Manuel S.

Enverga University Foundation College of Nursing and Allied Health Sciences

A Case Study of a Patient with

End Stage Renal Disease secondary to Chronic Glumerulonephritis

In Partial Fulfillment of the Requirement for Nursing Enhancement Program (Related Learning Experience) @ Hemodialysis Unit, QMC (Lucena City)

Presented To: Ms. Claire E. Davila Clinical Instructor

Presented By: Group 4 B Basco, Christine Lozada, Grace Morin, Angielyn Perez, Maricel Reyes, Ralph Lawrence

December 2012

GENERAL OBJECTIVES
At the end of our duty in QMC Hemodialysis Unit, Level IV nursing students of MSEUF-MAIN will be able to impart acquired knowledge and effective skills towards achieving the patients optimum level of functioning through promoting, providing and maintaining, physiologic and psychological stability, and health restoration as to apply the right attitudes of the nursing students in rendering care to the patient experiencing hemodialysis due to health condition of END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS, its importance and implication. readers The aim of this study is to provide understanding to the students as well as the regarding END STAGE RENAL DISEASE secondary to CHRONIC

GLUMERULONEPHRITIS. This study will show the contributing factors, occurrence and complication of the condition which is important in the preventive, promotive and rehabilitative care of the patient.

SPECIFIC OBJECTIVES
Establish a trusting relationship to client and family. Perform the assigned task efficiently and dynamically Understand precisely what END STAGE RENAL DISEASE is. To be able to distinguish its clinical manifestations. To illustrate the Anatomy and Physiology of the affected organ or the part of the body To discuss and outline its pathophysiology. Find out how the health status of the client had been affected by the above disorders by: Determining its predisposing factors Determining the causative agents of the disease Conducting physical examination Analyzing the results of the laboratory examinations done to the client.

Determine the appropriate nursing care and management that should be provided to the client by: Being familiar with the various treatment done to the client; Understanding the different drugs ordered for the client and determines its therapeutic effects and adverse reactions. Evaluate the effectiveness of the medical treatment and the nursing care plans rendered to the client. To apply right attitude by respect through providing privacy and maintaining clients confidentiality.

I INTRODUCTION
End Stage Renal Disease (ESRD), also known as Chronic Kidney Disease Stage V, is a progressive loss of renal function over a period of months or years. The symptoms of worsening kidney function are unspecific, and might include feeling generally unwell and experiencing a reduced appetite.

Incidence, race, gender, age, ratio and proportion

Kidney disease is on the rise and is an important cause of death in the Philippines. It is the 9th leading cause of death among Filipinos today. It is said that a Filipino is having the disease hourly or 120 Filipinos per million populations per year. 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. Unfortunately though only 73% or about 7, 267 patients received treatment. An estimate of about a quarter of the whole population probably just died without receiving any treatment. According to DOH said that in the past, chronic glomerulonephritis was the most common cause of chronic renal failure. Today, diabetes mellitus and hypertension have taken center stage in increasing the risk of ESRD which together account for almost 60% of dialysis patients.

The prevalence of kidney/renal diseases has been in an increasing trend, especially the end-stage renal disease (ERSD) as reported in the Philippine Renal Disease Registry (PRDR). The rate of death due to end-stage renal disease has been in the top ten list of the mortality of the Department of Health (DOH). There are more males acquiring the condition with a ratio of 2:1. This particularly afflicts children and young adolescents, (5-15 years of age) while a smaller portion, 10% occur in patients above 40 years. It may however be acquired at any time in the lifespan.

Rational for choosing the case

The group decided to choose this case; END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS for it will be a good study because we are all aware that this is one of the diseases that gives a largest contribution to the morbidity rate here in the Philippines. This is an opportunity for us not just to learn more about the causes and treatments of this disease but also an opportunity to show our role and contribution as a nursing student. The information and learning we will gain is advantage for us, once we encounter it again in the future.

Significance of the Study

The significance of this study is to enhance and gain knowledge, as well as to develop skills and to apply interventions for patient with END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS. This study will serve as guidelines in assessing and providing nursing care. This study also aims to educate the people about the disease of the kidneys specifically END STAGE RENAL DISEASE to serve as their eye opener for understanding how important our kidney is and its functions to our daily life activities.

