
important because
urinary and bowel
movement affects
your entire
physiology. It makes
the body pH in
balance and it
eliminates body
toxins with it

He urinates 2-3
times a day
approximately 300500 cc

4. ACTIVITY AND EXERCISE PATTERN

PRIOR TO
HOSPITALIZATION
Walking is his only
form of exercise
He spends most of
the time watching
television and
listening to the
radio

DURING HOSPITALIZATION
The patient stays in
bed almost all of
the time
Can ambulate but
with assistance due
to dizziness and
general weakness

12

ANALYSIS
Individuals who
have in active
lifestyles, all who
are faced with
inactivity because
of illness or injury
are at risk for many
problems that can

 He usually reads
newspaper

He spends most of
the time talking to
his children

affect major body

systems
There is a limitation
in his activities of
daily living and a
disruption in his
leisure and
recreation pattern

5. SLEEP REST PATTERN

PRIOR TO
HOSPITALIZATION
He usually sleeps
approximately 4-5
hours at night
Take afternoon naps
of 30 minutes - 1
hour per day

DURING HOSPITALIZATION
He sleeps 3-5 hours
at night and take 12 afternoon naps
about 30 minutes to
1 hour
Patient spends time
lying on his bed

He has sleep
disturbance

ANALYSIS
Illness that causes
distress can result
in sleep problems.
People who are ill
requires more sleep
than normal and
normal rhythm and
wakefulness is often
disturbed
There is sleep
disturbance

Watching television,
listening to the
radio and reading
newspaper is a
form of relaxation
for him

6. COGNITIVE PERCEPTUAL PATTERN

PRIOR TO
HOSPITALIZATION
He is able to
understand and
follow instructions
or directions

DURING HOSPITALIZATION
Oriented to people,
time and place
Responds to stimuli

13

ANALYSIS
There was a change
in cognitive and
perceptual pattern
in terms of stimuli

 He can read and

write well
He has no hearing
aid
He has reading
glasses

verbally and
physically
No sensory deficits
but functions are
diminished due to
age

because it is limited
only to the
environment which
is within the
hospital area and
patients room

His sensory
perception is limited
to the hospital room

7. SELF PERCEPTION/SELF CONCEPT

PRIOR TO
HOSPITALIZATION
The patient
describe himself as
a happy and
cheerful person
He is hopeful to be
relieved and treated

DURING HOSPITALIZATION
He is easily agitated
and irritated
because of his
condition and lack
of sleep
He feels anxious
and sometimes
depressed
He doesnt feel
good about himself

ANALYSIS
Events or situations
may change the
level of self-concept
Due to his present
condition, there is a
change to the level
of patient self
perception and self
concept due to his
illness on his age of
life

His attention span

is short and he does
not maintain eye
contact

8. ROLE RELATIONSHIP PATTERN

PRIOR TO
HOSPITALIZATION
The patient is a
widower

DURING HOSPITALIZATION
His children were
with him during
confinement

He lives with his son

14

ANALYSIS
When illness occurs,
roles changes for
both patient and
family

and his family

They were
supportive in giving
the needs of the
patient

He socializes with
his relatives and
neighbors

They verbalized
that they wish that
their father would
be relieved and
treated

The patient
achieves his
emotional and
moral support from
his families and
friends, which will
help him to cope
with his present
condition

They were ready to

adhere to the
therapeutic regimen
that would be
prescribed
The patient was
visited by his
relatives and some
friends
9. SEXUALITY REPRODUCTIVE
PRIOR TO
HOSPITALIZATION
He doesnt engage
in sexual activity
after his wifes
death, and also due
to his age

DURING HOSPITALIZATION
He considers
himself healthy
even though he is
not sexually active

ANALYSIS
There are no
changes in patient
sexuality and
reproductive
pattern

10. COPING STRESS TOLERANCE

PRIOR TO
HOSPITALIZATION
When he is stressed
he usually wants to
be alone

DURING HOSPITALIZATION
He copes with his
children

He drinks to forget
his problems

He verbalizes what
he feels to his
children

He usually pray in

He take deep

15

ANALYSIS
Coping is the
cognitive and
behavioral effort to
manage specific
external and
internal demands
that are appraised
as taxing exceeding

time of crisis

breaths and try to

relax
Prayer is also his
way in coping stress

the resources of the

person
The patient has
outlet to let his
feelings of stress
out by interacting
with the family and
friends

11. VALUE BELIEF PATTERN

PRIOR TO
HOSPITALIZATION

DURING HOSPITALIZATION

The patient is
Roman Catholic. He
considers this an
important aspect in
life and states that
having faith is
essential in
maintaining his
health

His faith remained

unchanged

He seldom attends
mass during
Sundays

He believes that
everything has a
purpose or a reason

He verbalized that
God is the source of
his strength and he
believes that only
God can help him
get through this

He prays every
night before he
sleeps

16

ANALYSIS
A persons values
influence belief
about human
needs, health, and
illness, the practice
of health behaviors
and human
responses to illness

C. Laboratory and Diagnostics Examinations

BIOCHEMISTRY
Date Ordered: Aug. 20, 2014

Actual Range

Normal Range

Interpretation

Total Protein

68 g/L

64-82

Normal

Albumin

39mmol/L

34-50

Normal

Globulin

35 g/L

15-35

Normal

A/G ratio

1.20

1.10-2.40

Normal

SGPT (ALT)

13 u/L

0-55

Normal

BUN

44.6

2.5-6.4

High

Uric Acid

527

155-428

High

Sodium

140

135-145

Normal

Potassium

6.2

3.5-5.1

High

Creatinine

735

53-115

High

Interpretation

17

BUN Uric Acid and Creatinine levels are high because the kidneys are unable to
excrete chemicals waste so as a result, it will be retained in the body. Metabolic acidosis
causes hyperkalemia which is a compensatory mechanism of the body.

NUCLEAR MEDICINE RESULT

Date ordered: Aug. 20, 2014

Test

Result

Normal Values

Interpretation

FT3 (RIA)

19.68

2.5-5.8 pmol/L

HIGH

FT4 (RIA)

38.41

11.5-23.0 pmol/L

HIGH

TSH ( IRMA)

0.01

0.27-3.75 ul/ mL

LOW

Interpretation
In people with hyperthyroidism (overactive thyroid) the level of TSH will usually be
low. This is usually because the thyroid gland is making too much of its hormones. When
levels of T3 and T4 are high, the pituitary is 'turned off' and the amount of TSH produced
is less.

URINALYSIS

18

Date requested: Aug. 20, 2014

Appearances
Color:

light yellow

Transparency:

clear

Specific gravity:

1.030 (NORMAL: 1.000 to 1.030)

pH:

6.0

( Interpretation: Acidic because of retained waste chemicals in the body)

Sugar:

NEGATIVE

Protein:

1+

( Interpretation: Approx. 30 mg/dl is loss because the kidneys are unable to reabsorb)
RBC:

0-1 (NORMAL: 0-2/hpf)

WBC:

0-2 ( NORMAL: 0-4/hpf)

Bacteria:

NONE

Crystals:

NONE

Cast:

NONE

ARTERIAL BLOOD GAS RESULT

Date ordered: Aug. 20, 2014

Parameter
s

pH

PCO2

P02

HC03

O2
Saturation

Actual
Range

7.21

28

75

11.2

92%

19

Normal
Range

7.35-7.45

36-45
mmHg

80-120

22-27

94-95%

Interpretation
PCO2 level is regulated by the lungs, while the HCO3 level is regulated by
the kidneys. The pH is 7.21 which is ACIDOTIC. PCO2 is 28 which is
ALKALOTIC which means that the lungs are able to compensate. HCO3 is
11.2 which means ACIDOTIC so the problem would be of METABOLIC
ACIDOSIS. The PO2 and O2 saturation results reflect that the patient
cannot receive oxygen adequately.
A. Acid Base Balance
Normal _____
Abnormal X Simple _Mixed
B. Primary defect
_Respiratory
X Acidosis
X Metabolic _ Alkalosis
_ Uncompensated
XPartially compensated
_Fully compensated
C. Oxygenation: Adequate

Interpretation: ALL FINDINGS ARE NORMAL.

