OBECTIVES OF CASE STUDY

GENERAL OBJECTIVES:-

The general objective of the case study is to gain the comprehensive knowledge about the disease to gain the practical exercise about the Adult Health Problem and also to gain Practical experience working with a patient having chronic kidney disease and to give holistic patient care according to their need.

SPECIFIC OBJECTIVES:-

The specific objectives of the case study are given below:-

To assess the patient and find out need of patient according to nursing process. establish a nurse-client relationship to the client, as well as to the family by rendering a

therapeutic nurse-patient relationship;

gather adequate information to be used in the development of the study

present the clients personal data;

illustrate the patient’s family tree and trace significant diseases which may be of relevance to the

study

trace the health history of the client and the family by collecting information both of the past and

present illnesses;

To provide holistic nursing care to the client to all ages using nursing process. To manage promptly as necessary to built up comfort. To provide psychological support to the patient To apply knowledge from the science, nursing theory and other related courses to plan and

implement nursing care. To provide continuous care till discharge and follow-up care. Counsel and make aware the patient party about importance of continuity of medicine and

psychological support to prevent from worsens. To provide the discharge teaching to the patient and family member.

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BIOGRAPHIC DATA

1) HEALTH HISTORY

A) DEMOGRAPHIC DATA NAME: laxman kumar pandit AGE: 68yrs SEX: male ADDRESS: Permanent: nayapati -6, jorpati RELIGION: Hindu EDUCATION iliterate DATE OF ADMISSION: 068/4/6 DATE OF DISCHARGE: 068/4/17 IP NO. : 200821/410159 OCCUPATION: farmer MARITAL STATUS: married ATTENDING DOCTOR: Dr. P.K.C INFORMATION SOURCE: patient and his son DIAGNOSIS: CKD 5 BLOOD GROUP: A +ve BED NO: 205 WARD: nephrology

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B) CHIEF COMPLAINTS: Swelling of legs, face for 2 days

C) HISTORY OF PRESENT ILLNESS: According to the patient’s, he come for haemodialysis, due

to increased shortness of breath during dialysis he was admitted in the nephrology ward. His general

condition is ill looking and oriented with time place and person.

D) HISTORY OF PAST ILLNESS:

According to the patient’s party, he is undergoing regular dialysis and is under antihypertensive medicine.

ALLERGIESAccording to the patient, he doesn’t have any allergic reaction to any factors.

.

PREVIOUS HOSPITALIZATION: Nepal medical college teaching hospital for the diagnosis of CKD

OPERATIONS OR SPECIAL TREATMENT: no any

E) FAMILY HISTORY: Type of family: joint No. of Family Members: 8

Fig.1 Family Tree

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Table 1 Family Medical history

DISEASE FATHER’S RELATION MOTHER’S RELATION

Tuberculosis Absent AbsentCancer Absent AbsentHeart disease Absent Absent

Jaundice Absent Absent

Epilepsy Absent AbsentPsychological Absent AbsentHypertension Present Present

HEALTH SEEKING PRACTICE: He belongs to literate family, According to laxman kumar pandit, they were not dependent in superstitious beliefs. If someone becomes ill in their family they take homemade medicine then some times go to hospital.

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PERSONAL HISTORY: Health Habits:

Smoker but has left 1-2 months ago, Non alcoholic, Non vegetarian. No food allergy. Maintain personal hygiene

Religion belief and worship kuldeuta. Dietry history:

Non vegetarian. Foods like egg-curry, rice, daal etc.

SOCIO-ECONOMIC STATUS:He belongs to middleclass family. The major source of income is farming and business. They are the permanent residence of jorpati. They are well satisfied with their economic status. They have very good inter relationship in the community.

ENVIRONMENTAL FACTOR: Housing Pattern: Well facilitated Waste disposal: They are practicing collective approach to manage the waste

product. Such as temporary container, burning and making compost manure. The people from nagarpalika also come to take waste from there home.

Pollution and noise: his house is near the road , so he is very much affected by the noise of the vehicle and the air pollution caused by the vehicle.

F) DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT CLIENTS

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Robert Havighurst’s Developmental Tasks

Developmental Tasks

Description Passed or Failed

1. Adjusting to decreasing physical strength and health

Older adults also have to adjust to decreasing physical strength and health. The prevalence of chronic and acute diseases increase in old age. Thus, older adults may be confronted with life situations that are characterized by not being in perfect health,serious illness and dependency on people.

Passed

2. Adjusting to retirement and reduced income

A central developmental task that characterized the transition into old age is adjustment to retirement. The period after retirement has to be filled with new projects, but is characterized by few valid cultural guidelines. The achievement of this task may be obstructed by the management of another task, living in a reduced income after retirement.

Passed

3. Adjusting to death of a spouse

Older adults may become caregivers to their spouses. Some older adults have to adjust to the death of

Failed

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their spouses. After they have lived with a spouse for many decades, widowhood may force older people to adjust to loneliness, moving to a smaller place,and learning about business matters.

4. Establishing an explicit affiliation with one's aged group

The development of a large part of the population into old age is historically recent phenomenon to modern cities. Thus, advancements understanding of the aging process may lead to identifying further developmental tasks associated with gains and purposeful lives for adults.

Passed

5. Meeting social and civil obligations

Older people might accumulate knowledge about life, and thus may contribute to the development of younger people and the society.

Passed

6. Establishing satisfactory physical living arrangements

Oder adults are generally challenged to create positive sense of their lives as a whole. The feeling that life has order and meaning results in happiness.

Passed

 

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Eric Erikson’s Developmental Task

Integrity vs. Despair                   Erikson felt that much of life is preparing for the middle adulthood stage and the last stage

recovering from it. Perhaps that is because as older adults we can often look back on our lives with

happiness and are contented, feeling fulfilled with a deep sense that life has meaning and we've made

contribution to life, a feeling Erikson called integrity. On the other hand, some adults may reach this

stage and despair at their experiences and perceived failure.

