I.

Demographic Data Name: Mrs. NSP Address: Tanauan City, Batangas Age: 66 Gender: Female Religion Affliation: Roman Catholic Marital Status: Married Nationality: Filipino Occupation: N/A Room and Bed: 414 B Admission Date: October 04, 2010 Admission time: 12:40 P.M. Chief Complaint: Difficulty of Breathing Provisional Diagnosis: Chronic Kidney Disease Attending Physician: Dr.Punzalan

II.

Reason for Seeking Care A. Chief Complaint Nahihirapan akong huminga dahil sa ubo ko as verbalized by the patient. B. The patient experienced difficulty of breathing before being admitted. She has been noted to have productive cough with thick, tenacious sputum. One of the manifestations of Chronic Kidney Disease (CKD) on the respiratory system is shortness of breath and cough with thick, tenacious sputum. History of Present Health Concern The patient has manifested cough and phlegm at home. 3 hours while undergoing dialysis, the patient complained of difficulty of breathing associated with chills, negative fever, and pain on lower back and positive body weakness that prompted the patient to be admitted in the ward. Vital Signs upon admission: Blood Pressure: 180 / 90 Heart rate: 86 Respiratory Rate: 22 Temperature: 36.8oC
1

III.

IV.

Past Health History A. Past Health History The client did not experience any childhood diseases. She doesnt have any allergies. She also stated that she did not experience any accident or injuries in the past. She was hospitalized before because she gave birth to her 2 sons via Caesarian Section. The medications she has taken in the past were anti-hypertensive drugs and her medications for Diabetes Mellitus (DM). B. Family History of Illness The clients patients both died of cerebrovascular accident (stroke). She has 6 siblings, her younger sister also has DM while her younger brother has a heart disease. According to her, the remaining four siblings were all healthy.

V.

Genogram
CVA HPN CVA

Heart disease DM

DM HPN CKD

Legend: = dead female = dead male = female = male = patient 3

VI.

Review of Systems Neurologic: weakness and fatigue, inability to concentrate, behavioral changes Integumentary: gray-bronze skin, dry, flaky skin, pruritus Cardiovascular: hypertension, bipedal pitting edema, periorbital edema Pulmonary: crackles, shortness of breath, cough with thick, tenacious sputum Gastrointestinal: anorexia Hematologic: anemia Urinary: anuria Reproductive: decreased libido

VII.

Psychosocial Assessment

A. Health perception and health management pattern Before Hospitalization: Before being hospitalized, the client was already concerned about her health because she was already diagnosed with DM. She has followed the prescribed diet for her (low sugar) and has taken her prescribed medications. She tried to consult an albularyo just to try it but did not really believe that it can actually improve her health status. She also stated that she never smoked nor drank alcoholic beverages. According to her, she believed that eating too much butong pakwan and drinking soft drinks have caused her to develop her present disease (chronic kidney disease).

During hospitalization: During her hospital stay, the client was obliged to follow a stricter diet. She has adjusted to the diet that was prescribed for her. She was diagnosed with chronic kidney disease and was given additional medications. She stated that the things that were important to her were mainly on financial concerns because only one of his sons was able to support her. Interpretation: When diagnosed with another disease, the patient has adjusted to the diet that was prescribed for her. In the sense that she has already adjusted, it can be inferred that she was concerned about her health. Analysis: According to the stages of Health Behavior change, the client is under the maintenance stage. During this stage, the person strives to prevent relapse by integrating newly adopted behavior into his or her lifestyle. This stage last until the person no longer experiences temptation to return to previous unhealthy behavior. Reference: Page 282 Fundamentals of nursing by Kozier & Erb 8th edition B. Nutritional and metabolic pattern Before Hospitalization: Before being hospitalized the client was following the prescribed diet for her because she was already diagnosed with DM. Basically, she was eating foods that were low in sugar. She also stated that she was eating fish and pork most of the time because they were selling such in the market. Long time ago before she was diagnosed with DM and her present disease, she never ate vegetables because she doesnt like the taste. She was able to consume 8-10 glasses of water a day. Before, she has a very good appetite that leads her to gain weight up to 81 kg (overweight for her age) then suddenly became 45kg at the present time because she reported loss of appetite.

During hospitalization: During her hospital stay, the client was under a strict renal diet. She was also under a limited fluid intake of up to 5 glasses per day only. Even if she really doesnt want to eat vegetables, she was forced to do so. She also reported loss of appetite brought about by loss of taste in foods (walang panlasa). Interpretation: The client changed her unhealthy diet and have loss her appetite brought about by the effect of her disease. Analysis: Although the nutritional content of food is an important consideration when planning a diet, an individuals food preferences and habits are often a major factor affecting actual food intake habits about eating are influenced by development considerations gender ethnicity and culture, beliefs about food personal preferences, religious practices, life style, economics, medication and therapy, alcohol consumption advertising and psychologic factors Reference: Page 1237 Fundamentals of nursing by Kozier & Erb 8th edition C. Elimination Before Hospitalization: Before being hospitalized, the client has a regular bowel time pattern every morning, once a day. The character of the stool was soft and firm and brown in color. She has not experienced any difficulty in defecating except when she was experiencing constipation but it seldom happened. She urinated for 10-12 times a day and did not experience any difficulty in urinating. During hospitalization: During her hospital stay, the client reported to have difficulty in both defecating and urinating. She defecated only once a week and very little urine output of 10cc during her hospital stay. Interpretation: The clients urinary and defecating pattern changed.

