SYSTEMS PLUS COLLEGE FOUNDATION

MacArthur Highway, Balibago, Angeles City

COLLEGE OF NURSING
nd
2 Semester, S.Y. 2019-2020

A Case Study of Chronic Kidney

Disease Stage 5 Secondary to
Diabetes Mellitus

Presented by

Marianne P. Masangcay

Presented to

Name of Clinical Instructor

Clinical Instructor

January 06, 2020

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INTRODUCTION

Background of the Disease

Chronic kidney disease (CKD) means the kidneys are damaged and cannot filter blood
the way it should. The main risk factors for developing kidney disease are diabetes, high blood
pressure, heart disease, and a family history of kidney failure. CKD or chronic renal failure
(CRF), as it was historically termed as a term that encompasses all degrees of decreased renal
function, from damaged at risk through mild, moderate, and severe chronic kidney failure.
CKD as either kidney damage or a decreased glomerular filtration rate (GFR) of less than
60 mL/min/1.73 m2 for at least 3 months. Whatever the underlying etiology, once the loss of
nephrons and reduction of functional renal mass reaches a certain point; the remaining nephrons
begin a process of irreversible sclerosis that leads to a progressive decline in the GFR.
Hyperparathyroidism is one of the pathologic manifestations of CKD.

Staging
The different stages of CKD form a continuum. The stages of CKD are classified as follows:
• Stage 1: Kidney damage with normal or increased GFR (>90 mL/min/1.73 m 2)
• Stage 2: Mild reduction in GFR (60-89 mL/min/1.73 m 2)
• Stage 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m 2)
• Stage 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m 2)
• Stage 4: Severe reduction in GFR (15-29 mL/min/1.73 m 2)
• Stage 5: Kidney failure (GFR < 15 mL/min/1.73 m 2 or dialysis)

By itself, measurement of GFR may not be sufficient for identifying stage 1 and stage 2
CKD, because in those patients the GFR may in fact be normal or borderline normal. In such
cases, the presence of one or more of the following markers of kidney damage can establish the
diagnosis:
• Albuminuria (albumin excretion > 30 mg/24 hr. or albumin: creatinine ratio > 30 mg/g [>
3 mg/mmol])
• Urine sediment abnormalities
• Electrolyte and other abnormalities due to tubular disorders
• Histologic abnormalities
• Structural abnormalities detected by imaging
• History of kidney transplantation in such cases

Hypertension is a frequent sign of CKD but should not by itself be considered a marker
of it, because elevated blood pressure is also common among people without CKD. In an update
of its CKD classification system, use GFR and albuminuria levels together, rather than
separately, to improve prognostic accuracy in the assessment of CKD.
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More specifically, the guidelines recommended the inclusion of estimated GFR and
albuminuria levels when evaluating risks for overall mortality, cardiovascular disease, end-stage
kidney failure, acute kidney injury, and the progression of CKD. Referral to a kidney specialist
was recommended for patients with a very low GFR (< 15 mL/min/1.73 m²) or very high
albuminuria (> 300 mg/24 h). Patients with stages 1-3 CKD are frequently asymptomatic.
Clinical manifestations resulting from low kidney function typically appear in stages 4-5
Signs and symptoms
Patients with CKD stages 1-3 are generally asymptomatic. Typically, it is not until stages
4-5 (GFR < 30 mL/min/1.73 m²) that endocrine/metabolic derangements or disturbances in water
or electrolyte balance become clinically manifest.

Signs of metabolic acidosis in stage 5 CKD include the following:

• Protein-energy malnutrition
• Loss of lean body mass
• Muscle weakness

Signs of alterations in the way the kidneys are handling salt and water in stage 5 include the
following:
• Peripheral edema
• Pulmonary edema
• Hypertension

Anemia in CKD is associated with the following:

• Fatigue
• Reduced exercise capacity
• Impaired cognitive and immune function
• Reduced quality of life
• Development of cardiovascular disease
• New onset of heart failure or the development of more severe heart failure
• Increased cardiovascular mortality

Other manifestations of uremia in ESRD, many of which are more likely in patients who are
being inadequately dialyzed, include the following:
• Pericarditis: Can be complicated by cardiac tamponade, possibly resulting in death if
unrecognized
• Encephalopathy: Can progress to coma and death
• Peripheral neuropathy, usually asymptomatic
• Restless leg syndrome
• Gastrointestinal symptoms: Anorexia, nausea, vomiting, diarrhea
• Skin manifestations: Dry skin, pruritus, ecchymosis
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• Fatigue, increased somnolence, failure to thrive

• Malnutrition
• Erectile dysfunction, decreased libido, amenorrhea
• Platelet dysfunction with tendency to bleed

Screen adult patients with CKD for depressive symptoms; self-report scales at initiation
of dialysis therapy reveal that 45% of these patients have such symptoms, albeit with a somatic
emphasis.
Diabetes is the leading cause of kidney failure, accounting for 44% percent of new cases.
Current research suggests that control of high blood pressure is a key factor in slowing this
disease. Strict control of blood sugar levels and reduction of dietary protein intake are also
important. Treatment to prevent diabetic kidney disease should begin early before kidney
damage develops. The blood glucose, or blood sugar, levels are too high. Over time, this can
damage the kidneys. If there is damaged, waste and fluids build up in the blood instead of
leaving the body.
Kidney damage from diabetes is called diabetic nephropathy. Patients with diabetes can
develop high blood pressure as well as rapid hardening of the arteries, which can also lead to
heart disease and eye disorders. Research suggests high blood pressure may be the most
important predictor for diabetics developing chronic kidney disease. (National Kidney
Foundation 2016)

Type 1 Diabetes
Is also called insulin-dependent diabetes. It used to be called juvenile-onset diabetes,
because it often begins in childhood. It is an autoimmune condition. The body attacking its own
pancreas with antibodies causes it. In people with type 1 diabetes, the damaged pancreas does
not make insulin. This type of diabetes maybe cause by a genetic predisposition. It could also be
the result of faulty beta cells in the pancreas that normally produce insulin.

Type 2 Diabetes
Used to be called adult – onset diabetes but with the epidemic of obese and overweight
kids, more teenagers are now developing type 2 diabetes. It was also called non – insulin
independent diabetes and it is often a milder form of diabetes than type 1. Nevertheless, type 2
diabetes can still cause major health complication particularly in the smallest blood vessels in the
body that nourish the kidneys, nerves, and eyes. It also increases the risk of heart disease and
stroke. With type 2 diabetes, the pancreas usually produces some insulin but either the amount
produce is not enough for the body’s needs, or the body’s cells are resistant to it. Insulin
resistance or lack of sensitivity to insulin happens primarily in fat, liver, and muscle cells.
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STATISTICS
CKD is more common in people aged 65 years or older (38%) than in people aged 45-64
years (13%) or 18-44 years (7%). CKD is more common in women (15%) than men (12%) are.
CKD is more common in non-Hispanic blacks (16%) than in non-Hispanic whites (13%) or non-
Hispanic Asians (12%). About 14% of Hispanics have CKD.

WORLD
CKD is a worldwide public health problem. In the United States, there is a rising
incidence and prevalence of kidney failure, with poor outcomes and high cost. CKD is more
prevalent in the elderly population. However, while younger patients with CKD typically
experience progressive loss of kidney function, 30% of patients over 65 years of age with CKD
have stable disease. CKD is associated with an increased risk of cardiovascular disease and end-
stage renal disease (ESRD). Kidney disease is the ninth leading cause of death in the United
States.

PHILIPPINES
One Filipino develops chronic renal failure every hour or about 120 Filipinos per million
population per year. More than 5,000 Filipino patients are presently undergoing dialysis.

