I.

Introduction

Have you ever imagine what would happen to you and your body when the
heart and pancreas clashes? Have you ever thought in your entire nursing
profession or even of being a student nurse what could be the effect on your
entire body and system when these two organs continuously misunderstood
each other? How fatal their blows are, but most of all, how will you
psychologically cope with it?
We all know how Filipinos fond of eating. In food, we find love, satisfaction,
comfort, fulfillment in every taste, texture, and even amount that we yearn for. It
doesnt matter if we dine in a fancy restaurant or take a munch of lutongbahay
as what we term it. But how many of us are fully aware of how much calories we
take in a day? How many of us maintain or at least strive to attain a balanced
meal? Do we find ourselves guilty of it and only to realize, weve consumed too
much of our limits. And as we grow physically older, we pay the price.
In this generation, our food has evolved and went along with the pace of
time. Rarely, we eat at home and prefer to eat ready-to-cook meals. At times, we
opt to buy viands in fast food chains and little do we know that there are other
ingredients being mixed or even used in the food.
How about another thought for us to ponder? How many of us or how many
Filipinos take time or allot time to get physically fit and promote adequate
circulation in the body? Do we admit the fact that we fail to comply doing a
simple jogging in the morning or a brisk walking after an 8-hour shift in the
office? How frequent do we take physical exercise?
Allow us to point three (3) diseases that every Filipino citizen knowingly or
unknowingly have: 1. Hypertension. 2. Diabetes Mellitus. And 3.Chronic Kidney
Disease.

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In a population of 92.34 Million (Philippine Statistics Authority, May 2010),

one in every four Filipino adults, that is 25.7 %, are hypertensive (Lapea,
August 2012). Sad to say 30% of Filipinos die of hypertension.Next in the line is
Diabetes Mellitus.
One of the known pharmceuticals in the country has cited that by year 2030,
6.16 million of the Philippine population will be diabetics (Crisostomo, March
2013). And as of 2010, 3.4 diabetes cases or 7.7% prevalence rate were
recorded (American Association of Clinical Endocrinology-Philippines).
There are two types of Diabetes Mellitus. One is the insulin-dependent
diabetes mellitus or commonly known as Juvenile Diabetes. It is also pertained
to as Type I Diabetes. And the other is known as Non-insulin dependent diabetes
mellitus or Type II Diabetes. Apparently, 90% of the Philippine population is
accounted to Type II diabetes mellitus (Crisostomo, March 2013). When these
two diseases strike, complication arises and one of which is Chronic Kidney
Disease.
Kidney diseases, particularly End Stage Renal Disease, are the 7 th leading
cause of death amongst Filipinos. One Filipino develops chronic kidney disease
every hour; tantamount to 120 Filipinos per million of population per year and
more than 5000 Filipinos undergo dialysis (National Kidney and Transplant
Institute).
In 2003, Department of Health reported 2.6 prevalence rate of Chronic Kidney
Disease amongst adult Filipinos (Amarga, 2013).
As of 2012, Kidney failure ranks as the 9 thleading cause of death. 44.6% of
the population having CKD intiated from Diabetes, followed by Hypertension as a
runner-up with 23%.
With the numbers mentioned above, this case presentation aims, in general,
to increase awareness regarding these diseases and how to manage them.
OBJECTIVES
GENERAL OBJECTIVES:
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 To be able to familiarize ourselves with the condition or the disease that will
be discussed today.
To provide deeper theoretical and practical knowledge and information about
chronic kidney disease.
SPECIFIC OBJECTIVES:
To identify the factors associated with the development of End-stage renal
disease secondary to diabetic and hypertensive nephropathy.
To discuss the pathophysiology of End-stage renal disease secondary to
diabetic and hypertensive nephropathy.
To know and to correlate the clinical manifestations, medical management,
surgical management and nursing management for patients with End-stage
renal disease secondary to diabetic and hypertensive nephropathy.
To use the nursing process as a framework for care of the patient with Endstage renal disease secondary to diabetic and hypertensive nephropathy.
To describe the nursing management of patients with chronic renal failure.
To describe the nursing management of the hospitalized patient on dialysis.
To enhance the critical thinking skills to prevent developing chronic kidney
disease.
To holistically attend to the needs of the patient with End-stage renal disease
secondary to diabetic and hypertensive nephropathy.

II.

Assessment

A. Patients data

Name: R.S.A.

Age: 68 years old

Sex: Female

Race: Filipino

Marital status: Widow

Occupation: Housewife (after death of husband)

Allergies: none

Religion: Roman Catholic

Health Care Financing and usual source of Medical Care: None

Chief complaint: Scheduled for Hemodialysis, Fever few hours prior

to admission

Date of admission: 19 January 2015

Diagnosis: Urosepsis/Septic shock secondary to UTI

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Final Diagnosis: End Stage Renal Disease secondary to Hypertensive

and Diabetic Nephropathy

B. History of Present Illness

Patient was at the hemodialysis unit to have her routine dialysis. During the
procedure, patient was having chills with low back pain, had dizziness, and
generalized body weakness. Hemodialysis was discontinued and rushed to
Emergency room for immediate management. Her vital signs as follows:

BP =

90/60 mmHg; T= 38.6 degrees Celsius; respiratory rate = 20cpm; heart rate = 136
bpm. She was then started on norepinephrine drip (levophed) to counter act her
blood pressure. She was also given a starting dose of her Piperacillin-Tazobactam for
her Urinary Tract Infection. She was then admitted at Intensive care unit on 19
January 2015, at around 10:20pm for close monitoring and to continue dialysis. On
the first day of hospital confinement, her complaint was more of having low back
pain and was given Gabapentin. Initially was monitored her blood pressure and
heart rate was persistently at rapid rate, amiodarone drip was then initiated. On the
second day of hospital confinement, the patient had episodes of loose bowel
movement and also monitored for blood pressure. She had episodes of 80/50 mmHg
and was placed on Norepinephrine treatment.
C. Past Medical history
The patient stated that she had complete immunization status. No accidents
or hospitalizations that she had experienced as far as she recalls it. However, the
patient had a history of undergoing Cholecystectomy and Hysterectomy in the year
1990. No further details were given regarding these past medical histories. After 6
years, she was then diagnosed of hypertension. She had maintenance medications
and cannot remember her other maintenance medications other than taking
Twynsta.
In the year 2012, patient had experienced having Herpes Zoster or Shingles.
The same year, patient was experiencing right pelvic pain. As she recalls, the pain
was 10 out of 10. She cannot tolerate sitting on the bed or even of sitting on the
toilet bowl. Also the patient stated that she did not have any difficulties of urinating
nor did not have painful urination. Sometime 4 th week of September,She then
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decided to have an executive check up with a nephrologist. That same year, she
was then diagnosed of Diabetes mellitus type 2 and kidney problem. She was given
Diamicron as her maintenance medication for her Diabetes, and unfortunately she
doesnt regularly comply of checking her blood sugar. She doesnt have a diary to
monitor the pattern of her CBG. Sometime November 2014, the patient experienced
headache and consulted her internist. She was then suggested to undergo plain
cranial CT scan, and the results were normal. She too complained of chest pain and
had a check up with another nephrologist. She was then suggested to undergo ECG,
and eventually was confined in the hospital due to Stroke.

D. Family History

Family history is hereditary.

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E. Gordons Functional Health Pattern

HEALTH PERCEPTION
Before Hospitalization:
The patient, a wife and a mother of four
children perceived herself as a healthy
woman and was able to perform
activities of daily living effectively. She
does have a complete immunization. She
doesnt engage in any drug activity or
abuse. She doesnt have any vices. She
drinks occasionally red wine. She was an
athlete when she was a student. She
exercises a lot in luneta. She was having
a difficulty in walking recently. She was
having a back pain and using ointments
to relieve the pain. She was hospitalized
in 2013 with shingles.

HEALTH MANAGEMENT
During Hospitalization:
During hospitalization, the patient starts
to perceive herself as an unhealthy
person because of her condition. She
needs complete support from her
significant other to perform her slight
movements. She verbalize that she
wants to exercise again. She wasnt able
to perform her activity of daily livings at
all. She has a daily intake of the
prescribed medicines to improve her
condition.
She
is
underwent
hemodialysis. Though the patient is ill,
she is still oriented and cooperative
towards the hospital staff. She strongly
believes that what the nurses and
doctors does everyday makes a
difference in his condition. She is
compliant in her treatment.

NUTRITIONAL METABOLIC PATTERN

Before Hospitalization:
During Hospitalization:
The patient has a good appetite and During
hospitalization,
patient
often eats 3 times a day. She drinks an experience decrease in appetite. Taking
estimated eight glasses of water a day. appetizers to eat. Follows full renal diet,
The patient does having difficulty of dm diet then shifted to low salt, low fat
swallowing. She always wanted to cook diet of 2000cal, 100g protein divided
oily food. She always wanted to eat with into 3 meals plus 3 snacks after she was
friends. Her favorite viands are pork and referred to nutrition service. She
chicken but seldom in fishes and preferred to eat fishes and vegetables.
vegetables.
Her fluid intake was decreased. The
patients weight is 100 kg, and 52 ft. or
157.48 cm. Her BMI is
ELIMINATION PATTERN
Before Hospitalization:
During Hospitalization:
The patient had an average urine Patient has a foley catheter. Her urine
frequency of three to five times a day. output is less than 30cc/hr. She had an
An average bowel movement of two episode of LBM.
times a day. No history of constipation
and diarrhea for the past months.
Doesnt experience any pain, itchiness,
incontinence or burning sensation during
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the elimination activity. Patient does not

need laxatives for her elimination.
ACTIVITY EXERCISE PATTERN
Before Hospitalization:
During Hospitalization:
Walking is the patients primary means of During hospitalization the patient is in
exercise about 1 hour a day outside their complete bed rest. Patient now usually
house, but sometimes it was difficult for takes bed bath by her significant other.
her to walk. Usually took a bath twice a The patient is not able to attend to her
day, one in the morning, one in the work like before. Patient now needs
evening. Patient has the ability to feed, complete assistance from his significant
groom, bath and walk. Patient was able other. Cannot perform ROM except for
to perform ROM. Always in luneta to slight hand movement.
attend exercise program with friends.
She loves to cook pork and chicken
viands.

SLEEP REST PATTERN

Before Hospitalization:
During Hospitalization:
She was always watching television at She cant experience her complete sleep
night before sleeping. Waking up in the because of the round the clock checking
middle of the night around 4am then she routine of the nurses. She expresses
cant continue her sleep. Usually sleepy that her sleep is almost 5-6hrs. Sleeps in
in the morning between 9-11am.
the morning and takes nap in the
afternoon.

