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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.

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

1

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.

To ensure that the diagnosis of hyperparathyroidism is made early in the

course of chronic kidney disease, it is important to educate primary care

physicians, cardiologists, endocrinologists and other healthcare providers who

may see patients in the early stages of chronic kidney disease, so that they may

assess blood parathyroid hormone levels to uncover this complication and either

embark on the treatment of hyperparathyroidism or consider referral to a

nephrologist for further advice on the appropriate management strategies.

Referral to a nephrologist would appear to be preferable at the present time as

the field is advancing with new therapies being evaluated and implemented in

practice.

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

2

health teachings to improve the condition of our patients to the best of our

abilities. One of the characteristics that 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.

ANATOMY AND PHYSIOLOGY

Kidneys

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently,

they are major controller of fluid and electrolyte homeostasis. The kidneys also

have several non-excretory metabolic and endocrine functions, including blood

pressure regulation, erythropoietin production, insulin degradation, prostaglandin

synthesis, calcium and phosphorus regulation and Vitamin D metabolism

3

The kidneys are located retroperitoneally, in the posterior aspect of the

abdomen. On either side of the ventral column. They lie between the 12 th thoracic

and third lumbar vertebrae. The left kidney is usually positioned slightly higher

than the right. Adult kidneys are average approximately 11 cm in length, 5 to 7.5

cm in width, and 2.5 cm in thickness. The kidney has a characteristic curved

shape, with a convex distal edge and a concave medial boundary.

4

The left kidney is usually positioned slightly higher than the right. Adult kidneys

are average approximately 11 cm in length, 5 to 7.5 cm in width, and 2.5 cm in

thickness. The kidney has a characteristic curved shape, with a convex distal

edge and a concave medial boundary.

Human kidneys viewed from behind with spine removed

5

Structure

1. Renal pyramid • 2. Interlobar artery • 3. Renal artery • 4. Renal vein 5. Renal

hilum • 6. Renal pelvis • 7. Ureter • 8. Minor calyx • 9. Renal capsule • 10. Inferior

renal capsule • 11. Superior renal capsule • 12. Interlobar vein • 13. Nephron •

14. Minor calyx • 15. Major calyx • 16. Renal papilla • 17. Renal column

Ureters, Urinary Bladder and UrethraThe ureters are small tubes that carry urine from the renal pelvis of the

kidney to the posterior inferior portion of the urinary bladder. The urinary bladder

is a hollow muscular container that lies in the pelvic cavity just posterior to the

pubic symphysis. It functions to store urine, and its size depends on the quantity

of urine present. The urinary bladder can hold from a few milliliters to a maximum

of about 1000 mL of urine. When the urinary bladder reaches a volume of a few

hundred mL, a reflex is activated, which causes the smooth muscle of the urinary

bladder to contract and most of the urine flows out of the urinary bladder through

urethra. The urethra is a tube that exits the urinary bladder inferiorly and

anteriorly. The triangle-shaped portion of the urinary bladder located between the

opening of the ureters and the opening of the urethra is called trigone. The

urethra carries urine from the urinary bladder to the outside of the body.

6

Renal Blood flow and Glomerular FiltrationThe kidney receive 20% to 25% of the cardiac output under resting

conditions, averaging more than 1 L of arterial blood per minute. The renal

arteries branch from the abdominal aorta at the level of he second lumbar

vertebra, enter the kidney, and progressively branch into lobar arteries. Blood

flows from the interlobular arteries through the afferent arteriole, the glomerular

capillaries, the efferent arteriole and the peritubular capillaries. Some of the

peritubular capillaries carry a small amount of blood to the renal medulla in the

vasa recta before entering the venous drainage. The blood leaves the kidney in

venous system closely corresponding to the arterial system: interlobular veins,

arcuate veins, interlobar veins, and the renal vein. The renal circulation then

empties into the inferior vena cava.

PhysiologyCharacteristics of Urine

Urine is a watery solution of nitrogenous waste an inorganic salts that are

removed from the plasma and eliminated by the kidneys. It is 5% water and 5%

dissolved solids and gases. The amount of these dissolved substances is

indicated by it specific gravity. The specific gravity of pure water, used as a

standard is 1.000. Because of the dissolved materials it contains, urine has a

specific gravity that normally varies from 1.010 to 1.040. When the kidneys are

diseased, they lose the ability to concentrate urine, and the specific gravity no

longer varies as it does when the kidneys function normally.

Urine formationThe chief function of the kidneys is to produce urine. Each part of the

nephrons performs a special function. There are three important processes by

which urine is formed. They are glomerular filtration, tubular reabsorption and

tubular secretion

7

The path of the Formation of Urine

Electrolyte BalanceFluid and ElectrolyteS Balance are important constituents of body fluids.

These are compounds that separate into positively and negatively charged ions

and carry an electric current in solution. The main source of electrolytes is food.