Analysis: Normal urinary output is approximately equal to the fluid intake (1200-1500 cc) straw, amber transparent in color and faint aromatic in odor. Elimination can be affected by a persons developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional states, pathologic process and medications. Reference: Page 1264 Fundamentals of nursing by Kozier 7th edition Page 1340 Fundamentals of nursing by Kozier 7th edition D. Activity and exercise pattern Before Hospitalization: Before being hospitalized, the client was not really fond of doing exercises. During her spare time, she watched television programs and listened to the radio. Her usual daily activities were doing the household chores such as cooking and cleaning the house. She stated she did not require assistance or supervision from another person or device when doing self-care activities. During hospitalization: During her hospital stay, the client was still not doing any exercises mainly because of her condition. She cannot perform her usual daily activities anymore. She often prayed rosary by herself. She also stated that she already needed assistance in taking a bath because she might fall. Interpretation: The client became dependent on some of her activities due to her situation. Analysis: According to researchers at Harvards School of Public Health (HSPH), a mixture of healthy eating and regular physical activity is the best form of health promotion and maintenance. Regular physical activity is important for everyone and a sedentary lifestyle increases the chances of becoming over weight as well as developing a number of chronic diseases. Reference: Page 1105 Fundamentals of nursing by Kozier & Erb 8th edition
7

E. Sleep-rest pattern Before Hospitalization: Before being hospitalized, the client reported having a regular sleep pattern of 6-8 hours of sleep at night. She sometimes took a nap in the afternoon for 1 hour. She did not experience any problem in falling asleep. She was watching television programs and listening to the radio as a form of relaxation. During hospitalization: During her hospital stay, the client reported having difficulty falling asleep probably because of the side effects of the medications she have taken (Mucobron). She was not able to sleep for 3 consecutive days in the hospital. Interpretation: The clients sleeping pattern changed due to her situation and the adverse reaction of her medication. Analysis: The quality of sleep is often diminished in elders. Some of the factors that often are influential in sleep disturbances include the following: *side effects of medication *pain from arthritis, increases stiffness or impaired mobility *depression Reference: Page 1169 Fundamentals of nursing by kozier & Erb 8th edition F. Cognitive-perceptual pattern Before Hospitalization: Before being hospitalized, the patient had no difficulty on hearing and has blurring of vision but did not wear eye glasses. She reported that she forget things easily.

During hospitalization: During her hospital stay, nothing changed about the clients cognitive perceptual pattern. Her changes in memory were evidenced by forgetting to pray the rosary that was her usual activity in the hospital while lying on bed. Interpretation: The client has manifested a neurologic effect of her disease such as inability to concentrate on the things to be done. Analysis: Perception or the ability to interpret the environment depends in the awareness of the senses. If the aging persons senses are impaired, the ability to perceive the environment and react appropriately is diminished changes in the nervous system may also affect perceptual capacity changes in the cognitive structure occur as a person ages. The brain loses mass with aging. In addition blood flow to the brain decreases, the meninges thicken, and brain metabolism slows as yet, little is known about the effect of these physical changes in the cognitive functioning of the older adult life-long mental activity, particularly verbal activity, help the elder retain a high level of cognitive function and helps maintain long-term memory. Reference: Page 418 Fundamentals of nursing by Kozier & Erb 8th edition G. Self-perception pattern Before Hospitalization: Before being hospitalized, the client described herself as someone who cannot spend a day without laughing (happy person). She was also very familyoriented. She dealt with her problem on a positive way. During hospitalization: During her hospital stay, the client felt very lonely because she cannot perform her usual activities anymore brought about by her illness. According to her husband, she got easily irritable and always hot-headed. She felt very sorry for herself but still was not losing hope because she said she was never left by her family.

Interpretation: The client has manifested a neurologic effect of her disease such as behavioral changes. Analysis: According to Eriksons stages of development, maturity starts from 65 years to death. Integrity indicates acceptance of worth and uniqueness of ones own life and acceptance of death while despair indicates sense of less or contempt for others. Reference: Page 353 Fundamentals of nursing by Kozier & Erb 8th edition

H. Role relationship pattern Before Hospitalization: The client was living with her family together with her husband and one son. They were only 3 who were living in the house. Her other son was working abroad. The usual problem that arouse in their family was more on financial needs because her son who was working abroad was the only who was able to support their financial needs. They were able to handle such problem by trusting God that he will never let them to suffer and through diskarte as stated by her husband. They worry a lot when a member of the family developed an illness. The client belonged to a social group in their area called Senior Citizens. She also stated that she was fond of mingling with other people especially to their neighbors. During hospitalization: During her hospital stay, the one who stayed with the client in the hospital was her husband while his other son stayed in their house. They have their own schedule of switching on who will stay next. Before her other son who works abroad left, he visited the client and prayed for her. She cannot mingle with her friends anymore because of her current situation. Interpretation: The client values her family so much and they play a vital role in the wellbeing of the client.