PARASITOLOGY AND FECALYSIS

Date requested: Aug 20, 2014

FECALYSIS
Character:

semi-formed

Color:

brownish

Blood:

Negative

Mucus:

Negative

20

PARASITES
No ova or parasites seen
CBC
Hemoglobin
Hematocrit
Erythrocytes
MCV
MCH
MCHC
Total WBC
Differential
Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Platelet Count
protozoa

Result
82 g/L
0.26
2.94
68
28
31.80
7.5

Normal Values
135-160
0.40- 0.48
4.5-5.0
80-96
27-33
33-36
5.0-10.0

Interpretation
LOW
LOW
LOW
LOW
LOW
LOW
NORMAL

0.72
0.20
0.05
0.02
NORMAL

0.55-0.65
0.25-0.40
0.02-0.06
0.01-0.05

HIGH
LOW
NORMAL
NORMAL

INTERPRETATION: ALL FINDINGS ARE NORMAL

HEMATOLOGY
Date Ordered: Aug. 21, 2014

21

No

Interpretation
Because of damaged kidneys, it cannot secrete erythropoietin which is a hormone
needed by the bone marrow to secrete RBCs. The result, RBCs or erythrocytes are low in
number which will also result to the decrease of hematocrit, the percentage of the
volume of whole blood that is made of RBC. The MCV, MCH and MCHC, which are part of
RBC indices, will also be low. Neutrophils increased in any inflammation or tissue injury
but lowers lymphocyte count.
X-RAY
Date requested: Aug. 25, 2014

Examination: Chest Portable

Findings:
There is no evident pneumothorax
Both lungs are hyperaerated
Heart is not enlarged

BIOCHEMISTRY
Date Ordered: Aug. 25, 2014

Glucose fasting
Cholesterol
BUN
Creatinine
Sodium
Potassium
Iron
Calcium

Result
6.1
2.1
17.9
264
139
2.8
6.1
1.75

Normal Values
3.9-6.1
0-5.2
2.5-6.4
53-115
136-145
3.5-5.1
8.8-32.4
2.10-2.60

22

Interpretation
NORMAL
NORMAL
HIGH
HIGH
NORMAL
LOW
LOW
LOW

Magnesium
Phosphorus

0.59
1.48

0.65-1.07
0.74-1.52

LOW
NORMAL

Interpretation

Because of damaged kidneys, waste chemical of the body cannot be filtered

effectively. The result would be the waste chemicals will be retained inside the body
which caused the increased in BUN and creatinine. Because of hemodialysis, the
patients potassium level goes down rapidly. He was given Kaliumdurule to correct this
imbalance. Iron level is low same with the number of RBCs. The kidneys are also
responsible for the production of dehydrocalciferol (Vitamin D derivative) which is
needed for the absorption of Calcium in the intestines. Without it, calcium could not be
absorb in the bloodstream. Magnesium cannot be reabsorb by a damaged kidney so it
will continually be excreted in the urine.

COURSE IN THE WARD

Date/
Time
Aug.
21,
2014

Aug.
21,
2014
250am

Health Care Providers notes

Physicians orders

- seen and examined, 80 y/o male, with

easy fatigability, with general body
weakness, with decreased appetite, with
nausea, with sleep disturbance, with
occurrence of abdominal pain, no
palpitation, no melena
- BP 160/100, CR 80, RR 20, afebrile
- pale palpebral conjunctiva, dry skin,
dry lips, dry oral mucosa, non-tender
abdomen, no edema
- for transfer of 2 u PRBC
- with general body weakness, with
shortness of breath, with bone pains on
the lower back, with poor appetite
- BP 170/100, HR 110, RR 21

23

start nepro can 1 can TID

NaHCO3 650 mg/tab 1 tab TID
Ketor 2 tabs TID
PNSS 1L 10cc/hr while on BT

Aug.
21,
2014
715am

-flat on bed, no peripheral edema, with

generalized pallor

then monitor at 60 cc/hr for 8

hours
- MROD to evaluate hydration
status
- repeat serum K in am
- lactulose 30 cc now then
ODHS
- decrease CBG to BID
- start carvedilol 6.25 mg/tab 1
tab BID
- Algesia tab Q8 PRN for pain

- awake, flat on bed, 3x BM, ongoing BT,

still with poor appetite
- BP 160/70, HR 90, RR 21
- with generalized pallor, clear breath
sounds, with peripheral edema, I 1020,
O 520
- K 5.3

- facilitate serum K
- lactulose 30 cc if no BM ODHS

Aug.
21,
2014
1140a
m
Aug.
21,
2014
140pm
Aug.
21,
2014
230pm
Aug.
21,
2014
330pm
Aug.
21,
2014
345pm
Aug.
21,
2014
350pm
Aug.
21,
2014
830pm

- discontinue cardio monitor

- consent for IJ cath insertion for
HD
- for HD today

- please send patient to OR,

inform me once schedule is
available
- reserved 1 u PRBC for possible
BT
- s/p IJ catheter insertion

- for chest x-ray now

- for anti Hbs, HbsHg, anti Hcl

- include Ca, Mg, Phosphorus
- chest x-ray (initial), no pneumothorax

- s/p HD, no chest pain

- decrease IVF to 40 cc/hour

24

Aug.
22,
2014
620am
Aug.
22,
2014
805am
Aug.
22,
2014
10am

Aug.
22,
2014
1120a
m

Aug.
22,
2014
125pm
Aug.
22,
2014
215pm

- awake, comfortable, no DOB, no chest

pain
- BP 160/80, CR 88, RR 20, Temp
36.0
- no edema
- weak looking, with pallor,
- s/p HD yesterday
- Uremia, CKD stage 5 secondary to
HPNS
- Anemia secondary to CKD
- awaiting anti HBS, HbsAg, anti Hcl
- with nausea, with poor appetite, slight
headache, able to sleep well last night,
no vomiting
- BP 150/80, CR 104, RR 23, Temp
36.5
- I 1200, O 240
- s/p HD, clear breath sounds, no edema
- Ca 1.56, Mg 0.50, K 3.2
- low K 3.2
- low Mg 0.5
- low Ph 0.21
- NGT feeding, Nepro Q4
- Kalium durule TID
- Mg Oxide 250 mg TID
- BT 2 more u
- For Hep B vaccine 2ml
- no consent yet for NGT
- Hgb/ Hct 82/26
- K 3.2

- include serum K now

- hold kalimate

- insert NGT, Neprocan Q4

- transfuse 2 more u of PRBC
during HD

- comfortable
- BP 140/80, CR 96, RR 22, Temp
-36.0
- no abdominal tenderness, no edema
- I 1,200, O 240

Aug.
22,
2014
845pm

Aug.
23,
2014
9am

- give due Anti HPN meds

- CBC today

- awake comfortable, with weakness but

improved appetite

25

- IVF to follow: PNSS 1L for 20

cc/ hour
- transfuse 2 u PRBC properly
typed and cross-matched during
dialysis tomorrow
- Start PTU 50 mg/tab 1 tab TID
hold methimazole
- hold PNSS side drip
- transfuse 2 units PRBC
available while on HD today
- Set IVF to minimum
- discontinue NaHCO3 tablet
- inc. amlodipine to 10mg/tab
1tab OD

Aug.
23,
2014
10am
Aug.
23,
2014
1030a
m
Aug.
23,
2014
117pm
Aug.
24,
2014
545am
Aug.
24,
2014
8am

Aug.
24,
2014
840am
Aug.
24,
2014
1030a
m
Aug.
24,
2014
1pm
Aug.
25,
2014
9am

- ongoing HD
- conscious, coherent, not in distress,
good appetite, no nausea, and vomiting
- no dizziness, no edema, clear breath
sounds
- ongoing HD, comfortable, able to finish
breakfast

- s/p HD, s/p 2 u PRBC

- BP 180/80, HR 80, RR 20
- slightly pale palpebral conjunctiva
- no BM for 2 days
- BP 130/70, CR 83, RR 20, temp
36.0
- I 1250, O - 1070
- awake, had good sleep, claims to have
good appetite
- BP - 160/80, CR 77, RR 16, Temp
36.0
- I 1750, O - 940

- give dulcolax rectal

suppository 1 suppository now

- tolerated sitting on bedside but with

dizziness on standing
- for AVF creation as out patient
- for HD 3x a week for now

- d/c IVF
- d/c CBG monitoring

- clonidine 75mg/tab 1 tab BID

- amlodipine 10 mg 1 tab ODam
- clonidine 75mg/tab 1 tab BID
- EPO 5000 units, 2x/week
- ketosteril 2 tab TID
- carvedilol 6.25 mg/tab 1 tab
BID
- tamsulosin 1 tab OD
- moriamin tab 1 tab OD
- FeSo4 500mg/tab 1 tab OD

- give lactulose 30 cc ODHS if

no bowel movement for the day
- discontinue O2
- may sit at bedside
- give Hep B vaccine 2ml (40
mcg/ml) deep IM today
- 2nd dose: 2ml (40 mcg/ml) on
Sept. 25, 2014
- 3rd dose: 2ml (40 mcg/ml) on
Feb. 25, 2015
26

Aug.
25,
2014
1120a
m
Aug.
25,
2014
1145a
m
Aug.
25,
2014
730pm

- rounds with Dr. babaran

- K 2.8, Na - 139

- refer to Dr. Lukban for AVF

creation
- include fruits in diet

- AKI

- schedule for HD in am
- inform MROD once TIBC result
is available

Aug.
25,
2014
840pm
Aug.
26,
2014
2am
Aug.
26,
2014
6am
Aug.
26,
2014
645am
Aug.
26,
2014
720am

- noted schedule for AVF creation

Aug.
26,
2014
845am

- schedule for AVF creation

tomorrow 4pm
- inform OR
- secure consent
- inform all attending physicians

- given lactulose but still no BM

- will give rectal suppository if still
unable to defecate this morning
- still with urge to defecate,
unable/difficulty passing stool,
constipation

- May give dulcolax suppository

1 suppository now

- (+) BM, black stool

- no abdominal pain, no vomiting

- observe succeeding
characteristics of stool
- inform MROD of next BM

- (+) bowel movement, watery

- with cramping abdominal pain, with
appetite
- hyperactive bowel movement
- BP 130/70, CR 78
- clear breath sounds, hyperactive bowel
sounds, (-) edema
- Input and output 710 vs 500
(-) neck vein distention
(-) peripheral edema
Clear breath sounds

- give HNBB 1 ampule IV now

- lactulose 30 cc ODHS if no
bowel movement for the day
- For HD today

Nephro notes:
- comfortable, (+) bowel movement,
black stools this bowel movement
- BP- 140/70, HR 20, RR- 20, temp
36.0
- Input vs output 710 vs 500

- inform MROD once TIBC

results are in
- inform MROD once patient is
at kidney center

27

Aug.
26,
2014
1025a
m
Aug.
26,
2014
120pm
Aug.
26,
2014
220pm
Aug.
27,
2014
910am
Aug.
27,
2014
930am

Fe 6.1, Total Iron Binding Capacity

129, Ferritin 767.60
- IV iron 100 mg during HD every 2
weeks

Aug.
27,
2014
1120a
m

- better appetite, BP- 150/70, HR- 95, RR18, Temp- 36.0, Input vs Output 900 vs
550
- for AVF creation prior to discharge, HD
2x/week

Aug.
27,
2014
1220p
m
Aug.
27,
2014
220pm
Aug.

