I.

INTRODUCTION
Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the bodys internal environment. CRF can develop insidiously over
many years, or it may result from an episode of a cure renal failure from which
the client has not recovered.
Chronic renal failure affects many body systems. It can also lead to many
complications. This is the goal of health care providers, to prevent any
occurrence

of

complications.

One

of

the

complications

of

CRF

is

hyperparathyroidism; this is due to the compensatory mechanism of the

parathyroid hormone once it detects any alteration in the calcium level of the
body.
It

is

important

for

clinicians

to

recognize

the

problem

of

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

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

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

on in terms of morbidity and mortality will be achieved.
To ensure that the diagnosis of hyperparathyroidism is made early in the
course of chronic kidney disease, it is important to educate primary care
physicians, cardiologists, endocrinologists and other healthcare providers who
may see patients in the early stages of chronic kidney disease, so that they may
assess blood parathyroid hormone levels to uncover this complication and either
embark on the treatment of hyperparathyroidism or consider referral to a
nephrologist for further advice on the appropriate management strategies.
Referral to a nephrologist would appear to be preferable at the present time as
the field is advancing with new therapies being evaluated and implemented in
practice.
As nurses, we could help our patients by having a deep understanding of
the disease, that we may learn the proper interventions for the chronic kidney
disease patients. In this way, we could render quality care for them. We could as
well lead them to the proper treatment to lessen their sufferings brought by the
kidney failure, in anyhow. By having a wide understanding of the disease, we
could impart teachings on how we could prevent the occurrence of chronic
kidney disease. As nurses, it is our responsibility to render information and impart
health teachings to improve the condition of our patients to the best of our
abilities. One of the characteristics that we, nurses, should have is to be
informative and only through a keen study of disease such as this way for us to
gain all the information that we need to learn.
ANATOMY AND PHYSIOLOGY
Kidneys
The kidneys balance the urinary excretion of substances against the
accumulation within the body through ingestion or production. Consequently, they
are major controller of fluid and electrolyte homeostasis. The kidneys also have
several non-excretory metabolic and endocrine functions, including blood

pressure regulation, erythropoietin production, insulin degradation, prostaglandin

synthesis, calcium and phosphorus regulation and Vitamin D metabolism

The kidneys are located retroperitoneally, in the posterior aspect of the

abdomen. On either side of the ventral column. They lie between the 12 th thoracic
and third lumbar vertebrae. The left kidney is usually positioned slightly higher
than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5
cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved
shape, with a convex distal edge and a concave medial boundary.

The left kidney is usually positioned slightly higher than the right. Adult kidneys
are average approximately 11 cm in length, 5 to 7.5 cm in width, and 2.5 cm in
thickness. The kidney has a characteristic curved shape, with a convex distal
edge and a concave medial boundary.

Human kidneys viewed from behind with spine

removed

Structure

1. Renal pyramid 2. Interlobar artery 3. Renal artery 4. Renal vein 5. Renal

hilum 6. Renal pelvis 7. Ureter 8. Minor calyx 9. Renal capsule 10. Inferior
renal capsule 11. Superior renal capsule 12. Interlobar vein 13. Nephron
14. Minor calyx 15. Major calyx 16. Renal papilla 17. Renal column
Ureters, Urinary Bladder and Urethra
The ureters are small tubes that carry urine from the renal pelvis of the
kidney to the posterior inferior portion of the urinary bladder. The urinary bladder
is a hollow muscular container that lies in the pelvic cavity just posterior to the
pubic symphysis. It functions to store urine, and its size depends on the quantity
of urine present. The urinary bladder can hold from a few milliliters to a maximum
of about 1000 mL of urine. When the urinary bladder reaches a volume of a few
hundred mL, a reflex is activated, which causes the smooth muscle of the urinary
bladder to contract and most of the urine flows out of the urinary bladder through
urethra. The urethra is a tube that exits the urinary bladder inferiorly and
anteriorly. The triangle-shaped portion of the urinary bladder located between the
opening of the ureters and the opening of the urethra is called trigone. The
urethra carries urine from the urinary bladder to the outside of the body.

Renal Blood flow and Glomerular Filtration

The kidney receive 20% to 25% of the cardiac output under resting
conditions, averaging more than 1 L of arterial blood per minute. The renal
arteries branch from the abdominal aorta at the level of he second lumbar
vertebra, enter the kidney, and progressively branch into lobar arteries. Blood
flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the
peritubular capillaries carry a small amount of blood to the renal medulla in the
vasa recta before entering the venous drainage. The blood leaves the kidney in
venous system closely corresponding to the arterial system: interlobular veins,
arcuate veins, interlobar veins, and the renal vein. The renal circulation then
empties into the inferior vena cava.
Physiology
Characteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are
removed from the plasma and eliminated by the kidneys. It is 5% water and 5%
dissolved solids and gases. The amount of these dissolved substances is
indicated by it specific gravity. The specific gravity of pure water, used as a
standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are
diseased, they lose the ability to concentrate urine, and the specific gravity no
longer varies as it does when the kidneys function normally.

