I.

Introduction The researcher choose this case for case study to help in imparting knowledge, skills, and attitude to student nurses on how acute renal failure affects the entire body system of a certain patient and how it is all about including its pathophysiology, signs and symptoms and its management which includes pharmacological, medical and surgical approach. Understanding the kidneys and the consequences of this disease enables the nurse to anticipate physiologic changes and plan interventions to address them. This case study will also serve as a guide and a tool at the same time in planning care to patients with acute renal failure which is the core of nursing practice, to render holistic nursing care. After the case study, the researcher expects to meet her goals and objectives towards the care of her patient. The researcher anticipates to promote the patients health to its optimal level. In order to prevent complications, the researcher also expect that her patient will be able to understand and utilize the knowledge she just had imparted to her. Renal failure is a condition in which the kidneys fail to remove metabolic end products from the blood and regulate the fluid, electrolyte, and pH balance of the extracellular fluids. The underlying cause may be renal disease, or urologic defects of nonrenal origin. Acute renal failure is abrupt in onset and often is reversible if recognized early and treated appropriately. In contrast, chronic renal failure is the end result of irreparable damage to the kidneys. It develops slowly, usually over the course of a number of years. Acute renal failure represents a rapid decline in renal function sufficient to increase blood levels of nitrogenous wastes and impair fluid and electrolyte balance. Unlike chronic renal

failure, acute renal failure is potentially reversible if the participating factors can be corrected or removed before permanent kidney damage has occurred. Acute renal failure is a common threat to seriously ill persons in intensive care units, with a mortality rate ranging from 42% to 88%. Although treatment methods such as dialysis and renal replacement methods are effective in correcting life threatening fluid and electrolyte disorders, the mortality rate from acute renal failure has not changed substantially since 1960s. this probably is because acute renal failure is seen more often in older persons than before, and because it frequently is superimposed on other life threatening conditions such as trauma, shock, and sepsis. The most common indicator of acute renal failure is azotemia, an accumulation of nitrogenous wastes in the blood. In acute renal failure the glomerular filtration rate is decreased. As a result, excretion of nitrogenous wastes is reduced and fluid and electrolyte balance cannot be maintained. Persons with acute renal failure often are asymptomatic, and the condition is diagnosed by observation of elevations in blood urea nitrogen and creatinine.

I. Objectives Student Nurse Centered: General Objectives: After 2 days of providing holistic nursing care and student nurse-patient interaction, the student nurse will be able gain knowledge, acquire skills and shows positive attitude to accommodate general lifestyle changes appropriate for her patients condition, and incorporate it into her patients activities of daily living to promote optimum level of functioning. Specific Objectives: After 8 hours of providing holistic nursing care the student nurse will be able to:
1. establish rapport to the patient.

2. relate the family and the individual information, social and health history to present health status. 3. explain the level of growth and development of the patient in relation to her physical, mental, emotional and social changes experienced. 4. define the present profile of functional health patterns. 5. point out the normal anatomy and physiology of the organ systems affected. 6. construct a schematic diagram on the pathophysiology of the disease process and its effect on the tissue or organ. 7. cite the disease process and its effect on different organs or systems.
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8. make the following: 8.1 Care guide of the patient 8.2 Nursing care plan 8.3 Health teaching plan
8.4 Drug therapeutic record

9. evaluate and recommend the following:

9.1 Prognosis of patient based on nursing assessment and rationale 9.2 Recommendation to promote early recovery and rehabilitation
11 provide evaluation and implication of this case study to nursing practice, nursing and

nursing research.

Patient Centered: General Objectives: After 2 days of providing holistic nursing care and student nurse-patient interaction, the patient will be able to gain knowledge, acquire skills and shows positive attitude towards her condition and management of her disease. Specific Objectives: After 8 hours of student nurse-patient interaction, the patient will be able to: 1. establish rapport towards the student nurse 2. discuss the factors that predispose and precipitates the occurrence of disease 3. participate with the student nurse in activities aimed at the patients holistic well being, such as in a health teaching
4. cooperate in procedures performed by the student nurse to the patient for

management and treatment, such as vital signs monitoring and taking in of medications 5. understand the disease process of her condition 6. able to utilize the knowledge and skills the student nurse have imparted if complication arises 7. comply with the physicians recommendations on her course of treatment.

III. Nursing Assessment 1. Personal History 1.1 Patients Profile name: Mrs. Abala, Claire Absuelo age: 36 years old sex: female civil status: married religion: Roman Catholic date of admission: July 16, 2011 @ 10:25am complaints: urinary frequency and difficulty of urination diagnosis: Acute Renal Failure physician: Dr. Pino A case of Mrs. Claire Abala, 46 years old, female, Roman Catholic, married to Froilan Abala, Jr. and been raising three daughters. About two weeks prior to admission, patient had onset of joint pain, she tolerated her condition. Three days prior to admission, patient noted urinary frequency and difficulty in urination. Mrs. Abala sought consult due to persistence of her condition and creatinine elevation was noted thus admitted last July 16, 2011 @ 10:25am at Mactan Doctors Hospital. Medical history shows positive for hypertension and was diagnosed three years ago. Familial history reveals hypertension on mothers side, her father died because of liver cancer.

