I. INTRODUCTION

Chronic or irreversible, renal failure is a progressive reduction of functioning renal tissue

such that the remaining kidney mass can no longer maintain the body’s internal environment.

CRF can develop insidiously over many years, or it may result from an episode of a cure renal

failure from which the client has not recovered. The incidence of CRF varies widely by state and

country. In the United States, the incidence is 268 new cases per million populations.

Chronic renal failure affects many body systems. It can also lead to many complications.

This is the goal of health care providers, to prevent any occurrence of complications. One of the

complications of CRF is hyperparathyroidism; this is due to the compensatory mechanism of the

parathyroid hormone once it detects any alteration in the calcium level of the body.

It is important for clinicians to recognize the problem of hyperparathyroidism early in the

course of chronic kidney disease so that growth of the parathyroid glands can be prevented or

halted, and excessive secretion of hyperthyroidism can be controlled to help minimize the adverse

consequences on bone and mineral metabolism, which may lead to bone pain and bone fractures,

decreased growth in children, muscle weakness, and elevations in the calcium phosphorus

product, which contributes to calcification of the heart valves and blood vessels and contributes

to the high cardiovascular mortality in patients with advanced kidney disease.

Early detection of this complication of chronic kidney disease will provide an opportunity

to intervene to control the secretion of parathyroid hormone and, thus, minimize the problem.

Early detection will also allow for the opportunity to prevent further growth of the parathyroid

glands so that the magnitude of the problem will be lessened as kidney function deteriorates.

There is also some evidence that the control of hyperparathyroidism may help to slow the

progression of kidney disease. Ultimately, it is hoped that with timely intervention to control this

complication of chronic kidney disease, improved patient outcomes on in terms of morbidity and

mortality will be achieved.

As nurses, we could help our patients by having a deep understanding of the disease, that

we may learn the proper interventions for the chronic kidney disease patients. In this way, we

could render quality care for them. We could as well lead them to the proper treatment to lessen

their sufferings brought by the kidney failure, in anyhow. By having a wide understanding of the

disease, we could impart teachings on how we could prevent the occurrence of chronic kidney

disease. As nurses, it is our responsibility to render information and impart health teachings to

improve the condition of our patients to the best of our abilities. One of the characteristics that

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we, nurses, should have is to be informative and only through a keen study of disease such as this

way for us to gain all the information that we need to learn.

II. NURSING ASSESSMENT

A. Personal Data and History (Demographic Data)

Mr. C is a 53-year-old male, married. He was born on September 16, 1952 in Laguna. He

is married for 29 years now and has six children. He was not able to finished his desired career

during his college years because their family business was suddenly went bankrupt. According to

Mr. C, education is important that’s why he decided to look for more affordable career. While

studying he decided to work to be able to support his education. With his perseverance and

determination, he was able to finished aircraft maintenance. But with all of this stress and

difficulties happening in his life, he learned how to smoke. According to him, smoking helps him

to be relaxed. He consumed 8 sticks/day. He was also an occasional drinker. He worked as

aircraft maintenance in Clark Air Base in Pampanga for more than 20 years.

Mr. C said that he is fond of eating meat and poultry products. After work, he only stays

at home because he feels very tired after work. At present, he still works as aircraft maintenance

in Clark Air Base in Pampanga.

Mr. C was admitted in Our Lady of Mt. Carmel Medical Center last August 25, 2010. He

was admitted due to body weakness and severe anemia. He was discharged on August 25, 2010.

B. Family Health-Illness History

Mother Side Father Side

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Lola (+) DM Lolo (+) HPNLolaLolo

Moma

Pop

Mr. C(+) HPN(+)Kidney Failure

C. History of Past Illness

Mr. C was known for being hypertensive for 5 years now. He was diagnosed of

hypertension and kidney failure last 2006. He was hospitalized in St. Luke’s Hospital because of

the said health problem. According to him, his chief complain that time was only hypertension.

He was discharged from the hospital after six days of confinement. After his discharge, Mr. C

consistently having his blood chemistry and creatinine check-up every month in OLMCMC. If

the results are all normal, his check-up becomes every month. These all became routine on him.

On May 2004, he was hospitalized for the second time in OLMCMC. After two days of

confinement in the hospital, he decided to transfer in St. Luke’s Hospital. Mr. Bean experienced

difficulty of breathing and fatigability that time. He was diagnosed of Pulmonary Congestion.

