Chronic Kidney Disease

Objectives
Biographic data
Name: A. B.
Age: 30
Gender: Female
Status: Single
Religion: Catholic
Citizenship: Filipino
Date of Birth: June 16th 1978
Address: Pasay City
Date of Admission: November 1st 2007
Readmitted on January 18th 2009
Present History of Illness
One day PTA, January 17th, when patient
had failed to submit herself for regular
hemodialysis session (three days post last
hemodialysis) because of financial
constraints, she experienced an increased
severity of difficulty in breathing
accompanied by non-productive cough,
chills and fever. Prompt hospital-ER
consult, hence admission.
Past Medical History
No known allergies.
Not a known diabetic but diagnosed as
hypertensive for about five years and is
taking telmisartan 80mg OD and
metoprolol 100mg OD as maintenance.
Completely immunized.
She had chicken pox when she was seven.
Had frequent episodes of sore throat since
childhood (at least 3 times a year) without
seeking medical advice.
On November 1, 2007, she was brought to
the ER of San Juan de Dios hospital due
to difficulty in breathing.
Diagnosis was CKD stage five thence, she
had undergone immediate hemodialysis
using a temporary Mahurkar catheter via
right subclavian vein approach.
She was admitted and stayed there for two
weeks.
December 4, 2007, an arteriovenous fistula
was made on her left wrist and she has
been undergoing hemodialysis twice a
week from then on, Wednesdays and
Saturdays.
Obstetrics and Gynecological
History
Menarche at twelve.
LMP was last December 14th 2008.
Nulligravida.
Family History of Illness
Has no familial history of Diabetes Mellitus,
hypertension, cancer, Tuberculosis and
asthma.
Her father died at the age of 48 due to
chronic kidney disease stage III .
Psychosocial History
Patient is a 30-year old office worker in a
sales company in Alabang since 2003.
Non-smoker, occasional alcoholic beverage
drinker, consuming 3-4 bottles at least
four times a year.
With preference on taking in soda (four 8
ounce-bottles per day) and consuming
only at least 4 half glasses of water per
day.
She is third in a brood of four in the family.
Hobbies include shopping and net surfing;
and when faced with stress, considers
sleep.
Activities of Daily Living
 Activity Before hospitalization During hospitalization Analysis
Pre hemodialysis

Fluids and nutrition Drinks alcoholic
beverages occasionally at
3 to 4 bottles four times a
year. She eats 2 full
meals per day (skips
either breakfast or
dinner). For breakfast she
usually haves bread and
water.
Lunch – usually fast food
consisting of deep fried
dishes
Snacks – junk food
(chips) and soda,
approximately 4 8-ounce
bottles per day
The patient’s fluids are IV fluids are given for
partly supplied hydration. She eats twice
intravenously: 0.9 NaCl a day. Pre hemodialysis,
500cc running at 10cc/hr. the patient frequently
Her diet was maintained skips one meal due to
to low salt, low protein, lack of time because of
low potassium. She eats 3 office work. During
times per day but in small hospitalization the patient
amounts because of poor had a diet restriction (low
appetite. The patient salt, low protein and low
drinks a maximum of four potassium). This was the
glasses of water a day. diet ordered by the doctor
since high levels of these
three worsen the client’s
condition.

Drinks 4 half-glasses of
water daily

Dinner - often skipped

Activity Before hospitalization During hospitalization Analysis

During hemodialysis

Eats 3 full meals of low

salt, low protein and low
potassium on free days,
Wednesdays and
Saturdays, which are HD
sessions

Ceased eating junk food

and drinking soda and
alcoholic beverages

Drinks approximately four

half glasses of water
daily
 Activity Before hospitalization During hospitalization Analysis
Pre hemodialysis

Elimination The patient usually voids The patient voids two to Less urine output due to
4 – 6 times a day and four times a day, inability of the kidneys to
defecates regularly at approximately 240cc, and concentrate urine
least once a day. defecates regularly. because of the disease
process.
During hemodialysis

Voids two to four times

per day and defecates
regularly.
The patient has an The patient now has an Interrupted sleep during
average of 6 hours of irregular pattern of sleep. hospitalization because of
Rest and sleep
continuous sleep. environmental factors and
hospital procedures.
Exercise The patient prefers Exercises through short Easy fatigability because
walking when going to sitting and standing ups. of lack of oxygenation
work.
Hygiene Takes a full bath once Does partial baths and Because fatigue is a likely
daily and brushes thrice. brushes thrice daily. problem.
Physical Assessment
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