1.3 Level of Growth and Development 1.3.1 Normal Development at Young Adulthood PHYSICAL DEVELOPMENT Young adults is the period between 12-36 years old. The young adult has usually completed physical growth by the age of 20. Young Adults are usually quite active, experiences severe illness less commonly than older age-group, tend to ignore physical symptoms, and often postpone seeking health care. In their early 20s they are at their prime year physically. The musculoskeletal system is well developed and coordinated. This is the period when athletic endeavors reach their peak. All other systems of the body (e.g. circulatory and reproductive) are also functioning at peak efficiency. COGNITIVE DEVELOPMENT Critical Thinking habits increase steadily through the young and middle adult years. Formal and informal educational experiences, general life experiences, and occupational opportunities dramatically increase the individuals conceptual, problem-solving and motor skills. Identifying preferred occupational area is a major task of young adults. When people know their skills, talents, and personality characteristics, educational preparations and occupational choices are easier and more satisfying. Many young adults, however, lack the resources or the support systems to facilitate further support systems to facilitate further education or the development of skills necessary for
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many positions in the workplace. As a result, some young adults may have limited occupational choices. MORAL DEVELOPMENT Young adults now enter the post conventional level. At this time, the person is able to separate self from the expectations and rules of others and to define morality in terms of personal principles. When individuals perceive a conflict with the societys rules and laws, they judge according to their own principles. PSYCHOLOGICAL DEVELOPMENT The young adult belong in the stage of Intimacy vs. Isolation in Eriksons Psychological Theory. Young adults are viewed as developing an intimate, lasting relationship with another person or a cause, institution, or a creative effort. If young persons have not achieved a sense of personal identity, they may experience feelings of isolation from others and the inability to form meaningful attachments.

1.3.2 The Ill Person During Acute Renal Failure

The young adult years are generally a time of good physical and emotional health. Potential health hazards may be related to lifestyle. Acute care for young adults is frequently related to accidents, substance abuse, exposure to environmental and occupational hazards, stress-related illnesses, respiratory infections, gastroenteritis, influenza, urinary tract infections, and minor surgery. An acute minor illness can cause a disruption in life activities of the young adult and increase stress in an already hectic lifestyle. Dependency and limitations posed by treatment regimens can also increase frustration for the young adult. To give young adults a sense of maintaining control of their health care choices, it is important to keep them informed about their health status and involve them in health care decisions. Patient with acute renal failure may definitely feel anxious about their present condition. This disease might be acute but without proper management, it may further lead to a more progressive disease. Thus, with regards to this case, the student nurse took charge of providing holistic nursing care for her patient with acute renal failure. The patient had a good positive response to the nursing interventions the student nurse has provided for promoting her optimal health level. The patient cooperates specially in vital signs taking, medication therapy and health teaching. Though the patient feels weak, shes still very responsive to the questions asked more particularly about her intake and output. The patients behavior while still under the student nurses care exhibits a good, positive attitude although she was ill. The patient was able to manage her attitude towards the student nurse who provided care in order to prevent further complication of her disease. 2. Name of Patient: Mrs. Abala, Claire Absuelo
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Room no.: FM1 Age: 36 years old DIAGNOSTIC TESTS DIAGNOSTIC NORMAL TEST VALUES URINE CHEMISTRIES: 24hr urine 600-1600ml/24hour volume PATIENTS RESULT SIGNIFICANCE

2,225ml/24hr

-increased May be due to medication such as diuretics (IgnataviciusWorkman, MedicalSurgical Nursing, th vol.2., 8 ed., p. 1753) -increased May be due to glomerular damage (IgnataviciusWorkman, MedicalSurgical Nursing, th vol.2., 8 ed., p. 1753) -increased may appear prior to the development of high blood pressure, heart disease or chronic kidney disease. (http://www.mayoclini c.com/health/highuric-acidlevel/MY00160) -increased

Total protein

42-225mg/24hr

45mg/dl=1001.25mg/24hr

Uric acid

250-750mmol/24hr

8.3mg/dl=184,675mg/24hr

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Creatinine

0.7-1.2mg/dl

3.2mg/dl

May be due to disease condition (http://www.medicinen et.com/creatinine_bloo d_test/page2.htm)

CHEMISTRY FBS Uric acid

70-100mg/dl 2.7-7.3mg/dl

89.58mg/dl 9.75mg/dl

-normal -increased may appear prior to the development of high blood pressure, heart disease or chronic kidney disease. (http://www.mayoclini c.com/health/highuric-acidlevel/MY00160) -normal -increased Hypertensive patient may have a high cholesterol level (http://www.jhsph.edu/ publichealthnews/press _releases/PR_2000/ch olesterol_kidney.html) -increased Due to increase cholesterol level (http://www.jhsph.edu/ publichealthnews/press _releases/PR_2000/ch olesterol_kidney.html) -decreased Seen in patients with hypertension

SGPT/ALT Cholesterol

4-41u/l <200mg/dl

14u/l 218.19mg/dl

Triglyserides

10-190mg/dl

193.11mg/dl

Lipoprotein HDL

>65mg/dl

55.83mg/dl
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(http://www.jhsph.edu/ publichealthnews/press _releases/PR_2000/ch olesterol_kidney.html) -normal -normal -normal

LDL VLDL CHON/HDL ratio

<130mg/dl 2.06-38.0mg/dl <4.40

123.74mg/dl 38.0mg/dl 3.91

3. Functional Health Patterns 1. Health Perception-Health Management Pattern Mrs. Abala describes her condition fairly well. Although she is experiencing anxiety regarding the disease shes been diagnosed to. She follows all the physicians order and cooperates with the
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health provider in treating her condition. She sometimes felt worried regarding the possible outcome of her condition 2. Nutritional-Metabolic Pattern Prior to admission, the patient eats three times a day and sometimes take some snacks in between meals. She has a good appetite. She usually eats vegetables a lot. She also drinks a lot of water, more than 8 glasses a day. She also has vitamins, ferrous sulfate, and she takes it every day. She stated that she dont have any food allergies. During admission, patient had a less appetite to eat and considers the food restriction as the mere cause of it. She doesnt want to eat the foods being served in the hospital because she was not very much used to it and sometimes dont like the taste of the food. 3. Elimination Pattern The patient do have problem in urinating. Prior to admission, she experiences urinary frequency and difficulty in urination. She usually eliminates urine 4-10 times a day, 30-40 cc in amount per voiding and yellow in color. She experiences pain upon urination. She defecates regularly, everyday, early morning. No assistive devices are used. Skin condition is warm, dry and poor skin turgor. Presence of edema noted on lower extremities, particularly the right foot and is nonpitting. 4. Activity/ Exercise Pattern Prior to admission, the patient usually jogs and considers doing household chores as her means of exercise. She does not experience difficulty in moving nor doing self care activities. Patient works as a customer services representative. She works almost 10 hours a day for the said firm.
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Patient verbalized that she felt tired and stressed out of her work. During admission, patient feels so weak and has a decreased chances in performing activities of daily living such as combing her hair. 5. Cognitive/ Perceptual Pattern Mrs. Abala does not wear glasses and no hearing aid is used. She is able to read and write, as well as communicate in Cebuano and Tagalog. She is oriented and has no psychological complaints. 6. Sleep / Rest Pattern Before admission, Mrs. Abala gets enough rest and sleep averaging 7-8 hours of sleep a day. But when she was admitted she had problems in sleeping because of the unfavorable environment and because of the anxiety she felt about her condition. 7. Self- Perception Pattern Mrs. Abala is very hopeful that her condition be treated. She is more concerned about getting well and be able to go home. She feels different from her present condition, fearing that medications and diagnostic tests she will undergo.

