CHAPTER ONE

ASSESSEMENT OF PATIENT AND FAMILY

Nursing care study is the act of caring for patients, their relatives and their community

in all realms of their existence. It may include, the following jurisdiction of health;

physical, spiritual, mental, social, economic and others. Nurses are interested in the

total wellbeing of their client and as a student nurse, I am conducting this care study

on Mr. S.O and his family in all aspects of their existence. Mr. S.O detailed health

history from conception to his present health state would be examined.

ASSESSMENT OF PATIENT

Assessment of the patient and family is the beginning of the nursing process. This

includes particulars of the patient and family, medical and socio economic history, the

developmental history of the patient, patients lifestyle and hobbies, past and present

medical history, admission of the patient, patients familys concept of the illness,

literature review of condition and validation of data.

THE PATIENTS PARTICULARS

Master S.O is the first son of his father, late Mr. S. He is twenty-one years old and was

born on the 6th of May, 1996. He is dark in complexion and is One Hundred and forty-

six (146) centimeters tall and weighs fifty kilograms. He is the first born among the

eight siblings of his parents; five females and three males of which none is deceased.

1
He comes from Agona Swedru in the Central Region of Ghana. He is an Assin by

tribe. He is married to Mrs. G.O. Mr. next of kin is the yet to be born child and wife.

Mr. S.O and his wife live at Assin Enyinesi with house number B/13 near the Enyinesi

market. He is a Christian by religion and attends the Methodist Church. He is a trader

who has been selling shoes and sandals at Enyinesi market for the past five years. He

completed Enyinesi Enkran Ghankyen primary school and junior high school and could

not further his education even though he passed the Basic Education Certificate

Examination. This was due to financial constraints.

FAMILY MEDICAL AND SOCIO-ECONOMIC HISTORY

Through constant interactions with my patient and family, I got to know that, apart

from hypertension, there is no known other chronic diseases such as epilepsy, leprosy,

tuberculosis or any mental illness existing in their family.

He also stated that, family members at least once in a while suffered minor illnesses

such as headache, abdominal discomfort for which they sought treatment from drug

shops and sometimes at the Out-Patients Department of Abura Dunkwa Hospital . I

was also made to know that local medicines were sometimes used in treating of their

minor illnesses. Patient is a farmer and his wife is also a trader. The family all attend

Methodist church. Late Mr. S was a farmer.

PATIENTS DEVELOPMENTAL HISTORY

According to the mother of Mr. O.S, he was delivered at home and was immunized

by community health nurses. Mr. S.O started crawling at eight months and by age

2
one, he could walk alone without support. He started taking complementary feeds

when he was nine months old and was fully weaned at age one (1). He did not

experience any kind of developmental delays and started developing pubic hairs at

age fourteen. He attended Enyinesi Enkran Ghankyen nursery at two and half years

and proceeded to its Primary and Junior High school. He was brought up by both

parents. He got married and later left his parents home (Agona Swedro) to establish

his new home at Enyinesi.

PATIENTS LIFESTYLE AND HOBBIES

Mr. O.S is a trader who usually wakes up around 5:30 to 6:30am. From then, he

brushes his teeth and takes his bath. After performing his personal hygiene, he prays

with his family and takes his breakfast around 8:30 to 9:00am before setting off to his

work place. He does not skip meals. Mr. O.S almost takes all kinds of foods, most

especially Plantain with stew and fish. He does not eat food prepared outside his

house or food not prepared by his direct relatives. He engages himself in games such

as Ludo, playing card and mobile games and sometimes jogging etc. Though Mr.

O.S is a Christian, He goes to church once in a blue moon.

Mr. OS normally closes from work at 5:30pm and sleeps between 9:00PM and

10:00PM

PATIENTS PAST MEDICAL HISTORY

3
Mr. O.S stated that, he does not usually get sick until six months ago when he was

diagnosed with hypertension and malaria at Abura Dunkwa hospital

Mr. S.O was admitted to the Abura Dunkwa Hospital six months ago and was

diagnosed with hypertension and malaria during his hospitalization .According to Mr.

S.O he has been smoking marijuana and drinking alcohol [akpeteshie] for the past six

years. He stated that he stopped these habits two years ago due to the influence of his

spiritual father.

PATIENTS PRESENT MEDICAL HISTORY

Mr. O.S stated that, he had headache and vomited three times during the last three

days which made him take over the counter drugs. He also complained of cough

which started last night. Patient complained that his urine volume had decreased and

sometimes for a day he would not even urinate. Patient has facial swelling and chest

pain during episodes of cough. These were the things that prompted him to seek

medical service at Abura Dunkwa where he was later on referred to Cape Coast

Teaching Hospital for further investigation and management.

THE ADMISSION OF PATIENT

Mr. O.S was admitted to the male medical ward of the Cape Coast Teaching Hospital

at 6:30 am on the 28th of September,2017 through the accident and emergency unit

4
accompanied by a nurse and patients wife . Patient and wife were welcomed and

offered a seat. Patients particulars were crosschecked before he was seen by Dr.