A few of the most important ions are considered here.

1. Sodium- chiefly responsible for maintaining osmotic balance and body fluid

volume. It is the main positive in extracellular fluids. Sodium is required for

nerve impulse conduction and is important in maintaining acid-base balance.

2. Potassium- important in the transmission of nerve impulse; a major positive

ion in the intracellular fluids. It is involved in cellular enzyme activities and

helps regulate the chemical reactions by which carbohydrate is converted to

protein.

3. Calcium-required for bone formation, muscle contraction, nerve impulse

transmission, and blood clotting

8

Blood enters the

Efferent

Now it becomes filtrate (blood minus RBC’s and plasma

protein

To Bowman’s capsule

Passes through the

Glomeruli

To the distal convulated

tubule

To the collecting tubule (at this about 99% of the filtrate

has been reabsorbed)

To the loop of HenleContinues through

the proximal convulated tubule

Approximately 1 ml of urine is formed per

minute

The 1 ml of urine goes to the renal

pelvis

To the ureterTo the bladder

To the urethra

To the urinary meatus

4. Phosphate- essential in the metabolism of carbohydrates, bone formation and

acid-base balance. They are found in the cell membrane and in the nucleic

acids.

5. Chloride- essential for formation of the hydrochloric acid of the gastric juice.

Electrolytes must be kept in the proper concentration in both intracellular and

extracellular fluids. Although some electrolytes are lost in the feces and through

the skin as sweat, the job of balancing electrolytes is left mainly to the

kidneys.There are several hormones that are involved in this process.

Aldosterone produced by the adrenal cortex promotes the reabsorption of sodium

and the elimination of potassium. Hormones from parathyroid and thyroid glands

regulate calcium and phosphate levels. Parathyroid hormones increases blood

calcium, levels by causing the bones to release calcium and by causing the

kidneys to reabsorb calcium. The thyroid hormone calcitonin lowers blood

calcium by causing calcium to be deposited in the bone .

Function of the Urinary SystemThe 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.

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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.

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

participate in the synthesis of vitamin D.

Chronic Renal FailureChronic 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. Chronic Renal failure can develop

insidiously over many years, or it may result from an episode of acute renal

failure from which the client has not recovered.

Precipitating Factors Chronic glomerular disease such as glomerunephritis

Chronic infections such as chronic pyelonephritis or tuberculosis

Congenital anomalities such as polycystic

Vascular diseases, such as renal nephrosclerosis or hypertension Obstructive processes such as calculi

Collagen diseases such as systemic lupus erythematosus

nephrotoxic agents such as long-term aminoglycoside

endocrine diseases such as diabetic neuropathy

Such conditions gradually destroy the nephrons and eventually cause

irreversible renal failure. Similarly, acute renal failure that fails to respond to

treatment becomes chronic renal failure.

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Predisposing Factors Sex- both sexes are affected by chronic renal failure. But in 1998, based on

United States Renal Data System, a higher total number of males with ESRD

was found

Age- CRF can be found in people of any age, from infants to the very old.

The elderly population also is the most rapidly growing ESRD population in

the United States. Note that age 30 years progressive physiological

glomerulosclerosis. Aging also results in concomitant progressive

physiological decrease in muscle mass such that daily urinary creatinine

excretion also decreases.

Clinical ManifestationsThe clinical manifestations of CRF are present throughout the body. No

organ system is spared.

Electrolyte imbalances

Electrolyte balance may be upset by impaired excretion and

utilization in the kidney. Although many clients maintain normal serum

sodium level, the salt-wasting properties of some failing kidneys, in

addition to vomiting and diarrhea, may cause hyponatremia. Because the

kidneys are efficient at excreting potassium, potassium levels usually

remain within normal limits until late in the disease.

Several mechanisms contriburte to hypocalcemia. Conversion of

25-hydroxycholecalciferol to 1,25-dihyroxycholecalciferol (necessary to

absorb calcium) is decreased, which results in reduced intestinal

absorption of calcium. At the same time, phosphate is not excreted, which

causes hyperphosphatemia. Because calcium and phosphate are

inversely related, a high phosphate level results in a reduced calcium

level.

Metabolic changes

In advancing renal failure, BUN and serum creatinine rise as waste

products of protein metabolism accumulate in the blood. The serum

creatinine level is the most accurate measure of renal function. The

11

proteinuria accompanying renal disease and sometimes inadequate

dietary intake of proteins cause hypoproteinuria, which lowers the

intravascular oncotic pressure. Metabolic acidosis occurs because of the

kidney’s inability to excrete hydrogen ions. Decrease reabsorption of

sodium bicarbonate and decreased formation of dihydrogen phosphate

and ammonia contribute to this problem. Acidosis accentuates

hyperkalemia and the reabsorption of calcium from the bones.

