end stage renal disease 2o hypertensive nephrosclerosis

8/19/2019 End Stage Renal Disease 2o Hypertensive Nephrosclerosis

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End-stage renal disease

2o hypertensivenephrosclerosis

Presented by: Christelle Queen S. Bacalla


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INTRODUCTION

End-stage renal disease (ESRD) represents a clinical state orcondition in hich there has been an irre!ersible loss o" renal"unction in hich the body#s ability to $aintain $etabolic and%uid and electrolyte balance "ails& resulting in ure$ia ora'ote$ia (retention o" urea and other nitrogenous astes inthe blood)& and these patients usually need to accept renalreplace$ent therapy (dialysis or idney transplantation) inorder to a!oid li"e-threatening ure$ia. t is the +nal stage(stage ,) o" chronic idney disease (CD). his $eansidneys are only "unctioning at /0 to /, percent o" their

nor$al or not "unctioning at all. idney disease is usuallyprogressi!e. t typically does not reach the end stage until /0to 10 years a"ter you are diagnosed ith chronic idneydisease& hich $ay also de!elop sloly.


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INTRODUCTION

2ost cases o" ESRD are caused by diabetes orhigh blood pressure. Chronic idney disease (CD)is an u$brella ter$ that describes idney da$ageor a decrease in glo$erular +ltration rate (34R) "or

5 or $ore $onths. 6ntreated CD can result in end-stage renal disease (ESRD) and necessitate renalreplace$ent therapy (dialysis or idneytransplantation). Chronic idney disease is identi+ed

by a blood test "or creatinine. 7igher le!els o"creatinine indicate a "alling glo$erular +ltration rateand as a result a decreased capability o"the idneys to e8crete aste products.


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INTRODUCTION

Creatinine le!els $ay be nor$al in the early stages o" CD& and thecondition is disco!ered i" urinalysis shos that the idney is alloing theloss o" protein or red blood cells into the urine. o "ully in!estigate theunderlying cause o" idney da$age& !arious "or$s o" $edical i$aging&blood tests and o"ten renal biopsy are e$ployed to +nd out i" there is are!ersible cause "or the idney $al"unction.

he +!e stages o" CD are based on the glo$erular +ltration rate (34R)herein the nor$al 34R is /1, $9$in/.;5$1. Stage / is hen there isidney da$age ith nor$al or 34R


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INTRODUCTION Benign nephrosclerosis is a gradual and prolonged deterioration o" the

renal arteries. 4irst the inner layer o" the alls o" s$aller !esselsthicens& and gradually this thicening spreads to the hole all&so$eti$es closing the central channel o" the !essel. 4at then beco$esdeposited in the degenerated all tissue. he larger arteries gain ane8cess o" elastic tissue& hich $ay bloc their channels. Both o" theseconditions cause the blood supply to the !ital idney areas to be

bloced& and tissue deterioration ensues.

n $alignant nephrosclerosis a si$ilar process occurs but at a $uch"aster rate. he disease $ay de!elop so rapidly that there is little ti$e"or gross idney changes to occur. he sur"ace o" the idney& hoe!er& isnearly alays co!ered ith large red blotches at points here bleeding

has occurred. n the $alignant disease the arteriole alls thicen and$ay be closed o by rapid cell groth. he nuclei o" these cells die& andthe elastic +bers disappear. ith the loss o" the elastic +bres& the allso" the !essels beco$e $uch $ore "ragile and easily distended. Se!ereruptures and he$orrhages are "reuent. he arterioles o"ten suerspas$s that can "orce blood through lesions in the !essel alls thetissues beco$e sollen as a result.


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INTRODUCTION

Fccording to the 10// 6S Renal DataSyste$ (6SRDS) data& in the year 100


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INTRODUCTION

chose this case because ant to gainco$prehensi!e noledge about the disease.

HbIecti!es o" $y case study are the "olloing: o understand the nature and pathophysiology o"

the disease. o identi"y signs and sy$pto$s e8hibited by the

patient ith ESRD. o assess the patient& +nd out need o" patient and

co$e up ith appropriate inter!entions utili'ingthe nursing process.

o pro!ide discharge plan to the patient ithESRD.


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DEMOGRA!IC RO"I#E

Aa$e: Patient 2. Fge: ?5 years old Se8: 2ale Ci!il Status: 2arried Religion: Se!enth day Fd!entist Fddress: P-? Cantugas& 2ainit& SDA

Date o" Birth: 0?0=/


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A$T MEDICA# !I$TOR% he patient as diagnosed ith 7ypertension as early as 5/

years o" age but did not co$ply ith his treat$ent regi$en. 7eould usually buy Captopril hene!er he "eels lie his bloodpressure is ele!ated.

7e as ad$itted at Surigao 2edical Center on Dece$ber 10/5due to !o$iting and diarrhea. he patient#s doctor suggestedhi$ to undergo 7e$odialysis "or the reason that his seru$

creatinine as ele!ated a$ounting to 51$gdl. 7oe!er& thepatient re"used& thining that he$odialysis as Iust a aste o"$oney and that sooner or later he ill die. Hn Fpril 10/?& he asbrought to CR7 by his daughter because he had an alteredsensoriu$& !o$iting& and peripheral ede$a. Fccording to hi$&

his creatinine increased to //1 and his B6A as !ery ele!ated&he cannot recall the rest o" the history. 7e as then diagnosedith ESRD secondary to 7ypertensi!e Aephrosclerosis.Frterio!enous 4istula as created at his le"t ar$ on Fpril 0=&10/? by Dr.Jcong. he patient also !erbali'ed that his doctore8plained to hi$ the result o" his sonography that both o" his

idneys shrun.