- GI comfortable, no melena, no
abdominal pain, stable vital signs, clear
breath sounds, no pallor, Hgb 10.5, Hct
- 0.30

- ongoing HD, last 17 minutes remaining,

comfortable, (-) headache, clear breath
sounds, BP- 158/67, HR 70, (+) melena
2x, (+) epigastric pain
(+) melena x 1, no abdominal pain, feels
comfortable after defecating, flat, soft,
non-tender abdomen
- black stool x 1
- with epigastric pain, currently on FeSo4
- BP 140/70, CR -78, RR 20, Temp
36.5
- awake, comfortable, ambulatory with
appetite, no difficulty of breathing, no
chest pain, BP- 130/70, HR- 70, clear
breath sounds, no peripheral edema
- awaiting AVF creation, HD 3x/ week
- no recurrence of melena, no headache
no dizziness, not in distress, BP- 150/70,
CR- 78, RR- 20, Temp- 36.5, clear breath
sounds, no edema
- HD 2x/week

- HD 2x/week, next HD 8/29/2014

- Rounds with Dr. Babaran

28

- start omeprazole 40 mg TID

now then OD pre-breakfast
- continue EPO 5000 u, 2x/week
after hemodialysis (Tuesdays
and Thursdays)
- Review of medications
- give dulcolax rectal
suppository 1 suppository now
- EPO 5000 units, 2x/week
- tamsulosin 1 tab OD
- moriamin tab 1 tab OD
- FeSo4 500mg/tab 1 tab OD
- lactulose 30 cc ODHS if no
bowel movement
- ketosteril 2 tab TID
- carvedilol 6.25 mg/tab 1 tab
BID
- clonidine 75mg/tab 1 tab BID

27,
2014
5pm
Aug.
27,
2014
740pm
Aug.
28,
2014
650am

- no clearance from business office

Aug.
28,
2014
820am
Aug.
28,
2014
255pm
Aug.
28,
2014
7pm
Aug.
28,
2014
1030p
m

- better appetite
- with dark stools, on FeSo4

Aug.
28,
2014
1120p
m
Aug.
29,
2014
725am
Aug.
29,
2014
10am

- noted AVF creation schedule, updated

APs

no recurrence of melena, Hemoglobin

10.5 10.8, Hematocrit -0.30 0.30
comfortable, no difficulty of breathing,
no chest pain, good appetite, no melena,
no abdominal pain, BP 140/70, HR
60, RR- 20
- clear breath sounds, no peripheral
edema, Input vs Output 1220 vs 1200
- Still for AVF, for HD
-for HD tomorrow am
- Shift omeprazole 40 mg IV to
40 mg 1 tab OD am
- for hemodialysis tomorrow

- Final disposition care of Dr.

Naidas
- business office cleared

- schedule patient for AVF

creation tomorrow to follow 1st
case of Dr. Lukban, under local
anesthesia
- secure consent
- inform OR, inform other API

- for HD today and AVF creation

- MGH tomorrow
- continue maintenance HD on
outpatient
- comfortable, no uremic symptoms
- good urine output
- good appetite
- BP 100/60, CR 73, RR 20, temp
36.7
- I- 1000, O 930
- HD 2x per week
29

Aug.
30,
2014
8am
Aug.
30,
2014
830am
Aug.
30,
2014
9am
Aug.
30,
2014
1150a
m

Aug.
30,
2014
2pm
Aug.
31,
2014
940am
Aug.
31,
2014
1040a
m
Aug.
31,
2014
1130a
m
Sept 1,
2014
530am
Sept 1,
2014

- asleep, comfortable, s/p HD yesterday,

s/p AVF creation
-BP 140/70, HR 80, clear breath
sounds, no peripheral edema, I 700, O
800
- still for home HD 2x a week
- May go home

- (+) thrills on AVR R arm

- dry dressing, no pain, good capillary
refill
- THM
- PTU 50 m/tab 1 tab TID
- Tamsulosin 1 tab OD
- Moriamin 1 tab OD
- Carvedilol 6,25 mg/tab 1 tab
BID
- Clonidine 7.5 mg/tab 1 tab
BID
- Amlodipine 10 mg/tab 1 tab
OD
- Ferrous Sulfate 500 mg/tab 1
tab TID
- Comfortable, stable VS

- Stable VS

- comfortable, no DOB
- BP 140/80, HR 72, clear breath
sounds, no peripheral edema
- no difficulty of breathing, no chest
pain, comfortable
- BP 130/70, Temp 36.7, PR 80, RR
20
- I 510, O 1,400
- (+) thrills on AVF R arm
- no pain, dry dressing, no steal
syndrome
- normal

30

- may ambulate around the

room as tolerated

- okay for discharge

-follow up at room 1005 after 1

6pm
Sept.
2, 2014
830am
Sept.
2, 2014
3pm
Sept.
3,2014
3pm

- Scheduled for HD today (Tuesdays and

Thursdays)
- s/p HD UF 500 cc
- BP 120/70, HR 90, afebrile, no chest
pain, I- 710cc, O 1580cc
- (+) productive cough with yellowish
phlegm
- BP 110/70, HR 62, RR 25, Temp
36.0
- no NVE, not in respiratory distress,
occasional rales, no wheezing, Adynamic
Pericardium

week, call for appointment

- remove heplock
- for hemodialysis today

- start fluimucil 600 mg mix in

glass of water TID
- Start levofloxacin 750 mg
every 48 hours, give 1st dose
today

CLINICAL DISCUSSION OF THE DISEASE

ANATOMY AND PHYSIOLOGY
I. Thyroid Gland
The thyroid is a highly vascular,
brownish-red, butterfly-shaped gland located
anteriorly in the lower neck, extending from
the level of the fifth cervical vertebra down to
the first thoracic. The gland varies from an H
a U shape and is formed by 2 elongated
lateral lobes with superior and inferior poles
connected by a median isthmus, with an
average height of 12-15 mm, overlying the
second to fourth tracheal rings.

to

The primary function of the thyroid is

production of the hormones Triiodothyronine
(T3), Thyroxine (T4) and calcitonin. The T4 and
T3
hormones stimulate every tissue in the body
to
produce proteins and increase the amount of oxygen used by cells. The harder the cells
work, the harder the organs work. The calcitonin hormone works together with the
parathyroid hormone to regulate calcium levels in the body.

31

Levels of hormones secreted by the thyroid are controlled by the pituitary gland's
thyroid-stimulating hormone, which in turn is controlled by the hypothalamus.
II. Cardiovascular System
The cardiovascular system consists of the heart, blood vessels, and
approximately 5 liters of blood that the blood vessels transport. Responsible
transporting oxygen, nutrients, hormones, and cellular waste products throughout
body, the cardiovascular system is powered by the bodys hardest-working organ
heart.

the
for
the
the

The Heart
The

heart is located in the

chest
between
the
lungs
behind
the
sternum and above the
diaphragm.
It is surrounded by the
pericardium.
Its size is about that of
a fist, and its
weight is about 250300 g. Its
center is located about
1.5 cm to
the
left
of
the
midsagittal
plane. Located above
the heart are
the great vessels: the
superior and
inferior vena cava, the
pulmonary
artery and vein, as well
as the aorta. The aortic arch lies behind the heart. The esophagus and the spine
lie further behind the heart.
The heart has four valves. Between the right atrium and ventricle lies the
tricuspid valve, and between the left atrium and ventricle is the mitral valve. The
pulmonary valve lies between the right ventricle and the pulmonary artery, while
the aortic valve lies in the outflow tract of the left ventricle (controlling flow to the
aorta).

32

The blood returns from the systemic circulation to the right atrium and from
there goes through the tricuspid valve to the right ventricle. It is ejected from the
right ventricle through the pulmonary valve to the lungs. Oxygenated blood
returns from the lungs to the left atrium, and from there through the mitral valve
to the left ventricle. Finally blood is pumped through the aortic valve to the aorta
and the systemic circulation.