CURRENT TRENDS
Prevention and or delay in CKD progression require adequate: a glycemic regulation and,
BP control. Any class of antihypertensive medications can be used, but blockers of the renin-
angiotensin system are preferred due to their albuminuria reducing action; however, with their
use, serum creatinine and serum potassium should be frequently monitored.
Long-acting diuretics may be indicated in the presence of moderate to severe renal
functional impairment. It is essential to achieve appropriate salt and protein intake. Initiation of a
combination of angiotensin converting enzyme inhibitors (ACEI) and angiotensin receptor
blockers (ARB) in ADPKD patients appears to be effective in strict BP control and in slowing
cyst progression.
In patients with normal renal function, a high fluid intake is an additional therapeutic
measure that may delay cyst growth. Lipid lowering drugs are indicated for the treatment of
dyslipidemia and CVD protection. However, there is no evidence that they prevent or delay CKD
progression. Recent evidence suggests that a Mediterranean Diet is associated with both
renoprotection and improved survival.
The relation between adherence to a Mediterranean dietary pattern, renal function and
mortality was assessed in a population-based cohort of 1111 elderly Swedish men (age=70
years). Greater adherence to the Mediterranean Diet predicted a lower risk of CKD and greater
10 year survival in those with manifest CKD. Similarly, in an international study involving
elderly subjects at high risk of coronary heart disease, a Mediterranean diet, maintained for one
year, appears to be associated with an improvement in renal function. (Berbari 2018).
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PURPOSE OF THE STUDY

The purpose of this study is to be able to give information regarding the patient’s
condition and to deliver logical presentation about Chronic Kidney Disease Stage 5 Secondary to
Diabetes Mellitus. And to be able to gain knowledge, skills and attitude on how to handle patient
and to develop an awareness of the potential, physical, behavioral and psychosocial effects of
Chronic Kidney Disease Stage 5 Secondary to Diabetes Mellitus.

Objectives:
Nurse-centered objectives:
After the completion of this case study, the student nurses should be able to:
Cognitive:
• Determine the condition, risk factors, complication, prevention, and management of CKD
• Identify the signs, symptoms and clinical manifestations of CKD.
• Discuss the pathophysiology of the disease process.
• Identify nursing problems based on the client’s condition.
• Evaluate effective treatment of CKD.
Affective
• Motivate the client to improve diet and lifestyle.
• Evaluate patient response with regards to the activities given.
• Encourage family members to discuss health issues that may concern them.
• Explain ways that may be helpful in taking precautions against the disease.
Psychomotor
• Obtain necessary information about the patient for medical management.
• Serve the client by attending to her needs at the period of student nurses’ duty.
• Apply appropriate nursing interventions and skills based on the nursing care plan.
• Promote health and provide medical understanding of such condition to the patient.

Patient-centered objectives:
After the completion of the case study, the patient will be able to:
Cognitive
• Understand the health teachings provided by the student nurse
• Enumerate appropriate interventions to perform when having symptoms of the condition
Affective
• Motivate family members to participate in the treatment
• Express appreciation of health modalities to treat CKD
Psychomotor
• Demonstrate proper skills in managing CKD at home
• Identify safety measures in provision of self-care in the course of the treatment
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I. NURSING ASSESSMENT

A. Personal history (demographics, educational attainment, occupation, religion )

Ms. CKD a 51-year-old female stands as mother of six children the eldest is 33 years old
while the youngest is 27 years old. She is married to Mr. CKD. They live in Angeles City,
Pampanga. Her nationality is Filipino and was born in Pampanga on 28th of July 1968. Ms. CKD
is presently running their own business.

Ms. CKD graduated Secondary Education. She was raised as a Catholic, where she learned about
religious values. She believes in super natural forces and superstitious belief. The client seeks
medical help from a physician for a serious health condition although Ms. CKD admits to seek
help from the “Hoax doctor “or the local “albularyo “who would prescribed alternative medicine
to relieve mild signs and symptoms and other bodily discomfort.

B. Socio economic
Ms. CKD owns a building where she has tenant-paying rental 10,000 pesos a month. The
client source of income is coming from the rental fee of her tenant. Ms. CKD daily needs like
foods and allowance are coming from her children as stated by Ms. CKD.
She stated that their monthly bills are paid mostly by their children as they are already
working. The client is the one responsible for paying other miscellaneous including the expenses
in her medications and treatment of her present disease. She saved some money for her future
and in case of emergency; she has a money to use.

C. Environment
Ms. CKD resides in Angeles City and occupies the ancestry house of her family and still
living with her other children. The location of their house is accessible to hospitals, health
centers and other government institutions. Ms. CKD did not report problems regarding her
environment that could interfere with her condition but instead states that sometimes she cannot
control her emotions like getting sad and getting tired of her repetitive treatment of twice a week
hemodialysis.

Activities of Daily living (diet and nutrition, habits/vices, etc.)

Ms. CKD said that she is not consuming coffee in a day, but instead she includes only
water in her meal. She eats a lot of vegetables and fish. She also said that she does not exercise at
all because of her present conditions.
The client would usually wake up at 4:00 in the morning and then she would drink milk
while her daughter is the one preparing for their breakfast. Her daughter cooks fried rice and fish
in the morning as their breakfast but sometimes her daughter will just buy” pandesal” and put
spread on it. At 6:00 am, she and her daughter will have a small talk while listening to her
favorite music.
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In between 9 am to 10 am, she will take her snack and usually eat bread. She takes her
lunch at 12:00 pm and preferred to eat vegetables and fish. The client will stay until 5:00 pm
watching her favorite TV shows or sometimes played her favorite movie.
At 6:00 pm her daughter will prepare their dinner at exact 7:00 pm, she will take her
dinner and her favorite food, which is vegetable and fish, and at 8:00 pm, she will watch
television until she fall asleep. The client has no bad habits or vices. She does not smoke and
drink liquor at all that can interfered her present condition.

D. Family health history with pedigree

Hereditary disease in the family is hypertension and Diabetes mellitus that her uncle
currently has and the reason of death of her father, her father’s sibling had a heart attack due to
hypertension. This shows that hypertension and Diabetes Mellitus is evident in their family
and is hereditary. Her other uncle and aunt died naturally but only her one uncle died of cancer
while her one aunt die of pregnancy complications.
Ms. CKD grandfather died naturally at the age of 100+ and her grandmother died
naturally at the age of [Link] maternal side her grandmother died with pneumonia at the age of
90 while her grandfather died of natural death at the age of 95. The client’s mother died because
of diabetes at the age of 89 while her father died of hypertension at the age of 88.
Ms. CKD’s uncle died at the age of 60 and she cannot recall anymore the cause of death
while her auntie, her mother’s siblings died of heart attack at the age of 60. On maternal side, her
grandmother and grandfather died in natural death and all of her uncle and auntie, siblings of her
father were all alive and healthy.
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FAMILY HEALTH HISTORY WITH PEDIGREE

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II. Health history (Past and Present Illnesses)

Besides being hospitalized for her present condition, Ms. CKD had a previous hospital
stays. In 2014, Ms. CKD planned to have a laser treatment to her both eyes because of poor
eyesight. In regards to this, Ms. CKD decided to go under complete blood count even there is no
physician’s order.
The result of her CBC revealed that she has an increased glucose measuring 300+. She
then ask her neighbor who has a diabetes of what kind of medicine he’s taking to and after she
learned what kind of medicine her neighbor taking to, she then bought the same name of the
medicines and took them also. She took the medicine for almost one month, which the patient
cannot recall the name of medicine as she stated.
In 2017, Ms. CKD experienced muscle weakness that she cannot even take a step in an
elevated part. She cannot walk without support as she stated. She went to the doctor to seek help
with her daughter and she was advice to stay in the hospital for monitoring. After all, the
laboratory procedures done, she was diagnosed of Diabetes Mellitus and found a stone in her
kidney and with a fatty liver. She was gone under medications which the patient cannot recalled
the name of the drug but stated that she maintained her injectable insulin. In addition, continued
to take medicines as part of her maintenance.
She has also episodes of fever, cough and colds and this was managed by taking over the
counter drug like Paracetamol for fever, Solmux for cough and Neozep for colds. She has also
episodes of diarrhea and this was managed by taking over the counter drug like Diatabs.
In regards to her present illness, Ms. CKD stated that she was supposed to go on her
follow up checkup but unfortunately her doctor went out of the country and instead to seek
advice to other doctor she decided to wait for his doctor to come back but her doctor took so long
for him to come back. She continued her medications until her doctor went back in 2018.
She undergo in some laboratory procedure and the result appeared that one side of her
kidney is already affected and she was adviced to stay in the hospital for monitoring until her
doctor decided that Ms. CKD would undergo hemodialysis. She started hemodialysis on March
2018.
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Physical Assessment (IPPA-cephalocaudal approach)