Urine formation
The chief function of the kidneys is to produce urine. Each part of the
nephrons performs a special function. There are three important processes by
which urine is formed. They are glomerular filtration, tubular reabsorption and
tubular secretion

The path of the Formation of Urine

Blood enters
the
Efferent

To the distal
convulated
tubule
To the collecting
tubule (at this about
99% of the filtrate
has been
reabsorbed)

To the urinary
meatus

Passes through
the
Glomeruli

To Bowmans
capsule

To the loop of Henle

Approximately 1 ml
of urine is formed per
minute

To the
urethra

To the
bladder

Now it becomes
filtrate (blood minus
RBCs and plasma
protein

Continues through
the proximal
convulated tubule
The 1 ml of urine
goes to the renal
pelvis

To the ureter

Electrolyte Balance
Fluid and ElectrolyteS Balance are important constituents of body fluids.
These are compounds that separate into positively and negatively charged ions
and carry an electric current in solution. The main source of electrolytes is food. A
few of the most important ions are considered here.
1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid
volume. It is the main positive in extracellular fluids. Sodium is required for
nerve impulse conduction and is important in maintaining acid-base balance.
2. Potassium- important in the transmission of nerve impulse; a major positive
ion in the intracellular fluids. It is involved in cellular enzyme activities and
helps regulate the chemical reactions by which carbohydrate is converted to
protein.
3. Calcium-required for bone formation, muscle contraction, nerve impulse
transmission, and blood clotting
7

4. Phosphate- essential in the metabolism of carbohydrates, bone formation and

acid-base balance. They are found in the cell membrane and in the nucleic
acids.
5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.
Electrolytes must be kept in the proper concentration in both intracellular and
extracellular fluids. Although some electrolytes are lost in the feces and through
the skin as sweat, the job of balancing electrolytes is left mainly to the
kidneys.There are several hormones that are involved in this process.
Aldosterone produced by the adrenal cortex promotes the reabsorption of sodium
and the elimination of potassium. Hormones from parathyroid and thyroid glands
regulate calcium and phosphate levels. Parathyroid hormones increases blood
calcium, levels by causing the bones to release calcium and by causing the
kidneys to reabsorb calcium. The thyroid hormone calcitonin lowers blood
calcium by causing calcium to be deposited in the bone .
Function of the Urinary System
The major functions of the urinary systems are performed by the kidneys and
the kidneys plays the following essentials roles in controlling the composition and
volume of body fluids:
1. Excretion. The kidneys are the major excretory organs of the body. They
remove waste products, many of which are toxic, from the blood. Most waste
products are metabolic by- products of cells and substances absorbed from
the intestine. The skin, liver, lungs, and intestines eliminate some of these
waste products, but they cannot compensate if the kidneys fail to function.
2. Blood volume control. The kidneys play an essential role in controlling blood
volume by regulating the volume of water removed from the blood to produce
urine.
3. Ion concentration regulation. The kidneys help regulate the concentration
of the major ions in the body fluids.

4. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in
the blood and the respiratory system also play important roles in the
regulation of pH
5. Red blood cell concentration. The kidneys participate in the regulation of
red blood cell production and therefore, in controlling the concentration of red
blood cells in the blood.
6. Vitamin D synthesis. The kidneys. Along with the skin and the liver,
participate in the synthesis of vitamin D.

Chronic Renal Failure

Chronic or irreversible, renal failure is a progressive reduction of
functioning renal tissue such that the remaining kidney mass can no longer
maintain the bodys internal environment. Chronic Renal failure can develop
insidiously over many years, or it may result from an episode of acute renal
failure from which the client has not recovered.
Precipitating Factors
Chronic glomerular disease such as glomerunephritis
Chronic infections such as chronic pyelonephritis or tuberculosis
Congenital anomalities such as polycystic
Vascular diseases, such as renal nephrosclerosis or hypertension
Obstructive processes such as calculi
Collagen diseases such as systemic lupus erythematosus
nephrotoxic agents such as long-term aminoglycoside
endocrine diseases such as diabetic neuropathy
Such conditions gradually destroy the nephrons and eventually cause
irreversible renal failure. Similarly, acute renal failure that fails to respond to
treatment becomes chronic renal failure.

Predisposing Factors
Sex- both sexes are affected by chronic renal failure. But in 1998, based on
United States Renal Data System, a higher total number of males with ESRD
was found
Age- CRF can be found in people of any age, from infants to the very old.
The elderly population also is the most rapidly growing ESRD population in
the United States. Note that age 30 years progressive physiological
glomerulosclerosis.

Aging

also

results

in

concomitant

progressive

physiological decrease in muscle mass such that daily urinary creatinine

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

10

proteinuria accompanying renal disease and sometimes inadequate

dietary intake of proteins cause hypoproteinuria, which lowers the
intravascular oncotic pressure. Metabolic acidosis occurs because of the
kidneys inability to excrete hydrogen ions. Decrease reabsorption of
sodium bicarbonate and decreased formation of dihydrogen phosphate
and

ammonia

contribute

to

this

problem.

Acidosis

accentuates

hyperkalemia and the reabsorption of calcium from the bones.