Hematologic changes

The primary hematologic effect of renal failure is anemia, usually

normochromic and normocytic. It occurs because the kidneys are unable to

produce erythropoietin, a hormone necessary for red blood cell production.

Frequently, the fatigue, weakness, and cold intolerance accompanying the

anemia lead to a diagnosis of renal failure.

Gastrointestinal changes

The entire gastrointestinal system is affected. Transient anorexia,

nausea, vomiting are almost universal. Clients often experience a constant

bitter , metallic, or salty taste, and their breath commonly smells fetid, fishy or

ammonia-like. Stomatitis, parotitis and gingivitis are common problems

because of poor oral hygiene and the formation of ammonia from salivary

urea. Accumulations of gastro may be a major cause of ulcer disease.

Esophagitis, gastritis, colitis, gastrointestinal bleeding, and diarrhea may be

present. Serum amylase level may be increased, although they do not

necessarily indicate pancreatitis.

Immunologic changes

Impairment of the immune system makes the client more susceptible

to infection. Several factors are involved, including depression of humoral

antibody formation, suppression of delayed hypersensitivity and decreased

chemotactic function of leukocytes. Immunosuppression is an important part

of the medical management of renal diseaes such as glomerulonephritis.

Cardiovascular changes

The most common clinical manifestation is hypertension, produced

through:

12

mechanism of volume overload, stimulation of the renin-angiotensin system,

sympatheically mediated vasoconstriction, absence of prostaglandins.

Respiratory changes

Some of the respiratory effects such as pulmonary edema can be

attributed to fluid overload. Metabolic acidosis causes a compensatory

increase in respiratory rate as the lungs try to eliminate excess hydrogen

ions.

Musculoskeletal changes

The etiologic mechanism involves the kidney-bone-parathyroid and

calcium-phosphate-vitamin D connections. As the GRF decreases, the

phosphate excretion decreases and calcium elimination increases. Abnormal

levels of calcium and phosphate stimulate the release of parathyroid hormone

that mobilizes calcium from the bones and facilitates phosphate excretion.

Integumentary changes

The skin is also often very dry because of atrophy of the sweat glands.

Severe and intractable pruritus may result from secondary

hyperparathyroidism and calcium deposits in the skin. The pallor of anemia is

evident.

NURSING ASSESSMENT

A. Personal Data and History (Demographic Data)

Mr. Ibrahim Daud is a 61-year-old male, married living in Kampung Pokok

Sena Pokok Sena Alor Setar Kedah. He was born on 7 April 1939.He is married

for 30 years now and has 9 children. He is a smooker. And according to him,

smoking helps him to be relaxed. He consumed 8 sticks/day. He worked as a taxi

driver for more than 20 years.

13

Mr. Ibrahim was admitted in Hospital Sultanah Bahiyah Alor Setar On Mac

10 2010. He was admitted due to body weakness and severe anemia. He was

discharged on .17 Mac 2010.

General Health History History of Past Illness

Mr.Ibrahim was known hypertension for being for 7 years. Mr. Ibrahim

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

Klinik Kesihatan Pokok Sena.

History of Present IllnessFour days prior to admission, Mr.Ibrahim 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 . 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-36.7, RR- 24, PR- 72, BP- 180/100.

Physical Examination Upon Admission:10/3/2010 Vital Sign:

T - 36.7

RR - 24

PR - 72

BP - 180/100

14

Integumentary

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

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

seconds)

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- with dry and pale lips

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

GIT: loss of appetite

Renal and Urologic changes: fatigability, oliguria

Cardiovascular changes: hypertension

Hematopoietic changes: anemia

Skeletal changes: hypocalcemia and hyperphosphatemia

11/3/2010 Vital Signs:

T - 36.8

RR - 22

PR - 80

BP - 170/100

Integumentary

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

15

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

seconds)

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- with dry and pale lips

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

Cardiovascular changes: hypertension

Renal and urologic changes: oliguria

Hematopoietic changes: anemia

12/3/2010 Vital Signs:

T - 36.9

RR - 18

PR - 78

BP - 170/100

Integumentary

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

16

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

seconds)

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, dry lips

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

13/3/2010 Vital Signs:

T - 37

RR - 20

PR - 74

BP - 150/100

Integumentary

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

17

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

seconds)

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- with (-) pallor, dry lips

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

14/3/2010 Vital Signs:

T - 37

RR - 18

PR - 82

BP - 170/90

Integumentary

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

D. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4

seconds)

18

Head-no mass palpated

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

I. Eyes- with pale palpebral conjunctiva, no discharges noted, pupils are equally

round and reactive to light and accommodation

J. Ears- symmetrical with cerumen, no discharges noted

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

L. Mouth- (-) pallor

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

pain

N. Chest and Lungs- with bibasal rales

Abdomen- soft, flat, tender

Renal and Urologic changes: oliguria

Cardiovascular changes: hypertension

Hematopoietic changes: anemia

15/3/2010 Vital Signs:

T - 37

RR - 18

PR - 84

BP - 160/90

Integumentary

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

19

F. Nails- pallor nailbed, clean with weak capillary refill (approximately within 4

seconds)

Head-no mass palpated

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

P. Eyes- no pale palpebral conjunctiva, no discharges noted, pupils are equally

round and reactive to light and accommodation

Q. Ears- symmetrical with cerumen, no discharges noted

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

S. Mouth- (-) pallor

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

pain

U. Chest and Lungs- with bibasal rales

Abdomen- soft, flat, tender

Renal and Urologic changes: oliguria

Cardiovascular changes: hypertension

Hematopoietic changes: anemia

Diagnostic and Laboratory Procedures

Diagnostic/ Laboratory Procedure

Indication (s)Purpose (s) Result Normal

ValuesAnalysis and Interpretation

1.FBC

Hgb

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

7.17.58.88.99.09.510.1

13.0-17.0gm%

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

20

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

.23

.31

.33

.36

.32

.34

.37

40-.50 %

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

WBCLeukocytes

Determines any inflammation and infection

11.769.018.408.588.58.08.2

5-10x109/L

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

Neutrophils Determines any acute bacterial infection

81.75.71.72.74.72.79

50-.70 Results were all above normal level. This shows presence of bacterial infection

Lymphocytes Determines any chronic bacterial infection or viral infection

.17

.13

.20

.15

.13

.15

.14

.10-.40 Results were all within normal level. Showing absence of chronic infection

Monocytes Determines any acute bacterial infection

.05

.08

.04

.09

.07

.05

.08

.00-.07 Some of the results were all above normalLevel indicating presence of bacteria.

21

Eosinophils To determine any allergic reaction of the body

.04

.04

.04

.05

.04

.06

.06

.00-.07 Results were all within the normal level. This shows no allergic reactions.

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

Indication (s)Purpose (s) Result Analysis and

Interpretation

2.Hepatitis Profile This is usually

done before proceeding in hemodialysis. This is to determine if the patient was expose to the virus of if there is presence of hepatitis virusIn the blood of the patient.

HBSAG- non-reactiveANTI-HCV- non-reactiveANTI-HBC- non-reactiveANTI-HBS-reactiveHAV-IGM- non- reactive

Result revealed that the patient has no hepatitis virus and was not exposed to any of it.

Nursing Responsibilities:

22

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. Handle the specimen as if it were capable of transmitting hepatitis

5. Immediately discard the needle in the appropriate receptacle

6. Send the specimen to the laboratory promptly

Diagnostic/ Laboratory Procedure

Indication (s)

Purpose (s)Result

Normal Values used by

the hospital

Analysis and Interpretation

3.Urinalysis 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, (-), (-)

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.

23

Bacteria: (-), few, (-)

Amorphous urates:Moderate, moderate, few

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

Indication (s)Purpose (s) Result

Normal Values

used by the hospital

Analysis and Interpretation

4. Creatinine

5. Na+

This test was ordered in order to evaluate renal function.

To evaluate fluid and electrolyte imbalance and identify renal dysfunction

149914301649731730725500

137

62-106 umol/L

135-150 mmol/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

24

6. K+

7. Calcium

8. Phosphate

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.

4.78

6.4

186

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.

Results were all above the normal level indicating renal malfunction.

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

The Patient and his Care

Medical Management

Medical Management

General Description

Indication (s)Purpose (s)

Client’s initial reaction to

the treatment

Client’s response to the treatment

1. N/S A crystallized solution that is available in a variety of concentrated water and

To maintain fluid balance of the patient.

Patient felt discomfort Patient experienced bleeding and felt discomfort

Patient fluid status was maintained

25

2.. Subclavian catheterization

3.Blood Transfusion

4.Hemodialysis

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 wastes materials from the blood of patient.

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.

I

t is indicated for the patient because the kidneys cannot function very well to excrete the

on incision site

Patient was slightly nervous about the procuder..

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 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 during and after the procedure

26

nitrogenous waste products, thus leading to its accumulation in the blood.

Hemodialysis

Hemodialysis schematic

Main articles: Hemodialysis and Home hemodialysis

In hemodialysis, the patient's blood is pumped through the blood compartment of

a dialyzer, exposing it to a partially permeable membrane. The dialyzer is

composed of thousands of tiny synthetic hollow fibers. The fiber wall acts as the

semipermeable membrane. Blood flows through the fibers, dialysis solution flows

around the outside the fibers, and water and wastes move between these two

solutions. [5] The cleansed blood is then returned via the circuit back to the body.