The patient was first met (12/12/19) lying in bed with ongoing hemodialysis, with dry
weight of 57 kgs and gained [Link] of ultra-filtration is 2.3 Liters, accessed at right
arteriovenous fistula with fistula needle of 16 and dialyzer of F8 with regular Heparin. Duration
of 4 hours, dialysate flow of 500 and blood flow of 150-350. Ms. CKD is wearing a white t-shirt
with pajama and was conscious (GCS 15/15). Vital signs were taken and recorded as follows:
T- 37.2 Celsius degree
RR- 19 cycle per minute
PR- 77 beat per minute
BP-130/80 mmHg
O2SAT- 96

Skin, Hair, and Nails Inspection

Skin
Skin is pale

Hair and Scalp

Hair is gray, fine, and even in distribution

Nails
Nails are smooth, firm and clean.
Nails go back in 3 seconds after capillary test.

Head and Neck Inspection

Head
Head is round, symmetric, erect, proportional
No presence of visible lesion

Neck
Neck is symmetric with head centered and without bulging masses.

Eyes and Ears Inspection

Eyes
No presence of swelling, redness, or lesions of the eye
Upper and lower palpebral conjunctiva are free of swelling or lesions
Eyes are sunken appearance
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Ears
Ears are equal in size bilaterally.

Mouth, Nose and Sinuses Inspection

Mouth
Lips are pale and dry

Nose
Color is the same as the rest of the face
Sinuses do not appear enlarged or swollen

Peripheral and Vascular Inspection

Arms are bilaterally symmetric with variation in size and shape
Presence of fistula on the right upper arm
Legs are free of lesions and ulcerations
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LABORATORY PROCEDURES

DIAGNOSTICS/ LABORATORY CREATININE

PROCEDURES A creatinine blood test measures the level of

creatinine in the blood. Creatinine is a waste

product that that forms when creatinine

breaks down. Creatinine is found in the

muscle. Creatinine levels in the blood can

provide the physician with information about

how well the kidneys are working. Creatinine

is one of the substances that the kidneys

normally eliminate from the body.

DATE REQUESTED/ Doctors ordered:

DATE RESULT(S) IN December 10,2019

PURPOSE(S) OF THE PROCEDURE They measure the level of creatinine of \the

( Patient Centered) patient in the blood and it is used to diagnose

impaired renal function and assess

glomerular filtration.

RESULTS 8.28 mg/dL

NORMAL VALUES 0.40- 1.40 mg/dL

ANALYSIS AND INTERPRETATION OF RESULTS This test showed that the result was in above

normal range. It shows that the kidney of the

patient is not functioning well and it may

already damage brought about the disease or

the medications.
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DIAGNOSTICS/ LABORATORY Phosphate

PROCEDURES Phosphate is a charged particle (ion) that

contains the mineral phosphorus. The body

needs phosphorus to build and repair bones

and teeth, help nerves function, and make

muscles contract. ... The kidneys help control

the amount of phosphate in the blood. When

your kidneys start to fail they cannot remove

the excess phosphate from your body. Kidney

disease also leads to an increase in production

of parathyroid hormone.

DATE REQUESTED/ Doctors ordered:

DATE RESULT(S) IN December 10,2019
PURPOSE(S) OF THE PROCEDURE They measures the amount of phosphate in
( Patient Centered) a blood sample. It is used to diagnose kidney

disorder.

RESULTS 6.0 mg/dL.

NORMAL VALUES 2.5-4.5 mg/dL.
ANALYSIS AND INTERPRETATION OF RESULTS This test showed that the result was in above

normal range. It shows that the patient have

hyperphosphatemia and might have bone

and muscles problem and increase the risk of

heart attack and stroke brought about the

disease or the medications.

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COMPLETE BLOOD COUNT

DIAGNOSTICS/ LABORATORY HEMOGLOBIN

PROCEDURES A main component of RBC, which is conjugated

protein, that serves as a vehicle for the

transportation of oxygen to the tissue and

carbon dioxide from the tissue.

DATE ORDERED December 10, 2019

DATE RESULTS December 10, 2019

INDICATION OR PURPOSE This test was indicated for the patient to

measure the total amount of hemoglobin in the

blood.

RESULTS 100g/L
NORMAL VALUES 140-180 g/L
ANALYSIS AND INTERPRETATION OF RESULTS The result showed a decreased number of

hemoglobin. These may indicate that the

patient is experiencing kidney malfunction that

cannot produce erythropoietin, which is

responsible in RBC production.

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DIAGNOSTICS/ LABORATORY Red Blood Cell Count

PROCEDURES RBC count also called an erythrocyte count, is

part of a complete blood count. It is used to

detect the number or red blood cells in

microliter, or cubic millimeter of whole blood.

The RBC blood itself provides no qualitative

information regarding the size, shape or

concentration of HGB within the corpuscles, but

it may be used to calculate two erythrocyte

indices; MHC, MCV.

DATE ORDERED December 10, 2019

DATE RESULTS

INDICATION OR PURPOSE This test was indicated for the patient to check

if there is still a normal ratio between the bloods

total volume which is mainly compose of plasma

and the amount of red blood cells.

RESULTS 3.5 iu/L

NORMAL VALUES 5.5-6.5 iu/L
ANALYSIS AND INTERPRETATION OF RESULTS The result showed a decreased number of red

blood cells due to hemo concentration of blood.

These may indicate that the patient is

experiencing kidney malfunction that cannot

produce erythropoietin, which is responsible in

RBC production.
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DIAGNOSTICS/ LABORATORY HEMATOCRIT

PROCEDURES A hematocrit test, which maybe perform

separately or as part of complete blood count,

measures percentage by volume packed red

blood cells in a whole blood sample.

Hematocrit is the proportion or ration of the

total blood volume (Plasma) and the amount of

red blood cells.

DATE ORDERED December 10, 2019

DATE RESULTS

INDICATION OR PURPOSE This test was indicated for the patient to check

if there is still a normal ratio between the bloods

total volume which is mainly compose of plasma

and the amount of red blood cells.

RESULTS 0.30 g/L

NORMAL VALUES 0.40-0.54

ANALYSIS AND INTERPRETATION The result showed a decreased number of

OF RESULTS hematocrit due to hemo concentration of blood.

These may indicate that the patient is

experiencing kidney malfunction that cannot

produce erythropoietin, which is responsible in

RBC production.
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ANATOMY AND PHYSIOLOGY

Structure and functions of Kidney

The kidneys are a pair of bean-shaped organs present in all vertebrates. They remove
waste products from the body, maintain balanced electrolyte levels, and regulate blood pressure.
The kidneys are some of the most important organs.

Structure
The kidneys play a role in maintaining the balance of body fluids and regulating blood
pressure, among other functions. The kidneys are at the back of the abdominal cavity, with one
sitting on each side of the spine. The right kidney is generally slightly smaller and lower than the
left, to make space for the liver. Each kidney weighs 125–170 grams (g) in males and 115–155 g
in females. A tough, fibrous renal capsule surrounds each kidney. Beyond that, two layers of fat
serve as protection. The adrenal glands lay on top of the kidneys. Inside the kidneys are a
number of pyramid-shaped lobes. Each consists of an outer renal cortex and an inner renal
medulla. Nephrons flow between these sections. These are the urine-producing structures of the
kidneys. Blood enters the kidneys through the renal arteries and leaves through the renal veins.
The kidneys are relatively small organs but receive 20–25 percent of the heart's output. Each
kidney excretes urine through a tube called the ureter that leads to the bladder.

