final ppt of grand case presentation about ckd

Chronic Kidney Disease

Objectives

Biographic data

Name: A. B.

Age: 30

Gender: Female

Status: Single

Religion: Catholic

Citizenship: Filipino

Date of Birth: June 16th 1978

Address: Pasay City

Date of Admission: November 1st 2007

Readmitted on January 18th 2009

Present History of Illness

One day PTA, January 17th, when patient had failed to submit herself for regular hemodialysis session (three days post last hemodialysis) because of financial constraints, she experienced an increased severity of difficulty in breathing accompanied by non-productive cough, chills and fever. Prompt hospital-ER consult, hence admission.

Past Medical History

No known allergies.

Not a known diabetic but diagnosed as hypertensive for about five years and is taking telmisartan 80mg OD and metoprolol 100mg OD as maintenance.

Completely immunized.

She had chicken pox when she was seven.

Had frequent episodes of sore throat since childhood (at least 3 times a year) without seeking medical advice.

On November 1, 2007, she was brought to the ER of San Juan de Dios hospital due to difficulty in breathing.

Diagnosis was CKD stage five thence, she had undergone immediate hemodialysis using a temporary Mahurkar catheter via right subclavian vein approach.

She was admitted and stayed there for two weeks.

December 4, 2007, an arteriovenous fistula was made on her left wrist and she has been undergoing hemodialysis twice a week from then on, Wednesdays and Saturdays.

Obstetrics and Gynecological History

Menarche at twelve.

LMP was last December 14th 2008.

Nulligravida.

Family History of Illness

Has no familial history of Diabetes Mellitus, hypertension, cancer, Tuberculosis and asthma.

Her father died at the age of 48 due to chronic kidney disease stage III .

Psychosocial History

Patient is a 30-year old office worker in a sales company in Alabang since 2003.

Non-smoker, occasional alcoholic beverage drinker, consuming 3-4 bottles at least four times a year.

With preference on taking in soda (four 8 ounce-bottles per day) and consuming only at least 4 half glasses of water per day.

She is third in a brood of four in the family.

Hobbies include shopping and net surfing; and when faced with stress, considers sleep.

Activities of Daily Living

Activity Before hospitalization During hospitalization Analysis

Fluids and nutrition

Pre hemodialysis

Drinks alcoholic beverages occasionally at 3 to 4 bottles four times a year. She eats 2 full meals per day (skips either breakfast or dinner). For breakfast she usually haves bread and water.

Lunch – usually fast food consisting of deep fried dishes

Snacks – junk food (chips) and soda, approximately 4 8-ounce bottles per day

Drinks 4 half-glasses of water daily

Dinner - often skipped

The patient’s fluids are partly supplied intravenously: 0.9 NaCl 500cc running at 10cc/hr. Her diet was maintained to low salt, low protein, low potassium. She eats 3 times per day but in small amounts because of poor appetite. The patient drinks a maximum of four glasses of water a day.

IV fluids are given for hydration. She eats twice a day. Pre hemodialysis, the patient frequently skips one meal due to lack of time because of office work. During hospitalization the patient had a diet restriction (low salt, low protein and low potassium). This was the diet ordered by the doctor since high levels of these three worsen the client’s condition.


During hemodialysis

Eats 3 full meals of low salt, low protein and low potassium on free days, Wednesdays and Saturdays, which are HD sessions

Ceased eating junk food and drinking soda and alcoholic beverages

Drinks approximately four half glasses of water daily


Elimination

Pre hemodialysis

The patient usually voids 4 – 6 times a day and defecates regularly at least once a day.

During hemodialysis

Voids two to four times per day and defecates regularly.

The patient voids two to four times a day, approximately 240cc, and defecates regularly.

Less urine output due to inability of the kidneys to concentrate urine because of the disease process.

Rest and sleep

The patient has an average of 6 hours of continuous sleep.

The patient now has an irregular pattern of sleep.

Interrupted sleep during hospitalization because of environmental factors and hospital procedures.

Exercise The patient prefers walking when going to work.

Exercises through short sitting and standing ups.

Easy fatigability because of lack of oxygenation

Hygiene Takes a full bath once daily and brushes thrice.

Does partial baths and brushes thrice daily.

Because fatigue is a likely problem.

