assigment final end stage renal failure

8/3/2019 Assigment Final End Stage Renal Failure

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NURSING MANAGEMENT FOR PATIENT UNDERGOING HEMODIALYSIS

1. INTRODUCTION

Nowadays people of Malaysia are threatened with a variety of illnesses caused by life style

among the diseases that involve the kidneys of "renal failure". We know that the kidney is one of

the most important organs in the human body functions. Renal is derived from the Latin word

renes, meaning kidneys. Can be defined is a pair of kidneys are located behind the abdominal

organs. Each kidney is about 4 or 5 inches long. It is about a fist size. Right kidney is located

right below the diaphragm and behind the heart. While the left kidney is located below the

diaphragm and spleen organ behind. Above each kidney is adrenal gland also known as

(suprarenal glands), and each kidney contains about one million units, which is referred to

neurons. Irregular position in the abdominal area due to the liver causing the right kidney is

slightly lower than the left kidney.

Retro peritoneum and kidneys is approximately 9 to 13 cm in diameter, which is slightly larger

left than the right. It was around the level of T12 to L13 vertebral level. Some parts of the

kidney is protected by the bones of the eleventh rib and two twelve and each adrenal gland is

fully protected by two layers of fat (per renal and Para renal fat) and renal fascia which helps

cushion it..

1.1 KIDNEY FUNCTION

The bladder holds about 400 ml (1 / 4 pints) of urine when full. Normal urine normally produced

is around 2 liters per day. The main function of the kidney is responsible for the generation of

waste from the body, regulating electrolyte balance and blood pressure and stimulates production

of red blood cells. It cleanses the blood and makes urine from waste and they produce them.

Blood is pumped by the heart to the kidneys. Their kidneys have a drainage system that takes

urine from the kidneys to the bladder. Drainage system as a channel with a tube (ureter) that

connects the kidney to the bladder. Urine down ureter (for each kidney) into the bladder. Urine is

stored in the bladder prior to discharge from the body through another tube called the ureter


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Another kidney function helps blood pressure. Fine blood pressure is controlled by a healthy

kidney. When the kidneys fail one of their blood pressure usually rises. Although it is not really

known why. Pressure high blood pressure will not cause symptoms except for very high

pressure, but it increases the risk of stroke or heart attack.

The kidneys also help control the actual manufacture of blood cells. The kidneys help regulate

blood cells, the actual manufacturing in the bone marrow. Floating in the liquid if the blood

(plasma). Their job is to carry oxygen around the body.

The kidneys also produce certain hormones that have important functions in the body, including

the following:

Active form of vitamin D (calcitriol or 1.25 dihydroxy-vitamin D), which controls the

absorption of calcium and phosphorus from foods, promoting formation of strong bones.

Erythropoietin (EPO), which stimulates bone marrow to produce red blood cells.

Renin, which regulates blood volume and blood pressure


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2. END STAGE RENAL FAILURE

As we know, kidney failure is in various stages. Among them are the "acute renal failure",

"chronic renal failure" and the final stage is the "end stage renal failure". Based on studies in theUnited State is created by the National Kidney Foundation in 2001, a total of 370,000 person end

stage renal failure have a number of cases increased approximately 8% each year.

End-stage kidney failure (ESRF) defined by Abassi et all 2010 as a reduction in the

irreversible in kidney function , which is severe enough to be fatal in the absence of

dialysis or transplantation.

.

"End stage renal failure" can also be defined as an irreversible decline in kidney function that is

severe enough to be fatal in the absence of dialysis or transplantation. In general, end stage renal

failure occurs when there is less than 10% of the remaining kidney function. In 2000 the final

stage of kidney failure than 375,000 American affected aspects of MRE increased to 651,000 by

2010.

Stage 5 chronic kidney disease can be described as kidney failure, also known as end stage renal

failure and chronic kidney disease has developed. Renal replacement therapy, dialysis or kidney

transplant may be needed to sustain life.

2.2CAUSES OF END STAGE RENAL FAILURE

Although chronic kidney disease sometimes results from the major diseases of the kidney itself,

the main reasons for diabetes and high blood pressure.

1. Type 1 and type 2 diabetes mellitus can cause a condition called diabetic nephropathy,which is the main cause of kidney disease in the United States.

