TABLE OF CONTENTS I. INTRODUCTION A. Definition B. Statistics i. International ii. Local II. OBJECTIVES A. General Objective B. Specific Objectives III. ANATOMY AND PHYSIOLOGY IV. VITAL INFORMATION V. CLINICAL ASSESSMENT A. Nursing History B. Past Health Problem/Status C. Family History of Illness VI. SOCIAL, CULTURAL, RELIGIOUS BACKGROUND AND PATTERN OF FUNCTIONING. a. Educational Background b. Occupational Background c. Religious practices d. Economic status VII. CLINICAL INSPECTION A. Vital Signs Upon Admission During our Care B. Physical Assessment (Cephalocaudal) I. General Appearance II. Skin, hair and nails III. Head, face, and lymphatics IV. Eyes, ears, nose, mouth and throat V. Neck and upper extremities VI. Chest, breast and axilla VII. Respiratory system VIII. Cardiovascular system IX. Gastrointestinal system X. Genitor-urinary system XI. Musculoskeletal system C. General Appraisal I. Speech II. Language III. Hearing IV. Mental status V. Emotional status VIII. LABORATORY AND DIAGNOSTIC DATA IX. PATHOPHYSIOLOGY X. MEDICAL MANAGEMENT 1
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TABLE OF CONTENTS
I. INTRODUCTION
A. Definition
B. Statistics
i. International
ii. Local
II. OBJECTIVES
A. General Objective
B. Specific Objectives
III. ANATOMY AND PHYSIOLOGY
IV. VITAL INFORMATION
V. CLINICAL ASSESSMENT
A. Nursing History
B. Past Health Problem/Status
C. Family History of Illness
VI. SOCIAL, CULTURAL, RELIGIOUS BACKGROUND AND PATTERN OF FUNCTIONING.
a. Educational Background
b. Occupational Background
c. Religious practices
d. Economic status
VII. CLINICAL INSPECTION
A. Vital Signs
Upon Admission
During our Care
B. Physical Assessment (Cephalocaudal)
I. General Appearance
II. Skin, hair and nails
III. Head, face, and lymphatics
IV. Eyes, ears, nose, mouth and throat
V. Neck and upper extremities
VI. Chest, breast and axilla
VII. Respiratory system
VIII. Cardiovascular system
IX. Gastrointestinal system
X. Genitor-urinary system
XI. Musculoskeletal system
C. General Appraisal
I. Speech
II. Language
III. Hearing
IV. Mental status
V. Emotional status
VIII. LABORATORY AND DIAGNOSTIC DATA
IX. PATHOPHYSIOLOGY
X. MEDICAL MANAGEMENT
A. Drug Study
B. Medi Map
XI. NURSING MANAGEMENT
A. Concept Map of Nursing Problems
B. Nursing Care Plan
XII. DISCHARGE PLANNING
XIII. JOURNALS
XIV. ACKNOWLEDGEMENT
1
OBJECTIVES
A. General Objective
After the discussion of this case presentation, the students will be able to deal
and care for a patients with End – Stage Renal Disease integrally by applying their
knowledge, skills, and positive attitudes based on what they have learned out of the
discussion.
B. Specific Objectives
At the end of individual case discussion, it is expected that the students will be
able to:
Skills
1. Deal patient with ESRD.
2. Provide proper care according to the problem manifested by the patient.
3. Conduct physical assessment and organize data efficiently.
4. Perform nursing procedures effectively and correctly to attain optimum level of
wellness.
Knowledge
1. Define ESRD.
2. Have an overview about the diseases, including its causes and complications.
3. Determine the signs and symptoms and the possible symptomatic treatment of
each.
4. Review the anatomy and physiology of the organ affected.
5. Understand the pathophysiology of the disease.
6. Identify and enumerate the management needed for ESRD and its related
complications.
7. Formulate nursing care plans that will aid in the improvement of patient’s
condition.
Attitudes
1. Develop a positive attitude in caring the patient with ESRD throughout the
nursing Process.
2. To be able to establish rapport with the patient and folks.
3. To be able to develop respect and trust.
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INTRODUCTION
A. Definition
End stage kidney disease is the final stage of chronic kidney disease (CKD). It is the
most severe illness with poor life expectancy if untreated. It also called established chronic
disease and occurs when GFR falls below 15 mL/min/1.73 m2. Patients with ESRD are
dependent on renal replacement therapy (RRT) to survive. The incidence of ESRD in the
developing world is difficult to estimate and ranges from 40 per million population (pmp) to 340
pmp. The prevalence of ESRD can be more accurately recorded as the number of patients
receiving RRT.