Hematologic changes
The primary hematologic effect of renal failure is anemia, usually
normochromic and normocytic. It occurs because the kidneys are unable to
produce erythropoietin, a hormone necessary for red blood cell production.
Frequently, the fatigue, weakness, and cold intolerance accompanying the
anemia lead to a diagnosis of renal failure.
Gastrointestinal changes
The entire gastrointestinal system is affected. Transient anorexia,
nausea, vomiting are almost universal. Clients often experience a constant
bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or
ammonia-like. Stomatitis, parotitis and gingivitis are common problems
because of poor oral hygiene and the formation of ammonia from salivary
urea. Accumulations of gastro may be a major cause of ulcer disease.
Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be
present. Serum amylase level may be increased, although they do not
necessarily indicate pancreatitis.
Immunologic changes
Impairment of the immune system makes the client more susceptible
to infection. Several factors are involved, including depression of humoral
antibody formation, suppression of delayed hypersensitivity and decreased
chemotactic function of leukocytes. Immunosuppression is an important part
of the medical management of renal diseaes such as glomerulonephritis.
Cardiovascular changes
The most common clinical manifestation is hypertension, produced
through:

11

mechanism of volume overload, stimulation of the renin-angiotensin system,

sympatheically mediated vasoconstriction, absence of prostaglandins.
Respiratory changes
Some of the respiratory effects such as pulmonary edema can be
attributed to fluid overload. Metabolic acidosis causes a compensatory
increase in respiratory rate as the lungs try to eliminate excess hydrogen
ions.
Musculoskeletal changes
The etiologic mechanism involves the kidney-bone-parathyroid and
calcium-phosphate-vitamin D connections. As the GRF decreases, the
phosphate excretion decreases and calcium elimination increases. Abnormal
levels of calcium and phosphate stimulate the release of parathyroid hormone
that mobilizes calcium from the bones and facilitates phosphate excretion.
Integumentary changes
The skin is also often very dry because of atrophy of the sweat glands.
Severe

and

intractable

pruritus

may

result

from

secondary

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

evident.

NURSING ASSESSMENT
A. Personal Data and History (Demographic Data)
Mr. Ibrahim Daud is a 61-year-old male, married living in Kampung Pokok
Sena Pokok Sena Alor Setar Kedah. He was born on 7 April 1939.He is married
for 30 years now and has 9 children. He is a smooker. And according to him,
smoking helps him to be relaxed. He consumed 8 sticks/day. He worked as a taxi
driver for more than 20 years.

12

Mr. Ibrahim was admitted in Hospital Sultanah Bahiyah Alor Setar On Mac
10 2010. He was admitted due to body weakness and severe anemia. He was
discharged on .17 Mac 2010.

General Health History

History of Past Illness

Mr.Ibrahim was known hypertension for being for 7 years. Mr. Ibrahim
consistently having his blood chemistry and creatinine check-up every month in
Klinik Kesihatan Pokok Sena.
History of Present Illness
Four days prior to admission, Mr.Ibrahim experienced easy fatigability. No
other accompanying signs and symptoms. His condition was persisted until one
day prior to admission, he already experiencing body weakness, body malaise,
pallor and fatigability . He was advised to have laboratory examination (Hgb and
Hct), which revealed anemia and he was advised to be admitted. His initial vital
signs were as follows: T-36.7, RR- 24, PR- 72, BP- 180/100.

Physical Examination
Upon Admission:10/3/2010
Vital Sign:
T

- 36.7

RR

- 24

PR

- 72

BP

- 180/100
13

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
GIT: loss of appetite
Renal and Urologic changes: fatigability, oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia
Skeletal changes: hypocalcemia and hyperphosphatemia

11/3/2010
Vital Signs:
T

- 36.8

RR

- 22

PR

- 80

BP

- 170/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor

14

B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with dry and pale lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Cardiovascular changes: hypertension
Renal and urologic changes: oliguria
Hematopoietic changes: anemia

12/3/2010
Vital Signs:
T

- 36.9

RR

- 18

PR

- 78

BP

- 170/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor

15

B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension

13/3/2010
Vital Signs:
T

- 37

RR

- 20

PR

- 74

BP

- 150/100

Integumentary
A. Skin- pallor, brown in complexion, with good skin turgor
16

B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
A. Scalp- hair evenly distributed without any presence of lice and lesions
B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
C. Ears- symmetrical with cerumen, no discharges noted
D. Nose- without flaring of nostrils, no discharges noted
E. Mouth- with (-) pallor, dry lips
F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
G. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia

14/3/2010
Vital Signs:
T

- 37

RR

- 18

PR

- 82

BP

- 170/90

Integumentary
C. Skin- pallor, brown in complexion, with good skin turgor
D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
17

Head-no mass palpated

H. Scalp- hair evenly distributed without any presence of lice and lesions
I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
J. Ears- symmetrical with cerumen, no discharges noted
K. Nose- without flaring of nostrils, no discharges noted
L. Mouth- (-) pallor
M. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
N. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia

15/3/2010
Vital Signs:
T

- 37

RR

- 18

PR

- 84

BP

- 160/90

Integumentary
E. Skin- pallor, brown in complexion, with good skin turgor

18

F. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4
seconds)
Head-no mass palpated
O. Scalp- hair evenly distributed without any presence of lice and lesions
P. Eyes- no pale palpebral conjunctiva, no discharges noted, pupils are equally
round and reactive to light and accommodation
Q. Ears- symmetrical with cerumen, no discharges noted
R. Nose- without flaring of nostrils, no discharges noted
S. Mouth- (-) pallor
T. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and
pain
U. Chest and Lungs- with bibasal rales
Abdomen- soft, flat, tender
Renal and Urologic changes: oliguria
Cardiovascular changes: hypertension
Hematopoietic changes: anemia

Diagnostic and Laboratory Procedures

Diagnostic/
Laboratory
Procedure
1.FBC
Hgb

Indication (s)
Purpose (s)
Usually done to a pt.
with renal disease to
determine if the
kidneys ability to
release
erythorpoietin factor
is already affected