Scope and limitation of the study

This study would focus only on END STAGE RENAL DISEASE secondary to CHRONIC GLUMERULONEPHRITIS which indicates the disease process and clients present health condition and the nursing action relevant for the clients situation within the rotation at QMC Dialysis Unit.

Conceptual and Nursing Theory

Imogene M. King - Theory of Goal Attainment

The concepts of self, perception, communication, interaction, transaction, role and decision making were selected to represent how individuals and groups in the health care system interact to achieve goals. This transaction model developed to represent the process whereby individuals interact to set goals that result in goal attainment (King, 1981). The theory of goal attainment, developed by Imogene M. King, is based on the assumption that human beings are the focus of nursing.the goal of nursing is health: its promotion, maintenance, and/or restoration; the care of the sick or injured; and the care of the dying. King's model consists of three interacting systems: personal, interpersonal, and social. The three interacting relationships involve the individual, nurse-client interaction and nursing. Nurse-client interactions are thought to be individual perceptions which influence the process of goal attainment.

The group chose this theory because the primary nursing goal of patient having END STAGE RENAL DISEASE is to assist the patient to achieve, preserve, and reclaim health. The theory emphasizes the importance of knowledge and information that the nurse and the client both bring to the relationship, working together to achieve goals. Imogene M. Kings conceptual framework is best described as a holistic view of the complexity in nursing and multiple health care systems.

Related Literature
Overview of the disease End stage renal disease is irreversible and progressive reduction of functioning renal tissue. It occurs when the remaining kidney mass can no longer maintain the bodys internal environment which results to renal failure. It is also called Chronic Kidney Disease (CKD) and is labeled stage 5. ESRD can develop insidiously over many years or may result from an episode of renal failure from which the client has not recovered. It usually occurs when chronic kidney disease has worsened to the point at which kidney function is less than 10% of normal. ESRD almost always follows chronic kidney disease Causes The causes of ESRD are numerous. Various injuries and disease process that may result in kidney failure were Chronic Glumerulonephritis, Acute Renal Failure, Polycystic Kidney Disease, Obstruction, repeated episodes of Pyelonephritis, and Nephrotoxins. Systemic diseases such as Diabetes Mellitus, Hypertension, Lupus Erythematous, Sickle Cell Disease and Amyloidosis may produce chronic kidney disease.

Diabetes Mellitus is the leading cause and accounts for more than 30% of clients who receive dialysis. Hypertension is the second leading cause of ESRD. Clinical Manifestations The symptoms for acute and chronic kidney disease may be different. The following are the most common manifestations of chronic renal failure. However, each individual may experience symptoms differently. Symptoms may include: poor appetite vomiting bone pain headache insomnia itching dry skin malaise fatigue with light activity muscle cramps high urine output or no urine output recurrent urinary tract infections

urinary incontinence pale skin bad breath hearing deficit detectable abdominal mass

tissue swelling irritability poor muscle tone change in mental alertness metallic taste in mouth

Treatment Dialysis or kidney transplantation is the only treatment for ESRD. A patient must prepare for dialysis before it is absolutely necessary. The preparation includes learning about dialysis and the types of dialysis therapies, and placement of a dialysis access.

Medications usually include an ACE inhibitor, angiotensin receptor blocker, or other medications for high blood pressure.

Changes in DIET: Eat a low-protein diet Get enough calories if you are losing weight Limit fluids Limit salt, potassium, phosphorous, and other electrolytes

Other treatments may include: Extra calcium and vitamin D Special medicines called phosphate binders, to help prevent phosphorous levels from becoming too high Treatment for anemia, such as extra iron in the diet, iron pills, special shots of a medicine called erythropoietin, and blood transfusions.

Procedures and Tests

Blood tests. Kidney function tests look for the level of waste products, such as creatinine and urea, in your blood.

Urine tests. Analyzing a sample of your urine may reveal abnormalities that point to chronic kidney failure and help identify the cause of chronic kidney disease.

Imaging tests. The doctor may use ultrasound to assess your kidneys' structure, size and degree to which they reflect sound waves (echogenicity). Other imaging tests may be used in some cases.