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$OCIA# !I$TOR%

he patient li!es in P-? Cantugas& 2at-& SDA. 7e has 5children& to o" the$ ha!e their on "a$ily& and theyoungest is currently li!ing ith hi$ and his i"e attheir residence. Be"ore he as diagnosed ith ESRD&

he as li!ing only ith his youngest daughter ho isstudying in 7igh School because his i"e oredabroad. F"ter his hospitali'ation& his i"e ent ho$eto tae care o" hi$. 7e "or$erly ored as a treasurerin their $unicipality and stopped hen he as alreadydiagnosed ith ESRD because he easily gets tired andhas to go on he$odialysis tice a ee. he patientdoes not s$oe& and only drins liuors occasionally.7e has a good relationship ith his neighbors.


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"AMI#% !I$TOR% O" I##NE$$

he patient !erbali'ed that his parentsha!e a history o" 7PA.


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!%$ICA# A$$E$$MENT

&ITA# $IGN$' BP: /=0/00 $$7g K />0//0 $$7g E2PERF6RE: 5=.?oC P69SE RFE: >= bp$ RESPRFHRJ RFE: 1/ bp$


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$(IN' Color: Dar bron ntegrity: ntact 2oisture: Dry %ay sin (L)pruritus M ar$s and bac

!AIR'

Color: Blac hicness: hic and dry hair


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NAI#$' Shape: Aor$al sy$$etrical e8ture: S$ooth Aailbed color: Pale

Capillary Re+ll: Aor$al Fppearance: Dirty

"ACE' Sy$$etry o" 2o!e$ents: Sy$$etrical Fppearance: puy chees

E%E$' Color: hite 7olloness: Sunen Pale conIuncti!a


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UI#$' Color: Bron Shape: Circular

Sy$$etry: Sy$$etricalAURIC#E$' Aor$al and sy$$etrical e8ture& elasticity& tenderness: 4ir$ non-tender

Sin lesions: Ao sin lesions

NO$E' Sy$$etrical (-)%aring


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MOUT!' (-)halitosis ithout dentures eeth color: light yello Fppearance: pale

#UNG$' Breath sounds: (L)cracles on both lung +elds

A)DOMEN' Distended

ARM$' Sy$$etrical& ith FN4 M 9 ar$

#EG$' Sy$$etrical& ith scar M posterior 9 cal"& ede$a (/L)

on both "eet


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GORDON*$ T%O#OG% O" !EA#T! ATTERN

!EA#T! ERCETION + !EA#T! MANAGEMENT he patient rarely sees $edical attention hene!er he has

an illness because he belie!es that it is Iust a aste o"$oney. Be"ore he as diagnosed ith ESRD& he does nottae any !ita$ins and only buys Captopril hene!er he"eels di''y and his BP beco$es ele!ated. But no he isalready co$pliant to his prescribed $edications ith thehelp o" his i"e by re$inding hi$ to tae his $eds. 7eundergoes he$odialysis tice a ee& and undergoes bloodtrans"usion o" PRBC hene!er his RBC count beco$es !ery

lo usually e!ery 5 $onths. he i"e !erbali'ed that thepatient is !ery hard headed because the patient o"ten ti$eson#t listen to hi$ and his diet is still salty and high in "at.

he patient $aintains a eight o" ,?.,g pre-7D andeight goal post-7D is ,/g.


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NUTRITIONA# + META)O#IC ATTERN 7is usual ater intae is ?-= ti$es a day. 7is diet is usually

salty and high in "at. 7e o"ten drins soda and Cobra energydrin "or 1-5 ti$es a day be"ore he as diagnosed. 7edrins liuors occasionally and ne!er s$oe. he patientdoes not ha!e "ood allergies. 7e o"ten has no appetite andhis i"e usually has to bring hi$ to restaurants to eat he!erbali'ed that his appetite depends on the s$ell andappearance o" the "ood. 7oe!er& he still eats salty "oodse!en though he#s already diagnosed ith ESRD. 7e does

not li$it his %uid intae though his doctor ad!ised hi$ toli$it %uid intae to /9 per day. he patient also !erbali'edthat a"ter eating salty "oods or drining soda& he ille8perience selling o" the "eet and bone pains Iust hourslater.


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E#IMINATION ATTERN he patient usually !oids ,-; ti$es a day in

scanty-$ini$al a$ount& dar yello in color orcolorless. 7is boel $o!e$ent is usually oncee!ery 1 days.

ACTI&IT%, #EI$URE, AND RECREATIONA#ACTI&ITIE$ 7e pre!iously ored as a treasurer in their

2unicipal oOce. he patient did not engage ine8ercises be"ore and until no. 7e atchestele!ision $ore o"ten and does not usually go out"or a al. he patient does not do householdchores because he gets easily tired.


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$#EE AND RE$T ATTERN he patient usually sleeps at /0p$ and oe up at

?a$. H"ten ti$es he e8perienced aing up atnight to !oid. 7e !erbali'ed aron nga naingani

nao& naa rao pir$i sa balay aon atulog ay dili$an o pa trabahuon saong asaa.

COGNITI&E-ERCETUA# ATTERN he patient is a college graduate. 7e has diOculty

seeing near obIects. 7e e!en holds his cellphoneaay hile reading a te8t $essage. 7e is !erysensiti!e in the s$ell and appearance o" "ood hichaects his appetite.


