END STAGE RENAL DISEASE

A Mini Case Report

Presented to the College of Nursing

In Partial Fulfillment

of the Requirement in
NCM 98: INTENSIVE PRACTICUM

DOROTHY PEARL L. PALABRICA, SN IV

MARCH 2017
 Table of Contents

I. INTRODUCTION ................................................................................................. 2
II. HISTORY OF PRESENT ILLNESS ..................................................................... 4
III. PAST HEALTH HISTORY ................................................................................... 6
IV. NORMAL ANATOMY AND PHYSIOLOGY ........................................................ 17
V. PATHOPHYSIOLOGY ....................................................................................... 20
VI. DIAGNOSTICS .................................................................................................. 20
VII. INTERVENTIONS .............................................................................................. 20
VIII. ACTUAL NURSING CARE PLANS ................................................................... 26
IX. REFERENCES ................................................................................................. 34

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 I. INTRODUCTION

Chronic renal failure (CRF, end-stage renal disease, ESRD) is a progressive

deterioration of renal function, which ends fatally in uremia (an excess of urea and
other nitrogenous wastes in the blood) and its complications unless dialysis or kidney
transplantation is performed. It may result from chronic kidney disease, such as
bilateral pyelonephritis or congenital polycystic kidney disease, or from systemic
disorders such as hypertension or diabetes (Boyer, 2010).
The gradual loss of nephrons is asymptomatic until it is well advanced
because the kidneys normally have considerable reserve function. Once advanced,
the progress of chronic renal failure may be slowed but cannot be stopped because
the scar tissue and loss of functional organization tend to cause further degenerative
changes.
According to the National Kidney Foundation (2010), approximately 20 million
Americans have some type of chronic kidney disease. Most cases are asymptomatic
until later stages. The Department of Health (DOH) said close to 23,000 Filipinos
underwent dialysis due to kidney failure in 2013, nearly four times higher than the
4,000 cases recorded in 2004, or a 10 to 15 percent increase a year.

Chronic renal failure has several stages, progressing from decreased renal
reserve, to insufficiency, to end-stage renal failure or uremia. In the early stages of
decreased reserve (around 60% nephrons lost) there is a decrease in GFR, serum
creatinine levels that are consistently higher than average but within normal range,
serum urea levels that are normal, and no apparent clinical signs. The remaining
nephrons appear to adapt, increasing their capacity for filtration (Linkermann et.al,
2011).
The second stage (around 75% nephrons lost), or that of renal insufficiency, is
indicated by a change in blood chemistry and manifestations. At this point, GFR is
decreased to approximately 20% of normal, and there is significant retention of
nitrogen wastes (urea and creatinine) in the blood. Tubule function is decreased,
resulting in failure to concentrate the urine and control the secretion and exchange of
acids and electrolytes (Morton, 2009). Osmotic diuresis occurs as the remaining
functional nephrons filter an
increased solute load. This
stage is marked by excretion of
large volumes of dilute urine
(low fixed specific gravity).
Erythropoiesis is decreased,
and the patients blood pressure
is elevated. The cardiovascular
system must compensate for
these effects.
Uremia, or end-stage
renal failure (more than 90%
nephrons lost), occurs when
GFR is negligible. Fluid,
electrolytes, and wastes are

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retained in the body, and all body systems are affected. In this stage, marked oliguria
or anuria develops. Regular dialysis or a kidney transplant is required to maintain the
patients life (Quian et.al, 2010).
The early signs of chronic renal failure include:

Increased urinary output (polyuria), manifested as frequency and nocturia

General signs such as anorexia, nausea, anemia, fatigue, unintended weight
loss, and exercise intolerance
Bone marrow depression and impaired cell function caused by increased
wastes and altered blood chemistry
High blood pressure

As the kidneys fail completely (end-stage failure), uremic signs appear:

Oliguria
Dry, pruritic, and hyperpigmented skin, easy bruising
Peripheral neuropathyabnormal sensations in the lower limbs
Menstrual irregularities in women
Encephalopathy (lethargy, memory lapses, seizures, tremors)
Congestive heart failure, arrhythmias
Failure of the kidney to activate vitamin D for calcium absorption and
metabolism, combined with urinary retention of phosphate ion, leading to
hypocalcemia and hyperphosphatemia with osteodystrophy, osteoporosis,
and tetany
Possibly uremic frost on the skin and a urinelike breath odor in the terminal
stage or if infection is present
Systemic infections such as pneumonia (common), owing to poor tissue
resistance related to anemia, fluid retention, and low protein levels

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II. HISTORY OF PRESENT ILLNESS

a) Patients profile

Name: Vita Plus

Gender: Female
Age: 52 years old
Birthdate: May 31, 1964
Marital status: Married
Race: Asian
Nationality: Filipino
Religion: Pentecostal
Address: Purok-7 Pinatilan, Valencia City, Bukidnon
Occupation: Housewife
Usual source of
medical care: Physician in hospitals
Source of information: Husband
Admission date: February 18, 2017
Admission time: 12:00 PM
Hospital: BPH-Maramag
Area: Medical Ward-MIX
Admitting Diagnosis: Anemia secondary to colonic carcinoma,
nephrolithiasis; Diabetes Mellitus type II
Admitting Physician: Dr. Sweet and Sour
b) Chief Complaint
Shortness of breath