2. High blood pressure (hypertension), if uncontrolled, can damage the kidneys, from timeto time.


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3. Glomerulonephritis inflammation and damage to the kidney filtration system, which canlead to kidney failure. Post infectious conditions and lupus which is one source of many

Glomerulonephritis.

4. Polycystic kidney disease is an example for the children of chronic kidney disease inwhich both kidneys have multiple cysts.

5. The use of painkillers such as acetaminophen (Tylenol) and ibuprofen (Motrin, Advil)fixed on a long period of time can lead to analgesic nephropathy, another cause of kidney

disease. Some other drugs can also damage the kidneys.

6. clogging and hardening of the arteries (atherosclerosis) that lead to the kidneys causes acondition called ischemic nephropathy, which is another cause of progressive kidney

damage.

7. Obstruction of urine flow by the rocks, the restrictions (narrowing), or cancer can alsocause kidney disease.

8. Other causes of chronic kidney disease, including HIV infection, the cells sickle disease,heroin abuse, amyloidosis, kidney stones, chronic kidney infections and certain cancers.

3.0 CLINICAL FINDINGS AND EFFECTS ON PATIENTS

Patient with end stage renal failure have a variety of signs or symptoms that can be seen and

different. It can be explicit or hidden. Based on the laboratory results obtained from Madam

Wong her serum creatinine is higher than normal readings, the normal creatinine are in range

less than 97. Creatinine blood test is to find proper kidney function and is used to

determine glomerular filtration rate, by the result found her had to undergo hemodialysis

immediately.

Based on the symptoms shown, she suffered "Shortness of breath '. It is caused by fluid

accumulation in the lungs. Other signs that patient also experience fatigue and


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confusion in which the patient is in a state of uremia syndrome. In this situation can be seen

where the level of creatinine in the blood are increase. This syndrome can affect body systems

such as the intestines, nerves and heart. Another cause of fatigue maybe patient have a mild

anemia due to hemoglobin are 10.1 g/ dl. For the patient who need to go to hemodialysis

,hemoglobin should be maintain at 11 g/dl.

"Pitting edema" is one of the symptoms listed for renal patients which it occur when kidney

function has deteriorated it could no longer filter the liquid and keep the balance of salt. When

this happens, fluid and salt from the body fluid build up in body tissues and cause edema.

Other symptoms that may be identified as the patient's skin will become dark or bright, unusual

skin than the original and will be a change in the nails.

Others laboratory examination done such as taking blood for "blood urea nitrogen," in which to

look at kidney function. Urea is the main product of protein metabolism. Its formed in liver

and excreted mainly by kidney in urine. If the kidneys are unable to remove the urea in the

blood it will rise.

Besides taking full blood count is one of examination must do in patient with renal failure,

its for detect renal anemia which full blood count is a component, such as hemoglobin,

hematocrit .

Urine output are also one of symptom that can be seen in end stage renal failure was caused

when 90% of nephrons almost fails it can cause "blood urea nitrogen" and "creatinine"

increases so that it causes "polyuria" changed to "oliguria . "

Chronic disease have characteristic that lead to patient fatigue and symptoms of

depression. End stage renal failure in terms of influencing an individual's physical,

psychological, and emotional health. The impacts can be seen is that according to Morsch,

Concalus & Banis, 2006 end stage renal failure is Associated with poor quality of life,


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depression (Kimmel & Peterson, 2006), reduced physical functioning Ability (Cleary & Diennan

2005; O'Sullivan 2007 ), poor sleep quality (Elder et all, 2007) and fatigue (Mc Cann & Boore,

2008; O'Sullivan & Mc Carthy, 2007).

Having chronic condition such end stage renal disease is likely to have a impact on

patient everyday life. The concerns commonly identified among of end stage renal failure

patient are disruption of lifestyle (Devins et all.2001).Whereas Blaschek 2003 said that

suffering from continuing symptom , stress and uncertainly of life. Intervention aimed at

modifying know mortality risk factors are expected to have considerable impact in this

patient population in survival and hopefully, Qol (Lindquist& Syoden 1998, Golper 2001,

Loss- Ayau et all- 2008 ).

Other symptoms, if untreated, can cause life-threatening condition and can be formed.

1. metabolic acidosis, or increased acidity of the body due to the inability to manufacturebicarbonate, will alter enzyme and oxygen metabolism, causing organ failure.