Removing a sample of kidney tissue for testing. The doctor may recommend a kidney biopsy to remove a sample of kidney tissue. Kidney biopsy is often done with local anesthesia using a long, thin needle that's inserted through your skin and into your kidney. The biopsy sample is sent to a lab for testing to help determine what's causing your kidney problems.

II CLINICAL SUMMARY
General Data Profile
Name: Address: Birthday: Birth Place: Nationality: Religion: Occupations: Date of admission: AAA Brgy. Talipan purok Maligaya Pgbilao, Quezon Oct. 28, 1978 Lucena City Filipino Roman Catholic Businessman July 9, 2012 End stage renal disease secondary to chronic glomerolunephritis

Admitting Diagnosis:

Admitting Physician:

Dr. Joseph Michael Abcede, MD

Chief Complaint
Patient was admitted @ MCDGH with chief complaint of vomiting, shortness of breath, body weakness, and elevated blood pressure.

History of present illness

2 days prior to admission patient AAA felt dizzy, loss of appetite, shortness of breath and body weakness but he ignore it. Patient AAA has history of family hypertension. Prior to admission, patient was brought to ER-QMC for consultation and ROD ordered laboratory examination like CBC and urinalysis in order to know the problem and give right medication for the patient. His blood pressure was 270/170mmHg and the doctor ordered antihypertensive medication to decrease blood pressure, and the patient remained in the hospital for 3 days.

a. Childhood Illness b. Immunizations c. Allergies d. Accidents e. Hospitalization f. Medications or currently taking g. Domestic Travels

According to the patient, he only experienced simple cough and colds The patient has complete immunizations -

The patient had no allergic reactions in any foods and drugs. None According to the patient it was his first hospitalization when the doctor diagnosed him End stage renal failure Clonidine, Carvidolol Amlodipine, Losartan, Ferrous Sulfate,

Tagaytay, Cavite, Lucena

Family History Genogram

Legends: = Male

= Female

= Patient

In the family genogram of our client, there are no kidney disorders in their family, however there are diseases that could contribute to his disease. Both of his parents had a history of stroke and experiencing hypertension. Hypertension is one of the leading causes of ESRD in the Philippines.

Psychosocial Theory According to Erik Erikson

According to this theory young adulthood had intimate relationship with another person and a commitment to work and relationship. Based on our interview with the patient, we found out that the theory of Erikson correlates with the information that weve gathered to the patient. According to the patient, he really loves his wife and their 6 kids. And they help each other to provide all the needs of the family. After the patient resigned in his previous work, he decided to have an owned business.

Psychosexual theory According to Sigmund Freud

According to this theory, the genital stage correlates to the patients age because the patient wanted to gain independence and decision making by working and from his age the patient wanted to be a good husband to his wife and father to their children. When it comes with decision making, the patient is the one who make decision for his problem as long as he knows that he can solve it with his own. The patient is in the stage of independency.

Environment / Living Condition

The patient lives in Brgy. Talipan Pagbilao, Quezon. In the surroundings of their house, there are trees and lots of houses. Although their house is in front of the Barangay Health Center, he didnt even make a consultation whenever he feels ill. Since he was diagnosed with End Stage Renal Disease, he has a maintenance medication for hypertension and currently undergoing a hemodialysis twice a week. Unlike when he was not already diagnosed with ESRD, he is always drinking alcohol after his work, consumed 2 packs of cigarettes a day and eats a lot of salty, and fatty foods that he wants but now he is very strict with regards to his food and he is also a former driver in a bank where he resigned because of his present condition.