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$E#" ERCETION-$E#" CONCET ATTERN he patient lies to sociali'e ith his or$ates be"ore.

7e thought that he as healthy and does not ha!e anyproble$ about his hypertension. 7e !erbali'ed in an

inappropriate aect ala gyud o nag tuo nga $uabutsa ingani& nga $aingani o& aron nghulat nalang o nus-a $a$atay.

RO#E RE#ATION$!I

7is pri$ary dialect is Surigaonon. 7e is $arried& ith 5children ho he is ell-supported and lo!ed. he patientis currently li!ing ith his i"e and youngest child. 7iseldest daughter ho is a nurse abroad is the only oneho supports hi$ on his treat$ents.


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$E.UA#IT%-RERODUCTI&E ATTERN 6na!ailable.

COING AND $TRE$$ TO#ERANCE hene!er he has proble$s& he does not usually tell it to his "a$ily

especially no because he does not ant to be a burden in the"a$ily.

&A#UE$-)E#IE" ATTERN he patient#s religion is Se!enth Day Fd!entist. 7e does not

regularly go to Church but he alays pray to 3od. 7e reali'ed that

pro$oting good health is really i$portant than to regret later inyour li"e particularly in his condition in hich he has to undergohe$odialysis "or a li"eti$e. 7oe!er& e!en though he is already onhe$odialysis& he does not change his li"estyle and diet because hebelie!es that it is oay to eat salty "oods and drin soda since he#salready on he$odialysis hich "unctions no as his idneys& and

besides& he ill still die in the end.


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RENE H4 FAFH2J FADP7JSH9H3J#ocation

he idneys are a pair o" organs"ound along the posterior $uscularall o" the abdo$inal ca!ity. hele"t idney is located slightly $oresuperior than the right idney dueto the larger si'e o" the li!er on the

right side o" the body. 6nlie theother abdo$inal organs& theidneys lie behind the peritoneu$that lines the abdo$inal ca!ity andare thus considered to beretroperitoneal organs. he ribs

and $uscles o" the bac protectthe idneys "ro$ e8ternal da$age.Fdipose tissue non as perirenal"at surrounds the idneys and actsas protecti!e padding.


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$tr/ct/re he idneys are bean-shaped ith thecon!e8 side o" each organ locatedlaterally and the conca!e side $edial.

he indentation on the conca!e side o"

the idney& non as the renal hilus&pro!ides a space "or the renal artery&

renal !ein& and ureter to enter theidney.

F thin layer o" +brous connecti!e tissue

"or$s the renal capsule surroundingeach idney. he renal capsule pro!ides

a sti outer shell to $aintain the shapeo" the so"t inner tissues.

Deep to the renal capsule is theso"t&dense& !ascular renal corte0.Se!en cone-shaped renal pyra$ids "or$the renal $edulla deep to the renalcorte8. he renal pyra1ids are alignedith their bases "acing outard toard

the renal corte8 and their ape8es pointinard toard the center o" the idney.

Each ape8 connects to a $inor caly8& as$all hollo tube that collects urine. he$inor calyces $erge to "or$ 5 larger

$aIor calyces& hich "urther $erge to"or$ the hollo renal pel!is at the

center o" the idney. he renal pel!ise8its the idney at the renal hilus& here


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The Nephron

Each idney containsaround / $illion

indi!idual nephrons&the idneys#$icroscopic "unctionalunits that +lter bloodto produce urine. he

nephron is $ade o" 1$ain parts: the renalcorpuscle and therenal tubule.


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Responsible "or +ltering the blood& our renal corpuscle is"or$ed by the capillaries o" the glo$erulus and theglo$erular capsule (also non as Bo$an#s capsule). he glo$erulus is a bundled netor o" capillaries thatincreases the sur"ace area o" blood in contact the blood!essel alls. Surrounding the glo$erulus is the glo$erularcapsule& a cup-shaped double layer o" si$ple sua$ousepitheliu$ ith a hollo space beteen the layers.Special epithelial cells non as podocytes "or$ the layer

o" the glo$erular capsule surrounding the capillaries o"the glo$erulus. Podocytes or ith the endotheliu$ o"the capillaries to "or$ a thin +lter to separate urine "ro$blood passing through the glo$erulus. he outer layer o"the glo$erular capsule holds the urine separated "ro$ the

blood ithin the capsule. Ft the "ar end o" the glo$erularcapsule& opposite the glo$erulus& is the $outh o" therenal tubule.

F series o" tubes called the renal tubule concentrate urineand reco!er non-aste solutes "ro$ the urine. he renal

tubule carries urine "ro$ the glo$erular capsule to therenal el!is.


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he cur!y +rst section o" the renaltubule is non as the pro8i$alcon!oluted tubule. he tubule cellsthat line the pro8i$al con!olutedtubule reabsorb $uch o" the ater andnutrients initially +ltered into the urine.

6rine ne8t passes through the loop o"7enle& a long straight tubule thatcarries urine into the renal $edullabe"ore $aing a hairpin turn and

returning to the renal corte8.4olloing the loop o" 7enle is the distalcon!oluted tubule.

4inally& urine "ro$ the distalcon!oluted tubules o" se!eralnephrons enters the collecting duct&hich carries the concentrated urine

through the renal $edulla and into therenal pel!is.

4ro$ the renal pel!is urine "ro$ $anycollecting ducts co$bines and %osout o" the idneys and into the ureters.