                  My patient achieved happiness and contentment in his life based on his actions and speeches.

He is faithful and devoted to his religion. He is ready to accept death completely and he has shared his

experiences to his beloved grandchildren. Even though he accepted death fully but his faith and love for

his worshipped God never changed.

 

Physical Assessment

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Name: Mr.laxman kumar pandit Ward: nephrology Ward Bed: 205 Age: 68 yrs Sex: male Civil Status: Married

Vital Signs

Axillary T=97 degree F, PR= 90/ min, RR= 22/ min, BP= 150/80 mmHg.

General survey

Height= 5 ft and 8 inches, weight= 56 kilos,. No signs of distress noted upon assessment, able to

smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show

calmness during the examination. He has no IVF infused, and was asleep at initial assessment.

Skin

Skin is brown in color, rough, dry and warm. He has good skin turgor. Brownish discolorations

that resemble wrinkles are observed on face.

Head

Skull is round in shape, symmetrical. No masses noted. Facial movement is symmetrical,

alopecia. Scalp is clear from dandruff and lice. No scars and wounds noted.

Eyes

Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color

with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and

bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings

(puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva

are pinkish in color while the pupils constricted to light, round in shape. He is able to rotate eyes and has

coordinated eye movements.

Ears

Auricle has same color with the skin, has symmetrical shape and located a little bit higher than

the eye. Pinnas are symmetrical with no lesions noted. He has wet cerumen noted on both ears when

pulled down and back for better visualization. he is able to hear on both ears.

Nose

Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is

flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration.

Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and

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in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses

noted.

Mouth

Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with

thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light

pink in color while hard palate is lighter in color. Gums are pinkish in color. Plagues are present on his

teeth

Pharynx

Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not

inflamed.

Neck

Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. he is

able to flex and extend neck and move it laterally (L and R).

Chest and Lungs

Breathing pattern is regular. Anteroposterior diameter to transverse diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm). No tenderness, lump, Presence of breath sound in all area of lungs

Heart and Central Vessels

Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in

apical area upon auscultation.

Back and Extremities

Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have

a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted.. His hands are

a little rough. Muscle strength is equal on both sides of the upper and lower extremities. He is able to

stand and walk on both feet independently, and his movements are well coordinated. Toes point straight

ahead. And he is able to sit up straight.

Abdomen

His abdomen’s color is same with the rest of the part of the body. His umbilicus is coated with

blackish dirt.

Neurologic Assessment

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Cranial Nerves: able to identify aromas by smelling with eyes closed; able to see objects; pupil

constricted to light sensation; able to move eyeball downward and laterally; able to blink eyes; able to

smile, raise eyebrows, puff cheeks and close eyes; able to respond to questions being heard;) has rough

and vibrating sound; able to shrug shoulders, elevate and flex arms and legs against resistance; able to

protrude tongue and move it side to side.

FINDINGS:

Skin is dry and rough Alopecia of hair wet cerumen noted on both ears plaques are present Nails are long and untrimmed

3) DEFINATION, CAUSE AND PATHOPHYSIOLOGY OF CLIENTS DISEASES.

Definition:

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Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years in which the body’s ability to maintain metabolic and fluid

and electrolyte balance fails, resulting in uremia or azotemia. In this condition, the GFR falls below 10% of the normal rate.

Causes: Heredity Glomerular dysfunction Diabetic nephropathy Hypertension Glomerulonephritis Polycystic kidney disease Urinary tract obstruction Bladder tumour Urethral obstruction Hypertensive nephrosclerosis (hardening of the kidney)

Other causes: Hiv infection Kidney stones Chronic kidney infections and certain cancers Regular use of anti – inflammatory drugs Vesicoureteral reflux ( a urinary tract problem in which urine travels the wrong way back

towards kidney)

Stages of chronic kidney disease

STAGE DESCRIPTION GFR ML/MIN1. Slight kidney damage with

normal or increased filtration

More than 90

2. Mild decrease in kidney function

60-89

3. Moderate decrease in kidney function

30-59

4. Severe decrease in kidney disease

15-29

5. Kidney failure Less than 15 or dialysis

Pathophysiology:

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Numbness and paresthesia

Decrease insulin production/sensitivity

Predisposing FactorsGeneticsAge >40

PrecipitatingEnvironment(intrapartal)Toxin/VirusObesityDecrease Serum Potasium

Elevated Serum GlucoseIncreased Osmolarity

due to Glucose

Polydipsia Polyuria Polyphagia

Weight loss

Chronic elevation of Serum Glucose

Impaired immune function

Infection

Delayed wound healing

Accelerated atherosclerosis

Increase LDL levels

Hypertension

Coronary artery disease

Diabetic neuropathy

Small vessel disease

Diabetic retinopathy

Diabetic nephropathy

Loss of vision End-stage renal failure

Symmetrical loss of sensation

Autonomic neuropathy

Wasting of intrinsic muscles

Diabetic foot ulceration

Charcot changes in jointsNeurogenic

bladder

Dry, cracked skin

Impotence

Gastroparesis

4) COMPARISON OF:

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A) SIGNS AND SYMPTOMS

NeurologicACCORDING TO BOOK ACCORDING TO PATIENT Weakness and fatigue present Confusion present Inability to concentrate absent seizures absent Restlessness of legs present Burning to soles of feet present Behavior changes present

integumetry

ACCORDING TO BOOK ACCORDING TO PATIENT Dry, flaky skin present Thin, brittle nails present Thinning hair absent

cardiovascular

ACCORDING TO BOOK ACCORDING TO PATIENT Hypertension present Pitting edema present Periorbital edema present

pulmonary

ACCORDING TO BOOK ACCORDING TO PATIENT Shortness of breath present tachypnea present Kussmaul- type respiration present