D. History of Present Illness

Four days prior to admission, Mr. C experienced easy fatigability. No other

accompanying signs and symptoms. His condition was persisted until one day prior to admission,

he already experiencing body weakness, body malaise, pallor and fatigability that’s why he

consulted OLMCMC. He was advised to have laboratory examination (Hgb and Hct), which

revealed anemia and he was advised to be admitted. His initial vital signs were as follows: T-

36.8, RR- 22, PR- 64, BP- 170/100.

E. Physical Examination

Vital Signs:

T - 37

RR - 17

PR - 85

BP - 180/90

Integumentary

A. Skin- pallor, brown in complexion, with good skin turgor

B. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4 seconds)

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Head-no mass palpated

A. Scalp- hair evenly distributed without any presence of lice and lesions

B. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally round and

reactive to light and accommodation

C. Ears- symmetrical with cerumen, no discharges noted

D. Nose- without flaring of nostrils, no discharges noted

E. Mouth- (-) pallor

F. Neck- no mass palpated, without lesions, no enlargement of lymph nodes and pain

G. Chest and Lungs- with bibasal rales

Abdomen- soft, flat, tender

Renal and Urologic changes: oliguria

Cardiovascular changes: hypertension

Hematopoietic changes: anemia

F. Diagnostic and Laboratory Procedures

Diagnostic/ Laboratory Procedure

Date OrderedDate Result in

Indication (s)Purpose (s)

ResultNormal Values used by the hospital

Analysis and Interpretation

1. CBC

Hgb

Hct

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Usually done to a pt. with renal disease to determine if the kidney’s ability to release erythorpoietin factor is already affected

Used to measure RBC number and volume. It is an integral part of the evaluation of anemic patients

72103107118109

.23

.31

.33

.36

.32

120-170 g/L

.40-.50

Results were all below the normal level, thus indicating renal malfunction and thereby causing anemia

Result were all below the normal range thus, showing anemia and renal disease

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WBCLeukocytes

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Ordered2/3,4,6,8,9/05

Result:2/3,4,6,8,9/05

Determines any inflammation and infection

Determines any acute bacterial infection

Determines any chronic bacterial infection or viral infection

Determines any acute bacterial infection

To determine any allergic reaction of the body

7.766.019.408.589.5

.81

.75

.71

.72

.74

.1

.13

.20

.15

.13

.05

.08

.04

.09

.07

.04

.04

.05

.04

.06

5-10x109/L

.50-.70

.10-.40

.00-.07

.00-.07

Results were all above normal level. This shows presence of inflammation and infection

Results were all above normal level. This shows presence of bacterial infection

Results were all within normal level. Showing absence of chronic infection

Some of the results were all above normalLevel indicating presence of bacteria.

Results were all within the normal level. This shows no allergic reactions.

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Nursing Responsibilities:

1. Explain the procedure to the patient

2. Tell the patient that no fasting is required

3. Apply pressure or a pressure dressing to the venipuncture site

4. Assess the venipuncture site for bleeding

Diagnostic/ Laboratory Procedure

Date OrderedDate Result in

Indication (s)Purpose (s)

Result

Normal Values used by the hospital

Analysis and Interpretation

3.Urinalysis Ordered:2/3,6,7/05

Result:2/3,6,7/05

To diagnose and monitor renal or urinary tract disease

Color: straw, light yellow, light yellow

Appearance: slightly turbid

pH: 5

Specific Gravity:1.020, 1.025, 1.020

Albumin:3+

Sugar: negative

Pus Cells: 1-2/HPF, 0-2/HPF, 2-5 /HPF

Red cells: 1-3/HPF, 1-3/HPF,4-6/HPF

Epithelial Cells:Rare

Mucus thread:Rare, (-), (-)

Bacteria: (-), few, (-)

Amorphous urates:Moderate, moderate, few

Laboratory results revealed that there is presence of albumin in the blood; this indicates that the glomerular cannot filter large molecules such as that of albumin. It also revealed that there is bacterial infection as evidenced by presence of bacteria, pus cells and red cells in the urine.

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Nursing Responsibilities:

1. Explain the procedure to the patient

2. Tell the patient that no fasting is required

3. Instruct the patient to catch the midstream urine for better result

4. Send the specimen to the laboratory promptly

Diagnostic/ Laboratory Procedure

Date OrderedDate Result in

Indication (s)Purpose (s)

Result

Normal Values used by the hospital

Analysis and Interpretation

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4. Creatinine

5. Na+

6. K+

7. Calcium

8. Phosphate

Ordered:2/3,4,6,8/05

Result in:2/3,4,7,9/05

Ordered:2/3/05

Result in:2/3/05

Ordered:2/3,6/05

Result in:2/3,7/05

Ordered: 2/3/05

Result in:2/3/05

Ordered: 2/3/05

Result in:2/3/05

This test was ordered in order to evaluate renal function.