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he $ain "unction o" the idneys is to +lter

ater& i$purities and astes "ro$ the blood. he blood "ro$ the body enters the idneysthrough the renal arteries. Hnce in the idney&the blood passes through the nephrons& here

aste products and e8tra ater are re$o!ed. he clean blood is returned to the body throughthe renal !eins. he aste products +ltered"ro$ the blood are then concentrated into urine.

he urine is collected in the renal pel!is. heureters $o!e the urine to the bladder& here itis stored. 6rine is passed out o" the bladder andthe body through the urethra.


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ater !o1eostasis

he idneys are able to control the !olu$e o" 3ater in the4ody by changing the reabsorption o" ater by the tubules o"the nephron. 6nder nor$al conditions& the tubule cells o" thenephron tubules reabsorb (!ia os$osis) nearly all o" the aterthat is +ltered into urine by the glo$erulus.

ater reabsorption leads to !ery concentrated urine and theconser!ation o" ater in the body. he hor$ones antidiuretichor$one (FD7) and aldosterone both increase thereabsorption o" ater until al$ost /00G o" the ater +lteredby the nephron is returned to the blood. FD7 sti$ulates the

"or$ation o" ater channel proteins in the collecting ducts o"the nephrons that per$it ater to pass "ro$ urine into thetubule cells and on to the blood. Fldosterone "unctions byincreasing the reabsorption o" AaL and Cl- ions& causing $oreater to $o!e into the blood !ia os$osis.


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Acid5)ase !o1eostasis

he idneys regulate the p7 le!el o" the blood by controlling thee8cretion o" hydrogen ions (7L) and bicarbonate ions (7CH5-).7ydrogen ions accu$ulate hen proteins are $etaboli'ed in theli!er and hen carbon dio8ide in the blood reacts ith ater to "or$carbonic acid (71CH5). Carbonic acid is a ea acid that partially

dissociates in ater to "or$ hydrogen ions and bicarbonate ions.Both ions are +ltered out o" the blood in the glo$erulus o" theidney& but the tubule cells lining the nephron selecti!ely reabsorbbicarbonate ions hile lea!ing hydrogen ions as a aste product inurine. he tubule cells $ay also acti!ely secrete additional hydrogenions into the urine hen the blood beco$es e8tre$ely acidic.

he reabsorbed bicarbonate ions enter the bloodstrea$ herethey can neutrali'e hydrogen ions by "or$ing ne $olecules o"carbonic acid. Carbonic acid passing through the capillaries o"the lungs dissociates into carbon dio8ide and ater& alloing us toe8hale the carbon dio8ide.


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)lood ress/re !o1eostasis

he idneys help to control blood pressure in the body by regulating the e8cretiono" sodiu$ ions and ater and by producing the en'y$e renin. Because blood is$ostly $ade o" ater& an increased !olu$e o" ater in the body results in an

increase in the !olu$e o" blood in the blood !essels. ncreased blood !olu$e$eans that the heart has to pu$p harder than usual to push blood into !esselsthat are croded ith e8cess blood. hus& increased blood !olu$e leads toincreased blood pressure. Hn the other hand& hen the body is dehydrated& the!olu$e o" blood and blood pressure decrease.

he idneys are able to control blood pressure by either reabsorbing ater to$aintain blood pressure or by alloing $ore ater than usual to be e8creted intourine and thus reduce blood !olu$e and pressure. Sodiu$ ions in the body help to$anage the body#s os$otic pressure by draing ater toards areas o" highsodiu$ concentration. o loer blood pressure& the idneys can e8crete e8trasodiu$ ions that dra ater out o" the body ith the$. Con!ersely& the idneys$ay reabsorb additional sodiu$ ions to help retain ater in the body.

4inally& the idneys produce the en'y$e renin to pre!ent the body#s bloodpressure "ro$ beco$ing too lo. he idneys rely on a certain a$ount o" bloodpressure to "orce blood plas$a through the capillaries in the glo$erulus. " bloodpressure beco$es too lo& cells o" the idneys release renin into the blood. Reninstarts a co$ple8 process that results in the release o" the hor$one aldosterone bythe adrenal glands. Fldosterone sti$ulates the cells o" the idney to increase theirreabsorption o" sodiu$ and ater to $aintain blood !olu$e and pressure.


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!or1ones

he idneys $aintain a s$all but i$portant endocrine "unction byproducing the hor$ones calcitriol and erythropoietin.

Calcitriol is the acti!e "or$ o" !ita$in D in the body. ubulecells o" the pro8i$al con!oluted tubule produce calcitriol "ro$inacti!e !ita$in D $olecules. Ft that point& calcitriol tra!els

"ro$ the idneys through the bloodstrea$ to the intestines&here it increases the absorption o" calciu$ "ro$ "ood in theintestinal lu$en.

Erythropoietin (EPO) is a hor$one produced by cells o" theperitubular capillaries in response to hypo8ia (a lo le!el o"

o8ygen in the blood). EPH sti$ulates the cells o" red bone$arro to increase their output o" red blood cells. H8ygenle!els in the blood increase as $ore red blood cells $ature andenter the bloodstrea$. Hnce o8ygen le!els return to nor$al&the cells o" the peritubular capillaries stop producing EPH.