G.I

ACCORDING TO BOOK ACCORDING TO PATIENT Metallic taste Absent Anorexia, nausea Absent Vomiting, constipation/ diarrhea present

Hematologic

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ACCORDING TO BOOK ACCORDING TO PATIENT Anemia present

Reproductive

ACCORDING TO BOOK ACCORDING TO PATIENT amenorrhea Absent infertility Absent Testicular atrophy absent

Musculoskeletal

ACCORDING TO BOOK ACCORDING TO PATIENT Muscle cramps Present Loss of muscle strength Present Bone pain Present Bone fracture absent

B) INVESTIGATION

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ACCORDING TO BOOK ACCORDING TO PATIENTLaboratory test: Blood urea: 119.0 mg/dl

Creatinine:9.1Na+:139.oK+:5.2 meq/rSerum albumin:2.8gm/dlHb:9.6gm%Glucose f:120 mg/dlGlucose pp : 141mg/dl

USG Done but report was not availablebiopsy Done but report was not availableKUB filmIt is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images.

Normal Size in cm:Left Kidney Right Kidney10.8 +-

0.8Length 9.7 +-

0.74.2 + -

0.5Width 4.3 +-

0.54.8 +-

0.5Thick 3.9 +-

0.51.5 C. Thick 1.5

Not done

C) COMPARISON OF MEDICAL MANAGEMENT

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The goal of management is to maintain kidney function and homeostasis for as long as possible. Because of the great deterioration of renal function, the duration of management may vary from months to years. Nothing can be done to prevent or delay the fatal outcome.

ACCORDING TO BOOK ACCORDING TO PATIENT Control of urinary volume: fluids

are forced since kidney has lessened ability to concentrate solids. more fluids about 2litres is needed to excrete waste. Sometimes frusemide may be required to increase urine production.

My patient was prescribed to drink lee than 500 ml water in a day.Tab lasix 40 mg, po, od, is given to my patient.

Control of nausea and vomiting: anorexia, nausea and vomiting tend to develop when the cretinine clearance falls below 5ml/min. so reduction in protein is required to improve nausea. Blood: 0.8-1.4 mg/dL is the normal. Due to impaired kidney function, creatinine in the blood elevates.

Creatinine clearance rate was 10.g mg/dl on 4/2, 8.5 mg/dl on 068/4/6, 9.7mg/dl on 068/4/9.

Antiseizure agents Since my patient didn’t develop any kind of seizure. So antiseizure agents were not used.

Antihypertensive agents: hypertension is managed by intravascular volume control and a variety of anti- hypertensive agents.

Tab nifedipine 10 mg,tds was given to my patient to control hypertension.

Control of hyperkalaemia will be treated with I/V glucose and insulin in a ratio of 3 gm Glucose to 1 unit soluble insulin.

Control of anemia: blood transfusion are frequently required.

Since my patient didn’t develop anemia so bllod transfusion was not done.

Accurate record of input and output chart should be maintained

Input and output chart was maintained.

4/6 : 200ml total input and 200ml was total output

4/7: 350ml was total input and 250 mi was total output

4/8: 500ml total input and 350ml total output

4/9: 530ml was total intake and 150 ml was total output

4/10: 450ml total input and 300ml

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total output 4/11: 400 ml total input and 300 ml

total output Other therapy: dialysis

It is usually initiated when the patient cannot maintain a reasonable lifestyle with conservative treatment.

My patient is undergoing regular dialysis, 2-3 times in a week

COMPARISON OF SURGICAL MANAGEMENT

ACCORDING TO BOOK ACCORDING TO PATIENT Kidney transplantation: it involves

transplanting a kidney from a living donor to a recipient who has ESRD. The success rate increases if kidney transplantation from a living donor is performed before dialysis is initiated.

Kidney transplantation cannot be performed in my patient because of hypertension and slow wound healing due to diabetes mellitus.

D) COMPARISON OF NURSING MANAGE MENT

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The patient with chronic renal failure requires astute nursing care to avoid the complications of reduced renal failure and the stresses and anxieties of dealing with a life threatening illness.

ACCORDING TO BOOK ACCORDING TO PATIENT Nursing care is directed toward assessing

fluid status and identifying potential source of imbalance

As a nurse I assessed the fluid status of my patient by monitoring input and output record closely.

Implement a dietary program to ensure proper nutritional intake within the limits of the treatment regimen.

My patient was prescribed to have fluid less than 500ml/day and was on renal diet. As a nurse I closely observe the dietary pattern of my patient

Promote positive feelings by encouraging increased self care

I encouraged my patient to perform his activity of daily living by himself and promoted the positive feelings.

Provide explanations and information to the patient and family concerning ESRD, treatment options and potential complications

As a nurse I provided explanation to the patient and his family members about his treatment options and potential complications.

Nurse must be familiar with various drugs and their side effects

As a nurse I provided information to my patient regarding various drugs used in it.

Provide emotional support to the patient and his family because of the numerous changes experienced.

I provided my patient and his family emotional support so that anxiety and tension is relieved to some extent.

5) DRUGS CARD OF MEDICINES

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My patient has used the following drug:- Tab nifedipine 10mg, tds Tab lasix 40mg, od Tab pantop 40 mg Diclofenac gel Tab domel 1 tab Tab haloperidol

1. Tab nifedipine

Therapeutic class: antianginal, antihypertensive, calcium channel blocker

Action :antihypertensive agent that inhibits calcium ion movement across cell membranes, depressing

contraction of cardiac and vascular smooth muscles

Therapeutic effect: decreases blood pressure

Indication: chronic stable angina, hypertension

Contra- indication: severe hypotension

Side effects: peripheral edema, headache, dizziness, (occasional): nausea, muscle cramps and pain,

dyspnea, cough (rare): hypotension, rash, constipation, sexual difficulties

Nursing management: administer on an empty stomach

Do not crush or chew sustained release dosage forms

2. Furosemide

Novosimide; PMS-Furosimide

Classification: Loop diuretics

Indications: Edema d/t heart failure, hepatic impairment

or renal disease. Hypertension.