Ultrafiltration occurs by increasing the hydrostatic pressure across the dialyzer

membrane. This usually is done by applying a negative pressure to the dialysate

compartment of the dialyzer. This pressure gradient causes water and dissolved

27

solutes to move from blood to dialysate, and allows the removal of several litres

of excess fluid during a typical 3 to 5 hour treatment. In the US, hemodialysis

treatments are typically given in a dialysis center three times per week (due in

the US to Medicare reimbursement rules); however, as of 2007 over 2,500

people in the US are dialyzing at home more frequently for various treatment

lengths. Studies have demonstrated the clinical benefits of dialyzing 5 to 7 times

a week, for 6 to 8 hours. These frequent long treatments are often done at home,

while sleeping but home dialysis is a flexible modality and schedules can be

changed day to day, week to week. In general, studies have shown that both

increased treatment length and frequency are clinically beneficial.

Hemodialysis

Hemodialysis in progress

Hemodialysis machine In medicine, hemodialysis is a method for removing waste products such

as creatinine and urea, as well as free water from the blood when the

kidneys are in renal failure. Hemodialysis is one of three renal

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replacement therapies (the other two being renal transplant; peritoneal

dialysis).

Hemodialysis can be an outpatient or inpatient therapy. Routine

hemodialysis is conducted in a dialysis outpatient facility, either a purpose

built room in a hospital or a dedicated, stand alone clinic. Less frequently

hemodialysis is done at home. Dialysis treatments in a clinic are initiated

and managed by specialized staff made up of nurses and technicians;

dialysis treatments at home can be self initiated and managed or done

jointly with the assistance of a trained helper who is usually a family

member

Principle

Semipermeable membrane

The principle of hemodialysis is the same as other methods of dialysis; it involves

diffusion of solutes across a semipermeable membrane. Hemodialysis utilizes

counter current flow, where the dialysate is flowing in the opposite direction to

blood flow in the extracorporeal circuit. Counter-current flow maintains the

concentration gradient across the membrane at a maximum and increases the

efficiency of the dialysis.

Fluid removal (ultrafiltration) is achieved by altering the hydrostatic pressure of

the dialysate compartment, causing free water and some dissolved solutes to

move across the membrane along a created pressure gradient.

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The dialysis solution that is used is a sterilized solution of mineral ions. Urea and

other waste products, potassium, and phosphate diffuse into the dialysis solution.

However, concentrations of sodium and chloride are similar to those of normal

plasma to prevent loss. Sodium bicarbonate is added in a higher concentration

than plasma to correct blood acidity. A small amount of glucose is also commonly

used.

Prescription

A prescription for dialysis by a nephrologist (a medical kidney specialist) will

specify various parameters for a dialysis treatment. These include frequency

(how many treatments per week), length of each treatment, and the blood and

dialysis solution flow rates, as well as the size of the dialyzer. The composition of

the dialysis solution is also sometimes adjusted in terms of its sodium and

potassium and bicarbonate levels. In general, the larger the body size of an

individual, the more dialysis he/she will need. In the North America and UK, 3-4

hour treatments (sometimes up to 5 hours for larger patients) given 3 times a

week are typical. Twice-a-week sessions are limited to patients who have a

substantial residual kidney function. Four sessions per week are often prescribed

for larger patients, as well as patients who have trouble with fluid overload.

Finally, there is growing interest in short daily home hemodialysis, which is 1.5 -

4 hr sessions given 5-7 times per week, usually at home. There also is interest in

nocturnal dialysis, which involves dialyzing a patient, usually at home, for 8–10

hours per night, 3-6 nights per week. Nocturnal in-center dialysis, 3-4 times per

week is also offered at a handful of dialysis units in the United States.

Side effects and complications

Hemodialysis often involves fluid removal (through ultrafiltration), because most

patients with renal failure pass little or no urine. Side effects caused by removing

too much fluid and/or removing fluid too rapidly include low blood pressure,

fatigue, chest pains, leg-cramps, nausea and headaches. These symptoms can

occur during the treatment and can persist post treatment; they are sometimes

collectively referred to as the dialysis hangover or dialysis washout. The severity

30

of these symptoms is usually proportionate to the amount and speed of fluid

removal. However, the impact of a given amount or rate of fluid removal can vary

greatly from person to person and day to day. These side effects can be avoided

and/or their severity lessened by limiting fluid intake between treatments or

increasing the dose of dialysis e.g. dialyzing more often or longer per treatment

than the standard three times a week, 3–4 hours per treatment schedule.

Since hemodialysis requires access to the circulatory system, patients

undergoing hemodialysis may expose their circulatory system to microbes, which

can lead to sepsis, an infection affecting the heart valves (endocarditis) or an

infection affecting the bones (osteomyelitis). The risk of infection varies

depending on the type of access used (see below). Bleeding may also occur,

again the risk varies depending on the type of access used. Infections can be

minimized by strictly adhering to infection control best practices.

Heparin is the most commonly used anticoagulant in hemodialysis, as it is

generally well tolerated and can be quickly reversed with protamine sulfate.