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AT!O!%$IO#OG%

http://var/www/apps/conversion/tmp/scratch_4/PATHOPHYSIOLOGY.docxhttp://var/www/apps/conversion/tmp/scratch_4/PATHOPHYSIOLOGY.docx


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#A)ORATOR% RE$U#T$

COMONENT RE$U#T$NORMA#

&A#UE$

ANA#%$I$

R)C 1.; ?.,-,.1 8 /0.? /5.,-/;.,gd9 Decreased

!e1atocrit 1,.;G ?0-,1G Decreased

)C


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COMONENT RE$U#T$ NORMA#

&A#UE$

ANA#%$I$

)UN ,; ;-/>$gd9 ndicates renal proble$

Creatinine 51 0.;-/.5$gd9 ndicates renal proble$

he B6A and Creatinine ere belo their nor$al range thusshoing inability o" the idney to e8crete nitrogenous aste.


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COMONENT RE$U#T$ NORMA# &A#UE$

ANA#%$I$

R)C 1.? ?.,-,.1 8 /00$l.


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COMONENT RE$U#T$ NORMA# &A#UE$ ANA#%$I$

Creatinine /5 0.;-/.5$gd9 ndicates renal

proble$

he Creatinine as belo nor$al range thus shoing inability o" theidney to e8crete nitrogenous aste.


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COUR$E IN T!E ARD

he patient arri!ed in the dialysis unit at around ;a$. he patient as ell-groo$ed. 7e had a pre-7D eighto" ,?.,g. 7e as cal$& cooperati!e& and hadspontaneous speech throughout the inter!ie.7oe!er& hen discussing sel" perception-sel" concept

pattern& the patient displayed beha!ior suggesti!e o"altered sel"-concept such as a!oidance o" eye contactduring such discussion& and speaing in aninappropriate aect. 7is !ital signs throughout the

dialysis period ere as "ollos: BP: /=0-/>0/00-//0$$7g& PR: >,-


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DRUG $TUD% DRUG

NAME

MoA INDICATION CONTRAINDICATION $IDEE""ECT$

INTER&ENTION$

Clonidine

-Antihypertens

ive

Clonidine

sti$ulatesalpha-

1receptors in

brainste$

hich results

in reduced

sy$pathetic

out%o "ro$

the CAS and

a decreasein peripheral

resistance

leading to

reduced BP

and pulse

rate. t does

not alter

nor$alhe$odyna$i

c response

to e8ercise

at

reco$$ende

d dosages.

7ypertensio

n& usedalone or as

part o"

co$bination

therapy.

7ypersensiti!ity.

Disorders o" cardiacpace$aer acti!ity

and conduction.

Pregnancy and

lactation.

dry $outh&

drosiness&di''iness&

irritability&

$ood

changes& sleep

proble$s

(inso$nia or

night$ares)&

headache& earpain& "e!er&

"eeling hot&

constipation&

diarrhea&

sto$ach pain&

increased

thirst&

decreaselibido&

i$potence&

cold sy$pto$s

such as runny

or stuy nose&

snee'ing&

cough& or sore

throat

FRAA3:

Do not discontinueabruptly discontinue

therapy by reducing the

dosage gradually o!er

1K? days to a!oid

rebound hypertension&

tachycardia& %ushing&

nausea& !o$iting&

cardiac arrhyth$ias

(hypertensi!eencephalopathy and

death ha!e occurred

a"ter abrupt cessation

o" clonidine).

Do not discontinue

transder$al therapy

prior to surgery$onitor BP care"ully

during surgery ha!e

other BP-controlling

drugs readily a!ailable.

Continue oral clonidine

therapy ithin ?hr. o"

surgery then resu$e as

soon as possibletherea"ter.


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DRUGNAME

Mechanis1o6 Action

INDICATION CONTRAINDICATION

$IDEE""ECT$

INTER&ENTION$

F$lodipine

-Calciu$Channelblocer

F$lodipinedecreasesarterial s$ooth

$usclecontractilityandsubseuent!asoconstriction by inhibitingthe in%u8 o"calciu$ ionsthrough

calciu$channels.nhibition o"

the initial in%u8o" calciu$decreases thecontractileacti!ity o"arterial s$ooth

$uscle cellsand results in!asodilation.

he!asodilatoryeects o"a$lodipineresult in ano!erall

decrease inblood pressure.

reat$ent "orhypertension orin co$bination

ith otherantihypertensi!es.

7ypersensiti!ity to the drug.

Blood pressureless than


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DRUG

NAME

MoA INDICATION CONTRAINDICATION $IDE

E""ECT$

INTER&ENTION$

T3ynsta

ynstacontains aco$binationo"F$lodipine

and el$isartan.F$lodipineis a calciu$channelblocer.F$lodipinerela8es(idens)

blood!essels andi$pro!esblood %o.

el$isartanis anangiotensin receptor

antagonist. el$isartaneeps blood!essels "ro$narroing&hich loersbloodpressure andi$pro!es

blood %o.

his product

is used to

treat

hypertension.

hese

$edications

are used

together

hen one

drug is notcontrolling

the blood

pressure. he

doctor $ay

direct the

patient to

start taingthe indi!idual

$edications

+rst& and

then sitch

to this

co$bination

product i" it is

the best dose

7ypersensiti!ity to

F$lodipine and

el$isartan.

Chec ith thephysician +rst i" thepatient has any o"the "olloing:Se!ere Aarroing o"the Fortic 7eartNal!e& Renal FrteryStenosis& Fbnor$ally9o Blood Pressure&9i!er Proble$s&Se!ere 9i!er Disease&idney Disease&Pregnancy&Decreased BloodNolu$e& E8tre$e

9oss o" Body ater&7igh F$ount o"Potassiu$ in theBlood.