Brew who on examination gave a diagnosis of Chronic Kidney Disease complicated by

anemia after patient presented a history of fatigue, palpitation, oliguria, facial

puffiness, difficulty in breathing, cough and chest pain. Patient was put on the

following medications IV Furosemide 40mg stat, cap Ferosalite200mg 8hourly 30

days, tab Methyldopa 500mg 12hourly 30 days, tab folic acid 5mg daily for 30 days,

hydralazine 10mg stat, NaHCO3 500mg 8 hourly30 days, methyldopa 500mg 8

hourly, cap fersolate 200mg 8 hourly. Laboratory investigations requested include

Renal Functional Test, Full Blood Count, HCV, HBsAg, chest-x ray, abdominal

ultrasound, retro screening , Liver Functional Test, urine dipstick, serum electrolytes.

Patient was received into an already prepared simple unoccupied bed and was

assisted to change into hospital gown. Oxygen was setup at a flow rate of 5ml per

minute. Start dose drugs were given to stabilize the patient and he was orientated to

the ward after stability and his belongings were given to his wife. and Patients wife

was informed about the visiting hours and patient was educated on the importance

of the National Health Insurance Scheme. During physical examination, there was no

abnormalities found apart from the symptoms stated above. Patient particulars were

entered into the admission and discharge book and the daily ward state and a

consent form for dialysis was given to patient to sign. His vital signs on admission

were as follows:

Temperature: 36 c

5
 Pulse: 122bpm

Blood pressure:180/110 mmHg

Respiration: 28cpm

SPO2: 87%

PATIENTS CONCEPT ABOUT THE ILLNESS

Mr. O.S attributed his illness to spiritual forces. Upon asking Mr. O.S what

could have caused his illness, he said people in my locality dont like my

progress and are after me in the spiritual realm.

LITTERATURE REVIEW

Kidney disease is defined as either a reduced glomerular filtration rate (GFR)

resulting in a serum creatinine of greater than 1.3 mg/dL in women or greater than

1.5 mg/dL in men, or albuminuria of greater than 300 mg/dL.

AETIOLOGY/CAUSES

1. Chronic glomerulonephritis, pyelonephritis

2. Uncontrolled hypertension

3. Systemic diseases such as diabetes mellitus (Leading cause)

4. Obstruction of the urinary tract

5. Hereditary lesions such as in polycystic kidney disease, vascular disorders,

infections.

6. Medication or toxic agents

6
 7. Environmental and occupational agents such as mercury, chromium, lead and

cadmium.

8. Smoking

9. Aging and renal function

10 genetics

Incidence

CKD is more prevalent in the elderly population. However, while younger patients

with CKD typically experience progressive loss of kidney function, 30% of patients

over 65 years of age with CKD have stable disease

Pathophysiology

A normal kidney contains approximately 1 million nephrons, each of which

contributes to the total glomerular filtration rate (GFR). In the face of renal injury

(regardless of the etiology), the kidney has an innate ability to maintain glomerular

filtration rate, despite progressive destruction of nephrons, as the remaining healthy

nephrons manifest hyper filtration and compensatory hypertrophy. This nephron

adaptability allows for continued normal clearance of plasma solutes. Plasma levels

of substances such as urea and creatinine start to show measurable increases only

after total GFR has decreased to 50%.

The plasma creatinine value will approximately double with a 50% reduction in GFR.

The hyper filtration and hypertrophy of residual nephrons, although beneficial for

7
the reasons noted, has been hypothesized to represent a major cause of progressive

renal dysfunction. The increased glomerular capillary pressure may damage the

capillaries, leading initially to secondary focal and segmental glomerulosclerosis

(FSGS) and eventually to global glomerulosclerosis.

8
Stages of Chronic Kidney Disease

CKD has been classified into five stages by the National Kidney Foundation

(NKF). Stage 5 results when the kidneys cannot remove the bodys metabolic

wastes or perform their regulatory functions and renal replacement therapies

are required to sustain life

Stages of CKD

Stages are based on the glomerular filtration rate (GFR). The normal GFR is

125 mL/min/1.73 m2.

Stage 1

GFR :90 mL/min/1.73 m2 Kidney damage with normal or increased GFR

Stage 2

GFR: 6089 mL/min/1.73 m2 Mild decrease in GFR

Stage 3

GFR :3059 mL/min/1.73 m2 Moderate decrease in GFR

Stage 4

GFR : 1529 mL/min/1.73 m2 Severe decrease in GFR

Stage 5

GFR :15 mL/min/1.73 m2 Kidney failure (end-stage renal disease [ESRD])

Diagnosis

Laboratory studies

9
Laboratory studies used in the diagnosis of CKD can include the following:

Complete blood count (CBC)

Basic metabolic panel

Urinalysis

Serum albumin levels: Patients may have hypoalbuminemia due to

malnutrition, urinary protein loss, or chronic inflammation

Lipid profile: Patients with CKD have an increased risk of cardiovascular

disease

Evidence of renal bone disease can be derived from the following tests:

Serum calcium and phosphate

25-hydroxyvitamin D

Alkaline phosphatase

Intact parathyroid hormone (PTH) levels

In certain cases, the following tests may also be ordered as part of the

evaluation of patients with CKD:

Serum and urine protein electrophoresis and free light chains: Screen for

a monoclonal protein possibly representing multiple myeloma

Antinuclear antibodies (ANA), double-stranded DNA antibody levels:

Screen for systemic lupus erythematosus

Serum complement levels: Results may be depressed with some

glomerulonephritides

Cytoplasmic and perinuclear pattern antineutrophil cytoplasmic antibody

(C-ANCA and P-ANCA) levels: Positive findings are helpful in the

10
 diagnosis of granulomatosis with polyangiitis (Wegener granulomatosis);