Heparin allergy can infrequently be a problem and can cause a low platelet

count. In such patients, alternative anticoagulants can be used. In patients at

high risk of bleeding, dialysis can be done without anticoagulation.

First Use Syndrome is a rare but severe anaphylactic reaction to the artificial

kidney. Its symptoms include sneezing, wheezing, shortness of breath, back

pain, chest pain, or sudden death. It can be caused by residual sterilant in the

artificial kidney or the material of the membrane itself. In recent years, the

incidence of First Use Syndrome has decreased, due to an increased use of

gamma irradiation, steam sterilization, or electron-beam radiation instead of

chemical sterilants, and the development of new semipermeable membranes of

higher biocompatibility. New methods of processing previously acceptable

components of dialysis must always been considered. For example, in 2008, a

series of first-use type or reactions, including deaths occurred due to heparin

contaminated during the manufacturing process with oversulfated chondroitin

sulfate.

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Longterm complications of hemodialysis include amyloidosis, neuropathy and

various forms of heart disease. Increasing the frequency and length of treatments

have been shown to improve fluid overload and enlargement of the heart that is

commonly seen in such patients.

Listed below are specific complications associated with different types of

hemodialysis access.

Access

In hemodialysis, three primary methods are used to gain access to the blood: an

intravenous catheter, an arteriovenous (AV) fistula and a synthetic graft. The type

of access is influenced by factors such as the expected time course of a patient's

renal failure and the condition of his or her vasculature. Patients may have

multiple accesses, usually because an AV fistula or graft is maturing and a

catheter is still being used.

Catheter

Catheter access, sometimes called a CVC (Central Venous Catheter), consists of

a plastic catheter with two lumens (or occasionally two separate catheters) which

is inserted into a large vein (usually the vena cava, via the internal jugular vein or

the femoral vein) to allow large flows of blood to be withdrawn from one lumen, to

enter the dialysis circuit, and to be returned via the other lumen. However, blood

flow is almost always less than that of a well functioning fistula or graft.

Catheters are usually found in two general varieties, tunnelled and non-tunnelled.

Non-tunnelled catheter access is for short-term access (up to about 10 days,

but often for one dialysis session only), and the catheter emerges from the skin

at the site of entry into the vein.

Tunnelled catheter access involves a longer catheter, which is tunnelled under

the skin from the point of insertion in the vein to an exit site some distance away.

It is usually placed in the internal jugular vein in the neck and the exit site is

32

usually on the chest wall. The tunnel acts as a barrier to invading microbes, and

as such, tunnelled catheters are designed for short- to medium-term access

(weeks to months only), because infection is still a frequent problem.

Aside from infection, venous stenosis is another serious problem with catheter

access. The catheter is a foreign body in the vein and often provokes an

inflammatory reaction in the vein wall. This results in scarring and narrowing of

the vein, often to the point of occlusion. This can cause problems with severe

venous congestion in the area drained by the vein and may also render the vein,

and the veins drained by it, useless for creating a fistula or graft at a later date.

Patients on long-term hemodialysis can literally 'run out' of access, so this can be

a fatal problem.

Catheter access is usually used for rapid access for immediate dialysis, for

tunnelled access in patients who are deemed likely to recover from acute renal

failure, and for patients with end-stage renal failure who are either waiting for

alternative access to mature or who are unable to have alternative access.

Catheter access is often popular with patients, because attachment to the

dialysis machine doesn't require needles. However, the serious risks of catheter

access noted above mean that such access should be contemplated only as a

long-term solution in the most desperate access situation.Hemodialysis

Nursing Responsibilities:

Before

a. Explain the purpose of the transfusion

b. Have client void

c. Chart client’s weight

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

(unless ordered otherwise)

During

33

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.

Name of Drug

Route of admin.

Dosage and freq. Of admin.

General action

Indication (s)Purpose(s)

Client’s response to medication

Amlodipine besylate

norvasc

PO 5 mg OD Calcium antagonist, antihypertensive

To decrease increase blood pressure

Patient did not show any side effects

Metoprolol tartate

PO 50 mg

OD

Beta blockers, antihypertensive drug

To decrease increase blood pressure

Patient did not show any side effects

Iberet- folic acid

PO 1 cap

BID

Iron

deficiencyFor patient having anemia

Patient’s stool was dark green in color

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furosemide lasix

PO 40 mg

OD

Diuretic For oliguric patient

Patient did notshow any side effects

calcium carbonate

PO 1 tab.

OD

Calcium supplement

To treat hypocalcemia

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 BP

3. Prepare the drug and the materials

4. 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.