Signs o" an

allergic

reaction to

ynsta: hi!es

diOculty

breathingselling o"

your "ace&

lips& tongue&

or throat.

Co$$on

ynsta side

eects $ayinclude:

selling in the

hands or "eet&

"ast

heartbeats&

di''iness&

drosiness&

tired "eeling

%ushing

(ar$th&

redness& or

tingly "eeling)

bac pain or

nausea&

diarrhea&

sto$achpain.

Chec blood

pressure be"ore

and a"ter gi!ing

the drug.

nstruct patient to

a!oid getting up

too "ast "ro$ a

sitting or lying

position& or he

$ay "eel di''y.


43/63

DRUG

NAMEMoA INDICATION CONTRAINDICATION $IDE

E""ECT$

INTER&ENTION$

Terra6err

on

-&it7 and

1inerals

s/pple1e

nt8

Antiane1i

c

Consists o"

4olic Fcid&

ron (4errousSul"ate)&Nita

$in

B/&Nita$in

B/1&Nita$in

B1&Nita$in

B5&

Nita$in B=&

Nita$in C.

Sti$ulates

the

he$atopoieti

c syste$.

Pre!ention

and

treat$ento" iron

de+ciency

ane$ia.

hro$boe$bolis$&

erythre$ia&

erythrocytosis&increased sensiti!ity

to cyanocobala$in.

Aausea

No$iting

Fllergic

reaction:

6rticaria.

Drin ith

orange Iuice to

i$pro!eabsorption and

to $ini$i'e

nausea.

Do not tae ith

$il& tea or

coee.


44/63

DRUG

NAME

MoA INDICATION CONTRAINDICATION $IDEE""ECT$

INTER&ENTION$

Clopidogr

el

-

antiplatelet

nhibits

platelet

acti!ation

andaggregati

on

through

the

irre!ersibl

e binding

o" its

acti!e$etabolit

e to FDP

receptors

on

platelets.

4or pre!ention

or treat$ent

o" stroe and

heart attac.

7ypersensiti!ity&

Peptic ulcer or

intracranial

he$orrhage.

6se cautiously ith

bleeding disorders&

recent surgery& renal

or hepatic

i$pair$ent&

pregnancy.

Di''iness&

easy

bruising& 3

upset&headache.

Fd!erse

eects:

Rash& DHB&

chest

tightness&

con"usion&tarry stool.

2onitor blood

pressure.

Pro!ide co$"ort

$easures andarrange "or

analgesics i"

headache occurs.

Pro!ide s$all&

"reuent $eals i" 3

upset occurs.


45/63

DRUG NAME MoA INDICATION CONTRAINDICATION $IDE

E""ECT$

INTER&ENTION$

Montel/9as

t :

#evocitiri;ine

Binds to

cysteinyl

leuotrien

e type /

(Cys9 / )

receptor

in the

upper and

loer

airays to

pre!entleuotrien

e-

$ediated

eects

associated

ith

allergic

rhinitis.

Prophyla8is

or

treat$ento" allergic

reactions

such as

chronic

urticaria&

obstructi!e

airaydiseases

and rhinitis.

7ypersensiti!ity&

patients ith

hepatici$pair$ent.

Aausea&

dry $outh&

drosiness

&

dyspepsia&

headache.

Fd!ise patients that

$onteluast can be

taen ithout

regard to $eals but

to tae it ith "ood

i" sto$ach upset

occurs.

Fd!ise patients ith

non aspirin

sensiti!ity to

continue a!oidanceo" aspirin and

ASFDs hile taing

the drug.


46/63

DRUG

NAMEMoA INDICATION CONTRAINDICATION $IDE

E""ECT$

INTER&ENTION$

Ni6edipin

e

-calci/1

channel

4loc9er

Decreases

arterial

s$ooth$uscle

contractility

and

subseuent

!asoconstricti

on by

inhibiting the

in%u8 o"calciu$ ions

through

calciu$

channels.

4or treat$ent

o"

hypertension.

7ypersensiti!ity to the

drug& CFD& history o"

heart attac.

Di''iness&

urticaria&

%ushing&tre$ors&

nausea&

heartburn.

2onitor BP

care"ully during

titration period.Patient $ay

beco$e se!erely

hypotensi!e&

especially i" also

taing other drugs

non to loer BP.

ithhold drug and

noti"y physician i"systolic BP @


47/63


E""ECT$

INTER&ENTION$

N-

Acetylcystein

e

-1/colytic

E8erts its

$ucolytic

action

through

its "ree

sul"hydryl

group&

hich

reduces

the

disul+de

bonds in

the

$ucus

$atri8

and

loers

$ucus

!iscosity.

ndicated as

adIu!ant

therapy "or

patients ith

abnor$al&

!iscous or

thic

secretions.

Drug hypersensiti!ity Aausea&

!o$iting&

hypotension

& diarrhea or

constipation

.

2onitor patient#s NS

especially RR and

7R.


48/63

DRUG

NAME

MoA INDICATION CONTRAINDICATIO

N

$IDE E""ECT$ INTER&ENTION$

CaCO<

-phosphat

e 4inder

-dietary

s/pple1e

nt

Fs dietarysupple$ent&used to

pre!ent ortreatnegati!ecalciu$balance inosteoporosis& it helps topre!ent ordecrease

the rate o"bone loss.