Result
7.1
7.5
8.8
8.9
9.0
9.5
10.1

Normal
Values
13.017.0
gm%

Analysis and
Interpretation
Results were all below
the normal level, thus
indicating renal
malfunction and thereby
causing anemia

19

Hct

Used to measure
RBC number and
volume. It is an
integral part of the
evaluation of anemic
patients

.23
.31
.33
.36
.32
.34
.37

40-.50
%

Result were all below the

normal range thus,
showing anemia and
renal disease

WBC
Leukocytes

Determines any
inflammation and
infection

11.76
9.01
8.40
8.58
8.5
8.0
8.2

510x109/
L

Results were all above

normal level. This shows
presence of
inflammation and
infection

Neutrophils

Determines any
acute bacterial
infection

81
.75
.71
.72
.74
.72
.79

50-.70

Results were all above

normal level. This shows
presence of bacterial
infection

Lymphocytes

Determines any
chronic bacterial
infection or viral
infection

.17
.13
.20
.15
.13
.15
.14

.10-.40

Results were all within

normal level. Showing
absence of chronic
infection

Monocytes

Determines any
acute bacterial
infection

.05
.08
.04
.09
.07
.05
.08

.00-.07

Some of the results were

all above normal
Level indicating
presence of bacteria.

20

Eosinophils

To determine any
allergic reaction of
the body

.04
.04
.04
.05
.04
.06
.06

.00-.07

Results were all within

the normal level. This
shows no allergic
reactions.

Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding

Diagnostic/
Indication (s)
Laboratory
Purpose (s)
Procedure
2.Hepatiti
s Profile
This is usually
done before
proceeding in
hemodialysis.
This is to
determine if the
patient was
expose to the
virus of if there is
presence of
hepatitis virus
In the blood of the
patient.

Result
HBSAG- non-reactive
ANTI-HCV- nonreactive
ANTI-HBC- nonreactive
ANTI-HBS-reactive
HAV-IGM- non- reactive

Analysis and
Interpretation
Result revealed that
the patient has no
hepatitis virus and was
not exposed to any of
it.

Nursing Responsibilities:

21

1. Explain the procedure to the patient

2. Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Handle the specimen as if it were capable of transmitting hepatitis
5. Immediately discard the needle in the appropriate receptacle
6. Send the specimen to the laboratory promptly

Diagnostic/
Laboratory
Procedure

Indication
(s)
Purpose (s)

3.Urinalysis

To diagnose
and monitor
renal or
urinary tract
disease

Result

Color: straw, light

yellow, light yellow
Appearance:
slightly turbid
pH: 5
Specific Gravity:
1.020, 1.025,
1.020
Albumin:
3+
Sugar: negative

Normal
Values
used by
the
hospital

Analysis and
Interpretation

Laboratory results
revealed that there
is presence of
albumin in the blood;
this indicates that
the glomerular
cannot filter large
molecules such as
that of albumin. It
also revealed that
there is bacterial
infection as
evidenced by
presence of
bacteria, pus cells
and red cells in the
urine.

Pus Cells: 12/HPF, 0-2/HPF, 25 /HPF

Red cells: 13/HPF,
1-3/HPF,4-6/HPF
Epithelial Cells:
Rare
Mucus thread:
Rare, (-), (-)

22

Bacteria: (-), few,

(-)
Amorphous urates:
Moderate,
moderate, few

Nursing Responsibilities:
1. Explain the procedure to the patient
2. Tell the patient that no fasting is required
3. Instruct the patient to catch the midstream urine for better result
4. Send the specimen to the laboratory promptly

Diagnostic/
Laboratory
Procedure

Indication (s)
Purpose (s)

Result

Normal
Values
used by the
hospital

Analysis and
Interpretation

23

4. Creatinine

This test was

ordered in
order to
evaluate renal
function.

1499
1430
1649
731
730
725
500

62-106
umol/L

Results were all

above the normal
level indicating renal
malfunction. The
kidney cannot
excrete nitrogenous
waste product of
protein leading to its
accumulation in the
blood
Normal result which
means there is still
fluid and electrolyte
balance

5. Na+

6. K+

7. Calcium

8. Phosphate

To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
To evaluate
fluid and
electrolyte
imbalance and
identify renal
dysfunction
To evaluate
muscle
contraction,
nerve impulse
transmission,
and blood
clotting
To evaluate
the
metabolism of
carbohydrates
, bone
formation and
acid-base
balance.

137

4.78

135-150
mmol/L

3.5-5.5
mmol/L

6.4

8.5-10.5
mg/dl

186

30-150 u/L

Normal result which

means there is still
fluid and electrolyte
balance
Results were all
above the normal
level indicating renal
malfunction.

Results were all

above the normal
level indicating renal
malfunction.

24

Nursing Responsibilities:
1. Explain the procedure to the patient
2.Tell the patient that no fasting is required
3. Apply pressure or a pressure dressing to the venipuncture site
4. Assess the venipuncture site for bleeding

The Patient and his Care

Medical Management
Medical
Management
1. N/S

2.. Subclavian
catheterization

3.Blood
Transfusion

General
Description
A crystallized
solution that is
available in a
variety of
concentrated
water and
calories are
provided. It is
hypertonic
solution
containing equal
amounts of Na
and Cl

Indication (s)
Purpose (s)
To maintain
fluid balance
of the
patient.