2. Unable to remove potassium and increases in serum potassium levels (hyperkalemia) isAssociated with a fatal heart rhythm disturbances (arrhythmias), including ventricular

tachycardia and ventricular fibrillation.

3. Increased level of urea in the blood (uremia) can affect the function of various organs ofthe brain (encephalopathy) with alteration of thinking, inflammation of the lining of the

heart (pericarditis), decreased muscle function because of low calcium levels

(hypocalcemia).

4. The weakness may be caused by anemia in which red blood cell count decreased, because of lower levels of erythropoietin produced by the kidneys failed be able to

stimulate the bone marrow. The decrease in red cells with a decrease in the ability to

carry oxygen in the blood, resulting in decreased oxygen delivery to the cells for them to

do the work, therefore, the body tires quickly. And, with less oxygen, the cells are easier

to use anaerobic metabolism (= without aerobic = oxygen). This can lead to the total

increase in acid production which can not be handled by the kidneys that have failed


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5. As waste products build in the blood, loss of appetite, lethargy and fatigue was verystrong. This can lead to decreased mental function, and coma may occur.

4. .MANAGEMENT OF THE PATIENT UNDERGOING HEMODIALYSIS

Dialysis is a treatment that takes over the task performed by the kidneys. Once for the

last stage kidney failure (end stage renal failure), most patient requiring dialysis treatment.

This treatment is likely for life except for kidney transplants.

According to Wong et all 2007 there are approximately 3000 patient on dialysis of

whom 80% are on continuous ambulatory peritoneal dialysis and remaining 20% are

receive hemodialysis.. Hemodialysis is done where an artificial kidney (haemodialyzer)connected to a machine that filters work to remove waste impurities and excess fluid from the

body. This procedure is carried out in a special unit (hemodialysis unit) in the hospital and takes

around four hours per session to three sessions a week. The patient will require fistula of blood

from the body to flow into the artificial kidney. The surgeon will make this fistula by connecting

an artery to the venous blood vessels to become larger blood vessels. During dialysis, wasteproducts in the bloodstream are carried out of the body. At the same time, electrolytes and other

chemicals are added to the blood. The purified, chemically-balanced blood is then returned to the

body.

In the hemodialysis treatment of several aspects of care should be taken into consideration,

including the vascular access. Patients who undergo dialysis vascular access and so requires

access sites must be protected from damage or infection. Malovrh 2005 suggests a long-term

survival and quality of life of patients on hemodialysis depend on dialysis adequacy through the

appropriate vascular access. Ateriovenous fistula and graft require subcutaneous access and, to protect their access sites from unnecessary pressure or injury, venepuncture, cannulation,


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arterial-line insertion and the use of blood-pressure cuffs must be avoided (Richard and

Engebretson 2010).

In addition of vascular access, care diet is also important for end stage renal failure patients.

Among are fluid intake and other food. The volume of urine passed by patients undergoingdialysis is too small to remove all the fluid from their food and drink. Fluid retention leads to

increased blood volume, distended blood vessels and high blood pressure, which can in turn

lead to pulmonary edema (Agar 2010).

According to Kalanter-Zadeh (2009)in a study of fluid gain in patients undergoing dialysis

found that the average patient gained between 1.5 and 2.0kg of fluid between dialysis sessions,

and that a weight gain of at least 4kg over two consecutive dialysis sessions was associated with

a 28 per cent increased risk of death. Optimal fluid management is a determinant of survival in

patients undergoing renal replacement therapy (Collins and Mujais 2002) and,Blair 2009 states

that patients with chronic kidney disease, morbidity and mortality are increased by excessive

fluid intake.

Most patients undergoing dialysis are restricting to 1 liter fluid a day and if they are given extra

fluids intravenously, they must be monitored constantly.

Hyperkalaemia in most people, about 90 per cent of potassium is excreted by the kidneys and

patients undergoing dialysis who fail to adhere to dietary advice may be at risk of

hyperkalaemia due to decreased potassium excretion (Challinor 2008). Hyperkalaemia affectsthe ability of cardiac muscle tissue to conduct electrical impulses, potentially resulting in

ventricular fibrillation and a systolic arrest (Ahee and Alexander 2000),


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NURSING PROCESS

PROBLEM GOAL INTERVENTION EVALUATION

High risk of

Arterivenous Fistula

thrombosis and

Aneurysm due to

knowledge deficit.