c) History of present Illness

Three weeks prior to admission, Vita plus was admitted in Hospital XYZ
for a week after experiencing severe flank pain . The family then requested to
be discharged against medical advice after financial constraints. Husband
then explained that they took care of Vita plus at home. She appeared very
weak and pale as described and confined to bed. Vita plus was supposed to
undergo dialysis but family decline due to unavailability of funds for the said
treatment. Not later than three days, Vita plus had attacks of excruciating
flank pain and not able to void, eat and became extremely weak and pale that
lead the family to decide to seek medical help and admit her in Bukidnon
Provincial Hospital-Maramag on February 18, 2016 12:00 PM.
During hospital stay, level IV students were able to provide care and
monitored patient condition for two days (February 23-24, 2016). Vita plus
was supposed to be transferred as soon as possible to Northern Mindanao
Medical Center after Dr. Nephrons recommendation to undergo application
for assistance in order for dialysis to be possible. Unfortunately, the family
opted to remain in BPH and utilize whatever treatment is available due to
personal preferences.
Assessment of Vita Plus showed poor prognosis. During the first day of
duty, she was still awake, appeared weak with poor muscle strength, pale,
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with noticeable labored breathing attached with oxygen @ 4 liters per minute.
A foley bag catheter attached to urobag, draining dark yellow blood tinged
colored urine with a total drainage of 150 ml was also noted. Patients diet
was on low salt, low fat but she consumes her share with poor appetite. Fluid
intake was limited to 1 liter a day but patient cannot tolerate intake of oral
fluids due to episodes of shortness of breath resulting to dry mucous
membranes, poor skin turgor and paleness were noted. Intravenous fluid was
also limited to KVO rate due to poor functioning kidneys. Vital signs were
very poor as well. Usual temperature during the first day was 36.9-37.4
degree Celsius and declines to an average of 35.4-36.1 degree Celsius during
the second day of duty. Respiratory and heart rate were consistent in a range
of 36-44 cycles per minute and 115-128 beats per minute. Blood pressure
ranged from 100/70 mmHg to 90/60 mmHg.
All the said assessments began to deteriorate during the second day
where patient then showed decreased level of consciousness with a GCS of 8
from GCS 13. Urine draining in the urobag also turned to dark brown colored
in 50 cc level. The physician had appraised the family again of the patients
condition and asked their decision of the possibility of an endotracheal
intubation. The family refused and also signed a Do-Not-Resuscitate II order.
On the other hand, a hard mass was inspected and lightly palpated on
right lower quadrant of the abdomen. Husband explained that it was just later
in 2016 that they have discovered the mass and after her wife undergone
ultrasound; they have known that the mass was malignant and during hospital
stay at XYZ, the doctor already appraised them regarding colonic cancer and
its therapy including prognosis considering the patients present disease and
condition concerning kidneys.

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III. PAST HEALTH HISTORY

IMMUNIZATION

Vita plus sister explained that she didnt know if sister has completed
immunization since childhood. But she have mentioned that sister had tetanus
immunizations during pregnancy and had regular visits for prenatal check-up after
knowing increased pregnancy risk secondary to hypertension and increased blood
glucose level. As verbalized, Wa ko ma familiar maam kung na kumpleto iyang
bakuna, siguro kumpleto. Ang katong tetanus nuon niya, murag nakahisgot to siya
sa una. High blood man gud ni siya pagpanganak sa iyang kinamanghuran, sige to
siyag balik balik sa center.

SURGERY/OPERATION

There were no any invasive or surgical procedures undergone prior to

admission. Husband and sister mentioned that Vita plus should have undergone
surgery to remove stones before but opted to maintain medicines only.

ALLERGIES

Upon assessment of allergies, husband reported no known drug and food

allergies.

PSYCHIATRIC HISTORY

Husband described cognitive and behavioral aspects of the child as normal.

He have mentioned that Vita plus was a happy-go-lucky type of a person and very
loving to children. As added, husband verbalized that Vita plus always ensures
safety and health condition of children despite her bad lifestyle. She pursues each of
them to finish school. Dili mani siya dali saputon maam, muagwanta ra gyud ni siya.
Mao pud lagi ang nakalain kay di magsaba diretso kung unsay gabation niya. Unya
ug badlungon ni nimo siya, lambingon na hinuon ka aron lang makakaon sa iyang
gusto. Malipay na lang oud ko nga Makita siya nga lipay siya maam labi na katong
ga grabi na siya, tanan niyang request itigayon nalang gyud namo kay di mi ganahan
nga maguol pa siya. Changes in level of consciousness began during
hospitalization in medical ward.

HOME MEDICATIONS

Upon assessment of any home medications used by client and family, the
husband showed the receipts of meds Vita plus has been taking. Among the
medications in the receipt include: Potassium Citrate 15 mEq oral solution TID x 3
months; Hydrochlorothiazide 25 mg 1 tab once a day x 30;

6
FAMILY HISTORY

Sister explained that both his paternal and maternal side has history of
hypertension, diabetes mellitus, and cancer. Vita plus sister claimed that father died
of stroke and mother has diabetes mellitus type II. An aunt in the paternal side has
recurrent urinary tract infection secondary to nephrolithiasis.
Common illnesses in the family include cough, colds fever, UTI which they
usually managed at home using herbal medications and food supplements with
adequate rest and balanced diet.

DEVELOPMENT OF DISEASE
As described by husband, Vita plus during her adolescence was already fond
of consuming foods salty foods paired with soft drinks. As verbalized by husband,
Katong nag-uban nami ug puyo maam, gabadlungon gyud nako na siya nga mag
control, pero mag-away na lang mi, magtuman gyud na siya. Nang dagko nalang na
akong mga anak mao lang gyud gyapon iyang paagi sa pag kaon. Mo kaon siyag
utan, pero naa gyud nay asin sa kilid kay tab-ang kuno. Mo inom ug tubig pero
ginagmay ra pud lagi kay mag soft drinks ra gyud lagi siya.
Vita Plus was only 31 years old when she began to felt early symptoms such
as frequent abdominal discomforts, with occasional chills and fever that she didnt
give much attention at first and thought that it was only panuhot and due to fatigue.
She became alarmed and thought of seeing medical help not until she experienced
sudden onset of headache, severe lower back pain radiating to abdomen and felt
nauseated and vomited small amounts of dirty white-colored vomitus. She also
urinated small amounts of blood-tinged urine. Vita plus was admitted in Hospital ABC
for 5 days and was informed that she has kidney stones and that shell be taking
medications to manage the pain and facilitate dissolution and passing out of stones
as well as given instructions to limit intake of salty and sweet foods since blood
glucose level was also borderline to high level. According to the husband, they
havent completely adhere to the advised treatment for her stones but tried to
manage it using natural way such as use of herbal plants. When asked about any
changes regarding the lifestyle and diet upon knowing presence of stone, husband
verbalized, Pagkabalo niya maam, nahadlok siya mao tong control2 pa siya ato, gi-
agwanta gyud niya. Dugay dugay pud nga wala na siyay gibati nga sakit, mao tong
wala na lang pud mi nag pa follow up kay basin naihi na pud niya ang bato.
As estimated by the husband, it was during 2003 that another acute attack
happened that made them rushed Vita Plus again in the hospital. Nag-ingon tong
doctor maam, nga mas nidaghan lagi daw ang stones unya daghan lagi daw ug
abnormal sa iyang result. Wa pud ko kabalo kung unsa to sila, creatinine ra man to
akong mahinumduman. Gi kumpirma pud sa doctor nga naa gyud siyay Diabetes.
Gi catheter pud gani to siya maam kay dili naman gyud siya makaihi. Husband was
asked what might have precipitated the attack and he explained that wife has once
again gone back to her unhealthy diet consuming large amounts of salt and limited
intake of water and consumes habitual intake of soft drinks instead. A sedentary
lifestyle was also described because wife was fond of watching television all day
after doing household chores in the morning.