Glomerulonephritis is the main cause of ESRD worldwide (11% – 49%). Proliferative
glomerulonephritis is more common in developing countries and may be secondary to endemic
infections like streptococcus, schistosomiasis, and malaria. Focal segmental glomerulonephritis is
also common in Africa, while IgA nephropathy is common in Asia and Pacific regions. Diabetes
mellitus and hypertension remain important factors in the etiology of ESRD, but less so in the
developing world than in the USA where they account for around 65% of ESRD.
It is very important to take really good care of our kidneys because our kidneys play a
big role to our body which is to filter our body wastes. Nowadays, cases of ESRD is increasing
in continue to spread all over the world. Having discipline to ourselves regarding our health
could be a big help to prevent diseases because most of us abuse our body that’s why we had a
lot diseases which is developing in our body and most of them could lead to death. Having a
good health is one of the greatest treasures we could have; this could make us disease free of
such serious illness. Regarding ESRD, we could only say that proper nutrition and proper care
of our kidneys is one of the important ways to prevent and to eliminate this disease to occur
within us. And what we said earlier is that, one of the best way to have good health is to have a
self-discipline regarding health care because we are the one who are deciding whether to have
a disease or not. Living with a healthy lifestyle and good health is one of the achievable and
could have a satisfying life.
As student nurses, we could help our patient by having a deep understanding of the
disease, that we may learn the proper interventions for the end-stage renal disease patients. In
this way, we could render quality care for them. We could as well lead them to the proper
treatment to lessen their sufferings brought by the kidney failure, in anyhow. By having a wide
understanding of the disease, we could impart teachings on how we could prevent the
occurrence of the disease. It is our responsibility to render information and impart health
teachings to improve the condition of our patients to the best of our abilities. One of the
characteristics that we, student nurses, should have is to be informative and only through a
keen study of disease such as this way for us to gain all the information that we need to learn.
May this case study served its purpose through the help of our Lord, Jesus Christ.
3
B. Statistics
International:
93,327 people commenced treatment for end-stage renal disease annually in the US 2001
(United States Renal Data System, 2003, NIDDK)
31% of cases of ESRD each year occurs in African Americans in America (Renal Data
Report, ANS, 1999)
2% of cases of ESRD each year occurs in native Americans (Renal Data Report, ANS,
1999)
31% of cases of ESRD each year occurs in Caucasians in America (Renal Data Report,
ANS, 1999)
Local:
Kidney disease is on the rise and is an important cause of death in the Philippines.
Statistics show that kidney disease among the Filipinos is shooting up every year. Almost
10,000 Filipinos requiring either dialysis for life or a kidney transplant for survival. About 31% of
them have the most advanced stage of the disease.
The main cause of kidney disease seems to be the increasing diabetic conditions
among the Filipinos. It is seen that about 55% of Filipinos develop kidney disease when they
suffer from diabetes. The Philippine Society of Nephrology (PSN) issued the statement that
diabetes is the single most common cause of kidney failure among diabetes mellitus
nephropathy patients.
4
ANATOMY AND PHYSIOLOGY
The KIDNEYS are known as
MASTER CHEMIST. Actually, they are
pair of bean shaped, brownish-red
structures located retroperitoneally on the
posterior wall of the abdomen-from the
12th thoracic vertebra to the third lumbar
vertebra in the adult.
The average adult kidney weighs
approximately 13 to 170 g (about 4.5 oz) and is 10 to 12 cm of the long, 6 cm wide and
2.5 cm thick. The right kidney is slightly lower than the left due to the location f the liver.
An adrenal gland lies on top of each kidney. The kidneys and adrenals are independent
in function, blood supply and innervation.
NEPHRONS
- from Greek word “nephros”, meaning "kidney". It is the basic structural
and functional unit of the kidney. Its functions are vital to life and are regulated by the
endocrine system by hormones such as antidiuretic hormone, aldosterone, and
parathyroid hormone. In humans, a normal kidney contains 800,000 to one million
nephrons. Its chief function is to regulate the concentration of water and soluble
substances like sodium salts by filtering the blood, reabsorbing what is needed and
excreting the rest as urine.