P-ANCA is also helpful in the diagnosis of microscopic polyangiitis

Antiglomerular basement membrane (anti-GBM) antibodies: Presence

is highly suggestive of underlying Goodpasture syndrome

Hepatitis B and C, human immunodeficiency virus (HIV), Venereal

Disease Research Laboratory (VDRL) serology: Conditions associated

with some glomerulonephritides

Imaging studies

Imaging studies that can be used in the diagnosis of CKD include the

following:

Renal ultrasonography: Useful to screen for hydronephrosis, which may

not be observed in early obstruction or dehydrated patients; or for

involvement of the retroperitoneum with fibrosis, tumor, or diffuse

adenopathy; small, echogenic kidneys are observed in advanced renal

failure

Retrograde pyelography: Useful in cases with high suspicion for

obstruction despite negative renal ultrasonograms, as well as for

diagnosing renal stones

Computed tomography (CT) scanning: Useful to better define renal

masses and cysts usually noted on ultrasonograms; also the most

sensitive test for identifying renal stones

11
 Magnetic resonance imaging (MRI): Useful in patients who require a CT

scan but who cannot receive intravenous contrast; reliable in the

diagnosis of renal vein thrombosis

Renal radionuclide scanning: Useful to screen for renal artery stenosis

when performed with captopril administration; also quantitates the renal

contribution to the GFR

Biopsy

Percutaneous renal biopsy is generally indicated when renal impairment

and/or proteinuria approaching the nephrotic range are present and the

diagnosis is unclear after appropriate workup.

CLINICAL FEATURES

1. Fluid volume deficit

2. Fatigue and lethargy

3. Sexual dysfunction

4. Headache

5. Painful menstruation

6. Anorexia, nausea and vomiting

7. General weakness (malaise)

8. Anemia

9. Increase blood pressure

10. Bleeding tendencies

11. Mental confusion

12
 12. Metallic taste in the mouth

13. Pruritus

14. Muscle twitching

15. Uremic frost

16. Petechia and ecchymosis

17. Edema

18. Muscle cramps

19. Bone fracture

20. Diarrhea or constipation

21. Pleuritic pain

COMPLICATIONS

1. Hyperkalemia

2. Pericarditis

3. Pericardial effusion

4. Pericardial tamponade

5. Hypertension

6. Anemia

7. Bone disease and metastatic calcifications

MEDICAL MANAGEMENT

Pharmacologic Therapy

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Complications can be prevented or delayed by administering prescribed

antihypertensive, erythropoietin (Epogen), iron supplements, phosphate-binding

agents, and calcium supplements.

Antacids

Hyperphosphatemia and hypocalcemia are treated with aluminum-based antacids that

bind dietary phosphorus in the GI tract. However, concerns about the potential long-

term toxicity of aluminum and the association of high aluminum levels with neurologic

symptoms and osteomalacia have led some physician to prescribe calcium carbonate in

place of high doses of aluminum-based antacids.

Antihypertensive and cardiovascular agents

Hypertension is managed by intravascular volume control and a variety of

antihypertensive agents. Heart failure and pulmonary edema may also require

treatment with fluid restriction, low-sodium diets, and diuretic agents, inotropic agents

such as digitalis or dobuyamine, and dialysis.

Anti-seizure agents

Neurologic abnormalities may occur, so the patient must be observed for early evidence

of slight twitching, headache, delirium, or seizure activity. If seizures occur, the onset

of the seizure is recorded along with the type, duration, and general effect on the patient.

The physician is notified immediately. Intravenous diazepam (Valium) or phenytoin

(Dilantin) is usually administered to control seizures.

Erythropoietin

14
 Anemia associated with chronic renal failure is treated with recombinant human

erythropoietin (Epogen). Anemic patients (hematocrit less than 30%) present with

nonspecific symptoms, such as malaise, general fatigability, and decreased activity

tolerance. Epogen therapy is initiated to achieve a hematocrit of 33% to 38%, which

generally alleviate the symptoms of anemia. Epogen is administered either

intravenously or subcutaneously three times a week. It may take 2 6 weeks for the

hematocrit to rise; therefore, Epogen is not indicated for patients who need immediate

correction of severe anemia.

Nutrition therapy

Dietary intervention is necessary with deterioration of renal function and includes

careful regulation of protein intake, fluid intake to balance fluid losses, sodium intake

to balance sodium losses, and some restriction of potassium. At the same time, adequate

caloric intake and vitamin supplementation must be ensured. Protein is restricted

because urea, uric acid, and organic acids the breakdown products of dietary and

tissue proteins accumulate rapidly in the blood when there is impaired renal clearance.

The allowed protein must be of high biologic value (dairy products, eggs, meats).

High-biologic-value proteins are those that are complete proteins and supply the

essential amino acids necessary for growth and cell repair.

Usually, the fluid allowance is 500 to 600 ml more than the previous days 24-hours

urine output. Calories are supplied by carbohydrates and fat to prevent wasting.

Vitamin supplementation is necessary because a protein-restricted diet does not provide

the necessary complement of vitamins. Additionally, the patient on dialysis may lose

water-soluble vitamins from the blood during the dialysis treatment.