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 With the events aforementioned, they havent fully complied with the
maintenance to control diabetes as well as the stones due to financial crisis. In
addition, at 40 years old, Vita plus became high-risk after experiencing pregnancy
induced hypertension and increased incident of diabetes while conceiving their 5 th
child.
Because treatment regimen was not given full attention and there werent
consistency with lifestyle modifications as correlated to lack of adequate financial
resources, the family specifically Vita plus, neglect the need of following up her
diagnosis and just managed symptoms by taking the pain reliever during attacks
which can be correlated to the extent of damage of her condition at present.

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IV. ANATOMY AND PHYSIOLOGY

The urinary system comprises the kidneys, ureters, bladder, and urethra. A
thorough understanding of the urinary system is necessary for assessing individuals
with acute or chronic urinary dysfunction and implementing appropriate nursing care.
Kidneys

The kidneys are a pair of brownish-red structures located retroperitoneally

(behind and outside the peritoneal cavity) on the posterior wall of the abdomen from
the 12th thoracic vertebra to the 3rd lumbar vertebra in the adult. An adult kidney
weighs 120 to 170 g (about 4.5 oz) and is 12 cm (about 4.5 inches) long, 6 cm wide,
and 2.5 cm thick. The kidneys are well protected by the ribs, muscles, Gerotas
fascia, perirenal fat, and the renal capsule, which surround each kidney. The kidney
consists of two distinct regions, the renal parenchyma and the renal pelvis. The renal
parenchyma is divided into the cortex and the medulla. The cortex contains the
glomeruli, proximal and distal tubules, and cortical collecting ducts and their adjacent
peritubular capillaries. The medulla resembles conical pyramids. The pyramids are
situated with the base facing the concave surface of the kidney and the apex facing
the hilum, or pelvis. Each kidney contains approximately 8 to 18 pyramids (Boyer,
2010).
The pyramids drain into 4 to 13 minor calices that, in turn, drain into 2 to 3
major calices that open directly into the renal pelvis. The hilum, or pelvis, is the
concave portion of the kidney through which the renal artery enters and the renal
vein exits. The renal artery (arising from the abdominal aorta) divides into smaller
and smaller vessels, eventually forming the afferent arteriole. The afferent arteriole
branches to form the glomerulus, which is the capillary bed responsible for
glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and
flows back to the inferior vena cava through a network of capillaries and veins
(Tanagho et.al, 2008).
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Nephrons

Nephrons from Greek word

nephros, meaning "kidney". It is the
basic structural and functional unit of
the kidney. Its functions are vital to life
and are regulated by the endocrine
system by hormones such as
antidiuretic hormone, aldosterone, and
parathyroid hormone. In humans, a
normal kidney contains 800,000 to one
million nephrons. Its chief function is to
regulate the concentration of water and
soluble substances like sodium salts by
filtering the blood, reabsorbing what is
needed and excreting the rest as
urine.are structurally divided into two
types: cortical and juxtamedullary.
Cortical nephrons are found in the
cortex of the kidney, and
juxtamedullary nephrons sit adjacent to
the medulla. The juxtamedullary
nephrons are distinguished by their
long loops of Henle and the vasa recta,
long capillary loops that dip into the
medulla of the kidney (Yakin, 2011).
Glomerulus

The glomerulus is composed of three filtering layers: the capillary

endothelium, the basement membrane, and the epithelium. The glomerular
membrane normally allows filtration of fluid and small molecules yet limits passage of
larger molecules, such as blood cells and albumin. Kidney function begins to
decrease at a rate of approximately 1% each year beginning at approximately age
30.
Ureters, Bladder, and Urethra

Urine, which is formed within the nephrons, flows into the ureter a long
fibromuscular tube that connects each kidney to the bladder.
The ureters are narrow, muscular tubes, each 24 to 30 cm long that originate at the
lower portion of the renal pelvis and terminate in the trigone of the bladder wall.
There are three narrowed areas of each ureter: the ureteropelvic junction, the
ureteral segment near the sacroiliac junction, and the ureterovesical junction. The
angling of the ureterovesical junction is the primary means of providing antegrade, or
downward, movement of urine, also referred to as efflux of urine. This angling
prevents vesicoureteral reflux, which is the retrograde, or backward, movement of
urine from the bladder, up the ureter, toward the kidney. During voiding (micturition),
increased intravesical pressure keeps the ureterovesical junction closed and keeps
urine within the ureters. As soon as micturition is completed, intravesical pressure
returns to its normal low baseline value, allowing efflux of urine to resume.
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 Therefore, the only time that the
bladder is completely empty is in
the last seconds of micturition
before efflux of urine resumes.

The urinary bladder is a

muscular, hollow sac located just
behind the pubic bone. Adult
bladder capacity is about 300 to
600 mL of urine. In infancy, the
bladder is found within the
abdomen. In adolescence and
through adulthood, the bladder
assumes its position in the true pelvis. The bladder is characterized by its central,
hollow area called the vesicle, which has two inlets (the ureters) and one outlet (the
urethrovesical junction), which is surrounded by the bladder neck (Boyer, 2010).
MAJOR FUNCTIONS OF KIDNEY (Yakin, 2011):

Regulation of water excretion

-kidneys are the major excretory organs of the body. They remove waste
products, many of which are toxic, from the blood. Most waste products are
metabolic by products of cells and substances absorbed from the intestine. The
skin, liver, lungs and intestines eliminate some of these waste products, but they
cannot compensate if the kidneys fail to function.
Regulation of electrolyte excretion
- When the kidneys are functioning normally, the volume of electrolytes excreted
per day is equal to the amount ingested. The regulation of sodium volume
excreted depends on aldosterone, a hormone synthesized and released from the
adrenal cortex. With increased aldosterone in the blood, less sodium is excreted
in the urine, because aldosterone fosters renal absorption of sodium.