Action: Inhibits the reabsorption of sodium and chloride from

the loop of Henle and distal renal tubule. Increases renal

excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in

impaired renal function. Decreased blood pressure.

Dosage: 1 tablet, 200 mg

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Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur;

Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol

intolerance.

Precautions: Severe liver disease; electrolyte depression

Side effects: CNS – blurred vision, dizziness, head ache, vertigo

EENT – hearing loss, tinnitus

CV – hypotension

GI – anorexia, constipation, diarrhea, dry mouth, nausea, vomiting

GU – excessive urination

Derm – photosensitivity, rash

F and E – dehydration

Nursing Responsibilities:

1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth,

hypotension, or oliguria occurs.

2. Monitor blood pressure and pulse before and during administration.

3. Monitor blood glucose closely; may cause increased blood glucose level.

4. Caution patient to change positions slowly to minimize orthostatic hypotension.

5. Advise patient to contact health care professional immediately if muscle weakness, cramps,

nausea, dizziness and numbness occurs.

6. Caution older patients or their caregivers about increased risk for falls.

3. tab pantop Generic name: pantoprazole Functional class: proton pump inhibitor

Action: it inhibits the secretion of hcl in the stomach by specific action on the proton pumps of the patietal cells.

Dose and routes:Adult: 40 mg/day (PO) In pathological hypersecretory conditions: adult I/V 80 mg over 12 hours

Indication: Peptic ulcer,zollinger ellison syndrome, NSAIDS associated peptic ulcer

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Contraindication: lactation, hypersensitivity to drug

Side effects:CNS: headache, insomnia, mental depression, confusionGI system: diarrhea, abdominal pain, constipationINTEG: rash, peripheral edemaMuscular system: myalgia( pain in the muscles)

4. diclofenac gel

therapeutic class: NSAID, antipyretic, non narcotic analgesic

action: NSAID that inhibits prostaglandin synthesis reducing the intensity of pain

therapeutic effect: produces analgesic and anti-inflammatory effects

indication: osteoarthritis, rheumatoid arthritis, pain, primary dysmennorrhea

contra indication: hypersensitivity to aspirin, diclofenac

side effects: headache, abdominal cramps, constipation, diarrhea, nausea

5. Domperidone

Motilium (1 tab, 100 mg)

Classification: Anti-emetic and anti-vertigo

Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopamine-

receptors in the chemo-emetic trigger zone produces an anti-emetic effect.

Interactions:

Concomitant administration of anti-cholinergic drugs may inhibit the anti-dyspeptic effects of

MOTILIUM.

Anti-muscarinic agents and opioid analgesics may antagonize the effect of MOTILIUM

MOTILIUM suppresses the peripheral effects (digestive disorders, nausea and vomiting) of

dopaminergic agonists.

Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of concomitant

orally administered medicines, particularly those with sustained release or enteric coated

formulations.

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As MOTILIUM interferes with serum prolactin levels, it may interfere with other

hypoprolactinaemic agents and with some diagnostic tests.

Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be

taken after meals and not before meals, i.e. they should not be taken simultaneously with

MOTILIUM.

Reduced gastric acidity impairs the absorption of domperidone.

Oral bioavailability is decreased by prior administration of cimetidine or sodium bicarbonate

Side Effects:

Allergic reactions, such as rash or urticaria, have been reported.

Abdominal cramps have been reported.

Reversible raised serum prolactin levels have been observed which may lead to gynaecomastia.

Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the

possible occurrence of neurological side-effects cannot be totally excluded

Nursing Responsibilities:

1. Assess for extra-pyramidal effects such as jerking and tongue protrusion.

2. Check for hypotension.

6. HaloperidolTherapeutic class: antipsychotic

Action: an antipsychotics agent that competitively block postsynaptic dopamine receptors

Therapeutic effect: produces tranquilizing effect

Indication: treatment of psychotic disorders

Contra indication: CNS depression, hepatic disease

Side effects: blured vision, constipation, dry mouth, peripheral edema, difficulty urinating,

decreased thirst, dizziness, drowsiness

Nursing consideration:

take with food or milk

donot mix liquid formulation with coffee or tea

use a sunscreen during sun exposure to prevent burns

7. inj. Novapid 4 units

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Func class: antidiabeticChem.. class: exogenous unmodified insulin

Action: decreases blood glucose, by transport of glucose into cells and the conversion of glucose to glycogen, indirectly increases blood pyruvate and lactate, decreases phosphate and potassium

Uses: DM type 1 and 2

Doses and routes:Adult: subcut dosage individualized, give within 15 min before or 20 min after starting a meal

Side effects:EENT: blurred vision, dry mouthINTEG: flushing, swelling, rednessMETA: hypoglycemiaSYST: anaphylaxis

Contraindication: hypersensitivity to protamine

Precaution: pregnancyNursing Interventions:

1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet,

lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration,

drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea,.

2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid

deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst.

3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin

dose.

4. Monitor blood glucose every 6 hours during therapy.

6. Store insulin in refrigerator. Do not use if cloudy, discolored or unusually viscous.

7. Rotate site of infection.

8. Instruct patient on proper techniques for administration.

9. Explain to the patient that this medication controls hyperglycemia but does not cure

diabetes.