10

Analysis: Family roles are especially important to people because family relationship are particularly close. Relationships are particularly close. Relationships can be supportive and growth producing or at the opposite extreme highly stressful if there in violence or abuse. Reference: Page 1009 Fundamentals of nursing by kozier & Erb 8th edition I. Sexually Reproductive Pattern Before Hospitalization: The client has not been really active in having sexual intercourse with her husband due to her age. During Hospitalization: The client has loss interest in doing sexual interaction that indicated decreased libido, an effect of her disease on her reproductive system. She was also taking medications that have an adverse effect of decreasing sexual desire. Interpretation: Some of the factors that have caused the loss of interest in sexual intercourse of the patient were the effect of her disease in her reproductive system decreasing her libido and the adverse effects of the medications she was taking. Analysis: Many prescription medications have side effects that affect sexual beyond those intended for that purpose. Most frequently the impact is negative but sometimes there is a positive impact. Antihypertensive decreased sexual desire failure, Beta-blockers decreases sexual desire, cardiotonics decreased sexual desire, diuretics decreased vaginal lubrication and decreases sexual. Reference: Page 1028 Fundamentals of nursing by Kozier & Erb 8th edition

11

J. Coping- Stress Tolerance

Before hospitalization The client dealt with her problems on a positive way and found her family most helpful in talking things over. When she has problems, she was able to handle them accordingly. For the client her family played the 2nd most important role in her life second to God. During Hospitalization When she knew about her illness, the client became lonely but never lost hope because she knew her family would never leave her alone. Interpretation: The client found her family as the people whom she can count on whenever she has problems. Analysis: Coping may be described as dealing with changes successfully or unsuccessfully. A coping strategy (coping mechanism) is a natural or learned way of responding to a changing environment or specific problem or situation. Emotion-focused coping includes thoughts and actions that relieve emotional distress, Emotion-focused coping does not improve the situation, but the person often feels better. Reference: Page 1068 Fundamentals of nursing by kozier & Erb 8th edition K. Value-belief pattern Before hospitalization For the client, the things that she was considered most important in her life were God and her family. She believed her religion have helped her a lot when difficulties started to arise. She doesnt belong to any religious group but regularly attended the mass.

12

During Hospitalization During her hospital stay, she was not able to go to the church and attend the mass regularly but still performed her obligation to serve the lord by praying the rosary. Interpretation: The client still finds time to serve God despite her situation. She values her religion very much. Analysis: Values are enduring beliefs or attitudes about the worth of a person, object, ideas or action. Values are important because they influence decisions and actions, including nurses ethical decision making. Even though they may be unspoken and perhaps even unconsciously held, questions of value underlie all moral dilemmas. Reference: Page 80 Fundamentals of nursing by Kozier & Erb 8th edition

13

VIII.

Laboratory and Diagnostics LABORATORY RESULTS

HEMATOLOGY ANALYTE RESULT NORMAL RANGE SIGNIFICANCE

Oct. 4, 2010 Nursing Consideration Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to consult the dietitian about the diet. 5. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 1. Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to
14

1.

Hematocrit

0.33 Vol %

0.37 0.47

Low. There is a decrease in hematocrit signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company

Hemoglobin

107.00 g/L

120.00 150.00

Low. There is a decrease in hemoglobin signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company Medical Surgical Nursing

by J.B. Lippincott Company

RBC count

3.8 x10 12/L

4.0 -6.0

Low. There is a decrease in red blood cells signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company

WBC count

35.0 x10 9/L

5.0 10.0

High. In increase WBC infection is indicated. Medical Surgical Nursing by J.B. Lippincott Company

consult the dietitian about the diet. 5. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 1. Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to consult the dietitian about the diet. 5. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 1. Assess for local and systemic sign of infections: Local: pain on urination, hematuria, cloudy urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia.
15

MCV

85.90 fL

86.00 110.00

Low. There is a decrease in MCV signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company

2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/noninvasive to prevent introduction of organisms. 1. Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to consult the dietitian about the diet. 5. Provide periods of rest of sleep/ rest to conserve energy and oxygen.

MCH MCHC

27.90 pg 32.50 g/dL

26.00 38.00 31.00 37.00

Within the normal range Within the normal range

16

Platelet count

267000/cumm

150000 - 350000

Within the normal range

17

SCHILLINGS DIFFERENTIAL

Oct. 4, 2010

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE

Nursing Consideration 1. Assess for local and systemic sign of infections: Local: pain on urination, hematuria, cloudy urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia. 2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. 1. Assess for local and systemic sign of infections: Local: pain on urination, 18 hematuria, cloudy

Neutrophils

0.941 %

0.370 0.720

High. Increase Neutrophils infection is indicated. Medical Surgical Nursing by J.B. Lippincott Company

Lymphocytes

0.015 %

0.200 0.500

Low. Decrease lymphocytes infection is indicated. Medical Surgical Nursing by J.B. Lippincott Company

urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia. 2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. Eosinophils Monocytes Basophils 0.000 % 0.044 % 0.000 % 0.000 0.060 0.000 0.140 0.000 0.010 Within the normal range Within the normal range Within the normal range

19

SINGLE FINDINGS

Oct. 4, 2010

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE High. Indicates reduction in filtrate formation and function of the tubular epithelium and inability of the kidney to excrete metabolic waste products of protein through urine cause increase in BUN and Creatinine. Medical Surgical Nursing by J.B. Lippincott Company High. Indicates reduction in filtrate formation and function of the tubular epithelium and inability of the kidney to excrete metabolic waste products of protein through urine cause increase in BUN and Creatinine. Medical Surgical Nursing by J.B. Lippincott Company Low. Decrease in sodium indicates fluid overload/excess due to inability of the kidney to excrete such fluid. (PPDs Nursing Drug Guide

Nursing Consideration 1. Assess for urine ferrous, odor of breath, stomatitis and gastro inttinal bleeding. 2. Provide oral hygiene. 3. Promote skin care to prevent uremiafrost and pruritus.