Type of diet General description

Indication (s)Purpose (s)

Client’s response to the diet

Low salt, low protein

Foods that has low salt and protein value

To decrease further production of purine which can contribute in increasing level

Patient strictly complied with the prescribed diet

35

of creatinine in the blood

Nursing Responsibilities

Prior:1. Check and determine the prescribed diet

2. Inform the food unit about the prescribed diet

3. Explain the procedure and purpose of the prescribed diet

4. Cite foods that are restricted.

During:

1. Check vital signs to obtain baseline data

2. Observe for initial response.

After:

1. Informfood unit if it would be changed

2. Observe and monitor for changes

Type of activity General description

Indication (s)Purpose (s)

Client’s response to the activity

Bed rest An activity wherein the patient is not allowed to do any activity. Patient stays at bed.

To decrease consumption of oxygen and to be able to conserve energy

Patient strictly complied with the prescribed activity

Nursing Responsibilities

1. Explain the procedure to patient.

2. Explain importance of activity.

3. Assist patient in doing the activity.

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Surgical Management

Arteriovenous FistulaAV fistula

A radiocephalic fistula.

AV (arteriovenous) fistulas are recognized as the preferred access method. To

create a fistula, a vascular surgeon joins an artery and a vein together through

anastomosis. Since this bypasses the capillaries, blood flows rapidly through the

37

fistula. One can feel this by placing one's finger over a mature fistula. This is

called feeling for "thrill" and produces a distinct 'buzzing' feeling over the fistula.

One can also listen through a stethoscope for the sound of the blood

"whooshing" through the fistula, a sound called bruit.

Fistulas are usually created in the nondominant arm and may be situated on the

hand (the 'snuffbox' fistula'), the forearm (usually a radiocephalic fistula, or so-

called Brescia-Cimino fistula, in which the radial artery is anastomosed to the

cephalic vein), or the elbow (usually a brachiocephalic fistula, where the brachial

artery is anastomosed to the cephalic vein). A fistula will take a number of weeks

to mature, on average perhaps 4–6 weeks. During treatment, two needles are

inserted into the fistula, one to draw blood and one to return it.The advantages of

the AV fistula use are lower infection rates, because no foreign material is

involved in their formation, higher blood flow rates (which translates to more

effective dialysis), and a lower incidence of thrombosis. The complications are

few, but if a fistula has a very high blood flow and the vasculature that supplies

the rest of the limb is poor, a steal syndrome can occur, where blood entering the

limb is drawn into the fistula and returned to the general circulation without

entering the limb's capillaries. This results in cold extremities of that limb,

cramping pains, and, if severe, tissue damage. One long-term complication of an

AV fistula can be the development of an aneurysm, a bulging in the wall of the

vein where it is weakened by the repeated insertion of needles over time. To a

large extent the risk of developing an aneurysm can be reduced by careful

needling technique. Aneurysms may necessitate corrective surgery and may

shorten the useful life of a fistula. To prevent damage to the fistula and aneurysm

or pseudoaneurysm formation, it is recommended that the needle be inserted at

different points in a rotating fashion. Another approach is to cannulate the fistula

with a blunted needle, in exactly the same place. This is called a 'buttonhole'

approach. Often two or three buttonhole places are available on a given fistula.

This also can prolong fistula life and help prevent damage to the fistula.

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AV graft

An arteriovenous graft.

AV (arteriovenous) grafts are much like fistulas in most respects, except that an

artificial vessel is used to join the artery and vein. The graft usually is made of a

synthetic material, often, but sometimes chemically treated, sterilized veins from

animals are used. Grafts are inserted when the patient's native vasculature does

not permit a fistula. They mature faster than fistulas, and may be ready for use

several weeks after formation (some newer grafts may be used even sooner).

However, AV grafts are at high risk to develop narrowing, especially in the vein

just downstream from where the graft has been sewn to the vein. Narrowing

often leads to clotting or thrombosis. As foreign material, they are at greater risk

for becoming infected. More options for sites to place a graft are available,

because the graft can be made quite long. Thus a graft can be placed in the thigh

or even the neck (the 'necklace graft').

Fistula First project

AV fistulas have a much better access patency and survival than do venous

catheters or grafts. They also produce better patient survival and have far fewer

complications compared to grafts or venous catheters. For this reason, the

39

Centers for Medicare & Medicaid (CMS) has set up a Fistula First Initiative ],

whose goal is to increase the use of AV fistulas in dialysis patients.

An AV fistula requires advance planning because a fistula takes a while

after surgery to develop (in rare cases, as long as 24 months). But a properly

formed fistula is less likely than other kinds of vascular accesses to form clots or

become infected. Also, fistulas tend to last many years, longer than any other

kind of vascular access.

A surgeon creates an AV fistula by connecting an artery directly to a vein,

usually in the forearm. Connecting the artery to the vein causes more blood flow

into the vein. As a result, the vein grows larger and stronger, making repeated

insertions for hemodialysis treatment easier. For the surgery, you will be given a

local anesthetic. In most cases, the procedure can be performed on an outpatient

basis.