COGNITIVE PERCEPTUAL PATTERN

Before Hospitalization:
During Hospitalization:
The patient doesnt experience any The patient is aware of her current
physical, mental, emotional and spiritual situation. She perceives pain when she
pain or confusion. The patient can decide is undergoing dialysis.
in accordance to her knowledge. Patient
experienced decrease in vision since
2014. She verbalized that she has a
cataract on her left eye but didnt
consulted a doctor because it was gone
by 1 month. Wearing eyeglasses when
reading.
SELF-PERCEPTION-SELF CONCEPT PATTERN
Before Hospitalization:
During Hospitalization:
The patient believes in herself. She has a Fear started to arise in the mind of the
very high self esteem. She stands to patient. She is feeling weak because of
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what she believe is right. She always

gives her best when it comes to
supporting her family.

her condition. The patients self esteem

was decreased due to his inability to
perform activities of daily living. With
the help of her significant other, the
patient is willing to enhance her selfconcept. She express that sometimes
she thinks of her present condition that
it will put an end to her life. The patient
is in a Generativity stage of Erik
Eriksons
Theory
of
psychosocial
development.

ROLE RELATIONSHIP PATTERN

Before Hospitalization:
During Hospitalization:
The patient is a loving wife and a good She is worried about her financial status.
mother to her children. She has a healthy The family is worried financially but the
relationship with his family, relatives and family members are trying their best to
friends. She is an open minded woman help one another for the benefit of
ready to accept opinions and sees things everybody. Her family is supportive,
objectively. Living with her daughter and they visiting her often and always on her
maids at home. She gets mad easily side.
when someone in her family doesnt
follow her orders. She is a good role
model to her children.
SEXUALITY REPRODUCTIVE PATTERN
Before Hospitalization:
During Hospitalization:
The patient is heterosexual with only one Patient is currently sexually inactive due
partner. The patient does not experience to her hospitalization. Expresses love to
any troubles on his sexual performance. family not in sexual contacts but in
Perceived her sexual relationship as words and advices.
satisfying. The patient does not use
contraceptives and
often
practices
natural method. The patient does not use
medications to improve her sexual
performance.

COPING STRESS TOLERANCE PATTERN

Before Hospitalization:
During Hospitalization:
The patient always gives her best in The patient starts to develop stress with
order for her to adapt in to the changes regards to her health and financial
of her environment. When problem status. The significant other and the
health care team are trying their best to
arises, she deals with it calmly until she
help the patient regain her strength. Has
finds the best way to solve it.
anxiety of her condition. Her coping
mechanism is adaptation, because she
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verbalize that she needs to accept it.

VALUE BELIEF PATTERN
Before Hospitalization:
During Hospitalization:
The patient is a Roman Catholic. She During hospitalization, the patients
always hears mass every Sunday. The faith is strengthened. Though the
patient prays daily asking for wisdom, patient is currently experiencing a lot of
guidance and support not to only to her distress, she believes that God will
but also to her family.
never leave her and her family. She has
a great love to the Lord that is why she
accepts things that is happening to her.
She firmly trusts that God has a plan for
her and with that she is able to deal with
the daily challenges of life.
F. Physical Examination
A. Level of Consciousness:
Glascow Coma Scale Score:
Eye Response:

4 with spontaneous eye opening

Verbal Response:

5 patient is oriented to time, place, and person

Motor Response:

6 Able to move freely can elevate extremities as

per command.

Mood and Behavior:

Upon assessing the patient, shes cooperative

and able to answer our queries while history

Memory:

taking. Very fond of telling her story and what her

Short Term:

lifestyle was prior to hospital confinement. As to

Long Term:

test her short term and long term memory, shes

fully aware that she is confined in the hospital
and what happened to her prior to admission. She
can recall when her husband died and what
cause.

B. Vital Signs
Blood Pressure:

Upon assessment, patients blood pressure is

Pulse Pressure:

140/80 mmHg. Pulse pressure is 60 mmHg, and

Mean Arterial Pressure:

the mean arterial pressure is 120mmHg.

Pulse Rate:
Pulse Deficit

Pulse rate is ranging from 100-105 beats per

minute. No pulse deficit noted both extremities.

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Rhythm:

Upon palpation, the pulse is full and bounding.

Amplitude:

The rhythm is normal/ regular as the interval per

Respiratory Rate:
Rhythm

beat is the same. The amplitude is strong.

Respiratory rate is ranging from 20-24 cycles per

Temperature:

minute and of regular rhythm.

Pain:

Temperature

is

36.5c

and

considered

as

Location:

normthermic.

Characteristics:

During the assessment, there was no presence of

pain.

C. Head
Scalp and Hair:

The hair of the client is curly and thick, silky hair

is evenly distributed. No signs of infection and
infestation observed. Scalp is intact and no

Eyes:

lesions and infections noted.

The Bulbar conjunctiva appeared transparent with

Symmetry:

few

Conjunctiva and Sclera:

white.The palpebral conjunctiva appeared shiny,

Swelling:

smooth and pink.There is no edema or tearing of

Cornea and Lens:

the lacrimal gland.Cornea is transparent, smooth

Pupillary Reflex:

and shiny and the details of the iris are visible.

Right:
Left:
Extraocular Muscles:

capillaries

sclera

appeared

The client blinks when the cornea was touched.

The pupils of the eyes are black and equal in size.
The iris is flat and round. PERRLA (pupils equally
round

Peripheral Vision

evident.The

respond

to

light

accommodation),

illuminated and non-illuminated pupils constricts.

Pupils constrict when looking at near object and
dilate at far object. Pupils converge when object
is moved towards the nose.When assessing the
peripheral visual field, the client can see objects
in

Ears:

the

periphery

when

looking

straight

ahead.When testing for the Extraocular Muscle,

External Structures:

both eyes of the client coordinately moved in

External Auditory Canal:

unison with parallel alignment.

