Chronic Renal Failure

I.
INTRODUCTION
Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the bodys internal environment. CRF can develop insidiously over
many years, or it may result from an episode of a cure renal failure from which
the client has not recovered. The incidence of CRF varies widely by state and
country. In the United States, the incidence is 268 new cases per million
populations.
Chronic renal failure affects many body systems. It can also lead to many
complications. This is the goal of health care providers, to prevent any
occurrence
of
complications.
One
of
the
complications
of
CRF
is
hyperparathyroidism; this is due to the compensatory mechanism of the

parathyroid hormone once it detects any alteration in the calcium level of the
body.
It
is
important
for
clinicians
to
recognize
the
problem
of
hyperparathyroidism early in the course of chronic kidney disease so that growth

of the parathyroid glands can be prevented or halted, and excessive secretion of
hyperthyroidism can be controlled to help minimize the adverse consequences
on bone and mineral metabolism, which may lead to bone pain and bone
fractures, decreased growth in children, muscle weakness, and elevations in the
calcium phosphorus product, which contributes to calcification of the heart
valves and blood vessels and contributes to the high cardiovascular mortality in
patients with advanced kidney disease.
Early detection of this complication of chronic kidney disease will provide
an opportunity to intervene to control the secretion of parathyroid hormone and,
thus, minimize the problem. Early detection will also allow for the opportunity to
prevent further growth of the parathyroid glands so that the magnitude of the
problem will be lessened as kidney function deteriorates. There is also some
evidence that the control of hyperparathyroidism may help to slow the
progression of kidney disease. Ultimately, it is hoped that with timely intervention
to control this complication of chronic kidney disease, improved patient outcomes

on in terms of morbidity and mortality will be achieved.
To ensure that the diagnosis of hyperparathyroidism is made early in the
course of chronic kidney disease, it is important to educate primary care
physicians, cardiologists, endocrinologists and other healthcare providers who
may see patients in the early stages of chronic kidney disease, so that they may
assess blood parathyroid hormone levels to uncover this complication and either
embark on the treatment of hyperparathyroidism or consider referral to a
nephrologist for further advice on the appropriate management strategies.
Referral to a nephrologist would appear to be preferable at the present time as
the field is advancing with new therapies being evaluated and implemented in
practice.
At the American Society of Nephrology Renal Week 2004 meeting, results
are being presented on the administration of oral paricalcitol, now in capsular
form, so that its use can be evaluated in patients with earlier stages of kidney
disease (stage III and IV), who are not yet on dialysis. The phase 3 studies of
orally administered paricalcitol showed that this strategy is effective in reducing
the degree of hyperparathyroidism, and that the administration of this vitamin D
analog
is
not
associated
with
hypercalcemia,
hyperphosphatemia,
or
hypercalcuria. Thus, the treatment was effective and well tolerated and appeared
to be free of side effects. These studies are important because they provide a
new therapy for the complication of hyperparathyroidism in the course chronic
kidney disease, and, thus, if the diagnosis of this complication can be made
earlier in the course of chronic kidney disease, treatments such as oral
paricalcitol may be effective in managing this complication.
As nurses, we could help our patients by having a deep understanding of
the disease, that we may learn the proper interventions for the chronic kidney
disease patients. In this way, we could render quality care for them. We could as
well lead them to the proper treatment to lessen their sufferings brought by the
kidney failure, in anyhow. By having a wide understanding of the disease, we
could impart teachings on how we could prevent the occurrence of chronic
kidney disease. As nurses, it is our responsibility to render information and impart

health teachings to improve the condition of our patients to the best of our
abilities. One of the characteristics that we, nurses, should have is to be
informative and only through a keen study of disease such as this way for us to
gain all the information that we need to learn. May this case study served its
purpose through the help of our Lord, Jesus Christ.
II. NURSING ASSESSMENT
A. Personal Data and History (Demographic Data)
Mr. Scrooge is a 53-year-old male, married living at 21 St. Cecilia, Paula
Complex, Laguna. He was born on September 16, 1952 in Laguna. He is married
for 29 years now and has six children. He was not able to finished his desired
career during his college years because their family business was suddenly went
bankrupt. According to Mr. Scrooge, education is important thats why he decided
to look for more affordable career. While studying he decided to work to be able
to support his education. With his perseverance and determination, he was able
to finished aircraft maintenance. But with all of this stress and difficulties
happening in his life, he learned how to smoke. According to him, smoking helps
him to be relaxed. He consumed 8 sticks/day. He was also an occasional drinker.
He worked as aircraft maintenance in Clark Air Base in Pampanga for more than
20 years.
Mr. Scrooge said that he is fond of eating meat and poultry products. After
work, he only stays at home because he feels very tired after work. At present,
he still works as aircraft maintenance in Clark Air Base in Pampanga.
Mr. Scrooge was admitted in Angeles University Foundation Medical
Center last February 3, 2005. He was admitted due to body weakness and
severe anemia. He was discharged on February 10, 2005.
B. Family Health-Illness History