TWO PARTS OF RENAL PARENCHYMA:
Medulla
- (latin renes medulla = kidney middle)
which is approximately 5 cm wide. It contains
the structures of the nephrons responsible for
maintaining the salt and water balance of the
blood. These structures include the vasa
rectae (both spuria and vera), the venulae
rectae, the medullary capillary plexus, the loop
of Henle, and the collecting tubulle. The renal
medulla is hypertonic to the filtrate in the
nephron and aids in the reabsorption of water.
5
Cortex
- is the outer portion of the kidney between the renal capsule and the renal medulla. In
the adult, it forms a continuous smooth outer zone with a number of projections (cortical
columns) that extend down between the pyramids. It contains the renal corpuscles and the
renal tubules except for parts of the loop of Henle which descend into the renal medulla. It
also contains blood vessels and cortical collecting ducts. The renal cortex is the part of the
kidney where ultrafiltration occurs.
MAJOR FUNCTIONS OF KIDNEY:
Regulation of water excretion
A person normally ingests about 1300 mL of oral fluids and 1000 mL of water in food per
day. Of the fluid ingested, approximately 900 mL is lost through the skin and lungs (called
insensible loss), 50 mL through sweat and 200 mL through feces.
Regulation of electrolyte excretion
When the kidneys are functioning normally, the volume of electrolytes excreted per day
is equal to the amount ingested. The regulation of sodium volume excreted depends on
aldosterone, a hormone synthesized and released from the adrenal cortex. With increased
aldosterone in the blood, less sodium is excreted in the urine, because aldosterone fosters renal
absorption of sodium.
Regulation of acid-base balance
The kidney performs two major functions to assist in this balance. 1.) To reabsorb and
return to the body’s circulation any bicarbonate from the urinary filtrate; 2.) To excrete acid in
the urine.
Autoregulation of blood pressure
Rennin converts angiotensinogen to angiotensin I, which is then converted to
angiotensin II, the most powerful vasoconstrictor known; angiotensin II causes the blood
pressure to increase.
The adrenal cortex secretes aldosterone in response to poor perfusion or increasing
serum osmolality. The result is an increase in blood pressure.
Renal clearance
It is the ability of the kidneys to clear solutes from the plasma.
Regulation of red blood cell production
When the kidneys detect to decrease in the oxygen tension in renal bllod flow, they
release erythropoietin that stimulates the bone marrow to produce RBC and carry oxygen
throughout the body.
Vitamin D synthesis6
Secretion of prostaglandins
Excretion of waste products
The kidneys eliminate the body’s metabolic waste products which is the urea that
excreted daily for about 25 to 30 mg.
Urine storage
Bladder emptying
TEXTBOOK DISCUSSION
A. Definition
End - stage renal disease, also known as chronic kidney disease (CKD), specifically
the fifth stage of CKD. It means, it is the complete or almost complete failure of the kidneys to
function. The kidneys can no longer remove wastes, concentrate urine, and regulate many other
important body functions.
ESRD almost always follows chronic kidney disease. A person may have gradual
worsening of kidney function for 10 - 20 years or more before progressing to ESRD. Patients
who have reached this stage need dialysis or a kidney transplant.
B. Risk factors
Persons with the following conditions:
Chronic glomerulonephritis
ARF
Excessive intake of drugs Changed smoker and alcoholic beverages drinker. Polycystic kidney disease
Obstruction
Repeated episodes of pyelonephritis
Diabetes mellitus
- is the leading cause & accounts for more than 30% of clients who receive dialysis.
Hypertension
Lupus erythematous
Polyarteristis
Sickle cell disease
Amyloidosis
7
C. Signs/Symptoms
CLINICAL MANIFESTATION
DISTINCTIVE
GROUPING
From the textbook
Manifested
by the
patientRationale
Electrolyte
Imbalances
Hyperkalemia
Hyponatremia The salt – wasting properties of some
failing kidneys, in addition to vomiting
and diarrhea.
Hypocalcemia
Hyper-
phosphatemia
Hypercalcemia
Mildly elevated
serum Mg
Metabolic
changes
↑ serum creatinine Serum creatinine increases as waste
products of protein metabolism
accumulate in the blood. And due to
decrease GFR.
Proteinuria The metabolic function of the kidney
which includes the metabolism fails
which tends protein to be excreted via
urine.