Function
The main role of the kidneys is maintaining homeostasis. This means they manage fluid
levels, electrolyte balance, and other factors that keep the internal environment of the body
consistent and comfortable. They serve a wide range of functions.

Waste excretion
The kidneys remove a number of waste products and get rid of them in the urine. Two
major compounds that the kidneys remove are:
• urea, which results from the breakdown of proteins
• uric acid from the breakdown of nucleic acids

Reabsorption of nutrients
The kidneys reabsorb nutrients from the blood and transport them to where they would
best support health. They also reabsorb other products to help maintain homeostasis.

Reabsorbed products include:

• glucose
• amino acids
• bicarbonate
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• sodium
• water
• phosphate
• chloride, sodium, magnesium, and potassium ions

Maintaining pH
In humans, the acceptable pH level is between 7.38 and 7.42. Below this boundary, the
body enters a state of acidemia, and above it, [Link] this range, proteins and enzymes
break down and can no longer function. In extreme cases, this can be fatal. The kidneys and
lungs help keep a stable pH within the human body. The lungs achieve this by moderating the
concentration of carbon dioxide. The kidneys manage the pH through two processes:
• Reabsorbing and regenerating bicarbonate from urine: Bicarbonate helps neutralize acids.
The kidneys can either retain it if the pH is tolerable or release it if acid levels rise.
• Excreting hydrogen ions and fixed acids: Fixed or nonvolatile acids are any acids that do
not occur because of carbon dioxide. They result from the incomplete metabolism of
carbohydrates, fats, and proteins. They include lactic acid, sulfuric acid, and phosphoric
acid.

Osmolality regulation
Osmolality is a measure of the body's electrolyte-water balance, or the ratio between fluid
and minerals in the body. Dehydration is a primary cause of electrolyte imbalance. If osmolality
rises in the blood plasma, the hypothalamus in the brain responds by passing a message to the
pituitary gland. This, in turn, releases antidiuretic hormone (ADH).In response to ADH; the
kidney makes a number of changes, including:
• increasing urine concentration
• increasing water reabsorption
• reopening portions of the collecting duct that water cannot normally enter, allowing water
back into the body
• retaining urea in the medulla of the kidney rather than excreting it, as it draws in water

Regulating blood pressure

The kidneys regulate blood pressure when necessary, but they are responsible for slower
adjustments. They adjust long-term pressure in the arteries by causing changes in the fluid
outside of cells. The medical term for this fluid is extracellular fluid. These fluid changes occur
after the release of a vasoconstrictor called angiotensin II. Vasoconstrictors are hormones that
cause blood vessels to narrow. They work with other functions to increase the kidneys'
absorption of sodium chloride, or salt.
This effectively increases the size of the extracellular fluid compartment and raises blood
pressure. Anything that alters blood pressure can damage the kidneys over time, including
excessive alcohol consumption, smoking, and obesity.
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Secretion of active compound

The kidneys release a number of important compounds, including:
• Erythropoietin: This controls erythropoiesis, or the production of red blood cells. The
liver also produces erythropoietin, but the kidneys are its main producers in adults.
• Renin: This helps manage the expansion of arteries and the volume of blood plasma,
lymph, and interstitial fluid. Lymph is a fluid that contains white blood cells, which
support immune activity, and interstitial fluid is the main component of extracellular
fluid.
• Calcitriol: This is the hormonally active metabolite of vitamin D. It increases both the
amount of calcium that the intestines can absorb and the reabsorption of phosphate in the
kidney.

Structure and functions of pancreas

Location and structure:

 The pancreas is an elongated (12 to 15 cm), fleshy organ consisting of head, body and
tail.
 It is located posterior to the stomach with the head tucked into the curve of the
duodenum.
 The body and tail extend laterally to the left, with the tail making contact with the spleen.
 It is considered as a mixed gland (heterocrine gland) because it functions both with ducts
(as an exocrine gland) and without ducts (as an endocrine gland).
 As an exocrine gland, it secretes digestive enzymes (protease, pancreatic lipase, amylase
etc.) and alkaline materials into a duct that empties into the small intestine.
 The cluster of cells called pancreatic islets (islets of Langerhans) acts as an endocrine
part, which is only about 1% of the total weight of pancreas.
 There are about 200,000 to 2,000,000 pancreatic islets scattered throughout the gland.
 Four special groups of cells, called alpha, beta, delta and F cells are found in the islets.

Hormones secreted by islets of Langerhans:

 Alpha cells synthesize, store and secrete the hormone glucagon.
 Beta cells produce insulin.
 Delta cells secrete somatostatin.
 F cells secrete pancreatic polypeptide that is released into the bloodstream after a meal,
the endocrine function of which is not yet known.

Insulin:
 When the blood glucose level rises, insulin is produced to lower the blood concentration
of glucose.
 It facilitates glucose transport across the plasma membranes.
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 Insulin enhances the conversion of glucose to glycogen (glycogenesis), which is then

stored in liver as a ready source of blood glucose.
 The conversion of glucose into fatty acids is enhanced by insulin.

Glucagon:
 When the concentration of blood glucose falls, glucagon stimulates the liver to convert
glycogen into glucose (glycogenolysis), which causes the blood glucose level to rise.
 It also stimulates gluconeogenesis (formation of glucose from non-carbohydrate sources
such as amino acids and fatty acids).
 The release of fatty acids and glycerol from adipose tissue is also stimulated by glucagon.

The two hormones insulin and glucagon work in antagonistic way but in concert to maintain
a normal blood glucose concentration.

Somatostatin:
 Functioning of alpha cells and beta cells is controlled by somatostatin.
 A growth hormone-inhibiting hormone also inhibits the secretion of both glucagon and
insulin.
Hyposecretion of insulin or hyposecretion of glucagon:
 It causes diabetes mellitus, which can occur as either Type 1 (insulin-dependent)
diabetes, which usually begins early in life or Type 2 (insulin-independent) diabetes,
which occur later in life, mainly in overweight people.

Type 1 diabetes:
 It results when beta cells do not produce enough insulin.
 Glucose accumulates in the blood and spills into the urine, but does not enter the cells.
 Excess glucose in urine is a diuretic and causes dehydration and the body begins to
starve.
 Appetite may increase, but eventually the body consumes its own tissues, literally eating
itself up.

Type 2 diabetes:
 In this type, there is a nearly normal plasma concentration of insulin, but the problem is
hypo responsiveness or no response, to insulin, a condition known as insulin resistance.
 Because the removal of glucose from the kidneys requires large amount of water, a
diabetic person produces excessive sugary urine and may excrete as much as 20 liters of
sugary urine a day, which increases the thirst.