GCS: 15(M6V5E4)
VITAL SIGNS:
T: 36.8
PR: 76
RR: 33
BP: 180/100
WT: 50kg
BEFORE DIALYSIS:
40.5kg
AFTER DIALYSIS:
40.2kg
HT: 5 feet and 2
inches
 ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

• GENERAL
SURVEY

Body build, height Inspection Proportionate Underweight (BMI of Due to protein –

and weight in 16.12) energy malnutrition
(Normal – 20-25)
relation to and effects of wasting
client’s age
Inspection
Client’s posture and Relaxed, erect Relaxed, erect Normal
gait, standing, posture, coordinated posture, coordinated
sitting, and movement movement
walking
Inspection Neat and clean Neat and clean Normal
Overall hygiene and
grooming
Inspection No body/minor body No body/minor body
Body and breath odor odor; no breath odor odor; no breath odor Normal
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

Obvious signs Inspection Healthy appearance Pallor, weakness, Inadequate circulating

of health obvious illness blood or Hgb and
or illness subsequent reduction
in tissue oxygenation
and decreased
metabolic energy
production and
dietary restrictions

Inspection Cooperative Cooperative Normal

Client’s attitude
Inspection Appropriate to Appropriate to Normal
Client’s mood; situation situation
assess the
appropriatenes
s of
the client’s Inspection Understandable; Understandable; Normal
response exhibit thought exhibit thought
association association
Quality,
quantity
and
organization of
speech
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

Relevance and Inspection Logical sequence Logical sequence Normal

organization of
thoughts

A) SKIN
Skin color Inspection Varies to light – deep Sallow (grayish – Impaired excretion of
brown bronze) urinary pigments
(urochromes) as well
as the presence of
Uniformity of skin Inspection Generally uniform Areas that have anemia due to lack of
color except in areas Sallow (grayish – erythropoetin being
exposed to sun bronze) produced

Assess edema Inspection No edema With edema @ R Due to water retention

hand , IV site (edema and increase
scale 1+, barely permeability of
detectable) membrane that
results from shifting of
fluids

Observe and palpate Inspection Moisture in skin folds Generalized dryness Decrease in hydration
skin moisture and the axillae of the skin that affects circulation
and tissue integrity at
the cellular level

Skin temperature Palpation Uniform; within Uniform; within Normal

normal range normal range
 ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

Skin turgor Inspection When pinched, skin When pinched, skin Normal
springs back to springs back to
previous state previous state

Inspect, palpate and Inspection No abrasions/lesions Presence of stitches The incision is due to
describe skin lesions Birthmarks, freckles and incision scars on insertion of
wrist (with AVF), wheal arteriovenous fistula at
and punctured wound the wrist, a wheal from
skin test and punctured
wound by a syringe to
collect specimen (CBC)
C) HAIR
Evenness of growth over Inspection Evenly distributed Evenly distributed Normal
the scalp
Thickness or thinness of Inspection Thick hair Thick hair Normal
hair
Texture & oiliness Inspection Silky and resilient hair Silky and resilient hair Normal
Presence of infections or Inspection No infection or infestation No infection or infestation Normal
infestations
D) NAILS
Fingernail plate shape Inspection Convex curvature Convex curvature Normal
Texture Inspection Smooth Smooth Normal

Nail bed color Inspection Highly vascular, pink Pallor Circulatory impairment
due to decreased
erytropoietin

Tissues surrounding Inspection Intact epidermis Intact epidermis Normal

nails
Allen’s test inspection Prompt return Weak return (approx Circulatory impairment
w/in 4 sec)
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

E) HEAD
Size, shape and Inspection Palpation Rounded, smooth Rounded, smooth normal
symmetry skull contour skull contour
Presence of nodules, Inspection Palpation Absence of nodules Absence of nodules normal
masses or and masses and masses
depressions in
the skull
Facial features Inspection Symmetric/ slightly Symmetric/ slightly Normal
asymmetric asymmetric