8. Role Relationship Pattern The patient speaks in Cebuano. She speaks clearly and fluently can express herself and understand others well. She is a college graduate and has been in Cebu since she was married to

14

Mr. Froilan Abala, Jr. She is originally from Bohol. She is currently residing in Basak, LapuLapu now, where her work is as a customer services representative. 9. Sexuality- Reproductive Pattern Mrs. Abala has a regular menstruation every month. She usually consumes 3-4 pads per day. Her menstruation lasts 3-5 days during onset of menstruation. She has an active sexual relationship with her husband and considers it as a positive sign of a good relationship with her husband. 10. Coping- Stress Tolerance Pattern When it comes to health and financial decisions, Mrs. Abala is the one who decides the most although there are also times wherein her husband also helps in making decisions regarding financial situations. When problem arises, Mrs. Abalas family help her in making her not feel alone. Seeing her children in good condition, usually covers all of her stress away. Moreover, with her good mutual relationship with her husband, she easily copes up with her problems.

11. Value- Belief System As a child raised in a Roman Catholic Family, Mrs. Abala has this great faith in God and does her best to live a good Christian life. She finds strength and meaning in her daily prayers, energizing her at the start of the day and securing her at night. 4. Pathophysiology and Rationale 4.1 Normal Anatomy and Physiology

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The kidneys are bean-shaped organs, each about the size of a tightly clenched fist. They lie on the posterior abdominal wall, behind the peritoneum, with one kidney on either side of the vertebral column. Structures that are behind the peritoneum are said to be retroperitoneal. A connective tissue renal capsule surrounds each kidney. Around the renal capsule is a thick layer of fat, which protects the kidney from mechanical shock. On the medial side of each kidney is the hilum, where the renal artery and nerves enter where the renal vein and ureter exit the kidney. The hilum opens into a cavity called the renal sinus, which contains blood vessels, part of the system for collecting urine , and fat. The kidney is divided into an outer cortex and an inner medulla, which surround the renal sinus. The bases of several cone-shaped renal pyramids are located at the boundary between the cortex and the medulla, and the tips of the renal pyramids project toward the center of the kidney. A funnel-shaped structure called calyx surround the tip of each renal pyramid. The calyces from all the renal pyramids join to form a larger funnel called renal pelvis. The renal pelvis then narrows to form a small tube, the ureter, which exits the kidney and connects to the urinary bladder. Urine passes from the tips of the renal pyramids into the calyces. From the calyces, urine collects in the renal pelvis and exits the kidney through the ureter. The functional unit of the kidney is the nephron, and there are approximately 1.3 million of them in each kidney. Each nephron consists of a renal corpuscle, a proximal tubule, a loop of Henle, or a nephronic loop and a distal tubule. Fluid enters the renal corpuscle and then flows into the proximal tubule. From there, it flows into the loop of Henle. Each loop of Henle has a descending limb, which extends toward the renal sinus, and an ascending limb, which extends back toward the cortex. The fluid flows through the ascending limb of the loop of Henle

16

to the distal tubule. Many distal tubules empty into a collecting duct, which carries the fluid from the cortex, through the medulla. Many collecting ducts empty their contents into a calyx. The renal corpuscle and both convoluted tubules are in the renal cortex. The collecting duct and loop of Henle enter the medulla. Approximately 15% of the nephrons, called juxtamedullary nephrons, have loops of Henle that extend deep into the medulla of the kidney. The other nephrons, called cortical nephrons, have loops of Henle that do not extend deep into the medulla. The renal corpuscle of the nephron consists of Bowmans capsule and the glomerulus. Bowmans capsule consists of the enlarged end of the nephron, which is intended to form a double-walled chamber. The indentation is occupied by a tuft of capillaries called the glomerulus, which resembles a ball of yarn. The cavity of Bowmans capsule opens into the proximal tubule, which carries fluid away from the capsule. The inner layer of the Bowmans capsule surrounds the glomerulus and consists of specialized cells called podocytes. The outer layer of Bowmans capsule consists simple squamous epithelial cells. The glomerular capillaries have pores in their walls, and the podocytes have cell processes with gaps between them. The endothelium of the glomerular capillaries, the podocytes, and the basement membrane between them form a filtration membrane. In the first step of urine formation, fluid called filtrate is filtered from the glomerular capillaries into Bowmans capsule through the filtration membrane. Most of the nephron and collecting duct are made up of simple cuboidal epithelium. However, the thin segment of the descending and ascending limbs of Henles loophave very thin walls made up of simple squamous epithelium. The cells of the proximal tubules, thick segment
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of the ascending limb of Henles loop, distal tubules, and collecting ducts have microvilli and many mitochondria. The proximal tubule, thick segment of the Henles loop, and the collecting duct actively transport molecules and ions across the wall of the nephron. The thin segment of the descending limb of Henles loop is very permeable to water and solutes, and the thin segment of the ascending limb is permeable to solutes, but not to water.