Clients initial
reaction to
the treatment
Patient felt
discomfort
Patient
experienced
bleeding and
felt
discomfort on
incision site

Clients response
to the treatment
Patient fluid
status was
maintained

A catheter tube
Temporary
is inserted into
access for
vein in either
hemodialysis
your neck,
chest, leg or
near the groin. It
has two
chambers to
allow two-way
flow of blood

Patient was
slightly
nervous
about the
procuder.
.

Patient did not

show any further
bleeding

It is intravenous
replacement of

During the
blood

Patient did
manifest some

To
immediately

25

loss or
destroyed blood
compatible
citrated human
blood it is also
the introduction
of whole blood
or blood
Component

4.
Hemodialysis

restore blood
volume to
treat severe
anemia, to
be able to
maintain
oxygen
transport to
the different
parts of the
body.

transfusion,
patient was
chilling for a
short period
of time. There
was no
further
adverse
reaction
noted upon
the
transfusion

reaction such as
chilling but there
was not further
reaction after the
treatment

I
Medical
treatment used
to promote
excretion of
wastes
materials from
the blood of
patient.

t is indicated
for the
patient
because the
kidneys
cannot
function very
well to
excrete the
nitrogenous
waste
products,
thus leading
to its
accumulatio
n in the
blood.

Patient was
slightly
nervous
about the
treatment
.

There was no
adverse reaction
noted during and
after the
procedure

26

Hemodialysis

Hemodialysis schematic
Main articles: Hemodialysis and Home hemodialysis
In hemodialysis, the patient's blood is pumped through the blood compartment of
a dialyzer, exposing it to a partially permeable membrane. The dialyzer is
composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the
semipermeable membrane. Blood flows through the fibers, dialysis solution flows
around the outside the fibers, and water and wastes move between these two
solutions.

[5]

The cleansed blood is then returned via the circuit back to the body.

Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer

membrane. This usually is done by applying a negative pressure to the dialysate
compartment of the dialyzer. This pressure gradient causes water and dissolved
solutes to move from blood to dialysate, and allows the removal of several litres
of excess fluid during a typical 3 to 5 hour treatment. In the US, hemodialysis
treatments are typically given in a dialysis center three times per week (due in
the US to Medicare reimbursement rules); however, as of 2007 over 2,500
people in the US are dialyzing at home more frequently for various treatment
lengths. Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times
27

a week, for 6 to 8 hours. These frequent long treatments are often done at home,
while sleeping but home dialysis is a flexible modality and schedules can be
changed day to day, week to week. In general, studies have shown that both
increased treatment length and frequency are clinically beneficial.

Hemodialysis

Hemodialysis in progress

Hemodialysis machine

In medicine, hemodialysis is a method for removing waste products such

as creatinine and urea, as well as free water from the blood when the
kidneys are in renal failure. Hemodialysis is one of three renal
replacement therapies (the other two being renal transplant; peritoneal
dialysis).

Hemodialysis can be an outpatient or inpatient therapy. Routine

hemodialysis is conducted in a dialysis outpatient facility, either a purpose
built room in a hospital or a dedicated, stand alone clinic. Less frequently
hemodialysis is done at home. Dialysis treatments in a clinic are initiated

28

and managed by specialized staff made up of nurses and technicians;

dialysis treatments at home can be self initiated and managed or done
jointly with the assistance of a trained helper who is usually a family
member
Principle

Semipermeable membrane
The principle of hemodialysis is the same as other methods of dialysis; it involves
diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes
counter current flow, where the dialysate is flowing in the opposite direction to
blood flow in the extracorporeal circuit. Counter-current flow maintains the
concentration gradient across the membrane at a maximum and increases the
efficiency of the dialysis.
Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of
the dialysate compartment, causing free water and some dissolved solutes to
move across the membrane along a created pressure gradient.
The dialysis solution that is used is a sterilized solution of mineral ions. Urea and
other waste products, potassium, and phosphate diffuse into the dialysis solution.
However, concentrations of sodium and chloride are similar to those of normal
plasma to prevent loss. Sodium bicarbonate is added in a higher concentration
than plasma to correct blood acidity. A small amount of glucose is also commonly
used.

29

Prescription
A prescription for dialysis by a nephrologist (a medical kidney specialist) will
specify various parameters for a dialysis treatment. These include frequency
(how many treatments per week), length of each treatment, and the blood and
dialysis solution flow rates, as well as the size of the dialyzer. The composition of
the dialysis solution is also sometimes adjusted in terms of its sodium and
potassium and bicarbonate levels. In general, the larger the body size of an
individual, the more dialysis he/she will need. In the North America and UK, 3-4
hour treatments (sometimes up to 5 hours for larger patients) given 3 times a
week are typical. Twice-a-week sessions are limited to patients who have a
substantial residual kidney function. Four sessions per week are often prescribed
for larger patients, as well as patients who have trouble with fluid overload.
Finally, there is growing interest in short daily home hemodialysis, which is 1.5 - 4
hr sessions given 5-7 times per week, usually at home. There also is interest in
nocturnal dialysis, which involves dialyzing a patient, usually at home, for 810
hours per night, 3-6 nights per week. Nocturnal in-center dialysis, 3-4 times per
week is also offered at a handful of dialysis units in the United States.
Side effects and complications
Hemodialysis often involves fluid removal (through ultrafiltration), because most
patients with renal failure pass little or no urine. Side effects caused by removing
too much fluid and/or removing fluid too rapidly include low blood pressure,
fatigue, chest pains, leg-cramps, nausea and headaches. These symptoms can
occur during the treatment and can persist post treatment; they are sometimes
collectively referred to as the dialysis hangover or dialysis washout. The severity
of these symptoms is usually proportionate to the amount and speed of fluid
removal. However, the impact of a given amount or rate of fluid removal can vary
greatly from person to person and day to day. These side effects can be avoided
and/or their severity lessened by limiting fluid intake between treatments or
increasing the dose of dialysis e.g. dialyzing more often or longer per treatment
than the standard three times a week, 34 hours per treatment schedule.