Blood Urea Nitrogen

31.29 mg/dL

8.00 23.00

Creatinine

3.97 mg/dL

0.51 0.95

1. Assess for urine ferrous, odor of breath, stomatitis and gastro inttinal bleeding. 2. Provide oral hygiene. 3. Promote skin care to prevent uremiafrost and pruritus.

Sodium

125.00 mmol/L

135.00 148.00

1. Accurate measurement and recording of intake and output. 2. Monitor for weight gain and edema. 3. Encourage patient to remain within prescribed
20

2nd edition)

fluid restriction. 4. Provide hard candy and chewing gum on ice cube as thirst-quenchers.

Potassium

3.60 mmol/L

3.50 4.50

Within the normal range

21

HEMATOLOGY ANALYTE RESULT NORMAL RANGE SIGNIFICANCE

Oct. 7, 2010 Nursing Consideration 1. Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to consult the dietitian about the diet. Provide periods of rest of sleep/ rest to conserve energy and oxygen. 1. Encourage intake of diet as ordered. 2. Encourage activity within limits and avoid fatigue 3. Administer medication as prescribed. 4. Instruct the family member to consult the dietitian
22

Hematocrit

0.36 Vol %

0.37 0.47

Low. There is a decrease in hematocrit signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company

Hemoglobin

113.00 g/L

120.00 150.00

Low. There is a decrease in hemoglobin signifies anemia due to inability of the kidney to secrete erythropoietin. Medical Surgical Nursing by J.B. Lippincott Company

about the diet. Provide periods of rest of sleep/ rest to conserve energy and oxygen. RBC count 4.1 x10 12/L 4.0 -6.0 Within the normal range 1. Assess for local and systemic sign of infections: Local: pain on urination, hematuria, cloudy urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia. 2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/noninvasive to prevent introduction of organisms.
23

WBC count

25.5 x10 9/L

5.0 10.0

High. In increase WBC infection is indicated. Medical Surgical Nursing by J.B. Lippincott Company

MCV MCH MCHC Platelet count

88.40 fL 27.90 pg 31.60 g/dL 275000/cumm

86.00 110.00 26.00 38.00 31.00 37.00 150000 - 350000

Within the normal range Within the normal range Within the normal range Within the normal range

24

SCHILLINGS DIFFERENTIAL

ANALYTE

RESULT

NORMAL RANGE

SIGNIFICANCE

Nursing Consideration 1. Assess for local and systemic sign of infections: Local: pain on urination, hematuria, cloudy urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia. 2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms. 1. Assess for local and systemic sign of infections: Local: pain on
25

Neutrophils

0.865 %

0.370 0.720

High. Increase Neutrophils infection is indicated. Medical Surgical Nursing by J.B. Lippincott Company

Lymphocytes

0.058 %

0.200 0.500

Low. Decrease lymphocytes infection is indicated. Medical Surgical Nursing

by J.B. Lippincott Company

urination, hematuria, cloudy urine and redness, edema, or drainage in areas of skin breakdown. Systemic: chills, fever, and tachycardia. 2. Instruct client and family member to avoid exposure to others with infection. 3. Maintain aseptic technique when performing invasive/non-invasive to prevent introduction of organisms.

Eosinophils Monocytes Basophils

0.020 % 0.056 % 0.001 %

0.000 0.060 0.000 0.140 0.000 0.010

Within the normal range Within the normal range Within the normal range

26

X-RAY RESULT

Interpretation: CHEST PA Haziness seen in the left base. Heart is enlarged. Thoracic aorta is calcified. Diaphragm and sulci are intact. Bones and soft tissue outline are unremarkable.

Tip of the central venous line is at the level of the superior vena cava.

Interpretation: Pneumonia left base. Cardiomegaly. Atherosclerotic aorta

27

IX. Anatomy and Physiology THE URINARY SYSTEM

The principal function of the urinary system is to maintain the volume and composition of body fluids within normal limits. One aspect of this function is to rid the body of waste products that accumulate as a result of cellular metabolism. Other aspects of its function include regulating the concentrations of various electrolytes in the body fluids and maintaining normal pH of the blood. In addition to maintaining fluid homeostasis in the body, the urinary system controls red blood cell production by secreting the hormone erythropoietin. The urinary system also plays a role in maintaining normal blood pressure by secreting the enzyme renin. The urinary system consists of the kidneys, ureters, urinary bladder, and urethra. The kidneys form the urine and account for the other functions attributed to the urinary system. The ureters carry the urine away from kidneys to the urinary bladder, which is a temporary reservoir for the urine. The urethra is a tubular structure that carries the urine from the urinary bladder to the outside.