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

To evaluate muscle contraction, nerve impulse transmission, and blood clotting

To evaluate the metabolism of carbohydrates, bone formation and acid-base balance.

149914301649731

137

4.78

6.4

186

44.20-150.30 umol/L

135-150 mmol/L

3.5-5.5 mmol/L

8.5-10.5 mg/dl

30-150 u/L

Results were all above the normal level indicating renal malfunction. The kidney cannot excrete nitrogenous waste product of protein leading to its accumulation in the blood

Normal result which means there is still fluid and electrolyte balance

Normal result which means there is still fluid and electrolyte balance

Results were all above the normal level indicating renal malfunction.

Results were all above the normal level indicating renal malfunction.

Nursing Responsibilities:

1. Explain the procedure to the patient

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2.Tell the patient that no fasting is required

3. Apply pressure or a pressure dressing to the venipuncture site

4. Assess the venipuncture site for bleeding

III. ANATOMY AND PHYSIOLOGY

The kidneys are paired organs with several functions. They are seen in many types

ofanimals, including vertebrates and some invertebrates. They are an essential part of theurinary

system and also serve homeostatic functions such as the regulation of electrolytes, maintenance

of acid-base balance, and regulation of blood pressure. They serve the body as a natural filter of

the blood, and remove wastes which are diverted to the urinary bladder. In producing urine, the

kidneys excrete wastes such as urea and ammonium; the kidneys also are responsible for the

reabsorption of water, glucose, and amino acids. The kidneys also

produce hormones including calcitriol, renin, and erythropoietin.

Located at the rear of the abdominal cavity in the retroperitoneum, the kidneys receive

blood from the paired renal arteries, and drain into the paired renal veins. Each kidney excretes

urine into a ureter, itself a paired structure that empties into the urinary bladder.

Function of the Urinary System

The major functions of the urinary systems are performed by the kidneys and the kidneys

plays the following essentials roles in controlling the composition and volume of body fluids:

1. 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.

2. 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.

3. Ion concentration regulation. The kidneys help regulate the concentration of the major ions

in the body fluids.

4. 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

5. 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.

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6. Vitamin D synthesis. The kidneys. Along with the skin and the liver, participate in the

synthesis of vitamin D.

IV. PATHOPHYSIOLOGY

V. The Patient and his Care

A. Medical Management

Medical Management

Date orderedDate performed

General Description

Indication (s)Purpose (s)

Client’s initial reaction to the treatment

Client’s response to the treatment

1. D5 LRS iL x KVO

Ordered:2/3,7,9/05Performed:2/3,7,9/05

To maintain fluid balance of the pt.

Patient felt discomfort

Patient fluid status was maintained

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2. D5 NaCl iL x KVO

3. Subclavian catheterization

4.Blood Transfusion

5.Hemodialysis

Changed:2/3/05D/C2/10/05

Ordered:2/3/05Performed:2/3/05

Ordered:2/7/05Performed:2/7/05

Ordered:2/3/05

Performed:2/3/05

Ordered:2/7,8,9/05

Performed:2/7,8,10/05

A crystallized solution that is available in a variety of concentrated water and calories are provided. It is hypertonic solution containing equal amounts of Na and Cl

A catheter tube is inserted into vein in either your neck, chest, leg or near the groin. It has two chambers to allow two-way flow of blood

It is intravenous replacement of loss or destroyed blood compatible citrated human blood it is also the introduction of whole blood or blood Component

Medical treatment used to promote excretion of

To maintain fluid balance of the pt.

Temporary access for hemodialysis

To immediately restore blood volume to treat severe anemia, to be able to maintain oxygen transport to the different parts of the body

It is indicated

Patient experienced bleeding and felt discomfort on incision site

During the blood transfusion, patient was chilling for a short period of time. There was no further adverse reaction noted upon the transfusion

Patient was slightly nervous about the treatment.