15
 Other therapy

Dialysis

Hyperkalemia is usually prevented by ensuring adequate nebulization with salbutamol

or dialysis treatments with potassium removal and careful monitoring of all

medications, both oral and intravenous, for their potassium content. The patient is

placed on a potassium-restricted diet. Occasionally Kayexalate, a cation-exchange

resin, administered orally, may be needed. The patient with increasing symptoms of

chronic renal failure is referred to a dialysis and transplantation center early in the

course of progressive renal disease. Dialysis is usually initiated when the patient

cannot maintain a reasonable lifestyle with conservative treatment.

NURSING MANAGEMENT

The patient with chronic renal failure requires critical nursing care to avoid

the complications of reduced renal function, the stresses and anxieties of dealing with

a life-threatening illness.

Fluid and electrolyte balance is very important in the management of chronic renal

failure;

Assessment of fluid and electrolyte balance is continuous. The patient and family

should be taught to identify signs and symptoms of fluid excess or dehydration and to

16
adjust fluid intake accordingly. The patient is also taught to recognize the signs of

hyperkalemia and other electrolyte imbalances and to adjust diet as necessary.

In the early stages of chronic renal failure, tubular reabsorption of water is

decreased so the intake must be increased to approximately 2000ml per day to avoid

dehydration. When oliguria is present the fluid intake is limited to 400-500ml plus the

measurable loss

Nutrition: The prescribed diet varies with the severity of disease and the type of

maintenance treatment used. In the early stages, protein restrictions may be based on

the glomerular filtration rate (GFR), but when the GFR decreases to 2-5ml/minute,

protein restrictions are no longer effective in reducing the retention of nitrogenous

wastes and dialysis is required. Protein is lost during continuous ambulatory peritoneal

dialysis (CAPD) and the loss is greater if peritonitis develops. Less protein is lost

during hemodialysis, but some free amino acids escape with this treatment. The protein

intake must be adjusted to compensate for the loss and prevent catabolism of body

protein. Calorie intake must be sufficient to permit activity without breakdown of

tissue protein.

Electrolyte balance is maintained by adjusting the dietary intake according to serum

electrolyte levels. As impaired tubular re-absorption results in an excessive loss of

sodium, salt is not restricted in the diet unless there is edema or hypertension. Dietary

sodium is restricted following a transplant as corticosteroid therapy leads to sodium

and water retention. Foods high in potassium are restricted for most renal patients

because potassium is not effectively removed by impaired kidneys. The serum

17
phosphate level is usually controlled by the use of phosphate binders, such as an

aluminum hydroxide antacid, and avoidance of foods high in phosphorus.

Dietary management in chronic renal failure becomes more complex

when he or she experiences sudden stress such as infection, surgery or trauma. Food

and fluid intake must be closely monitored and adjusted to body needs.

Prevention of infection and bleeding: Immunosuppressive drugs or uremia affect white

cell activity, making the person prone to infection. Preventive measures and prompt

treatment of infection are essential. Uremic blood also has altered clotting ability and

the patient therefore needs to be monitored for signs of bleeding from the dialysis

access, mucous membranes or surgical sites.

Activity intolerance: the individual with chronic renal failure

experiences considerable fatigue and lethargy; anemia may contribute to the decreased

energy. The anemia may be due to decreased erythropoietin production, depression of

the bone marrow associated with uremia, or to blood loss due to increased tendency to

bleed and through dialysis. It develops gradually and may not be symptomatic at first.

The nurse working with hemodialysis patients should therefore take precautions to

minimize blood loss during dialysis.

Enquiry should be made concerning joint and muscle pain and any changes in range of

motion or mobility. Signs of hypocalcaemia, tetany, carpopedal spasm, seizures,

numbness and tingling of extremities, or confusion should be noted and reported to

medical staff.

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Skin and oral mucosa: Assessment of the skin of the patient with chronic renal failure

may show pallor, a yellow-grey colour, dryness, bruising and decreased sweating. The

patient complains of itching. The hair is dry, becomes brittle and the nails are rigid and

dry. The mouth should be inspected regularly for signs of inflammation and bleeding.

The patient is taught to care for skin, mouth, hair and nails; this includes

following the dietary regimen to control serum calcium and phosphorus levels and

avoiding tissue trauma.

Clouding of consciousness: Changes in the patients level of awareness usually develop

gradually as uremia increases. Rapid progression of the disease produces severe

disturbances in behavior and cognition. Dialysis should be started before the

progression of these neurological complications.

Early symptoms may include headache, lethargy, dizziness, euphoria,

depression, apathy, sleeplessness or drowsiness. Recent and remote memory and

attention span are decreased and decision-making is impaired. In the late stages of

renal failure, confusion, slurred speech, stupor, coma and convulsions may develop.

The patient is assessed for orientation to time, place and person. Changes in behavior

as perceived by the patient and family are noted and relatives are helped to understand

that the patient cannot always control behavior.

Cognitive abilities should be evaluated before patient teaching is started. Explanations

of procedures should be simple, broken down into steps and repeated frequently. It is

possible that the patients home environment may need modification to promote safely.

19
Lack of knowledge: As the patient and family must assume the responsibility for

following the prescribed regimen, formal and informal instruction is planned. Patient

education is started at the time of diagnosis and the teaching is adjusted as the patients

needs change with progression of the disease and revision of the treatment plan. The

decision about home or hospital dialysis influences the degree of responsibility the

patient and family assume for self-care and the resources needed to help them.

When a patient with chronic renal failure is admitted to hospital, it is important that the

nursing staff assess the patients understanding of care and support the individuals

achievements by encouraging active patient participation in care. Taking away the

patients control on each hospital admission retards progress already made and

contributes to feelings of dependency.