Phosphatebinder:Binds ithdietaryphosphateto "or$

insolublecalciu$phosphate&hich ise8creted in"eces.

6sed "or the

treat$ent o"

hyperphosphate$

ia& nor$ali'ing

phosphate

concentrations in

patients ith CD.

t can also be

used as a calciu$

supple$ent in

these patients.

7ypersensiti!ity&

patients ith

hypercalce$ia&

and

hypophate$ia.

Aausea&

%atulence&

constipation&

8erosto$ia&

!o$iting.

2onitor seru$

calciu$ and

phosphate le!els.

Should be gi!en

ith $eals to

increase

absorption. 2ay

decrease iron

absorption& so

should bead$inistered /-1

hours be"ore or

a"ter iron

supple$entation

li$it intae o"

ith bran& "oods

high in o8alates

or hole graincereals hich

$ay decrease

calciu$

absorption.


49/63

DRUG

NAME

MoA INDICATION CONTRAINDICATION $IDE

E""ECT$

INTER&ENTION$

"e$O=

-iron

s/pple1ent

Ele!ates

seru$ iron

concentratio

n hich thenhelps to "or$

7igh or

trapped in

the reticulo-

endothelial

cells "or

storage and

e!entualcon!ersion to

a usable

"or$ o" iron.

6sed to treat

iron de+ciency

ane$ia.

7ypersensiti!ity&

se!ere hypotension.

Aausea&

!o$iting&

di''iness.

Fd!ise patient to

tae $edicine as

prescribed.

Caution patient to$ae position

changes sloly to

$ini$i'e orthostatic

hypotension.


50/63


E""ECT$

INTER&ENTION$

$odi/1

)icar4onate

Sodiu$

Bicarbo

nate

acts asan

alalini

'ing

agent

by

releasin

g

bicarbonate

ions.

6sed "or the

treat$ent o"

$etabolic

acidosishich $ay

occur in

se!ere renal

disease

2etabolic or respi.

alalosis&

hypocalce$ia&

hypo!entilation& andhypersensiti!ity to

drug.

7eadache&

anore8ia&

unpleasant

taste& tired"eeling&

nausea&

andor

!o$iting.

2onitor urinary p7

and urine output as

guide "or dosing.

2onitor patients NS

especially RR and

7R.


51/63


E""ECT$

INTER&ENTION$

!ydro0i;ine

-antihista1ine

7ydro8y'ine

reduces

acti!ity inthe central

ner!ous

syste$. t

also acts as

an

antihista$in

e that

reduces thenatural

che$ical

hista$ine in

the body.

Co$$only

used to treat

pruritus inpatients ith

ESRD.

7ypersensiti!ity&

glauco$a&

Dry $outh&

drosiness&

nausea&hypotensio

n.

Fssess patient#s

alertness.

nstruct patient notto drin alcohol.

nstruct patient to

increase %uid

intae.


52/63

A$$E$$MENT DIAGNO$I$ #ANNING INTER&ENTION$

O4>ective data'

Crea'


53/63

$/4>ective data'

HUsahay ra9o

1a9aihi nya

ginag1ay ra

/sahay 1/ t/lo ra

gy/d7 ag 1/9aon

9o /g parat1angh/pong

dayon a9ong tiil7

O4>ective data'

resence o6

peripheral

ede1a grade

B Distended

a4do1en

/y 6ace

Olig/ria

:crac9les in

the l/ngs

Crea'


54/63


O4>ective data'

peripheral

ede1a

grade B

Distendeda4do1en

/y 6ace

"reJ/ent

scratching o6

the ar1s7

I1paired s9in

integrity rt

ede$a and

pruritus FEBperipheral

ede$a&

distended

abdo$en&

"reuent

scratching on the

ar$s& puy "ace.

Short er$: F"ter ?

hours o" nurse-patient

interaction& the patient

ill establish beha!iorsto pre!ent sin

da$age.

9ong er$: he patient

ill $aintain intact

sin.

- nspect patient#s sin "or changes in

color& turgor& !ascularity.

- Fssess patient#s peripheral ede$a&ele!ate legs to pro$otes !enous

return& li$iting ede$a "or$ation.

- Pro!ide soothing sin care to

patient& applying oint$ent or crea$

to relie!e dry and craced sin.

- eep bedchair linen dry andrinle-"ree to reduce sin irritation.

- Reco$$end patient to use cool&

$oist co$presses to apply pressure

rather than scratch pruritic areas to

pre!ent sin inIury.

- nstruct patient to eep +ngernailsshort.



55/63

$/4>ective data'

HM/9aon gihapon

9og 1ga parat

9ay nag dialysis

na 4ita3 9o para

1a p/slan /nya

1ao ra gihapon

1a1atay ra1an

gihapon7 as

ver4ali;ed 4y the

patient7

DeKcient

9no3ledge rt

in"or$ation

$isinterpretatio

n about dialysis

therapy.

Short er$

ithin ? hours o" nursing

inter!entions& the

patient ill !erbali'e

understanding o"

condition and potential

co$plications.

9ong er$

he patient ill initiate

necessary li"estylechanges.

- Re!ie disease process and prognosis

and "uture e8pectations. his pro!ides

noledge base "ro$ hich patient

can $ae in"or$ed choices.- Re!ie patient#s diet and %uid

restriction as prescribed and e8plain to

the patient the ad!antage o" eating

the ordered diet.