Regulation of acid-base balance

-The kidney performs two major functions to assist in this balance. 1.) To
reabsorb and return to the bodys circulation any bicarbonate from the urinary
filtrate; 2.) To excrete acid in the urine.
Auto regulation of blood pressure
- Regulation of blood pressure is also a function of the
kidney. Specialized vessels of the kidney called the vasa
recta constantly monitor blood pressure as blood begins
its passage into the kidney. When the vasa recta detect
a decrease in blood pressure, specialized
juxtaglomerular cells near the afferent arteriole, distal
tubule, and efferent arteriole secrete the hormone renin.
Renin converts angiotensinogen to angiotensin I, which
is then converted to angiotensin II, the most powerful
vasoconstrictor known. The vasoconstriction causes the

11
blood pressure to increase. The adrenal cortex secretes aldostero ne in
response to stimulation by the pituitary gland, which in turn is in response to poor
perfusion or increasing serum osmolality. The result is an increase in blood
pressure. When the vasa recta recognize the increase in blood pressure, renin
secretion stops. Failure of this feedback mechanism is one of the primary causes
of hypertension.

Renal clearance
- Renal clearance refers to the ability of the kidneys to clear solutes from the
plasma. A 24-hour collection of urine is the primary test of renal clearance used
to evaluate how well the kidney performs this important excretory function.
Clearance depends on several factors: how quickly the substance is filtered
across the glomerulus, how much of the substance is reabsorbed along the
tubules, and how much of the substance is secreted into the tubules.
Regulation of Red Blood Cell Production

- When the kidneys sense a decrease in the oxygen tension in renal blood flow,
they release erythropoietin. Erythropoietin stimulates the bone marrow to produce
red blood cells (RBCs), thereby increasing the amount of hemoglobin available to
carry oxygen.
Vitamin D Synthesis
- The kidneys are also responsible for the final conversion of inactive vitamin D to
its active form, 1,25-dihydroxycholecalciferol. Vitamin D is necessary for
maintaining normal calcium balance in the body.

Secretion of Prostaglandins
- The kidneys also produce prostaglandin E (PGE) and prostacyclin (PGI), which
have a vasodilatory effect and are important in maintaining renal blood flow.

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 III. PATHOPHYSIOLOGY

Non-modifiable Factors: Modifiable Factors:

Genetics/Family history High salt diet

American, Hispanics Lifestyle
Gender: Female Diabetes Mellitus type II
Age: 52 Hypertension
Low socioeconomic status

Decreased renal blood flow secondary to primary

Legend: kidney disease and urine outflow obstruction

Pathway
Decreased glomerular filtration
Signs/Symptoms

Nursing Diagnosis
36 mg/dL BUN Hypertrophy of remaining nephrons Serum 9.4 mg/dL
Treatment Creatinine

Diagnostics Concentrated Inability to filter urine Increase Hypernatremia

urine: Dark brown sodium in urine
168 mEq/L
Further loss of nephron function

Loss of non-excretory renal function

Failure to convert Failure to produce Impaired Toxins irritate Immune Malfunction of 13

inactive forms of calcium erythropoietin insulin action pericardial sac disturbances RAAS
 Decreased Anemia Erratic blood May developed Delayed Sodium and
calcium absorption glucose pericarditis wound healing water retention
Hgb 8 g/dL
Hypocalcemia 210 mg/dL Susceptible to
Fatigue, infection Decreased
6.8 mg/dL weakness urine output
Sepsis
Osteodystrophy
Oliguria: 150 ml
WBC 15, 000
output in 8 hrs

Loss of excretory renal function

Excretion of Sodium Potassium Phosphate Decreased

nitrogenous waste reabsorption excretion excretion hydrogen
in tubule excretion
Hyperkalemia Hyperphosphatemia
Uremia Metabolic acidosis
Increased BUN, Water retention
Calcium
creatinine absorption
Edema
Proteinuria Urinalysis 2+ Hypocalcemia 6.8 mg/dL

Deposits on the skin Decomposition in the intestinal flora

CNS changes
Uremic frost Nausea and Altered taste & Abnormal breakdown
LOC GCS 8 vomiting Wt. loss
anorexia of nutrients
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 Ineffective renal tissue Continuous decline in
perfusion renal function

Continuous multisystem Pulmonary

Edema
affectation Edema

Multiple Organ Failure Dyspnea: RR-36 cpm

END STAGE RENAL

DISEASE

1. Acute pain related to stone obstruction and severe 3. Ineffective renal tissue perfusion related to
kidney damage as evidenced by facial grimace, renal damage as evidenced by oliguria, abnormal
restlessness, difficulty breathing and poor appetite vital signs, and dark brown colored urine
secondary to End stage renal disease secondary to end-stage renal disease

2. Ineffective breathing pattern related to pain and
respiratory muscle fatigue as evidenced by labored
breathing, shortness of breath, abnormal heart rate
response and respiratory rate secondary to kidney
failure.
4. Excessive fluid volume related to compromised
renal regulatory mechanism as evidenced by altered
mental status and respiratory pattern, decreased
Hemoglobin and hematocrit levels, dyspnea,
oliguria, restless and fatigue secondary to end stage
renal disease

5. Imbalanced nutrition less than body requirements related to

anorexia, and decreased level of consciousness as evidenced
by muscle wasting, weakness of muscle, altered mental status,
hyperactive bowel sounds and anorexia secondary to end-
15
stage renal disease
Pathophysiology of End-stage renal disease: A narrative

Be Chronic renal failure has several stages, progressing from decreased renal
reserve, to insufficiency, to end-stage renal failure or uremia. In the early stages of
decreased reserve (around 60% nephrons lost) there is a decrease in GFR, serum
creatinine levels that are consistently higher than average but within normal range,
serum urea levels that are normal, and no apparent clinical signs. The remaining
nephrons appear to adapt, increasing their capacity for filtration.
The second stage (around 75% nephrons lost), or that of renal insufficiency, is
indicated by a change in blood chemistry and manifestations. At this point, GFR is
decreased to approximately 20% of normal, and there is significant retention of
nitrogen wastes (urea and creatinine) in the blood. Tubule function is decreased,
resulting in failure to concentrate the urine and control the secretion and exchange of
acids and electrolytes. Osmotic diuresis occurs as the remaining functional nephrons
filter an increased solute load. This stage is marked by excretion of large volumes of
dilute urine (low fixed specific gravity). Erythropoiesis is decreased, and the patients
blood pressure is elevated. The cardiovascular system must compensate for these
effects (Morton, et.al, 2009).
Uremia, or end-stage renal failure (more than 90% nephrons lost), occurs when
GFR is negligible. Fluid, electrolytes, and wastes are retained in the body, and all
body systems are affected. In this stage, marked oliguria or anuria develops. Regular
dialysis or a kidney transplant is required to maintain the patients life (Qian, 2010).