Mother Side
Lola (+) DM
Father Side
Lolo
Mo
ma
Lola
Lolo (+) HPN
Po
p
Mr. Scrooge
(+) HPN
(+)Kidney Failure
C. History of Past Illness

Mr. Scrooge was known for being hypertensive for 5 years now. He was
diagnosed of hypertension and kidney failure last 2001. He was hospitalized in
St. Lukes Hospital because of the said health problem. According to him, his
chief complain that time was only hypertension. He was discharged from the
hospital after six days of confinement. After his discharge, Mr. Scrooge
consistently having his blood chemistry and creatinine check-up every month in
AUFMC. If the results are all normal, his check-up becomes every month. These
all became routine on him.
On May 2004, he was hospitalized for the second time in AUFMC. After
two days of confinement in the hospital, he decided to transfer in St. Lukes
Hospital. Mr. Bean experienced difficulty of breathing and fatigability that time. He
was diagnosed of Pulmonary Congestion.
D. History of Present Illness

Four days prior to admission, Mr. Scrooge experienced easy fatigability.
No other accompanying signs and symptoms. His condition was persisted until
one day prior to admission, he already experiencing body weakness, body
malaise, pallor and fatigability thats why he consulted AUFMC. He was advised
to have laboratory examination (Hgb and Hct), which revealed anemia and he
was advised to be admitted. His initial vital signs were as follows: T-36.8, RR- 22,
PR- 64, BP- 170/100.
E. Physical Examination
February 3, 2005
Upon Admission:
VS:
T
- 36.8
RR
- 22
PR
- 64
BP
- 170/100
Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and

pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
GIT: loss of appetite
Renal and Urologic changes: fatigability, oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Skeletal changes: hypocalcemia and hyperphosphatemia
February 7, 2005
Vital Signs:
T
- 36
RR
- 22
PR
- 81
BP
- 170/100
Integumentary
seconds)
E. Mouth- with dry and pale lips
pain
6

Renal and urologic changes: oliguria
February 8, 2005
Vital Signs:
T
- 36.2
RR
- 16
PR
- 80
BP
- 170/100
Integumentary
seconds)
E. Mouth- (-) pallor, dry lips
pain
Renal and Urologic changes: oliguria
February 9, 2005
Vital Signs:
T
- 36.4
RR
- 20
PR
- 71
BP
- 160/100
Integumentary
seconds)
E. Mouth- with (-) pallor, dry lips
pain
February 10, 2005

Vital Signs:
T
- 37
RR
- 17
PR
- 85
BP
- 180/90
Integumentary
C. Skin- pallor, brown in complexion, with good skin turgor
D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
H. Scalp- hair evenly distributed without any presence of lice and lesions
I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
J. Ears- symmetrical with cerumen, no discharges noted
K. Nose- without flaring of nostrils, no discharges noted
L. Mouth- (-) pallor
M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
N. Chest and Lungs- with bibasal rales
F. Diagnostic and Laboratory Procedures

Diagnostic/
Laboratory
Procedure
Date
Ordered
Date Result
in
Indication (s)
Purpose (s)
Result
Normal Values
used by the
hospital
Analysis and
Interpretation
1. CBC
Hgb
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Hct
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
WBC
Leukocytes
Ordered
2/3,4,6,8,9/
05
Usually done to a
pt. with renal
disease to
determine if the
kidneys ability to
release
erythorpoietin
factor is already
affected
72
103
107
118
109
120-170 g/L
Results were all

below the normal
level, thus indicating
renal malfunction
and thereby causing
anemia
Used to measure
RBC number and
volume. It is an
integral part of the
evaluation of
anemic patients
.23
.31
.33
.36
.32
.40-.50
Result were all below

the normal range
thus, showing
anemia and renal
disease
Determines any
inflammation and
infection
7.76
6.01
9.40
8.58
9.5
5-10x109/L
Results were all

above normal level.
This shows presence
of inflammation and
infection
Determines any
acute bacterial
infection
.81
.75
.71
.72
.74
.50-.70
Results were all

above normal level.
This shows presence
of bacterial infection
Result:
2/3,4,6,8,9/
05
Neutrophils
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
10
Lymphocytes
Ordered
2/3,4,6,8,9/
05
Determines any
chronic bacterial
infection or viral
infection
.1
.13
.20
.15
.13
.10-.40
Results were all

within normal level.
Showing absence of
chronic infection
Determines any
acute bacterial
infection
.05
.08
.04
.09
.07
.00-.07
Some of the results

were all above
normal
Level indicating
presence of bacteria.
To determine any
allergic reaction of
the body
.04
.04
.05
.04
.06
.00-.07
Results were all