28

Kidneys The kidneys are the primary organs of the urinary system. The kidneys are the organs that filter the blood, remove the wastes, and excrete the wastes in the urine. They are the organs that perform the functions of the urinary system. The other components are accessory structures to eliminate the urine from the body. The paired kidneys are located between the twelfth thoracic and third lumbar vertebrae, one on each side of the vertebral column. The right kidney usually is slightly lower than the left because the liver displaces it downward. The kidneys protected by the lower ribs, lie in shallow depressions against the posterior abdominal wall and behind the parietal peritoneum. This means they are retroperitoneal. Each kidney is held in place by connective tissue, called renal fascia, and is surrounded by a thick layer of adipose tissue, called perirenal fat, which helps to protect it. A tough, fibrous, connective tissue renal capsule closely envelopes each kidney and provides support for the soft tissue that is inside.

In the adult, each kidney is approximately 3 cm thick, 6 cm wide, and 12 cm long. It is roughly bean-shaped with an indentation, called the hilum, on the medial side. The hilum leads to a large cavity, called the renal sinus, within the kidney. The ureter and renal vein leave the kidney, and the renal artery enters the kidney at the hilum. The outer, reddish region, next to the capsule, is the renal cortex. This surrounds a darker reddish-brown region called the renal medulla. The renal medulla consists of a series of renal pyramids, which appear striated because they contain straight tubular structures and blood vessels. The wide bases of the pyramids are adjacent to the cortex and the pointed ends, called renal papillae, are directed toward the center of the kidney. Portions of the renal cortex extend into the spaces between adjacent pyramids to form renal columns. The cortex and medulla make up the parenchyma, or functional tissue, of the kidney.
29

The central region of the kidney contains the renal pelvis, which is located in the renal sinus and is continuous with the ureter. The renal pelvis is a large cavity that collects the urine as it is produced. The periphery of the renal pelvis is interrupted by cuplike projections called calyces. A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid. Several minor calyces converge to form a major calyx. From the major calyces the urine flows into the renal pelvis and from there into the ureter. Each kidney contains over a million functional units, called nephrons, in the parenchyma (cortex and medulla). A nephron has two parts: a renal corpuscle and a renal tubule. The renal corpuscle consists of a cluster of capillaries, called the glomerulus, surrounded by a double-layered epithelial cup, called the glomerular capsule. An afferent arteriole leads into the renal corpuscle and an efferent arteriole leaves the renal corpuscle. Urine passes from the nephrons into collecting ducts then into the minor calyces. The juxtaglomerular apparatus, which monitors blood pressure and secretes renin, is formed from modified cells in the afferent arteriole and the ascending limb of the nephron loop.

Ureter Each ureter is a small tube, about 25 cm long that carries urine from the renal pelvis to the urinary bladder. It descends from the renal pelvis, along the posterior abdominal wall, behind the parietal peritoneum, and enters the urinary bladder on the posterior inferior surface. The wall of the ureter consists of three layers. The outer layer, the fibrous coat, is a supporting layer of fibrous connective tissue. The middle layer, the muscular coat, consists of inner circular and outer longitudinal smooth muscle. The main function of this layer is peristalsis to propel the urine. The inner layer, the mucosa, is transitional epithelium that is continuous with the lining of the renal pelvis and the urinary bladder. This layer secretes mucus which coats and protects the surface of the cells.
30

Urinary Bladder The urinary bladder is a temporary storage reservoir for urine. It is located in the pelvic cavity, posterior to the symphysis pubis, and below the parietal peritoneum. The size and shape of the urinary bladder varies with the amount of urine it contains and with pressure it receives from surrounding organs. The inner lining of the urinary bladder is a mucous membrane of transitional epithelium that is continuous with that in the ureters. When the bladder is empty, the mucosa has numerous folds called rugae. The rugae and transitional epithelium allow the bladder to expand as it fills. The second layer in the walls is the submucosa that supports the mucous membrane. It is composed of connective tissue with elastic fibers. The next layer is the muscularis, which is composed of smooth muscle. The smooth muscle fibers are interwoven in all directions and collectively these are called the detrusor muscle. Contraction of this muscle expels urine from the bladder. On the superior surface, the outer layer of the bladder wall is parietal peritoneum. In all other regions, the outer layer is fibrous connective tissue.

There is a triangular area, called the trigone, formed by three openings in the floor of the urinary bladder. Two of the openings are from the ureters and form the base of the trigone. Small flaps of mucosa cover these openings and act as valves that allow urine to enter the bladder but prevent it from backing up from the bladder into the ureters. The third opening, at the apex of the trigone, is the opening into the urethra. A band of the detrusor muscle encircles this opening to form the internal urethral sphincter.