Electrical Conduction of the Heart

The heart functions to pump blood to the lungs and the body. In order to
pump, the heart requires an electrical impulse just like any other muscle in the
33

body. With normal electrical conduction, electricity for the heart originates from
the sinus node in the upper right corner of the right atrium. Electricity then
spreads across both atria before reaching the AV node where it momentarily
pauses. From the AV node, electricity then rapidly passes through the right and
left bundle branches to reach the ventricles. As electricity passes through the
ventricles, the muscle is stimulated to contract.
The sinus node is the pacemaker for the heart. The heart rate depends on
how fast the sinus node fires. Many things can affect the firing of the sinus node.
Adrenaline, the hormone the body releases in response to exercise, stress, or
emotion, typically causes the sinus node to fire faster and the heart rate to
increase.

A. Blood Vessels

34

Blood vessels are the bodys highways that allow blood to flow quickly and
efficiently from the heart to every region of the body and back again. The size of
blood vessels corresponds with the amount of blood that passes through the
vessel. All blood vessels contain a hollow area called the lumen through which
blood is able to flow.
There are three major types of blood vessels: arteries, capillaries and veins.
1. Arteries and Arterioles: Arteries are blood vessels that carry blood away from
the heart. Arteries face high levels of blood pressure as they carry blood being
pushed from the heart under great force. To withstand this pressure, the walls
of the arteries are thicker, more elastic, and more muscular than those of other
vessels. Arterioles are narrower arteries that branch off from the ends of
arteries and carry blood to capillaries.
2. Capillaries: Capillaries are the smallest and thinnest of the blood vessels in the
body and also the most common. They connect to arterioles on one end and
venules on the other. Capillaries carry blood very close to the cells of the
tissues of the body in order to exchange gases, nutrients, and waste products.
3. Veins and Venules: Veins are the large return vessels of the body and act as the
blood return counterparts of arteries. To facilitate the movement of blood,
some veins contain many one-way valves that prevent blood from flowing
away from the heart. Venules are similar to arterioles as they are small vessels
that connect capillaries, but unlike arterioles, venules connect to veins instead
of arteries. Venules pick up blood from many capillaries and deposit it into
larger veins for transport back to the heart.
B. Blood
The average human body contains about 4 to 5 liters of blood. As a liquid
connective tissue, it transports many substances through the body and helps to
maintain homeostasis of nutrients, wastes, and gases. Blood is made up of red
blood cells, white blood cells, platelets, and liquid plasma.

Red Blood Cells: Red blood cells, also known as erythrocytes, are by far the most
common type of blood cell and make up about 45% of blood volume. Erythrocytes

35

are produced inside of red bone marrow from stem cells at the rate of about 2
million cells every second. Erythrocytes transport oxygen in the blood through the
red pigment hemoglobin. Hemoglobin contains iron and proteins joined to greatly
increase the oxygen carrying capacity of erythrocytes.
White Blood Cells: White blood cells, also known as leukocytes, make up a very
small percentage of the total number of cells in the bloodstream, but have
important functions in the bodys immune system.
Platelets: Also known as thrombocytes, platelets are small cell fragments
responsible for the clotting of blood and the formation of scabs.
Plasma: Plasma is the non-cellular or liquid portion of the blood that makes up
about 55% of the bloods volume. Plasma is a mixture of water, proteins, and
dissolved substances.Many different substances can be found dissolved in the
plasma, including glucose, oxygen, carbon dioxide, electrolytes, nutrients, and
cellular waste products. The plasma functions as a transportation medium for
these substances as they move throughout the body.
Functions of the Cardiovascular System
The cardiovascular system has three major functions: transportation of materials,
protection from pathogens, and regulation of the bodys homeostasis.

Transportation: The cardiovascular system transports blood to almost all of the

bodys tissues. The blood delivers essential nutrients and oxygen and removes
wastes and carbon dioxide to be processed or removed from the body. Hormones
are transported throughout the body via the bloods liquid plasma.

Protection: The cardiovascular system protects the body through its white blood
cells. White blood cells clean up cellular debris and fight pathogens that have
entered the body. Platelets and red blood cells form scabs to seal wounds and
prevent pathogens from entering the body and liquids from leaking out. Blood also
carries antibodies that provide specific immunity to pathogens that the body has
previously been exposed to or has been vaccinated against.

Regulation: The cardiovascular system is instrumental in the bodys ability to

maintain homeostatic control of several internal conditions. .
Regulation of Blood Pressure
Certain hormones along with autonomic nerve signals from the brain affect the
rate and strength of heart contractions. Greater contractile force and heart rate
lead to an increase in blood pressure. Blood vessels can also affect blood pressure.
Vasoconstriction decreases the diameter of an artery by contracting the smooth
muscle in the arterial wall. The sympathetic (fight or flight) division of the
autonomic nervous system causes vasoconstriction, which leads to increases in
blood pressure and decreases in blood flow in the constricted region. Vasodilation
is the expansion of an artery as the smooth muscle in the arterial wall relaxes
after the fight-or-flight response wears off or under the effect of certain hormones

36

or chemicals in the blood. The volume of blood in the body also affects blood
pressure. A higher volume of blood in the body raises blood pressure by increasing
the amount of blood pumped by each heartbeat. Thicker, more viscous blood from
clotting disorders can also raise blood pressure.
III. The Kidney
The kidneys are part of the urinary system. There are 2 kidneys in the body, one
on either side of the spine under the lower ribs, deep inside the upper part of the
abdomen. The adrenal glands are found just above each kidney and are part of the
body's endocrine system.

The ureters are thin tubes about 2530 cm (1012 inches) long that connect
the kidneys to the bladder. The urethra is a small tube that connects the bladder
to the outside of the body.
Structure
The kidneys are bean-shaped organs, about 12 cm (45 inches) long, 6 cm
(23 inches) wide and 3 cm (12 inches) thick.
Each kidney is surrounded by:
a layer of fibrous tissue called the renal capsule
a layer of fatty tissue that holds the kidneys in place against the muscle at the
back of the abdomen
a thin, fibrous tissue on the outside of the fat layer called Gerota's fascia
The cortex is the tissue just under the renal capsule. The medulla is the inner part
of the kidney. The renal pelvis is a hollow collecting area in the centre of each kidney.

37

The renal artery brings blood to the kidney, and the renal vein takes blood back to
the body after it has passed through the kidney. The area where the renal artery,
renal vein and ureter enter the kidney is called the renal hilum.
Inside each kidney is a network of millions of small tubes called nephrons. Each
nephron has 2 main parts:
Tubule - are tiny tubes that collect the waste materials and chemicals from the
blood moving through the kidney.
Corpuscle - contain a clump of tiny blood vessels called glomeruli that filter the
blood.

Function
The main function of the kidneys is to filter water, impurities and wastes
from the blood.
The blood from the body enters the kidneys through the renal arteries.
Once in the kidney, the blood passes through the nephrons where waste products
and excess water are removed. The clean blood is returned to the body through
the renal veins.
The waste products filtered from the blood are then concentrated into urine.
The urine is collected in the renal pelvis. The ureters move the urine to the
bladder where it is stored. Urine is removed from the bladder through the urethra.
The kidneys also act as endocrine glands and produce certain types of hormones:
Erythropoietin (EPO) stimulates the bone marrow to make red blood cells

38

 Calcitriol, a form of vitamin D, helps the colon absorb calcium from the diet.
Renin helps control blood pressure.

PATHOPHYSIOLOGY

39

40

41

DRUG STUDY
DATE
ORDERED
NAME OF
MEDICATION
August 20,
2014
Calcium
polystyren
e sulfonate
(Kalimate)
15 g
TID

CLASSIFICATI
ON

ACTION

Antipotassium

reduces serum
levels of
potassium and
removes
excess
potassium
from the body
through the
GIT

SPECIFIC
INDICATION

Since patient
has ESRD
which means
his kidneys
are unable to
perform its
function of
eliminating
waste
products, he
retains
massive
amount of
potassium in
his blood
which results
to
hyperkalemi
a

43

CONTRAINDICATI
ON
Serum potassium
< 5 mmol/litre C
Conditions
associated with
hypercalcemia
(e.g.
hyperparathyroid
ism, multiple
myeloma,
sarcoidosis or
metastic
carcinoma)
History of
hypersensitivity
to polystyrene
sulfonate resins
Obstructive
bowel disease

COMMON SIDE
EFFECTS/
ADVERSE EFFECTS

NURSING
RESPONSIBILI
TIES

Hypokalemia and
Hypercalcemia
and their related
clinical
manifestations;
nausea, vomiting,
gastric irritation,
anorexia,
constipation and
occasionally,
diarrhea; Fecal
impaction and
gastrointestinal
concretions
(bezoars),
intestinal
obstruction, acute
bronchitis and/or
bronchopneumoni
a, Gastrointestinal
tract ulceration or
necrosis which
could lead to
intestinal
perforation

Use with
caution if
patient is
taking
digitalis
because of
the possibility
of digitalis
toxicity on
the heart,
manifested
by various
ventricular
arrhythmias
and A-V nodal
dissociation,
associated
with
hypokalemia
and/or
hypercalcemi
a
Use with
caution if
patient is
taking
aluminium
hydroxide
because of

possibility of
Intestinal
obstruction
Monitor for
signs of
Hypokalemia
and
Hypercalcemi
a (malaise,
palpitations,
muscle
weakness,
mild
hyperventilati
on, metabolic
acidosis

August 20,
2014

Antihypertensive

Clonidine
(Catapres)
75 mcg 1
tab
OD

Sympatholyti
c

stimulates CNS
alpha2adrenergic
receptors,
inhibits
sympathetic
cardio
accelerator
and

Indicated for
patients
hypertension

Hypersensitivity
to clonidine or
any adhesive
layer
components of
the transdermal
system
Use cautiously

44

drowsiness,
dizziness, lightheadedness,
headache,
weakness, dry
mouth, GI upset,
dreams,
nightmares,
dizziness,

Take this
drug exactly
as prescribed
Attempt
lifestyle
changes that
will reduce
your blood

vasoconstricto
r centers, and
decreases
sympathetic
outflow from
the CNS

with severe
coronary
insufficiency,
recent MI,
cerebrovascular
disease, chronic
renal failure,
pregnancy,
lactation

decreased libido,
palpitations
Drowsiness,
sedation,
dizziness, dry
mouth,
constipation,
Transient localized
skin reactions

pressure
(Stop
smoking and
drinking
alcohol, lose
weight,
restrict intake
of salt,
exercise
regularly)
Change from
a seated or
lying position
slowly to
avoid
dizziness.
Use caution
in performing
activities
requiring
alertness.