Urinary System

18

SCHEMATIC DIAGRAM
PREDISPOSING FACTORS 19 PRECIPITATING FACTORS

PREDISPOSING FACTORS

- age - gender

- diabetes mellitus - hypertension - renal insufficiency - heart failure - kidney failure - liver disease - environment

rapid in renal function

Collection of metabolic waste in the body

Sudden decrease in kidney function and to the affected kidney sites

Reduced blood flow, tubular ischemia, infection

Malfunction in glomerular filtration glomerular filtration stops

tubular cell injury tubular cells slough off and combine with other formed elements obstruct the tubular lumen and prevent urine outflow; blood vessel constriction reduced renal blood flow renal ischemia

20

Collection of nitrogenous waste in the blood increases the blood urea nitrogen and serum creatinine level

oliguria

MANIFESTATIONS
- Swelling, especially of the legs and

feet. - Little or no urine output. - Thirst and a dry mouth. - Feeling dizzy when you stand up. - Loss of appetite - Feeling confused, anxious and restless, or sleepy. - Pain on one side of the back, just below the rib cage and above the waist (flank pain).

Renal failure

4.4 Signs and Symptoms

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Classical Symptoms

Clinical Symptoms

Rationale

1. edema, especially of the 1. manifested (non-pitting Edema may be present on legs edema on the right foot) patients with acute renal failure due to malfunction of the kidneys that causes water retention (Ignatavicius-Workman, Medical-Surgical Nursing, th vol.2., 8 ed., p1729) 2. little or no urine output 2. manifested (oligura) urine per day) (<400ml of With tubular cell damage, tubular cells slough and combine with other formed elements, which then obstruct the tubular lumen and prevent urine outflow. (Ignatavicius-Workman, Medical-Surgical Nursing, th vol.2., 8 ed., p1729) 3. thirst and a dry mouth 3. not manifested Due to excessive retention in the body water

(Ignatavicius-Workman, Medical-Surgical Nursing, th vol.2., 8 ed., p1729) 4. feeling dizzy when standing 4. not manifested May be due to decreased circulation of oxygenated blood in the brain which results from reduced blood flow (Ignatavicius-Workman, Medical-Surgical Nursing, th vol.2., 8 ed., p1729) 5. loss of appetite 5. manifested (anorexia) Patient with acute renal failure may have this dietary restrictions in which patient was not able to adjust to the

22

new set of foods provided (Brunner and Suddarth, textbook of medical surgical nursing, 11th ed., p. 1526) 6. pain on one side of the back 6. manifested (manifested Due to acute damage of the upon performing kidney kidney punch during assessment) (Brunner and Suddarth, textbook of medical surgical nursing, 11th ed., p. 1526)

4.3 Discussion of the Disease Process Acute renal failure (ARF) is a reversible clinical syndrome where there is a sudden and almost complete loss of kidney function over a period of hours to days with failure to excrete
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nitrogenous waste products and to maintain fluid and electrolyte homeostasis. Although ARF is often thought of as a problem seen only in hospitalized patients, it may occur in the outpatient setting as well. ARF manifests as an increase in serum creatinine and BUN. Urine volume may be normal, or changes may occur. Possible changes include oliguria, nonoliguria, or anuria. Although the exact pathogenesis of ARF and oliguria is not always known, many times there is a specific underlying problem. Some of the factors may be reversible if identified and treated promptly, before kidney functions is impaired. This is true of the following conditions that reduce blood flow to the kidney and impair kidney function: (1) hypovoleia; (2) hypotension; (3) reduced cardiac output and heart failure; (4) obstruction of the kidney or lower urinary tract by tumor, blood clot or urinary stone; (5) bilateral obstruction of the renal arteries or veins. Although renal stones are not a common cause of ARF, some types may increase the risk for ARF. Some hereditary stone diseases, primarily struvite stones, and infection-related urolithiasis associated with anatomic and functional urinary tract anomalies and spinal cord injury may cause recurrent bouts of obstruction as well as crystal-specific damage to tubular epithelial cells and interstitial renal cells.

IV. Nursing Interventions Excess fluid volume related to decreased urine output - asses fluid status
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- limit fluid intake to prescribed volume - identify potential sources of fluid - explain to patient and family rationale for fluid restriction - assist patient to cope with the discomforts resulting from fluid restrictions - provide frequent oral hygiene

Imbalanced nutrition less than body requirements related to inability to ingest adequate nutrients in addition to therapeutic dietary restriction - asses nutritional status - provide patients food preferences within dietary restrictions
- encourage high-calorie, low protein, low-sodium, and low-potassium snacks between meals

- promote intake of high biologic value protein foods: eggs, dairy products, meats - alter schedule of medications so that they are not given immediately before meals - explain rationale for dietary restrictions and relationship to kidney disease and increased urea and creatinine levels - provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium.

25

Activity intolerance related to fatigue - asses factors contributing to intolerance] - promote independence in self-care activities as tolerated - encourage alternating activity with rest - adjust activities - promote comfort measures - assist client and demonstrate appropriate safety measures - suggest use of relaxation techniques, such as visualization and guided imagery

1. Nursing Assessment BODY PARTS Head INSPECTION PALPATION and pain PERCUSSION AUSCULTATION

Round, Smooth normocephalic hard, no and felt proportionate to

26

the body Forehead Brown in Smooth surface, complexion, no pain felt blackheads and pimples noted Black in color, Thick unfixed hair straight noted, covers the scalp, absence of lice hair,

Hair

Scalp

Lighter than the Smooth and no skin complexion, pain no dandruff, no lice Oblong in shape, No pain felt brown in complexion, mole noted at the upper left cheek Symmetrically aligned with each other, black in color Aligned with Smooth and dry, each other, no pain felt evenly distributed, black in color Present on both sides, curled slightly upward, black in color