31

Urethra The final passageway for the flow of urine is the urethra, a thin-walled tube that conveys urine from the floor of the urinary bladder to the outside. The opening to the outside is the external urethral orifice. The mucosal lining of the urethra is transitional epithelium. The wall also contains smooth muscle fibers and is supported by connective tissue. The internal urethral sphincter surrounds the beginning of the urethra, where it leaves the urinary bladder. This sphincter is smooth (involuntary) muscle. Another sphincter, the external urethral sphincter, is skeletal (voluntary) muscle and encircles the urethra where it goes through the pelvic floor. These two sphincters control the flow of urine through the urethra. In females, the urethra is short, only 3 to 4 cm (about 1.5 inches) long. The external urethral orifice opens to the outside just anterior to the opening for the vagina. In males, the urethra is much longer, about 20 cm (7 to 8 inches) in length, and transports both urine and semen. The first part, next to the urinary bladder, passes through the prostate gland and is called the prostatic urethra. The second part, a short region that penetrates the pelvic floor and enters the penis, is called the membranous urethra. The third part, the spongy urethra, is the longest region. This portion of the urethra extends the entire length of the penis, and the external urethral orifice opens to the outside at the tip of the penis.

32

IX.

Pathophysiology

Modifiable: Lifestyle Diet Exercise

Non-Modifiable: Age (66 yrs old) Gender Family history

F s

Thickening and/or an in the amount of collagen in the basement membranes of the small vessels Legend: = Risk factors = Pathology = Clinical manifestations = Treatment GFR = NCP
CREATINE

Impaired/sluggish blood flow

Glumerulosclerosis
LAB: BUN

Renal blood flow Stage 1 Reduced Renal Reserve GFR of 35% to 50% of Normal 33

Stage 2 Renal insufficiency GFR is 25% to 35% of Normal

Remaining nephrons undergo changes to compensate for those damage nephrons

Filtration of more concentrated blood by the remaining nephrons

Hypertrophy of nephrons

Intolerance and exhaustion of the remaining nephrons

Further damage of the nephrons

Dialysis

Stage 3 Renal failure GFR of 15% to 20% of normal

Impaired kidney function & urination

Reduction in renal capillaries Scarring of glomeruli Atrophy & Fibrosis of Renal tubules >85% of kidney damage

Continuous decline in renal function 34

Stage IV ESRD GFR of 15% of normal or less

Continuous multisystem affectation

Neurologic: -weakness and fatigue -inability to concentrate - behavioral changes

Integumentary: -gray-bronze skin -dry, flaky skin - pruritis

Cardiovascular: -hypertension -pitting edema of feet - periorbital edema

Pulmonary: -shortness of breath -crackles -cough with thick, tenacious sputum

Gastrointestinal: -anorexia

Activity intolerance related to fatigue, anemia, retention of waste products and dialysis procedure.

Impaired Skin Integrity related to accumulation of toxins in the skin as evidenced by pruritus

Fluid volume excess related to decrease urine output as manifested by edema.

Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough

Imbalanced Nutrition less than body requirement related to GI disturbances as evidenced by altered taste sensation.

Anti-hypertensive (Therabloc) (Norvasc) (Pritor Plus)

Mucolytic Expectorant (Mucobron)

((9((

Hematologic: -anemia

Urinary: -anuria

Reproductive: -decreased libido

Immune: -infection

LAB:
LAB:

Antibiotic Vigocid

WBC
HCT HGB RBC

Chest x-ray

35

X.

Prioritized List of Nursing Problems CUES Subjective: nahihirapan ako huminga dahil sa ubo koas verbalized by the patient. Objective: Shortness of breath Cough w/ thick tenacious sputum V/s taken as follow: Bp:180 / 90 Temp:36.8oC RR:22 PR:86 FLUID VOLUME EXCESS is the increased isotonic fluid retention, a HIGH PRIORITY problem that is life threatening. It can contribute to ineffective airway clearance through the accumulation of fluids in the pulmonary system. Interventions are needed quickly to resolve other associated problems. JUSTIFICATION INEFFECTIVE AIRWAY CLEARANCE is the inability to clear secretions or obstruction from the respiratory tract to maintain a clear airway. Loss of respiratory function can be life threatening, a HIGH PRIORITY problem.

NURSING DIAGNOSIS 1. Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough

2. Fluid volume excess related to decrease urine Subjective: output as manifested by edema namamanas ang paa ko as verbalized by the patient. Objective: Edema

36

3. Imbalanced Nutrition less than body requirement related to GI disturbances as evidenced by altered taste sensation.

Subjective:

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS is insufficient Wala akong ganang kumain simula ng intake of nutrients to meet the metabolic nagka-sakit ako as verbalized by the patient. needs of the body. A LOW PRIORITY problem that is not currently health Objective: threatening bur it could be if it were to persist. It will almost certainly resolve in a >gastrointestinal day or two as the medical problem is treated. If the medical problem does not anorexia resolve quickly, this will change to a medium priority. Subjective: ACTIVITY INTOLERANCE is insufficient nanghihina ako as verbalized by the patient physiological or psychological energy to endure or complete required or desired Objective: daily activities. It is a LOW PRIORITY problem that is cause by other higher inability to concentrate priority problems; therefore it will resolve weakness and fatigue as they resolve. behavioral changes

4. Activity intolerance related to fatigue, anemia, retention of waste products and dialysis procedure.

Subjective: 5. Impaired Skin Integrity related to accumulation of toxins in the skin as evidenced by pruritus Ang kati ng balat ko as verbalized by the patient. Objective: gray-bronze skin dry, flaky skin pruritis

IMPAIRED SKIN INTEGRITY is altered epidermis and/or dermis. It is a result of medical problem, but it is not a contributing factor. Therefore measures to promote intact skin will be a LOW PRIORITY.