within the normal
level. This shows no
allergic reactions.
Result:
2/3,4,6,8,9/
05
Monocytes
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Eosinophils
Ordered
2/3,4,6,8,9/
05
Result:
2/3,4,6,8,9/
05
Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding
11
Diagnostic/
Laboratory
Procedure
Date
Ordered
Date Result
in
2. Hepatitis Ordered:
2/3/05
Profile
Performed:
2/5/05
Indication (s)
Purpose (s)
Analysis and
Interpretation
Result
This is usually done

before proceeding in
hemodialysis. This is
to determine if the
patient was expose to
the virus of if there is
presence of hepatitis
virus
In the blood of the
patient.
HBSAG- non-reactive
ANTI-HCV- non-reactive
ANTI-HBC- non-reactive
ANTI-HBS-reactive
HAV-IGM- non- reactive
Result revealed
that the patient
has no hepatitis
virus and was not
exposed to any of
it.
4. Handle the specimen as if it were capable of transmitting hepatitis
5. Immediately discard the needle in the appropriate receptacle
6. Send the specimen to the laboratory promptly
Diagnostic/
Laboratory
Procedure
3.Urinalysis
Date
Ordered
Date Result
in
Ordered:
2/3,6,7/05
Result:
2/3,6,7/05
Indication (s)
Purpose (s)
To diagnose
and monitor
renal or
urinary tract
disease
Result
Color: straw, light

yellow, light yellow
Appearance: slightly
turbid
pH: 5
Normal
Values used
by the
hospital
Analysis and
Interpretation
Laboratory
results revealed
that there is
presence of
albumin in the
blood; this
indicates that
the glomerular
12
Specific Gravity:
1.020, 1.025, 1.020
Albumin:
3+
Sugar: negative
Pus Cells: 1-2/HPF, 02/HPF, 2-5 /HPF
Red cells: 1-3/HPF,
1-3/HPF,4-6/HPF
cannot filter
large molecules
such as that of
albumin. It also
revealed that
there is
bacterial
infection as
evidenced by
presence of
bacteria, pus
cells and red
cells in the
urine.
Epithelial Cells:
Rare
Mucus thread:
Rare, (-), (-)
Bacteria: (-), few, (-)
Amorphous urates:
Moderate, moderate,
few
3. Instruct the patient to catch the midstream urine for better result
4. Send the specimen to the laboratory promptly
13
Diagnostic/
Laboratory
Procedure
Date Ordered
Date Result in
Indication (s)
Purpose (s)
Result
Normal
Values used
by the
hospital
Analysis and
Interpretation
14
4. Creatinine
Ordered:
2/3,4,6,8/05
Result in:
2/3,4,7,9/05
5. Na+
Ordered:
2/3/05
Result in:
2/3/05
6. K+
Ordered:
2/3,6/05
Result in:
2/3,7/05
7. Calcium
Ordered:
2/3/05
Result in:
2/3/05
8. Phosphate
Ordered:
2/3/05
Result in:
2/3/05
This test was

ordered in
order to
evaluate renal
function.
1499
1430
1649
731
44.20-150.30
umol/L
Results were all

above the normal
level indicating
renal
malfunction. The
kidney cannot
excrete
nitrogenous
waste product of
protein leading to
its accumulation
in the blood
To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
137
135-150
mmol/L
Normal result
which means
there is still fluid
and electrolyte
balance
To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
4.78
3.5-5.5
mmol/L
Normal result
which means
there is still fluid
and electrolyte
balance
To evaluate
muscle
contraction,
nerve impulse
transmission,
and blood
clotting
6.4
8.5-10.5
mg/dl
Results were all

above the normal
level indicating
renal
malfunction.
To evaluate the
metabolism of
carbohydrates,
bone formation
and acid-base
balance.
186
30-150 u/L
Results were all

above the normal
level indicating
renal
malfunction.
15
2.Tell the patient that no fasting is required