30

Since hemodialysis requires access to the circulatory system, patients

undergoing hemodialysis may expose their circulatory system to microbes, which
can lead to sepsis, an infection affecting the heart valves (endocarditis) or an
infection affecting the bones (osteomyelitis). The risk of infection varies
depending on the type of access used (see below). Bleeding may also occur,
again the risk varies depending on the type of access used. Infections can be
minimized by strictly adhering to infection control best practices.
Heparin is the most commonly used anticoagulant in hemodialysis, as it is
generally well tolerated and can be quickly reversed with protamine sulfate.
Heparin allergy can infrequently be a problem and can cause a low platelet
count. In such patients, alternative anticoagulants can be used. In patients at
high risk of bleeding, dialysis can be done without anticoagulation.
First Use Syndrome is a rare but severe anaphylactic reaction to the artificial
kidney. Its symptoms include sneezing, wheezing, shortness of breath, back
pain, chest pain, or sudden death. It can be caused by residual sterilant in the
artificial kidney or the material of the membrane itself. In recent years, the
incidence of First Use Syndrome has decreased, due to an increased use of
gamma irradiation, steam sterilization, or electron-beam radiation instead of
chemical sterilants, and the development of new semipermeable membranes of
higher biocompatibility. New methods of processing previously acceptable
components of dialysis must always been considered. For example, in 2008, a
series of first-use type or reactions, including deaths occurred due to heparin
contaminated during the manufacturing process with oversulfated chondroitin
sulfate.
Longterm complications of hemodialysis include amyloidosis, neuropathy and
various forms of heart disease. Increasing the frequency and length of treatments
have been shown to improve fluid overload and enlargement of the heart that is
commonly seen in such patients.
Listed below are specific complications associated with different types of
hemodialysis access.
31

Access
In hemodialysis, three primary methods are used to gain access to the blood: an
intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft. The type
of access is influenced by factors such as the expected time course of a patient's
renal failure and the condition of his or her vasculature. Patients may have
multiple accesses, usually because an AV fistula or graft is maturing and a
catheter is still being used.
Catheter
Catheter access, sometimes called a CVC (Central Venous Catheter), consists of
a plastic catheter with two lumens (or occasionally two separate catheters) which
is inserted into a large vein (usually the vena cava, via the internal jugular vein or
the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to
enter the dialysis circuit, and to be returned via the other lumen. However, blood
flow is almost always less than that of a well functioning fistula or graft.
Catheters are usually found in two general varieties, tunnelled and non-tunnelled.
Non-tunnelled catheter access is for short-term access (up to about 10 days,
but often for one dialysis session only), and the catheter emerges from the skin
at the site of entry into the vein.
Tunnelled catheter access involves a longer catheter, which is tunnelled under
the skin from the point of insertion in the vein to an exit site some distance away.
It is usually placed in the internal jugular vein in the neck and the exit site is
usually on the chest wall. The tunnel acts as a barrier to invading microbes, and
as such, tunnelled catheters are designed for short- to medium-term access
(weeks to months only), because infection is still a frequent problem.
Aside from infection, venous stenosis is another serious problem with catheter
access. The catheter is a foreign body in the vein and often provokes an
inflammatory reaction in the vein wall. This results in scarring and narrowing of

32

the vein, often to the point of occlusion. This can cause problems with severe
venous congestion in the area drained by the vein and may also render the vein,
and the veins drained by it, useless for creating a fistula or graft at a later date.
Patients on long-term hemodialysis can literally 'run out' of access, so this can be
a fatal problem.
Catheter access is usually used for rapid access for immediate dialysis, for
tunnelled access in patients who are deemed likely to recover from acute renal
failure, and for patients with end-stage renal failure who are either waiting for
alternative access to mature or who are unable to have alternative access.
Catheter access is often popular with patients, because attachment to the
dialysis machine doesn't require needles. However, the serious risks of catheter
access noted above mean that such access should be contemplated only as a
long-term solution in the most desperate access situation.Hemodialysis
Nursing Responsibilities:
Before
a. Explain the purpose of the transfusion
b. Have client void
c. Chart clients weight
d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension
(unless ordered otherwise)
During
a. Obtain and record vital signs before and every 30 mins. during the
procedure
b. Ensure bedrest with frequent position changes for comfort
c. Proper heparinization must be done to prevent coagulation during the
therapy
d. Inform client that headache and nausea may occur
e. Monitor closely for bleeding since blood has been heparinized for
procedure

33

After
a. Weight the patient after the therapy and record
b. Monitor vital signs especially hypotension.

Name of
Drug

Amlodipine
besylate

norvasc

Route of
admin.
Dosage and
freq. Of
admin.