37

XI.

Nursing Care Plans Diagnosis

Ineffective Airway Clearance related to retained secretions as manifested by shortness of breath and productive cough

Assessment
Subjective: nahihirapan ako huminga dahil sa ubo koas verbalized by the patient. Objective: Shortness of breath Cough w/ thick tenacious sputum V/s taken as follow: Bp: 180 / 90 Temp: 36.8C RR: 22 PR: 86

Planning
After 2hours of nursing intervention the patient will demonstrate behaviours to improve airway clearance, e.g. cough expectorate secretions. maintain patent airway with breath sound clear/clearing

Nursing Intervention
Independent: 1. Monitor vital signs 2. Auscultate breath sounds. Note adventitious breath sound e.g, wheezes, crackles, rhonchi.

Rationale

Evaluation
GOAL MET:

1. To provide baseline data. 2. Some degree of bronchospasm is present with obstruction air way and may/may not be modified in adventitious breath sounds. 3. Elevation of the head of the bed facilities respiratory function by use of gravity; however patient, in severe distress will seek the position that most eases breathing. 4. Precipitators of allergic type of respiratory reaction that can trigger/exacerbates onset of cough effect.

After 2hours of nursing intervention the patient demonstrated behaviours to improve airway clearance, e.g. cough effectively and expectorant secretions

3. Assist patient to assume position of comfort e.g elevate head of bed, have patient lean on over bed table or sit on edge of bed. 4. Keep environmental pollution to a minimum e.g dust smokes &feather pillows.

38

5. Observe characteristics of cough e.g persistent, hacking, and moist. Assist with measures to improve effectiveness of cough effect Dependent: 6. Administer medications prescribed.

5. Cough can be persistent but ineffective, especially if patient is elderly, acutely ill, or debilitated. Coughing is most effective in an upright or in a head down-position after chest percussion.

6. To treat underlying as cause.

39

Assessment
Subjective: namamanas ang paa ko as verbalized by the patient. Objective: edema

Diagnosis

Planning

Nursing Intervention
Independent: 1.Assess fluid status: a. daily weight b. intake and output balance c. skin turgor and presence of edema d. blood pressure, pulse rate and rhythm e. respiratory rate and effort.

Rationale
1. Assessments provide baseline and on-going database for monitoring changes and evaluating interventions.

Evaluation
GOAL MET: After 2hours of nursing intervention the patient was able to maintain dietary and fluid restrictions.

Fluid volume excess related to decrease urine output as After 2 hours of manifested by nursing edema. intervention the patient will maintain dietary and fluid restrictions.

2. Limit fluid intake to 2. Fluid restrictions prescribed volume. will be determined on basis of weight urine output and response to therapy. 3.Identify potential source of fluid: a. medications and fluids used to take medications: oral and intravenous. b. foods 4. Explain to patient and family rationale for restrictions. 3. Unrecognized sources of excess fluid may be identified.

4. Understanding promotes patient and family cooperation with fluid restriction. 5. Assist patient to cope 5. Increasing patient with the discomforts comfort promotes resulting from fluid compliance with restrictions. dietary restrictions. 40

Assessment
Subjective: Wala akong ganang kumain simula ng nagka-sakit ako as verbalized by the patient. Objective: >gastrointestinal anorexia

Diagnosis
Nutrition; imbalanced less than body requirement related to GI disturbances as evidenced by altered taste sensation.

Planning

Nursing Intervention
Independent:

Rationale

Evaluation
GOAL MET:

After 4 hours of nursing intervention the patient will be able to follow the prescribed diet

1. Assess nutritional status: a. weight changes b. diet history food preferences c. calorie count 2. Assess patient nutritional dietary patterns: a. diet history b. food preferences c. calorie count

1. Baseline data allow for monitoring of changes and evaluating effectiveness of intervention.

After 4hours of nursing intervention the patient was able to follow the prescribed diet

2. Past and present dietary patterns are considered in planning meals.

3. Assess for factors 3. Information about contributing to altered other factor that may nutritional intake: be altered or eliminated to promote a.anorexia, nausea and adequate dietary vomiting intake is provided. b. Lack of understanding of dietary restrictions. 4. Provide patient food 4. Increased dietary preferences within intake is encouraged. dietary restrictions.

41

Assessment
Subjective: nanghihina ako as verbalized by the patient Objective: >inability to concentrate >weakness and fatigue >behavioral changes

Diagnosis
Activity intolerance related to fatigue, anemia, retention of waste products and dialysis procedure.

Planning

Nursing Intervention
Independent:

Rationale

Evaluation
GOAL MET: After 4 hours of nursing intervention the patient was able to demonstrate decrease in physiological signs of intolerance.

After 4 hours of nursing intervention the patient will demonstrate decrease in physiological signs of intolerance.

1.Assess factor 1. Indicates factor contributing to fatigue: contributing to severity of fatigue. a. anemia b. fluid and electrolyte imbalances c. retention of waste products 2.Promote independence 2. Promotes improved in self-care activities as self-esteem. tolerated; assist if fatigue. 3.Encourage alternating activity with rest 3. Promotes activity and exercise within limits and adequate rest.

4. Encourage patient to 4. Adequate rest is rest after dialysis encouraged after treatment. dialysis treatments which are exhausting to many patients.