Physical Assessment
Parameters General Appearance Normal Findings - Healthy in Appearance - Ambulatory - With full range of motion of neck and upper and lower extremities -able to speak clearly and articulate each word being spoken without any difficulty - with good gag reflex - With good skin turgor - With smooth skin and free from any type of wounds - Evenly distributed hair - Thick hair - With good capillary refill of 1-2seconds - With pinkish nail beds - Short clean cut nails Actual Findings - With slightly weak in appearance - Ambulatory - With full range of motion of neck and upper and lower extremities - Able to speak clearly and articulate each word being spoken without any difficulty -With good gag reflex -With slightly poor skin turgor - With smooth skin and free from any type of wounds -Evenly distributed hair -Thick hair -With poor capillary refill of 3-4 seconds -With pale nail beds -With short clean cut nails Interpretation -Due to his illness condition the patient is slightly weak in appearance

Skin

- Due to limited oral fluid intake

Hair

Nails

- due to decrease production of erythropoietin that leads to decrease level of oxygen in the upper and lower extremities

Skull and Face

- Rounded smooth skull contour - Symmetrical facial movement - No eye discharge - Eyebrows hair evenly distributed/skin intact - (+)blink reflex - With pinkish conjunctiva - Auricle color same

- Rounded smooth skull contour - symmetrical facial movement - No eye discharge - Eyebrows hair evenly distributed/skin intact - (+)blink reflex - With pale conjunctiva - Auricle color same -Due to ineffective tissue perfusion

Eyes

Ears

Mouth

Neck

as facial skin - Auricle are mobile firm and not tender - Able to hear on both ears - No edema and discharge - Mouth uniform consistency; absence of nodules and masses - Pinkish lips - With pink gums - With symmetrical contour - No masses

Abdomen

as facial skin - Auricle are mobile firm and not tender - Able to hear on both ears - No edema and discharge - Mouth uniform consistency; absence of nodules and masses - Dry and pale lips -with pale gums - with symmetrical contour -With mass on the right portion of the neck - No abdominal - No abdominal distention distention - Flat rounded -Flat rounded abdomen abdomen - Symmetrical contour -Symmetrical contour - Symmetrical - No atrophy - With full range of motion

- Due to limited oral fluid intake

- Due to hypersecretion of T3 and T4 - Due to limited intake of food and oral fluid but still the patient has normal findings in abdomen

Musculosketal (Upper - Symmetrical and lower extremities) - No atrophy - With full range of motion

Patterns of Functioning Functional Health Pattern Health management

Pattern

Before During Interpretation Hospitalization Hospitalization

Self-medicated (over the counter drugs) He is dependent to health care team and the medication with the prescription of M.D Hemodialysis The medications and treatments are rendered by the health care team and he usually seeks medical attention due to his condition.

Nutritional/ Metabolic -Five times a day with in between snacks (fast food lovers) consuming 1L of fluids -very good -during hemodialysis, he tries to eat foods that he cant usually eat. -good

a. Number of meals per day

b. Appetite

c. Glass of water per day

-2.5L

-1L including the food and fluids -thin than the normal body built 47.5 kg 54

Because of the condition of the client, he has limitation when it comes to food so as to avoid excess fluids and electrolytes. Despite of his situation he has a good appetite but he limit himself to eat. During the dialysis hes allowed to drink and eat but in moderate amount with strictly monitor due to his condition.

d. Body built

-he has good body built 72 kg 54

e. Height and weight

Elimination -10 times a day -30-60cc/hour -4 times a day -<30 cc/hour The dialysis removes the excess fluid, electrolytes, and toxins in the body.

a. Frequency of urination b. Amount of urine per day c. Frequency of bowel movement

-4 times a day

-once or twice a day -formed or semiformed -moderate

d. Consistency of the feces -formed or semiformed e. Amount defecated per day -moderate

Activity and Exercise -active exercise -limited every day (jogging movement and basketball) because of the body weakness -not easily get tired -easily get tired due to his condition -can do ADL but limited unlike before The patient wasnt able o do his usual routine before like exercise and he is easily get tired but despite of his condition is not hindrance to do some ADL but in limited time and action.

a. Exercise

b. Fatigability

c. ADL

-independent

Cognitive/Perceptual -aware to time, place and person -he is appropriately responds to verbal and physical stimuli -aware to time, place and person - he is appropriately responds to verbal and physical stimuli The client is oriented and the cognitive and perceptual status is totally intact and appropriately responds to the questions given.

a. Orientation
b. Responsiveness

Coping/Stress

-Socialize with his friends

-He always speak out to his wife and he want to take care of his children

He has a good coping techniques despite of his condition

Values and Beliefs

He is aware that GOD really exists

He is aware that GOD really exists, and his faith is more strengthened than before.