Physical Assessment

ASSESSMENT TECHNIQUE

USEDNORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

GCS: 15(M6V5E4)VITAL SIGNS:

T: 36.8PR: 76RR: 33

BP: 180/100WT: 50kg

BEFORE DIALYSIS: 40.5kgAFTER DIALYSIS: 40.2kgHT: 5 feet and 2 inches

ASSESSMENT TECHNIQUE USED

NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

A) GENERAL SURVEY

Body build, height and weight in relation to client’s age

Client’s posture and gait, standing, sitting, and walking

Overall hygiene and grooming

Body and breath odor

Inspection

Inspection

Inspection

Inspection

Proportionate

Relaxed, erect posture, coordinated movement

Neat and clean

No body/minor body odor; no breath odor

Underweight (BMI of 16.12)(Normal – 20-25)

Relaxed, erect posture, coordinated movement

Neat and clean

No body/minor body odor; no breath odor

Due to protein – energy malnutrition

and effects of wasting

Normal

Normal

Normal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

Obvious signs of health or illness

Client’s attitude

Client’s mood;assess theappropriatenes

s ofthe client’s

response

Quality, quantity and

organization ofspeech

Inspection

Inspection

Inspection

Inspection

Healthy appearance

Cooperative

Appropriate to situation

Understandable; exhibit thought association

Pallor, weakness, obvious illness

Cooperative

Appropriate to situation

Understandable; exhibit thought association

Inadequate circulating blood or Hgb and subsequent reduction in tissue oxygenation and decreased metabolic energy production and dietary restrictions

Normal

Normal

Normal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

Relevance and organization of thoughts

Inspection Logical sequence Logical sequence Normal

B) SKINSkin color Uniformity of skin

color

Assess edema

Observe and palpate skin moisture

Skin temperature

Inspection

Inspection Inspection

Inspection

Palpation

Varies to light – deep brown Generally uniform except in areas exposed to sun No edema

Moisture in skin folds and the axillae

Uniform; within normal range

Sallow (grayish – bronze)

Areas that have Sallow (grayish – bronze) With edema @ R hand , IV site (edema scale 1+, barely detectable)

Generalized drynessof the skin

Uniform; within normal range

Impaired excretion of urinary pigments (urochromes) as well as the presence of anemia due to lack of erythropoetin being produced

Due to water retention and increase permeability of membrane that results from shifting of fluids

Decrease in hydration that affects circulation and tissue integrity at the cellular level

Normal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

Skin turgor

Inspect, palpate and describe skin lesions

Inspection

Inspection

When pinched, skin springs back to previous state

No abrasions/lesionsBirthmarks, freckles

When pinched, skin springs back to previous state

Presence of stitches and incision scars on wrist (with AVF), wheal and punctured wound

Normal

The incision is due to insertion of arteriovenous fistula at the wrist, a wheal from skin test and punctured wound by a syringe to collect specimen (CBC)

C) HAIREvenness of growth over

the scalpThickness or thinness of

hairTexture & oilinessPresence of infections or

infestations

Inspection

Inspection

InspectionInspection

Evenly distributed

Thick hair

Silky and resilient hairNo infection or infestation

Evenly distributed

Thick hair

Silky and resilient hairNo infection or infestation

Normal

Normal

NormalNormal

D) NAILSFingernail plate shapeTexture

Nail bed color

Tissues surrounding nails

Allen’s test

InspectionInspection

Inspection

Inspection

inspection

Convex curvatureSmooth

Highly vascular, pink

Intact epidermis

Prompt return

Convex curvatureSmooth

Pallor

Intact epidermis

Weak return (approx w/in 4 sec)

NormalNormal

Circulatory impairment due to decreased erytropoietin

Normal

Circulatory impairment

ASSESSMENT TECHNIQUE

USEDNORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

E) HEADSize, shape and

symmetryPresence of nodules,

masses or depressions in the skull

Facial features

Inspect the eyes for edema and hollowness

Symmetry of facial movements

Inspection Palpation


Inspection

Inspection

Inspection

Rounded, smooth skull contourAbsence of nodules and masses

Symmetric/ slightly asymmetric

No edema and hollowness noted

Symmetric facial movements

Rounded, smooth skull contourAbsence of nodules and masses

Symmetric/ slightly asymmetric

Periorbital edema at OU

Symmetric facial movements

normal

normal

Normal

Due to fluid retention, increases permeability of membrane that results from shifting of fluidsNormal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

