ESRD-3rd Yr-1st Sem

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
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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 PKD throughout the nursing
Process.
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2. To be able to establish rapport with the patient and folks.
3. To be able to develop respect and trust.
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
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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.
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.
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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
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of Henle, and the collecting tubulle. The renal medulla is hypertonic to the filtrate in the
nephron and aids in the reabsorption of water.
 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.
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 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 synthesis
 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:

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 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
C. Signs/Symptoms
CLINICAL MANIFESTATION
Manifested
DISTINCTIVE From the textbook by the Rationale
GROUPING patient
Hyperkalemia
Hyponatremia  The salt – wasting properties of some
failing kidneys, in addition to vomiting
and diarrhea.
Hypocalcemia
Electrolyte Hyper-
Imbalances phosphatemia
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Hypercalcemia
Mildly elevated
serum Mg
↑ 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
Metabolic Carbohydrate
changes 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
Anemia  It occurs because the kidneys are unable
Hematologic to produce erythropoietin, a hormone
changes necessary for RBC production.
Iron or folate
depletion
Hemolysis &
platelet
abnormalities
Transient anorexia,  A possible cause of nausea and vomiting
nausea & vomiting is a decomposition of the urea by the
intestinal flora resulting in a high
concentration of ammonia.
Constant bitter
taste
Fetid, fishy or
Gastro-
ammonia-like
intestinal
breath smells
changes Metallic or salty
taste
Stomatitis
Hiccups  Due to the accumulation of toxic
substances that stimulates phrenic
nerves.
Ulcer disease
↑ serum amylase
Constipation
Depression of
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hormonal antibody
formation
Suppression of
delayed
Immunologic
hypersensitivity
changes
Decreased
chemotactic
function of the
leukocytes
Changes in Medication toxicity
medication
metabolism
HPN  Due to water retention.
Arterial
Cardio- calcifications
L ventricular
vascular
hypertrophy & HF
changes Chest pain  Due to the accumulation of toxins in the
body because the kidney is failing in
filtering it.
Dysrhythmias
Atherosclerosis
Anasarca  Due to water retention as a result of ↑
hydrostatic pressure or for activation of
renin – angiotensin aldosterone system
Respiratory Pulmonary edema
Pleuritis
changes
Osteomalacia
Osteitis fibrosa
Osteoporosis
Musculo- Osteosclerosis
skeletal Muscle cramps  These may result from osmolar changes
changes in the body fluids or sometimes from

hypokalemia.
Intractable pruritus
Brittle hair
Pallor  Due to anemia wherein the presence of
hemoglobin in the blood is decreased,
Integumentary
resulting to a decrease oxygen
changes
distribution throughout the body.
Nails are thin
Forgetfulness
Confusion  It occurs due to hypokalemia, as the
transmission of nerve impulses
decreases.
Peripheral
neuropathy
Inability to
Neurologic concentrate
Twitching
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changes Dysarthria
Uremic amaurosis
Reproductive Testicular atrophy
Oliguspermia
changes
Reduced sperm
motility
Endocrine ↑ growth hormone
changes & prolactin
Psychosocial Powerlessness
Changes in body  Due to edema
changes
image
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.
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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.
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
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- aids in diagnosis (specific gravity fixed at 1.010, proteinuria. glycosuria, RBCs,
leukocytes, casts or crystals, depending on the cause).
 Blood testing levels
- reveals elevated BUN, creatinine, low sodium level & potassium levels, increased
aldosterone secretion, low hemoglobin level & hematocrit, decreased RBC survival time,
mild thrombocytopenia, platelet defects & hyperglycemia.
 Renal ultrasound
- It determines the kidney size and presence of masses, cysts, obstruction in

upper urinary tract.
 Computed tomographic/ Magnetic resonance imaging
- It demonstrates the vessel disorders and kidney mass.
 Abdominal (KUB)radiograph
- It demonstrates the size of kidneys/ureters/bladder and presence of obstruction

(stones).
 Aortorenal angiography
- It assesses renal circulation and identifies extravascularities, masses.
 Retrogade pyelogram
- It outlines abnormalities of renal pelvis & ureters.
 Renal arteriogram
- Assess renal circulation and identifies extravascularities, masses.
 Voiding cystourethrogram
- It shows bladder size, reflux into ureters, retention.
 Renal biopsy
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- This can be done endoscopically to examine tissue cells for histologic
diagnosis.
 Renal endoscopy, nephroscopy
- It is done to examine renal pelvis, flush out calculi, hematuria & remove
selected tumors.
 ECG
- May be abnormal, reflecting electrolyte and acid-base imbalances.
 EEG
- May be performed to identify metabolic encephalopathy.
 X-ray of feet, skull, spinal column & hands
- May reveal demineralization/ calcifications resulting from electrolyte shifts

associated with CRF.
G. Nursing considerations
 Bathe the patient daily using superfatted soaps & skin lotion without alcohol to ease
pruritus
 Provide good perineal care using mild soap & water.
 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 daily
weight & document peripheral edema.
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 Monitor for bone or joint complications.
 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 hemoglobin level & hematocrit & check stool,
urine & vomitus for blood.
 Report signs of pericarditis such as pericardial friction rub and chest pain.
VITAL INFORMATION
Name Mr. N.D.
Sex Male
Age 26 years old
Address Bito – on Ilaya, Cuartero Capiz
Civil Status Married
Religion Roman Catholic
Occupation Dicer in Black & White
Educational Attainment High Graduate
Date & Time Admitted September 15, 2010; 9:30 pm
Ward Blessed Rosalie Rendu Ward
Room – 108
Chief complaint Vomiting
Admitting Diagnosis Acute gastritis t/c CKD 2° to Nephrolithiasis
Final Diagnosis ESRD
Diet NPO x 4°, soft diet if without urinalysis
Attending Physicians Dr. H., Dr. B.
CLINICAL ASSESSMENT
A. Nursing History
1 week prior to admission, Mr. N.D. had a very low appetite wherein he only eats bread
and milk in the morning and drinks about 5-7 bottle of soft drinks a day, and experienced an
episode of nausea.
And four days prior to admission, Mr. N.D. had several episodes of vomiting associated
with epigastric discomfort. Vomiting still persisted until on the day of admission, thus brought to ER
of St. Anthony college Hospital of Roxas City and was admitted.
B. Past Health Problem

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Mr. N.D is a known prohibited drugs user. He was admitted in Dao Provincial Hospital last
November 2009 due to Urinary Tract Infection but has been treated for just about a week or more.
Mr. N.D has also experienced a burning sensation in the chest and a pain in the epigastric
area thus; he thought to have an ulcer because of that manifestation. Other health problems than
what have been mentioned were just fever and common colds.
C. Family Genogram
STROKE
HYPERT
ENSION
LEGEND:
POOR
HEARING
ACUITY
ESRD
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PATTERNS OF FUNCTIONING
Nutritional History
a. Drinking Patterns
Mr. N.D is not fond of drinking water. And before he experienced those manifestations
before his admission, Mr. N.D is fond of drinking carbonated beverages like soft drinks for at least
5 – 7 bottles a day. He is also a known alcoholic drinker wherein he drinks together with his peer
every afternoon.
b. Eating Patterns
Mr. N.D told that when or after taken prohibited drugs before, his appetite also decreases.
At that time, he does not eat for almost 2 days and only drinks a lot of soft drinks to relieve his
thirst. But then, when his appetite came back, he eats every food that is being served in the table
very well.
Breathing Patterns
HOME HOSPITAL
 RR = 21 bpm
Mr. N.D does not experience any problem in Mr. N.D had an episode of SOB during the few
respiration before. days of his admission in this institution but was
relieved when in semi – or in high – fowler’s
position.
Circulation
Temperature 36°C
Pulse rate 75 bpm
Respiration rate 21 bpm
Blood pressure 120/70 mmHg
Apical rate 82 bpm
IVF
Left carpal vein # 2 PNSS 1L + 20 mEqs NaCl x 60 cc/°
Side Drip #2 D5W 500 cc + 100 mEqs NaHCO3 x 24°x 2
cycles
Right carpal vein #1 PNSS 500 cc x KVO
Daily Activity Patterns:

a. Rest and Sleeping Patterns
Home Hospital
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Mr. N.D usually sleeps at night after drinking Mr. N.D is weak and tends to sleep during day
alcoholic beverages with his peer and the time time if not feeling well or if he wants to. He
of sleeping is depending upon to his usually sleeps at 9 in the evening and rises at
companion and if when are they going to finish 5 – 5:30 in the morning.
drinking. Thus, he sleeps at continuously
without any difficulty or deprivation in sleeping.
His usual waking up time is 6 in the morning
because he has work at 9 am.
b. Personal Hygiene
Home Hospital
Mr. N.D takes a bath once a day before going Mr. N.D can perform personal hygiene by
to work. He is also conscious about his himself like brushing his teeth at least once
personal hygiene. every other day.
c. Elimination Patterns
 Bowel Movement
FREQUENCY PROBLEMS / DIFFICULTIES
Home Hospital Home Hospital
Once or twice a day Once every 2 or 3 He experienced None

every morning or days and there is a sometimes having
after lunch time the he defecates constipation.
twice a day.
 Urination
FREQUENCY PROBLEMS / DIFFICULTIES
Home Hospital Home Hospital
Urinates whenever Urinates whenever None Has difficulty in

feels to urge. feels to urge with a urination thus foley
urine output of 200 cc. catheter was inserted
and drained 80 cc of
urine after insertion.
A. Educational Background
-High school graduate. He also started a course of Criminology at Filamer Christian

University, but is not able to finish it.
B. Occupational Background
-He is a dicer in Black & White.