Goals for education should be established for each patient and teaching

should draw upon a range of different methods such as pamphlets, detailed instructions

for technical tasks, videos, group sessions and practical demonstrations. Content

includes the function of the kidneys, types of treatment (dialysis or transplant), self-

care measures and lifestyles adaptations.

Promoting Home and Community-Based Care

Teaching patients about self-care: The nurse plays an extremely important role in

teaching the patient with ESRD. Because of the extensive teaching needed, the home

care nurse, dialysis nurse, and nurse in the outpatient setting all provide ongoing

education and reinforcement while monitoring the patients progress and compliance

with the treatment regimen.

20
A nutrition referral and explanations of nutritional needs are helpful help because of

the numerous dietary changes required. The patient is taught how to check the vascular

access device for patency and how to take precautions, such as avoiding venipunctures

and blood pressure measurements on the arm with the access device.

Additionally, the patient and family require considerable assistance and support

in dealing with the need for dialysis and its long-term implications. For instance, they

need to know what problems to report to the health care provider, including the

following:

Worsening signs and symptoms of renal failure (nausea, vomiting, change in

usual urine output (if any), ammonia odor on breath)

Signs and symptoms of hyperkalemia (muscle weakness, diarrhea, abdominal

cramps)

Signs and symptoms of access problems (clotted fistula or graft, infection)

These signs and symptoms of decreasing renal function, in addition to increasing BUN

and serum creatinine levels, may indicate a need to alter the dialysis prescription. The

dialysis nurses also provide ongoing education and support at each treatment visit.

Continuing Care: The importance of follow-up examinations and treatment is stressed

to the patient and family because of changing physical status, renal function, and family

because of changing physical status, renal function, and dialysis requirements. Referral

for home care provides the home care nurse with the opportunity to assess the patients

environment, emotional status, and the coping strategies used by the patient and family

to deal with the changes in family roles often associated with chronic illness.

21
The home care nurse also assesses the patient for further deterioration of renal

function and signs and symptoms of complications resulting from the primary renal

disorder, the resulting renal failure, and effects of treatment strategies (e.g. Dialysis,

medications dietary restrictions). Many patients need ongoing education and

reinforcement on the multiple dietary restrictions required, including fluid, sodium,

potassium, and protein restriction. Reminders about the need for health promotion

activities and health screening are an important part

Validation of Data

Validation of data is an act of confirming and verifying information to keep

the data free of error. With the observations made through the comparison, laboratory

investigations in addition to the signs and symptoms presented by Mr. O.S, made it

clear that the data collected is valid and free from error and confirms the diagnosis as

chronic kidney disease

22
 CHAPTER TWO

ANALYSIS OF DATA

This is the stage in the nursing process which includes the comparison of information

obtained to standard to help determine any deviation from normal and physiological

functions of the body to help to formulate appropriate intervention.

COMPARISION OF DATA WITH STANDARD

Data collected from diagnostic investigations, causes of clients condition, signs and

symptoms, treatment, pharmacology of drugs and complications were compared with

standard from the literature review.

COMPARISM OF LABORATORY INVEESTIGATIONS

STANDARD DATA DATA ON MR. O.S

23
 1. Blood studies 1. FBC

2. Urinalysis 2. Renal Function Test

3. X- ray of the kidney 3. Abdominal ultrasound

Renal biopsy 4. ECG

5. In addition to investigation related to the kidney other test were requested and

done which include, HBsAg, Retro screening to rule out othe condition.

6. DATE SPECIMENT INVESTGATION RESULTS INTERPRETION REMARKS

28/09/2017 BLOOD Full blood count Only RBC is below NORMAL Two pints of Blood
normal
BELOW NORMAL was transfused

28/09/2017 Blood Grouping and Blood group O+ Client blood group O+ No treatment was

cross matching given

28/09/2017 Blood HBsAg positive Client is hepatitis B No treatment

positive given

28/09/2017 Blood HCV Negative Normal No treatment

given

28/09/2017 Blood Retro screening Negative Normal No treatment

24
 given

LIVER FUNCTION

TEST
Patient liver functional
28/09/2017 Blood Albumin 34.4 g/L
test all fell within the
Total protein 63.3 g/L No treatment
normal range
Globulin 28.9 g/L

RENAL FUNTON

TEST

INTERPRETATION
DATE SPECIMENT INVESTIGATION RESULTS TREATMENT
Patient creatinine is
28/09/2017 Blood Creatinine > 1326.0mol/L above normal Dialysis was not
indicating that the done because
kidneys are unable to
patient refused
excrete the creatinine
treatment

Above normal

28/09/2017 Blood Urea 34.71 mmol/L

Within normal

BUN/CRE 22.65

25
 LIPID PROFILE

DATE SPIECEMENT INVESTGATION RESULTS RESULT INTERPRETION REMARKS

INTERPRETATION

28/09/2017 BLOOD Cholesterol 8.22 mmol/L Above normal Patient has lipid Antihypertensive