To reduce

Arteriovenous Fistula

Complication

1.Educate her on the

care of Arteriovenous

Fistula

2.Avoid repeated

cannulation at the

same site

3.Treat infection if

Her arteriovenousFistula is still in good

condition andfuctioning well


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present

4.Cannulate carefully

try not to puncture the

fistula

5.Refer to Doctor if

there is bad aneurysm

6.Keep fistula clean

and dry

NURSING

PROBLEM

OBJECTIVE NURSING

INTERVENTION

EVALUATION

Fluid volume excess

related to failure or

comprised renal

regulatory mechanism

Patient will not show

signs and symptoms

of excess fluid.

1. Assist in dialysis

and monitor patient

progress.

2 .Administer

intravenous or oral

fluids as prescribed.

3. Monitor intake and

output chart .Strict

fluid intake to patient.

4. Use small cup to

drink ,so that patient

cannot take a lot of

water.

5. Do daily weight

and chart.

Patient not show sign

and symptoms of

excess fluid.


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6. Monitor vital sign

.Sign and symptom

Short of breath(SOB)

Early sign of fluid

overload

7. Offer ice chips or

flavored ice pops.

Record intake. Helps

minimizes thirst.

Provide frequent

mouth care. Helps

minimize thirst.

NURSING

PROBLEM

OBJECTIVE NURSING

INTERVENTION

EVALUATION

Pedal edema To reduce pedaledema

1 .Evaluate the

extended of edema

and its location ,so

that action could be

taken to relief the

condition.

2.Advice patient to

elevate his leg during

lying down to reduce

Pedal edema reduce

after intervention

given.


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swelling

3. Restricted fluid 500

ml POD (Previous

Day Output) and take

low salt diet to avoid

fluid retention.

4.Medication strictly

follow Doctors

ordered

5. Monitor the

condition of patient

during treatment and

inform doctor about

the changes

NURSING

PROBLEM

OBJECTIVE NURSING

INTERVENTION

EVALUATION

Impaired skin

integrity related to

pruritus and dry skin

secondary to uremia

and edema

Patient's skin remains

intact and free of

erythema and

abrasions.

1. Encourage use of

prescribed phosphate

binders when serum

phosphorus level is

elevated. Excess

phosphorus binds with

free calcium in the

serum. The resulting

calcium-phosphate


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complex is deposited

in soft tissues and can

cause necrotic patches

in the skin. In

addition, elevation in

calcium-phosphate

product is associated

with increased risk of

death, aortic

calcification, mitral

valve calcification,

and coronary artery

calcification.

Phosphate binders

help prevent elevation

in calcium-phosphate

product.

2. Administer

antihistamines as prescribed if needed.

Because accumulating

nitrogenous wastes

are excreted through

the skin, pruritus is

common in patients

with uremia and

causes frequent and

intense scratching.

Pruritus often

decreases with a

reduction in BUN and


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improved phosphorus

control. Decreases

itching and

subsequent scratching

that can result in

abrasions and/or

infection.

3. Keep patient's

fingernails cut short.

Prevents skin

abrasions when

scratching.

4. Teach patient

to monitor scratches

for evidence of

infection and to seek

medical attention

early if signs and

symptoms of infectionappear. Uremia

retards wound healing

and thus increases the

risk for infection.

5. Encourage use

of skin emollients and

soaps with high fat

content. Uremic skin

is often dry and scaly

because of reduction

in oil gland activity.

Skin emollients and


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soaps with high fat

content replace oils

and help reduce

itching from dryness.

6. Advise patient to

bathe every other day

and to apply skin

lotion immediately

upon exiting

bath/shower. Patients

should avoid harsh

soaps, soaps or skin

products containing

alcohol, and excessive

bathing, to prevent

skin dryness and

itching.

7. Advise patient and

significant othersabout increased risk

for bruising. Clotting

abnormalities and

capillary fragility

place patient with

uremia at increased

risk for bruising.

8. Provide

scheduled skin care

and position changes

for patients with

edema. Helps


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prevents skin

breakdown from

pressure.

PROBLEM OBJECTIVE INTERVENTION EVALUATION


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assigment final end stage renal failure

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