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C. Religious practices
-He does not attend to mass every Sunday and even praying the rosary every afternoon.
D. Economic status
-They belong in the middle class of economic level in this society.
SOCIO-CULTURAL HEALTH
A. Cultural Health
He does not believe to any superstitious beliefs. Rather, he believes on what he wanted to
do and that’s the reason why there is a conflict between his parents.
B. Recreational Pattern
Mr. N.D’s usual recreation is just watching television and talking with their borders
because he has only a little time for recreation due to his work. But if he had time for that,
then he is having fun with his friends; wherein they drink together every evening.
C. Environmental Pattern
He lives in a complicated situation of life due to his vices. He is living near at the roadside
together with his wife, which is seven months pregnant, at his Auntie’s custody. He is prone
also to accident because of the influence of his friends.
D. Interaction Pattern
According to him, he is not closed to her parents. Instead, he wants to be with his friends
and enjoys a lot if they are hanging out. He is not sweet to his wife and seems he is ‘siga” the
way he talks.
E. Coping Pattern
Before, he was neglected by his family when they knew that he is a drug user. But then,
they gave him another chance if he will stop taking prohibited drugs.
On the first few days after his admission, he was not visited by his parents & relatives.
Only his wife is the one taking care of him throughout his admission.
A week after, his Aunt visited him and gave an assurance that she will help him related to
his financial problems.
Now, his parents are also helping in taking care of him.
CLINICAL INSPECTION
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A. Vital Signs
 Upon Admission
Temperature Respiratory rate Apical pulse Radial pulse Blood pressure
37.5°C 20 bpm 92 bpm 79 bpm 110/80 mmHg
 During our Care

September 16, 2010
Time Temperature Respiratory Apical pulse Radial pulse Blood pressure
(°C) rate (bpm) (bpm) (mmHg)
(bpm)
8:00 36 20 82 75 140/100
12:00 36.1 20 84 78 130/90
September 17, 2010

(bpm)
8:00 37.5 20 92 72 140/100
12:00 37.1 20 88 80 150/100
During Blood Transfusion
1:25 36.6 21 96 90 140/90
1:45 21 94 88 140/90
September 23, 2010

(bpm)
8:00 36 18 82 80 130/90
12:00 36.4 19 88 84 140/90
B. Physical Assessment
General Appearance:
Mr. N.D is consciously lying on bed which appears weak, fatigue, with complaints
of pain in the anterior chest and with an ongoing IVF of #2 PNSS 1L + 20 mEqs NaCl x
60 cc/̊ at 500 cc level and a secured side drip of #2 D5W 500 c + 100 mEqa NaHCO3 x
24̊ x 2 cycles infusing well on the left carpal vein, #1 PNSS 500 cc x KVO at the right
carpal vein which is used for Blood Transfusion & O2 @ 2 Lpm via nasal cannula.
He is coherent and physically and mentally conscious wherein responsiveness to
any stimulus is observed, with non – edematous lower & upper extremeties noted but the
face is edematous during our 1st week of duty. Yet, anasarca was developed during our
second duty in the ward.
Cephalocaudal
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Body Parts Method of Findings Interpretation
Assessment
Skin Inspection  Skin is cold and dry, (+) Due to ↑ hydrostatic
pallor, anasarca. pressure; ESRD.
Normal
 Fair complexion.
 Skin is soft and no scar,
bruise or petechiae noted.
Head Inspection  Edematous face Due to ↑ hydrostatic

pressure; ESRD.
Normal
 Normocephalic, absence
of nodules, hair is evenly
distributed, black in color,
straight and smooth.
 Symmetrical feature of
the face.
(+) chest pain;
ESRD
 Facial grimace
Nails Inspection  Absence of thin nails Normal
 (-) of clubbing with an

angle of about 160.̊
Eyes Inspection  Eyebrows curled slightly
outward and evenly
distributed Normal
 Both pupils are equal in

size. Size= 2
 Moderately reactive to ESRD
light and accommodation.

↑ hydrostatic
 Edema over lacrimal
pressure; ESRD
gland
Palpation Normal
 (-) Tenderness
Ears Inspection  Color same as facial skin
 Auricle aligned with outer
canthus of the eye Normal
 Responsive to moderate
21
voices.
Nose Inspection  Symmetric with the nasal Normal
septum at the center
Mouth Inspection  With plaques Poor oral hygiene
 (+) dry lips ESRD

Neck Inspection  Coordinated, smooth Normal
movements with no
discomfort
 No lumps or swollen
glands ↑ hydrostatic
 (+) edema pressure; ESRD

Chest and Thorax Inspection  RR= 21 bpm ESRD
 (+) DOB
Normal
 Chest movement is
symmetrical upon
respiration.
Auscultation
 (-) tenderness, (-)
masses.
Abdomen Inspection  Uniform in color Normal
 Abdominal girt = 94 cm Due to fluid

accumulation.
Full bladder.
 (+) pain at hypogastric
area
Auscultation Due to fluid

 (+) bruits at the four
accumulation;
abdominal quadrants.
ESRD.
Palpation Full bladder.
 (+) tenderness, distended
urinary bladder
Normal
 Liver is not palpable
Extremities  Right arm muscle cramps ESRD; due to
hypokalemia
Cardiovascular Inspection  Chest pain ESRD
Auscultation  Hypertensive. Bp =
140/100 mmHg
Gastrointestinal Inspection  Anorexia, nausea & Due to the
vomiting. decomposition of
the urea by the
22
intestinal flora
resulting in a high
concentration of
ammonia.
Due to the
accumulation of
 Hiccups. toxic substances
that stimulates
phrenic nerves.
Genitourinary  Difficulty in urinating ESRD
 (+) oliguria
 (+) foley catheter
 UO = 50 cc,
Normal
 Urine is clear in color and
is aromatic
C. General Appraisal
i. Speech
-He is oriented and converses appropriately without any problem in his speech.
ii. Language
-He knows Ilonggo, Tagalong and a little in English.
iii. Hearing
-He is able to hear moderate sounds and interpret auditory stimuli appropriately.
iv. Emotional status
-He is worried about his condition and he really wanted that his disease will be treated. He
has a low self – esteem and is no t confident with his body structures; is cooperative
and can interact to people around him.
v. Mental status
-He is conscious, alert, coherent and oriented to person, time, place and events occurring
in the environment. He is fond of asking questions about something most especially
about his condition and able to comprehend instructions and commands.
23
LABORATORY AND DIAGNOSTIC DATA
Date: September 15, 20103

Fluid: Serum
Test Result Normal Significance
Values
Potassium ↓ 3.27 mmol/L 3.5-5.1 Due to prolonged vomiting.
Sodium ↓ 129.5 mmol/L 136-145 Due to the salt – wasting properties of
failing kidneys; vomiting.
Creatinine ↑ 1679.6 umol/L 77-133 Due to decrease glomerular filtration of the
kidneys.
Urinalysis
Values
Macroscopic
Protein 3+ 0 Due to increase creatinine which indicates renal failure,
and at that time the kidney is failing to metabolize the
protein, thus protein is being excreted via urine without
undergoing metabolism & impaired metabolism of renal
tubule.
Microscopic
RBC/hpf 3-8 0 – 2 / hpf It occurs because the kidneys are being damaged and a
presence of cyst in right kidney.
WBC/hpf 8-23 0 – 5 / hpf Infection; The body compensates to fight against bacteria,
& the dead WBC are being excreted in the urine since the
kidney cannot filter it.
Bacteria Few Invasion of pathogens in the urinary tract.
ABG Analysis
Test Result Normal Values Significance
pH 7.263 7.35-7.45 • Fully compensated metabolic acidosis &
pCO2 21.1 35-45 mmHg
pO2 154.1 80-100 mmHg respiratory alkalosis
HCO3 9.2 22-26 mmol/L It occurs because of the kidneys inability to excrete
hydrogen ions, ↓ reabsorption of NaHCO3, ↓
formation of dihydrogen phosphate and NH3.
O2 Sat. 99% 97-100% Normal
Date: September 16. 2010

Hematology
Values
Hematocrit .15 vol.(fr) 0.42 – 0.52 It occurs because the kidneys are unable to
24
Hemoglobin 50 gms/L 120 – 160 produce erythropoietin, a hormone necessary
RBC 1.75 X 10^12/L 4.6 – 6.2
for RBC production.
WBC 9.5 X 10^9/L 4.5 – 11 As a compensatory mechanism of the body to
Lymphocytes .06 25-30%
fight against the invasion of pathogens.
Monocytes .01 2-5%
Urinalysis
Macroscopic
Transparency Hazy Clear Due to presence of bacteria.
Specific gravity 1.005 .1.10 – 1.25 Due to the fluid that accumulates in the body.
Protein 2+ Negative Due to increase creatinine which indicates
renal failure, and at that time the kidney is
failing to metabolize the protein, thus protein is
being excreted via urine without undergoing
metabolism.
Microscopic
RBC/hpf 20-31 0 – 2 / hpf It occurs because the kidneys are being
damaged and a presence of cyst in right
kidney.
WBC/hpf 8-12 0 – 5 / hpf Infection; the body compensates to fight
against bacteria, & the dead WBC are being
excreted in the urine since the kidney cannot
filter it.
Bacteria Few Invasion of bacteria in the urinary tract.
Ultrasound: KUB
Significance
Kidneys:
 The right kidney measures approximately:
Coronal = 110.6 x 50.7 x 43mm (LWT) with a cortical thickness of 17.1 mm.
 The borders are fuzzy.
 There is increased parenchymal echopattern.
 A 7.1 x 6.2 x 7.0 mm (LWH) with a volume of .2 ml cystic mass is noted in the inferior
pole.
 There is no caliectasia.
 There is no lithiasis.
 The left kidney measures approximately:

Coronal = 102 x 64.8 x 48 mm (LWT) with a cortical thickness of 16.9 mm.
 The borders are fuzzy.