Auditory Acuity:
Page | 10

Webers Test:

The Auricles are symmetrical and has the same

Rhines Test:

color with his facial skin. The auricles are aligned

with the outer canthus of eye. When palpating for
the texture, the auricles are mobile, firm and not

Nose:

tender. The pinna recoils when folded. During the

Nares:

assessment of Watch tick test, the client was able

Septum:

to hear ticking in both ears.

Sense of Olfaction:
Mouth:

The nose appeared symmetric, straight and

Lips:

uniform in color. There was no presence of

Gums:

discharge or flaring. When lightly palpated, there

Teeth:

were no tenderness and lesions. Septum is in

Mucous Membrane:

nondeviated. Able to distinguish foul smelling

Pharynx:

odor.

Tongue:
The lips of the client are uniformly pink; dry,
symmetric and have a smooth texture. The client
was able to purse his lips when asked to whistle.
There are no discoloration of the enamels, no
retraction of gums, pinkish in color of gums
The buccal mucosa of the client appeared as
uniformly pink; dry, soft, matte and with elastic
texture.
Gag Reflex:

The tongue of the client is centrally positioned. It

is pink in color, dry and slightly rough. There is a

Face:

presence of thin whitish coating.

Skin:

The smooth palates are light pink and smooth

Sensation:

while the hard palate has a more irregular

texture.
The uvula of the client is positioned in the midline
of the soft palate.
Gag reflex is present which elicited with the use
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of tongue depressor.
The face of the client appeared smooth and has
uniform consistency and with no presence of
nodules or masses. No facial drooping noted.
Facial wrinkles noted.Able to discern and locate
presence of dull and sharp stimuli.
D. NECK
Swallowing:

The neck muscles are equal in size. The client

Position of Trachea:

showed coordinated, smooth head movement

Range of Motion:

with no discomfort.

Jugular Vein Distention:

The lymph nodes of the client are not palpable.

Carotid Pulsation:

The trachea is placed in the midline of the neck.

Thyroid:

The thyroid gland is not visible on inspection and

Cervical Lymph Nodes:

the glands ascend during swallowing but are not

SCM Strength:

visible. No jugular vein distention noted.

5+ (active motion without resistance)

E. Upper Back and Side

Skin of Back and Axilla

Skin of back and axilla are uniform in color.

Neither lesions norunusualities noted on the area.
No palpable nodes noted on both axillas.

Spine:

The spine is vertically aligned. The right and left

shoulders and hips are of the same height

Respiratory Movements:
Thoracic Diameters:
Breath Sounds:

The chest wall is intact with no tenderness and

masses. Theres a full and symmetric expansion,
with 2:1 ratio of thoracic diameters. The client

Posterior:

manifested

quiet,

rhythmic

and

effortless

Lateral:

respirations. With normal breath sounds without

dyspnea.

F. Anterior Chest
Skin Turgor Over Sternum:

Poor skin turgor

Lung fields:
Right

Both lung fields elicit normal breath sounds. No

crackles, wheezes, or other abnormal lung sounds

Page | 12

Left

noted.

PMI:

3rd to 4th intercostal space, midclavicular line.

Heaves/Thrills/Thrust

There were no visible pulsations on the aortic and

Heart Sounds:

pulmonic areas. There is no presence of heaves

or lifts.
The heart sound is appreciated at the Erbs point
and at the Tricuspid area. Noticed with arrhythmic
sound,

as

the

atria

beats

faster

and

uncoordinated with the ventricles.

Breast:
Non pendulous, no mass noted.
G. Abdomen:
Shape/Symmetry/Size/Lesions

The abdomen of the client has an unblemished

Bowel Sounds:

skin and is uniform in color. The abdomen has a

Liver Size/Tenderness:

globular contour (ascites). There were symmetric

movements

caused

associated

with

clients

Spleen:

respiration. Bowel sounds are normoactive. Non

Kidney:

tender, with liver span of 8cm per mid anterior

axillary line.
Non palpable
No costovertebral angle tenderness noted.

H. Skin
Color:

Patients skin is uniform in color, unblemished

Elasticity and Turgor:

and no presence of foul odor. Skin is senile and

Moisture:

takes 2-4 seconds to come back. Skin is cold to

Temperature:

touch and dry. No clubbing of nails noted, pale in

Nails:

color. Capillary refill unappreciated due to pallor.

Braden Scale:

17, patient is at risk of developing bed sores.

Bed sore:

There

is

no

bed

sore

Location/Grade/

prominences of the patient.

noted

on

the

bony

Page | 13

Characteristic/Size:
I. Extremities
Skin:

Skin is brown in color.

Capillary Filling:
Edema:

Capillary filling unappreciated on both extremities

due to pallor nail beds.Edemanoted on right hand
grade 2/4 (deep pitting with about 4mm

Pulsation:

depression that disappears 10 to 15 seconds).

Pulsations are graded as 2/4 (slightly more

Sensation:

diminished than normal) on left and right radial,

brachial, popliteal, dorsalispedis pulse.
Sensations of extremities are equal and able to

Muscle Strength:

distinguish sharp and dull sensation using needle

Right Upper Extremity:

and cotton.

Left Upper Extremity:

Grade 4 (active motion with some resistance)

Right Lower Extremity:

Grade 5 (active motion without resistance)

Left Lower Extremity:

Grade 4 (active motion with some resistance)

Range of Motion:

Grade 4 (active motion with some resistance)

Fingers:
Shoulders:

Full

Elbows:

Full

Wrists:

Full

Hips:

Full

Ankles:

Full

Contraptions:

Full
With AV fistula noted at left brachial arm, with no
hematoma noted. With thrill noted upon palpation
and strong bruit loudly audible upon auscultation.
With main line of PNSS 1 litre to run for 60cc/hr
infusing well at right metacarpal vein.
With side drip of D5 Water 500ml + 4 ampules of
levophed to run for 19cc/hr infusing well at right
metatarsal vein. With side drip of D5 Water 250
cc + 300mg Amiodarone to run for 18 hours
infusing well at right metatarsal vein.
Page | 14

J. Genitalia:
K. Whole Body Coordination

With Foley Catheter connected to urine bag.