Face

Eyes

Eyebrows

Lashes

Upper and lower Symmetrical, no lids swelling Sclera Anicteric sclera, prominent blood
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vessels noted Conjunctiva Pupil Moist, pale, no lesions Black in color, pupil on both eyes are equally round, reactive to light and accommodation Aligned, unusual movement no eye

Muscle function

Muscle balance Nose

Blinks symmetrically In midline of the No pain felt face, brown in color, no discharges present No swelling No pain felt around the area No swelling No present No pain felt Flat sound heard

Frontal sinus Maxillary sinuses Mouth

lesions No pain felt

Lips

Dry, pinkish in No pain felt, color, cracked, rough to touch no inflammation Moist, pink in No pain felt color, no lesions Whitish in color, 32 teeth present In midline of the
28

Gums Teeth Tongue

mouth, moist, pinkish in color, moves freely Frenulum Attached at the base of the tongue Concave, light pink in color Pink in smooth moist color, and

Hard palate Soft palate

Uvula

In midline of the throat, pinkish tonsils are present Pink and moist, non inflamed Bilaterally symmetrical No masses, no pain felt

Tonsils Ears External Internal

Equal in size, no No pain felt swelling Cerumen are moist upon viewing with the use of penlight Able to hear, able to respond when she is called In midline of the No pain felt head, able to move, no scars, no lesions In midline of the Flat sound over
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Auditory acuity

Neck

Trachea

neck Chest anterior Brown in color, No lumps, no presence of masses, no pain brown spots, no felt lesions present RR: 22cpm

clavicle and ribs

Lungs

Resonant sound heard upon auscultation, no crackles heard Tympany is Bowel sounds are heard on the audible stomach area and dullness on the other areas Kidneys: slight pain felt during kidney punch

Abdomen

Flat, smooth No pain felt surface, thin hair visible and is evenly distributed Non-palpable Fine hair present Warm to touch, and is evenly no pain felt distributed, skin is brown in color, poor skin turgor. Weakness noted Fine hair present and is evenly distributed, skin is brown in color, poor skin turgor. Weakness on lower extremities and edema noted at the right foot Patient was not able to resist upon exhibition of the muscle strength test on
30

Kidney, liver and spleen Upper extremities

Lower extremities

Warm to touch, no pain felt, non-pitting edema

Muscle strength

both upper and lower extremities, weakness on both areas noted gait and Patient was not coordination able to walk accordingly and needs assistance during ambulation

2. Nursing Care Plans Problems Physiologic overload: Edema Objective cues: - Oliguria ( <400 cc/ day of Nursing diagnosis Fluid volume overload: Edema related to decreased urine output Scientific basis Acute renal failure is a sudden and almost complete loss of kidney function over a period of Objectives of care After 3 days of holistic nursing care, the patient will be able to stabilize fluid volume as evidence by Nursing interventions Measures to stabilize fluid volume: Rationale

1. weigh daily Provides a or on regular comparative schedule, as baseline indicated

31

urine output prior to intake of medicatio ns) - Dry, poor skin turgor - Restless - Edematous foot, right, nonpitting Subjective cues: na-worry lang ko day ba kay taggagmay na lang jud ang akung ihi unya nanghupong pud ku

hours to days. balance I/O ARF manifests oliguria, anuria, and normal urine output are not as common. Thus, when there is less waste product excreted such as urine into normal daily urine output, decreased urine output is the most common outcome followed by edema. Source: Medicalsurgical nursing, Brunner and Suddarth, p. 1321, vol 2, 8th edition

2. limit fluid intake to prescribed volume

Fluid restriction will be determined on basis of weight, urine output, and response to therapy Unrecognized sources of excess fluids may be identified Understanding promotes patient and family cooperation with fluid restriction Increasing patient comfort promotes compliance with dietary restrictions

3. identify potential sources of fluid 4. explain to patient and family rationale for fluid restriction 5. assist patient to cope with the discomforts resulting from fluid restriction

6. provide Oral hygiene frequent oral minimizes hygiene dryness of oral mucous membranes 7. administer To provide medications treatment of as ordered the disease Source: textbook medical32

of

surgical nursing, Brunner and Suddarth,p. 1532, 11th ed.

Problems Physiologic deficit: Imbalanced nutrition Objective cues: - Pale conjunctiva -weakness of

Nursing Diagnosis Imbalanced nutrition: less than body requirements: decreased appetite related to dietary restrictions

Scientific Basis ARF causes nutritional imbalances, impaired glucose use and protein synthesis and increased tissue catabolism. Dietary

Objectives of Care After 8 hours of holistic nursing care, patient will be able to improve her appetite on the foods serve per dietary restrictions
33

Nursing Interventions Measures to improve appetite: 1. provide frequent oral hygiene

Rationale

Frequent oral hygiene will keep oral mucous membranes moist and stimulate

muscles due to food restriction - decreased appetite to eat -cracked lips due to inadequate food intake Subjective cues: wala jud kuy gana mukaon day kay wala ku maanad s mga pagkaon nga ila ginapakaon naku. Dili ku ganahan

restrictions are required in patient with ARF so as to maintain and minimize nutritional imbalances. Patient on this stage seems to have a hard time in adjusting his new set of diet and takes time to get used to eat the new set of foods serve. Proper supervision is then advised. Source: Brunner and Suddarth, textbook of medical surgical nursing, 11th ed., p. 1526

saliva production, which can help increase the patients oral intake 2. provide patients food preference within dietary restrictions 3. promote intake of high biologic value protein foods: eggs, dairy products, meats 4. encourage high-calorie, low sodium, and lowpotassium snacks between meals 5. alter schedule of medications so that they are not given immediately before meals 6. explain rationale for dietary restrictions and relationship to kidney disease and Increased dietary intake is encouraged

Complete proteins are provided for positive nitrogen balance Reduces source of restricted food and proteins and provides calories for energy Ingestion of medication before meals may produce anorexia and feeling of fullness Promotes patient understanding of relationships between diet and urea and creatinine