 There is increased parenchymal echopattern.
 There is no caliectasia.
 There is no lithiasis.
Urinary Bladder:
25
 The urinary bladder is well distended.
 It has smooth walls with a thickness of 5.2 – 6.3 mm.
 No intraluminal echoes seen.
 The full urinary bladder has a volume of approximately 178.6 cc.
 Post void scan shows no residual urine volume.
Impression:
 Normal urinary bladder ultrasonically.
 Diffuse renal parenchymal disease, both kidneys.
 Renal cyst, inferior pole, right kidney.
September 18, 2010

Hematology
Hematocrit .33 vol.(fr). .42 - .52 It occurs because the kidneys are unable to
produce erythropoietin, a hormone necessary
Hemoglobin 110 gms/L 12 – 160
for RBC production.
26
PATHOPHYSIOLOGY Precipitating factors:
Lifestyle
-alcoholic
drinker
Predisposing
factors: -illegal drugs
Family user
history of
Hypertensi -carbonated
on drinker for
about 5-7
bottles/day
Renal cyst
Thickening in the amount of collagen in

the basement membranes
of the small vessels
Decrease renal blood flow
Decrease glomerular filtration (GFR) ↑ Creatinine
Hypertrophy of remaining nephrons as

they filter large load of solutes
Inability to concentrate urine Specific gravity

adequately = ↓1.005
27
Hypertension,
Further loss of nephron function blood pH =
↓7.263
K = ↓ 3.27 Inability of the tubules to

mmol/L
reabsorb electrolytes
Na = ↓ 129.5
mmol/L
Proteinuri
Continuous decline in renal a
function
Anemia
oliguria
END-STAGE RENAL
DISEASE (ESRD)
GFR falls below 15

mL/min/1.73 m2
Body becomes unable to rid itself

of excess water, salt & other
waste products through the
Loss of
Loss of kidneys
excretor
nonexcret y renal
ory renal Pallor
function
function
SOB
Nausea &
Anemia
vomiting
28
Failure to Metabolic Decreased
produce Fatigue & hydrogen
acidosis
erythropoietin weakness excretion
Impaired
function of
RAAS
Chest pain
Decrease
Hiccups excretion of
nitrogenous
Anorexia waste
↑ rennin
Nausea &
secretion
vomiting
Facial grimacing Decreased

potassium
↑ rennin excretion
secretion
hypokalemia
Water retention
Edema
Vomiting
Hypertension
Anorexia
Muscle
cramps
29
MEDICAL MANAGEMENT
A. Drug Study
Brand Name Norvasc

Generic Name Amlodipine
Drug class Antihypertensive, calcium – channel blocker
Dosage 5 mg 1 tab OD
Indications Hypertension
Contraindications Hypersensitivity
Adverse reaction Dizziness, lightheadedness, headache, peripheral edema,
fatigue, lethargy, flushing, nausea
Mechanism of Action Inhibits the movement of calcium ions across the membranes
of cardiac & arterial muscle cells. Inhibits transmembrane
calcium flow which results in the depression of impulse
formation in specialized cardiac peacemaker cells, slowing of
the velocity of conduction of the cardiac impulse, depression of
myocardial contractility & dilation of coronary arteries &
arterioles and peripheral arterioles lead to decreased cardiac
work, decreased cardiac oxygen consumption.
Nursing Responsibilities  Administer with meals if upset stomach occurs.
 Monitor the BP, cardiac rhythm & output.
 Eat frequent small meals.
 Report irregular heartbeat, SOB, swelling of hands & feet
Generic Name Hydrocortisone

Drug class Adrenocortical steroid, Glucocortecoids
Dosage 250mg IV every 8 hours
Indications ESRD
Adverse reaction Euphoria, insomnia, seizures, heart failure, HTN, edema,

arrhythmias, thrombo embolism. cataracts glaucoma, PUD, GI
irritation, increase appetite, pancreatitis, hypokalemia,
hyperglycemia, carbohydrate intolerance. muscle weakness,
growth suppression in children, osteoporosis.. hirsutism,
delayed wound healing, acne, easy bruising
Mechanism of Action May stabilize leukocyte lysosomal membranes, suppress
immune response, stimulate bone marrow and influence
nutrient metabolism. It reduces inflammation, suppress immune
function and raises adrenocorticoid hormonal levels.
Nursing Responsibilities  Monitor patient’s weight, BP.

 Monitor patient’s for stress. Fever, trauma, surgery and
emotional problems may increase adrenal insufficiency.
 Periodically measure growth and development during high-
30
dose or prolonged therapy in infants and children.
 Be alert for adverse reactions and drug interactions
Brand Name Micardis plus

Generic Name Telmisartan
Drug class Angiotensin II receptor anatagonist
Dosage 40 mg 1 tab OD
Indications Treatment for hypertension
Contraindications  Hypersensitivity
 Use cautiously with hepatic or biliary impairment,
hypovelemia
Adverse reaction Lightheadedness, headache, muscle weakness, hypotension,
palpitations, constipation, flatulence, gastritis, dry mouth,
dyspnea, cough, back pain, gout
Mechanism of Action Selectively blocks the binding of angiotensin II to specific tissue
receptors found in the vascular smooth muscle and adrenal
gland; this action blocks the vasoconstriction effects of the
rennin-angiotensin system as well as the release of
aldosterone, leading to decrease BP
Nursing Responsibilities  Administer without regard to meals.
 If BP control does both reach desired levels, diuretics or
other antihypertensive may be added to telemesartan.
 Monitor BP carefully.
 Note chills, dizziness and pregnancy.
Brand Name Renogen

Generic Name Epoetin alfa recombinant
Drug class Erythropoietin
Dosage 2,000 units 3x / week
Indications ESRD, anemia
Contraindications  Uncontrolled hypertension
 Hypersensitivity
 Use in chronic renal failure clients who need severe anemia
corrected
Adverse reaction Hypertension, headache, fatigue, N and V, diarrhea, edema,
asthenia, respiratory congestion, cough, pyrexia, rash, SOB,
insomnia, pruritus, DVT (in surgery clients), hyperkalemia
Mechanism of Action Made by recombinant DNA Technology; it has the identical
amino acid sequence and same biologic effects as
endogenous erythropoietin (which is normally synthesized in
the kidney and stimulates RBC production). Epoetin alfa will
stimulate RBC production and thus elevate or maintain The
RBC level, decreasing the need for blood transfusion.
Nursing Responsibilities  Do not give with any other drug solutions.
 Do not dilute or give in conjunction with other drug
solutions.
 Note any sensitivity to mammalian cell-derived products or
31
human albumin.
 Determine CBC and iron stores.
 Assess BP, control hypertension. Assess for seizures with
any significant hematocrit increase.
 Regularly monitor CBC, renal function studies, I and O,
electrolytes, phosphorus and uric acid levels.
Generic Name Chlorpromazine hydrochloride

Drug class Antipsychotic, phenothiazine
Dosage 50 mg ¼ tab HS
Indications Positive intake of prohibited drugs and ESRD,
Adverse reaction Constipation, drowsiness, blurred vision, decreased sweating,
tremor, difficulty urinating, dark urine, dizziness, increased
appetite, menstrual iirigularities, swollen breast
Mechanism of Action Has significant antiemetic, hypotensive, and sedative effects;
moderated anticholinergic and extrapyramidal effects
Nursing Responsibilities  Solutions may cause contact dermatitis; avoid contact with
hands or clothing.
 Monitor vital signs, I&O, CBC, liver and renal function
studies. Ocular exams and ECG with prolonged activity.
 Assess male clients for S&S of prostatic hypertrophy
Generic Name Ranitidine hydrochloride

Drug class Histamine H2 receptor blocking drug
Dosage 50 mg IV every 8 hours
Indications Gastric Ulcer
Contraindications Cirrhosis of the liver, impaired renal or hepatic function
Adverse reaction Headache, abdominal pain, constipation, diarrhea, nausea and
vomiting
Mechanism of Action Competitively inhibits gastric acid secretion by blocking the
effect of histamine H2 receptors. Both daytime and nocturnal
basal gastric acid secretion, as well as food-and penetagastrin-
stimulated gastric acid are inhibited. Weak inhibitor of
cytochrome P-45 (drug-matabolizing enzymes); thus, drug
interactions involving inhibition of hepatic metabolism are not
expected to occur
Nursing Responsibilities  Visually inspect parenteral drug product for particulate
matter, and discoloration before administration.
 Monitor CBC, B12, RENAL, LFT’s. Asses for infections.
 Teach client to avoid alcohol, aspirin-containing products,
and beverages that contain caffeine (tea, cola, coffee);
these increase stomach acid.
 Tell client not to smoke; interferes with healing and drug’s
effectiveness
Brand Name Plasil
32
Generic Name Metoclopramide
Drug class Gastrointestinal Stimulant
Dosage 10 mg IV every 8 hours
Indications Anorexia and vomiting
Contraindications Pheochromocytoma ,gastrointestinal hemorrhage, obstruction,
or perforation, epilepsy,clients taking drugs likely to cause
extrapyramidal symptoms, such as phenothiazines
Adverse reaction Extrapyramidal symptoms, restlessness, drowsiness, fatigue,
lassitude, akathasia, dizziness, nausea, diarrhea
Mechanism of Action Dopamine antagonist that acts by increasing sensitivity to
acetylcholine; results in increased motility of upper GI tract and
relaxation of the pyloric sphincter and duodenal bulb
Nursing Responsibilities  Assess abdomen for bowel sounds, distention, N&V.
 Inject slowly IV over 1-2 minutes to prevent transient
feelings of anxiety and restlessness.
 Teach client that this drug increases movement/
concentrations of the stomach and intestine.
 Tell patient to avoid alcohol and CNS depressant.
Brand Name Cellcept

Generic Name Micophenolate mofeyil
Drug class Immunosuppressant
Dosage 500 mg 1 tab TID
Indications ESRD
Adverse reaction Chest pain, edema, hypertension, hemorrhage, kidney tubular
necrosis, anemie, leukopenia, thrombocytopenia,
hypercholesterolemia, hyperglycemia, hyper & hypokalemia,
hypophosphatemia, back pain, cough, dyspnea, acne, rash,
sepsis.
Mechanism of Action Inhibits proliferative responses of T – and B – lymphocytes,
suppresses antibody formation by B- lymphocytes, and may
inhibit recruitment of leukocytes into sites of inflammation and
graft ejection.
Nursing Responsibilities  Obtain a serum or urine pregnancy test within one week of
beginning therapy and provide contraception counceling.
 Obtain history of kidney transplant.
 Monitor CBC regularly.
 Monitor serum potassium and phosphate, glucose level,
and cholesterol level.
Brand Name Aldazide