4. Assess the venipuncture site for bleeding
III. ANATOMY AND PHYSIOLOGY

Function of the Urinary System
The major functions of the urinary systems are performed by the kidneys
and the kidneys plays the following essentials roles in controlling the composition
and volume of body fluids:
1. Excretion. The 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.
2. Blood volume control. The kidneys play an essential role in controlling blood
volume by regulating the volume of water removed from the blood to produce
urine.
3. Ion concentration regulation. The kidneys help regulate the concentration
of the major ions in the body fluids.
4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in
the blood and the respiratory system also play important roles in the
regulation of pH
5. Red blood cell concentration. The kidneys participate in the regulation of
red blood cell production and therefore, in controlling the concentration of red
blood cells in the blood.
6. Vitamin D synthesis. The kidneys. Along with the skin and the liver,
participate in the synthesis of vitamin D.
16
Kidneys
The kidneys balance the urinary excretion of substances against the
accumulation within the body through ingestion or production. Consequently, they
are major controller of fluid and electrolyte homeostasis. The kidneys also have
several non-excretory metabolic and endocrine functions, including blood
pressure regulation, erythropoietin production, insulin degradation, prostaglandin
synthesis, calcium and phosphorus regulation and Vitamin D metabolism.
The kidneys are located retroperitoneally, in the posterior aspect of the
abdomen. On either side of the ventral column. They lie between the 12 th thoracic
and third lumbar vertebrae. The left kidney is usually positioned slightly higher
than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5
cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved
shape, with a convex distal edge and a concave medial boundary.
Ureters, Urinary Bladder and Urethra
The ureters are small tubes that carry urine from the renal pelvis of the
kidney to the posterior inferior portion of the urinary bladder. The urinary bladder
is a hollow muscular container that lies in the pelvic cavity just posterior to the
pubic symphysis. It functions to store urine, and its size depends on the quantity
of urine present. The urinary bladder can hold from a few milliliters to a maximum
of about 1000 mL of urine. When the urinary bladder reaches a volume of a few
hundred mL, a reflex is activated, which causes the smooth muscle of the urinary
bladder to contract and most of the urine flows out of the urinary bladder through
urethra. The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle-shaped portion of the urinary bladder located between the
opening of the ureters and the opening of the urethra is called trigone. The
urethra carries urine from the urinary bladder to the outside of the body.
Renal Blood flow and Glomerular Filtration
The kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of he second lumbar
17
vertebra, enter the kidney, and progressively branch into lobar arteries. Blood
flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the
peritubular capillaries carry a small amount of blood to the renal medulla in the
vasa recta before entering the venous drainage. The blood leaves the kidney in
venous system closely corresponding to the arterial system: interlobular veins,
arcuate veins, interlobar veins, and the renal vein. The renal circulation then
empties into the inferior vena cava.
Physiology
Characteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are
removed from the plasma and eliminated by the kidneys. It is 5% water and 5%
dissolved solids and gases. The amount of these dissolved substances is
indicated by it specific gravity. The specific gravity of pure water, used as a
standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are
diseased, they lose the ability to concentrate urine, and the specific gravity no
longer varies as it does when the kidneys function normally.
Urine formation
The chief function of the kidneys is to produce urine. Each part of the
nephrons performs a special function. There are three important processes by
which urine is formed. They are glomerular filtration, tubular reabsorption and
tubular secretion
The path of the Formation of Urine
Blood enters the

Efferent arterioles
To the distal
convulated
To the collecting
tubule
(at
this about 99% oftubule
the filtrate
the reabsorbed)
urinary
hasTobeen
meatus
Passes through the

Glomeruli
To Bowmans capsule
Now it becomes filtrate

(blood minus RBCs
and plasma
protein
To the loop of Henle

Approximately 1 ml of urine is
To the urethraformed per minute
To the bladder
Continues through the proximal

18
tubule
Theconvulated
1 ml of urine
goes to
thethe
renal
pelvis
To
ureter
Fluid and Electrolyte Balance

Electrolyte Balance
Electrolytes are important constituents of body fluids. These are
compounds that separate into positively and negatively charged ions and carry
an electric current in solution. The main source of electrolytes is food. A few of
the most important ions are considered here.
1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid
volume. It is the main positive in extracellular fluids. Sodium is required for
nerve impulse conduction and is important in maintaining acid-base balance.
2. Potassium- important in the transmission of nerve impulse; a major positive
ion in the intracellular fluids. It is involved in cellular enzyme activities and
helps regulate the chemical reactions by which carbohydrate is converted to
protein.
3. Calcium-required for bone formation, muscle contraction, nerve impulse
transmission, and blood clotting
4. Phosphate- essential in the metabolism of carbohydrates, bone formation and
acid-base balance. They are found in the cell membrane and in the nucleic
acids.
5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.
19
Electrolytes must be kept in the proper concentration in both intracellular and

extracellular fluids. Although some electrolytes are lost in the feces and through
the skin as sweat, the job of balancing electrolytes is left mainly to the kidneys.
There are several hormones that are involved in this process. Aldosterone
produced by the adrenal cortex promotes the reabsorption of sodium and the
elimination of potassium. Hormones from parathyroid and thyroid glands regulate
calcium and phosphate levels. Parathyroid hormones increases blood calcium,
levels by causing the bones to release calcium and by causing the kidneys to
reabsorb calcium. The thyroid hormone calcitonin lowers blood calcium by
causing calcium to be deposited in the bone.
IV. THE PATIENT AND HIS ILLNESS
SYNTHESIS OF THE DISEASE (CLIENT CENTERED)
Chronic Renal Failure
Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the bodys internal environment. Chronic Renal failure can develop
insidiously over many years, or it may result from an episode of acute renal
failure from which the client has not recovered.
Precipitating Factors
Chronic glomerular disease such as glomerunephritis
Chronic infections such as chronic pyelonephritis or tuberculosis
Congenital anomalities such as polycystic
Vascular diseases, such as renal nephrosclerosis or hypertension
Obstructive processes such as calculi
Collagen diseases such as systemic lupus erythematosus
nephrotoxic agents such as long-term aminoglycoside
endocrine diseases such as diabetic neuropathy
20
Such conditions gradually destroy the nephrons and eventually cause