Finger Coordination

Able to perform

Finger to Nose Coordination;

Able to perform

Gait:

Gait and Rombergs test was not done since the

Rombergs Test:

patient is confined to complete bed rest and with

contraptions.

L. Reflexes:
Deep Tendon Reflex:
Biceps:

++ (normal)

Triceps:

++ (normal)

Brachioradialis:

++ (normal)

Patellar:

++ (normal)

Archilles Tendon:

++ (normal)

Babinski Reflex:
M. Cerebellars:

Negative

Nuchal Rigidity:

Nuchal rigidity, Kernigs sign, and Brudzinskys

Kernigs Sign:

sign are not noted on the patient during the

Brudzinskys Sign:

assessment.

Input and Output: 1-19-15

Shift
AM
PM
NIGHT

Oral

IVF

Total

Urine

Total

1040

1040
1040

125

125
125

IVF
1300
820
840

Total
1720
1160
1030
3950

Urine
180
130
150

Total
180
130
150
760

IVF
520
650
550

Total
840
800
600
2240

Urine
100
70
110

Total
100
70
110
280

Input and Output: 1-20-15

Shift
AM
PM
NIGHT

Oral
480
370
190

Input and Output: 1-21-15

Shift
AM
PM
NIGHT

Oral
320
150
50

Page | 15

Page | 16

G. Laboratory and Diagnostic Examinations

Complete Blood Count
Purpose: Is a blood test used to evaluate overall health and help in diagnosis of various disorders, including
anemia, infection, inflammation and leukemia to name a few. It is also used to monitor a condition or
effectiveness of a treatment such as antibiotics.
Nursing care: Explain the purpose of the test. If your blood sample is being tested only for a complete blood
count, you can eat and drink normally before the test. If your blood sample will be used for additional tests, you
may need to fast for a certain amount of time before the test. Your doctor will give you specific instructions.
Normal Value
January 19,2015
January 23,2015
Hemoglobin
120-150 g/l
110
98
Hematocrit
0.37-0.45 l
0.34
0.30
Erythrocyte No. Conc.
4-5x(10)12/L
3.74
3.22
MCV
80-90 fl
90.9
94.0
MCH
27-33 pg
28.3
30.4
MCHC
33-36 g/dl
31.2
32.5
RDW
11.60-14.60%
16.4
15.5
Leukocyte No. Conc.
5-10x(10)9/L
7.2
11.1
Segmenters
0.55-0.65
0.94
0.83
Stabs
0.01-0.05
0.04
0.04
Lymphocytes
0.25-0.40
0.02
0.11
Platelet Count
150-400x(10)9/L
180
208
ANALYSIS
Analysis of CBC results demonstrates presence of anemia because of the decrease in the level of red blood cells,
haemoglobin and hematocrit. Anemia could be correlated to the status of the kidney as this is involved in the
production of Erythrocytes. Anemia is essential to take note as this could aggravate heart failure. Based on the
trend of Erythrocytes, it continued to decrease over the time, this could be the result of multiple factors such as
inadequate functioning of the kidney.
Complete Blood Count
Purpose: A CK-MB test may be used as a follow-up test to an elevated CK in order to determine whether the
Page | 17

increase is due to heart damage or skeletal muscle damage. The test is most likely to be ordered if a person has
chest pain or if a person's diagnosis is unclear, such as if a person has nonspecific symptoms like shortness of
breath, extreme fatigue, dizziness, or nausea. Troponin tests are primarily ordered to evaluate people who have
chest pain to see if they have had a heart attack or other damage to their heart. Either a cardiac-specific
troponin I or troponin T test can be performed. However, troponins are the preferred tests for a suspected heart
attack because they are more specific for heart injury than other tests
Nursing Care: Explain the procedure to the patient. A blood sample drawn from a vein in their arm.
Normal Value
January 21,2015
CK-MB
7-25 IU/L
47.5
Troponin I
0.05-0.10 ng/ml
0.05

ANALYSIS
Although the CK-MB is elevated, it is considered normal in patients with ESRD. CK-MB is not an exact parameter
for heart disease hence why Troponin I was ordered.
Blood Chemistry Result
Normal Value
January 19,2015
Blood Urea Nitrogen
2.90-8.90
6.24
Sodium
mmol/L
140.5
SGPT(ALT)
132-152 mmol/L
28.3
10-41 U/L
Potassium
4.13
Creatinine
3.60-5.30
701.0
mmol/L
Inorganic Phosphorus
53-106 umol/L
0.52
Magnesium
0.74
0.81-1.55
Ionized Calcium
mmol/L
1.03
0.65-1.05
mmol/L

January 21,2015

January 23, 2015

4.42
799.0

3.45
526.0

1.09

Page | 18

1.18-1.30
mmol/L

ANALYSIS:
1-19-2015: Upon admission, the patient is undergoing hemodialysis and rushed to the ER. Her creatinine level is
elevated due to unfinished hemodialysis. Inorganic phosphorus and Ionized Calcium are decreased.
1-21-2015: Repeated creatinine shows that her kidneys are not functioning.
1-23-2015: In this day, it is post hemodialysis. Showing that the creatinine level decreased from previous results.
Kalium durule and Calcium gluconate is ordered to correct the levels of potassium and calcium.