Generic Name Spironolactone
Drug class K – sparing diuretics
Dosage 25 mg 1 tab BID
Indications Edema
Contraindications Acute renal insufficiency, anuria, hyperkalemia, pregnancy.
Adverse reaction Gynaecomastia, drowsiness, lethargy, rash, headache, mental
33
confusion, ataxia, impotence, menstrual irregularities,
agranulocytosis.
Mechanism of Action Promotes water and Na excretion and hinders potassium
excretion by antagonizing aldosterone in distal tubule.
Nursing Responsibilities  Monitor electrolyte level, fluid intake and output, weight and
blood pressure.
 Assess patient’s condition before starting therapy and
regularly thereafter to monitor drug’s effectiveness.
Maximum antihypertensive response may be delayed up to
2 weeks.
 Be alert for adverse reactions and drug interactions.
Brand Name Benadryl

Generic Name Diphenhydramine hydrochloride
Drug class Antihistamine
Dosage 50 mg 1 cap HS
Indications Allergy symptoms
Contraindications Contraindicated in patients with hypersensitivity and asthma
attack.
Adverse reaction Dizziness, drowsiness, sedation, seizures, sleepiness, dry
mouth, epigastric distress, nausea, vomiting, agranulocytosis,
thrombocytopenia, anaphylactic shock.
Mechanism of Action Competes with histamine for H1 – receptor sites on effector
cells. Prevents but doesn’t reverse histamine- mediated
responses, particularly histamine’s effect on smooth muscle of
bronchial tubes, GI tract, uterus, and blood vessels. Provides
local anesthesia by peventing initiation and transmission of
nerve impulses, and suppresses cough reflex by direct effect in
medulla of brain.
Nursing Responsibilities  Take the drug 30 minutes before travel, to avoid motion
sickness.
 Avoid alcohol and refrain from driving or performing other
hazardous activities that require alertness.
 Tell pt. That coffee or tea may reduce drowsiness.
 Obtain history of patient’s underlying condition before
therapy, and reassess regularly thereafter.
Brand Name Sodium Bicarbonate (NaHCO3)

Drug class Ion buffer, oral antacid
Dosage 650 mg 2 tabs BID
Indications Metabolic acidosis
Contraindications In pt. With metabolic and respiratory alkalosis, patients who are
losing chlorides from vomiting or continuous GI suction,
patients taking diuretics known to produce hypochloremic
alkalosis, patients with hypocalcemia in which alkalosis may
produce tetany, hypertension, seizures or heart failure; and
34
patients with acute ingestion of strong mineral acids.
Adverse reaction Belching, flatulence, gastric distension, hypernatremia,
hyperosmolaity, hypokalemia, metabolic alkalosis, iiritation and
pain in injection site.
Mechanism of Action Restore body’s buffering capacity and neutralizes excess acid.
Nursing Responsibilities  To avoid risk of alkalosis, obtain blood pH, PaO2, PaCO2,
and electrolyte level.
 If NaHCOe3 is being used to produce alkaline urine,
monitor urine pH every 4 – 6 hours.
 Give drug with water, not milk; drug may cause
hypercalcemia, alkalosis or possibly renal calculi.
Generic Name Furosemide

Drug class Loop diuretic
Dosage 20 mg IVTT every 6 hours
Indications Hypertension, edema (anasarca)
Drug Interactions  Increased risk of cardiac arrhythmias with digitalis
glycosides.
 Increased riskof ototoxicity with aminoglycoside antibiotics,
ciplastin.
 Decreased absorption of furosemide with phenytoin.
 Decreased GI absorption with charcoal.
Adverse reaction Dizziness, vertigo, paresthesias, xanthopsia, weakness,
orthostatic hypotension
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.
35
36
Risk factors:
B. Medi Map
Excessive intake of illegal
drugs
Laboratory and Diagnostic Test
Excessive alcoholic and Urinalysis Signs & symptoms:
carbonated drinker for Hematology Hyponatremia
about 5-7 bottles/day Serum electrolytes test: ↑ serum creatinine
Pathophysiology:
Proteinuria
In end stage renal disease (ESRD), the Potassium, chloride
Metabolic acidosis
blood flow to the kidneys may be drastically reduced Serum creatinie Anemia
due to all the damage to the filtering structures in the ABG analysis Anorexia, nausea & vomiting
kidney (the glomeruli). Urine output decreases as a
Ultrasound: KUB Hypertension
result, and toxic substances build up in the blood. The
Chest pain
sum effect of this is "uremia," a complex biochemical END-STAGE RENAL DISEASE Muscle cramps
syndrome that results from this toxic buildup. Blood Nursing interventions: Confusion
urea nitrogen and creatinine are two blood markers
Anasarca
that rise in renal disease. Electrolyte levels can also Turn the patient often & use a convoluted foam mattress to prevent skin Pallor
become deranged in renal disease.
breakdown.
Provide good oral hygiene by encouraging or performing frequent brushing

with a soft brush or sponge tip to reduce breath odor & providing
Medical Management
sugarless hard candy & mouthwash to minimize the metallic taste in the Drugs;
mouth & alleviate thirst. Amlodipine (Norvasc) 5 mg 1 tab OD
Hydrocortisone 250 mg IV q8h
Offer small, nutritious & palatable meals. Telmisartan (Micardis plus) 40 mg 1 tab OD
Epoetin alfa recombinant (Renogen) 2,000 units 3x/week
Monitor for signs of hyperkalemia. Watch for muscle irritability and a weak Chlorpromazine hydrochloride 50 mg ¼ tab HS
pulse rate. Ranitidine hydrochloride 50 mg IV q8h
Prevention: Metoclopramide (Plasil) 10 mg IV q8h
Low protein diet.
Sodium, potassium & phosphorus restrictions. Carefully assess the patient’s hydration status; check for jugular vein Mycophenolate mofetil (Cell cept) 500 mg 1 tab TID
Restriction of fluid intake. distention, auscultate the lungs for crackles, carefully measure daily (Aldazide) 25 mg 1 tab BID
Encourage cessation of toxic substances such Diphenhydramine hydrochloride (Benadryl) 50 mg 1 cap HS
intake & output, record
as alcohol and illegal drugs. Sodium Bicarbonate 650 mg 2 tab BID
Advise to eat nutritious food would Furosemide 20 mg IVTT q8h
Encourage deep breathing & coughing to prevent pulmonary congestion,
somehow help the patient on regaining IVF
auscultate the lungs often, stay alert foe clinical effects of pulmonary Left carpal vein - PNSS 1L + 20 mEqs NaCl x 60 cc/°
some strengths or energy to his body,
such as green leafy vegetables. edema & administer diuretics & other medications as ordered. Side drip - D5W 500 c + 100 mEqa NaHCO3x24°x 2
Right carpal vein - PNSS 500 cc x KVO
Observe for signs of bleeding & monitor haemoglobin level & hematocrit & O2 @ 2 Lpm via nasal cannula
check stool, urine & vomitus for blood.
Report signs of pericarditis such as pericardial friction rub and chest pain.
37
38
NURSING MANAGEMENT
Ineffective renal tissue
perfusion r/t decreased
hemoglobin
Impaired gas exchange concentration in blood.
r/t decreased O2 3. Imbalance nutrition: less
carrying capacity of the than body requirements r/t
blood loss of appetite and
vomiting.
8. Risk for impaired skin

integrity r/t the accumulation 4. Impaired urinary
A. fluid
of Concept Map
in the of Nursing Problems
interstitial elimination r/t diminished
space 2° imbalanced End – Stage Renal renal function.
nutritional state. Failure
Cc : vomiting
7. Altered comfort r/t 5. Fluid volume excess r/t the

excessive accumulation of
persistent hiccup.
fluid in the interstitial space 2°
to ↑ hydrostatic pressure.
6. Pain r/t the accumulation of

toxic substances 2° impaired 39
renal function.
2. Ineffective renal tissue perfusion r/t
decreased hemoglobin concentration in
blood. 3. Imbalance nutrition: less than
body requirements r/t loss of 4. Impaired urinary elimination r/t
Objective:
diminished renal function.
Impaired gas exchange r/t decreased Bp = 140/100 mmHg appetite and vomiting.
oxygen carrying capacity of the blood. (+) DOB
Subjective:
(+) anemia
Subjective: Subjective: “Indi ako kaihi”, as verbalized.
(+) oliguria
“Daw nabudlayan pa guid ko gyapon “Wala ako gana magkaon”, as
Serum creatinine = ↑1679.6 umol/L
Objective:
magginhawa”, as verbalized. Serum electrolytes: verbalized.
Bp = 140/100 mmHg
K = ↓ 3.27 mmol/L
(+) anasarca
Objective: Na = ↓ 129.5 mmol/L
Objective: Distended urinary bladder
Bp = 140/100 mmHg Hematology:
Bp = 140/100 mmHg (+) Oliguria
Hct = ↓ 15 vol.(fr)
RR = 21 bpm (+) fatigue
Hgb = ↓50 gms/L RR = 21 bpm
(+) DOB (+) weakness
RBC = ↓1.75 X 10^12/L (+) DOB Pain @ hypogastric area
(+) fatigue
ABG:
(+) fatigue No urine output for 7 hours
(+) weakness pCO2 = ↓21.1 mmHg
(+) weakness (+) tenderness
(+) pallor pO2 = ↑154.1 mmHg
Intake exceeds output. I = 230 cc, O =
(+) anemia Urinalysis: (+) anorexia
120 cc
(+) confusion Protein = +3 (+) nausea & vomiting. Difficulty upon urination
Hematology: RBC/hpf = ↑3 – 8 / hpf (hematuria)
(+) anasarca Adm. Dx: CKD 2° to nepholithiasis
WBC/hpf = ↑8 – 23 / hpf (pyuria)
Hct = ↓ 15 vol.(fr) (+) right arm muscle cramps Urinalysis:
KUB:
Hgb = ↓50 gms/L RBC/hpf = ↑3 – 8 / hpf (hematuria)
Diffuse renal parenchymal disease, both kidneys. (+) dry skin & lips
RBC = ↓1.75 X 10^12/L WBC/hpf = ↑8 – 23 / hpf (pyuria)
Renal cyst, inferior pole, right kidney. Serum electrolytes: KUB:
ABG: Renogen 2,000 units 3x/week
K = ↓ 3.27 mmol/L Diffuse renal parenchymal disease, both
pCO2 = ↓21.1 mmHg Amlodipine (Norvasc) 5 mg 1 tab OD
Na = ↓ 129.5 mmol/L kidneys.
pO2 = ↑154.1 mmHg Telmisartan (Micardis plus) 40 mg 1 tab OD
Renal cyst, inferior pole, right kidney
Aldazide 25 mg 1 tab BID Renogen 2,000 units 3x/week 40
Renogen 2,000 units 3x/week Furosemide 20 mg IVTT q8h
Furosemide 20 mg IVTT q8h Chlorpromazine hydrochloride 50 Aldazide 25 mg 1 tab BID
O2 @ 2 Lpm via nasal cannula O2 @ 2 Lpm via nasal cannula.
mg ¼ tab HS
41
5. Fluid volume excess r/t the excessive
8. Risk for impaired skin integrity
accumulation of fluid in the interstitial
6. Pain r/t the accumulation of toxic r/t the accumulation of fluid in the
space 2° to ↑ hydrostatic pressure.
substances 2° impaired renal interstitial space 2° imbalanced
Subjective: function. nutritional state.