As renal function declines, the end products of protein metabolism (which are
normally excreted in urine) accumulate in the blood. Uremia develops and adversely
affects every system in the body. The greater the buildup of waste products, the
more severe the symptoms. There are three well-recognized stages of chronic renal
disease: reduced renal reserve, renal insufficiency, and ESRD. The rate of decline in
renal function and progression of chronic renal failure is related to the underlying
disorder, the urinary excretion of protein, and the presence of hypertension. The
disease tends to progress more rapidly in patients who excrete significant amounts
of protein or have elevated blood pressure than in those without these conditions.
The severity of these signs and symptoms depends in part on the degree of
renal impairment, other underlying conditions, and the patients age. Hypertension
(due to sodium and water retention or from activation of the reninangiotensin
aldosterone system), heart failure and pulmonary edema (due to fluid overload), and
pericarditis (due to irritation of the pericardial lining by uremic toxins) are among the
cardiovascular problems manifested in ESRD (Ronco, 2009). Strict fluid volume
control has been found to normalize hypertension in patients receiving peritoneal
dialysis (Gunal, Duman, Ozkahya et al., 2001). Severe itching (pruritus) is common.
Uremic frost, the deposit of urea crystals on the skin, is uncommon today because of
early and aggressive treatment of ESRD with dialysis. GI signs and symptoms are
common and include anorexia, nausea, vomiting, and hiccups. Neurologic changes,
including altered levels of consciousness, inability to concentrate, muscle twitching,
and seizures, have been observed (Parker, 1990).

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IV. DIAGNOSTIC TESTS

1. Urinalysis (February 19, 2017)

-this test detects ion concentration of the urine. Small amounts of protein or
ketoacidosis tend to elevate results of the specific gravity. Specific gravity is
an expression of the weight of a substance relative to the weight of an equal
volume of water. Water has a specific gravity of one. The specific gravity of
urine is measured by a urinometer. It determines whether a person is
dehydrated or not. Normal urine specific gravity is 1.010-1.030. Above normal
specific gravity indicates dehydration.

NORMAL
TEST RESULT VALUES
SIGNIFICANCE
Indicates a concentrated
COLOR Dark yellow Amber straw
urine
May indicate presence of
TRANSPARENCY Hazy Clear
bacteria
Indicates dehydration
SPECIFIC which can be related to
1.035 1.010-1.030
GRAVITY limited fluid intake and
internal bleeding
Due to an increase
creatinine that may
indicate renal failure.
PROTEIN 2+ Negative
Protein is being excreted
in the urine since kidney
failed to metabolize
Occurs due to severely
RBC/hpf 20-31 0-2/hpf
damage of kidneys
Indicates presence of
infection. Body
compensates against the
WBC/hpf 8-12 0-5/hpf bacteria. Dead WBC are
being excreted in the
urine due to failure of
kidney to filter.
Indicates invasion of
Bacteria Plenty None bacteria in the urinary
tract

Preparation:
When obtaining a sample from an indwelling catheter, be sure
that the drainage tube is empty;
Clamp the tube distal to the specimen collection port. The
sample is obtained with a needle (25- to 21-gauge) and a 3- to
5-mL (larger if a greater amount is needed) syringe after the
tubing has been clamped for approximately 15 minutes.
Nursing considerations:
- Ensure client safety while performing the test.

17
 - The specimen port is cleansed with an antiseptic swab (e.g.,
alcohol sponge) and the sample is aspirated.
- Care must be taken to ensure that the catheter is unclamped after
the sample is obtained.
2. Hematology/Complete blood count (February 20, 2017)
- A complete blood count (CBC), also known as blood panel, gives information
about the cells in a patients blood. It includes (1) enumeration of the cellular
elements of the blood, (2) evaluation of RBC indices, and (3) determination of
cell morphology by means of stained smears. (Sacher, 2010). In this test,
WBC and RBC indices for possible indication of occult infection, microcytic or
hemolytic anemias, or immune deficiency (Bambang, 2000).

NORMAL
TEST RESULT SIGNIFICANCE
VALUES
Indicates anemia
HEMATOCRIT 29% 35-47%
secondary to failure of
kidney to produce
HEMOGLOBIN 8 g/dL 12-15 g/dL
enough erythropoietin
2.85 million/ 4.25.4 Supporting data for
RBC
mm3 million/mm3 presence of anemia
Indicates presence of
WBC 15,000 5,000-10,000
infection
Indicates presence of
Lymphocytes 38% 25-40%
infection. Body
compensates against the
Monocytes 8-12/hpf 0-5/hpf
bacteria.
150,000-
Platelets 210,000 mm3 Normal
450,000 mm3

Preparation:
Explain to the client:
-The purpose of the test
-The procedure, including the site from which the blood sample is likely
to be obtained
-That momentary discomfort may be experienced when the skin is
pierced
-That food, fluids, and drugs are to be withheld before to the test

Nursing considerations:
- Practice standard precaution procedures in collection and
transportation of specimens and disposal of used articles. Apply the
necessary pressure to the puncture site until the bleeding stops. If
oozing continues,
- Elevate the extremity and apply a pressure type of dressing.
- Remain with the client until the bleeding has completely stopped.
- If the client is experiencing excessive and lingering pain or syncope,
allow the client to lie down and rest.

18
3. Serum electrolytes (February 20, 2017)

- include serum creatinine, potassium and sodium levels that may aid in
determining kidney function

NORMAL
TEST RESULT SIGNIFICANCE
VALUES
An ideal substance for
determining renal
clearance because a
CREATININE 9.4 mg/dL 0.6-1.3 mg/dL fairly constant quantity is
produced within the
body. Increases due to
decreased GFR rate
Increases as extent of
BUN 36 mg/dL 8-25 mg/dL damage in nephrons
increases
Due to loss of excretory
POTASSIUM 6.7 mEq/L 3.5-5.5 mEq/L renal function,
hyperkalemia happens
Hypernatremia occurs
SODIUM 168 meq/L 135-145 mEq/L due to decreased
sodium reabsorption
Indicates hypocalcemia
secondary to failure of
CALCIUM 6.8 mg/dL 8.6-10 mg/dL
kidney to convert
inactive forms of calcium
Random blood Loss of non-excretory
210 mg/dL 70-110 mg/dL
sugar function of the kidney

Preparation:
Explain to the client:
-The purpose of the test
-The procedure, including the site from which the blood sample is likely
to be obtained
-That momentary discomfort may be experienced when the skin is
pierced
-That food, fluids, and drugs are to be withheld before to the test

Nursing considerations:
- Practice standard precaution procedures in collection and
transportation of specimens and disposal of used articles. Apply the
necessary pressure to the puncture site until the bleeding stops. If
oozing continues,
- Elevate the extremity and apply a pressure type of dressing.
- Remain with the client until the bleeding has completely stopped.
- If the client is experiencing excessive and lingering pain or syncope,
allow the client to lie down and rest.