August 20,
2014
Methimazo
le
(Tapazole)

Anti-thyroid
drug

inhibits the
synthesis of
thyroid
hormones

Since patient
has
hyperthyroidi
sm, this is
indicated to
decrease his

45

Allergy to antithyroid products,

pregnancy,
lactation
Use cautiously

Dizziness,
weakness, vertigo,
drowsiness,
nausea, vomiting,
loss of appetite,
rash, itching

Use caution
in performing
activities
requiring
alertness.

5mg 1 tab
OD

August 20,
2014
Erythropoi
etin
(Recormon
) 5,000
units SQ

thyroid
hormones

Hematopoieti
c
Agent

a natural
glycoprotein
produced in
the kidneys
which
stimulates red
blood cell
production in
the bone
marrow

Treatment of
patients
anemia
associated
with chronic
renal failure
since one of
the kidneys
function of
producing
erythropoieti
n which is
responsible
in the
production of
RBC via
stimulation
of the bone
marrow is
lost

46

with bone
marrow
depression

Paraesthesia,
neuritis, rash,
agranulocytosis,
granulocytopenia,
thrombocytopenia,
hypoprothrombine
mia, bleeding

Uncontrolled
hypertension,
hypersensitivity
to human
albumin

Dizziness,
headache,
seizures, fatigue,
joint pain, nausea,
vomiting, diarrhea

Use cautiously
with pregnancy,
lactation, sickle
cell anemia,
myelodysplastic
syndromes,
porphyria,
hypercoagulable
disorders

Headache,
arthralgias,
fatigue, asthenia,
dizziness,
hypertension,
edema, chest
pain, nausea,
vomiting, diarrhea

Eat small
frequent
meals to
prevent GI
symptoms
Report fever,
sore throat,
unusual
bleeding or
bruising,
headache,
general
malaise
Drug must be
given three
times per
week and can
only be given
IV,
subcutaneou
sly, or into a
dialysis
access line.
Use caution
in performing
activities
requiring
alertness.
Report
difficulty
breathing,
numbness or
tingling,
chest pain,

seizures,
severe
headache

August 20,
2014
Amlodipine
(Norvasc)
10mg/tab
OD in AM

Antihypertensive,
Anti-anginal,
Calcium
channel
blocker

inhibits the
movement of
calcium ions
across the
membranes of
cardiac and
arterial muscle
cells; inhibits
trans
membrane
calcium flow
which results
in the
depression of
impulse
formation in
specialized
cardiac
pacemaker
cells, slowing
the velocity of
conduction of
the cardiac
impulse,
depression of
myocardial
contractility,
and dilatation

Indicated for
patients
hypertension

Allergy to
amlodipine,
impaired hepatic
or renal function,
sick sinus
syndrome, heart
block, lactation
Use cautiously
with heart failure
and pregnancy

Nausea, vomiting,
headache
Dizziness, lightheadedness,
headache, fatigue,
lethargy,
peripheral edema,
flushing, nausea

Monitor BP
carefully if
patient has
other antihypertensive
drugs
Attempt
lifestyle
changes that
will reduce
your blood
pressure
(Stop
smoking and
drinking
alcohol, lose
weight,
restrict intake
of salt,
exercise
regularly)
Eat frequent
small feeding
Report
irregular

47

of coronary
arteries and
arterioles and
peripheral
arterioles;
these effects
lead to
decreased
cardiac work,
decreased
cardiac oxygen
consumption,
and increased
delivery of
oxygen to
cardiac cells

August 22,
2014
Propylthio
uracil
(PTU)
50 mg 1
tab
TID

Anti-thyroid
drug

inhibits the
synthesis of
thyroid
hormones;
partially
inhibits the
peripheral
conversion of
T4 to T3, the
more potent
form of thyroid
hormone

heartbeat,
shortness of
breath,
swelling of
the hands or
feet,
pronounced
dizziness,
constipation

Since patient
has
hyperthyroidi
sm, this is
indicated to
decrease his
thyroid
hormones

48

Allergy to antithyroid drugs,

pregnancy
Use cautiously
with lactation

Dizziness,
weakness, vertigo,
drowsiness,
nausea, vomiting,
loss of appetite,
rash, itching
Paresthesia,
neuritis, vertigo,
drowsiness, skin
rash, urticarial,
nausea, vomiting,
epigastric distress

Take this
drug aroundthe-clock at 8
hour intervals
This drug
must be
taken for a
prolonged
period to
achieve the
desired
effects
Report fever,
sore throat,
unusual
bleeding or

August 22,
2014
Carvedilol
(Carvid)
6.25 mg 1
tab
BID

Alpha and
beta
adrenergic
blocker,
Antihyperten
sive

Completely
blocks alpha,
beta, and
beta2
adrenergic
receptors and
has some
sympathomim
etic activity at
beta2
receptors.
Both alpha and
beta blocking
actions
contribute to
the BPlowering
effect; beta
blockade
prevents the
reflex
tachycardia
seen with
most alpha
blocking drugs
and decreases
plasma renin
activity.
Significantly
reduces
plasma renin
activity

Indicated for
my patients
hypertension

Decompensated
heart failure,
bronchial
asthma, heart
block,
cardiogenic
shock,
hypersensitivity
to carvedilol,
pregnancy,
lactation
Use cautiously
with hepatic
impairment,
peripheral
vascular disease,
thyrotoxicosis,
diabetes,
anesthesia,
major surgery

Depression,
dizziness, lightheadedness
Dizziness, vertigo,
tinnitus, fatigue,
bradycardia,
hypotension,
gastric pain,
flatulence,
constipation,
diarrhea, rhinitis

bruising,
headache,
general
malaise
Take drug
with meals
Do not stop
taking drug
unless
instructed to
do so by a
health care
provider
Avoid use of
over the
counter
medications
If you are
diabetic,
promptly
report
changes in
glucose level
Report
difficulty
breathing,
swelling of
extremities,
changes in
color of stool
or urine, very
slow heart
rate,
continued

49

dizziness

August 20,
2014

Oral Iron
Supplement

FeSO4
1 tab TID

Hematinic

Ferrous sulfate
replaces iron,
an essential
component in
the formation
of hemoglobin.

Treatment of
patients
anemia

Hemosiderosis,
primary
hemochromatosi
s, hemolytic
anemia unless
iron deficiency
anemia is also
present, peptic
ulceration,
ulcerative colitis,
or regional
enteritis.

Temporary
staining of teeth
(with liquid forms).
Nausea, epigastric
pain,
vomiting, constipa
tion, black
stools, diarrhea,
anorexia.

Use cautiously
on long-term
basis.

August 22,
2014
Omeprazol
e

Proton Pump
Inhibitor

It suppresses
stomach acid
secretion by
specific
inhibition of

To prevent
acid-base
disturbances
in the GI
tract
50

Atrophic
Gastritis, Liver
Problems,
Clostridium
Difficile Bacteria

Back, leg, or
stomach pain
bleeding or
crusting sores on

Drug may be
taken with
meals to
minimize GI
effects;
maximum
absorption
will occur if
drug is taken
between
meals.
Ferrous
sulfate
blackens
feces and
may interfere
with tests for
occult blood
in the stool;
the guaiac
test and
orthotoluidin
e test may
yield falsepositive
results, but
the benzidine
test is usually
not affected.
Swallow
capsules
whole with
water. Do not
take with

(Omepron)
40mg 1cap
OD

the H +/K +
ATPase system
found at the
secretory
surface of
gastric parietal
cells. Because
this enzyme
system is
regarded as
the acid
(proton, or H+)
pump within
the gastric
mucosa,
omeprazole
will inhibit the
final step of
acid
production.
Omeprazole
will also inhibit
both basal and
stimulated
acid secretion
irrespective of
the stimulus.

August 22,
2014

Ketoanalogue
s

Ketoanalo
gues
and
Essential
Amino
Acids
(Ketosteri)

Essential
Amino Acids

Normalizes
metabolic
process,
promotes
recycling
product
exchange.