Inspect the eyes for Inspection No edema and Periorbital edema at Due to fluid retention,
edema and hollowness noted OU increases
hollowness permeability of
membrane that
results from shifting of
Symmetry of facial Inspection Symmetric facial Symmetric facial fluids
movements movements movements Normal
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS
F) EYES
Inspect for Inspection Hair evenly Hair evenly Normal
eyebrows for distributed; intact distributed; intact
hair skin skin
distribution
and alignment
and skin Inspection Normal
quality and Skin intact; no Skin intact; no
movement discharge noted; discharge noted;
Inspect eyelids for no discoloration no discoloration
surface
characteristics
(skin quality & Inspection Due to retention of
texture) nitrogenous wastes
Transparent Yellowish in color which causes
Bulbar conjunctiva capillaries; sclera (icteric sclera) secondary
appears white hemolysis of RBC’s
thus increasing the
blood levels of
Inspection bilirubin

Extremely pale due to decrease

Palpebral shiny, smooth and erythropoietin
conjunctiva pink or red in color production;
Inadequate
circulating blood or
Hgb (9.5mm) and
subsequent
reduction in tissue
 ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

Pupils color, shape Inspection Black in color, equal Black in color, equal Normal
and symmetry of size size, normally 3 -7mm size, normally 3 -7mm
in diameter, round in diameter, round
Pupil’s direct and smooth smooth
consensual and Inspection Illuminated pupil Illuminated pupil Normal
reaction to light constricts (direct) constricts (direct)
Nonilluminated pupil Nonilluminated pupil
constricts constricts
Reaction to (consensual) (consensual)
accommodation inspection Pupils constrict when Pupils constrict when Normal
looking at near looking at near
objects; dilate when objects; dilate when
looking at far objects; looking at far objects;
pupils converge when pupils converge when
near objects is moved near objects is moved
toward nose toward nose

G) EARS Impaired excretion of

Auricles (color, Inspection Color same as facial Grayish-bronze color urinary pigments
symmetry, and skin; symmetrical; (sallow); symmetrical; (urochromes) as well as
position) aligned with outer aligned with outer the presence of anemia
canthus of eye canthus of eye due to lack of
erythropoetin being
produced
Client’s response to Inspection Normal voice tone normal voice tone
normal voice audible audible normal
tones
 ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS
H) NOSE Impaired excretion of
Deviations in shape, size, Inspection Symmetric, straight, no Symmetric, straight, no urinary pigments
color and presence discharge/flaring discharge/flaring; grayish – (urochromes) as well as
of flaring/discharge Uniform color bronze color (sallow) the presence of anemia
from nares due to lack of
erythropoetin being
produced
Presence of tenderness, Palpation Absence of Absence of
Normal
masses and lesion/tenderness lesion/tenderness
displacements of
bone and cartilage
Patency of both nasal Inspection Air moves freely as the Air moves freely as the Normal
cavities client breathes client breathes
I) MOUTH
Outer and inner lips for Inspection Uniform pink in color; Pallor, fissures and Due to excessive dryness,
symmetry of moist, smooth texture dryness decrease hydration and
contour, color and impaired circulation
texture
Condition of teeth Inspection Teeth is smooth, white in Teeth is smooth, white in Normal
color color
Position of tongue, Inspection Central position; no lesion Normal
presence of lesion
Sense of taste inspection Central position; no lesion Presence of metallic/salty Breakdown of urea to
Normal taste taste as stated by the ammonia in saliva
patient
J) NECK
Neck muscles for Palpation Muscle equal in size; head Muscle equal in size; head
Normal
abnormal swelling or centered centered
masses
Normal
Enlargement of lymph Palpation Lymph node not palpable Lymph node not palpable
nodes
 ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS
K) THORAX AND
LUNGS Auscultation Full and symmetric chest With slight evidence Due to compression
Breathing patterns expansion, quiet, rhythmic of substernal of lungs caused by
and effortless breathing retraction during accumulation of fluids
respiration

Adventitious breath Auscultation Absence of adventitious Presence of rales Increased fluid volume
sounds sounds
L) HEART
Abnormal pulsation, lifts Inspection No pulsation, lift and No pulsation, lift and Normal
and heaves Palpation heaves; symmetric pulse heaves; symmetric pulse
volumes volumes
Distention of jugular veins Palpation Jugular vein is not visible Jugular vein is not visible Normal