F) EYESInspect for eyebrows

for hair distribution and alignment and skin quality and movement

Inspect eyelids for surface characteristics (skin quality & texture)

Bulbar conjunctiva

Palpebral conjunctiva

Inspection

Inspection

Inspection

Inspection

Hair evenly distributed; intact skin

Skin intact; no discharge noted; no discoloration

Transparent capillaries; sclera appears white

shiny, smooth and pink or red in color

Hair evenly distributed; intact skin

Skin intact; no discharge noted; no discoloration

Yellowish in color (icteric sclera)

Extremely pale

Normal

Normal

Due to retention of nitrogenous wastes which causes secondary hemolysis of RBC’s thus increasing the blood levels of bilirubin

due to decrease erythropoietin production; Inadequate circulating blood or Hgb (9.5mm) and subsequent reduction in tissue oxygenation.


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

Pupils color, shape and symmetry of size

Pupil’s direct and consensual and reaction to light

Reaction to accommodation

Inspection

Inspection

inspection

Black in color, equal size, normally 3 -7mm in diameter, round smoothIlluminated pupil constricts (direct)Nonilluminated pupil constricts (consensual)Pupils constrict when looking at near objects; dilate when looking at far objects; pupils converge when near objects is moved toward nose

Black in color, equal size, normally 3 -7mm in diameter, round smoothIlluminated pupil constricts (direct)Nonilluminated pupil constricts (consensual)Pupils constrict when looking at near objects; dilate when looking at far objects; pupils converge when near objects is moved toward nose

Normal

Normal

Normal

G) EARSAuricles (color,

symmetry, and position)

Client’s response to normal voice tones

Inspection

Inspection

Color same as facial skin; symmetrical; aligned with outer canthus of eye

Normal voice tone audible

Grayish-bronze color (sallow); symmetrical; aligned with outer canthus of eye

normal voice tone audible


normal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

H) NOSEDeviations in shape, size,

color and presence of flaring/discharge from nares

Presence of tenderness, masses and displacements of bone and cartilage

Patency of both nasal cavities

Inspection

Palpation

Inspection

Symmetric, straight, no discharge/flaringUniform color

Absence of lesion/tenderness

Air moves freely as the client breathes

Symmetric, straight, no discharge/flaring; grayish – bronze color (sallow)

Absence of lesion/tenderness

Air moves freely as the client breathes


Normal

Normal

I) MOUTHOuter and inner lips for

symmetry of contour, color and texture

Condition of teeth

Position of tongue, presence of lesion

Sense of taste

Inspection

Inspection

Inspection

inspection

Uniform pink in color; moist, smooth texture

Teeth is smooth, white in color

Central position; no lesionNormal taste

Pallor, fissures and dryness

Teeth is smooth, white in colorCentral position; no lesion

Presence of metallic/salty taste as stated by the patient

Due to excessive dryness, decrease hydration and impaired circulation

Normal

Normal

Breakdown of urea to ammonia in saliva

J) NECKNeck muscles for

abnormal swelling or masses

Enlargement of lymph nodes

Palpation

Palpation

Muscle equal in size; head centered

Lymph node not palpable

Muscle equal in size; head centered

Lymph node not palpable

NormalNormal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

K) THORAX AND LUNGS

Breathing patterns

Adventitious breath sounds

Auscultation

Auscultation

Full and symmetric chest expansion, quiet, rhythmic and effortless breathing

Absence of adventitious sounds

With slight evidence of substernal retraction during respiration Presence of rales

Due to compression of lungs caused by accumulation of fluids

Increased fluid volume

L) HEARTAbnormal pulsation, lifts

and heaves

Distention of jugular veins

Peripheral perfusion

InspectionPalpation

Palpation

InspectionPalpation

No pulsation, lift and heaves; symmetric pulse volumesJugular vein is not visible

Skin color pink, temperature not excessively warm or cold

No pulsation, lift and heaves; symmetric pulse volumesJugular vein is not visible

Skin color is grayish – bronze (sallow), temperature within normal range

Normal

Normal

Deposition of pigmented metabolites or urochromes or urea itself

M) ABDOMENSkin integrity, color,

contour and symmetry

Bladder retention

InspectionPalpation

Palpation

Unblemished skin, uniform in color, no evidence of enlargement of liver or spleen, flat rounded or scaphoid