Hypersecretion of insulin:
 It causes low blood glucose or hypoglycemia.
 22

PATHOPHYSIOLOGY
A normal kidney contains approximately 1 million nephrons, each of which contributes
to the total glomerular filtration rate (GFR). In the face of renal injury (regardless of the
etiology), the kidney has an innate ability to maintain GFR, despite progressive destruction of
nephrons, as the remaining healthy nephrons manifest hyper filtration and compensatory
hypertrophy. This nephron adaptability allows for continued normal clearance of plasma solutes.
Plasma levels of substances such as urea and creatinine start to show measurable increases only
after total GFR has decreased 50%.
The plasma creatinine value will approximately double with a 50% reduction in GFR. For
example, a rise in plasma creatinine from a baseline value of 0.6 mg/ld. to 1.2 mg/ld. in a patient,
although still within the adult reference range, actually represents a loss of 50% of functioning
nephron mass.
The hyperfiltration and hypertrophy of residual nephrons, although beneficial for the
reasons noted, has been hypothesized to represent a major cause of progressive renal
dysfunction. The increased glomerular capillary pressure may damage the capillaries, leading
initially to secondary focal and segmental glomerulosclerosis (FSGS) and eventually to global
glomerulosclerosis. Factors other than the underlying disease process and glomerular
hypertension that may cause progressive renal injury include the following:
• Systemic hypertension
• Nephrotoxins (eg, nonsteroidal anti-inflammatory drugs [NSAIDs], intravenous contrast
media)
• Decreased perfusion (eg, from severe dehydration or episodes of shock)
• Proteinuria (in addition to being a marker of CKD)
• Hyperlipidemia
• Hyperphosphatemia with calcium phosphate deposition
• Smoking
• Uncontrolled diabetes

A strong association between episodes of acute kidney injury (AKI) and cumulative risk
for the development of advanced CKD in patients with diabetes mellitus who experienced AKI
in multiple hospitalizations. Any AKI versus no AKI was a risk factor for stage 4 CKD, and each
additional AKI episode doubled that risk.
 23

SCHEMATIC DIAGRAM OF THE PATHOPHYSIOLOGY OF THE CONDITION

 24

V. MEDICAL MANAGEMENT

Treatment or Medication Generic Name: EPOETIN ALFA

(Generic and Brand Name) Brand Name: EPOGEN, PROCRIT

Dosage: 4000 IU 3x a week

Route: SQ

General Action Glycoprotein that stimulates RBC production.

Hypoxia and anemia generally increase the

production of erythropoietin.

Purpose (Patient-Centered) The purpose of Epoetin Alfa is to treat the condition

of the patient caused by decreased red blood cells.

Date Ordered December 10, 2019

Response of the patient Patient did not manifest any signs or symptoms of

allergic reaction to the drug and increased red blood

cells.

Nursing Responsibilities [Link] doctor’s order for the medication, route,

dosage and frequency of administration

-To prevent errors.

2. Administer the drug exactly as prescribed.

-To prevent complication for the patient.

3. Administer the drug at least 1 hour after a meal.

-For SO knowledge about the medication.

[Link] GI symptoms

6. Tell the SO to inform prescriber of worsening signs

and symptoms, pain, or diarrhea that does not

improve.
 25

Treatment or Medication Generic Name: FERROUS SULFATE

(Generic and Brand Name) Brand Name: FEOSOL, FER IRON, FER-GEN-SOL

Dosage: 50 mg tab. BID

Route: oral

General Action Corrects erythropoietin abnormalities induced by

iron deficiency but does not stimulate EPO

Purpose (Patient-Centered) The purpose of this medication for the patient is

to correct simple iron deficiency and to treat iron

deficiency.

Date Ordered December 10, 2019

Response of the patient Patient did not manifest any signs or symptoms of

allergic reaction to the drug. In addition, it treats iron

deficiency.

Nursing Responsibilities [Link] whether patient is sensitive to

FERROUS SULFATE

2. Inspect patient’s skin for petechiae.

3. Tell SO not to stop drug abruptly or without

prescriber’s consent.

-For better absorption of the drug and to prevent

drug resistance.

4. Advice patient to take medicine as prescribed.

-Caution patient to make position changes slowly to

minimize orthostatic hypotension.

5. Instruct patient to avoid concurrent use of alcohol

or OTC medicine without consulting the physician.

6. Advise patient to consult physician if irregular

heartbeat, dyspnea, swelling of hands and feet and

hypotension occurs.
 26

Treatment or Medication Generic Name: LINAGLIPTIN TRADJENTA

(Generic and Brand Name) Brand Name: LANOXIN

Dosage: 5 mg tab. OD

Route: oral

General Action Increasing the binding of insulin to its receptor and

potentiating insulin action.

Purpose (Patient-Centered) To improve glycaemic control.

Date Ordered December 10, 2019

Response of the patient To improve glycaemic control.

Nursing Responsibilities 1. Observe patient for signs and symptoms of

hypoglycemic reactions (abdominal pain, sweating,

hunger, weakness, dizziness, headache, tremor,

tachycardia, anxiety).

2. Instruct patient to take linagliptin as directed.

Take missed doses as soon as remembered,

unless it is almost time for next dose; do not

double doses. Advise patient to read the Patient

Package Insert before starting and with each Rx

refill; new information may be available.

3. Explain to patient that linagliptin helps control

hyperglycemia but does not cure diabetes.

Therapy is usually long term.

4. Instruct patient not to share this medication with

others, even if they have the same symptoms

5. Encourage patient to follow prescribed diet,

medication, and exercise regimen to prevent

hyperglycemic or hypoglycemic episodes.

 27

Treatment or Medication Generic Name: FOLIC ACID

(Generic and Brand Name) Brand Name: FOLVITE

Dosage: 50 mg tab BID

Route: oral

General Action Acts against folic acid deficiency that impairs

thymidylate synthesis and results in production of

defective DNA that leads to megaloblastic formation

and arrest of bone marrow maturation.

Purpose (Patient-Centered) The purpose of Folic acid to the patient is to

Stimulates production of RBCs, WBCs, and platelets

Date Ordered December 10, 2019

Response of the patient The response of the patient to the medication is new

cells was maintained and anemia was treated.

Nursing Responsibilities 1. Encourage patient to comply with diet

recommendations of health care professional

2. Explain that the best source of vitamins is a well-

balanced diet with foods from the four basic food

-A diet low in vitamin B and folate will be used to

diagnose folic acid deficiency without concealing

pernicious anemia.

-Folic acid in early pregnancy is necessary to prevent

neural tube defects.

-Foods high in folic acid include vegetables, fruits,

and organ meats; heat destroys folic acid in foods.

3. Patients self-medicating with vitamin

supplements should be cautioned not to exceed RDA

 28

Treatment or Medication Generic Name: DIGOXIN

(Generic and Brand Name) Brand Name: LANOXIN

Dosage: 0.25 mg tab. OD

Route: Oral

General Action Increasing the force and velocity of myocardial

systolic contraction (positive inotropic effect). It also

decreases conduction velocity through the

atrioventricular node. Action is more prompt and less

prolonged than that of digitalis and digitoxin.

Purpose (Patient-Centered) Digoxin is used to the patient to Increases the

contractility of the heart muscle.

Date Ordered December 10, 2019

Response of the patient Patient Increased the contractility of the heart

muscle and the strain in the heart reduces and

maintained a normal, steady and strong heartbeat.

Nursing Responsibilities 1. Check doctor’s order for the medication, route,

dosage and frequency of administration.

2. Check the medication properly and read labels

properly.

Know the reason for which patient is receiving the

medication.

medication.

3. Check the label three times before administering.

4. Assess patient’s history of allergic reaction to the

drug.

5. Inform SO about the side effects and adverse

effects of the medication.

 29

Treatment or Medication Generic Name: CARVEDILOL

(Generic and Brand Name) Brand Name: COREG, COREG CR

Dosage: 6.25 mg tab. OD

Route: oral

General Action Adrenergic receptor blocking agent that combines

selective alpha activity and nonselective beta-

adrenergic blocking actions. Both activities

contribute to blood pressure reduction. Peripheral

vasodilatation and, therefore, decreased peripheral

resistance results from alpha1-blocking activity of

Coreg. It is 3–5 times more potent than labetalol in

lowering blood pressure.

Purpose (Patient-Centered) It was indicated to the patient to manage

hypertension.

Date Ordered December 10, 2019

Response of the patient It helps the patient’s to lower the blood pressure.
Nursing Responsibilities 1. Check doctor’s order for the medication, route,

dosage and frequency of administration.

2. Check the medication properly and read labels

3. Know the reason for which patient is receiving the

medication.

4. Check the label three times before administering.

5. Assess patient’s history of allergic reaction to the

drug.

-To prevent any kind of adverse reaction.

6. Inform SO about the side effects and adverse

effects of the medication.