Hematology Result
Purpose: Screening for certain coagulation factor deficiencies
Nursing Care: Explain the purpose of the test, its procedure and secure consent if needed. Schedule a test and
follow up with the laboratory. Immediately refer abnormal results to the doctor handling the patient.
Normal Value
January 24,2015
Prothrombin time
10-14 sec
11.3
Control
Sec
11.21
Inr
1.01
Protime activity
%
98.2
APTT
28-36 sec
36.6
Control
sec
30.8

Page | 19

ANALYSIS: Bleeding parameters are within normal range.

Arterial Blood Gas

Purpose: An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and carbon
dioxide in the blood from an artery. This test is used to check how well your lungs are able to move oxygen into
the blood and remove carbon dioxide from the blood.
Nursing Care: Explain the procedure to the patient. It uses a blood drawn from an artery.
Normal Value
January 19,2015
January 20,2015
PH
7.35-7.45
7.417
7.472
PC02
35-45 mmHg
29.6
23.3
P02
80-100 mmHg
50.4
142.4
HC03
22-26 mmol/L
19.3
23
02Sat
90-100%
86.2
93
B.E.
-+2
-5.4
-6.6
C02 Content
23-32 mmol/L
20.2
17.9
ANALYSIS
Compensated metabolic acidosis, suspect underlying respiratory alkalosis with hypoxemia.
1-19-2015: The patient is placed in oxygen inhalation of 2lpm. And given Sodium bicarbonate.
1-20-2015: Still the patient has oxygen inhalation of 2lpm. And continued Sodium bicarbonate.
Thyroid Function Test
Purpose: Thyroid function tests are currently the most accurate way to diagnose and manage thyroid disorders.
Nursing Care: Explain the procedure. A blood sample will be drawn in patients vein.
Normal Value
January 22,2015
FT3
2.62-5.69 pmol/l
2.01
TSH
0.35-4.94 uIU/ml
2.95
FT4
9.03-19.09 pmol/l
15.96
ANALYSIS:
1-22-2015: Before this day, the patient is ordered to take amiodarone. Amiodarone which is an antiarrythmic
drug can cause decrease in thyroid function test. Then it was discontinued
Page | 20

Routine Analysis
Purpose: Urinalysis can reveal diseases that have gone unnoticed because they do not produce striking signs or
symptoms. Examples include diabetes mellitus, various forms of glomerulonephritis, and chronic urinary tract
infections.
Nursing Care: A properly collected clean-catch, midstream urine after cleansing of the urethral meatus is
adequate for complete urinalysis.
January 20, 2015
Color
Yellow
Transparency
Slightly cloudy
Reaction
5.5
Specific Gravity
1.005
Glucose
Trace
Albumin
+
Epithelial Cells
Some
RBC
0-2/hpf
Pus Cells
0-1/hpf
Amorphous Urates
Some
Mucus Threads
Few
Bacteria
Moderate
ANALYSIS: Urinalysis is within the normal findings.

Stool Concentration Technique

Purpose: Fecalysis or stool exam is examination of the feces through chemical, microbiological, and microscopic
view to detect gastrointestinal diseases and bacterias such Escherichia coli, Staphylococcus aureus and other
parasites. It also helps in identifying bowel disorders, pancreatitis, malabsorption syndrome and distinguish
diarrhea from unknown origin.
Nursing Care: Explain the procedure. Tell the patient to catch a stool on a container.
January 21, 2015
Page | 21

Macroscopic
Color
Consistency
Microscopic
OVA
Cysts
Trophozoites
Pus Cells
RBC
Others
ANALYSIS: Fecalysis is within normal findings.

Brown
Unformed
None seen
None seen
None seen
0-1/hpf
0-1/hpf
Yeast cells:some

Chest X-ray
Purpose: Chest X-rays provide important information regarding the size, shape, contour, and anatomic location of
the heart, lungs, bronchi, great vessels (aorta, aortic arch, pulmonary arteries), mediastinum (an area in the middle
of the chest separating the lungs), and the bones (cervical and thoracic spine, clavicles, shoulder girdle, and ribs).
Changes in the normal structure of the heart, lungs, and/or lung vessels may indicate disease or other conditions.
Nursing Care: Explain the procedure to the patient.
January 19,2015
X-ray Report
Follow up study since 11/22/2014 taken in poor inspiration shows no active parenchymal infiltrates.
Heart is magnified.
Trachea is at the midline.
Right hemidiaphragm is elevated.
Right CP sulcus is blunted by cardiac shadow.
BACTERIOLOGY
C/S, G/S
January 24, 2015

Page | 22

Purpose

Bacteriology is a part of microbiology which encompasses the study of bacteria, viruses, and all
other sorts of microorganisms.

Nursing care

Explain the purpose of the test, its procedure and secure consent if needed. Schedule a test and
follow up with the laboratory. Immediately refer abnormal results to the doctor handling the
patient.
Candida albicans

Bacteria
isolated
Microbial
growth
Source

Heavy
Stool

Antibiotic
sensitivity

Sensitive
to:
flucytosine,
fluconazole, Resistant to: None
variconazole, amphotericin B, caspofungin,
micafungin
Analysis: The patient is on ceftriaxone then it is shifted to piperacillin/tazobactam.