6) SUMMARY OF CLIENT DAILY PROGRESS REPORT IN HOSPITAL

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DATE TIME TEMPERATURE

PULSE RESPIRATION

BP SUMMARY

04/O8/068 2am

6pm

98 degree F

97.6 degree F

80/m

88/m

20/m

28/m

200/80mm of hg

210/80 mm of hg

Pt’s g/c is seems satisfactory, vital signs monitored with rise in blood pressure. Prescribed medicine carried out. Input and output chart maintained. Paln for haemodialysis tomorrow. No any complain from the patient side.

04/09/068 12:30pm

98 degree F 82/m 24/m 210/100 mm of hg

1:20pm

98 degree F 90/m 20/m 210/100 mm of hg

pt’s g/c seems satisfactory. Vital signs are taken and recorded with rise in blood pressure. haemodialysis done. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side.

04/10/068 2pm 98 degree F 100/m 22/m 200/90 mm of hg

6pm 101.6 degree F 110/m 24/m 210/80 mm of hg

Pt’s g/c is satisfactory. Vital signs are taken and recorded with rise in blood pressure and temperature. Tab paracetamol and cold compresses given to the patient.All prescribed medication was carried out. Patient is on normal diet.

04/11/068 10am 97 degree f 90/m 20/m 210/90 mm of hg

2pm 97 degree f 88/m 20/m 210/90 Pt’s general condition is

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mm of hg satisfactory. Vital signs are taken with rise in blood pressure. prescribed medicine carried out. Normal bowel and bladder habit. Patient complain is dry and itching over skin of hands and legs. So he is in dermatology consultation. Dermatology department prescribed him coconut oilto apply in itching and dry areas three times a day.

04/12/068 10 am 97 degree f 92/ min 20/min 180/80 mm of hg

pt’s g/c seems satisfactory. Vital signs are taken and recorded with rise in blood pressure. haemodialysis done through left femoral vein. Put the sand bag pressure at the femoral site for 2 hours. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side.

2pm 98 degree f 88/min 20/min 180/70 mm of hg

04/13/068 10am 98 degree f 80/min 22/min 150/90 mm of hg

Patient general condition seems satisfactory. Vital signs taken with rise in blood pressure. Prescribed medicine carried out. Normal bladder habit but bowel habit is disturbed.no any such complain from patient side

04/14/068 10 am 97 degree f 80/ min 20/min 140/80 mm of hg

Patient general condition seems satisfactory. Patient general condition seems satisfactory. Vital signs taken with rise in blood pressure. Prescribed medicine carried out. Normal bowel and bladder habit. No any itching on the patient’s

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skin2pm 98 degree f 76/min 20/min 170/70

mm of hg04/15/068 10am 98 degree f 78/min 22/min 190/80

mm of hgpt’s g/c seems satisfactory. Vital signs are taken and recorded with rise in blood pressure. haemodialysis done through left femoral vein.dialysis three times a week that is on Sunday,Wednesday and Friday. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side.

04/16/068 10 am 97 degree f 80/ min 20/min 190/70 mm of hg

2pm 98 degree f 88/min 20/min 180/60 mm of hg

Pt’s g/c is improved. Vital signs taken with rise in blood pressure. All prescribed medication was carried out. . Discharge on o4/17/068.

04/17/068 10am 98 degree f 90/min 22/min 180/70 mm of hg

Patient general condition seems fair. Vital signs are taken and recorded with rise in blood pressure.prescribed medicine carried out,normal bowel and bladder habit.dialysis three times a week. That is on Sunday, Wednesday and Friday. Follow up on medical out patient department on Monday or Thursday.

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7) DIVERSIONAL THERAPY USED FOR CLIENTDiversional therapies are used to divert one’s thoughts from life stresses or to fill time.I have used the following aspects of diversional therapy to overcome his situation.

Physical therapy: deep breathing and coughing exercise was encouraged to perform. Proper position of the patient was maintained so that she can feel relaxed and comfortable.

Group therapy: I gave many examples of other people having the same disease condition and also introduced him with some of them so that he can realize that many others have and share problems which are very similar to their own problems and that they are not alone in their suffering.

Relaxation training: I encouraged my patient for performing yoga and meditation as relaxation produces physiological effect that are opposite to those anxiety, that is slow heart rate, increased peripheral blood flow.

Psychological therapy: I encourage my patient to express his feelings and attitude, and communicate with the care takers as well as the family members. Because of this his psychological depression can be reduced and he feels better.

Medicine therapy: I provided his medicine to relieve his pain and for his better recovery.

Recreational therapy: according to this therapy, I encouraged my patient to listen songs of his choice. I also encouraged him to sing songs as he loves to listen and sing old melody filmy songs songs. Beside these I also encouraged my patient to read magazines, newspaper, listen radio, etc. so that it would help patient diverse his mind away from his anxiety and depression.

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APPLICATION OF NURSING THEORIES Virginia Henderson’s Independent Theory:

In 1955, Henderson formulated unique function of nursing, she purposed 14 components of Basic nursing care. The components are as follows:

Breathe normally. Eat and drink adequately Eliminate body wastes Move and maintain desirable postures. Sleep and rest Select suitable clothes- dress and undress Maintain body temperature within normal range by adjusting clothing and modifying the

environment. Keep the body clean and well groomed and protect the integument. Avoid danger in the environment and avoid injuring others. Communicate with others in expressing emotions, needs, fear or opinion. Worship according to one’s faith. Play or participate in various forms of recreation. Learn, discover or satisfy the curiosity that leads to normal developmental and health and

use of the available facilities.

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APPLICATION OF THEORY ON MY PATIENT

Breath normally:- I encourage my patient to do deep breathing and coughing exercise. This helps to promote lung expansion and gases extent and also help to loosen and bring out secretion.