Bladder not palpable

Unblemished skin, grayish – bronze in color (sallow), no evidence of enlargement of liver or spleen, has rounded abdomenBladder is non-palpable at time of assessment

Deposition of pigmented metabolites or urochromes or urea itself

normal


NORMAL FINDINGS

ACTUAL FINDINGS

SIGNIFICANCE

A) EXTREMITIESUpper

Lower


InspectionPalpation

Equal in size, no deformities, no tenderness, swelling and edema

Equal in size, no deformities, no tenderness, swelling and edema

R hand, edema noted , wheal and punctured wound (1+ barely detectable)L hand, with arteriovenous fistula @ wrist with palpable strong thrill and bruits present

No tenderness, swelling, edema formation; no lesions; equal in size. Dry skin.

Due to water retention and increase permeability of membrane that results from shifting of fluids from intravascular and interstitial compartments

Decrease in hydration that affects circulation and tissue integrity at the cellular level

Anatomy and Physiology

The KidneysLocated at the right and left lumbar area

Responsible for the regulation of acid-base and electrolyte balance through excretion of nitrogenous waste.

Functions of the Urinary System

• Excretion

• Blood volume control

• Ion concentration regulation

• pH regulation

• Red blood cell concentration

• Vitamin D synthesis

Pathophysiology

LINK

Chronic GlomerulonephritisChronic Glomerulonephritis

Ischaemia, Nephron loss, Shrinkage of Kidney

Ischaemia, Nephron loss, Shrinkage of Kidney

Repeated InflammationRepeated Inflammation

Non-modifiable Risk Factors:

•Age

•Gender

•Heredity

Non-modifiable Risk Factors:

•Age

•Gender

•Heredity

Modifiable Risk Factors:

• Diet• Sedentary

Lifestyle• Nephrotoxins

Modifiable Risk Factors:

• Diet• Sedentary

Lifestyle• Nephrotoxins

Renal Blood Flow Renal Blood Flow

Renal Reserve Renal Reserve

Damage to NephronsDamage to Nephrons

Remaining nephrons must filter more solute particles from the blood

Remaining nephrons must filter more solute particles from the blood

As nephrons are destroyed, the remaining nephrons undergo changes to compensate for those that are lost

As nephrons are destroyed, the remaining nephrons undergo changes to compensate for those that are lost

GFR 50%

Normal BUN, Creatinine

Renal InsufficiencyRenal Insufficiency

More than 75% damageMore than 75% damage

50% damage50% damage

GFR 20-50%

BUN, Creatinine

Stage 2

Stage 2

Stage 3

Stage 3

Stage 1

Stage 1

Hypertrophy of remaining nephronsHypertrophy of remaining nephrons

Impaired kidney function & UremiaImpaired kidney function & Uremia

Renal FailureRenal Failure

80-90% damage80-90% damage

Further damage of nephronsFurther damage of nephrons

Nephrons cannot tolerate the workNephrons cannot tolerate the work

GFR 10-20%

Sharp BUN, Creatinine

GlucosuriaGlucosuria

Retention of wastesRetention of wastes

Cells become resistant to

insulin

Cells become resistant to

insulin

Phosphate retentionPhosphate retention

HyperphosphatemiaHyperphosphatemia

Ca+

absorption Ca+

absorption

Hypo-calcemia

Hypo-calcemia

AnemiaAnemia

Erythropoietin production Erythropoietin production

FatigueWeaknessPallor

FatigueWeaknessPallor

HCO3 production in kidney

HCO3 production in kidney

HyperkalemiaHyperkalemia

K+ retentionK+ retention

Metabolic AcidosisMetabolic Acidosis

OliguriaOliguria

Urine Output Urine Output

Na & H2O retentionNa & H2O retention

Blood volume Blood volume

EdemaEdema

Pulmonary Edema

Peripheral Edema

Pulmonary Edema

Peripheral Edema

BP BPHeart FailureHeart Failure

Stage 4

Stage 4

> 90% kidney damage> 90% kidney damage

End Stage Renal Dse. (ESRD)End Stage Renal Dse. (ESRD)

