Demographic Data Name: C.Z.

A Age: 84 y/o Religion: Roman Catholic Civil Status: Single Gender: Female Date of admission: December 31, 2011 Time of Admission: 10:06pm

Patient History Patient is a known hypertensive on Amlodipine 10 mg OD, diagnosed with papillary thyroid cancer (50 years ago) for radical neck dissection and RAI. Admitted due to progressive difficulty of breathing. History started one day PTA, patient developed cough with whitish sputum, patient self medicated with Fluimucil. Hoever, early morning she had tachypnea and dyspnea. Consult was done, Ci-Amoxiclav 625mg BID and Azithromycin were given. However, due to progressed DOB, patient was brought to ICU and admitted. Definition Acute renal failure (ARF) is defined as the rapid cessation of renal excretory function within a time frame of hours or days, accompanied by a rise in serum urea and creatinine, and accumulation of nitrogenous waste products in a patient whose renal function was previously normal. It is usually, but not always, accompanied by a fall in urine output. The condition is potentially reversible, and in routine clinical practice, measurement of serum creatinine is used to follow the changes in glomerular filtration rate (GFR). It is a usually marked by increased concentrations of blood urea nitrogen (BUN; azotemia) and creatinine; oliguria (less than 500 ml of urine in 24 hours); hyperkalemia; and sodium retention.


Acute renal failure are classified into following: 1. Prerenal failure results from conditions that interrupt the renal blood supply; thereby reducing renal perfusion (hypovolemia, shock, hemorrhage, burns impaired cardiac output, diuretic therapy). 2. Postrenal failure results from obstruction of urine flow. 3. Intrarenal failure results from injury to the kidneys themselves (ischemia, toxins, immunologic processes, systemic and vascular disorders). The disease progresses through three clinically distinct phase which is oliguric-anuric, diuretic, and recovery, distinguished primarily by changes in urine volume and BUN and creatinine levels.

Complication of ARF include dysrhythmias, increased susceptibility to infection, electrolyte abnormalities, GI bleeding due to stress ulcers, and multiple organ failure. Untreated ARF can also progress to chronic renal failure, end-stage renal disease, and death from uremia or related causes.

Incidence The incidence of ARF is difficult to state precisely because it depends on the parameters by which it is defined. The incidence of severe ARF (serum creatinine >500 mol/L) in the general population is estimated to be approximately 70 140 per million of the population, and around half of these will require dialysis. Less severe ARF (serum creatinine 177 mol/L or an increase of 50% above baseline) occurs in about 210/million/year. One hospital survey revealed some degree of renal impairment in around 5% of all admissions. In intensive care units (ICU), however, the figure is much higher, with at least 15% of admissions having renal impairment, of which the cause is sepsis in approximately 50% of cases. The financial implications of renal impairment are considerable: the cost of a survivor who had renal failure leaving ICU is 70 times that of a patient without renal impairment. Assessment: 1. Oliguric-anuric phase: urine volume less than 400 ml per 24 hours; increased in serum creatinine, urea, uric acid, organic acids, potassium, and magnesium; lasts 3 to 5 days in infants and children, 10 to 14 days in adolescents and adults. 2. Diuretic phase: begins when urine output exceeds 500 ml per 24 hours, end when BUN and creatinine levels stop rising; length is availabe. 3. Recovery phase: asymptomatic; last several months to 1 year; some scar tissue may remain. 4. In prerenal disease: decreased tissue turgor, dryness of mucous membranes, weight loss, flat neck veins, hypotension, tachycardia. 5. In postrenal disease: difficulty in voiding, changes in urine flow. 6. In Intrarenal disease: presentation varies; usually have edema, may have fever, skin rash. 7. Nausea, vomiting, diarrhea, and lethargy may also occur.

ANATOMY AND PHYSIOLOGY The Urinary System is a system of organs that produces and excretes urine from the body. Urine is a transparent yellow fluid containing unwanted wastes, mostly excess water, salts, and nitrogen compounds. The major organs of the urinary system are the kidneys, a pair of bean-shaped organs that continuously filter substances from the blood and produce urine. Urine flows from the kidneys through two long, thin tubes called ureters. With the aid of gravity and wavelike contractions, the ureters transport the urine to the bladder, a muscular vessel. The normal adult bladder can store up to about 0.5 liter (1 pt) of urine, which it excretes through the tubelike urethra. An average adult produces about 1.5 liters (3 pt) of urine each day, and the body needs, at a minimum, to excrete about 0.5 liter (1 pint) of urine daily to get rid of its waste products. Excessive or inadequate production of urine may indicate illness and doctors often use urinalysis (examination of a patient s urine) as part of diagnosing disease. For instance, the presence of glucose, or blood sugar, in the urine is a sign of diabetes mellitus; bacteria in the urine signal an infection of the urinary system; and red blood cells in the urine may indicate cancer of the urinary tract. Functions of the urinary system


    

Excretion. The kidneys are the major excretory organs of the body. They remove waste products, many of which are toxic, from the blood. Most waste products are metabolic by products of cells and substances absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some of these waste products, but they cannot compensate if the kidneys fail to function. Blood volume control. The kidneys play an essential role in controlling blood volume by regulating the volume of water removed from the blood to produce urine. Ion concentration regulation. The kidneys help regulate the concentrate of the major ion in the body fluids. pH regulation. The kidneys help regulate the pH of the body fluids. Buffers in the blood and the respiratory system also play important roles in the regulation of pH. Red blood cell concentration. The kidneys participate in the regulation of red blood cell production and, therefore, in controlling the concentration of red blood cells in the blood. Vitamin D synthesis. The kidneys, along with the skin and the liver, participate in the synthesis of vitamin D.