Eat and drink adequately:- I encourage my patient to eat and drink adequately according to body needs and the patient food habit was well maintained.he was prescribed to have fluid less than 500ml/day

Eliminate body waste:- My patient bowel and bladder habit was normal so his eliminate body waste pattern was well maintained.

Move and maintain desirable posture:- I helped my patient to move and maintain the desirable position

Sleep and rest: I encouraged patient to take a adequate rest and sleep according to body need and disease condition for a positive health.

Select suitable clothe and dress:- Suitable clothe was selected. Body cleanliness:- I encourage my patient to keep her body clean. Avoid danger in the environment and avoid injuring others: sometimes my patient

shows aggressive behavior so antipsychotics drugs were prescribed to my patient to avoid danger in the environment and also to avoid injuring others.

Communicate with others in expressing emotions, needs, fear or opinion:- As my patient was able to communicate, his communication pattern was maintaining.

Worship according to one’s faith Play or participate in various forms of recreation:- This component help me

inspire my patient to write new poems, story and jokes.

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9) NURSING CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATI

ONRATIONAL EVALUATI

ON

Subjective data: patient says that, “my hands and face are swelling”

objective data: patient’s face and hand was swelling

Excess fluid volume related to fluid accumulation between dialysis treatments.

Patient will maintain fluid volume status within established parameters.

-assess weight, lung sounds and extremities for presence of edema -monitor intake and output. Some patient continue to urinate small amounts, but it is inadequate to clear all waste products.-monitor laboratory data: blood urea,nitrogen,serum creatinine,sodium,potassium,calcium,hb,etc

-teach pt the need for maintaining fluid restrictions between treatment-teach pt the need for restricting sodium intake

-weight, lung sounds and extremities was assessed for presence of edema. -input and output was monitored.

-laboratory data was monitored

-fluid restrictions between treatment was maintained.

-the need for restricting sodium intake was teached.

-To determine the fluid volume so that treatment parameters can be identified.

-Intake is limited and must be monitored to prevent fluid volume overload.

-nitrogenous waste and electrolytes accumulate between treatments. Anemia and blood losses associated with hemodialysis are complications associated with kidney failure.-to prevent excess intake, which can lead to hypervolemia

-sodium intake stimulates thirst which can lead to excessive fluid intake and subsequent hypervolemia.

My goal was fully met as patient is free of peripheral edema.

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ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION

RATIONAL EVALUATION

Subjective data: patient says that, “my hand and face are swelling”

objective data: patient’s hand and face was swelling

Risk for skin integrity related to alterations in skin turgor (edema)

Patient will maintain an intact skin

-inspect skin for changes in colour,turgor,vascularity,note redness-monitor fluid intake and hydration of skin and mucous membranes-inspect dependent areas for edema. Elevate legs as indicated.

- provide soothing skin care. Restrict use of soaps. Apply ointments or creams.-keep linens dry, wrinkles free

-investigate reports of itching

- suggest wearing loose fitting cotton garments

-skin was inspect for changes in colour, turgor, vasclarity.- fluid intake and hydration of skin and mucous membranes was monitored.

-dependent areas for edema was inspected and legs was elevated as indicated.

-soothing skin care was provided and creams, ointments was applied.-linens were kept dry and wrinkles free.- reports of itching was investigated

- loose fitting cotton garments were suggested to wear.

-indicates areas of poor circulation/breakdown that may lead to infection.-detects presence of dehydration or overhydration that affect circulation and tissue integrity at the cellular level.-edematous tissues are prone to breakdown. Elevation promotes venous return, limiting venous stasis,edema formation.-lotions and ointment may be desired to relieve dry,cracked skin.

-reduces dermal irritation and risk of skin breakdown.-although dialysis has largely eliminated skin problems associated with uremic frost,itching can occur because the skin is an excretory route for waste products.-prevents direct dermal irritation and promotes evaporation of moisture on the skin.

My goal was fully met as patient maintain an intact skin.

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ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION

RATIONAL EVALUATION

Subjective data: patient says that, “I have itching in my neck”

objective data: patient’s neck was red.

Risk for injury related to infection

Patient will be free of infection

-assess skin , nothing redness,swelling,local warmth,tenderness-avoid contamination of assess site. Use aseptic technique and masks when applying/changing dressings and when starting/completing dialysis process.-monitor temperature, note presence of fever,chills

-culture the site/obtain blood samples as indicated-administer medicines as indicated

-nothing redness,local warmth,tenderness and skin was assessed

-Aseptic technique and masks were applied when changing dressings and when starting/completing dialysis process.

-signs of infection/sepsis requiring prompt medical intervention.-blood samples were obtained

-Medicines were administer as indicated.

-signs of local infection, which can progress to sepsis if untreated

-prevents introduction of organisms that can cause infection.

- signs of infection/sepsis requiring prompt medical intervention-determine presence of pathogens

-Prompt treatment of infection may save access, prevent sepsis

My goal was fully met as patient did not develop any sign of infection

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ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION

RATIONAL EVALUATION

Subjective data: patient says that, “I can’t do anything, I am useless”

objective data:

patient looks depressed

Situational low self esteem related to chronic kidney failure requiring machine dependency

Patient will mainatin positive body image

- monitor patients response to illness and treatments

-allow patient to grieve over his losses

-acknowledge patients grief about being dependent on a machine-support strengths,self confidence,determination and motivation to live

-help pt to develop or continue interests beyond dialysis and return to as near normal life as possible

-monitor for excessive concerns about losses,depression

-patients response to illness and treatments were monitored.

-patient was allowed to grieve over his losses-patient grief about being dependent on a machine was acknowledged-strengths,self confidence, determination and motivation to live was supported.