“Nagpalanghabok gidman sa”, as
verbalized by the folks. Subjective: Objective:
“Gasakit man gyapon akon dughan”, Bp = 140/100 mmHg
Objective: 7. Altered comfort r/t
as verbalized. RR = 21 bpm
Bp = 140/100 mmHg persistent hiccup
(+) anasarca
RR = 21 bpm
Objectives: (+) anemia
(+) DOB
Bp = 140/100 mmHg Subjective: (+) dry skin
Abdominal girth = 94 cm
RR = 21 “Ginasinidoh ako”, as
(+) anasarca
(+) anorexia (+) DOB verbalized. Serum electrolytes:
Distended urinary bladder (+) weakness K = ↓3.27 mmol/L
(+) of bruits in 4 abdominal quadrants upon (+) fatigue Objective: Na = ↓ 129.5 mmol/L
auscultation. (+) pallor Creatinine = ↑1679.6 umol/L
Bp = 140/100 mmHg
(+) weight gain over a short period of time. Hematology:
(+) hiccups
Weight before admission = 68 kg, current RR = 21 bpm
(+) facial grimace Hct = ↓ 15 vol.(fr)
weight = 72 kg. (+) DOB
(+) anterior chest pain with a pain scale Hgb = ↓50 gms/L
Fluid intake exceeds output. Intake = 230 (+) facial grimace
of 5. RBC = ↓1.75 X 10^12/L
cc, output = 120 cc.
(+) persistent hiccup ABG:
(+) fatigue (+) anorexia
Adm. Dx: CKD 2° to Nephrolithiasis. (+) weakness pH =↓ 7.263
(+) weakness
Furosemide 20 mg IVTT q8h Serum creatinine = 1679.6 umol/L (+) fatigue pCO2 = ↓21.1 mmHg 42
Aldazide 25 mg 1 tab BID O2 @ 2 Lpm via nasal cannula Chest pain progresses pO2 = ↑154.1 mmHg
O2 @ 2 Lpm via nasal cannula during hiccups. NaCO3 = ↓9.2 mmol/L
B. Nursing Care Plan
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Dependent:
Subjective: 1. Impaired gas To provide adequate Administered Renogen It has the same biologic Goal met.
“Daw nabudlayan pa gid exchange r/t oxygenation within the 2,000 units 3x/week effects as endogenous
ko gyapon magginhawa”, decreased oxygen shift. erythropoietin that Bp = 130/90 mmHg
as verbalized. carrying capacity of stimulate RBC
43
the blood. production and thus RR = 20 bpm
Objective: elevate or maintain The
 Bp = 140/100 mmHg RBC level. No any complaints of
 RR = 21 bpm DOB.
 (+) DOB Provided O2 @ 2 Lpm To provide oxygen

via nasal cannula. needed by the body for
 (+) SOB
functioning.
 (+) fatigue
 (+) weakness
Independent:
 (+) pallor
Monitored VS. To determine alteration
 (+) anemia in the vital signs which
includes the RR, BP,
 (+) confusion CR.
 Hematology:
Positioned with HOB
- Hct = ↓ 15 vol.(fr) Promotes better lung
elevated.
expansion & improve
- Hgb = ↓50 gms/L
gas exchange
- RBC = ↓1.75 X
10^12/L Provided rest periods to
Even simple activities
 ABG: prevent fatigue. such as bathing can
- pCO2 = ↓21.1 increase oxygen
consumption & cause
mmHg fatigue
- pO2 = ↑154.1 Recommended quiet
atmosphere and This enhances
mmHg
bed rest if indicated. rest to lower
body’s oxygen
requirements and
reduces strain on
the heart and
44
Encouraged to lungs.
perform foot exercises
every hour when This will promote
awake. venous return and
better circulation.
Encouraged a deep
breathing exercise. Promotes optimal lung
expansion.
Objective: 2. Ineffective renal To demonstrate Dependent: Goal met.

It has the same biologic
 Bp = 140/100 mmHg tissue perfusion r/t adequate oxygenation Administered Renogen
effects as endogenous
 (+) DOB decreased hemoglobin and perfusion within the 2,000 units 3x/week Bp = 130/90 mmHg
erythropoietin that
 (+) anemia concentration in blood. shift
stimulate RBC
RR = 20 bpm
 (+) oliguria production and thus
elevate or maintain The
(-) DOB
45
 Serum creatinine = RBC level.
↑1679.6 umol/L Adminitered Amlodipine
 Serum electrolytes: (Norvasc) 5 mg 1 tab OD Inhibits transmembrane
-K = ↓ 3.27 calcium flow which
mmol/L slowing of the velocity of
-Na = ↓ 129.5 conduction of the cardiac
mmol/L impulse, depression of
 Hematology: myocardial contractility &

dilation of coronary
- Hct = ↓ 15 vol.(fr)
arteries & arterioles and
- Hgb = ↓50 gms/L
peripheral arterioles lead
- RBC = ↓1.75 X
to decreased cardiac
10^12/L
work.
 ABG:
Administered
- pCO2 = ↓21.1 Telmisartan (Micardis
Selectively blocks the
mmHg plus) 40 mg 1 tab OD
binding of angiotensin II
- pO2 = ↑154.1
to specific tissue
mmHg
receptors found in the
 Urinalysis:
vascular smooth muscle
-Protein = +3 and adrenal gland
- RBC/hpf = ↑3 – 8 leading to decrease BP.
/ hpf
Administered Aldazide
(hematuria)
25 mg 1 tab BID Promotes water and Na
- WBC/hpf = ↑8 – excretion and hinders
23 / hpf potassium excretion by
46
(pyuria) antagonizing aldosterone
 KUB: in distal tubule that leads
-Diffuse renal to decrease Bp.
parenchymal Administered
Furosemide 20 mg IVTT
disease, both Inhibits reabsorption of
q8h
kidneys. Na & Cl from the
- Renal cyst, proximal and distal
inferior pole, tubules & ascending limb
right kidney. of the loop of Henle,
leading to a Na-rich
dieresis that leads to
decrease Bp.
Provided O2 @ 2 Lpm
via nasal cannula. To provide oxygen
needed by the body for
Independent: functioning.
Monitored VS.
To monitor patient from
any changes in his
status. Elevated VS may
indicate poor circulation
and oxygenation.
Maintained bed rest, To decrease oxygen and

provide quiet blood demand.
environment,
47
Subjective: 3. Imbalance nutrition: To be able to Dependent: Goal partially met,

“Wala ako gana less than body demonstrate selection of Administered Renogen It has the same biologic
magkaon”, as verbalized. requirements r/t loss of food necessary for 2,000 units 3x/week effects as endogenous Consumed 50% of
appetite and vomiting. weight gain and erythropoietin that served foods.
Objective: consume adequate stimulate RBC
 Bp = 140/100 mmHg nourishment within the production and thus (-) nausea & vomiting
 RR = 21 bpm shift. elevate or maintain The
 (+) DOB RBC level. (+) anorexia
 (+) fatigue
Administered Has significant
 (+) weakness
Chlorpromazine antiemetic, hypotensive,
 (+) anorexia
hydrochloride 50 mg ¼ and sedative effects;
 (+) nausea &
tab HS moderated
vomiting.
anticholinergic and
 (+) anasarca
extrapyramidal effects.
 (+) right arm muscle
cramps
Independent:
 (+) dry skin & lips Discouraged beverages These may decrease
that are caffeinated or appetite and lead to
 Serum electrolytes: carbonated. early satiety and will
-K = ↓ 3.27 make the client feel
mmol/L full easily.
-Na = ↓ 129.5
48
mmol/L Encouraged range of Metabolism and
motion exercise. utilization of nutrients are
enhanced by activity.
Ensured a pleasant It gives a relaxed

environment. feeling and will not
spoil her appetite.
Facilitated proper Aids in swallowing and
position by elevating reduces risk of aspiration
HOB.
Provided good oral Noxious tastes, smells,
and sight
hygiene and dentition. are prime deterrents to
Eliminated smells from appetite and can
produce nausea and
the environment. vomiting with increased
respiratory difficulty.
Reduces gastric
stimulation & vomiting
response
To prevent abdominal
distention
Junk foods
have
empty calories that
provide no nutritional
49
help to the client.
To provide ample
information and
Instructed to avoid gas- awareness.
producer, very hot & very
cold foods
To provide nourishment
needed by the body for
Instructed to
avoid junk foods. metabolic demand.
To make him aware

about his diet that is
needed for his
Educated regarding the
nourishment.
importance of healthy
foods and it’s benefits to
his body.
Encouraged to eat.
Taught about foods what