He never blames the Lord about his condition instead His faith becomes stronger than before.

Roles / Relationship He has a good relationship with his parents He has a good relationship with his parents and they are one of the reason why is more strong despite of his condition. With good relationship to his siblings became more bonded due to his condition. Despite of his condition he has still a good relationship with his family and became more bonded and intact with each other. He became stronger to face his situation because of his family.

a. As a son

b. As a brother

With good relationship to his siblings

c. As a husband

With a very good relationship with his wife and a good provider as a husband As a father With a very good relationship to his children and good provider to his children as a father

Become more stronger and bonded with each other despite of his condition. He has more time to take care of his children due to his condition but still good provider to them.

Course in the Ward

Date June 6, 2012 Doctors Order (+) Headache when taking Atenolol Shift Atenolol to Lozartan (Lifezar) 100mg/tab 1 tab OD For pH CBC, serum crreatinine, calcium, phosphorus To: QMC Hemodialysis Unit Please accommodate patient for 2x/ week hemodialysis ESRD secondary to Chronic Glomerulonephritis For referral to Dr. Dayahan for Endoscopy For TSH, T3, T4 For CBC, Creatinine, Calcium, Phosporus

July 4, 2012

July 9, 2012

July 14, 2012

October 2, 2012

Laboratory / Diagnostic Exam

October 3, 2012 Parameter RBC WBC Segmenters Lymphocytes Eosinophils Monocytes Basophils MCV MCH MCHC HGB HCT Platelet Results 9.5 Units 10 ^12/L 10^9/L Normal Range 4 - 4.5 5 10 0.55 - 0.65 0.25 - 0.35 0.01 0.05 0.01 0.1 0.01 0.08 82 92 27 32 32 - 36 12 16 37-45 150-400 Interpretation LOW the patient has anemia -

fL Pg % g/Dl % 10^9/L

IMPLICATIONS: A low hemoglobin count is a below average concentration of the oxygen carrying hemoglobin proteins in your blood. In many cases, a low hemoglobin count is only slightly lower than normal, isn't considered significant and causes no symptoms. A low hemoglobin count can also be caused by an abnormality or disease. In these situations, a low hemoglobin count is referred to as anemia. July 15, 2009 Pt. count 2.00 Cut-off 10.00 Remarks Non- reactive

Anti-HBS July 10, 2009

HBSAG Hepa.C Virus

Pt. count 0.018 0.055

Cut- off 0.075 0.392

Remarks Non-reactive Non-reactive

III CLINICAL DISCUSSION OF THE DISEASE

Anatomy and Physiology

Kidneys are solid organs found in the middle back that are responsible for removing water and water soluble waste from the blood. And a kidney plays the following essential roles in controlling the composition and volume of body fluids: Excretion Regulation of blood volume and pressure Regulation of the concentration of solutes in the blood Regulation of extracellular fluid ph Regulation of the red blood cell synthesis Vitamin D synthesis

Structures of the kidney: Renal pyramid - One of multiple cone-shaped portions of the kidney where urine is removed from blood and drained into the renal calices. Renal artery - The main blood vessel that brings blood to the kidney from the aorta. Renal vein - The main blood vessel that brings blood away from the kidney back to the inferior vena cava Renal capsule- This is the outer covering of the kidney. Nephron- This is the working unit of the kidney. Renal column- This is a solid portion of the kidney where blood vessels travel to and from the nephron.

Ureter Are small tubes that carry urine from the renal pelvis of the kidney to the posterior inferior portion of the urinary bladder

Bladder its functions is to store urine, and its size depend on the quantity urine present.

Urethra Is a tube that exits the urinary bladder inferiorly and anteriorly.