↑ uric acid
Carbohydrate
intolerance
Elevated
triglycerides
Metabolic acidosis It occurs because of the kidneys inability
to excrete hydrogen ions, ↓ reabsorption
of NaHCO3, ↓ formation of dihydrogen
phosphate and NH3.
Pericarditis
Hematologic
changes
Anemia It occurs because the kidneys are
unable to produce erythropoietin, a
hormone necessary for RBC production.
Iron or folate
depletion
Hemolysis &
8
platelet
abnormalities
Gastro-
intestinal
changes
Transient anorexia,
nausea & vomiting
A possible cause of nausea and
vomiting is a decomposition of the urea
by the intestinal flora resulting in a high
concentration of ammonia.
Constant bitter
taste
Fetid, fishy or
ammonia-like
breath smells
Metallic or salty
taste
Stomatitis
Hiccups Due to the accumulation of toxic
substances that stimulates phrenic
nerves.
Ulcer disease
↑ serum amylase
Constipation
Immunologic
changes
Depression of
hormonal antibody
formation
Suppression of
delayed
hypersensitivity
Decreased
chemotactic
function of the
leukocytes
Changes in
medication
metabolism
Medication toxicity
Cardio-
vascular
changes
HPN Due to water retention.
Arterial
calcifications
L ventricular
hypertrophy & HF
Chest pain Due to the accumulation of toxins in the
body because the kidney is failing in
filtering it.
9
Dysrhythmias
Atherosclerosis
Anasarca Due to water retention as a result of ↑
hydrostatic pressure or for activation of
renin – angiotensin aldosterone system
Respiratory
changes
Pulmonary edema
Pleuritis
Musculo-
skeletal
changes
Osteomalacia
Osteitis fibrosa
Osteoporosis
Osteosclerosis
Muscle cramps These may result from osmolar changes
in the body fluids or sometimes from
hypokalemia.
Integumentary
changes
Intractable pruritus
Brittle hair
Pallor Due to anemia wherein the presence of
hemoglobin in the blood is decreased,
resulting to a decrease oxygen
distribution throughout the body.
Nails are thin
Neurologic
changes
Forgetfulness
Confusion It occurs due to hypokalemia, as the
transmission of nerve impulses
decreases.
Peripheral
neuropathy
Inability to
concentrate
Twitching
Dysarthria
Uremic amaurosis
Reproductive
changes
Testicular atrophy
Oliguspermia
Reduced sperm
motility
Endocrine
changes
↑ growth hormone
& prolactin
Psychosocial
changes
Powerlessness
Changes in body
image
Due to edema
10
D. Complications
Uremia
- If there is failure of kidney to function well, urea and other waste products,
which are normally excreted into the urine, are retained in the blood.
Shock
- Severe condition from reduced blood circulation and it occurs because of
excessive urination and edema.
Pericarditis
- Is the inflammation of the pericardium. Due to retention of toxic substances as
a result of decreased renal function or renal failure.
Seizures
- It is an intellectual deficit due to hydroxylysinuria. It is a rare syndrome
characterized by mental retardation, seizures and high levels of hydroxylysine in the
urine.
Coma
- A profound or deep state of unconsciousness. The affected individual is alive
but is not able to react or respond to life around him/her. Coma may occur as an
expected progression or complication of an underlying illness, or as a result of an event
such as head trauma.
E. Treatment
Dialysis for hyperkalemia & fluid imbalances.
Emergency pericardiocentesis or surgery for cardiac tamponade.
Intensive dialysis and thoracentesis to relieve pulmonary edema & pleural effusion.
Peritoneal or hemodialysis to help control end-stage renal disease.
Kidney transplantation
Symptomatic treatment of ESRD
Diet:
Low protein diet to limit accumulation of end-products of protein metabolism that the
kidneys can’t excrete.
High-protein diet for patients on continuous peritoneal dialysis
High-calorie diet to prevent ketoacidosis & tissue atrophy.
Sodium, potassium & phosphorus restrictions to prevent elevated levels.
11
Medications:
Loop diuretics, such as furoemide to maintain fluid balances.
Cardiac glycosides, such as Digoxin to mobilze fluids causing edema.
Calcium carbonate (Caltrate) to treat renal osteodystrophy by binding phosphate &
supplementing calcium.
Antihypertensives to control blood pressure and edema.
Antiemetics to relieve nausea & vomiting.
Famotidine or ranitidine to decrease gastric irritation.
Docusate to prevent constipation.