HDL Cholesterol 1.59 mmol/L Above Normal profile indicating were

Triglycerides 2.31 mmol/L Above normal that he might administered

LDL Cholesterol 5.58 mmol/L Above normal have heart Rest was also

VLDL 1.05 mmol/L disease which promoted

Non-HDL CHOL 6.63 mmol/L Above normal pose him to

hypertension

26
 COMPARISM OF ETIOLOGIE OF CKD

CAUSES ACCORDING TO POSSIBLE CAUSES OF PATIENT

LITTERATURE CONDITION

1. Chronic glomerulonephritis, 1. Patient had nephrotic syndrome

pyelonephritis 2. Patient had history of

2. Uncontrolled hypertension hypertension

3. Systemic diseases such as 3. Patient had no history of

diabetes mellitus (Leading cause) diabetes

4. Obstruction of the urinary tract 4. Patient had no obstruction of his

5. Hereditary lesions such as in urinary truck

polycystic kidney disease, 5. Patient has no known hereditary

vascular disorders, infections. lesions of the kidney

6. Medication or toxic agents 6. patient has a past history of

7. Environmental and occupational alcoholism

agents such as mercury, 7. patient environment has no

chromium, lead and cadmium. hazard of mercury, chromium,

8. Smoking lead and cadmium

9. Aging and renal function 8. patient had history of smoking

10. gentic marijuana

9. age of patient is no responsible

for the condition

10. patient has no known genetic

predisposition

27
 COMPARISM OF SIGNS AND SYMTOMS

STANDARD SYMTOMS SYMTOMS OF MR. O.S

1. Fluid volume overload 1. Patient had fluid overload

2. Fatigue and lethargy 2. Patient had fatigue

3. Sexual dysfunction 3. No complaint of sexual

4. Headache dysfunction

5. Painful menstruation 4. Headache was present

6. Anorexia, nausea and vomiting 5. No pain on micturition

7. General weakness (malaise) 6. Anorexia, nausea and vomiting

8. Anemia present

9. Increase blood pressure 7. Patient was weak

10. Bleeding tendencies 8. Patient had anemia

11. Mental confusion 9. Patient blood pressure was high

12. Metallic taste in the mouth 10. No bleeding tendencies

13. Pruritus 11. Absent

14. Muscle twitching 12. Absent

15. Uremic frost 13. Absent

16. Edema 14. Absent

17. Muscle cramps 15. patient had uremic frost

18. Bone fracture 16. Patient his edema

19. Diarrhea or constipation 17. Absent

20. Pleuritic pai 18. Absent

28
 19. Absent

20. Absent

COMPARISM OF TREATEMENT

TREATMENT ACCORDINDING TO TREATMENT GIVEN TO PATIENT

LITTERATUER

Diuretics IV Furosemide 160mg then 60mg x

48hours

Antihypertensives tab Methyldopa 500mg 12hourly 30

days,

hydralazine 10mg stat,

Tb nifedipine 60mg 30 days

Tb losartan 100mg daily 2/52

hematinic cap fersolate 200mg 8 hourly

Tb folic acid tab folic acid 5mg daily for

30 days,
bronchodilators Neb. Salbutamol 5mg 6hourly 72
hours

29
 Other treatment that were give include; NaHCO3 500mg 8 hourly30 days
[prevent metabolic acidosis], Tb Ca+ + nitro 8hourly30 day and Neb. Salbutamol
5mg 6hourly 72 hours to [prevent hyperkalemia]

DATE DRUG CLASSIFI Dosage and Route of Desired Effect/ Desired SIDE
CATION Administration Action Effect/Action EFFECT
Given to Client Of DRUG
ON
PATIENT
28/09/ Furosemide Loop 40mg intravenously Act primarily on the Client urine No side effect
17 (lasix) diuretics for stat, followed by ascending loop of output increase of drug was
oral administration of Henle to limit water, observed
80mg daily x 30 days sodium, and chloride
absorption

DATE DRUG CLASSIFI Dosage and Route of Desired Effect/ Desired No side effect
Administration Action
CATION Effect/Action of drug was
Given to Client
on patient observed

28/09/ Fersolate Hematinic Client dose: 200mg Provides elemental iron Client pains No side effect
17 8hourly daily x 30 and essential formation was relieved of drug was
of hemoglobin observed

30
29/09/ Folic acid Vitamin B 5mg daily x 30 Needed for synthesis of Absence of No side effect
17 complex amino acids and DNA fatigue, of drug was
group weakness and observed
(suppleme dyspnea
nt)
30/09/ Whole Hypertonic 2 pints of whole blood To correct anemia Anemia was No side effect
17 blood solution corrected and of drug was
his general observed
condition
improved

losartan Antihypert Tb losartan 100mg To reduce blood Blood pressure No side effect
ensive daily 2/52 pressure and increase of patient was was observed
Oral route glomerulus filtration reduced

DATE DRUG CLASSIFI Dosage and Route of DESIRED EFFECT Desired Side effects
CATION Administration Effect/Action
observed
Given to Client on patient
when drug

was

administered

31
30/09/ Salbutamol Bronchodila Nebulizing(inhalation) To prevent 1.Hyperkalemi No side effect
17 tor salbutamol a was not
hyperkalemia was observed
5mg6hourly observed in
To treat bronchospasm patient after during and
72hours

in patients with treatment after the

2.Patient have
reversible obstructive treatment was
his breathing
given
airway rate being
improved

28/09/ Methyldopa Antihypert Tb methyldopa To reduce high blood Blood pressure No side
17 ensive pressure and to reduce of patient was
500mg 8 hours effects was
circulation load on the reduced
30 days observed
kidney

28/09/ nifedipine antihyperte Tab nifedipine 30mg To manage Patient blood Patient did not
17 hypertension to pressure was
nsive 12 bid 1/52 react to drug
reduce blood pressure reduced
after

administration

COMPLICATIONS DEVELOPED BY THE PATIENT

1. Hypertension
2. Anemia
MANAGEMENT OF COMPLICATIONS
Active management of hypertension was done through drugs and rest.patient
blood pressure was monitored every 30 minutes until he was stable.
Anemia was managed with drug and food as indicated by the dietitian

CLIENT\FAMILY STRENGTH

32
On admission, client was conscious and respond to questions appropriately. Client
was able to bath without assistance, cared for his mouth and also sit up in bed without
assistance. Patent was able to move without assistance. Clients family members
visited him in the mornings and evenings during visiting hours. Clients family were
able to afford all prescribed medications, besides his wife also provided him all his
basic needs for comfort.