- Educate patient that he$odialysis

treat$ent does not $ean he can eathate!er he lies. he pt. does not

recei!e dialysis treat$ent daily so he

needs to be care"ul o" hat he eats to

pre!ent co$plication such as li"e-

threatening ure$ia.

- n"or$ patient that eating therestricted diet can "urther increase the

patient#s blood pressure& and can also

precipitate bone pains and ede$a.

DIAGNO$I$ #ANNING INTER&ENTION$


56/63

DIAGNO$I$ #ANNING INTER&ENTION$Ris9 6or In>/ry

r5t in6ection7

ithin ? hours o" nursing

inter!entions& the patient ill

ha!e patent !ascular access

and be "ree o" in"ection.

- 2onitor internal FN shunt patency at "reuent

inter!als. Palpate sin around shunt "or ar$th.

Di$inished blood %o results in coolness o"

shunt.

- Palpate "or distal thrill. hrill is caused by

turbulence o" high-pressure arterial blood %o

entering lo-pressure !enous syste$ and should

be palpable abo!e !enous e8it site.

- Aote color o" blood andor ob!ious separation o"

cells and seru$. Change o" color "ro$ uni"or$

$ediu$ red to dar purplish red suggests

sluggish blood %o andor early clotting.

Separation in tubing is indicati!e o" clotting. Nery

dar reddish-blac blood ne8t to clear yello %uid

indicates "ull clot "or$ation.

- F!oid trau$a to shunt by handling tubing gently&

$aintaining cannula align$ent. Aot taing BP or

draing blood sa$ples in shunt e8tre$ity. o

decrease ris o" clotting or disconnection.

- nstruct patient not to sleep on side ith shunt or

carry pacages& boos& purse on aected

e8tre$ity.

Fd$inister lo-dose o" 7eparin i" indicated to

A$$E$$MENT DIAGNO$I$ #ANNING INTER&ENTION$ Ris "or


57/63

O4>ective' L6atig/eLpale 1/co/s1e14ranesLpallor general

appearance R)C' 27=!g4' 7!ct' 2


58/63

DI$C!ARGE #AN


59/63

DI$C!ARGE #AN

nstruct patient to strictly tae $edicines as directedand to $ae a list o" the $edicines& !ita$ins& andherbs that the patient is taing& including the a$ounts&hen and hy the patient tae the$. nstruct also thepatient to bring the list to "ollo-up !isits. 2edicine list

should be carry by the patient in case o" an e$ergency. nstruct patient to eigh sel" daily& "olloing the goal

eight ordered by his physician. n!ol!e and assist patient in $aing his e8ercise plan

as directed. Regular e8ercise can help the patient

$anage high blood pressure. Strongly ad!ise patient to uit s$oing and a!oid

drining alcohol. Fd!ice patient to a!oid stress related "actors and ha!e

adeuate rest.


60/63

each the patient to properly care his FN4 or FN3 by"olloing these steps:

Clean the sin o!er the +stula or gra"t e!ery day ith soap and

ater. ae the bandage o the +stula or gra"t ? to = hours a"ter dialysis.

Chec the +stula or gra"t e!ery day "or good blood %o bytouching it ith +ngertips. he bu''ing sensation $eans that it isoring.

Chec "or bleeding& pain& redness& or selling. hese $ay be signs

o" in"ection or a clogged +stula or gra"t. o pre!ent da$age to the +stula or gra"t& no one should tae

blood pressure or dra blood "ro$ the ar$ ith the +stula orgra"t.

Should not ear tight-+tting shirts& Ieelry (such as bracelets)that $ay restrict blood %o on the access ar$.

$aing sure the straps or handles don#t tighten around the +stulahen carrying things (groceries& bags& luggage)&

2aing sure that the patient#s body& pillo or cushion doesn#t reston the ar$ ith +stula hen sitting or sleeping&


61/63

nstruct patient to as his doctor i" he need

!accines. n"ections such as pneu$onia&in%uen'a& and hepatitis can be $ore har$"ulor $ore liely to occur hen a person ha!eCD. Naccines reduce the ris o" in"ection ith

these !iruses. nstruct patient to "ollo up chec-up regularly

ith his physician as directed. nstruct patient to eat "oods directed by his

doctor. 7is doctor $ay ad!ise hi$ to eat "oodlo in sodiu$& potassiu$& phosphorus& orprotein. he patient $ay need to see adietitian i" he needs help planning $eals.


62/63

nstruct patient to discuss ith hisphysician regarding ho $uch %uid hehas to drin e!ery day and hat %uidsthe patient can and cannot drin.

Encourage patient to suc on hard candyor che gu$ to help eep $outh $oistithout ha!ing to drin liuids.

nstruct patient to see $edical attentioni$$ediately i" the sin around the +stulaor gra"t is pain"ul& hot& red& or sollen.

REA#IATION


63/63

REA#IATION

7igh blood pressure can aect the idneys and can

cause renal da$age. End-Stage Renal Disease brings $any co$plications

to the body that causes the patient to suer. Renal disease is a progressi!e disease and is

asy$pto$atic at +rst renal "ailure can be pre!entedthru regular chec-up and early inter!ention.

7a!ing an ESRD is costly& hassle& and boring youha!e to spend $oney and ?-,hr. o" your ti$e perdialysis session "or the rest o" your li"e. Jou ha!e to

$ae changes such as $odi"ying your li"estyle anddiet to a!oid co$plications.

Jou ill ha!e an altered body i$age.

end stage renal disease 2o hypertensive nephrosclerosis

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