General
action

PO 5 mg OD Calcium
antagonist,
antihyperten
sive

Beta
blockers,
antihyperten
sive drug

Metoprolol
tartate

PO 50 mg

Iberet- folic
acid

PO 1 cap

Iron

BID

deficiency

furosemide

PO 40 mg

Diuretic

OD

lasix

calcium
carbonate

OD

PO 1 tab.
OD

Calcium
supplement

Indication (s)
Purpose(s)

To decrease
increase blood
pressure

To decrease
increase blood
pressure

For patient
having anemia

For oliguric
patient

To treat
hypocalcemia

Clients response to
medication

Patient did not

show any side
effects

Patient did not

show any side
effects

Patients stool was

dark green in color

Patient did not

show any side
effects

Patient did not

show any side
effects

34

Nursing Responsibilities
Prior:
1. Check and determine the prescribed the drug.
2. Inform the patient about the prescribed the drug.
3. Explain the procedure, purpose, indication and side effects of the drug.
During:
1. Check vital signs to obtain baseline data.
2. Monitor BP
3. Prepare the drug and the materials
4. Observe for initial assessment.
5. Observe for any initial response to the treatment.

After:
1. Observe for any intolerance and side effects on the prescribed drug.

Type of diet
Low salt, low
protein

General
description

Indication (s)
Purpose (s)

Foods that has

low salt and
protein value

To decrease
further production
of purine which
can contribute in
increasing level
of creatinine in
the blood

Clients response to the

diet
Patient strictly complied
with the prescribed diet

Nursing Responsibilities
Prior:
1. Check and determine the prescribed diet
2. Inform the food unit about the prescribed diet
3. Explain the procedure and purpose of the prescribed diet

35

4. Cite foods that are restricted.

During:
1. Check vital signs to obtain baseline data
2. Observe for initial response.
After:
1. Informfood unit if it would be changed
2. Observe and monitor for changes

Type of activity
Bed rest

General
description
An activity
wherein the
patient is not
allowed to do
any activity.
Patient stays at
bed.

Indication (s)
Purpose (s)
To decrease
consumption of
oxygen and to be
able to conserve
energy

Clients response to the

activity
Patient strictly complied with
the prescribed activity

Nursing Responsibilities
1. Explain the procedure to patient.
2. Explain importance of activity.
3. Assist patient in doing the activity.

36

Surgical Management
Arteriovenous Fistula
AV fistula

A radiocephalic fistula.
AV (arteriovenous) fistulas are recognized as the preferred access method. To
create a fistula, a vascular surgeon joins an artery and a vein together through
anastomosis. Since this bypasses the capillaries, blood flows rapidly through the
fistula. One can feel this by placing one's finger over a mature fistula. This is
called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula.
One can also listen through a stethoscope for the sound of the blood
"whooshing" through the fistula, a sound called bruit.
Fistulas are usually created in the nondominant arm and may be situated on the
hand (the 'snuffbox' fistula'), the forearm (usually a radiocephalic fistula, or socalled Brescia-Cimino fistula, in which the radial artery is anastomosed to the

37

cephalic vein), or the elbow (usually a brachiocephalic fistula, where the brachial
artery is anastomosed to the cephalic vein). A fistula will take a number of weeks
to mature, on average perhaps 46 weeks. During treatment, two needles are
inserted into the fistula, one to draw blood and one to return it.The advantages of
the AV fistula use are lower infection rates, because no foreign material is
involved in their formation, higher blood flow rates (which translates to more
effective dialysis), and a lower incidence of thrombosis. The complications are
few, but if a fistula has a very high blood flow and the vasculature that supplies
the rest of the limb is poor, a steal syndrome can occur, where blood entering the
limb is drawn into the fistula and returned to the general circulation without
entering the limb's capillaries. This results in cold extremities of that limb,
cramping pains, and, if severe, tissue damage. One long-term complication of an
AV fistula can be the development of an aneurysm, a bulging in the wall of the
vein where it is weakened by the repeated insertion of needles over time. To a
large extent the risk of developing an aneurysm can be reduced by careful
needling technique. Aneurysms may necessitate corrective surgery and may
shorten the useful life of a fistula. To prevent damage to the fistula and aneurysm
or pseudoaneurysm formation, it is recommended that the needle be inserted at
different points in a rotating fashion. Another approach is to cannulate the fistula
with a blunted needle, in exactly the same place. This is called a 'buttonhole'
approach. Often two or three buttonhole places are available on a given fistula.
This also can prolong fistula life and help prevent damage to the fistula.
AV graft

38

An arteriovenous graft.
AV (arteriovenous) grafts are much like fistulas in most respects, except that an
artificial vessel is used to join the artery and vein. The graft usually is made of a
synthetic material, often, but sometimes chemically treated, sterilized veins from
animals are used. Grafts are inserted when the patient's native vasculature does
not permit a fistula. They mature faster than fistulas, and may be ready for use
several weeks after formation (some newer grafts may be used even sooner).
However, AV grafts are at high risk to develop narrowing, especially in the vein
just downstream from where the graft has been sewn to the vein. Narrowing
often leads to clotting or thrombosis. As foreign material, they are at greater risk
for becoming infected. More options for sites to place a graft are available,
because the graft can be made quite long. Thus a graft can be placed in the thigh
or even the neck (the 'necklace graft').
Fistula First project
AV fistulas have a much better access patency and survival than do venous
catheters or grafts. They also produce better patient survival and have far fewer
complications compared to grafts or venous catheters. For this reason, the
Centers for Medicare & Medicaid (CMS) has set up a Fistula First Initiative ],
whose goal is to increase the use of AV fistulas in dialysis patients.
An AV fistula requires advance planning because a fistula takes a while
after surgery to develop (in rare cases, as long as 24 months). But a properly
formed fistula is less likely than other kinds of vascular accesses to form clots or
become infected. Also, fistulas tend to last many years, longer than any other
kind of vascular access.
A surgeon creates an AV fistula by connecting an artery directly to a vein,
usually in the forearm. Connecting the artery to the vein causes more blood flow
into the vein. As a result, the vein grows larger and stronger, making repeated
39