34

increased urea levels to renal and creatinine disease levels 7. provide written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium Lists provide a positive approach to dietary restrictions and a reference for patient and family to use when at home

Problems Physiologic deficit: Fatigue Objective cues: -weakness -decreased chances to perform ADLs

Nursing diagnosis Activity intolerance: fatigue related to generalized weakness

Scientific basis Almost every system of the body is altered when there is failure of the normal renal regulatory mechanisms. The patient may appear clinically ill

Objectives of care After 8 hours of holistic nursing care, patient will be able to verbalize decrease weakness as evidence by capability to perform simple task
35

Nursing intervention Measures to decrease weakness: 1. provide a positive atmosphere, while acknowledging difficulty of the situation for the patient

Rationale

Helps to minimize frustrations, rechannel energy

(unfixed hair, unchanged clothes for 2days) -inability to walk without assistance Subjective cues: nkafeel jd kug pgkaluya krun day

and lethargic. Patient with ARF usually exhibits signs of fatigue, the skin and mucous membranes may be dry due to dehydration. Source: Brunner and Suddarth, textbook of medicalsurgical nursing, 11th ed., p.1523

like combing hair

2. promote independence in self-care activities 3. encourage alternating activity with rest

Promotes improved self-esteem Promotes activity and exercise within limits and adequate rest To prevent overexertion To protect client from injury To prevent injuries

4. adjust activities 5. assist with activities 6. assist client to learn and demonstrate appropriate safety measures 7.encourage client to use positive attitude: suggest use of relaxation techniques, such as visualization/ guided imagery

To enhance sense of wellbeing

Source: Brunner and Suddarth, textbook of medical surgical nursing, 11th

36

ed., p. 1534 & Marilynn Doenges, nurses pocket guide, 9th ed., p. 60-63

Patients name: Mrs. Abala, Claire Absuelo Complaints: difficulty in urination; urinary frequency SOAPIE # 01

Impression: Acute Renal Failure Physician: Dr. Pino

S na worry lang ko day ba kay tag-gagmay na lang jud ang akung ihi unya nanghupong pud ku.

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O seen patient lying on bed, conscious, coherent without intravenous fluid. Dry and poor skin turgor was noted. Non-pitting edema on the right foot was observed. Patient was restless upon interview. Oliguria noted urine output of <400 cc/day. A Excess fluid volume: edema related to decreased urine output P the patient will be able stabilize fluid volume as evidenced by balance intake and output I weighed daily; limited fluid intake to prescribed volume; explained to patient and family rationale for fluid restriction; assisted patient to cope with the discomforts resulting from fluid restriction; provided frequent oral hygiene; administered medications as ordered E patient has a stabilized fluid volume as evidenced by balance intake and output

Ms. Abigail Labayan, RN, MAN Clinical Instructress

Patients name: Mrs. Abala, Claire Absuelo Complaints: difficulty in urination; urinary frequency SOAPIE # 02

Impression: Acute Renal Failure Physician: Dr. Pino

S wala jud koy gana mukaon day kay wala ko maanad sa mga pagkaon nga ila ginapakaon naku. Dili ko ganahan jud.
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O seen patient sitting on bed, conscious, coherent, without intravenous fluid. Pale conjunctiva was noted upon assessment. Weakness of muscles was observed. Decreased appetite and

cracked lips was also observed upon assessment. A imbalanced nutrition less than body requirements: decreased appetite related to dietary restrictions P the patient will be able to improve her appetite on the foods serve per dietary restrictions I provided frequent oral hygiene; provided patients food preference within dietary restrictions; promoted intake of high biologic value protein foods: eggs, dairy products, meats; encouraged high-calorie, low-sodium, and low potassium snacks between meals; altered schedule of medications so that they are not given immediately before meals; explained rationale for dietary restrictions; provided written lists of foods allowed and suggestions for improving their taste without use of sodium or potassium E the patient was able to improve her appetite on the foods serve per dietary restrictions as evidence by verbalization of patients increased appetite level Ms. Abigail Labayan, RN, MAN Clinical Instructress

Patients name: Mrs. Abala, Claire Absuelo Complaints: difficulty in urination; urinary frequency SOAPIE # 03 S nakapamati jud kug pagkaluya karun day
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Impression: Acute Renal Failure Physician: Dr. Pino

O seen patient lying on bed, conscious, coherent, without intravenous fluid. Weakness noted. Decreased chances to perform ADLs (unfixed hair, unchanged clothes for 2days) was observed. Inability to walk without assistance was also noted. A activity intolerance: fatigue related to generalized weakness P patient will be able to verbalize decrease weakness as evidenced by capability to perform simple task like combing hair I provided a positive atmosphere, while acknowledging difficulty of the situation for the patient; promoted independence in self-care activities; encouraged alternating activity with rest;adjusted activities; assisted with activities; assisted client to learn and demonstrate appropriate safety measures; encouraged client to use positive attitude: suggest use of relaxation techniques, such as visualization/ guided imagery E patient was able to verbalize decrease weakness as evidenced by capability to perform simple task like combing hair

Ms. Abigail Labayan, RN, MAN Clinical Instruct 3. Drug Therapeutic Record Name of drug Colchicine 1 tab, BID PO Classification/ Mechanism of action Antigout Inhibits the migration of neutrophils into the area of inflammation. Indications/ Principles of Contraindications/ Care Side effects I: recurrent gouty - Monitor for arthritis; acute dose-related gout adverse effects C: blood dyscrasias; severe GI; renal, hepatic,
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Treatment - provide oral care - Encourage adequate rest - decrease fiber

-monitor for early signs of colchicines

Although it does not inhibit phagocytocis of uric acid crystals, it does not appear to prevent the release of an inflammatory glycoprotein from phagocytes in the inflammatory process

or cardiac disease; toxicity pregnancy including weakness and SE: nausea; abdominal vomiting; discomfort diarrhea; abdominal pain; -monitor I&O anorexia; ratio and pattern pancreatitis -keep physician informed of patients progress

diet - serve food according to patients preference within dietary restrictions - provide comfort - encourage patient to sleep in a right-sided position as possible

Name of drug

Allopurinol 100mg. 1 tab OD PO Allopurinol reduces endogenous uric acid by selectively inhibiting action of xanthine oxidase, the

Classification/ Mechanism of action Antigout agent

Indications/ Contraindications/ Side effects I: to control primary hyperurecemia that accompanies severe gout; to prevent possibility of flare-up of acute gouty attack
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Principles of Care -monitor for therapeutic effectiveness which is indicated by normal serum and urinary uric acid levels -monitor for

Treatment -encourage patient to drink enough fluid to produce urinary output of atleast 2000ml/d -provide adequate rest

enzyme responsible for converting hypoxanthine to xanthine and xanthine to uric acid.