Related Colitis,
Osteoporosis,
Broken Bone,
Low Amount of
Magnesium in
the Blood

the lips
blisters
bloody or cloudy
urine
chills
continuing ulcers
or sores in the
mouth

other liquids
or open
capsule and
sprinkle onto
food.
Take on an
empty
stomach at
least 1 h
before meals.

difficult, burning,
or painful urination
fever

Indicated for
patients
metabolic
acidosis

Hypercalcemia
Disturbed amino
acid metabolism
Caution use for
patietn with

Reduces ion
concentration

51

Hypercalcemia
may develop

Take drug as
prescribed
Warn the
patient about
possible side
effects and
how to

600 mg 2
tabs
TID

of potassium,
magnesium
and
phosphate.

phenylketonuria

recognize
them
Give with
food if GI
upset occurs

August 20,
2014
Moriamin
Forte
(AminoVita
)
1 tab OD

Multivitamins
Essential
Amino Acids
Folic Acid

Moriamin Forte
is a combined
amino acidsmultivitamins
preparation,
which contains
8 essential
amino acids
and 11
vitamins in
well-balanced
proportion.
Amino acids
are required
for
incorporation
into protein of
the blood and
tissues, to
replace amino
acids already
present, to
restore the
damaged

Indicated for
patients
vitamin
deficiencies
and anemia

52

Patients with
malabsorption
syndrome

Headache,
nausea, vomiting,
stomach disorder,
unpleasant taste
bud, diarrhea and
abdominal cramp

Frequently
assess for
hypercalcemi
a
Use carefully
to patients
with Diabetes
Mellitus

tissue, and to
form new
protein.

August 20,
2014
Lactulose
(Duphalac)
30cc OD at
HS if no BM

Hyperosmotic
Laxative

Produces
increased
osmotic
pressure
within colon
and acidifies
its contents,
resulting in
increased
stool water
content and
stool
softening.
Causes
migration of
ammonia
from blood
into colon,
where it is
converted to
ammonium
ion and
expelled
through
laxative
action.

Indicated for
patients
constipation

Patients who
require lowgalactose diet.

Gaseous
distention with
flatulence or
belching,
abdominal
discomfort and
cramping,
diarrhea, nausea,
vomiting.

Advise
patient that
drug can be
mixed with
fruit juice,
water, or milk
to make it
more
palatable.
Inform
patient that
drug may
cause
belching,
flatulence, or
abdominal
cramps.
Instruct
patient to
notify health
care provider
if these
symptoms
become
bothersome
or if diarrhea
occurs.
Instruct

53

patient not to
take other
laxatives
while
receiving
lactulose
therapy.
Encourage
patient to
increase
dietary fiber
and fluid
intake and
participate in
regular
exercise.

54

NURSING PROCESS
PROBLEM LIST

Date
Identified

Nursing Diagnosis

Degree
of
Priority
1st

Sept
3,2014

Ineffective Airway
Clearance

Upon
Admission
Aug 2124, 2014
Esp. Aug.
22, 2014

Ineffective Tissue
Perfusion

2nd

Upon
Admission
Aug 21

Electrolyte Imbalance

3rd

55

Justification

Airway is always the top

priority.
Maintaining
a
patent airway is vital to life.
Mainly because the loss of
oxygen supply in the brain,
even in less than two
minutes will already result
to
brain
and
tissue
damage.
An obstructed
airway would stem to other
different problems. Thus,
resolution of this airway
problem
would
prevent
further deterioration of the
condition of the patient.
This is a circulation problem
and it is in second priority
because the patient has
been hypertensive for 20
years and is suffering from
decreased tissue perfusion
for the longest time. His
consistently high blood
pressure readings would
indicate a problem in the
patients circulation.
The renal systems primary
function is excretory and
therefore it maintains the
internal environment of the
body by selectively
excreting or retaining
substances according to an
individuals specific body
needs. However, a problem
in this system may disrupt

this homeostatic
mechanism making it
unable to filter effectively.
Thus, making the body lose
its needed electrolytes and
retain its unnecessary
waste products. This will be
our priority prior to fluid
volume excess because one
of the reasons for excess
fluid, or edema, is an
imbalance in the
electrolytes in the body.
Aug 22
O:240
Aug 22
NGT
insertion

Fluid Volume Excess

4th

Imbalanced Nutrition:
Less than body
requirements

5th

August 25

Acute Pain

6th

Self-care Deficit

7th

This will be our 5th priority,

we acknowledge this
problem since the patient
can no longer tolerate to
eat or lacks appetite to
food, which according to
Maslows hierarchy, is one
of our basic physiological
needs.
Since the patient only
reported an epigastric pain
rate of 4/10 which is
intermittent when he was
having a hard time passing
out stool, this will be our
next priority. According to
Virginia Hendersons 21
Nursing Problems, one is
to promote optimal
activity; exercise, rest and
sleep. In order to do so, we
must acknowledge and
resolve this problem in
order for the patient to do
tasks on his own, as to
providing comfort, and
relieving pain.
When the patient is
experiencing pain, his
activities are limited thus
needing help doing

56

August 21

Sleep Disturbance

8th

Aug 21,
After IJ
Cath
insertion
and AVF
creation

Risk for Infection

9th

activities of daily living. We

must acknowledge this
problem in order to
promote independence to
our patient and provide
plans for necessary
assistance needed.
Also as part of our
physiological needs, one
must be able to have
adequate rest periods. Also,
according to Virginia
Hendersons 14 human
needs, one is sleeping and
resting. Sleep plays a vital
role in good health and
well-being throughout your
life. Getting enough quality
sleep at the right times can
help protect your mental
health, physical health,
quality of life, and safety.
The patient is at risk for
infections because of the
invasive procedure he went
through, IJ cath insertion
and AVF creation. In order
to prevent the problem for
such risk, we must also
prioritize this in order to
prevent further
complications. Since it is
only a risk, this will be our
last priority among our
problems.

57

NURSING CARE PLAN

Cues and
Clues
Subjective:
Hindi ko nga
mailabas
yung plema
ko eh.
Complains of
difficulty of
breathing
Objective:
(+)
shortness of
breath

Diagnosis
Ineffective
airway
clearance
related to
copious
tracheobronchial
secretions

Scientific
Rationale
A state in
which an
individual is
unable to
clear
secretions or
obstructions
from the
respiratory
tract to
maintain
airway
patency.

Objectives

Interventions

Rationale

Evaluation

After the 8-hour shift,

the patient will:
Expectorate and
clear secretions
more readily.

DEPENDENT
Administered
expectorants and
bronchodilators
as ordered

DEPENDENT
To facilitate
easy expulsion
of secretions
and open
airways

After the 8-hour

shift, the patient
will:
1. Expectorate
and clear
secretions more
easily
Able to cough
out secretions

Demonstrate
reduction of
congestion.

Demonstrate the
use of incentive
spirometry, as
ordered

Demonstrate
behaviors to
improve or
maintain clear
airway.

Increase fluid
intake, amount
specifically
ordered by MD

(+) cough

INDEPENDENT
Monitor
respirations and
breath sounds
such as crackles,
stridor, wheezes

(+)productiv
e cough with
yellowish
phlegm
(+)
occasional
rales

Check clients
cough and gag
reflex and
swallowing
ability

(+) crackles

58

Breathing
exercises help
maximize
ventilation
Adequate
hydration can
help liquefy
secretions
INDEPENDENT
To be able to
identify
presence of
respiratory
distress and
accumulation of
secretions
To determine
the ability to

2. Demonstrate
reduction of
congestion
Clear breath
sounds
Noiseless
respiration
Improved
oxygen
exchange
Absence of
cyanosis
Oxygen
saturation
within normal
limits
Not using
accessory
muscles for

LONG TERM GOAL

Identify potential
complications and
how to initiate
appropriate
preventive and
corrective actions.
Provide
information about
disease
process/prognosis
and treatment
regimen.

Elevate head of
bed and change
position every
two hours and as
needed

Assist patient
with self-care
activities as
needed
Monitor for
restlessness,
anxiety, and air
hunger

Support active
patient control of
condition.