42

Assessment
Subjective: Ang kati ng balat ko as verbalized by the patient Objective: gray-bronze skin dry, flaky skin pruritis

Diagnosis
Impaired skin integrity related to accumulation of toxins n the skin as evidenced by pruritis.

Planning
After 2hours of nursing intervention the patient will maintain intact skin

Nursing Intervention
Independent: 1. Inspect skin for changes in color, turgor, and vascularity. Note redness, excoriation. Observe for ecchymosis, purpura. 2. Monitor fluid intake and hydration of skin and mucous membranes.

Rationale

Evaluation
GOAL MET:

1. Indicates areas of poor circulation/ breakdown that may lead to decubitus formation/ infection. 2. Detects presence of dehydration or over dehydration that affects circulation and tissue integrity at the cellular level. 3. Baking Soda and cornstarch bath decrease itching and are less drying than soaps, lotions, and ointments may be desired to relieve dry crackle skin. 4. Reduces normal irritation and risk of skin breakdown. 5. Although Dialysis has largely eliminated skin problems

After 2 hours of nursing intervention the patient maintained intact skin

3.Provides soothing skin care, restrict use of soaps, apply ointments or creams

4.keep linen dry, wrinkle free 5.Investigate reports of itching

43

associated with uremic frost, itching can occur because the skin is excretory route for waste product. 6. Recommend client use cool, moist compresses to apply pressure (rather than scratch). Pruritic areas keep finger nails short; encourage use of gloves during sleep if needed. 7. Suggest wearing loose filling cotton garments. 6. Alleviates discomfort and reduces risk of dermal injury.

7. Prevents direct dermal irritation and promotes evaporation of moisture on the skin.

44

XII. Drug name Generic name: Atenolol

Drug Study Dosage Frequency 25 mg 1 tab OD Classification Antihypertensive Indication >Hyperten sion, Angina pectoris Contraindication >sinus bradycardia heart block other than first degrees cardiogenic shock, acute unstable heart failure. Adverse Reactions >Bradycardia, hypotension, precipitation of severe CHF, dizziness, fatigue, mental depression, diarrhea, nausea, hypoglycemia in non diabetic patients. Nursing consideration >Always remember the ten rights of giving medication. >Monitor patients blood pressure. >Monitor hemodialysis patients closely because of hypotension risk.

Brand name: Therabloc

45

Drug name Generic name: Amlodipine Brand name: Norvasc

Dosage Frequency 10 mg 1 tab OD

Classification

Indication

Contraindication

Adverse Reactions >Headache, nausea, hypotension, tachycardia, restlessness, dizziness, abdominal pain.

Nursing consideration >Always remember the ten rights of giving medication. >monitor patient carefully. >Monitor blood pressure frequently during initation of therapy. >Notify prescribed if signs of heart failure occurs such as swelling of hands and feet or shortness of breathing.

Anti-anginal/ Antihypertensive drugs

>Reductio >Marked anemia n of Blood severe pressure hypotension. unresponsi ve CHF, unstable angina.

46

Drug name Generic name: Tazobactam Brand name: Vigocid

Dosage Frequency

Classification

Indication

Contraindication

Adverse Reactions

Nursing consideration

Antibiotic 2.25 g / IV TID >Treatment of systemic or local bacterial infection caused by sensitive organisms, lower respiratory tract. >Hypersensitivit y to penicillin. >Diarrhea, constipation , nausea, headache, rash, vomiting, allergic reactions, and super infection. >Always remember the ten rights of giving medication. >Monitor if the patient experiencing diarrhea or fever.

47

Drug name Mucobron

Dosage Frequency 1 cap TID

Classification

Indication

Contraindication

Adverse Reactions

Nursing consideration

Anti-cough and cold remedies.

>mucolytic expectorant for excessive dry, hacking and useless coughing.

>Coronary thrombosis, hypertension, and asthma.

>Sleep disturbances, excitability, raised blood pressure, tachycardia, anginal attacks.

>Always remember the ten rights of giving medication. >Give some idea to the patient for her not to remember her illness like watching television.

48

Drug name

Dosage Frequency

Classification

Indication

Contraindication

Adverse Reactions >Fatigue and flu like symptoms of dizziness, diarrhea, nausea, sinusitis, upper respiratory tract infection.

Nursing consideration >Always remember the ten rights of giving medication. >Monitor blood pressure. >Monitor fluid intake and output.

Brand name: Pritor Plus GlaxoSmith Kline Generic name: Hydrochlorothiazide

80/125 mg 1 tab

AntiHypertensive

Treatment for hypertension, edema.

>Contraindication with patient hypersensitive to other thiazimides.

49

References: Kozier and Erbs Fundamentals of nursing volume 1, 8th edition by Berman, Snyder, Kozier and Erb Brunner and Suddarths Medical-surgical nursing volume 2, 10th edition by Smeltzer and Bare Medical Surgical Nursing by J.B. Lippincott Company Nursing Care Plans, 6th edition by Doenges Nursing 2005 Drug Handbook Lippincott Williams and Wilkins PPDs Nursing Drug Guide 2nd edition http://www.web-books.com/eLibrary/Medicine/Physiology/Urinary/Urinary.htm

50