insertions for hemodialysis treatment easier. For the surgery, you will be given a
local anesthetic. In most cases, the procedure can be performed on an outpatient
basis.
These fistulas require up to 6 weeks to mature before they can be used,
which makes this approach inappropriate for immediate hemodialysis. Peritoneal
dialysis or large venous access catheters may be used while the fistula is
maturing. External arteriovenous shunts are rarely used.
Nursing management
NURSING PROCESS

Nursing
Diagnosis
Fluid volume

Objectives
Patient will not

Nursing
Interventions
1.Assist in dialysis

Evaluation
Patient not show

axcess related to

show signs and

and monitar

signs and

failure or

symptoms of

patient progress.

symptoms of

comprised renal

excess fluid.

excess fluid.

regulatory

2.Administer

mechanism.

intravenous or oral

No edema.

fluids as
prescribed.
3.Monitor intake
and output chart.

40

Nursing
Diagnosis
Potential for injury

Objectives
Patient exhibits no

Nursing
Intervations
1.Assist in

Patient exhibits no

related to

evidence of waste

dialysis.

evidence of waste

accumulated

accumulation.

electrolytes and
waste products

Evaluation

accumulation.
2.Assist in

Patients BP will

collecting

Patients BP is

remain within

laboratory

acceptable limits

acceptable limits

specimens.

140/90 mmhg.

3.Serve low
protein,low
sodium and low
potassium as
prescribed.
4.Provide rest for
patient.
5.Monitor vital
signs.

41

Nursing
Diagnosis
Potential for

Objectives
Patient will not

Nursing
Intervations
1.Avoid patient in

infections related

contact any

contact with

to lowered body

infections.

infected patients.

Evaluation
Patient having no
fever.Tempreture
is normal 36.8.

defense
2.Practise medical
asepsis.
3.Monitor medical
signs.
4.Teach parents
regarding
preventive
measures

Nursing
Diagnosis
Potential impaired

Objectives
Patient will have

Nursing
Interventions
1.Provide good

Skin brown in

skin integrity

no skin

skin care.

complexion, with

related to oedema

breakdown or
sores.

Evaluation

good skin turgor.

2.Clean and
supply powder to
skin surfaces.
3.Change position
frequently and
maintain good
body alignment.

42

Nursing
Diagnosis
Anxiety related to

Objectives
Parents fear and

Nursing
Intervations
1.Give clear

the disease.

anxiety towards

explanation to

the disease will

parents.

Evaluation
Patient looked
Calm.

be reduced to the
minimum.

2.Encourage
patient to ask
question.

Nursing
Diagnosis
Knowledge deficit

Objectives
Patient and family

Nursing
Intervations
1.Explain to

related to

members will

patient and family

ignorance

acquire adequate

members the

personal hygiene

knowledge on

importance of

personal hygiene.

personal hygiene.

Evaluation
Patient and family
understood and
follow what have
been teach to him.

2.Provide Health
Educations:
2.1. Wash hands
before eating and
after going to
toilet.
2.2. Wash hands
before handling
the food.
2.3. Cover the
food.

43

2.4. Use clean

food containers for
storing food.
2.5. Boil water
before drinking
and eat cooked
food.
2.6. Proper
disposal of refuse
and sewage.

Discharge Planning
Mr. Scrooge was discharge on Mac 17 2010, Upon discharged, Mr.
Ibrahims physical appearance was improved. There was absence of paleness in
the conjunctiva and lips, fatigability is decrease, and with decrease creatinine
level as compared when he was admitted in the hospital. His vital signs were as
follows: T- 36.8, PR- 80, RR-18, BP- 140/90 mmhg.
Instructed to complied strictly with the following home medications
Augmentin 375 mg 1 tab TID
Nifedipine lozenges QID
For twice a week hemodialysis
Bed rest
proper wound care (subclavian (IJC) and fistula)
strict compliance to the medications and in hemodialysis
O>follow-up check up on Mac 30 2010.
D>avoid foods rich in salt and protein
>Limit fluid intake

44

Conclusion and Recommendations

Chronic renal failure is an irreversible and progressive disease. It is cause
by many factors. Knowing the precipitating factors leading to the development of
this health problem, people should have an extra care when it comes to health.
Giving care to a patient whether pediatric, geriatric, a medical case or
surgical case makes no difference. Rendering care to everyone who needs it is a
real sense of responsibility. In making this case study, I was able to work well
because I know for myself that I did my best for my patient.
We can say that nursing is significant therapeutic and dynamic process. It
is therefore significant for the nurse caring for the patient to wholeheartedly
understand what she is doing like in carrying out some basic skills in relation to
identified goals, comfort and care, interventions and prevention of illness.

VIII. Bibliography
Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company
Philadelphia
Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation
Springhouse, Pennsylvania
Pagana (2002). Mosbys Manual of Diagnostic and Laboratory Tests.
MIMS. (2003)
www.yahoo.com
www.google.com

45