Encourage warm
than cold liquids
as appropriate
Encourage to
take a deep
breath, hold for 2
seconds, and
cough two or
three times in
succession

COLLABORATIVE

59

protect the
airway
To allow the
gravity to
decrease
pressure on the
diaphragm and
enhance
drainage to
different lung
segments

breathing
3. Demonstrate
behaviors to
improve or
maintain clear
airway
Use of coughing
exercises

Reduce oxygen
demand
These are early
indicators of
hypoxia
To help in
liquefying
secretions
Controlled
coughing is
accomplished
by closure of
the glottis and
the explosive
expulsion of air
from the lungs
by the work of
abdominal and
chest muscles

LONG TERM GOAL

4. To be able to
achieve a timely
and appropriate
intervention
5. Support
active patient

AND SELF CARE

MANAGEMENT
Assist in
performing
postural drainage
and percussion
as indicated
Assist with the
use of respiratory
devices such as
nebulization as
indicated
Stress the need
for regular
medical and
laboratory followup

Educate client
about reportable
symptoms like
restlessness,
anxiety, use of
accessory
muscles,
changes in sleep
pattern
Advise client to
monitor amount,
color and
consistency of

60

COLLABORATIVE
AND SELF CARE
MANAGEMENT
To aid in
facilitating easy
expectoration of
secretions
To maintain
adequate
airway and
improve
respiratory
function and
gas exchange
To evaluate the
progression of
disease and
monitor
response to
therapy
To provide
opportunity for
timely
evaluation and
intervention

To identify any
infectious
process and
promote timely

control of
condition
Necessary
lifestyle/behavio
ral changes
initiated.

sputum

Cues and
Clues
Subjective:
Matagalnaa
kong may
high-blood.
Objective:
Consistent
elevated BP
readings
(160/100,
170/100,
160/80)
(+) HTN for
20 years
(+) Family
history of
HTN
(+) Anemia
Low Hgb, Hct
(+)
Atherosclerot
ic aorta

Diagnosis
Ineffective
tissue
perfusion
related to
high blood
pressure

Scientific
Rationale
As blood
flows through
arteries it
pushes
against the
inside of the
artery walls.
The more
pressure the
blood exerts
on the artery
walls, the
higher the
blood
pressure will
be. If the
force of the
blood against
the artery
walls is high
enough, it
may
eventually
cause heart
problems.

intervention

Objectives

Interventions

Rationale

Evaluation

After the 8-hour shift,

the patient will:
Manifest increased
perfusion as
individually
appropriate

DEPENDENT
Administered
anti-hypertensive
drugs as ordered

DEPENDENT
To improve
tissue perfusion
and organ
function

After the 8-hour

shift, the patient
will:
6. Achieve
increased
perfusion
Blood
Pressure
within norma
acceptable
limits OR a
decrease in
the systolic
BP of 20-30
mm Hg

Absence or
reduction of signs
and symptoms of
altered tissue
perfusion
Demonstrate
techniques to
improve circulation
Prevent
complications

Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated
INDEPENDENT
Provide calm and
restful
surroundings,
minimize
environmental
stimulation
Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted
rest

(+) Blood
Transfusion

Assist patient
with self-care
61

To promote
optimal blood
flow, organ
perfusion and
function
INDEPENDENT
Helps reduce
sympathetic
stimulation and
promotes
relaxation
Reduces
physical stress
and tension that
affect blood
pressure
To decrease
cardiac demand

7. Absence o
reduction of
signs and
symptoms of
altered tissu
perfusion,
such as:
(-) edema,
paresthesia,
intermittent
claudication
Normal
laboratory

(+) pale,
weak-looking

activities as
needed
LONG TERM GOAL
Provide
information about
disease
process/prognosis
and treatment
regimen.
Support active
patient control of
condition.

Provide comfort
measures like
elevation of head
of bed
Instruct in
relaxation
techniques like
deep breathing
exercises and
guided imagery
Apply
intermittent
compression
devices or elastic
compression
stockings to
lower extremities
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Monitor response
to medications to
control blood
pressure

Implement

62

values
Decreases
discomfort and
may reduce
sympathetic
stimulation
Can reduce
stressful stimuli,
produce
calming effect,
thereby
reducing BP
To promote
circulation and
limit
complication

COLLABORATIVE
AND SELF CARE
MANAGEMENT
Response to
drug therapy is
important to
determine the
lowest dosage
of medications
and achieve
optimal effect
These
restrictions can

8. Demonstr
e techniques
to improve
circulation
Blood
Pressure
within norma
acceptable
limits OR a
decrease in
the systolic
BP of 20-30
mm Hg

9. Prevent
complication
(-) edema,
paresthesia,
intermittent
claudication

LONG TERM
GOAL
10. Provide
information
about diseas
process/
prognosis an
treatment
regimen.
11. Support
active patien
control of
condition
Necessary

dietary sodium,
fat, and
cholesterol
restrictions as
indicated

help manage
fluid retention
and decrease
myocardial
workload

Stress the need

for regular
medical and
laboratory followup

To evaluate the
progression of
disease and
monitor
response to
therapy

Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs
Emphasize the
need for regular
exercise program
Educate client
about reportable
symptoms like
decreased in
pain sensation,
non-healing
wounds.

63

To promote
independence
and ability to
deal and
manage own
needs
To enhance
circulation and
promote wellbeing
To provide
opportunity for
timely
evaluation and
intervention

lifestyle/beha
vioral
changes
initiated.

Cues and
Clues
Objective:
(+) Uremia
(+)Hyperkale
mia
(+)Metabolic
Acidosis
(+)Anemia of
Chronic
Disease

Diagnosis
Electrolyte
Imbalance
related to
renal
dysfunction

Scientific
Rationale
The kidney
maintains the
internal
environment
of the body
by selectively
excreting or
retaining
fluids or
electrolytes
or waste
products
according to
an
individuals
specific body
needs.
However, in
renal failure,
the kidneys
become
damaged.
Thus, it
cannot
selectively
filter the
fluids,
electrolytes
and waste
products
which are to
be excreted
or retained.

Objectives

Interventions

Rationale

Evaluation

After the 8-hour shift,

the patient will:
1. Display
laboratory results
within normal
range for
individual
2. Prevent
complications

DEPENDENT
Review clients
medications

DEPENDENT
To improve
tissue perfusion
and organ
function

After the 8-hour

shift, the patient
will:
12. Display
laboratory
results within
normal range
for individua
13. Prevent
complication

Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated
Collaborate in
the treatment of
the underlying
conditions

LONG TERM GOAL

3. Identify
individual risks
and engage in
appropriate
behaviors or

64

Instruct patient
in use of
potassiumcontaining salts
(salts
substitutes),
taking potassium
supplements
safely
INDEPENDENT
Monitor heart

To promote
optimal blood
flow, organ
perfusion and
function
To prevent or
limit effects of
electrolyte
imbalances
caused by
organ
dysfunction
Utilizing
electrolytes
depends on the
client regularly
receiving it in a
more readily
available form
INDEPENDENT
Dysrhythmias
are often
associated with

LONG TERM GOA

14. Identify
individual
risks and
engage in
appropriate
behaviors or

lifestyle changes
to prevent and
reduce frequency
of electrolyte
imbalances

rate and rhythm

by palpation and
auscultation
Auscultate
breath sounds,
assess rate and
depth of
respirations and
ease of
respiratory effort
Assess fluid
intake and
output

Watch out for

abdominal
cramping,
fatigue,
hyperactivebowe
l sounds, muscle
twitching, muscle
weakness
Watch out for
anorexia,
abdominal
distention,
diminished bowel
sounds, postural
hypotension,
muscle
weakness, flaccid
65

problems in
potassium
levels
To monitor the
effect of high or
low potassium
levels in the
body and
promote timely
intervention
Fluid imbalance
usually disrupt
electrolyte
transport,
function and
excretion
Monitoring of
these signs of
excess
potassium in
the blood will
promote timely
intervention

Monitoring
these signs of
low potassium
in the blood will
facilitate timely
intervention

lifestyle
changes to
prevent and
reduce
frequency of
electrolyte
imbalances

paralysis
Measure and
report all fluid
losses including
emesis, diarrhea

66

Loss of fluids
rich in
electrolytes can
lead to an
imbalance

Maintain fluid
balance

To prevent
dehydration and
shifts of
electrolytes

COLLABORATIVE
AND SELF CARE
MANAGEMENT

COLLABORATIVE
AND SELF CARE
MANAGEMENT

Monitor response
to medications to
control blood
pressure

Response to
drug therapy is
important to
determine the
lowest dosage
of medications
and achieve
optimal effect

Stress the need

for regular
medical and
laboratory followup

To evaluate the
progression of
disease and
monitor
response to
therapy

 Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs

Cues and
Clues
Subjective:
Verbalization
of shortness
of breath and
coughing
episodes
Reported
inability to
pass out
urine
Objective:
(+) Difficulty
of breathing
(+)
Hemodialysis
(8/22/14)
I 1200,
O 240
(+)mild

Diagnosis
Fluid
volume
excess
related to
compromise
d regulatory
mechanism
(kidney
failure)

Scientific
Rationale
Fluid volume
excess, or
hypervolemia
, occurs from
an increase
in total body
sodium
content and
an increase
in total body
water.

To promote
independence
and ability to
deal and
manage own
needs

Objectives

Interventions

Rationale

Evaluation

After the 8-hour shift,

the patient will:
Demonstrate
adequate fluid
volume and
electrolyte balance

DEPENDENT
Restrict sodium
and fluid intake
as indicated

DEPENDENT
To prevent
further fluid
excess

After the 8-hour

shift, the patient
will:
15. Demonstr
e adequate
fluid volume
and
electrolyte
balance
Vital signs
within norma
limits
Clear lung
sounds
No signs of
pulmonary
congestion
No edema
present
(-) oliguria
Stable weigh
16. Reported
understandin

Verbalize
understanding of
individual dietary
and fluid
restrictions

In renal
failure, the
glomeruli are
damaged
resulting in
fluid
overload.
Thus, this
increases the
hydrostatic
pressure
thereby

Administered
anti-hypertensive
drugs as ordered
Maintain rate of
IV fluid
administration as
ordered
Administer
diuretics as
prescribed
INDEPENDENT
Monitor input
and output every
shift

67

To improve
tissue perfusion
and organ
function
To prevent
peaks and
valleys in fluid
level and thirst
To prevent fluid
overload
INDEPENDENT
To obtain an
accurate fluid
volume status

swelling of
the hands
and feet
(+) oliguria
(+) HTN

Weigh daily with

the same type of
clothes

causing fluid
to be pushed
into the
interstitial
spaces. Since
fluids are not
reabsorbed
at the venous
end, fluid
volume
overloads the
lymph
system and
stays in the
interstitial
spaces
leading the
patient to
have edema,
pulmonary
congestion.