Patient fluid status was maintained

Patient did not show any further bleeding

Patient did manifest some reaction such as chilling but there was not further reaction after the treatment

There was no adverse reaction noted

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wastes materials from the blood of patient.

for the patient because the kidneys cannot function very well to excrete the nitrogenous waste products, thus leading to its accumulation in the blood.

during and after the procedure

Nursing Responsibilities

1. Blood transfusion

Before

a. Assess client for history of previous BT and any adverse reactions

b. Ensure that the client has an 18 to 19 gauge IV catheter in place

c. Use 0.9% sodium chloride IVF

d. Verify the ABO group, Rh type, client and blood numbers and expiration date.

e. Take baseline vital signs before initiating BT

f. Identify the patient prior to transfusion

g. Explain the purpose of the transfusion

During

a. Start transfusion slowly

b. Maintain prescribed transfusion rate

c. Monitor patient closely. Check vital signs every 15 mins. Until 2 hours post transfusion

After

a. Monitor for adverse reactions

b. Documentation

2. Hemodialysis

Before

a. Explain the purpose of the transfusion

b. Have client void

c. Chart client’s weight

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d. Withhold antihypertensive, sedatives, vasodilators, to prevent hypotension (unless

ordered otherwise)

During

a. Obtain and record vital signs before and every 30 mins. during the procedure

b. Ensure bedrest with frequent position changes for comfort

c. Proper heparinization must be done to prevent coagulation during the therapy

d. Inform client that headache and nausea may occur

e. Monitor closely for bleeding since blood has been heparinized for procedure

After

a. Weight the patient after the therapy and record

b. Monitor vital signs especially hypotension.

c. Assess for complications (hypovolemic shock, dialysis disequilibrium syndrome)

Name of Drug

Date orderedDate TakenDate changed or D/C

Route of admin. Dosage and freq. Of admin.

General actionIndication (s)Purpose(s)

Client’s response to medication

Amlodipine besylate

norvasc

Metoprolol tartate

neobloc

Iberet- folic acid

Ordered:2/3/05

Taken:2/3-10/05

Ordered:2/3/05

Taken:2/3-10/05

Ordered:2/3/05

Taken:2/3-10/05

changed:2/3/05

PO 5 mg OD

PO 50 mg OD

PO 1 cap BID

Calcium antagonist, antihypertensive

Beta blockers, antihypertensive drug

Iron deficiency

To decrease increase blood pressure

To decrease increase blood pressure

For patient having anemia

Patient did not show any side effects

Patient did not show any side effects

Patient’s stool was dark green in color

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furosemide

lasix

calcium carbonate

Ordered:2/3/05

Taken:2/3-10/05

Ordered:2/3/05

Taken:2/3-10/05

D/C:2/3/05

PO 40 mg OD

PO 1 tab. TID

Diuretic

Calcium supplement

For oliguric patient

To treat hypocalcemia

Patient did not show any side effects

Patient did not show any side effects

Nursing Responsibilities

Prior:

1. Check and determine the prescribed the drug.2. Inform the patient about the prescribed the drug.3. Explain the procedure, purpose, indication and side effects of the drug.

During:1. Check vital signs to obtain baseline data.2. Monitor BP3. Prepare the drug and the materials4. Observe for initial assessment.5. Observe for any initial response to the treatment.

After:1. Observe for any intolerance and side effects on the prescribed drug.

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A. Nursing management

Actual SOAPIE

August 2010

S >

O> received patient on supine position, awake, afebrile with pale conjunctiva,

appears weak with easy fatigability

> VS taken and recorded as follows: T-36, PR-90, RR-16, BP-170/90

A > decreased cardiac output r/t vascular resistance secondary to hypertension

P > after 6 hrs of nursing interventions, patient will improve cardiac output as evidence by normal

vital signs and decreased in paleness and fatigability

I > monitored VS and recorded

> Established rapport

> Instructed to avoid strenuous activity

> Provided calm environment

> Encourage to ambulate early

> Assisted in changing position

> Instructed SO to avoid introducing stress to the patient

> Monitored I&O strictly

E > goal met as evidence by decreased in paleness and fatigability

B. Discharge Planning

Mr. Scrooge was discharge last February 10, 2005, Upon discharged, Mr. Scrooge’s

physical appearance was improved. There was absence of paleness in the conjunctiva and lips,

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fatigability is decrease, and with decrease creatinine level as compared when he was admitted in

the hospital. His vital signs were as follows: T- 36.5, PR- 85, RR-18, BP- 140/100.

M> Instructed to complied strictly with the following home medications

Norvasc 10 mg 1 tab OD

Iberet+FA 1 tab BID

Ketosteril 1 tab TID after meals

Alutab 1 tab TID during meals

Furosemide 40 mg 1 tab OD for edema or oliguria

Mucosolvan 1 tsp. TID

Augmentin 375 mg 1 tab TID

Nifedipine lozenges QID

>For twice a week hemodialysis

E>Bed rest

T>proper wound care (subclavian and fistula)

H>strict compliance to the medications and in hemodialysis

O>follow-up check up on February 15, 2005

D>avoid foods rich in salt and protein

>Limit fluid intake

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