Pathophysiology Book based

INITIATING EVENT (infection, antigen antibody formation, systemic disease) DM CGN HPN LSE ARF Nephrotoxins Pyelonephritis Polycystic Kidney Disease

Glomerular Capillary Membrane Inflammation

Decreased renal blood flow

Glomerular Permeability

Decreased GFR

Activation of Renin Angiotensin Aldosterone Sysstem

HEMATURIA PROTEINURIA INCREASED BUN AND CREATININE

Na and water retention

Decreased vasopressor activity

HYPERETENSION

Prolonged hypertension

Arterial walls are damaged

Atherosclerosis in glomerular capillaries

Progressive deterioration of GF, tubular secretion and reabsorption

Kidney attempt to maintain GFR

Glomerular hyperfiltration

Decreased renal mass, nephrons are destroyed

Glomerular Sclerosis

Further loss of functional nephrons

(ESRD) END STAGE RENAL DISEASE

Client based
Modifiable Risk factors o Cigarette smoking o Drinking alcohol o Fast food lovers o High intake of food rich in sodium o Over use of over the counter drugs o Lifestyle (eating processed foods, junk foods, salty and fatty foods) Non-modifiable Risk factors o Family history of Hypertension Develops Urinary Tract Infection (UTI)

Initiating event (infection, antigen-antibody formation, systemic disease)

Renal insufficiency; retention of sodium, water and waste

Renal blood flow and glomerular filtration are decreased

Rapidly progressive glomerulonephritis

Severe glomerular injury (chronic glomerulonephritis)

Chronic Renal Failure

(ESRD) END-STAGE RENAL DISEASE

IV NURSING PROCESS
Long Term Objectives
The study aims to restore and maintain the patients body weight, strict adherence to his diet and to prevent further complications through collaborative management of the health care team. The patient should adhere to his scheduled hemodialysis to excrete the metabolic waste that the kidneys cannot excrete. Kidney transplantation is needed to attain the patients optimum wellness.

Prioritized List Nursing Problem

DIAGNOSIS Decreased Tissue Perfusion r/t to constricted peripheral blood vessels as manifested by increase blood pressure of 200/130 RANK REASON The group decided to prioritize first the decreased tissue perfusion due to decrease circulating RBCs in the blood therefore decrease oxygen level; Circulation should be prioritized first among the problems. The group ranked the Fluid volume excess as number two because it is the presenting problem in our patient, to prevent further deteriorating his ill condition. We ranked it as our least priority because in the case of the patient frequent IV cannula will introduce microorganism in the blood circulation that would trigger systemic infection since there is only a risk and problems the first thing that should be managed since this problem can be fatal if left untreated.

Fluid Volume Excess r/t decrease Glomerular filtration Rate and sodium retention as manifested by increase BP of 200/130 Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute secondary defense

Discharge Plan (METHOD)

Clients with Renal Disease are instructed to take the following plan for discharge:

Medication Medications should be taken regularly as prescribed, on exact dosage, time, & frequency, making sure that the purpose of the medication s d i s c l o s e d b y t h e health care provider. Advise patient to take the prescribed medicines continuously at home. Medication as follows: o Amlodipine 5mg/tab 1tab OD (7pm) o Lozartan (Lifezar) 100mg 1 tab OD (7am) o Clonidine (Catapres) 150 mg/tab 1 tab BID (10am-10pm) o Carvedilol 25mg 1 tab OD (12nn) Environment Maintain quiet, clean and calm environment for alleviating the patients discomfort o Provide safety measure to promote safe environment and individual safety Exercise should be promoted in a way by stretching hand and feet every morning. Encourage the patient to keep active to adhere to exercise program and to remain as self sufficient as possible. But if there is presence of pain rest should be provided. Assist patient in doing ADLs.

Treatment Instructed the patient to continue medication and compliance to strict regimen.

Health teaching Encouraged a diet high in carbohydrates within the prescribed sodium,

potassium, phosphorus and protein limits. Encouraged patient to avoid salty and fatty foods Encouraged patient to have enough rest Instructed the patient to do exercise as tolerated such as walking. Encouraged activity within prescribed limits but avoid fatigue. Emphasized the importance of practicing proper hand washing Instructed to do deep breathing and coughing exercises Encouraged patient to eat nutritious foods. Protect the client from exposure to infectious agents.

Out patient check-up

Instructed to comeback for the next hemodialysis on November 30, 2012 Friday at Dialysis Unit at Quezon Medical Center Lucena, City

Diet Advised the patient to follow the Doctors Order regarding her diet with strict 1L of fluids per day including the food fluid. Advised the patient to a renal diet.