Lungs CompensatesLungs Compensates

Stage 5Stage 5

Dialysis

• Remove fluid and uremic waste products

• Methods of therapy– Hemodialysis

Dialysis by need

• Acute dialysis– Increased serum potassium level– Fluid overload– Impending pulmonary edema– Increasing acidosis– Medications and toxins in the blood

• Chronic dialysis– CRF (ESRD)– Presence of uremic signs and symptoms– Hyperkalemia– Fluid restriction

Hemodialysis

• A continuous renal replacement therapy

• Treatment usually occurs three times a week for at least three to four hours

• For survival in control of uremic symptoms

Principles of Hemodialysis

• Diffusion

• Osmosis

• ultrafiltration

Arteriovenous Fistula

• A permanent access by joining an artery into a vein, either side to side or end to side

• Needles are inserted into the vessel to obtain blood flow adequate to pass through the dialyzer

Dialyzer

Complications of Hemodialysis

• GIT problems• Major sleep problems• Hypotension during treatment• Muscle cramps• Dysrhythmias• Air embolism• Chest pain• Dialysis disequilibrium

Laboratory and Diagnostic Examinations

Chest X-Ray (Portable)

Date: 18 January 2009

Result

Findings:

Chest AP view shows congestive changes in both lungs.

Heart is magnified.

Analysis:

Congestion is due to pulmonary edema. Retention of Na and H2O.

Arterial Blood Gas Reports Date: 18 January 2009 Time: 3:37 PM

FIO2: 28% (/)NasalCannula/ Oxygen Mask

Result: Normal Range Actual Value

pH 7.35-7.45 7.33

PaCO2 35-45mmHg 24mmHg

PaO2 80-100mmHg 52

HCO3 22-26mmEq/L 13

Base Excess 0+ / -2 -11

O2 97-100% 85%

Interpretation:

A. Oxygenation

Inadequate

B.Acid-BaseBalance

Partial compensation

Complete Blood CountDiagnostic/Laboratory Normal Values Result Analysis and Interpretation

HEMATOLOGY:

Leukocytes 5.0-10.0 / mm3 21.70 “H” Result was above normal. This shows that there is presence of infection.

Erythrocytes 4.2-5.4 / mm3 3.24 “L” Result was below normal. This indicates alteration in erythropoietin production secondary to renal malfunction.

Hemoglobin 11.0-15.0 / mm3 9.5 “L” Result was below normal. This shows the decrease in the oxygen carrying capacity of the blood secondary low hematocrit..

Hematocrit 37.0-47.0 / mm3 28 “L” Result was below normal, thus showing anemia related to insufficient RBC production.

Thrombocytes 150-450 / mm3 442 Normal.

Neutrophils 50-70 / mm3 89.200 “H” Result shows increased in normal level, indicating bacterial infection.

Diagnostic/Laboratory Normal Values Result Analysis and Interpretation

Lymphocytes 20.0-40.0 / mm3 55.00 “H” Result is above the normal range, indicating bacterial infection.

Monocytes

0.0-7.0 / mm3 3.800 Normal.

Eosinophils 0.00-5.00 / mm3 1.200 Normal.

Basophils 0.000-1.000 / mm3 0.300 Normal.

ChemistryNormal value Result Analysis

CHEMISTRY:

Urea Nitrogen

7-20 111 mg/dl “H” Result was above the normal range indicating renal malfunction.

Creatinine0.52-1.25 16.83mg/dl “H” Result was above

normal thus showing inability of the kidney to excrete nitrogenous waste.

Sodium 137-145 150 mmol/l “H” Result shows an

increased in normal level of sodium, thus suggesting renal dysfunction.

Normal value Result Analysis

Potassium 3.5-5.1 6.2 mmol/l ”H” Result shows an

increased in normal level of potassium, thus suggesting renal dysfunction.

Phosphorus2.5-4.5 12.9mg/dl ”H” Result shows an

increased in normal level of phosphorus, thus suggesting renal dysfunction.

Calcium 1.12-1.32 1.08mmol/l ”H” Result shows an increased in normal level of calcium, thus indicating renal dysfunction.

UrinalysisResult Analysis

Physical Color Light Yellow Normal

Reaction 8.5 ph Substance in the body thatcontribute to the acidity levelof the blood remains, and thisinability to concentrate urinemay be a cause of renal dysfunction.