& not what to eat
(↓protein, Na & fluid
restriction, ↑ fats &
carbohydrates =
calories).
50
Subjective: 4.Impaired urinary To relieve abdominal Dependent: Inhibits reabsorption of Goal met.
“Indi ako kaihi”, as elimination r/t discomfort & eliminate Administered Na & Cl from the
verbalized. diminished renal retention of urine after 30 Furosemide 20 mg IVTT proximal and distal Obtained 80 cc of clear
function. mins of nursing q8h tubules & ascending limb urine after
Objective: intervention. of the loop of Henle, catheterization.
 Bp = 140/100 mmHg leading to a Na-rich
 (+) anasarca dieresis. Reported relief of
 Distended urinary hypogastric area.
bladder
 (+) Oliguria Administered Aldazide Promotes water and Na Total urine output within
 (+) fatigue 25 mg 1 tab BID excretion and hinders the shift = 210 cc.
potassium excretion by
 (+) weakness
antagonizing aldosterone
 Pain @ hypogastric Independent: in distal tubule.
area Monitored VS.
 No urine output for 7 To evaluate any
hours manifestation caused by
 (+) tenderness abdominal discomfort &
 Intake exceeds bladder retention like BP,
output. I = 230 cc, O RR, AR.
= 120 cc
Monitored I & O. Provides information
 Difficulty upon about kidney function
urination and presence of
 Adm. Dx: CKD 2° to complications.
nepholithiasis
Maintained client Allows relaxation of
 Urinalysis: on semi-fowler’s or abdominal & perineal
- RBC/hpf = ↑3 – 8 position of comfort muscles to promote
/ hpf bladder emptying.
(hematuria)
- WBC/hpf = ↑8 –
23 / hpf
(pyuria) Foley catheter inserted & To facilitate elimination
 KUB: secured as order. of urine that can
-Diffuse renal decrease abdominal
parenchymal discomfort.
51
disease, both
kidneys. Demonstrated proper To facilitate drainage
-Renal cyst, positioning of catheter and prevent reflux.
inferior pole, drainage tubing and bag.
right kidney.
Provide catheter care. To prevent ascending
UTI which may
aggravate the condition
Instructed to limit Na & To prevent further water

fluid intake. retention that causes
edema.
Maintained acidic To discourage bacterial

environment of the growth.
bladder by the use of
agents, or vit. C from
fruits and buko juice.
Instructed to avoid To prevent bladder

caffeinated and irritation.
carbonated beverages.
Subjective: 5. Fluid volume excess To stabilize fluid volume Dependent: Inhibits reabsorption of Goal met.
52
“Nagpalanghabok r/t the excessive within the shift. Administered Na & Cl from the
gidman sa”, as accumulation of fluid Furosemide 20 mg IVTT proximal and distal Bp = 130/90mmHg
verbalized by the folks. in the interstitial space q8h tubules & ascending limb
2° to ↑ hydrostatic of the loop of Henle, RR = 20 bpm
Objective: pressure. leading to a Na-rich
 Bp = 140/100 mmHg dieresis. (-) DOB
 RR = 21 bpm
 (+) DOB Administered Aldazide Promotes water and Na Total urine output within
 Abdominal girth = 94 25 mg 1 tab BID excretion and hinders the shift = 210 cc.
cm potassium excretion by Total fluid intake = 190
 (+) anasarca antagonizing aldosterone cc.
in distal tubule.
 (+) anorexia
 Distended urinary Provided O2 @ 2 Lpm To provide oxygen
bladder via nasal cannula. needed by the body for
 (+) of bruits in 4 functioning.
abdominal quadrants
upon auscultation.
 (+) weight gain over Independent:
a short period of Monitored & recorded To obtain baseline data
time. Weight before vital signs
admission = 68 kg,
current weight = 72
kg. Instructed to limit fluid & To monitor kidney
 Fluid intake exceeds Na intake. function and fluid
output. Intake = 230 retention
cc, output = 120 cc.
 (+) fatigue Elevated edematous This increases venous
 (+) weakness extremities. return and, in turn,
decreases edema.
Reduced constriction of This prevents venous

vessels by avoiding pooling.
crossing of legs or
ankles
53
Encouraged quiet, restful To conserve energy &
atmosphere. lower tissue oxygen
demand.
Implemented comfort Edema can cause skin to

measures& safety breakdown faster.
precautions to prevent
skin breakdown.
Encouraged not to lie on To reduce tissue

bed all the time. breakdown & risk of skin
breakdown.
Assisted to a semi – To facilitate movement of

fowler’s position. diaphragm, thus
improving respiratory
effort.
Subjective: 6.Pain r/t the To demonstrate a relief Dependent: Goal met as evidenced
“Gasakit man gyapon accumulation of toxic of pain as evidenced by Provided O2 @ 2 Lpm To provide an oxygen by a decreased in pain
akon dughan”, as substances 2° decreased pain scale of via nasal cannula as needed by the body for scale of 2.
verbalized. impaired renal 2 or 3 after 4 hours of ordered. compensation.
function. nursing intervention. RR = 20 bpm
Objectives: Independent:
 Bp = 140/100 mmHg Provided comfort Promotes relaxation, (-) DOB
 RR = 21 measures & an reduces muscle tension,
 (+) DOB environment conducive and enhances coping. (-) facial grimace
 (+) weakness for rest.
 (+) fatigue
To monitor client’s pain
 (+) pallor
Monitored V/S. status. Pain can cause
 (+) hiccups elevation of VS.
 (+) facial grimace
54
 (+) anterior chest This position makes
pain with a pain Assisted to sit on chair. patient comfortable &
scale of 5. helps in relieving client’s
 (+) anorexia pain.
 Adm. Dx: CKD 2° to
Nephrolithiasis. Encouraged to limit Water and Na retention
intake of fluid & Na – rich in the body may
 Serum creatinine =
foods. contribute to the chest
1679.6 umol/L
pain & discomfort as the
fluids accumulate in the
chest cavity.
Encouraged a deep Promotes relaxation and

breathing exercises & reduces muscle tension.
relaxation techniques.
Provided diversional Promotes relaxation and

activities like watching helps client refocus
TV & talking with others. attention on something
besides discomfort.
Elevated the head of This position makes

bed. patient comfortable &
helps in relieving client’s
pain.
Subjective: 7. Altered comfort r/t To provide pt’s comfort Independent: Goal partially met.
“Ginasinidoh ako”, as persistent hiccup. within the shift. Provided rest periods. To facilitate comfort,
55
verbalized. sleep, and relaxation. Still have a complaint of
discomfort but the
Objective: Provided diversional Distraction techniques episodes had lessen.
 Bp = 140/100 mmHg activities like watching TV heighten one’s
 RR = 21 bpm and talking with others. concentration upon non- “Nag-ayo-ayo na yanda‘,
 (+) DOB painful stimuli as verbalized.
 (+) facial grimace to decrease one’s
 (+) persistent hiccup awareness
 (+) weakness
Provided relaxation Relaxation exercises
 (+) fatigue techniques and cheerful Techniques are used
 Chest pain conversations. to bring about a state of
progresses during physical and
hiccups. mental awareness and
tranquility.
Maintained a calm & To minimize stimulus

quiet environment. that could
aggravate the condition.
Provided a dim and light To add comfort to the pt.

but providing good
Ventilation.

8.Risk for impaired
Objective: skin integrity r/t the To maintain skin integrity Independent:
 Bp = 140/100 mmHg accumulation of fluid & prevent skin VS monitored & Changes in vital signs Goal met.
 RR = 21 bpm in the interstitial space breakdown within the recorded. may indicate infection
 (+) anasarca 2° imbalanced shift. caused by skin No signs of skin
 (+) anemia nutritional state. breakdown breakdown or complaints
 (+) dry skin of discomfort in the bony
Use safety measures in These measures reduce prominences.
changing the position. shearing forces on the
 Serum electrolytes:
Encouraged use of lift skin.
- K = ↓3.27 mmol/L
56
- Na = ↓ 129.5 sheets to move patient in
mmol/L bed and discourage
-Creatinine = patient or caregiver from
↑1679.6 elevating HOB
umol/L repeatedly.
Demonstrated good skin Maintaining clean & dry

hygiene by washing skin provides barrier to
 Hematology: thoroughly and pat dry infection. Patting skin dry
- Hct = ↓ 15 vol.(fr) carefully. instead of rubbing
- Hgb = ↓50 gms/L reduces risk of dermal
- RBC = ↓1.75 X trauma to fragile skin.
10^12/L
Instructed to maintain Skin friction can cause
 ABG:
clean & dry clothes, by stiff or rough clothes
- pH =↓ 7.263 preferably cotton fabric. leads to irritation of
- pCO2 = ↓21.1 fragile skin & increase
mmHg risk for infection.
- pO2 = ↑154.1
mmHg Encouraged not to lie on Lying on bed all the time
-NaCO3 = ↓9.2 bed all the time and can increase risk of skin
mmol/L provide range of motion integrity wherein a
exercise. pressure is being applied
in the tissue. ROM
exercise facilitates
circulation.
Recommended elevation To enhance venous

of lower extremities return & & reduce edema
when sitting. formation.
57
DISCHARGE PLANNING
edications
 Encourage the patient to have a strict compliance with regards to the medication to attain
therapeutic effects.
 Explain to the patient the use and side effects of the medications so that he will be aware
of its effects.
 Give adequate instructions to the significant others about the importance of the following
medications and dietary regimens so that the patient’s condition can remain stable as
soon as possible.
1. Renogen 2, 000 units 3x a week

2. NaHCO3 650 mg 2 tabs TID
3. Cellcept 500 mg 1 tab TID
4. Micardis plus 50 mg 1 tab OD
5. Amlodipine (Norvasc) 5 mg 1 tab OD
6. Aldazide 25 mg 1 tab BID
7. Chlopromazine 50 mg ¼ tab HS
xercise
 Instruct the patient to practice moving his lower extremities to promote blood circulation
and even to improve the range of motion of his foot or feet so that he could somehow, able
to ambulate with himself in later times.
 Educate the patient about bed exercises such as leg exercise, since patient is always on
bed and have limitations on his physical activity because his still weak.
 Teach how to perform range-of-motion exercises because it helps reduce stiffness and
maintain or increase proper joint movement and flexibility.
reatment
 Aware the patient to avoid over work for the following days and must have adequate bed
rest to regain energy or strength.
 By means of anticipating the needs on the course of healing and curing process,
train the patient to focused to himself by not always depending on the interventions that
are not highly needed just to ease or prevent any health problem regarding his condition.
ome teaching
To promote adherence to the therapeutic programs. Teach the following:
 Weighed self every morning to avoid fluid overload.
 Drink limited amounts of fluid only when thirsty.
 Measure alloted fluids and save some for ice cubes, sucking on ice is thirst quenching.
58
 Eat food before drinking fluids to alleviate dry mouth.
 Use hard candy or chewing gum to moisten the mouth.
 Environmental sanitation is needed to provide a therapeutic way of curing himself.