THE PATIENT/FAMILY HEALTH PROBLEMS

1. Swollen face

2. Fatigue

3. Shortness of breath

4. Anxiety.

5. Knowledge deficit.

6. Loss of appetite

7. Financial problem

NURSING DIAGNOSES

1. Breathing pattern disturbance (dyspnea) related to low hemoglobin

level

2. Disturbed body image related to facial swollen

3. Altered nutrition (less than body requirement) related to decreased

appetite and dietary restriction.
4. Fluid volume excess (pedal edema) related to compromised
regulatory mechanism (renal failure).
5. Anxiety related to impending procedure [dialysis] and it outcome on

his body image

6. Activity intolerance related to fatigue

33
 7. Sleep pattern disturbance related to discomfort of current condition

8. Inability to underwent the medical procedure [dialysis] related to

lack of funds

CHAPTER THREE

PLANNING FOR CLIENT AND FAMILY CARE

This chapter is the third phase of the client and family care study and deals with

planning the nursing care. It entails the process of formulating nursing

strategies required to prevent, reduce or eradicate the client and the familys

health problems which were identified at the analysis stage.

To achieve this, setting of clear objectives or outcome criteria and the stating

of specific nursing measures are necessary as they go a long way to help the

client and the family to meet their health needs.

OBJECTIVE/OUTCOME CRITERIA

A. Patients breathing rate will return to normal [16-20cpm] within 24hours as

evidenced by:

1.Nurse observing a respiratory rate and depth within normal range

2.Client verbalizing ability to breath comfortably.

34
B. Patient will demonstrate enhanced body image within 12 hours as evidenced by

1.patient verbalizing acceptance self in situation

C. patient nutritional status would be restored within five days of hospitalization as

evidenced by
1.Clients participation in food selection within dietary restriction
2.Nurse observing patient eating 2/3rd of meal served
D. Patient fluid volume would be restored to normal within 5-days of hospitalization

as evidenced by

1 Absence of edema

2 patient losing 3-5 Kg of body weight

3 blood pressure reading within normal

E. Patient level of anxiety will be reduced within 24 hours as evidenced by

1. Patient verbalizing that he is not anxious

2.Patient signing consent to go for dialysis

F. Patient will demonstrate enhanced body image within 12 hours as evidenced by

1. patient verbalizing acceptance self in situation

G. Patient will be able to participate in his activities for daily living within 24 hours
as evidence by

1.patient performing his activity of daily living without complaining

2.his vital signs being stable

H. Patient will have get funds within 48 hours as evidenced by

35
 1.Patient enough fund for the procedure

2.organisation coming to support patient with funds

Date/ti Nursing Objective/outcom Nursing orders Intervention Evaluation Signatu

me diagnosis e criteria re /date

28/09/ Breathing Patients breathing 1.Reassure O.S 1. O.S was reassured Goal fully
met as
pattern rate will return to 2.Put client in a 2. O.S was kept in YWS
2017 Patient
comfortable 29/09/2
disturbance normal [16- comfortable position position respiratory
rate fell
within 017
(dyspnea) 20cpm] within 3.Prop up patient in
normal range
related to 24hours as bed and support with [19cpm] and
3. O.S was propped he breathing
low evidenced by: pillows in bed comfortably
in bed
hemoglobi 4.Open the windows
1.Nurse observing
n level for proper
a respiratory rate 4. Windows were
opened
ventilation
and depth within
1. 5. monitor vital
normal range 5. Vital signs and
signs especially SPO2 were
monitored every
2.Client
respiration, SPO2 30 minutes and
recorded
verbalizing ability
every 30minutes and
to breath
record findings 6. Oxygen was
comfortably. administered as
6.Administer oxygen prescribed

as ordered

36
28/09/ Disturbed Patient will 1.Reassure patient 1.Patient was reassured. Goal was 28/09/17
fully met as
body image demonstrate 2.Assess the degree 2.Degree of swollen was evidenced by YWS
17 assessed. patient
related to enhanced body of the swollen 3.impact of swollen on verbalizing
ADL was assessed. acceptance of
facial image within 12 3.Assess the impact situation
4.impact of swollen on
swollen hours as evidenced of swollen on ADL relationship was assessed
5.patient was told the
by 4. assess the result of reason for the swollen and
the fact that change wasnt
body image on permanent
1.patient
patient relationship
verbalizing
6.duirrectics were
others
acceptance self in administered
5.Educate the reason
situation
for the swollen that