Iron & folate supplements or RBC transfusion to treat anemia.
Synthetic erythropoietin to stimulate the bone marrow to produce RBCs; conjugated
estrogens & desmopressin to combat hematologic effects.
Antipruritics to relieve itching.
Phosphate-removing drugs to decrease serum phosphate levels.
F. Diagnostic studies
Urinalysis
- aids in diagnosis (specific gravity fixed at 1.010, proteinuria. glycosuria, RBCs,
leukocytes, casts or crystals, depending on the cause).
Mechanism of Action Inhibits reabsorption of Na & Cl from the proximal and distal
tubules & ascending limb of the loop of Henle, leading to a Na-
rich diuresis.
Nursing Responsibilities Administer with food or milk to prevent GI upset.
Give early in the day so that increased urination will not
disturb sleep.
Monitor I & O.
Measure & record weight.
Avoid rapid position changes & hazardous activities.
Use frequent mouth care.
34
35
B. Medi Map
36
Pathophysiology:In end stage renal disease (ESRD), the
blood flow to the kidneys may be drastically reduced due to all the damage to the filtering structures in the kidney (the glomeruli). Urine output decreases as a result, and toxic substances build up in the blood. The sum effect of this is "uremia," a complex biochemical syndrome that results from this toxic buildup. Blood urea nitrogen and creatinine are two blood markers that rise in renal disease. Electrolyte levels can also become deranged in renal disease.
Pathophysiology:In end stage renal disease (ESRD), the
blood flow to the kidneys may be drastically reduced due to all the damage to the filtering structures in the kidney (the glomeruli). Urine output decreases as a result, and toxic substances build up in the blood. The sum effect of this is "uremia," a complex biochemical syndrome that results from this toxic buildup. Blood urea nitrogen and creatinine are two blood markers that rise in renal disease. Electrolyte levels can also become deranged in renal disease.
Risk factors:
Excessive intake of illegal drugs
Excessive alcoholic and carbonated drinker for about 5-7 bottles/day
Risk factors:
Excessive intake of illegal drugs
Excessive alcoholic and carbonated drinker for about 5-7 bottles/day
Prevention:Low protein diet.Sodium, potassium & phosphorus restrictions.Restriction of fluid intake.Encourage cessation of toxic substances such as alcohol and illegal drugs.
Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables.
Prevention:Low protein diet.Sodium, potassium & phosphorus restrictions.Restriction of fluid intake.Encourage cessation of toxic substances such as alcohol and illegal drugs.
Advise to eat nutritious food would somehow help the patient on regaining some strengths or energy to his body, such as green leafy vegetables.
Nursing interventions:
Turn the patient often & use a convoluted foam mattress to prevent skin
breakdown.
Provide good oral hygiene by encouraging or performing frequent brushing
with a soft brush or sponge tip to reduce breath odor & providing
sugarless hard candy & mouthwash to minimize the metallic taste in the
mouth & alleviate thirst.
Offer small, nutritious & palatable meals.
Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak
pulse rate.
Carefully assess the patient’s hydration status; check for jugular vein
distention, auscultate the lungs for crackles, carefully measure daily
intake & output, record
Encourage deep breathing & coughing to prevent pulmonary congestion,
auscultate the lungs often, stay alert foe clinical effects of pulmonary
edema & administer diuretics & other medications as ordered.
Observe for signs of bleeding & monitor haemoglobin level & hematocrit &
check stool, urine & vomitus for blood.
Report signs of pericarditis such as pericardial friction rub and chest pain.
Nursing interventions:
Turn the patient often & use a convoluted foam mattress to prevent skin
breakdown.
Provide good oral hygiene by encouraging or performing frequent brushing
with a soft brush or sponge tip to reduce breath odor & providing
sugarless hard candy & mouthwash to minimize the metallic taste in the
mouth & alleviate thirst.
Offer small, nutritious & palatable meals.
Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak
pulse rate.
Carefully assess the patient’s hydration status; check for jugular vein
distention, auscultate the lungs for crackles, carefully measure daily
intake & output, record
Encourage deep breathing & coughing to prevent pulmonary congestion,
auscultate the lungs often, stay alert foe clinical effects of pulmonary
edema & administer diuretics & other medications as ordered.
Observe for signs of bleeding & monitor haemoglobin level & hematocrit &
check stool, urine & vomitus for blood.
Report signs of pericarditis such as pericardial friction rub and chest pain.