C: hypersensitivity to allopurinol; idiopathic hemochromatosis; children except those with hyperurecemia secondary to neoplastic disease SE: drowsiness; headache; vertigo; nausea; vomiting;

signs and symptoms of an acute gouty attack -monitor patient with renal disorders more often

-perform oral care as necessary -assist patient in ambulation -provide care

Classification/ Mechanism of action Sulodexide 1 cap Antithrombotic BID PO Inhibits platelet aggregation by preventing fibrinogen, von Willebrands factor, and other molecules from adhering to GPIIb/IIIa

Name of drug

Indications/ Principles of Contraindications/ Care Side effects I: patient with -minimize all acute coronary vascular and syndromes other trauma during treatment C: hypersensitivity -immediately to eptifibatide; stop infusion active bleeding; medication if GI or GU bleeding at bleeding within arterial access 6weeks; site cannot be
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Treatment -provide adequate rest -improve patients comfort -increase ironrich food within dietary restrictions

receptor sites on platelets

thrombocytopenia SE: anemia

controlled by pressure -monitored carefully for signs and symptoms of bleeding

Name of drug Ketosteril 2 tabs 500mg BID PO

Classification/ Mechanism of action Ketoanalogues; essential amino acids

Indications/ Contraindications/ Side effects I: Protein energy malnutrition; Prevention and treatment of Normalizes conditions caused metabolic by modified or process, insufficient promotes protein recycling product metabolism in exchange. chronic renal Reduces ion failure
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Principles of Care - Evaluate for any contraindications - Take drug as prescribed - Warn the patient about possible side effects and how to recognize them

Treatment - Give with food if GI upset occurs - Frequently assess for hypercalcemia

concentration of potassium, magnesium and phosphate.

C: Allergy and hypersensitivity to any content of this drug Hypercalcemia; Disturbed amino acid metabolism; Caution use for patietn with phenylketonuria SE: Hypercalcemia may develop

Patients name: Mrs. Abala, Claire Absuelo Complaints: difficulty in urination; urinary frequency

Impression: Acute Renal Failure Physician: Dr. Pino

HEALTH TEACHING PLAN OBJECTIVES General objectives: After 8 hours of student nurse-patientsignificant others ineraction, the CONTENT METHODOLOGY EVALUATION

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patient and significant others will be able to gain knowledge, acquire skills and shows positive attitude towards her condition and management of her disease. Specific objectives: After 45 minutes of student nursepatientsignificant others interaction, the patient and significant others will be able to: 1. define acute renal failure Definition of Acute Renal Failure - Acute (sudden) renal failure is the sudden loss of the ability of the kidneys to remove waste and concentrate urine without losing electrolytes.

After 45 minutes of student nurse-patientsignificant others interaction, the patient and significant others was able to: Lecture discussion 1. define acute renal failure

2. identify the possible causes of acute renal failure

Possible causes of acute renal failure: Acute tubular necrosis (ATN) Autoimmune kidney disease, including: o Acute nephritic syndrome o Interstitial nephritis Decreased blood flow due to very low blood pressure, which can result from:
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Lecture discussion 2. identify the possible causes of acute renal failure

Burns Dehydration Hemorrhage Injury Septic shock Serious illness Surgery Disorders that cause clotting within the kidney's blood vessels: o Hemolytic-uremic syndrome o Idiopathic thrombocytopenic thrombotic purpura (ITTP) o Malignant hypertension o Transfusion reaction o Scleroderma Infections that directly injure the kidney, such as: o Acute pyelonephritis o Septicemia Pregnancy complications, including: o Placenta abruptio o Placenta previa Urinary tract obstruction
o o o o o o o

3. enumerate the symptoms of acute renal failure

Symptoms of acute renal failure; Bloody stools Breath odor Bruising easily Changes in mental status or mood Decreased appetite Decreased sensation, especially in the hands or feet Fatigue Flank pain (between the ribs and hips) Hand tremor
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Lecture discussion 3. enumerate the symptoms of acute renal failure

High blood pressure Metallic taste in mouth Nausea or vomiting, may last for days Nosebleeds Persistent hiccups Prolonged bleeding Seizures Slow, sluggish movements Swelling generalized (fluid retention) Swelling of the ankle, foot, and leg Urination changes: o Decrease in amount of urine o Excessive urination at night o Urination stops completely Lecture discussion 4. state the possible complications that may arise to patients with acute renal failure

4. state the possible complications that may arise to patients with acute renal failure

Possible complications: Chronic (long-term) kidney failure Damage to the heart or nervous system End-stage kidney disease High blood pressure Loss of blood in the intestines How to take a blood pressure Using a digital (DIJ-uhtull) blood pressure monitor: It is important to read the directions before using your blood pressure monitor. Each blood pressure monitor may work in a different way. The digital device may include an inflatable cuff and monitor. The device has a built-in pump which
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5. demonstrate proper blood pressure-taking

Discussion/ demonstration/ return demonstration

5. demonstrate proper blood pressure-taking

inflates the cuff. The blood pressure is shown on the digital display. The following steps may be helpful to take a blood pressure.