 Teach the patient and family how to measure blood pressure.
 Teach the patient the importance of hand washing to avoid the spread of
infection.
ut-patient
 Remind the patient that he must come back to the hospital one week after, for the follow-
up check-up to confirm if the patient’s condition is really restored. Also to know if there are
complications sited during the check up to know if patients condition have worsen or not.
 Advise patient and the family to report to the physician if any recurrence or severity of
symptoms, any adverse effects to the medication, and any development of complications.
iet
 Instruct him to avoid foods high in phosphorus, potassium & sodium because it can lead
to high probability of current of many diseases. These foods also can build up in the
bloodstream & can cause harm when they cannot eliminate by the kidneys.
 Encourage cessation of toxic substances such as alcohol and illegal drugs in order to
prevent totally the worsening again of the problem and it can damage the kidneys by
causing a decrease in renal blood flow, obstructing urine flow, directly damaging
tubulointestinal structures or by producing hypersensitivity reaction.
 Advise to eat nutritious food would somehow help the patient on regaining some strengths
or energy to his body, such as green leafy vegetables
 Inform the client and the client’s relatives on the specific types of food that may help
speed up the recovery from the condition.
pirituality
 Encourage the patient to read the Bible and pray to God always, ask for guidance and
pray for the healing and restoration of health.
 Ask the patient to reflect on the Bible Scripture, “For I will restore health to you and heal
you on your wounds.” says the Lord. (Jeremiah 30:17).
 Always seek spiritual advice and go on Sunday masses.
59
MY JOURNAL
Experiencing a duty in RENDU ward was all worth it because it enhances your skills and
knowledge in clinical area. In my first week of duty in RENDU ward I handle a seriously ill patient
with a medical diagnosis of prostate cancer. I was scared that moment because I never handle a
patient with a serious illness like him. It was my first time to do suctioning and my second time to
do an NGT. I admit that I am so nervous that moment and I don’t know what I am going to do. My
hands were shaking and I can’t perform well the said procedures. Ma’am Bengan continue the
suctioning because I can’t do it and in NGT feeding, I also failed because the septo syringe was
dislodge when I instill 30cc of water for flushing. I was so disappointed to myself because I didn’t
apply what I have learned during our OSCE in doing the procedure. I guess I need to change my
attitude being nervous every time I do nursing procedure as what Ma’am Bengan said to me.
In my 2 weeks of duty in RENDU, I also learned things such as making nurses notes. It is
much easier for us to do a sample charting because Ma’am Bengan helped and corrected our
mistakes in doing a sample charting. Unfortunately, I was not able to administer more drugs
unlike my other group mates.
They said Ma’am Bengan was so strict, but I guess it’s wrong because Ma’am was so nice
to her students and she helps the student to become a competent nurse someday. She is strict in
a right way and she always makes us feel that we should be serious to our studies. I am thankful
because I have the time to be with her, and become our clinical instructor in clinical area. I will
never forget what Ma’am Bengan said to me “Ms. Adricula daw sobra ka pa bla sa my
Alzheimer’s”. Thank you Ma’am for sharing your knowledge to us, the enjoyment that we have
experience and the laugh trip ……LAUGH, LAUGH, LAUGH..
Kris Joy D. Adricula, S.N
60
MY JOURNAL
Being exposed in the clinical setting or having our duty at the hospital is indeed to
be one of the most unforgettable experiences being a student nurse; it is a step towards my goal
of becoming a nurse.
Taking care of my client is my responsibility being a nursing student; I am there to