Peripheral perfusion Inspection Skin color pink, Skin color is grayish – Deposition of pigmented
Palpation temperature not bronze (sallow), metabolites or urochromes
excessively warm or cold temperature within normal or urea itself
range
M) ABDOMEN
Skin integrity, color, Inspection Unblemished skin, uniform Unblemished skin, grayish Deposition of pigmented
contour and Palpation in color, no evidence of – bronze in color (sallow), metabolites or urochromes
symmetry enlargement of liver or no evidence of or urea itself
spleen, flat rounded or enlargement of liver or
scaphoid spleen, has rounded
abdomen
Bladder retention Bladder not palpable Bladder is non-palpable at normal
Palpation
time of assessment
ASSESSMENT TECHNIQUE NORMAL ACTUAL SIGNIFICANCE
USED FINDINGS FINDINGS

• EXTREMITIES
Upper Inspection Equal in size, no R hand, edema Due to water retention
Palpation deformities, no noted , wheal and and increase
permeability of
tenderness, swelling punctured wound
membrane that
and edema (1+ barely results from shifting of
detectable) fluids from
L hand, with intravascular and
interstitial
arteriovenous fistula
compartments
@ wrist with
palpable strong thrill
and bruits present

Lower Inspection Equal in size, no No tenderness,

Decrease in
Palpation deformities, no swelling, edema
hydration that
tenderness, swelling formation; no
affects circulation
and edema lesions; equal in
and tissue integrity
size. Dry skin.
at the cellular level
Anatomy and Physiology
The Kidneys
Located at the right and left lumbar
area

Responsible for the regulation of

acid-base and electrolyte balance
through excretion of nitrogenous
waste.
Functions of the Urinary System

• Excretion

• Blood volume control

• Ion concentration regulation

• pH regulation

• Red blood cell concentration

• Vitamin D synthesis
Pathophysiology

LINK
 Non-modifiable Risk Factors: Modifiable Risk Factors:

Chronic Glomerulonephritis •Age • Diet

• Sedentary
•Gender Lifestyle
• Nephrotoxins
Repeated Inflammation •Heredity

Ischaemia, Nephron loss,

Stage Shrinkage of Kidney
Renal Blood
1
Flow

Renal Reserve

Damage to Nephrons

Stage 50% damage GFR 50%

2
Normal BUN, Creatinine

More than 75% damage GFR 20-50%

Stage
3
BUN, Creatinine

Renal Insufficiency

As nephrons are destroyed, the

remaining nephrons undergo
changes to compensate for those
that are lost

Remaining nephrons must filter

more solute particles from the blood
 Na & H2O Erythropoietin Phosphate
retention production retention Hypertrophy of remaining nephrons

Nephrons cannot tolerate the work

Urine 
Output Blood
volume Anemia Hyperphosphatemia Further damage of nephrons

Oliguria
80-90% damage

Fatigue
Ca+
Edema Heart  Weakness Renal Failure
absorption
Failure BP Pallor

Impaired kidney function & Uremia

Hypo-
calcemia
> 90% kidney damage
Pulmonary Edema
Stage
Peripheral Edema End Stage Renal
5
Dse. (ESRD)

GFR 10-
20%

Sharp Stage
BUN, 4
Creatinine

Retention K+ HCO3
of wastes retention productio
n in
Cells become kidney
resistant to
insulin Hyperkalemia

Glucosuria
Lungs Metabolic
Compensates Acidosis
 Dialysis
• Remove fluid and uremic waste products
• Methods of therapy
– Hemodialysis
 Dialysis by need
• Acute dialysis
– Increased serum potassium level
– Fluid overload
– Impending pulmonary edema
– Increasing acidosis
– Medications and toxins in the blood
• Chronic dialysis
– CRF (ESRD)
– Presence of uremic signs and symptoms
– Hyperkalemia
– Fluid restriction
 Hemodialysis
• A continuous renal replacement therapy
• Treatment usually occurs three times a
week for at least three to four hours
• For survival in control of uremic symptoms
 Principles of Hemodialysis
• Diffusion
• Osmosis
• ultrafiltration
 Arteriovenous Fistula
• A permanent
access by joining
an artery into a
vein, either side to
side or end to side
• Needles are
inserted into the
vessel to obtain
blood flow
adequate to pass
Dialyzer
 Complications of Hemodialysis
• GIT problems
• Major sleep problems
• Hypotension during treatment
• Muscle cramps
• Dysrhythmias
• Air embolism
• Chest pain
• Dialysis disequilibrium
Laboratory and Diagnostic
Examinations
 Chest X-Ray (Portable)
Date: 18 January 2009

Result
Findings:

Chest AP view shows congestive changes in both lungs.