irreversible renal failure. Similarly, acute renal failure that fails to respond to
treatment becomes chronic renal failure.
Predisposing Factors
Sex- both sexes are affected by chronic renal failure. But in 1998, based on
United States Renal Data System, a higher total number of males with ESRD
was found
Age- CRF can be found in people of any age, from infants to the very old.
The elderly population also is the most rapidly growing ESRD population in
the United States. Note that age 30 years progressive physiological
glomerulosclerosis.
Aging
also
results
in
concomitant
progressive
physiological decrease in muscle mass such that daily urinary creatinine

excretion also decreases.
Clinical Manifestations
The clinical manifestations of CRF are present throughout the body. No
organ system is spared.
Electrolyte imbalances
Electrolyte balance may be upset by impaired excretion and
utilization in the kidney. Although many clients maintain normal serum
sodium level, the salt-wasting properties of some failing kidneys, in
addition to vomiting and diarrhea, may cause hyponatremia. Because the
kidneys are efficient at excreting potassium, potassium levels usually
remain within normal limits until late in the disease.
Several mechanisms contriburte to hypocalcemia. Conversion of
25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to
absorb calcium) is decreased, which results in reduced intestinal
absorption of calcium. At the same time, phosphate is not excreted, which
causes hyperphosphatemia. Because calcium and phosphate are
21
inversely related, a high phosphate level results in a reduced calcium

level.
Metabolic changes
In advancing renal failure, BUN and serum creatinine rise as waste
products of protein metabolism accumulate in the blood. The serum
creatinine level is the most accurate measure of renal function. The
proteinuria accompanying renal disease and sometimes inadequate
dietary intake of proteins cause hypoproteinuria, which lowers the
intravascular oncotic pressure. Metabolic acidosis occurs because of the
kidneys inability to excrete hydrogen ions. Decrease reabsorption of
sodium bicarbonate and decreased formation of dihydrogen phosphate
and
ammonia
contribute
to
this
problem.
Acidosis
accentuates
hyperkalemia and the reabsorption of calcium from the bones.

Hematologic changes
The primary hematologic effect of renal failure is anemia, usually
normochromic and normocytic. It occurs because the kidneys are unable to
produce erythropoietin, a hormone necessary for red blood cell production.
Frequently, the fatigue, weakness, and cold intolerance accompanying the
anemia lead to a diagnosis of renal failure.
Gastrointestinal changes
The entire gastrointestinal system is affected. Transient anorexia,
nausea, vomiting are almost universal. Clients often experience a constant
bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or
ammonia-like. Stomatitis, parotitis and gingivitis are common problems
because of poor oral hygiene and the formation of ammonia from salivary
urea. Accumulations of gastro may be a major cause of ulcer disease.
Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be
present. Serum amylase level may be increased, although they do not
necessarily indicate pancreatitis.
Immunologic changes
22
Impairment of the immune system makes the client more susceptible

to infection. Several factors are involved, including depression of humoral
antibody formation, suppression of delayed hypersensitivity and decreased
chemotactic function of leukocytes. Immunosuppression is an important part
of the medical management of renal diseaes such as glomerulonephritis.
Cardiovascular changes
The most common clinical manifestation is hypertension, produced
through:
mechanism of volume overload, stimulation of the renin-angiotensin system,
sympatheically mediated vasoconstriction, absence of prostaglandins.
Respiratory changes
Some of the respiratory effects such as pulmonary edema can be
attributed to fluid overload. Metabolic acidosis causes a compensatory
increase in respiratory rate as the lungs try to eliminate excess hydrogen
ions.
Musculoskeletal changes
The etiologic mechanism involves the kidney-bone-parathyroid and
calcium-phosphate-vitamin D connections. As the GRF decreases, the
phosphate excretion decreases and calcium elimination increases. Abnormal
levels of calcium and phosphate stimulate the release of parathyroid hormone
that mobilizes calcium from the bones and facilitates phosphate excretion.
Integumentary changes
The skin is also often very dry because of atrophy of the sweat glands.
Severe
and
intractable
pruritus
may
result
from
secondary
hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is