Measure
abdominal girth
daily
Elevate
edematous
extremities
Change positions
frequently
Place in semifowlers position

Provide calm and

restful
surroundings,
minimize
environmental
stimulation

LONG TERM GOAL

Provide
information about

68

Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted

To evaluate the
effectiveness of
diuretic therapy
used
To monitor signs
of fluid
retention
To reduce tissue
pressure
To reduce
likelihood of
skin breakdown
To facilitate
movement of
diaphragm and
improve
respiratory
effort
To promote
relaxation and
reduce tension

To conserve
energy and
lower tissue
oxygen demand

To decrease

g about fluid
restrictions
and diet
modification

disease
process/prognosis
and treatment
regimen.
Support active
patient control of
condition.

rest
Assist patient
with self-care
activities as
needed
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Monitor response
to medications
and diuretic
therapy

Implement
dietary sodium,
fat, and
cholesterol
restrictions as
indicated
Stress the need
for regular
medical and
laboratory followup

Identify
necessary
lifestyle changes
and assist client

69

oxygen demand
in tissues
COLLABORATIVE
AND SELF CARE
MANAGEMENT
Response to
drug therapy is
important to
determine the
effectiveness of
therapy
These
restrictions can
help manage
fluid retention
and

To evaluate the
progression of
disease and
monitor
response to
therapy
To promote
independence
and ability to
deal and
manage own
needs

LONG TERM
GOAL
17. Provide
information
about diseas
process/
prognosis an
treatment
regimen.
18. Support
active patien
control of
condition
Necessary
lifestyle/beha
vioral
changes
initiated.

to incorporate
disease
management
into ADLs
Emphasize the
need for regular
exercise program
Educate client
about
Hemodialysis
and care for the
AVF

Cues and
Clues
Subjective:
Walangwalatalagaak
ongganangk
umain.
Objective:
(+)
decreased
appetite
(+) NGT
insertion
(+) pale
and weaklooking

Diagnosis
Altered
nutrition:
less than
body
requirement
s related to
decrease in
appetite

Scientific
Rationale
The state in
which an
individual
experiences
an intake of
nutrients
insufficient to
meet
metabolic
needs

To enhance
circulation and
promote wellbeing
To provide
adequate
knowledge to
facilitate selfcare
management

Objectives

Interventions

Rationale

Evaluation

After the 8-hour shift,

the patient will:
Demonstrate
improvement in
fluid intake

DEPENDENT
Administer fluids,
electrolytes,
nutrients and
oxygen as
indicated

DEPENDENT
To promote
optimal blood
flow, organ
perfusion and
function

After the 8-hour

shift, the patient
will:
1. Demonstrate
improvemen
in fluid intak
Tolerate
feeding in
the
nasogastr
c tube

LONG TERM GOAL

Support active
patient control of
condition
Present
behaviors, lifestyle
changes to regain
and/or maintain
appropriate weight
70

INDEPENDENT
Provide oral
hygiene daily
Observe for
absence of
subcutaneous fat
and muscle
wasting, loss of
hair, fissuring of
nails, delayed

INDEPENDENT
To improve
taste
To assess
degree of
malnutrition

LONG TERM GOA

19. Support
active patien
control of
condition
20. Report:
Weight

 Height: 57

healing

Weight:
145lbs
BMI: 22.8

Use flavoring
agents like
lemons as
indicated

To enhance food
satisfaction and
stimulate
appetite

Maintain activity
restrictions
(complete bed
rest) and
schedule periods
of uninterrupted
rest

To conserve
energy

Assist patient
with self-care
activities as
needed
Encourage client
to choose foods,
or have family
bring foods that
seem appealing,
if not
contraindicated
Promote
adequate and
timely fluid
intake and limit
fluids 1 hour pre
meals
COLLABORATIVE
AND SELF CARE
MANAGEMENT

71

To reduce
anxiety and
tension
To enhance food
satisfaction and
stimulate
appetite

To reduce
possibility of
early satiety
COLLABORATIVE
AND SELF CARE
MANAGEMENT
To implement
interdisciplinary

within
normal
range for
client
Normal
BUN and
serum
albumin,
Hct, Hgb,
and
lymphocy
levels
No further
decline in
strength
and activi
tolerance
Healthy
oral
mucous
membran
21.Demonstr
ed change
in behavio
and
lifestyle
changes

 Consult dietitian
or nutritional
team, as
indicated
Stress the need
for regular
medical and
laboratory followup

Identify
necessary
lifestyle changes
and assist client
to incorporate
disease
management
into ADLs

72

team
management
To evaluate the
progression of
disease and
monitor
response to
therapy
To promote
independence
and ability to
deal and
manage own
needs

DISCHARGE PLANNING
Medicines
Instruct patient to take medications as directed:
1.
2.
3.
4.
5.
6.
7.
8.

Exercises
Treatment
Health Teachings

PTU 50 mg/ tab twice a day

Tamsulosin 1 tab once a day
Moriamin Forte 1 cap once a day
Carvedilol 6.25 mg 1 tab twice a day
Clonidine 75mg 1 tab twice a day
Amlodipine 5 mg 1 tab once a day
Ferrous Sulfate 500mg/tab 3 times a day
Recormon 5000 units twice a week (Tuesday and Friday)
carry after dialysis

Simple and tolerable exercises may be done. Such as walking

and stretching. Isometric exercises if possible.
Instruct patient to continue Hemodialysis on Out-Patient
Arteriovenous fistula or graft care:
Clean the skin over the fistula or graft every day with soap
and water.
Take the bandage off the fistula or graft 4 to 6 hours after
dialysis.
Check your fistula or graft every day for good blood flow by
touching it with your fingertips. The buzzing sensation
means that it is working. Check for bleeding, pain, redness,
or swelling. These may be signs of infection or a clogged
fistula or graft.
To prevent damage to the fistula or graft, no one should
take your blood pressure or draw blood from the arm with
the fistula or graft. Do not wear tight clothes or jewelry or
sleep on that arm.
Watch -out for sign and symptom of infection such as fever.
Contact Caregiver If:
You have a fever.
You cannot make it to your follow-up or dialysis visit.
You do not feel a buzzing sensation in your fistula or
graft.
You have chills, cough, or feel weak and achy.
Your skin is itchy or has a rash.
You have questions or concerns about your care or
treatment.
Seek Care Immediately If:
You are breathing fast, have a fast heartbeat, or feel

73

Out-Patient Follow-Up:

confused, dizzy, or lightheaded.

You are passing little or no urine at all.
You cannot eat or drink because you are vomiting
(throwing up).
You have chest pain or trouble breathing all of a sudden.
Your skin around your fistula or graft is painful, feels hot,
looks red, or is swollen.
Your bandage becomes soaked with blood.
Your fingers below the fistula or graft look blue or pale or
feel cool to touch.
Dr. Babaran: Room 409 Loc. 3409
Schedule: MWF (2pm-4pm); TTHS (10am-12nn)
Dr. Naidas: Room 1008
Tel:3746381 loc. 5008 Schedule:
Tuesday, Thursday and Saturday (4pm-6pm by appointment)

Diet:

Sexual Activity:
Spiritual Activity:

Dr. Lukban- Follow-up at RLG

Loc. ECUT Schedule: Tuesday
and Thursday (by appointment)
The patient may need to be on a special diet. He may need
to eat foods that are low in sodium (salt), potassium, and
protein. Eat foods that have a lot of fiber in them. Good
examples of foods with fiber are cereal, fruits, and
vegetables. Some fruits and vegetables are high in
potassium.
Do not drink alcohol. Alcohol can damage your brain, heart,
and liver. Almost every part of your body can be harmed by
alcohol. Drinking alcohol can also make your kidney failure
worse.
Not Applicable
Encourage family and community support for the patient.
Address spiritual needs by participating in religious
practices.

74

RECOMMENDATION

75

REFERENCES
Books:
Tomey AM, Alligood. MR. Nursing theorists and their work. (5th ed.). Mosby,
Philadelphia, 2002
19th Edition, the Merck Manual of Diagnosis and Therapy Merck, July 20, 2011
Doenges, M., Moorhouse, M., Murr, A. (2011). Nurse's pocket guide: diagnosis, prioritized
interventions and rationales. 12th edition. iGroup press co. Ltd: Thailand.
Berman, A., Snyder, S., Kozier, B., Erb, G. (2008). Fundamentals of nursing. 8th edition.
Pearson education south asia: Singapore.
Rod. R. Seeley, Trent D. Stephens, & Philip Tate, Essentials of Anatomy and Physiology,
6th edition by McGraw-Hill International Edition, 2007
MediMarketing, MIMS Philippines, 136th Edition 2014
Internet:
http://nurseslabs.com/nursing-nursing-related-theories-theorists-an-ultimate-guide/
http://www.simplypsychology.org/maslow.html

76