19
 4. Ultrasound of Kidneys, Ureter and Bladder
The right kidney measures approximately: Coronal = 110.6 x 50.7 x 43mm
(LWT) with a cortical thickness of 17.1 mm.
The borders are fuzzy.
There is increased parenchymal echopattern. Hyperechoic.
A 7.1 x 6.2 x 7.0 mm (LWH) with a volume of .2 ml cystic mass is noted in
the inferior pole.
A significant change in size of the hyperdense structure measuring 0.50 x
0.47 cm at the calyx
Multiple lithiasis on ureteropelvic junction and pelvic brim difficult to
measure due to severe hydronephrosis
The left kidney measures approximately: Coronal = 102 x 64.8 x 48 mm
(LWT) with a cortical thickness of 16.9 mm.
Irregular shaped mass seen on inferior pole of left kidney
Urinary bladder is well-distended with irregular mucosal contours. Walls
are thickened.
Intraluminal echoes seen
Uterus not enlarged. Non-movable pelvic mass on left area seen
measuring 12.4 x 10.22 cm
Osteophytes are seen along thoracolumbar vertebral margins

Impression:
Right ureterolithiasis at calyx, ureteropelvic junction and pelvic brim
Diffuse renal parenchymal disease, both kidneys.
Renal cyst, inferior pole, right kidney.
Renal mass, inferior pole, left kidney
Urinary bladder with irregular mucosal contours and thickened walls
Pelvic mass on left area 12.4 x 10.22 cm
Thoracolumbar spondylosis
V. INTERVENTIONS

A. General Nursing Interventions

1. Monitor for signs and symptoms of hypovolemia
or hypervolemia because regulating capacity of
kidneys is inadequate.
2. Monitor urinary output and urine specific
gravity; measure and record intake and output
including urine, gastric suction, stools, wound
drainage, perspiration (estimate)
3. Monitor serum and urine electrolyte
concentrations
4. Weigh the patient daily to provide an index of
fluid balance; expected weight loss is 1/2 to 1 lb
(0.25 to 0.5 kg) daily
5. Adjust fluid intake to avoid volume overload and
dehydration.

20
 6. Fluid restriction is not usually initiated until renal function is quite low.
7. During oliguric and anuric phase, give only enough fluids to replace losses
(usually 400 to 500 mL/24 hours plus measured fluid losses)
8. Fluid allowance should be distributed throughout the day
9. Restrict salt and water intake if there is evidence of
extracellular excess
10. Measure blood pressure regularly with patient in supine,
sitting, and standing positions
11. Auscultate lung fields for rales
12. Inspect neck veins for engorgement and extremities,
abdomen, sacrum, and eyelids for edema.
13. Evaluate for signs and symptoms of hyperkalemia, and
monitor serum potassium levels. Notify health care
provider of value above 5.5 mg/L
14. Watch for ECG changes-tall, tented T waves;
depressed ST segment; wide QRS complex
15. Administer sodium bicarbonate or glucose and
insulin to shift potassium into the cells
16. Administer cation exchange resin (sodium
polystyrene sulfonate [Kayexalate]) orally or rectally
to provide more prolonged correction of elevated
potassium
17. Watch for cardiac arrhythmia and heart failure from
hyperkalemia, electrolyte imbalance, or fluid
overload. Have resuscitation equipment on hand in
case of cardiac arrest.
18. Instruct patient about the importance of following prescribed diet, avoiding
foods high in potassium.
19. Monitor for all signs of infection. Be aware that renal failure patients do not
always demonstrate fever and leukocytosis
20. Carry out meticulous wound care.
21. Low-protein diet may be supplemented with essential amino acids and
vitamins.

B. Medical Interventions
1. Pharmacological Interventions
a) Epoetin Alpha 50 iu/kg x 3 a week
b) Furosemide 20 mg IVTT every 6 hours
c) Sodium Bicarbonate 650 mg 2 tabs BID
d) Ranitidine 50 mg IVTT every 8 hours
e) Calcium Carbonate 1 tab TID
*Respective drug study is on the following page

21
Generic Name:
Classification:
Epoetin Alfa
Brand Name:
Renogen; Epogen
Hematopoietic
Pharmacologic class:
Haematopoietic Agents
Dosage, timing & route Mechanism of Action
50 iu/kg IVTT x 3 a Epoetin alfa stimulates
week the differentiation and
proliferation of erythroid
precursors, release of
reticulocytes into the
circulation and synthesis
of cellular Hb thus
regulating erythropoiesis.
Indication
Contraindication: Side/Adverse Effects: Nursing Intervention:
Hypersensitivity to
albumin (human) or Headache, Monitor for side
mammalian cell- hypertension and effects
derived products seizures. Inject the drug
Uncontrolled Hypertensive over at least 1
hypertension crisis with minute or as slow
encephalopathy- 5 minutes in
like symptoms; patients who
Thrombosis at experience flu-like
vascular access symptoms as side
sites effects.
Transient Monitor laboratory
increases in the results
platelet count.
Flu-like
symptoms
including chills
and myalgia;

Increase yield of
autologous blood for
anemia in chronic renal
failure

22
Generic Name:
Classification: Contraindication:
Furosemide
Brand Name:
Lasix
Anti-inflammatory
Antipyretic
Pharmacologic class: Anticoagulant
Diuretic
Dosage, timing & route Mechanism of Action
20 mg IVTT every 6 Inhibits sodium and
hours water reabsorption in the
loop of Henle and
increases urine
Indications formation. As the bodys
plasma volume
To reduce edema decreases, aldosterone
caused by renal failure
production increases,
which promotes sodium
reabsorption and the loss
of potassium and
hydrogen ions.
Furosemide also
increases the excretion
of calcium, magnesium,
bicarbonate, ammonium,
and phosphate .
Side/Adverse Effects: Nursing Intervention:
Hypersensitivity to Dizziness, fever, Obtain patients
furosemide, headache weight before and
sulfonamides, or Paresthesia, periodically during
their components Restlessness furosemide
Vertigo therapy to monitor
Weakness fluid loss.
Orthostatic Administer drug
slowly I.V. over 1
hypotension
Blurred vision, to 2 minutes to
prevent
oral irritation
ototoxicity.
Monitor blood
pressure and
hepatic and renal
function as well as
BUN, blood
glucose, and
serum creatinine,
electrolyte, and
uric acid levels, as
appropriate.
23
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Sodium Bicarbonate