 30

Treatment or Medication Generic Name: TRIMETAZIDINE

(Generic and Brand Name) Brand Name: VASTEL MR

Dosage: 35 mg tab. TID

Route: oral

General Action Inhibits β-oxidation of fatty acids through inhibition

of long-chain 3-ketoacyl-CoA thiolase, which

enhances glucose oxidation. It ensures proper

functioning of ionic pumps and transmembrane Na-K

flow by preventing decrease in intracellular ATP

levels.

Purpose (Patient-Centered) It used this medicine to help treat chest pain.

Date Ordered December 10, 2019
Response of the patient Patient chest pain was relief.
Nursing Responsibilities 1. Assess allergic reactions: rashes, urticarial; if

these occur

2. Teach SO warning signs that needs immediate

attention of the physician.

3. Evaluate therapeutic effects.

4. Inform SO about the side effects and adverse

effects of the medication.

5. Observe the patient for any reaction to the drug.

6. Chart the medication after administering.

-For documentation of all the procedure that being

administer to the patient and for legality purposes.

7. Take Trimetazidine with food.

 31

Treatment or Medication Generic Name: SEVELAMER

(Generic and Brand Name) Brand Name: RENAGEL, RENVELA

Dosage: 80 mg tab. TID

Route: oral

General Action Polymer that binds intestinal phosphate; interacts

with phosphate by way of ion exchange and

hydrogen binding. Advantageously, does not contain

aluminum or calcium acetate in treating

hyperphosphatemia in end stage kidney failure.

Purpose (Patient-Centered) It used this medicine to help treat chest pain.

Date Ordered December 10, 2019

Response of the patient The purpose of Sevelamer for the patient is to

decrease the phosphate level in blood.

Nursing Responsibilities 1. Check doctor’s order for the medication, route,

dosage and frequency of administration.

2. Check the medication properly and read labels

properly.

3. Know the reason for which patient is receiving the

medication.

4. Lab tests: Obtain frequent serum phosphate

levels.

5. Do not use capsules after printed expiration date.

6. Take daily multivitamin supplement approved by

physician.

7. Instruct patient to take sevelamer with meals as

directed and to adhere to prescribed diet.

 32

Treatment or Medication Generic Name: PANTOPRAZOLE

(Generic and Brand Name) Brand Name: PROTONIX

Dosage: 40 mg tab

Route: oral

General Action Gastric acid pump inhibitor; belongs to a class of ant

secretory compounds. Gastric acid secretion is

decreased by inhibiting the H+, K+-ATPase enzyme

system responsible for acid production.

Purpose (Patient-Centered) The purpose of Pantoprazole to the patient is

suppresses gastric acid secretion.

Date Ordered December 10, 2019

Response of the patient The response of the patient in diazepam medication

gastric acid secretions suppresses

Nursing Responsibilities 1. Check doctor’s order for the medication, route,

dosage and frequency of administration.

2. Check the medication properly and read labels

properly.

3. Know the reason for which patient is receiving the

medication.

4. Check the label three times before administering.

5. Assess patient’s history of allergic reaction to the

drug.

6. Inform SO about the side effects and adverse

effects of the medication.

-For SO knowledge about the mediation being

administering for the patient.

7. Observe the patient for any reaction to the drug.

 33

Treatment or Medication Generic Name: LEVAQUIN

(Generic and Brand Name) Brand Name: LEVOFLOXACIN

Dosag e: 500 mg 1 tab OD

Route: Oral

General Action A broad-spectrum fluoroquinolone antibiotic that

inhibits DNA-gyrase, an enzyme necessary for

bacterial replication, transcription, repair, and

recombination.

Purpose (Patient-Centered) This medication is used to treat infections.

Date Ordered December 10, 2019

Response of the patient Patient infections was treated.
Nursing Responsibilities 1. Explain use and administration of drug to patient

and family.

2. Tell SO to report adverse effects.

3. Chart the medication after administering.

4. Contraindicated in allergies

5. May cause QT prolongation, avoid use with other

drugs that can cause QT prolongation

-Can cause seizures, arrythmias,

pseudomembranous colitis, anaphylaxis, Stevens

Johnson

syndrome

-May decreased of phenytoin

6. Monitor renal panel

7. Assess for infection, obtain cultures prior to

therapy

8. Monitor liver function tests

 34

SURGICAL MANAGEMENT

Dialysis:

When kidney failure no longer can be managed conservatively, dialysis is required to

sustain life. Dialysis is the passage of molecules through a semipermeable membrane into a
special solution called dialysate solution.

Dialysis operates like the kidney. Small molecules such as urea, creatinine, and
electrolytes pass out of the blood, across a membrane, and into a solution.

The goals of dialysis are to do the following:

• Remove the end products of protein metabolism from the blood

• Maintain safe concentrations of the serum electrolytes
• Correct acidosis and replenish the body’s bicarbonate buffer system
• Remove excess fluid from the blood

Dialysis enables many patients to maintain or regain self-esteem and t be productive

members of the society. However, initial positive feelings about dialysis sometimes turn to
depression as the reality of “being tied to a machine” is recognized. Two primary means of
dialysis are (1) hemodialysis and (2) peritoneal dialysis.

Hemodialysis:

Hemodialysis is a process by which blood is removed from the body and circulated
through an “artificial kidney” for removal excess fluid, electrolytes, and wastes. The dialyzed
blood is then returned to patient. Hemodialysis requires vascular access (i.e., access to the
patient’s bloodstream). This may be accomplished by catheter, cannula, graft, or fistula.
Subclavian or femoral catheters can be used for temporary access for dialysis during acute renal
failure white a graft or fistula matures (dilates and toughens) or for patients on peritoneal dialysis
who need immediate access for hemodialysis.
Internal connections between veins and arteries do not require dressings. An internal
connection between the patient’s artery and vein is called fistula. A fistula requires
approximately 6 to 8 weeks to mature and may be used for 3 to 5 years. Connections also may be
made using bovine or synthetic grafts that require 2 to 4 weeks to heal before use and last for 7 to
9 years. Grafts have an increased rate of thrombosis and infection compared with fistulas.
An arteriovenous shunt or cannula is an external connection between an artery and a vein.
By connecting the external ends of the synthetic tubing for dialysis, venipuncture is not
necessary. However, because the cannula is external, danger of hemorrhage, risk of skin
 35

breakdown, restriction of activities, and risk of site infection exist. The arteriovenous shunt is
very rarely used because of the potential complications.
All vascular access sites must be accessed for patency. Check pulses below the shunt to
ensure that circulation is adequate. Steal syndrome occurs when too much arterial blood is
diverted from the extremity by the access device. Palpate the venous side of the shunt for a thrill
or rippling sensation caused by movement of blood through a changed pathway. A bruit or
swoosh may be heard through a stethoscope with each heartbeat. Absence of these signs may
indicate occlusion of the vessel, making it unsuitable for hemodialysis.
Once vascular access is established, the patient may be hemodialysis. Blood flows from
the artery through the vascular access device, circulates through the dialyzer, and returns through
the venous line. Heparin is used as an anticoagulant to prevent blood for clothing. Hemodialysis
requires specially trained personnel and expensive equipment. Although dialysis for chronic
kidney disease is usually performed in a dialysis center, home dialysis is available. The
hemodialysis process takes approximately 4 hours and is usually antihypertensive agents may be
withheld.
Advantages of hemodialysis include the usefulness in emergencies and the rapid removal
of wastes, electrolytes and fluids. Disadvantages include the need for vascular access, the use of
anticoagulant, and the potential for hemorrhage, anemia, rapid fluid and electrolyte shifts
(dialysis disequilibrium syndrome), muscle cramps, nausea and vomiting, and air emboli.
Complications of hemodialysis include the atherosclerotic cardiovascular disease,
anemia, gastric ulcers, disturbed calcium metabolism, and hepatitis. The leading causes of death
for patients being treated with hemodialysis are cerebrovascular accident (CVA) and myocardial
infarction, followed by infection.