Drug Study

NAME OF THE DRUG

Amlodipine (AMVASC) Therapeutic Classification: Antihyperten siv Calcium Channel Blocker

DOSAGE
Doctors Order: 10mg/tab 1 OD 7PM

ACTION

INDICATION

CONTRA INDICATION
Sick sinus syndrome, second or third degree heart block, hypertensivity, severe aortic stenosis, severe obstructive coronary artery disease.

ADVERSE EFFECT
CNS: headache, fatigue, dizziness CV: dysrhythmia, peripheral edema, hypotension, palpitations, syncope, chest pain GI: nausea, vomiting, diarrhea, gastric upset, constipation, flatulence, anorexia, gingival

NURSING RESPONSIBILITY
Exercise the ten rights of giving medication upon administering. Assess fluid volume status Monitor blood pressure and pulse; if blood pressure drops call prescriber Monitor platelet count. Monitor cardiac status: blood pressure, ECG, PR,RR

Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth muscle and peripheral vascular smooth muscle; dilates coronary arteries;increasing myocardial oxygen delivery in patient with vasospastic angina.

hypertension, may co-administer with other antihypertensives.

NAME OF THE DRUG

Generic name: Carvedilol Classifications: Antihyper tensive

DOSAGE
Doctors Order: 25 mg 1 tab OD 12nn

ACTION

INDICATION

CONTRA INDICATION
Hypersensitivity, bronchial asthma, class IV decompensated cardiac failure, 2nd, or 3rd degree heart block, cardiogeneric shock, severe bradycardia, pulmonary edema.

ADVERSE EFFECT
CNS: seizures, dizziness, headache GI: abdominal pain, diarrhea, increased AST/ ALT, increased alkaline phosphatase CV: bradycardia, postural hypotension, dependent edema, peripheral edema GU: UTI Resp: rhinitis, pharyngitis, dyspnea

NURSING RESPONSIBILITY
Exercise the ten rights of giving medication upon administering. Monitor renal studies including protein, BUN, creatinine. Monitor input and output and weight daily. Monitor blood pressure Monitor apical or pulse ratebefore administration Assess for edema in feet and legs daily, fluid overload.

A mixture of nonselective Bblocking and ablocking activity; decreases cardiac output, exercise inducedtachycardia, reflex orthostatic tachycardia; causes reduction in peripheral vascular resistance and vasodilatation

Essential hypertension alone or in combination with other antihypertensive

NAME OF THE DRUG

Generic Name: Epoetin Alfa (Renogen) -Human Recombinant Erythropoietin Therapeutic Classification: Blood formers Hematopoietic growth factor

DOSAGE
Doctors Order: 4000u 2x a week

ACTION

INDICATION

CONTRA INDICATION
Uncontrolled hypertension and known hypersensitivity to mammalian cell derived products and albumin (human)

ADVERSE EFFECT
CNS: Seiz ures, heada che. CV: Hyper tension GI: Nausea , diarrhea. Hematolog ic: Iron deficiency, thrombocyt osis, clottin g of AV fistula. Other: Sw eating, bone pain, arthralgias.

NURSING RESPONSIBILITIES
Control BP adequately prior to initiation of therapy and closely monitor and control during therapy. Hypertension is an adverse effect that must be controlled. Monitor for hypertensive encephalopathy in patients with CRF during period of increasing Hct. Monitor for premonitory neurological symptoms. The potential for seizures exists during periods of rapid Hct increase Important to comply with antihypertensive medication and dietary restrictions. Do not drive or engage in other potentially hazardous activity during the first 90 d of therapy because of possible seizure activity.

Glycoprotein that stimulates RBC production. Hypoxia and anemia generally increase the production of erythropoietin.

Elevates the hematocrit of patients with anemia secondary to chronic kidney failure (CRF); patients may or may not be on dialysis; other anemias related to malignancies and AIDS. Autologous blood donations for anticipated transfusions. Reduces need for blood in anemic surgical patients.