Purpose
Nursing care

Bacteria
isolated
Time to detect
Source

BACTERIOLOGY
A.R.D.
January 24, 2015
Bacteriology is a part of microbiology which encompasses the study of bacteria, viruses, and all
other sorts of microorganisms.
Explain the purpose of the test, its procedure and secure consent if needed. Schedule a test and
follow up with the laboratory. Immediately refer abnormal results to the doctor handling the
patient.
Acinetobacter baumannii
32 hours
Blood (Right Arm)
Page | 23

Antibiotic
sensitivity

Sensitive
to:
piperacillin/tazobactam,
ceftazidime, ceftriaxone, cefepime, doripenem,
imipenem,
ciprofloxacin,
levofloxacin,
cefotaxime
tetracycline,
trimethoporin/sulfamethoxazole, tobramycin,
ampicillin/ sulbactam, ticarcillin/clavulanic acid

Resistant
to:
meropenem,
amikacin, netimicin

gentamicin,

Analysis: The patient is on ceftriaxone then it is shifted to piperacillin/tazobactam.

Electrocardiogram
Purpose: This test is used to evaluate primary conduction abnormalities, cardiac arrhythmias, cardiac
hypertrophy, pericarditis, electrolyte imbalances, myocardial ischemia, and the site and extent of MI.
January 19,2015
Atrial Fibrillation to Supra Ventricular Tachyarrythmia
Nursing Care:
Assess patients history of thrombolytic disease.
Carotid massage for at least 60 secs.
Administer Adenosine as ordered.
- Prep: Flush 15cc isotonic solution
- Rapid push
Elevate upper arm (depending on IV site) for better absorption

Page | 24

Capillary Blood Glucose Results

Date
1-19-15
1-20-15

Time
10pm
6am

Results of CBG
180 mg/dl
247 mg/dl

1-20-15
1-20-15
1-20-15
1-21-15
1-21-15
1-21-15
1-21-15

12pm
6pm
10pm
6am
12pm
6pm
10pm

155
132
168
109
127
152
223

mg/dl
mg/dl
mg/dl
mg/dl
mg/dl
mg/dl
mg/dl

Insulin coverage
None
Apidra 5 units
Subcutaneous
None
None
None
None
None
None
Apidra 5 units
Subcutaneous
Page | 25

1-22-15

6am

111 mg/dl

None

Page | 26

III. Case Analysis

End Stage Renal Disease is the final stage of Chronic Kidney disease wherein
the damage to the kidneys is already irreversible, permanent and it doesnt work
anymore enough for an individual to live therefore the only treatments are either
dialysis for life or a kidney transplant (American Kidney Fund Inc., 2015). This case
is about a 68 year old female who is diagnosed to have End Stage Renal Disease
secondary to hypertensive and diabetic nephropathy. The patient is currently having
ongoing dialysis and is compliant with the treatment regimen. It is known that both
hypertension and diabetes mellitus can cause permanent damage to the kidneys
leading to CKD and if the kidney stops working completely then it goes to ESRD
(The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins
Health System). This case was chosen because we would like to know how both the
diseases of hypertension and diabetes mellitus can cause and lead to ESRD, the
reasons for the treatment regimens given by the medical field to the patient, and
the nursing interventions that as a nurse we ourselves need to do when we are
faced with such disease as ESRD.
The possible impact of this case to our role as a clinician is that it will
enhance our knowledge on ESRD which will enable us to identify the clinical
presentation or the signs and symptoms of the disease and to be able to give the
appropriate intervention need when faced with such disease. As a researcher, it will
give us insight on the different updates and new trends related with the disease
through our research of different journals and review of related literature. As an
educator, guided by the knowledge we obtained about ESRD, we will be able to
educate the patients and individuals who are at risk at the preventive level in order
to avoid developing such disease.

Page | 27

IV. Theoretical Background

A. Review of Related Literature
End Stage Renal Disease or ESRD is a state or condition wherein the
functions of the Kidney already stops working well enough for the individual thus
leading them to need treatment such as dialysis or kidney transplant in order to live
and survive (American Kidney Fund Inc., 2015). End stage renal disease begins first
with Chronic Kidney Disease or CKD and is considered to be the final stage or
stage 5 of CKD wherein there is less than 15% or less than 15ml/min of estimated
glomerular filtration rate (eGFR) (Renal Association, 2013). CKD is described as
abnormal kidney function or structure and commonly occurs due to the presence of
other diseases such as diabetes mellitus and cardiovascular disease (Dr. Jayne
Haynes, 2009). According to Dr. Haynes, a person can be classified as having CKD if
he or she has the following: structural abnormality of the kidneys found through
either ultrasound scanning or other radiologic imaging, having persistent hematuria
or proteinuria after ruling out other causes, and an estimated GFR of less than
60ml/min/1.73 m. CKD is classified into 5 stages depending on their estimated GFR.
It is shown through the table below:
Stage
1
2
3A
3B
4
5

Description
eGFR greater than 90ml/min/1.73 m, with other evidence of kidney
damage
eGFR 60-89 ml/min/1.73 m, with other evidence of kidney damage
eGFR 45-59 ml/min/1.73 m
eGFR 30-44 ml/min/1.73 m
eGFR 15-29 ml/min/1.73 m
eGFR less than 15 ml/min/1.73 m or on dialysis

The epidemiology of CKD, stage 3 in particular according to Dr. Haynes, is

very common. 1.4% in those with ages less than 65 years and about 30% in those
with ages more than 75 years. The risk factors for developing CKD according to
American Kidney Fund Inc. are the following: diabetes mellitus, hypertension, heart
disease, having a family history of kidney disease, being on part of the race of
Page | 28