Sit up or lie down with the arm stretched out. The arm should be level with the heart. Put the cuff about 1 inch (2.5 cm) above the elbow. Wrap the cuff snugly around the arm. The blood pressure reading may not be correct if the cuff is too loose. Turn on the blood pressure monitor and follow the directions that come with the monitor. Write down your BP, the date, the time, and which arm was used to take the BP. Let the air out of the cuff. Turn off the monitor and take
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off the BP cuff.

Using a sphygmomanometer (sfigmo-man-OM-i-ter) and a stethoscope (STETH-uhskop): A sphygmomanometer is a device for measuring blood pressure. It includes an inflatable cuff, inflating bulb, and a gauge showing the blood pressure. The stethoscope has 2 earpieces, tubing, and a diaphragm (DI-uhfram) (flat disk at the end). It is used for listening to sounds from the body. Carefully read the directions before using your blood pressure kit. Each blood pressure kit may work in a different way. The following steps may be helpful to take a blood pressure.

Sit up or lie down with the arm stretched out. The arm should be level with the heart. Put the cuff about 1 inch (2.5 cm) above the elbow.
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o o

Wrap the cuff snugly around the arm. The blood pressure reading may not be correct if the cuff is too loose. Put the earpieces in your ears. Using your middle (long) and index (pointer) fingers, gently feel for the pulse in the bend of the elbow. This is the brachial (BRA-kee-ull) artery. You will feel the pulse beating when you find it. Do not use your thumb to feel for the pulse because your thumb has a pulse of its own. Put the diaphragm of the stethoscope over the brachial artery pulse. Listen for the heartbeat. Tighten the screw on the bulb and quickly squeeze and pump the bulb. This will cause the cuff to tighten. Keep squeezing the bulb until the scale on the gauge reads about 160. Or, until the gauge reads at least 10 points higher than
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when you last hear the heartbeat. Slowly loosen the screw to let air escape from the cuff. Let the gauge fall about 5 points a second. Carefully look at the gauge and listen to the sounds. Remember the number on the gauge where you first heard the thumping sound. Continue to listen and read the gauge at the point where the sound stops. The number of the first sound is the systolic (top number) pressure. The second number is the diastolic (bottom number) pressure. Write down your BP, the date, the time, and which arm was used to take the BP. Let the air out of the cuff. Sharing - discussion 6. show positive attitude in the care and management of the disease

6. show positive attitude in the care and management of the disease

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V. Evaluation The patient and the nurse were able to achieve the specific objectives. After 3 days of confinement, the patient went home with an improved condition as evidenced by having sufficient knowledge, skills and positive attitude in managing her disease condition; increased energy levels as evidenced by performance of activities of daily living and a proper technique in taking blood pressure for her own blood pressure monitoring. She was given discharge health teaching about her diet, management of complications and importance of blood pressure monitoring. Take home medications instruction was also given.

Recommendation:

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The best recommendation in this case would be referral for home care for continuing the care, if indicated. The home care nurse or family member assesses the patients recovery from her disease condition. Intake and output should be monitored and reinforced instruction about proper home care. Family responsibilities and factors relating the home environment that produce emotional tension have often been implicated as precipitating causes of possible reoccurrence of acute renal failure.. Before discharge, patient and family member should be informed about the signs and symptoms of the complications that may occur and those that should be reported.

VI. Implication of this case study to:

NURSING PRACTICE This case study provides information about Acute Renal Failure and nursing interventions and therapeutic techniques used with patients who have this disease. It also provides information about the plan of care for patients who have this disease condition for efficient nursing care. This case study will help the student to have an adequate knowledge to be utilized in rendering care for a specific patient with acute renal failure.

NURSING EDUCATION
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To nursing education, this case study would help by proving information about the disease condition Acute Renal Failure. The student nurses, as well as the teachers could gain additional information about this disease that is common in children, so that it could better equip them for efficient nursing care in the future. This case study will be used as a tool to promote students understanding in the disease process of acute renal failure and serves as a baseline towards students learning and progress.

NURSING RESEARCH To the research team, that they will be able to come up with a new and better interventions, whether medical or nursing, to treat the disease at an early duration as well as knowing the latest facts to prevent the occurrence of the disease, acute renal failure. This will help them promote the optimal health level of the patient and for the advancement of their knowledge, skills and attitudes in improving a holistic and effective nursing care.

VI. The Referral and Follow-up The patient was advised to visit her doctor, Dr. Pino, one week after discharge for followup check up. The patient was also advised to maintain dietary restrictions and compliance of her medications for her own benefits. She was then encouraged to refer to her physician immediately if signs and symptoms of possible complications will occur.

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VII. Bibliography Books: Brunner and Suddarth, the textbook for medical surgical, 11th edition Deglin, Judith and Vallerand, April. Daviss Drug Guide for nurses. 5th edition. Philadelphia, Pennsylvania., 1997 Doenges, Marilynn. Nurses Pocket Guide, 9th ed., Ignatavicius-Workman, Medical-Surgical Nursing: Critical Thinking for Collaborative Care, vol.2., 8th ed., Kozier, Barbara, et al. Fundamentals of Nursing: Concept, Process and Practice, 5th edition. USA, Addison-Wesley Longman, Inc. 1998.

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Martini, Frederic. Fundamentals of Anatomy and Physiology 6th edition. USA: Pearson Education, Inc., 2004 Phipps, Wilma, et al., Medical Surgical nursing: Health and illness perspectives. 7th edition. St. Louis, Missouri: Mosby, Inc., 2003

Internet sources: http://www.drugs.com/cg/how-to-take-a-blood-pressure.html http://www.ehow.com/about_5101223_risk-factors-acute-renal-failure.html http://www.jhsph.edu/publichealthnews/press_releases/PR_2000/cholesterol_kidney.html http://www.mayoclinic.com/health/high-uric-acid-level/MY00160 http://www.nlm.nih.gov/medlineplus/ency/article/000501.html

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