NCP Based on the sequence of Prioritized problems

Assessment Subjective: Objective: Oliguria Hyper-tensive Cold and clammy skin Hgb 9.5 g/dL

Nursing Diagnosis Decrease tissue perfusion related to peripheral vasoconstriction as manifested by high blood pressure. 200/130mmhg

Planning After 4 hours of nursing intervention the patient will demonstrate increase perfusion as individually appropriate

Intervention Nurse patient interaction. Measure and recorded blood pressure Observe skin color, moisture, temperature and capillary refill time Note presence, quality of central and peripheral pulses.

Rationale To establish rapport

Evaluation Goal met

Provide objective data for After 4 hours of monitoring nursing intervention the patient was able to demonstrate Presence of pallor, cool increase tissue moist skin and delays perfusion as capillary time may be due manifested seen to peripheral patient cooperative vasoconstriction and interested, and his blood pressure became 160/100. Bounding carotid, jugular, radial, and femoral pulses may be observed/ palpated.Pulses in the legs/ feet may be diminished, reflecting effects of vasoconstriction and venous congestion.

 Explain the importance of providing calm, restful surroundings, minimize environmental activity and noise Provide adequate rest period of time and limit the number of visitor and the length of stay

It helps reduce sympathetic stimulation, promotes relaxation and reduces physical stress and tension that affect blood pressure. It decrease discomfort and may reduce sympathetic stimulation

Encourage compliance with Adherence to diet and fluid restrictions and dietary and fluid dialysis schedule restrictions therapy prevents excess fluid and sodium accumulation Monitor response to medications to control blood pressure. Response to drug therapy is dependent on both individual as well as the synergistic effects of the drug

Assessment

Diagnosis Excess fluid volume r/t decrease Glomerular filtration Rate and sodium retention as manifested by increase blood pressure of 200/130

Planning After 4 hours of nursing interventions, patient will demonstrate behaviors to monitor fluid status and reduce recurrence of fluid excess

Intervention 1. Establish rapport

Rationale To gain trust and rapport

Evaluation Goal met The patient demonstrated behaviors to monitor fluid status and reduce recurrence of fluid excess

Subjective (none) Objectives Blood pressure of 200/130 mmHg Oliguria noted

2. Monitor and record vital signs 3. Assess possible risk factors 4. Assess patients appetite

To obtain baseline data To assess precipitating and causative factors. To note for presence of nausea and vomiting To prevent fluid overload and monitor intake and output To monitor fluid retention and evaluate degree of excess For presence of crackles or congestion To determine fluid retention

5. Note amount/rate of fluid intake from all sources

6. Compare current weight gain with admission or previous stated weight 7. Auscultate breath sounds

8. Note presence of edema.

9. Measure abdominal girth for changes. 10. Evaluate mentation for confusion and personality changes. 11. Change position of client timely.

May indicate increase in fluid retention May indicate cerebral edema. To prevent pressure ulcers.

12. Review lab data like BUN, Creatinine, Serum electrolyte. 13. Restrict sodium and fluid intake if indicated

To monitor fluid and electrolyte imbalances

To lessen fluid retention and overload.

14. Weigh client

Weight gain may indicate fluid retention and edema.

15. Encourage quiet, restful atmosphere.

To conserve energy and lower tissue oxygen demand.

Assessment

Nursing Diagnosis Risk for systemic infection r/t hemodialysis procedure as manifested by inadeqaute secondary defense

Planning

Intervention

Rationale

Evaluation

Subjective (none)

Objectives Decrease hemoglobin 9.5g

After 4 hours of nursing intervention the patient will not experience sign and symptom of infection

NPI established and maintained Promoted good hand washing Use aseptic technique when manipulating/IV invasive lines

To gain trust

Goal met After 4 hours of nursing intervention the patient did not experienced any sign and symptom of infection.

Reduce risk of cross contamination Reduces bacterial colonization

Explain the importance of deep breathing, coughing frequent position changes

It Prevents atelectasis and mobilizes secretion to reduce risk of pulmonary infections Excoriations from scratching may become secondarily infected Fever and increase pulse and respiration is typical increase metabolic rate resulting from inflamatory process

Asses skin integrity

Monitor vital signs