-pt was helped to develop interest beyond dialysis and return to as near normal life as possible

-excessive concerns about losses, depression was monitored

-to determine the effect of health status changes so that appropriate interventions can be planned-grieving is a necessary part of recovery

-demonstrate empathy and validates the patients feeling

-Patients undergoing dialysis are not disabled in all aspects of life. Many live nearly normal lives while maintaining treatment schedule-pt may tend to withdraw from social activities because of their new schedule and feelings of loss,focusing on other interests will help the pt place less focus on his dependency-there may be indications of suicidal ideation,which needs to be identified and treated quickly

My goal was fully met as patient verbalizes acceptance of treatment regimen as part of lifestyle

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ASSESSMENT DIAGNOSIS GOAL PLANNING IMPLEMENTATION

RATIONAL EVALUATION

Subjective data: patient says that, “I can’t do anything, I am useless”

objective data:

patient looks depressed

Disturbed thought processes related to accumulation of toxins

Patient will mainatin optimal level of mentation

- assess extent of impairment in thinking ability, memory and orientation-provide quiet/calm environment

-reorient to surroundings, person. Provide calendars, clocks, outside window-present reality concisely,briefly and do not challenge thinking

-communicate information in simple, short sentences. Repeat explanation as necessary

-promote adequate rest and sleep-prepare for dialysis

- impairment in thinking ability, memory and orientation was assessed-quiet/calm environment was provided

-reorientation to surroundings and person along with calendars, clock was provided-reality was present consicely

-information was communicated in simple and short sentences. Explanations was repeated as necessary-adequate rest and sleep was provided- patient was prepared for dialysis

-uremic syndrome’s effect can begin with minor confusion, irritability-minimizes environmental stimuli and reduces confusion -provides clues to aid in recognition of reality

-confrontation potentiates defensive reaction and may lead to pt mistrust and heightened denial of reality-may aid in reducing confusion and increases possibility that communications will be understood

-sleep deprivation may further impair cognitive abilities-marked deterioration of thought processes may indicate worsening of azothemia & g/c,requiring prompt intervention to regain homeostasis

My goal was fully met as patient

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DISCHARGE TEACHING:-Categories Plan Rationale

Medication

Instruct patient to take prescribed

medications regularly and comply with

the treatment regimen prescribed by the

physician.

Teach patient regarding the names of

the drug, its dosage, time of

administration, its contraindication and

side effects.

Inform patient and significant others not

to take drugs not prescribed by the

physician.

Instruct the patient to check for the

expiration date of the drug before taking

it.

Do not administer any other drug with

same action without the physician’s

prescription.

Educate the patient and the significant

others about the expected responses of

drug to the body, side effects, adverse

effects that may possibly seen into the

patient.

Instruct the significant others to report

any remarkable adverse reactions or

any appearance of side effects noted.

-Compliance to appropriate

medication and treatment

prevents further complications

and resistance to antibiotics and

promote continuous recovery of

optimal health.

-The patient has the right to know

his drug’s therapeutic effects as

well as its adverse effects. He

also has the right to gain

awareness about why is it given

to him.

-Drug interactions may occur

which may be fatal to patient’s

current situation.

-Checking for the expiration date

of the drug before administering it

ensures it potency and safety. It

also prevents any unwanted

reactions like hypersensitivity.

-Non-prescription drug may have

antagonistic or synergistic effects

if taken with other drugs.

-To be geared up of enough

information that may lead to

immediate medical responses.

-For immediate remedial action

response and to prevent any

complicated reactions.

Exercise Explain to patient the significance of

regular exercise like walking and

stretching. If unable to mobilize alone,

instruct the watcher to give assistance

-Exercises promote proper blood

circulation and prevent arterial and

venous stasis thus lessens platelet

coagulation to aged people. Older

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all the time. Encourage to use crutches

or any device for support. Stretching

upper extremities also promote healthy

living. Also instruct patient to perform

passive range of motion.

Teach patient to wait for 1 to 2 hours

after eating before performing any

physical activities.

Instruct the patient to practice deep

breathing exercise.

people have weakened blood

vessel walls which can cause any

alteration in blood flow.

Also exercise prevents atrophy of

the muscles.

-Older people has slower digestion

rate, thus they need to conserve

more oxygen which will be

necessary for digestion of food.

Activities must be limited to

decrease oxygen demand by

organs and tissues other than the

digestive system.

-Deep breathing exercises promote

thoracic expansion which allows air

to enter the respiratory tract and

provide oxygen to the alveoli to

avoid atelectasis or lung collapse

due to increase fluid pressure in

the pleural space.

Treatment Instruct patient to comply with his

medication treatment like the continuous

use of beta blocker Metoprolol for

control of hypertension and Insulin for

diabetes mellitus.

Instruct client to seek medical help if any

unusualties are felt such as tingling

sensation or paresthesia, fatigue and

body malaise, dizziness, headaches,

irritability, tremors, diaphoresis, etc.

As part of long-time treatment, advise

patient to wear medical alert bracelet all

the time and wherever he goes. It

contains the patient’s name, disease

condition, address and contact person.

-Maintenance meds should not be

forgotten to achieve highest

therapeutic effect.

-These unusualties may be

indicative of worsening condition.

-Medical alert bracelet provides

basic information about the client in

case of accidents.

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Advise to have a family member take

your blood pressure to check if you’re

maintaining a stable blood pressure.

Since the client has his own glucose

monitor, tell client to continue monitoring

blood glucose level, and immediately

seek for medical help if level is

abnormally high.

-Monitor of blood pressure is

significant for evaluating the

medication’s effectiveness.

-Glucose monitoring is a big factor

in the management of diabetes

mellitus.

Hygiene Instruct patient to practice foot care to

prevent ulceration and formation of

gangrenous tissues to the lower

extremities.

- Check and carefully wash your feet

every day.

-Do not wear shoes that are too small or

socks that do not fit right inside your

shoes.