Heart is magnified.

Analysis:
Congestion is due to pulmonary edema. Retention of Na and
H2O.
 Arterial Blood Gas Reports
Date: 18 January 2009 Time: 3:37 PM

FIO2: 28% (/)NasalCannula/ Oxygen Mask

Result: Normal Range Actual Value

pH 7.35-7.45 7.33
PaCO2 35-45mmHg 24mmHg
PaO2 80-100mmHg 52
HCO3 22-26mmEq/L 13
Base Excess 0+ / -2 -11
O2 97-100% 85%
Interpretation:

A. Oxygenation
Inadequate

B.Acid-BaseBalance

Partial compensation
 Complete Blood Count
Diagnostic/Laboratory Normal Values Result Analysis and Interpretation

HEMATOLOGY:

Leukocytes 5.0-10.0 / mm3 21.70 “H” Result was above normal. This
shows that there is presence of
infection.

Erythrocytes 4.2-5.4 / mm3 3.24 “L” Result was below normal. This
indicates alteration in
erythropoietin production
secondary to renal malfunction.

Hemoglobin 11.0-15.0 / mm3 9.5 “L” Result was below normal. This
shows the decrease in the oxygen
carrying capacity of the blood
secondary low hematocrit..

Hematocrit 37.0-47.0 / mm3 28 “L” Result was below normal, thus

showing anemia related to
insufficient RBC production.

Thrombocytes 150-450 / mm3 442 Normal.

Neutrophils 50-70 / mm3 89.200 “H” Result shows increased in normal

level, indicating bacterial infection.
 Diagnostic/Laboratory Normal Values Result Analysis and Interpretation

Lymphocytes 20.0-40.0 / mm3 55.00 “H” Result is above the normal

range, indicating bacterial
infection.

Monocytes 0.0-7.0 / mm3 3.800 Normal.

Eosinophils 0.00-5.00 / mm3 1.200 Normal.

Basophils 0.000-1.000 / mm3 0.300 Normal.

 Chemistry
Normal value Result Analysis
CHEMISTRY: 7-20 111 mg/dl “H” Result was above the
normal range
Urea Nitrogen indicating renal
malfunction.

0.52-1.25 16.83mg/dl “H” Result was above

Creatinine normal thus showing
inability of the kidney
to excrete
nitrogenous waste.

137-145 150 mmol/l “H” Result shows an

Sodium increased in normal
level of sodium, thus
suggesting renal
dysfunction.
 Normal value Result Analysis
3.5-5.1 6.2 mmol/l ”H” Result shows an
Potassium increased in normal
level of potassium,
thus suggesting renal
dysfunction.

2.5-4.5 12.9mg/dl ”H” Result shows an

Phosphorus increased in normal
level of phosphorus,
thus suggesting renal
dysfunction.

Calcium 1.12-1.32 1.08mmol/l ”H” Result shows an

increased in normal
level of calcium, thus
indicating renal
dysfunction.
 Urinalysis
Result Analysis
Normal
Physical Color Light Yellow

Reaction 8.5 ph Substance in the body that

contribute to the acidity level
of the blood remains, and this
inability to concentrate urine
may be a cause of renal

dysfunction.
Transparency Turbid It contains RBCs, WBCs and
pus which indicates

malfunction of the kidneys to

Specific Gravity 1.010 Normal
reabsorb and filters.
 Result Analysis
Albumin +++ Increased albumin excretion
is an indicative of increased
permeability of the filters of
kidney (glumerolus), and may
be caused by disease
(diabetes, hypertension,
lupus, infections, nephritis).
Sugar Trace High level of glucose and
other sugar in the urine can
be caused by advanced
kidney disease, impaired
tubular reabsorption.
Pus cells There is presence of bacterial
4-6/hpf infection as evidenced by
presence of bacteria, pus
cells and RBCs.