These fistulas require up to 6 weeks to mature before they can be used,

which makes this approach inappropriate for immediate hemodialysis. Peritoneal

dialysis or large venous access catheters may be used while the fistula is

maturing. External arteriovenous shunts are rarely used.

Nursing management

NURSING PROCESS

Nursing Diagnosis

Objectives Nursing Interventions

Evaluation

Fluid volume

axcess related to

failure or

comprised renal

regulatory

mechanism.

Patient will not

show signs and

symptoms of

excess fluid.

1.Assist in dialysis

and monitar

patient progress.

2.Administer

intravenous or oral

Patient not show

signs and

symptoms of

excess fluid.

No edema.

40

fluids as

prescribed.

3.Monitor intake

and output chart.

Nursing Diagnosis

Objectives Nursing Intervations

Evaluation

Potential for injury

related to

accumulated

electrolytes and

waste products

Patient exhibits no

evidence of waste

accumulation.

Patient’s BP will

remain within

acceptable limits

1.Assist in

dialysis.

2.Assist in

collecting

laboratory

specimens.

3.Serve low

protein,low

sodium and low

potassium as

prescribed.

4.Provide rest for

patient.

Patient exhibits no

evidence of waste

accumulation.

Patient’s BP is

acceptable limits

140/90 mmhg.

41

5.Monitor vital

signs.

Nursing Diagnosis

Objectives Nursing Intervations

Evaluation

Potential for

infections related

to lowered body

defense

Patient will not

contact any

infections.

1.Avoid patient in

contact with

infected patients.

2.Practise medical

asepsis.

3.Monitor medical

signs.

4.Teach parents

regarding

preventive

measures

Patient having no

fever.Tempreture

is normal 36.8.

Nursing Objectives Nursing Evaluation

42

Diagnosis InterventionsPotential impaired

skin integrity

related to oedema

Patient will have

no skin

breakdown or

sores.

1.Provide good

skin care.

2.Clean and

supply powder to

skin surfaces.

3.Change position

frequently and

maintain good

body alignment.

Skin brown in

complexion, with

good skin turgor.

Nursing Diagnosis

Objectives Nursing Intervations

Evaluation

Anxiety related to

the disease.

Parents fear and

anxiety towards

the disease will

be reduced to the

minimum.

1.Give clear

explanation to

parents.

2.Encourage

patient to ask

question.

Patient looked

Calm.

Nursing Diagnosis

Objectives Nursing Intervations

Evaluation

Knowledge deficit

related to

ignorance

personal hygiene

Patient and family

members will

acquire adequate

knowledge on

personal hygiene.

1.Explain to

patient and family

members the

importance of

personal hygiene.

2.Provide Health

Patient and family

understood and

follow what have

been teach to him.

43

Educations:

2.1. Wash hands

before eating and

after going to

toilet.

2.2. Wash hands

before handling

the food.

2.3. Cover the

food.

2.4. Use clean

food containers for

storing food.

2.5. Boil water

before drinking

and eat cooked

food.

2.6. Proper

disposal of refuse

and sewage.

Discharge PlanningMr. Scrooge was discharge on Mac 17 2010, Upon discharged, Mr.

Ibrahim’s physical appearance was improved. There was absence of paleness in

the conjunctiva and lips, fatigability is decrease, and with decrease creatinine

44

level as compared when he was admitted in the hospital. His vital signs were as

follows: T- 36.8, PR- 80, RR-18, BP- 140/90 mmhg.

Instructed to complied strictly with the following home medications

Augmentin 375 mg 1 tab TID

Nifedipine lozenges QID

For twice a week hemodialysis

Bed rest

proper wound care (subclavian (IJC) and fistula)

strict compliance to the medications and in hemodialysis

O>follow-up check up on Mac 30 2010.

D>avoid foods rich in salt and protein

>Limit fluid intake

Conclusion and Recommendations

Chronic renal failure is an irreversible and progressive disease. It is cause

by many factors. Knowing the precipitating factors leading to the development of

this health problem, people should have an extra care when it comes to health.

Giving care to a patient whether pediatric, geriatric, a medical case or

surgical case makes no difference. Rendering care to everyone who needs it is a

real sense of responsibility. In making this case study, I was able to work well

because I know for myself that I did my best for my patient.

We can say that nursing is significant therapeutic and dynamic process. It

is therefore significant for the nurse caring for the patient to wholeheartedly

understand what she is doing like in carrying out some basic skills in relation to

identified goals, comfort and care, interventions and prevention of illness.

45

VIII. Bibliography

Black, J. et al. (2001) Medical-Surgical Nursing. W.B.Saunders Company

Philadelphia

Handbook of Diseases. (1999) 2nd edition.. Springhouse Corporation

Springhouse, Pennsylvania

Pagana (2002). Mosby’s Manual of Diagnostic and Laboratory Tests.

MIMS. (2003)

www.yahoo.com

www.google.com

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