Kidneys The kidneys are bean-shaped organs, each about the size of a tightly clenched fist. They lie on the posteriorabdominal 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. The kidneys are

abundantly supplied with blood vessels- they process blood the kidneys receive 20 25% of the resting cardiac output via the right and left renal arteries. In adults, blood flow through both kidneys (renal blood flow) is about 1200 ml per minute Function of the kidneys
       

Regulation of blood ionic composition Regulation of blood pH Regulation of blood volume Regulation of blood pressure Maintenance of blood osmolarity Production of hormones Regulation of blood glucose level Excretion of wastes and foreign substances

Three layers of tissue surround each kidney



 

The renal capsule. The deep layer, smooth, transparent sheet of dense irregular connective tissue. Serves as a barrier against trauma and helps maintain the shape of the kidneys. Continuous with the outer coat of the ureter. The adipose capsule. Middle layer, a mass of fatty tissue surrounding the renal capsule. Protects kidney from trauma and holds it firmly in place in the abdominal cavity. The renal fascia. The superficial layer, thin layer of dense irregular connective tissue. anchors the kidney to surrounding structures and to the abdominal wall

Internal anatomy of the kidneys Two regions

 

The renal cortex - superficial, smooth-textured reddish area The renal medulla deep, reddish-brown inner region. Consists of 8 to 18 cone-shaped renal pyramids
  

Renal pyramids. The base faces the renal cortex. The apex (renal papilla) points toward the renal hilum Renal columns. Portions of the renal cortex that extend between renal pyramids Renal lobe. A renal pyramind + its overlying area of renal cortex + 1/2 of each adjacent renal column

The parenchyma. The functional portion of the kidney. Consists of the renal cortex and renal pyramids of the renal medulla. Contains about 1 million mircoscopic structures called nephrons.

Ureters The ureters are two slender tubes that run from the sides of the kidneys to the bladder. Their function is to transport urine from the kidneys to the bladder. Bladder The bladder is a muscular organ and serves as a reservoir for urine. Located just behind the pubic bone, it can extend well up into the abdominal cavity when full. Near the outlet of the bladder is a small muscle called the internal sphincter, which contract involuntarily to prevent the emptying of the bladder? Urethra The urethra is a tube that extends from the bladder to the outside world. It is through this tube that urine is eliminated from the body.

Pathophysiology

Tubular necrosis

Decrease in GFR Endothelial cell necrosis and sloughing

Tubular obstruction

Increased tubular permeability

Oliguria

Azotemia

Fluid retention

Electrolyte imbalance

Metabolic acidosis

Impaired immune function

Risk for heart failure and pulmonary edema

Anemia

Assessment Objective: y Coughing y Sputum is yellow and sticky

Nursing Diagnosis Ineffective airway clearance

Planning Choose: Patient will maintain/improve airway clearance AEB absence of signs of respiratory distress

Interventions 1. Teach and encourage the use of diaphragmatic breathing and coughing exercises.

Rationale 1. These techniques help to improve ventilation and mobilize secretions without causing breathlessness and fatigue. 2. Minor respiratory infections that are of no consequence to the person with normal lungs can produce fatal disturbances in the lungs of an asthmatic person. Early recognition is crucial.

Evaluation Goal partially met

Patient will demonstrate behaviors that would prevent the recurrence of the problem

2. Early signs of infection that are to be reported to the clinician immediately. y Increases sputum production y Change in color of sputum y Increased thickness of sputum y Increased SOB, tightness of chest, or fatigue y Increased coughing y Fever or chills 3. If indicated, perform postural drainage with percussion and vibration in the morning and at night as prescribed.

3. Uses gravity to help raise secretions so they can be more easily expectorated.

4. Assist in administering nebulizer, as indicated.

4. This ensures adequate delivery of medications to the airways.

5. Administer Antibiotics as prescribed.

5. Antibiotics may be prescribed to treat the infection.

Assessment Subjective: Masakit yung sa paa ko. Objective: y Facial Grimaces y Guarding behaviors Pain scale of 5/10

Diagnosis Acute Pain

Planning Short Term: After 2-3 hours of nursing interventions, the patient will demonstrate use of relaxation skills to relieve pain.

Interventions 1. Monitor and record vital signs.

Rationale 1. To obtain baseline data.

Evaluation Goal met

2. Accept patient s description of pain.

2. Pain is a subjective experience and cannot be felt by other. 3. To be able to compare changes from previous reports to rule out worsening of underlying condition/develop ing complications

Long Term: After 8 hours of nursing interventions, the patient will report decrease in pain and pain scale decreased.

3. Perform a comprehensive assessment of pain ( location , onset, characteristics, frequency)

4. Assess patient s description of pain.

4. To acknowledge the pain experience convey acceptance of client s response to pain.

5. Observe nonverbal cues including how client walks, holds body, sits,

5. Observation may/ may not be congruent with

facial expressions, cool fingertips/ toes, which can mean constricted vessels

verbal reports indicating need for further evaluation.

6. Encourage verbalization of feelings about the pain.

6. To allow out let for emotions and enhance coping mechanism. 7. To prevent fatigue and lessen stimuli.

7. Provide quite environment, calm activities and adequate rest reinforce 8. Provide comfort measures such as back rub, change position, use of heat/ cold. 9. Instruct/encourage use of relaxation exercise such as focused breathing.

8. To provide nonpharmacologic pain management. 9. This is a form of relaxation technique that helps decrease level of pain. 10. Provides divertionary activities that help block the perception of pain by the brain.

10. Encourage diversional activities such as TV and socialization with others.

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