RBC 0-2/hpf

Epithelial cells Many

Bacteria Few
Medications
NAME OF DRUG INDICATION MECAHNISM OF CONTRAINDICATI Side Effects NURSING
ACTION ON RESPONSIBILITY

1.Telmisartan Hypertension Blocks Hypersensitivi diarrhea, Monitor

(Micardis) constricting ty to drug and angioedema, patient for
80 mg and its sinusitis, hypotension
OD aldosterone- components. pharyngitis, after starting
secreting
Oral backpain drug.
effects of
angiotensin II
by selectively Closely
blocking the monitor blood
binding of pressure.
angiotensin II Patients
to the undergoing
angiotensin I dialysis may
receptor in develop
many tissues, orthostatic
such as hypotension.
vascular
smooth
muscle and
the adrenal
gland.
NAME OF DRUG INDICATION MECAHNISM OF CONTRAINDICATI Side Effects NURSING
ACTION ON RESPONSIBILITY

beta adrenergic Monitor

2. Metoprolol Hypertension blocking agent hypersensitivi cns:fatigue,di
100 mg with preferential ty to drug and zziness, patient’s
OD effect on beta 1 in those with depression blood
adrenoreceptors pressure
Oral located primarily active hepatic cv:bradycardi
on cardiac disease or a,heart failure regularly.
muscles,. At active gi:nausea,dia
higher dose -After
metroprolol also cirrhosis rrhea
inhibits beta2 dialysis,
receptors located monitor
chiefly on patient for
bronchial and
vascular hypertension
musculature. Anti
hypertensive
action maybe
due to
competitive
antagonism of
catecholamines
at cardiac
adrenergic
neuron sites,
drug induce
reduction of
sympathetic
outflow to the
periphery, and to
suppression of
rennin activity.
NAME OF DRUG INDICATION MECAHNISM OF CONTRAINDICA Side Effects NURSING
ACTION TION RESPONSIBILITY

3. Levofloxacin - infection caused - a broad - contraindicated - CNS: headache, - If patient

500 mg by susceptible spectrum in patients dizziness, experiences
OD strains of fluoroquinolone hypersensitive to Insomnia symptoms of
Parenteral microorganisms antibiotics that drug, its CV: blood excessive CNS
in complicated inhibits DNA- components or dyscrasias stimulation, stop drug
and gyrase, an other Skin: rush, and notify prescriber.
uncomplicated enzyme fluoroquinolones. pruritus -Obtain specimen for
UTI and acute necessary for -Hypokalemia Special senses: culture and sensitivity
nephritis bacterial decreased vision, tests before starting
replication, ocular pain, therapy and as
transcription, photophobia needed to determine
repair, and Body as a whole: if bacterial resistance
recombination Pain in the has occurred.
injection site or -Monitor glucose
inflammation, level and renal,
chest pain or hepatic, and
back pain. hemapoietic blood
studies.
NAME OF DRUG INDICATION MECAHNISM OF CONTRAINDICA Side Effects NURSING
ACTION TION RESPONSIBILITY

4. Calcium -Acid Indigestion, - Rapid acting - Contraindicated -Constipation, -Record amount and
Carbonate calcium antacid with high in patients with flatulence, consistency of stool.
500 mg supplement neutralizing ventricular diarrhea, acid Manage constipation
TID -Helps maintain capacity and fibrillation or rebound, with laxatives or stool
Oral strong and relatively hypercalcemia. hypercalcemia softeners.
healthy bones. prolonged -Monitor calcium level,
duration of action. especially in patients
Decrease gastric with renal impairment.
acidity, thereby -Watch for evidence
inhibiting of hypercalcemia
proteolytic action (nausea, vomiting,
of pepsin on headache, confusion,
gastric mucosa. and anorexia)
Also increases
lower esophageal
sphincter tone.
NAME OF DRUG INDICATION MECAHNISM OF CONTRAINDICA Side Effects NURSING
ACTION TION RESPONSIBILITY