evident.
V. The Patient and his Care

A. Medical Management
Medical
Date ordered
General
Indication (s)
Clients initial
Clients
23
Management
Date performed
Description
1. D5 LRS iL x
KVO
Ordered:
2/3,7,9/05
Performed:
2/3,7,9/05
Changed:
2/3/05
D/C
2/10/05
2. D5 NaCl iL x
KVO
Ordered:
2/3/05
Performed:
2/3/05
A crystallized
solution that is
available in a
variety of
concentrated
water and
calories are
provided. It is
hypertonic
solution
containing
equal amounts
of Na and Cl
3. Subclavian
Ordered:
2/7/05
Performed:
2/7/05
A catheter tube
is inserted into
vein in either
your neck,
chest, leg or
near the groin.
It has two
chambers to
allow two-way
flow of blood
catheterization
4.Blood
Transfusion
Ordered:
2/3/05
Performed:
2/3/05
Purpose (s)
To maintain
fluid balance of
the pt.
It is intravenous
replacement of
loss or
destroyed
blood
compatible
citrated human
blood it is also
the introduction
reaction to the
treatment
response to the
treatment
Patient felt
discomfort
Patient fluid
status was
maintained
To maintain
fluid balance of
the pt.
Temporary
access for
hemodialysis
To immediately
restore blood
volume to treat
severe anemia,
to be able to
Patient fluid
status was
maintained
Patient
experienced
bleeding and
felt discomfort
on incision site
Patient did not

show any
further bleeding
During the
blood
transfusion,
patient was
chilling for a
short period of
time. There
was no further
adverse
Patient did
manifest some
reaction such
as chilling but
there was not
further reaction
after the
24
of whole blood
or blood
Component
5.
Hemodialysis
Ordered:
2/7,8,9/05
Performed:
2/7,8,10/05
Medical
treatment used
to promote
excretion of
wastes
materials from
the blood of
patient.
maintain
oxygen
transport to the
different parts
of the body
It is indicated
for the patient
because the
kidneys cannot
function very
well to excrete
the nitrogenous
waste products,
thus leading to
its
accumulation in
the blood.
reaction noted
upon the
transfusion
Patient was
slightly nervous
about the
treatment
.
treatment
There was no
adverse
reaction noted
during and after
the procedure
Nursing Responsibilities
1. Blood transfusion
Before
a. Assess client for history of previous BT and any adverse reactions
b. Ensure that the client has an 18 to 19 gauge IV catheter in place
c. Use 0.9% sodium chloride IVF
d. Verify the ABO group, Rh type, client and blood numbers and expiration
date.
e. Take baseline vital signs before initiating BT
f. Identify the patient prior to transfusion
g. Explain the purpose of the transfusion
During
a. Start transfusion slowly
b. Maintain prescribed transfusion rate
25
c. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post
transfusion
After
a. Monitor for adverse reactions
b. Documentation
2. Hemodialysis
Before
a. Explain the purpose of the transfusion
b. Have client void
c. Chart clients weight
d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension
(unless ordered otherwise)
During
a. Obtain and record vital signs before and every 30 mins. during the
procedure
b. Ensure bedrest with frequent position changes for comfort
c. Proper heparinization must be done to prevent coagulation during the
therapy
d. Inform client that headache and nausea may occur
e. Monitor closely for bleeding since blood has been heparinized for
procedure
After
a. Weight the patient after the therapy and record
b. Monitor vital signs especially hypotension.
c. Assess for complications (hypovolemic shock, dialysis disequilibrium
syndrome)
Name of Drug
Date ordered
Date Taken
Date changed
or D/C
Route of
admin. Dosage
and freq. Of
admin.
General action
Indication (s)
Purpose(s)
Clients
response to
medication
26
Amlodipine
besylate
Ordered:
2/3/05
Taken:
2/3-10/05
PO 5 mg OD
Calcium
antagonist,
antihypertensive
To decrease
increase blood
pressure
Patient did not

show any side
effects
Ordered:
2/3/05
PO 50 mg OD
Beta blockers,
antihypertensive
drug
To decrease
increase blood
pressure
Patient did not

show any side
effects
PO 1 cap BID
Iron deficiency
For patient
having anemia
Patients stool
was dark green
in color
PO 40 mg OD
Diuretic
norvasc
Metoprolol
tartate
neobloc
Taken:
2/3-10/05
Iberet- folic
acid
Ordered:
2/3/05
Taken:
2/3-10/05
changed:
2/3/05
furosemide
lasix
Ordered:
2/3/05
For oliguric
patient
Patient did not

show any side
effects
Taken:
2/3-10/05
calcium
carbonate
Ordered:
2/3/05
Taken:
PO 1 tab. TID
Calcium
supplement
To treat
hypocalcemia
Patient did not

show any side
effects
27
2/3-10/05
D/C:
2/3/05
Prior:
1. Check and determine the prescribed the drug.
2. Inform the patient about the prescribed the drug.
3. Explain the procedure, purpose, indication and side effects of the drug.
During:
1.
2.
3.
4.
5.
Check vital signs to obtain baseline data.