Brand Name:
Hypocalcemia in Mental or mood Monitor sodium
Citrocarbonate Antacid which alkalosis may changes intake of patient
Urinary alkalizer lead to tetany; Irregular Caution patient
Pharmacologic class: Electrolyte Hypochloremic heartbeat, not to take more
Antacid, Electrolyte alkalosis secondary peripheral edema drug than
to vomiting, (with large prescribed to
Dosage, timing & route diuretics, or doses), weak avoid adverse
Mechanism of Action
nasogastric suction; pulse reactions
650 mg 2 tabs BID Preexisting Dry mouth Avoid rapid I.V.
Increases plasma
bicarbonate level, buffers
metabolic or Abdominal infusion, which
respiratory alkalosis cramps, thirst can cause severe
excess hydrogen ions,
alkalosis. Be
and raises blood pH,
aware that during
thereby reversing
cardiac arrest, risk
Indication metabolic acidosis.
of death from
Sodium bicarbonate also
acidosis may
To provide urinary increases the
outweigh risks of
alkalinization excretion of free
rapid infusion.
bicarbonate ions in urine,
raising urine pH;

24
Generic Name:
Classification: Contraindication: Side/Adverse Effects: Nursing Intervention:
Ranitidine
Brand Name:
Zantac;Apo-Ranitidine Hypersensitivity to Dizziness, Be aware that
ranitidine or its drowsiness, ranitidine must be
Anti-ulcer agent components fever, headache, diluted for I.V. use
Pharmacologic class:
insomnia if not using
Aminoalkyl-substituted
furan derivative Vasculitis premixed solution.
Abdominal For I.V. injection,
Dosage, timing & route distress, dilute to total of 20
constipation, ml with normal
50 mg IVTT every 8 diarrhea, nausea, saline solution,
hours vomiting D5W, D10W,
Mechanism of Action
Bronchospasm lactated Ringers.
Inhibits basal and Give I.V. injection
nocturnal secretion of at no more than 4
gastric acid and pepsin ml/ min,
Indication
by competitively intermittent I.V
inhibiting the action of Tell patient that
To treat acute
histamine at H2 she may take
gastroesophageal reflux
receptors on gastric drug with food.
Disease and sour
stomach parietal cells. This Tell patient to stop
action reduces total taking ranitidine
volume of gastric juices and contact
and, thus, irritation of GI prescriber if she
mucosa. has trouble
swallowing,
vomits blood
passes black or
bloody stools.

25
 VI. NURSING CARE PLANS
Acute pain related to stone obstruction and severe kidney damage as evidenced by facial grimace, restlessness, difficulty breathing
and poor appetite secondary to End stage renal disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE EVALUATION

Objective data: Short term: Independent: 1. This allows patient At the end of 15
Severe Flank At the end of 15 minutes, to have an active minutes nursing
pain 10/10 the client will be able to: 1. Make changes in the role in treatment. interventions, the
Alteration in Show and express environment that will 2. To minimize or short term goals
muscle tone feeling of comfort and promote sleep. relieve pain. were partially met
Facial mask of relief from pain 2. Apply heat or cold as 3. To reduce muscle as evidenced by:
pain Rest comfortably prescribed. spasm and to Client able to
Guarding 3. Reposition patient and redistribute sleep but
behavior Long term: use pillows to splint or pressure on body some vital
Sleep At the end of 12 hours to support painful areas, parts. signs remain
disturbance 2 days, the client will be as appropriate. 4. Personal hygiene abnormal T-
Changes in able to: 4. Provide patient with and prebedtime 36.7 C; P-
appetite and Demonstrate use of sleep aids, such as rituals promote 120 bpm; R-
eating relaxation skills and pillows, bath before sleep in some 36cpm; BP-
Moaning or diversional activities sleep, and reading patients. Comfort 90/60 mmHg
crying as indicated for materials. Milk and measures act as
painful situation. some high-protein distracters from Long term goals
Dyspnea/ RR-36-
snacks, such as pain, reduce were not met due to
40 cpm
cheese and nuts, muscle tension or the severity of the
HR- 120 bpm
contain L-tryptophan spasm, and disease process
and are also sleep redistribute that cant be easily
promoters if those pressure on body controlled by
foods are not parts. alternative
contraindicated. 5. Purposeful measures.
5. Teach relaxation relaxation efforts
techniques such as usually help

26
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE EVALUATION
guided imagery, deep promote sleep.
breathing, meditation, 6. Help client focus
aromatherapy, and on non-pain-
progressive muscle related matters.
relaxation. Practice 7. Aids in alleviating
with the patient severe pain by
frequently and Blocking
especially at bedtime. cyclooxygenase,
6. Encourage activities an enzyme
that provide distraction, needed to
such as therapeutic synthesize
play prostaglandins.
Prostaglandins
Collaborative: mediate
inflammatory
7. Administer analgesic response and
medications (Ketorolac cause local
30 mg IVTT every 6 vasodilation,
hours PRN for pain) swelling, and pain.
indicated and as
prescribed.

27
Ineffective breathing pattern related to pain and respiratory muscle fatigue as evidenced by labored breathing, shortness of breath,
abnormal heart rate response and respiratory rate secondary to kidney failure.

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE EVALUATION

Objective data: Short term: Independent: 1. Promote At the end of 2 days

Dyspnea At the end of 30
Respiratory rate- minutes, the client will
36-40 cpm be able to:
Labored Maintain respiratory
breathing rate within 12-20
O2 saturation cycles per minute
95% Express feelings of
comfort when
breathing
Long term:
At the end of 12 hours
to 2 days, the client will
be able to:
Demonstrate
diaphragmatic
pursed-lip breathing
Achieve maximal
lung expansion with
adequate ventilation
Demonstrate skill in
conversing energy Collaborative:
while carrying out
activities
expansion of lungs duty, the short and
1. Assist patient to and provide long term objectives
Fowlers position or comfort. were not met since
adjust bed level 2. Turning and patient began to
2. Turn and reposition repositioning deteriorate and
patient at least every prevent skin breathing started to
2 hr. Establish a breakdown and get even worse.
turning schedule for improve lung
the dependent expansion and
patient. Post prevent atelectasis
schedule at bedside 3. This enables
and monitor caregivers to
frequency. participate in
3. Teach caregivers to patients care and
assist patient with encourages them
ADLs in a way that to support patients
maximizes patients independence
potential. 4. Improve patients
4. Provide emotional self-concept and
support and motivate patient to
encouragement participate with the
regimen
5. Attached oxygen @ Collaborative:
4-6 L/min as 5. Aids in delivering
prescribed via nasal enough oxygen to
cannula clients body.