Transparency Turbid It contains RBCs, WBCs and pus which indicates malfunction of the kidneys to reabsorb and filters.

Specific Gravity 1.010 Normal

Result Analysis

Albumin +++ Increased albumin excretion is an indicative of increasedpermeability of the filters ofkidney (glumerolus), and maybe caused by disease (diabetes, hypertension, lupus, infections, nephritis).

Sugar Trace High level of glucose and other sugar in the urine can be caused by advanced kidney disease, impaired tubular reabsorption.

Pus cells

RBC

Epithelial cells

Bacteria

4-6/hpf

0-2/hpf

Many

Few

There is presence of bacterial infection as evidenced by presence of bacteria, pus cells and RBCs.

Medications

NAME OF DRUG INDICATION MECAHNISM OF ACTION

CONTRAINDICATION

Side Effects NURSING RESPONSIBILITY

1.Telmisartan (Micardis)80 mgODOral

Hypertension Blocks constricting and aldosterone-secreting effects of angiotensin II by selectively blocking the binding of angiotensin II to the angiotensin I receptor in many tissues, such as vascular smooth muscle and the adrenal gland.

Hypersensitivity to drug and its components.

diarrhea,angioedema,sinusitis,pharyngitis,backpain

Monitor patient for hypotension after starting drug.

Closely monitor blood pressure. Patients undergoing dialysis may develop orthostatic hypotension.


CONTRAINDICATION


2. Metoprolol100 mgODOral

Hypertension beta adrenergic blocking agent with preferential effect on beta 1 adrenoreceptors located primarily on cardiac muscles,. At higher dose metroprolol also inhibits beta2 receptors located chiefly on bronchial and vascular musculature. Anti hypertensive action maybe due to competitive antagonism of catecholamines at cardiac adrenergic neuron sites, drug induce reduction of sympathetic outflow to the periphery, and to suppression of rennin activity.

hypersensitivity to drug and in those with active hepatic disease or active cirrhosis

cns:fatigue,dizziness,depressioncv:bradycardia,heart failuregi:nausea,diarrhea

Monitor patient’s blood pressure regularly.

-After dialysis, monitor patient for hypertension


CONTRAINDICATION


3. Levofloxacin500 mg

OD Parenteral

- infection caused by susceptible strains of microorganisms in complicated and uncomplicated UTI and acute nephritis

- a broad spectrum fluoroquinolone antibiotics that inhibits DNA- gyrase, an enzyme necessary for bacterial replication, transcription, repair, and recombination

- contraindicated in patients hypersensitive to drug, its components or other fluoroquinolones.-Hypokalemia

- CNS: headache,dizziness,InsomniaCV: blood dyscrasiasSkin: rush, pruritusSpecial senses: decreased vision, ocular pain, photophobiaBody as a whole:Pain in the injection site or inflammation, chest pain or back pain.

- If patient experiences symptoms of excessive CNS stimulation, stop drug and notify prescriber. -Obtain specimen for culture and sensitivity tests before starting therapy and as needed to determine if bacterial resistance has occurred.-Monitor glucose level and renal, hepatic, and hemapoietic blood studies.


CONTRAINDICATION


4. Calcium Carbonate

500 mgTIDOral

-Acid Indigestion, calcium supplement-Helps maintain strong and healthy bones.

- Rapid acting antacid with high neutralizing capacity and relatively prolonged duration of action. Decrease gastric acidity, thereby inhibiting proteolytic action of pepsin on gastric mucosa. Also increases lower esophageal sphincter tone.

- Contraindicated in patients with ventricular fibrillation or hypercalcemia.

-Constipation, flatulence, diarrhea, acid rebound, hypercalcemia

-Record amount and consistency of stool. Manage constipation with laxatives or stool softeners.-Monitor calcium level, especially in patients with renal impairment.-Watch for evidence of hypercalcemia (nausea, vomiting, headache, confusion, and anorexia)


CONTRAINDICATION


5. Aluminum Hydroxide

500 mgTIDOral

hyperphosphatemia in a chronic renal failure

-non systemic antacid with moderate neutralizing action. Decreases rate of gastric emptying and has demulcent, adsorbent, and mild astringent properties. Reduces acid concentration and pepsin activity by raising ph of gastric and intra esophageal secretion.