Monitor BP
Prepare the drug and the materials
Observe for initial assessment.
Observe for any initial response to the treatment.
After:
1. Observe for any intolerance and side effects on the prescribed drug.
Type of diet
Date ordered
Date started
Date changed
General
description
Indication (s)
Purpose (s)
Clients response
to the diet
DAT
Ordered:
2/3/05
Started:
2/3/05
Changed:
2/3/05
Any foods and

fluids that are
being tolerated by
the patient
To provide
nutrients needed
by the body
Patient followed
the diet
Low salt, low

protein
Ordered:
2/3/05
Started:
2/3-10/05
Foods that has low

salt and protein
value
To decrease further Patient strictly

production of
complied with the
purine which can
prescribed diet
contribute in
28
increasing level of
creatinine in the
blood
Prior:
1.
2.
3.
4.
Check and determine the prescribed diet

Inform the SO about the prescribed diet
Explain the procedure and purpose of the prescribed diet
Cite foods that are restricted.
During:
1. Check vital signs to obtain baseline data
2. Observe for initial response.
After:
1. Inform SO if it would be changed
2. Observe and monitor for changes
Type of activity
Bed rest
Date ordered
Date started
Date changed
Ordered:
2/3/05
Started:
2/3-10/05
General
description
An activity wherein
the patient is not
allowed to do any
activity. Patient
stays at bed.
Indication (s)
Purpose (s)
To decrease
consumption of
oxygen and to be
able to conserve
energy
Clients response
to the activity
Patient strictly
complied with the
prescribed activity
1. Explain the procedure to patient.
2. Explain importance of activity.
3. Assist patient in doing the activity.
B. Surgical Management
Arteriovenous Fistula
29
An AV fistula requires advance planning because a fistula takes a while

after surgery to develop (in rare cases, as long as 24 months). But a properly
formed fistula is less likely than other kinds of vascular accesses to form clots or
become infected. Also, fistulas tend to last many years, longer than any other
kind of vascular access.
A surgeon creates an AV fistula by connecting an artery directly to a vein,
usually in the forearm. Connecting the artery to the vein causes more blood flow
into the vein. As a result, the vein grows larger and stronger, making repeated
insertions for hemodialysis treatment easier. For the surgery, you will be given a
local anesthetic. In most cases, the procedure can be performed on an outpatient
basis.
These fistulas require up to 6 weeks to mature before they can be used,
which makes this approach inappropriate for immediate hemodialysis. Peritoneal
dialysis or large venous access catheters may be used while the fistula is
maturing. External arteriovenous shunts are rarely used.
C. Nursing management
Actual SOAPIE
30
February 3, 2005
S> madali akong mapagod
O> received patient on semi-fowlers position, with an ongoing IVF of D5 NM 1 L
X120 cc/hr @ 900 cc level, infusing well on the right hand
> Afebrile, with pink conjunctiva and lips, easy fatigability, appears weak
>VS taken and recorded as follows: T-36, PR-64, RR-18, BP-150/90
A>altered peripheral tissue perfusion r/t decrease circulating hemoglobin
P>after 6 hrs of nursing interventions, patient will have an improvement on tissue
perfusion as evidence by decrease in paleness in lips and conjunctiva, and
increase in activity tolerance
I > monitored VS and recorded
> Established rapport
> Provided adequate rest to conserve energy
> Discussed the effect of decrease hemoglobin in the body
> Instructed to eat nutritious food especially those rich in iron
> Maintained IVF regulation
> Monitored Intake and Output strictly
> Monitored patients response to blood transfusion
E >goal met as evidence by decreased in paleness and increased activity
tolerance
Actual SOAPIE
February 08. 2005
S>
31
O> received patient on supine position, awake, afebrile with pale conjunctiva,
appears weak with easy fatigability
> VS taken and recorded as follows: T-36, PR-90, RR-16, BP-170/90
A > decreased cardiac output r/t vascular resistance secondary to hypertension
P > after 6 hrs of nursing interventions, patient will improve cardiac output as
evidence by normal vital signs and decreased in paleness and fatigability
I > monitored VS and recorded
> Established rapport
> Instructed to avoid strenuous activity
> Provided calm environment
> Encourage to ambulate early
> Assisted in changing position
> Instructed SO to avoid introducing stress to the patient
> Monitored I&O strictly
E > goal met as evidence by decreased in paleness and fatigability
VI. Patients Daily Progress in the Hospital