Arterioveneous Fistula

If a patient is in need of a permanent vascular access for dialysis a preferred method is

performed which is called the arteriovenous fistula that is surgically created usually in the
forearm by joining an artery to a vein to a process called anastomosing, either side to side or end
to side. Needles are inserted into the vessel to adequate blood flow to pass through the dialyzer.
The arterial segment of the fistula is used for arterial flow to the dialyzer ad the venous segment
for reinfusion of the dialyzed blood.

Arteriovenous Graft
Can be created by subcutaneously interposing a biologic, semi biologic, or synthetic graft
material between an artery and vein. Graft is usually created in patients who have a vascular
system which are compromised, often needing a graft due to vessels are not suitable for AVF.
Grafts are usually placed on the arms but can also be placed on the thigh and chest wall.
 36

Nursing Responsibilities:
Prior
 Remove any restrictive clothing or jewelry from the arm.
 Inform patient about procedure
 Monitor serum electrolytes, blood urea nitrogen, creatinine, and hemoglobin and
hematocrit levels.
 Monitor fluid status.
 Monitor coagulation studies because heparin is used to prevent clotting during dialysis.

During

 Palpate the vascular access to feel for a thrill or vibration that indicates arterial and
venous blood flow and patency.
 Auscultate the vascular access with a stethoscope to detect a bruit or "swishing" sound
that indicates patency.
 Check the patient's circulation by palpating his pulses distal to the vascular access;
observing capillary refill in his fingers; and assessing him for numbness, tingling, altered
sensation, coldness, and pallor in the affected extremity.
 Notify the healthcare provider promptly if you suspect clotting.
 Assess the vascular access for signs and symptoms of infection such as redness, warmth,
tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney
disease are at increased risk of infection.

After
 When you move the patient or help with ambulation, avoid trauma to or excessive
pressure on the affected arm.
 Assess for blebs (ballooning or bulging) of the vascular access that may indicate an
aneurysm that can rupture and cause hemorrhage.
 Monitor serum electrolytes, blood urea nitrogen, creatinine, and hemoglobin and
hematocrit levels.
 Monitor fluid status. Monitor coagulation studies because heparin is used to prevent
clotting during dialysis.
 Document assessment findings, any interventions and patient responses, patient teaching,
and the patient's level of understanding.
 37

LIST OF PRIORITY OF NURSING CARE PLAN:

1. Risk for Decreased Cardiac Output

2. Impaired Renal Tissue Perfusion

3. Impaired Urinary Elimination

 38

NURSING CARE PLAN

1. Risk for Decreased Cardiac Output related to accumulation of toxins

Assessment SUBJECTIVE;

“lagi masakit ang dibdib ko” as verbalized by the

patient

OBJECTIVE:

-presence of edema in extremities

Scientific Rationale for Nursing Diagnosis At risk for inadequate blood pumped by the heart to

meet metabolic demands of the body.

Scientific Explanation Cardiac output is the amount of blood pumped by

the heart per minute. It is the product of the heart

rate, which is the number of beats per minute, and

the stroke volume, which is amount pumped per

beat. CO = HR X SV. The cardiac output is usually

expressed in liters/minute.

Conditions like myocardial infarction, hypertension,

valvular heart disease, congenital heart disease,

cardiomyopathy, heart failure, pulmonary disease,

arrhythmias, drug effects, fluid overload, decrease

fluid volume, and electrolyte imbalance are

considered the common causes of Decreased Cardiac

Output.

Planned/ Expected Outcomes SHORT TERM:

After 1 to 2 days of intervention the patient will be

able to maintain cardiac output as evidenced by BP

and heart rate within patient’s normal range;

 39

peripheral pulses strong and equal with prompt

capillary refill time

LONG TERM:

After 1 to 2 weeks of intervention the patient will be

able to demonstra normal cardiac output.

Nursing Interventions 1. Assess presence and degree of hypertension:

monitor BP; note postural changes (sitting, lying, and

standing).

[Link] reports of chest pain, noting location,

radiation, severity (0–10 scale), and whether or not it

is intensified by deep inspiration and supine

position.

3. Assess activity level, response to activity.

4. Evaluate heart sounds (note friction rub), BP,

peripheral pulses, capillary refill, vascular congestion,

temperature, and sensorium or mentation.

5. Monitor Electrolytes (potassium, sodium, calcium,

magnesium), BUN and Creatanine.

6. Administer antihypertensive drugs.

7. Prepare for dialysis.

8. Auscultate heart and lung sounds. Evaluate

presence of peripheral edema, vascular congestion

and reports of dyspnea.

9. Assist with pericardiocentesis as indicated.

10. Monitor and record vital signs.

 40

Rationale 1. Significant hypertension can occur because of

disturbances in the renin-angiotensin-aldosterone

system (caused by renal dysfunction).

2. Although hypertension and chronic HF may cause

MI, approximately half of CRF patients on dialysis

develop pericarditis, potentiating risk of pericardial

effusion or tamponade.

3. Weakness can be attributed to Heart failure

and anemia.

4. Presence of sudden hypotension, paradoxic pulse,

narrow pulse pressure, diminished or absent

peripheral pulses, marked jugular distension, pallor,

and a rapid mental deterioration indicate

tamponade, which is a medical emergency.

5. Imbalances can alter electrical conduction and

cardiac function.

6. Reduces systemic vascular resistance and renin

release to decrease myocardial workload and aid in

prevention of HF and MI.

7. Reduction of uremic toxins and correction of

electrolyte imbalances and fluid overload may limit

and prevent cardiac manifestations, including

hypertension and pericardial effusion.

8. S3 and S4 heart sounds with muffled tones,

tachycardia, irregular heart rate, tachypnea,

dyspnea, crackles, wheezes, edema and jugular

distension suggest HF.

 41

9. Accumulation of fluid within pericardial sac can

compromise cardiac filling and myocardial

contractility, impairing cardiac output and

potentiating risk of cardiac arrest.

10. To obtain baseline data.

Evaluation Goal met Patient was be able to maintain

cardiac output as evidenced by BP and heart rate

within patient’s normal range; peripheral pulses

strong and equal with prompt capillary refill time.

After 1 to 2 weeks of intervention, the patient will

be able to demonstrate normal cardiac output.

 42

2. Impaired Renal Tissue Perfusion

Assessment SUBJECTIVE

“lagi namamaga ang mga paa at kamay ko” as

verbalized by the patient

OBJECTIVE:

Presence of edema in foot

Increase in Lab results (BUN, Creatinine,

Creatinine:

8.28 mg/ld.

Phosphate

6.0 mg/dL.
Scientific Rationale for Nursing Diagnosis Decreased in the oxygen resulting in the failure to

nourish the tissues at the capillary level.

For optimal cell functioning the kidney excrete

potentially harmful nitrogenous product-Urea,

Creatinine, Uric Acid but because of the loss of kidney

excretory functions there is impaired excretion of

nitrogenous waste product causing in increase in

Laboratory result of BUN, Creatinine, Uric Acid Level.

Scientific Explanation Decrease in oxygen, resulting in failure

to nourish tissues

at capillary level.

Blood is a connective tissue

comprised of a liquid extracellular matrix termed as

blood plasma which dissolves and suspends multiple

cells and cell fragments.

 43

Planned/ Expected Outcomes SHORT TERM: After 1 to 2 days of intervention the

patient will be able to demonstrate participation in

his recommended treatment program

LONG TERM: After 1 to 2 weeks of intervention the

patient will be able to demonstrate behavior/lifestyle

changes to prevent complications.

Nursing Interventions 1. Monitor and record vital signs

2. Determine factors related to individual situation

and note situation that can affect all body system.

3. Observe for dependent generalized edema.

4. Provide diet restriction as indicated, while

providing adequate calories.

5. Mentation status and review lab result such as

BUN and creatinine levels.

6. Assess patient’s general condition.

7. Note presence, location intensity duration of

pain.

8. Measure urine output on a regular schedule and

weigh daily.

9. Identify necessary changes in lifestyle and assist

client to incorporate disease management to ADLs.