- contraindicated in patients with phosphate depletion or hypophosphatemia

-GI: nausea vomiting diarrhea constipationMetabolic:Hypophosphatemia, hypomagnesemia

- When giving through NGT, make sure the tube is placed correctly and is patent.-Record amount and consistency of stools.-Monitor phosphate level-Watch for evidence of hypophosphatemia (anorexia, malaise, muscle weakness) with prolonged use.

AssessmentBackground Knowledge

Nursing Diagnosis Planning Intervention Rationale Evaluation

SubjectiveObjective

ralesCBC results: Hgb of 9.5 in a normal range of 11.0 – 15.0 mg/100mlABG results:

PaCO2 of 24 in a

normal range of 35 – 45 mmHg

PaO2 of 52 in a

normal range of 80 – 100 mmHg

RR: 33cpm

Erythropoietin, a hormone excreted by the nephrons, stimulates the bone marrow to produce erythrocytes. CBC results read that there is a low Hematocrit or a low count of erythrocytes in the blood. The nephrons are basically destroyed (because of exacerbating inflammation or chronic glomerulonephritis). The ability of the nephrons to excrete erythropoietin is reduced to a significant number, thence Hct is lowered, thence, Hgb or the amount of oxygen in erythrocytes are decreased. Thence, hypoxia manifested by a

low PaO2.

Impaired gas exchange related to altered oxygen-carrying capacity of the blood

After an 8 hour

duty, the patients level of oxygenation will remain within normal range of 80 – 100 mmHg and respiratory will

IndependentHave patient turn, cough and deep- breathe every 4 hoursAuscultate lungs every 4 hours and report abnormalities Have patient hyperventilateReduce activities to level of toleranceAdminister 2-3 L/min oxygen via nasal cannula

To prevent fluid build up in lungs and to enhance blood oxygen levelTo detect presence of adventitious breath soundsTo increase arterial oxygenTo decrease oxygen demandTo increase the amount of oxygen carried by available hemoglobin in the blood

Rr, O2

AssessmentBackground Knowledge

Nursing Diagnosis Planning Intervention Rationale Evaluation

SubjectiveObjectiveRales heard upon auscultationPeriorbital edema @ OUEdema at right hand, grade 1+Intake of 630ml and an output of 240ml in 24 hoursBP – 140/110Blood chem. Results:Na – 150 mEq/L in a normal range of 135-145 mEq/LBUN of 111 mg/dL in a normal range of 7-20 mg/dL+++ Albumin in the urineWeight: 40.5 kg

Plasma proteins (serum albumin) are large particles within the blood that exert a force called the colloid osmotic pressure which draws fluid from the ISF compartment into the IVS compartment, thereby counterbalancing the force of hydrostatic blood pressure which forces fluid out of the capillaries into the tissues. Thus, when the levels of PP drops below normal, the COP is diminished and fluid escapes from the IVS into the ISF.

Excess fluid volume related to compromised glomerular function as evidenced by edema and rales

After 4 hours of duty, Patient will have diminished or no adventitious breath sounds upon auscultationPatient will maintain fluid intake of no more than 1000 ml and output of no less than 800ml in 24 hoursPatient will restrict diet to permitted foods low in sodium and potassiumPatient’s weight will remain and not exceed 40.5 kg

IndependentMonitor blood pressure, pulse rate and breath sounds at least every four hours Monitor intake and output at least every four hoursPosition or elevate edematous body partProvide for scheduled rest periods

DependentModify diet to low-proteinGive IV fluids as ordered. Monitor IV flow rate Provide a restricted sodium diet as orderedWeigh patient daily

Changed parameters may indicate altered fluid and electrolyte statusIntake greater than output may indicate fluid retention or overloadTo promote venous return and diminish congestion to improve tissue perfusionBed rest can induce diuresis related to diminished peripheral venous pooling resulting in increased IVS volumeTo decrease BUN, which when in high levels, indicate renal failureFor hydrationRestricting the Na will favor the renal excretion of excess fluidA change in weight is a very good indicator of fluid volume excess

Outcome parltly metPatient has maintained a fluid intake of less than 1000ml, i.e., 630 mlPatient has complied with diet restriction, eating only which was served herPatient’s weight

final ppt of grand case presentation about ckd

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