A. Patients Daily Progress Chart (from admission to discharge)
Days
A. Nursing Problems
1. Altered tissue perfusion
2.Decreased cardiac output
3. Fluid volume excess
Admission
2/3
2
2/4
3
2/5
4
2/6
5
2/7
6
2/8
7
2/9
Discharge
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
2/10
32
4. Fatigue
5. Activity Intolerance
B. Vital Signs
T
RR
PR
BP
C. Diagnostic Procedures
1. CBC
2. Creatinine
3. Urinalysis
4. Hepatitis profile
D. Medical Management
1. D5 LRS 1 L
2.D5 NaCl
3. Blood transfusion
4. Hemodialysis
5. Subclavian catheterization
E. Drugs
1. Norvasc
2. Neobloc
3. Iberet +Folic
4. Calcium carbonate
5.furosemide
F. Diet
1. DAT
2. Low salt low protein
G. Activity / Exercise
1. Bed rest
*
*
*
*
*
*
36
18
64
36.1
20
62
36.4
20
84
36.1
20
81
36
22
81
36.2
16
80
36.4
20
71
37
17
85
150/
160/
140/
170/
170/
170/
160/
180/
90
100
80
80
110
90
100
90
B. Discharge Planning
Mr. Scrooge was discharge last February 10, 2005, Upon discharged, Mr.
Scrooges physical appearance was improved. There was absence of paleness
in the conjunctiva and lips, fatigability is decrease, and with decrease creatinine
level as compared when he was admitted in the hospital. His vital signs were as
follows: T- 36.5, PR- 85, RR-18, BP- 140/100.
M> Instructed to complied strictly with the following home medications
Norvasc 10 mg 1 tab OD
33
Iberet+FA 1 tab BID

Ketosteril 1 tab TID after meals
Alutab 1 tab TID during meals
Furosemide 40 mg 1 tab OD for edema or oliguria
Mucosolvan 1 tsp. TID
Augmentin 375 mg 1 tab TID
Nifedipine lozenges QID
>For twice a week hemodialysis
E>Bed rest
T>proper wound care (subclavian and fistula)
H>strict compliance to the medications and in hemodialysis
O>follow-up check up on February 15, 2005
D>avoid foods rich in salt and protein
>Limit fluid intake
VII. Conclusion and Recommendations
Chronic renal failure is an irreversible and progressive disease. It is cause
by many factors. Knowing the precipitating factors leading to the development of
this health problem, people should have an extra care when it comes to health.
Giving care to a patient whether pediatric, geriatric, a medical case or
surgical case makes no difference. Rendering care to everyone who needs it is a
real sense of responsibility. In making this case study, I was able to work well
because I know for myself that I did my best for my patient.
We can say that nursing is significant therapeutic and dynamic process. It
is therefore significant for the nurse caring for the patient to wholeheartedly
understand what she is doing like in carrying out some basic skills in relation to
identified goals, comfort and care, interventions and prevention of illness.
34
VIII. Bibliography
Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company
Philadelphia
Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation
Springhouse, Pennsylvania
Pagana (2002). Mosbys Manual of Diagnostic and Laboratory Tests.
MIMS. (2003)
www.yahoo.com
www.google.com
Homework Help
https://www.homeworkping.com/
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Chronic Renal Failure

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Chronic Renal Failure

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I.

hyperparathyroidism; this is due to the compensatory mechanism of the

hyperparathyroidism early in the course of chronic kidney disease so that growth

to control this complication of chronic kidney disease, improved patient outcomes

kidney disease. As nurses, it is our responsibility to render information and impart

B. Family Health-Illness History

Lolo (+) HPN

C. History of Past Illness

D. History of Present Illness

F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and

Abdomen- soft, flat, tender

February 10, 2005

F. Diagnostic and Laboratory Procedures

Results were all

Result were all below

Results were all

Results were all

Results were all

Some of the results

Results were all

This is usually done

Color: straw, light

This test was

Results were all

Results were all

Results were all

2.Tell the patient that no fasting is required

III. ANATOMY AND PHYSIOLOGY

The path of the Formation of Urine

Blood enters the

Passes through the

Now it becomes filtrate

To the loop of Henle

Continues through the proximal

Fluid and Electrolyte Balance

Electrolytes must be kept in the proper concentration in both intracellular and

Such conditions gradually destroy the nephrons and eventually cause

physiological decrease in muscle mass such that daily urinary creatinine

inversely related, a high phosphate level results in a reduced calcium

hyperkalemia and the reabsorption of calcium from the bones.

Impairment of the immune system makes the client more susceptible

hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is

V. The Patient and his Care

Patient did not

Patient did not

Patient did not

Patient did not

Patient did not

Check vital signs to obtain baseline data.

Any foods and

Low salt, low

Foods that has low

To decrease further Patient strictly

Check and determine the prescribed diet

An AV fistula requires advance planning because a fistula takes a while

VI. Patients Daily Progress in the Hospital

Iberet+FA 1 tab BID

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