5. Aluminum hyperphosphatem -non systemic - contraindicated -GI: nausea - When giving

Hydroxide ia in a chronic antacid with in patients with vomiting diarrhea through NGT, make
renal failure moderate phosphate constipation sure the tube is
500 mg neutralizing depletion or Metabolic: placed correctly and
TID action. Decreases hypophosphatemi Hypophosphatemi is patent.
Oral rate of gastric a a, -Record amount and
emptying and has hypomagnesemia consistency of stools.
demulcent, -Monitor phosphate
adsorbent, and level
mild astringent -Watch for evidence
properties. of hypophosphatemia
Reduces acid (anorexia, malaise,
concentration and muscle weakness)
pepsin activity by with prolonged use.
raising ph of
gastric and intra
esophageal
secretion.
 Background
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Knowledge
Rr, O2
Subjective Erythropoietin, a Impaired gas After an 8 hour Independent To prevent fluid
Objective hormone excreted exchange related Have patient turn, build up in lungs
duty, the
rales by the nephrons, and to enhance
to altered oxygen- patients level cough and deep-
CBC results: Hgb stimulates the blood oxygen
carrying capacity of breathe every 4
of 9.5 in a normal bone marrow to level
of the blood hours
range of 11.0 – produce oxygenation To detect
erythrocytes. CBC Auscultate lungs presence of
15.0 mg/100ml will remain
results read that every 4 hours and adventitious
ABG results: within normal
PaCO2 of 24 in a there is a low report breath sounds
range of 80 – abnormalities
normal range of Hematocrit or a To increase
low count of 100 mmHg Have patient arterial oxygen
35 – 45 mmHg
PaO2 of 52 in a erythrocytes in the and hyperventilate To decrease
normal range of
blood. The respiratory Reduce activities oxygen demand
nephrons are will to level of To increase the
80 – 100 mmHg
basically tolerance amount of oxygen
destroyed Administer 2-3 carried by
RR: 33cpm
(because of L/min oxygen via available
exacerbating hemoglobin in the
nasal cannula
inflammation or blood
chronic
glomerulonephritis
). The ability of the
nephrons to
excrete
erythropoietin is
reduced to a
significant
number, thence
Hct is lowered,
thence, Hgb or
the amount of
oxygen in
erythrocytes are
decreased.
Thence, hypoxia
manifested by a
low PaO2.
 Background
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Knowledge
Plasma proteins After 4 hours of
Subjective (serum albumin) Excess fluid duty, Independent Changed Outcome parltly
Objective are large particles volume related to Patient will have Monitor blood parameters may met
Rales heard upon within the blood compromised diminished or no pressure, pulse indicate altered Patient has
auscultation that exert a force glomerular adventitious rate and breath fluid and maintained a fluid
Periorbital edema called the colloid breath sounds sounds at least electrolyte status
function as intake of less than
@ OU osmotic pressure upon auscultation every four hours Intake greater
evidenced by 1000ml, i.e., 630
Edema at right which draws fluid Patient will Monitor intake than output may
hand, grade 1+ from the ISF edema and rales maintain fluid and output at least indicate fluid ml
Intake of 630ml compartment into intake of no more every four hours retention or Patient has
and an output of the IVS than 1000 ml and Position or elevate overload complied with diet
240ml in 24 hours compartment, output of no less edematous body To promote restriction, eating
BP – 140/110 thereby than 800ml in 24 part venous return and only which was
Blood chem. counterbalancing hours Provide for diminish served her
Results: the force of Patient will restrict scheduled rest congestion to Patient’s weight
Na – 150 mEq/L hydrostatic blood diet to permitted periods improve tissue
in a normal range pressure which foods low in perfusion
of 135-145 mEq/L forces fluid out of sodium and Dependent Bed rest can
BUN of 111 the capillaries into potassium Modify diet to low- induce diuresis
mg/dL in a normal the tissues. Thus, Patient’s weight protein related to
range of 7-20 when the levels of will remain and Give IV fluids as diminished
mg/dL PP drops below not exceed 40.5 ordered. Monitor peripheral venous
+++ Albumin in normal, the COP kg IV flow rate pooling resulting
the urine is diminished and Provide a in increased IVS
Weight: 40.5 kg fluid escapes from restricted sodium volume
the IVS into the diet as ordered To decrease
ISF. Weigh patient BUN, which when
daily in high levels,
indicate renal
failure
For hydration
Restricting the Na
will favor the renal
excretion of
excess fluid
A change in
weight is a very
good indicator of
fluid volume
excess