10. Administer medication as ordered.

Rationale 1. To obtain baseline data

2. To assess causative and contributing factors

3. To note degree of impairment of renal function.

4. Calories to meet body’s need while restriction of

 44

protein helps limit BUN.

5. Increase BUN and creatinine levels may alter

mentation.

6. To obtain baseline data.

7. May indicate pain on affected organ.

8. To assess renal perfusion and function.

9. To promote wellness and prevent further

progression of complication.

10. For faster recovery. It is used to treat the

client’s disease condition.

Evaluation Goal Met

patient was be able to demonstrate participation in

his recommended treatment program patient was be

able to demonstrate behavior/lifestyle changes to

prevent complications.
 45

3. Impaired Urinary Elimination

Assessment SUBJECTIVE:

“nahihirapan ako umiihi” as verbalized by the

patient.

OBJECTIVE:

Increase in Lab results (BUN, Creatinine,

Creatinine:

8.28 mg/ld.

Phosphate

6.0 mg/dL.

Scientific Rationale for Nursing Diagnosis Urinary elimination and together with prolonged use

of medications such as NSAIDs this will lead to

further kidney destruction which may thus

decreasing the glomerular filtration and destroying

of the remaining nephrons. This will result in to

inability of the kidney to concentrate urine which

makes the patient to have a nursing diagnosis of

impaired urinary elimination.

Scientific Explanation Renal Failure is a problem which results to loss of

kidney functions and as GFR decrease, the kidney

cannot excrete nitrogenous product and fluid causing

Disturbance in urinary elimination.

Planned/ Expected Outcomes SHORT TERM:

After 1 to 2 days of intervention the patient will be

able verbalize understanding of condition.

 46

LONG TERM:

After 1 to 2 weeks of intervention the patient will be

able to participate in measures to

correct/compensate for defects.

Nursing Interventions 1. Monitor and record vital signs.

2. Review for laboratory test for changes in renal

function.

[Link] clients pattern of elimination

[Link] pain, noting location

5. Note condition of skin and mucous membranes,

color of urine.

6. Assess patient’s general condition

7. Palpate bladder

8. Determine client’s usual daily fluid intake

9. Observe for signs of infection

10. Administer medication as ordered.

Rationale 1. To obtain baseline data.

2. To assess for contributing or causative factors.

3. To assess degree of interference.

4. To investigate extent of interference

5. To assess level of hydration.

6. To know what problem and interventions should

be prioritize.

7. To assess retention.

8. To help determine level of hydration.

9. To help in treating urinary alterations

 47

10. For faster recovery. It is used to treat the client’s

disease condition.

Evaluation Goal Met

patient was be able verbalize understanding of

condition.

patient was be able to participate in measures to

correct/compensate for defects.

 48

DISCHARGE PLANNING
A. OBJECTIVES

1. To maintain normal blood pressure.

2. To maintain the normal level of electrolytes in the body.
3. To maintain the normal glucose level in the blood.
4. To prevent anemia.

B. METHODS
1. MEDICATIONS

Name of the Dosage & Route Curative Effects Side Effects

Drug Frequency

Sevelamer 80 mg tab TID Oral Hypophodphstemic nausea &

Carbonate vomiting,

fatigue

Linagliptin 5 mg tab Oral Antiglycemic Loss of

Tradjenta OD appetite, fast

heart rate,

headache

Calcitriol 0.25 g Oral Antihypocalcimic dry skin,

BID numbness,
confusion

Ferrous Sulfate 50 mg tab Oral Anti - anemic stomach

BID cramps,

constipation

Folic Acid 50 mg tab BID Oral Vitamin Poor appetite,

trouble

sleeping

Digoxin 0.25 mg tab Oral Cardiac Glycoside Headache, rash

 49

OD

Carvedilol 6.25 mg tab Oral Antihypertensive Shortness of

OD breath, pain

Trimetazidine 35 mg tab TID Oral Anti - angina Abdominal

pain, nausea

Pantoprazole 40 mg tab OD Oral Proton pump Gas, dizziness,

inhibitors headache

2. Exercise / Activity

Light Activities such as:

• Brisk walking

• Dancing

• Swimming

• Deep breathing exercises

Brisk walking
Walks at a moderate level for 30 minutes at least four days a week.

Dancing
You should aim to get at least 30 minutes of aerobic exercise most days of the week. In
fact, the American Diabetes Association recommends 150 minutes of moderate intensity aerobic
exercise a week, which works out to 30 minutes five days a week.

Swimming
Start out slowly, even if it’s just 5 to 10 minutes per swim session, then try to work up to
45- to 60-minute sessions as you increase your endurance. Also, know that taking short rests
between sessions can help you recover some energy to keep going.

Deep Breathing Exercise

1. Get comfortable. You can lie on your back in bed or on the floor with a pillow under your
head and knees.
2. Breathe in through your nose. Let your belly fill with air.
3. Breathe out through your nose.
4. Place one hand on your belly
5. As you breathe in, feel your belly rise
6. Take three fuller, deep breaths
 50

Treatment
1. Comply with medications.
2. Utilize deep breathing and recommended exercises.
3. Comply with the treatment regimen such as: hemodialysis.

Health Teachings
1. Advice patient to follow the recommended follow up clinic visit.
2. Instruct patient to comply with follow up laboratory examinations.
3. Warn the patient about the side effects of the medications. Advice patient to report
immediately to the physician if any adverse effects occurs.
4. Encourage patient to do deep breathing exercise and other recommended exercises.

Observed
A. Observed signs and symptoms that need reporting:
- Report immediately to the hospital or to the physician if there is decrease or increase
blood pressure level.
- Adverse effect of the medications
- Increase laboratory exams
- Difficulty of breathing
- Elevated body tempereature
B. Interventions / home remedies that may be done immediately prior to seeking:
- Position high fowlers
- Adequate rest
- Increase fluid intake
- Apply tepid sponge bath (TSB)
- Deep breathing exercise

Diet
A. Diet as tolerated
Restriction
B. Low salt, low fat, low protein diet

Spiritual and Psychological needs

- Spiritual counseling
- Family support
- Stress and anger management
 51

LEARNING DERIVED

I have only been part of the health care team for a little amount of time yet I was able to
learn so much from my patient. Indeed, learning is not only found in the four corners of the
classroom, rather, in the vast reality of the outside world.
To be honest, I believe that the treatment and the nursing care I have provided to my
patient still lacks and that as a nursing student, I have a lot more to learn. To begin with are the
basics of therapeutic communication. I had a hard time communicating and establishing rapport
as I remember some acquaintances who were diagnosed with the same condition before. I could
not take away my emotions fully to the point I became sympathetic to my patient. I understand it
was not therapeutic and I admit I have a whole lot more to learn.
Furthermore, I was able to showcase my learning from our lecture, mainly the differently
skills I performed alongside my classsmates in our related learning experiences. Little by little,
we were able to perform such skills (e.g., vital signs monitoring, charting, etc) more accurately
than before.
I’d like to thank our clinical instructor for letting us experience all these learning. You are
amazing!
 52

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Levey, A. S., Coresh, J., Balk, E., Kausz, A. T., Levin, A., Steffes, M. W., ... & Eknoyan, G.
(2003). National Kidney Foundation practice guidelines for chronic kidney disease:
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Pradeep Arora, MD Assistant Professor of Medicine, University of Buffalo State University of

New York School of Medicine and Biomedical Sciences; Attending Nephrologist,
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Bruchfeld, A., Roth, D., Martin, P., Nelson, D. R., Pol, S., Londoño, M. C., ... & Robertson, M.
(2017). Elbasvir plus grazoprevir in patients with hepatitis C virus infection and stage 4–5
chronic kidney disease: clinical, virological, and health-related quality-of-life outcomes
from a phase 3, multicentre, randomised, double-blind, placebo-controlled trial. The lancet
Gastroenterology & hepatology, 2(8), 585-594. Retrieved from:
[Link]

Smith, H. W. (1951). The kidney: structure and function in health and disease (Vol. 1). Oxford
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