change is not

permanent

Administer prescribe

medication

37
28/09/ Altered Patient nutritional 1.Discuss dietary 2. Dietary restrictions Goal was 28/09/17
status would be and for preference was fully met as
nutrition restrictions and food YWS
2017 restored within discussed with patient
(less than preferences with and family Patient ate
five days of 2/3 of meal
3. Meal was attractively
body hospitalization as client and family served and
served
requiremen evidenced by 4. Sips of water was he
2.Serve food given between feds participating
t) related to 1.Clients in the meal
attractively
decreased participation in selection
food selection 3. Give sips of water 5. Patient was put in a
appetite within dietary sitting position during
and dietary restriction in between feds to
feeding
restriction. stimulate appetite
2.Nurse observing
patient eating 2/3rd 4.Position client 6. patient was educated
of meal served about 5 foods which
comfortably during contain high amounts
meals to promote of salt

easier breathing

5.educate the

patient about foods

that contain high salt

intake

28/09/ Fluid Patient fluid 1 monitor the 1 intake and output was Goal fully YWA
volume 2/10/17
2017 volume would be patients intake and strictly monitored met as
excess
restored to normal output every shift clients
(pedal 2 patient limbs and chest
edema) within 5-days of assess the patients weight
was elevated.
related to peripheral edema
hospitalization as reduced by
compromis 2.vital signs was checked
evidenced by every shift 2.5kg and
ed
6 hourly
regulatory 2 Elevate patient edema
1.Absence of
mechanism limbs and chest subsided
edema

38
 (renal 2. patient losing 1- 2 Weigh patient 4 Patient was told the
failure).
3Kg of body daily importance of notifying

weight 3 Check and record nurses before taking in

vital signs routinely any food or fluid

3.Blood pressure
especially blood
reading within 5 Prescribed medications
pressure
normal range for excretion of fluid were
4.educate patient on
served
the need to notify

nurses when taking

any food or fluid

5 Serve prescribed

medications

28/09/ Anxiety Patient level of 1 Educate patient on 1 patient was educated on Goal not met YWS

related to anxiety will be the importance of the importance of dialysis as patient 02/10/17
2017
12:15pm
impending reduced within 24 dialysis to his to his condition as well as requested for
1:30pm
procedure hours as evidenced condition and the prognosis discharge

[dialysis] by prognosis against

2 Patient and relatives
and its 2 Reassure patient medical
were reassured of
outcome and relative of advice
competent health care

39
 1. Patient competent health team and their interest to

verbalizing that he team help them

is less anxious 3 educate patient on

3 Patient was educated on YWS
28/09/ Goal not met
other treatment 01/10/17
2.Patient signing kidney transplant and the
2017 as patient
consent form alternative like
different types of dialysis
requested for
kidney transplant
4 different nurses and discharge
4. Invite other health
doctors were invited to against
care team to speak to
talk to patient on the need medical
patient and relative
for the procedure advice
5.Introduce patient

to other patients who

has undergone the

same procedure

29/09/ Knowledge Patient and the 1. Establish good 1. Nurse interacted with Goal fully YWS
family will have nurse-client client and the relatives to met as 29/09/17
17 deficit
adequate relationship gain their cooperation
related to Patient and
knowledge on
2. Assess client and 2. Nurse explored from family
lack of CKD within 1hour
the relatives the client and the relatives answering
as evidenced by
exposer to knowledge what they know about 75% of the
1.client and the
information renal failure questions
relatives being 3. Educate client and
asked to
on Chronic able to answer the relatives about 3. The causes, signs and
them
about 70% of chronic kidney symptoms, and prevention
kidney correctly
questions asked disease of renal failure were
disease explained to client and the
correctly 4. Allow them to ask
relatives.
question on areas

40
 they did not get 4. Client and the relatives
explanation well. asked about the causes of
29/09/1 renal failure and they were YWS
5. Ask client and
7 answered in simple terms
relatives questions 29/09/17

5. Series of questions
were asked for feedback
to evaluate their level of
understanding.

30/09/ Activity Patient will be able 1.Reassure client 1. Client was reassured Goal fully YWS
met as
to participate in his 2.Teach client to do 1/10/17
17 intolerance 2.Range of motion patient does
activities for daily range of motion AODL 1:10pm
related to exercises were taught and without
1:12pm living within 24 exercise
done complaints
fatigue hours as evidence 3check his vital and his vital
3.patient vital signs were signs fell
by signs 4 hourly
(anemia) within
4.Encourage client checked every 4 hours. normal range
1.patient
to take part in his up 4. Patient was advice to
performing his
keeping (personal brush his teeth and
activity of daily
hygiene) assisted bath room bathing
living without
5. administer was done by the patient
complaining
hematinic as 5.prescribed hematinic
2.his vital signs
prescribed were administered
being stable 6. administer blood 6. two pints of blood was

as prescribed administered

30/09/ Inability to Patient will have 1 Assess the client Patient financial Goal not met YWS
as
17 underwent get funds within financial status status was assessed
Patient do
not have the 2/10/17
the medical 2 As relative to Relatives were asked
required
procedure organize fun from funds for the
to mobilize fund from
procedure

41
 [dialysis] 48 hours as other relative and their relatives and and no
organization
related to evidenced by friends friends coming to
29/09/ the aid of
lack of 3 Ask relative to Relative were the patient
17 1.Patient enough with funds
funds contact their church encouraged to contact
fund for the
for assistance church for assistance YWS
procedure
4 Identify support Support groups were
2.organisation 2/10/17
groups related to consulted
coming to support
illness
patient with funds

42