-Soak your feet in warm soapy water for

10 minutes before cutting your nails.

Trim your toenails straight across to

prevent ingrown toenails. You may also

file down your toenails. Do not cut your

nails into the corners or close to the skin.

You should not dig under or around the

nail.

Emphasize the importance of bathing

everyday. Wash genitals with mild soap.

Instruct client to maintain good oral

hygiene.

Instruct to wear clean clothes and

-Proper foot care prevents injury to

feet and toes.

-Proper bathing eliminates

proliferation of germs and bacteria

in the body. Mild soap does not

irritate the skin and the genitals.

-Tooth brushing prevents build up

of plaques and cavities.

-Dirty or improperly washed

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underwear. underwear may become a

sanctuary for microbial growth.

Microbes may enter the genitals

and might worsen the client’s

UTI/Cystitis.

Out-Patient

Referral

Encourage patient to undergo physical

therapy sessions.

-A Physical Therapist is a source of

information to understand age-

related changes and offer

assistance for regaining lost

abilities or develop new ones.

Physical therapy can be applied to

the client’s condition: arthritis,

urinary and fecal incontinence,

amputation, and cardiac and

pulmonary disorders. It can :

a). increase, restore or maintain

range of motion, physical strength,

flexibility, coordination, balance

and endurance

b.) aids adaptations to make the

home accessible and safe

teach positioning, transfers, and

walking skills

c.) promote maximum function and

independence within an individual's

capability

d.) increase overall fitness through

exercise programs

e.) prevent further decline in

functional abilities through

education, energy conservation

techniques, joint protection, and

use of assistive devices to promote

independence

f.) improve sensation, joint

proprioception

g.) reduce pain

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Advise to have check-ups after discharge.

Advise to have regular laboratory exams

for creatinine, albumin, sodium,

potassium and calcium.

Encourage to undergo ABG Test every

month or once every 2 months.

-Serves as an evaluation process

to note if condition has progressed

to better or worse.

-To assess for renal function.

Diet Instruct client to avoid simple sugars.

Take energy from complex carbohydrates

like unpolished rice, bread and

vegetables.

Encourage patient to eat fibrous foods

like fruits and vegetables. But do not eat

too much as it can irritate the GI tract and

causes bleeding. Other examples of

sources of fiber are: whole grains, cereals

and legumes.

Limit intake of purine rich foods such as

liver, beef kidneys, brains and meat

extracts. Encourage to eat in moderate

amount: asparagus, cauliflower, spinach,

mushrooms, green peas, dried peas and

beans.

-Simple sugars easily break down

and enter the blood stream.

Complex carbohydrates can

sustain the body’s energy

requirement for a longer time

because they are not broken down

easily.

-A diet rich in fiber relieves

constipation. It adds bulk to the

excreta and facilities expulsion.

-Accumulation of uric acid in the

joints causes arthritis. Uric acid is

the by product of purine break

down in the liver. Because of renal

malfunction, uric acid is retained in

the blood stream and is shunted to

connective tissues.

WHAT I LEARNED FROM THIS CASE STUDY:-

Case study is the comprehensive study of one selected patient and comparative study with books. During my case study, I learned the following things.

i. About the disease:-

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I got opportunity to read and gain comprehensive knowledge through various books, literatures, teachers, doctors, ward staffs, colleagues and via. Secondary internet. I also obtained a comprehensive knowledge on the disease its treatment and management.

ii. About the patient:-My patient was a open book to learn for me, as I got an opportunity in learning through

involving patients care, treatment, diversional therapy and teaching not only from patient but also from his family member. I learned personal quality of patient and use the information in treating her. I also taught the families, socio cultural, economical, religious and traditional beliefs of the patient which influence her health.

iii. About nursing care:-I applied holistic approach while giving nursing care to the patient. I followed the theorie of Henderson in providing nursing care and I gained more knowledge and skill.

iv. About documentation.

12) CONCLUSIONS AND SUMMARY OF CASE STUDY

My patient name is mr. laxman pandit , 68yrs old, male with the diagnosis of Chronic kidney disease.Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years

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Heredity Glomerular dysfunction Diabetic nephropathy Hypertension Glomerulonephritis Polycystic kidney disease Urinary tract obstruction Bladder tumour Urethral obstruction Hypertensive nephrosclerosis (hardening of the kidney) are some of the causes of chronic kidney

diseaseThe clinical features of ESRD are: weakness and fatigue, confusion, seizures, burning soles of feet, thin, brittle nails, hypertension,periorbital oedema,etc

It can be investigate through laboratory test such as cbc, urinalysis, blood urea ,ultrasonography, kub film etc. During my case study, I provided health education, applied different diversional measures, treatment, investigation, diet, personnel hygiene etc. I feel great pleasure whenever patient and his family get treatment satisfaction and getting better. His general condition was improved so he was discharged.

13) REFERENCES

Nursing care plan, Marilynn E. Doengs, Mary. Francesmoorhoose, Alice C. Geissles. Murs 6th

edition

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Rai lalita “nursing concept theories and principles”; 1st edition

Helth learning materials centre Tu, institute of medicine, maharajgunj, ktm, textbook of adult

helath nursing

Mosby’s nursing drug reference,2007

Phipps Monahan and sands marek neighbors”medical surgical nursing health and illness

perspectives” 7th edition, page 1260 to 1271

A Lippincott manual ”the Washington manual of medical therapeutics”,33rd edition, page 430 to

433

http://www.emedicinehealth.com/chronic_kidney_disease/page2_em.htm

http://www.ehttp://www.emedicinehealth.com/chronic_kidney_disease/

page4_em.htmmedicinehealth.com/chronic_kidney_disease/article_em.htm

http://en.wikipedia.org/wiki/Chronic_kidney_disease

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