28
Ineffective renal tissue perfusion related to renal damage as evidenced by oliguria, abnormal vital signs, and dark brown colored
urine secondary to end-stage renal disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE EVALUATION

Objective: Short term: Independent: 1. Effective At the end of 2 days

FBC output 150 At the end of 30 management of nursing interventions,
ml in 8 hours minutes to 4 hours, the 1. Assess patient current chronic health the short and long
Hgb: 8 g/dL client will be able to: management of conditions will term objectives were
HR: 115-128 Maintain stable vital preexisting health help preserve not met after patient
bpm signs conditions that kidney function. start deteriorating as
Dyspnea Maintain warm and increase the risk of 2. To evaluate evidenced by
Fatigue dry skin decreased renal need for fluid abnormal vital signs
Weakness Exhibit no perfusion. replacement. and increasing
arrhythmias 2. Monitor intake and 3. Serum creatinine shortness of breath.
output levels and urine
3. Collect and evaluate protein and
Long term: laboratory and urine creatinine are
At the end of 12 hours data that may indicate sensitive
to 2 days, the client will renal damage. indicators of
be able to: 4. Provide patient and renal function.
Have normal fluid family with 4. To reinforce
and blood volume encouragement and positive health
and exhibit psychological support behaviors
increase in 5. Helps in
Hemoglobin Collaborative: supplying
adequate blood
5. Administer whole and prevent
blood as prescribed anemia
6. Administer 6. Stimulates the
erythropoietin alfa 50 differentiation
and proliferation

29
ASSESSMENT OBJECTIVES INTERVENTION RATIONALE EVALUATION
iu/kg IVTT x 3 a week of erythroid
precursors,
release of
reticulocytes into
the circulation
and synthesis of
cellular Hb thus
regulating
erythropoiesis

30
Excessive fluid volume related to compromised renal regulatory mechanism as evidenced by altered mental status and respiratory
pattern, decreased Hemoglobin and hematocrit levels, dyspnea, oliguria, restless and fatigue secondary to end stage renal disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Independent:
Objective: Short term: 1. Monitor and record vital
At the end of 1 hour, the client signs at least every 4
Altered mental status will be able to: hours
Altered respiratory State ability to breathe 2. Measure and record
pattern comfortably intake and output.
Decreased hemoglobin Maintain fluid intake at 3. Weigh patient at same
and hematocrit levels 1L/day time each day.
Dyspnea Maintain vital signs within 4. Monitor laboratory values
Oliguria normal limits and report significant
Restlessness changes to physician.
Fatigue Long term: 5. Help patient into a
At the end of 2 days, the client position that aids
Edema
will be able to: breathing, such as
Exhibit urine specific Fowlers or semi-Fowlers
gravity of 1.010-1.030 6. Restrict fluids to 1L ml
Have normal skin turgor per day
7. Reposition patient every
2 hr, inspect skin for
redness with each turn,
and institute measures as
needed
Collaborative:
8. Administer oxygen, as
ordered
9. Administer diuretics
Furosemide 20 mg IVTT
1. Changes may indicate
fluid or electrolyte
imbalances
2. Intake greater than output
may indicate fluid
retention and possible
overload.
3. To obtain consistent
readings.
4. High specific gravity
indicates fluid retention.
Fluid overload may alter
electrolyte levels.
5. To increase chest
expansion and improve
ventilation.
6. Excessive fluids will
worsen patients
condition.
7. To prevent skin
breakdown.
Collaborative:
8. To enhance arterial blood
oxygenation.
9. To promote fluid
excretion

31
Imbalanced nutrition less than body requirements related to anorexia, and decreased level of consciousness as evidenced by
muscle wasting, weakness of muscle, altered mental status, hyperactive bowel sounds and anorexia secondary to end-stage renal
disease

ASSESSMENT OBJECTIVES INTERVENTION RATIONALE

Independent:
Objective: Short term: 1. Obtain and record 1. To ensure keeping an
At the end of 30 minutes to 6 patients weight every accurate record of
Muscle wasting hours, the client will be able to: day at the same time weight.
Anorexia Consume the needed 2. Monitor fluid intake and 2. To provide adequate fluid
Hyperactive bowel calories per meal to output every 8 hr. replacement.
sounds achieve daily 3. Provide a diet prescribed 3. To ensure that the
Dyspnea requirement. for the patients specific patients dietary
Oliguria Demonstrate good condition and restrictions are followed
Restlessness appetite preferences as much as possible
Fatigue 4. Keep snacks at the 4. To allow the patient to eat
Long term: bedside small amounts frequently.
Edema
At the end of 2 days, the client 5. Approach patient and 5. This demonstrates
will be able to: parents in a unconditional positive
Maintain good skin turgor nonjudgmental manner respect for the patient.
Achieve adequate food 6. Teach self-healing 6. These techniques can be
intake and rest techniques to both the used to reduce anxiety
comfortably patient and family such and increase self-
Gain intended pounds per as meditation, guided reliance.
week and show progressive imagery, yoga, and 7. Helps in meeting the daily
development of proper prayer. Teach patient caloric intake
nutrition how to incorporate the requirements for the
use of self-healing patient.
techniques in carrying out 8. To enhance patients
usual daily activities. appetite.
7. Encourage nutritious, 9. Patients autonomy must
high-calorie, and fortified be respected. Control

32
ASSESSMENT OBJECTIVES INTERVENTION
fluids to increase nutrient
density.
8. After obtaining patients
food preferences, attempt
to obtain desired foods
for the patient. Offer food
that appeal to olfactory,
visual, and tactile senses
9. Acknowledge patients
right to choose not to
comply with prescribed
regimen.
Collaborative:
10. Administer prescribed
Ranitidine 50 mg IVTT
every 8 hours
RATIONALE
over patients actions is
legitimate only when
danger is posed to
patient or others.
10. Inhibits basal and
nocturnal secretion of
gastric acid and pepsin
by competitively inhibiting
the action of histamine at
H2 receptors on gastric
parietal cells. This action
reduces total volume of
gastric juices and, thus,
irritation of GI mucosa.
33
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Deglin, J., Vallerand, A. (2010). Davis Drug Guide for Nurses. F.A. Davis
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Sparks, S., Taylor, C. (2011). Nursing Diagnosis Pocket Guide. Wolters

Kluwer, Lippincott Williams and Wilkins; Philadelphia

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35