meet the needs of my client and to make sure that they are safe. As I take good care of my
patient, I could hardly say that it was worth it to work on them because they are the ones who
really give meaning to my chosen profession. I can’t deny that it’s really hard at first for me to deal
with them because there is still a phase of getting to know each other before I can have their
sympathy; they have doubts on my capacity to take good care of them because I am just a
student nurse, but despite of those criticisms I still managed to have a positive outlook and I am
glad that their impression to me at first was changed after our shift.
Within our two weeks of duty in Rendu Ward we have encounter different patient
having different problem. Some of them are what they say “toxic”, imagine in our last week of duty
two of our handled patient was intubated! But I am unfortunate because I am not the one who
was assigned to them.
Their are a lot of things that I have learned through this exposure the value of time
management, and trying my best not to commit any errors for it can make my patients life be at
risk, specially that we being the healthcare provider is dealing with their lives every step or
nursing care we make has a lot of contributions to the patients condition. A mistake must be
corrected and I must learn how to be flexible enough to manage all things like the personal
problem or anything that can affect my work.
I have learned a lot in the whole hospital exposure which I can treasure and use in
dealing different patients in the next exposure. This hospital exposure serves as a challenge to
me to face patients with different conditions and it serves also as a stepping stone to enhance my
skills, attitude, and knowledge in handling different clients. And I owe this experience to our CI’s
who understand and patiently shared their knowledge without hesitation.
61
Carol Ann D. Dela Cruz, S.N
MY JOURNAL
When I was a child, I wander myself working in a hospital as a nurse. I thought giving care
is easy as that but as a student nurse it wasn’t. Working in a hospital is just like a battlefield. You
have to be God-fearing, strong, confident, alert mind, carry with yourself the core values and be
ready to face different encounters. I’m on third year now. I encountered so many things in the
ward. I’m glad to have mistakes because I learned to know what should be done correctly. I may
learn new things during our duties but still there are lots of things I should be focusing on. Just
like rendering my care to my patient. Carrying my critical thinking skills all throughout the shift
which I am always reminded by my clinical instructor, is very useful. Not all the time, we should
just depend on what we see in textbooks or by just looking the charts without even knowing its
significance. Sometimes you have to go deeper for you to understand the existence of the
disease present in the patient as well as to render care accordingly. Thank you to my dear
clinical instructor for giving us activities every duty. I’ve learned different medical terms, the
responsibilities should be done and knotting them all to understand well. In charting, I enjoyed
making them because through the corrections made I was able to do better one the next time. In
giving medicine, now I can say I learned from my mistake before. I always assure to check the
physicians order and if things which I did not understand I ask my clinical instructor. All those
helped me a lot to be a responsible and effective nurse.
During my 1st and 2nd day duty at Blessed Rosalie Rendu Ward, I had a pt. named M.L,
female, 52 y.o. She had a gouty arthritis. Upon my care, I have already an idea in my mind
because I had a background of it. I was able to apply my nursing intervention well but I cannot
control her irritability. I understand because she is in pain. To maintain my care, what I did, I gave
her more patience. I respect her by not disturbing her when she is about to sleep. She might not
follow me to do warm compress but I’m still encouraging and providing her the health teaching
about the disease. I also establish rapport so that she trust me at the same time.
During my 3rd and 4th day of duty, I had E.C. as my patient. He is 65 y.o and had a DM
Type II. He undergone debridement on the left leg because the doctor should prevent the
progression of pathogens on the affected area caused by the TALABA. During the dressing done
by Dr. T., I was so amazed to see his left leg. I observed the incision. There is a seropurulent
drainage coming out. It is scary to look at because it’s my first time to see such wound. As doctor
cleaned, he told me not to put betadine inside the wound especially the meat-like part of the skin
because the cell inside will die. Imagine the talaba could really be a factor to introduce pathogens
inside the skin and its invasion will progress if not treated immediately. It will cause much damage
to the skin. During my care, I also advised my patient to include malunggay in his diet. I just read
it from a magazine in the library that malunggay is a miracle tree and it decreases blood glucose.
So I shared it to him. In administering humulin “R” since it was my first time, I’m nervous at first
but as I always remember not to panic and have presence of mind. Everything will go easy.
Ma. Rica Gracia Bulaso, S.N
62
MY JOURNAL
During our Duty at Blessed Rosalie Rendu Ward, I have encountered some
of the rarest diseases of the critically ill patients, I have widened my knowledge
about there disease process and enhanced my skills in caring for the sick. I have
also develop my intrapersonal skills in relation to interacting with the staff nurses in
the ward and in caring for my patient. I have learned how to interact with my
patient and how to deal with their problem regarding their condition. As the days
past by I have I wider and better understanding of the medication that we are
giving to our patient and what are the signs and symptoms that we should observe
and watch out for as we are giving our medication, and as a student or even the
staff nurse’s should always observe the 13 rights of administering medication, as a
student if you are in doubt in administering your medication always and foremost
consult your clinical instructor and consult the staff nurses in the ward. I have also
learned how to manage my time well in managing for the sick.
Daniel Delid,S.N
63
MY JOURNAL
During our fourth rotation with ma'am katz we are all having so much fun,
even though we are all busy doing our duties as a student nurses we still have
time to bond with the group and also with ma'am katz. I was able to learn more
things during our duty because we are having our ward class we would discuss
the things regarding some of the procedures that we are performing in the clinical
area for example how to instruct our patient in collecting urine. Some of the
disease that our patients manifest and a lot more. The last day of our duty is the
most memorable day because ma'am would share us some stories and we would
all laugh at it. It also funny how ma'am gives us some advices especially when
ma'am gives advice to Mr. Rufino. Sometimes im scared when ma'am calls out my
attention because im laughing very loud im scared that ma'am katz might get
angry with me and now im trying so hard not to laugh very loud. HAHAHA.
Krizia Allison Basas, S.N
64
MY JOURNAL
Interns are provided with introductory experiences and close staff supervision in counseling
patients. This is typically a fourth week rotation. Common patient diagnoses are
hypertension,CVA,Dengue fever,ESRD and ect. The focus of this experience is on developing
skills in planning care, counseling, and documenting care provided. This includes setting
priorities, long-term goals, and behavioral objectives for patients.
The last two weeks of our exposure here in the rendu ward there are lots of happy and sad
happenings happened. There are times that Ma’am Bengan always reminding us about our
medications and our vital signs. There are also bloopers in our charting. There are also sad
things that we’ve experience especially if Ma’am Bengan is not in mood and she is always telling
that we should be serious to our duty and we should have our commonsense also the presence
of mind.
I have experience that Ma’am Bengan was telling me if I have any problem because my
charting is wrong and she don’t know what she should do to me, but I was only listening to her
because I know that it is for my own good and she is only reminding me that I should be attentive
and I should be focused of the things that I was doing. Everytime that the doctors are doing their
rounds it is important for us to go with them because there are many things that we can learn
from them.
We’ve learned lots of things here in the Rendu Ward especially the five rights of giving
medications, the do’s and dont’s of medications used the proper charting and procedures that we
can be seen in the actual
We are very thankful because we have a clinical instructor that is always there for us to
reminding us of our duty in rendering of care to our patient.Clinical experience is very important!
Students must get experience in a medical environment in order to make an informed decision to
pursue a career in medicine. we should not think of clinical experiences simply in terms of putting
in a requisite number of hours to meet a minimal requirement for admission to medical school. As
important as devoting the time to gaining this experience is what you learn through it. Clinical
experience can have an added benefit for premed students.Nurses dispense comfort,
compassion, and caring without even a prescription.
Akemie C. Campos, S.N
65
MY JOURNAL
After 2 weeks of my exposure again in the Blessed Rosalie Rendu Ward with Mrs.
Katherine Conlu-Bengan, I have learned and experienced a lot of things, things that I am only
lucky enough to see and learn because of my chosen career.
On the first day, I was assigned to a patient who for proctosigmoidoscopy or the
endoscopic viewing of the rectum and the sigmoid colon and hemorrhoidectomy or a surgical
procedure to repair hemorrhoids. I was also assigned to a patient who was diagnosed to have
Myocardial Infarction but she was for discharge that morning so I wasn’t able to handle her for the
whole shift.
On the second day, I was still assigned to a same patient and that day was the day before
her operation. She was advised to have a clear liquid diet, in preparation for her operation. I was
able to apply the necessary preoperative care for her based from what I have seen and
experienced when my mother had also a surgery. On that day, Dr. B. made her rounds to check if
the patient is ready and if there are no contraindications for the surgery, fortunately there was
none.
I assessed also my patient’s emotional status, if she is anxious about what’s going to
happen to her and she said to me that yes, she is a little bit nervous but it helps her a lot, thinking
that she waited for this surgery to happen long time ago.
On our second week of exposure, I was assigned to an 8 year old girl who was diagnosed
to have UTI v/s Dengue Fever. During my care, I assessed her for signs of bleeding especially
when her platelet count dropped to 74 x 109/L (150-450 x 109/L), there was also a request for 2
packs of platelet concentration to be transfused to her.
On our second day of the week, my patient had successfully undergone a blood
transfusion. Her platelet and CBC was to be monitored that day. There was still no presence of
bleeding tendencies.
During this day also, one of our patients suffered from multiple injuries and he have a
Chest Tube Thoracostomy. Ma’am Bengan showed us how to assess for patients with this and
also she showed us what an oscillation in the tube looks like and also we assisted during the
ECG tracing. We’re lucky enough that we had actually seen those things after the recent
discussion in our OSCE.
Lucijane B. Bernas, S.N
66
MY JOURNAL
Clinical experience has been always an integral part of nursing
education. It prepares student nurses to be able of "doing" as well as
"knowing" the clinical principles in practice. The clinical practice stimulates
students to use their critical thinking skills for problem solving. Awareness of
the Existence of stress in nursing students by nurse educators and
responding to it will help to diminish student nurses experience of stress.
What I have learned for the 4 months of our clinical duty is to be more
responsible to handle my patient condition and the aims to work toward
better quality. I’ am very thankful to our CI’s who are not tired teaching us
when we are not sure in what we are doing in clinical area. I’m looking
forward to many things that I’m very eager and ecstatic to know about. I’m
hoping my nursing life will awaken my curiosity regarding other people’s
condition.
Joerez Ivan Rufino, S.N
67
MY JOURNAL
In our last two weeks of rotation of duty in the Blessed Rosalie Rendu Ward had
left me with so many experiences that thought me a lot of things to remember.
Experiencing in the clinical setting makes me feel excited of my future job as a nurse
someday but sometimes there are things that bothers me that makes me feel nervous. In
doing our charting it enhances my skill and ability in doing it. I always instilled on my mind
that I must be relaxed and do the things that is necessary to correct every time I’m in the
clinical area. I must do everything correctly for the benefit of my patients. It is good and
relieving feeling that the patient that I handled will be discharges immediately. I’ve
learned how to be responsible nurses especially in doing our works and I’ve challenged
to perform my task well as a student nurse and to be able to perform correct and effective
nursing care to my patient.
Christine Joy Dunton, S.N
68
ACKNOWLEDGEMENT
It’s certainly been weeks of demanding and challenging coursework and activities.
Yet instead of tearing many apart, we managed to work and be able to present ourselves
today in front of those who took so many risks just by teaching us and moulding us as
competent future nurses.
We would forever be grateful to them. We can say that they are our angels who
walk with us during our journey. And who are they? They are our adored and honored
clinical instructors. Starting with the most glowing and cheerful CI, Mrs. Edrelyn
Venturanza, who taught us how to manage our hectic days and works with radiant
attitudes. To the ever charming and smart CI, Ms. Maureen Patricio who taught us that
we should have the focus even in the smallest things that we do in the ward. And last but
certainly not the least, our clinical instructor for the past 2 weeks, the ever sophisticated
and our dearly loved Mrs. Katherine Conlu-Bengan.
“We can all heal, we can all save lives: we should just start to care about what we
have yet to do, rather than waste our time to do pointless things and focusing on what we
have failed to achieve”, that is what Ma’am Bengan has taught us. That is what her
criticisms have instilled in our minds and hearts. Without her looking out for us, making
sure that we don’t get into any messes, without her uplifting words and advices, that in
this point forward, we should start to become matured individuals and improve our
performance, we wonder if we can still be able to manage everything around us
especially those things that we should prioritize.
69
With countless reasons, our group would like to personally thank her for staying
with us, sharing laughs with us, for being patient with us and most especially, for sharing
her wisdom with us.
After several days of our duty with her in the BRRW, we already felt a sense of
accomplishment, because we have faced challenges that we never expected to have.
Her efforts to teach us made us realize that we wanted to be able to do things even as
not perfect as they should be, but enough to make her smile and lessen her worries for
us.
Whoever we are right now, in the field of nursing, are direct results of all the
teachings and flaws. We were also inspired by the saying: “Diamonds need pressure to
come into beings”, and so maybe, it would help if we think about it that way.
We will always try to remember patience and grace and hold on to the words that
our dear clinical instructors held on to when we tried their patience and grace once upon
our lives.
BSN III-B
Group I
70

ESRD-3rd Yr-1st Sem

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TABLE OF CONTENTS

VII. CLINICAL INSPECTION

VIII. LABORATORY AND DIAGNOSTIC DATA

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

4. Review the anatomy and physiology of the organ affected.

5. Understand the pathophysiology of the disease.

3. To be able to develop respect and trust.

Glomerulonephritis is the main cause of ESRD worldwide (11% – 49%). Proliferative

The KIDNEYS are known as

The average adult kidney weighs

TWO PARTS OF RENAL PARENCHYMA:

- (latin renes medulla = kidney middle)

MAJOR FUNCTIONS OF KIDNEY:

 Regulation of water excretion

 Regulation of electrolyte excretion

 Regulation of acid-base balance

 Autoregulation of blood pressure

Rennin converts angiotensinogen to angiotensin I, which is then converted to angiotensin

The adrenal cortex secretes aldosterone in response to poor perfusion or increasing

It is the ability of the kidneys to clear solutes from the plasma.

 Regulation of red blood cell production

 Excretion of waste products

Persons with the following conditions:

 Excessive intake of drugs

 Changed smoker and alcoholic beverages drinker.

 Polycystic kidney disease

 Repeated episodes of pyelonephritis

 Sickle cell disease

changes in the body fluids or sometimes from

- Severe condition from reduced blood circulation and it occurs because of

- Is the inflammation of the pericardium. Due to retention of toxic substances as a

- It is an intellectual deficit due to hydroxylysinuria. It is a rare syndrome

- A profound or deep state of unconsciousness. The affected individual is alive but

 Dialysis for hyperkalemia & fluid imbalances.

 Emergency pericardiocentesis or surgery for cardiac tamponade.

 Peritoneal or hemodialysis to help control end-stage renal disease.

 Symptomatic treatment of ESRD

 Blood testing levels

- It determines the kidney size and presence of masses, cysts, obstruction in

 Computed tomographic/ Magnetic resonance imaging

- It demonstrates the vessel disorders and kidney mass.

- It demonstrates the size of kidneys/ureters/bladder and presence of obstruction

- It assesses renal circulation and identifies extravascularities, masses.

- It outlines abnormalities of renal pelvis & ureters.

- Assess renal circulation and identifies extravascularities, masses.

- It shows bladder size, reflux into ureters, retention.

 Renal endoscopy, nephroscopy

- May be abnormal, reflecting electrolyte and acid-base imbalances.

- May be performed to identify metabolic encephalopathy.

 X-ray of feet, skull, spinal column & hands

- May reveal demineralization/ calcifications resulting from electrolyte shifts

 Provide good perineal care using mild soap & water.

 Offer small, nutritious & palatable meals.

B. Past Health Problem

Daily Activity Patterns:

Once or twice a day Once every 2 or 3 He experienced None

Urinates whenever Urinates whenever None Has difficulty in

-High school graduate. He also started a course of Criminology at Filamer Christian

-He is a dicer in Black & White.

-They belong in the middle class of economic level in this society.