African American, Hispanic, Native American, and Asian, and being over 60 years
old. The signs and symptoms of having ESRD include (DaVita Health Care Partners
Inc., 2004-2015): reduction in elimination (from oliguria to anuria) which then leads
to conditions like uremia and edema, an imbalance of the electrolytes magnesium,
sodium, and potassium, changes in body hormones in particular parathyroid
hormone which activates the vitamin D into a substance known as calcitriol which
helps the body absorb calcium, and there is also an elevated blood pressure due to
the Renin-Angiotensin-Aldosterone-Systems effects. According to Dr. Haynes, the
aim of the management for CKD is to minimize the progression of CKD and to
prevent the development of complications. These managements include lifestyle
measures such as: healthy diet, not smoking, regular exercise, achieving a healthy
body mass index, and a low salt diet, a regular laboratory assessment, blood
pressure monitoring and management of hypertension, and management of
associated diseases. IF all these fail and the patient progresses to ESRD, then
management can either be through Hemodialysis or Kidney transplant.
Hemodialysis is the most common treatment method used for the
treatment of advanced stages of kidney failure when there is already permanent or
irreversible

damage

(National

Kidney

and

Urologic

Diseases

Information

Clearinghouse, 2014). It involves the removal of harmful wastes excess electrolytes

and excess fluids by using a special filter, a few ounces at a time (National Kidney
and Urologic Diseases Information Clearinghouse, 2014).
Hemodialysis first began with the Scottish chemist Thomas Graham who is
also known as the father of dialysis (Fresenius Medical Care AG & Co. KGaA,
2015). His work was mainly about processes of osmosis which was used in chemical
laboratories which allowed the separation of dissolved substances through a semipermeable membrane. Throughout the years, some people also contributed to the
development of hemodialysis such as in 1855 with Adolf Flick with the diffusion
process quantitative description; in 1913 with John J. Abel was the first historical
description of the procedure wherein he dialyzed anesthetized animals, and in 1924
with Georg Haas started performing dialysis treatments to humans. It was not until
1945 that Willem Kolf succeeded in performing the dialysis treatment (Fresenius
Medical Care AG & Co. KGaA, 2015).
Page | 29

Hemodialysis works by allowing the blood to flow through a special filter or a

semi-permeable membrane that removes wastes and returns clean blood back to
the body (National Kidney and Urologic Diseases Information Clearinghouse, 2014).
The treatment lasts for four to five hours and can be performed several times a
week. But before all of these are done, a vascular access is first made either by
Arteriovenous Fistula which is surgically placed in the arm by joining an artery and
vein together (The Johns Hopkins University, The Johns Hopkins Hospital, and Johns
Hopkins Health System). The Hemodialysis machine has different parts; the dialyzer
which contains a large number of small fibers through which blood passes. Theses
fibers allow the wastes and excess fluids to pass from the blood into the solution
which is the dialysate. The dialysate is the cleansing fluid which contains chemicals
that make it act like a sponge (National Kidney and Urologic Diseases Information
Clearinghouse, 2014). The most common side effect of dialysis is hypotension as it
involves blood flowing out of the body (The Johns Hopkins University, The Johns
Hopkins Hospital, and Johns Hopkins Health System).
There are 2 known causes of CKD which are Hypertension and Diabetes
Mellitus. Hypertension according to Dr. Ruth Bond is defined as a systolic blood
pressure of greater than 140 mmHg and or a diastolic reading of greater than 90
mmHg. Blood is pressure is the force exerted by the blood on the walls of the blood
vessels. The higher the blood pressure, the harder the heart has to pump.
Hypertension is then graded shown through the table below:
Normal
High Normal

Systolic BP
<120
135-139

Diastolic BP
<80
85-89

(Prehypertension)
Mild Hypertension (Grade

140-159

90-99

1)
Moderate Hypertension

160-179

100-109

(Grade 2)
Severe Hypertension

>180

>110

(Grade 3)

Page | 30

Hypertension is classified as either essential or secondary. Essential

Hypertension is for hypertension without a known cause. It is accounted for about
95% of cases. Secondary Hypertension is hypertension with a known direct cause
such as kidney disease, tumors, or birth control pills. The risk factors for
hypertension include the following: smoking, obesity or being overweight, diabetes
mellitus, having a sedentary lifestyle. The symptoms of hypertension are usually not
present at all, it is estimated that about 33% of people actually do not even know
they have the disease which can make it last for years (MedicineNet Inc, 19962015). Having an extremely high blood pressure can cause the following symptoms:
severe headaches, nausea, fatigue or confusion, dizziness, vision problems, chest
pain, breathing problems, irregular heartbeats. The management for hypertension
involves the use of lifestyle intervention of the risk factors and through medications
with the goal of reducing blood pressure. Lifestyle interventions include: smoking
cessation, weight reduction, reduction in alcohol intake, and regular exercise.
According to Dr. Ruth Bond, Antihypertensives should be initiated in patients with a
persistently raised systolic BP of 160 mmHg and or diastolic BP over 100 mmHg.
Patients are managed through combinations of antihypertensives.

The classes of

drugs used to treat hypertension include: ACE inhibitors, ARB drugs, beta-blockers,
diuretics, *calcium channel blockers, alpha-blockers, and peripheral vasodilators.
There are 4 steps to drug management of hypertension according to Dr Ruth Bond.
The 1st step involves the use of monotherapy or single drug

with the choice of

either ACE inhibitor or calcium channel blocker which depends on the age and
ethnic group of the patient. Steps 2 and 3 involve combination of an ACE inhibitor
with a calcium channel blocker or diuretic. Steps 4 have an addition of an alpha or
beta blocker or another diuretic either a thiazide type or either a higher dosage.
Diabetes Mellitus is a disease which is characterized by abnormally high
blood glucose level caused by insufficient insulin (Merck Sharp and Dohme Corp.,
2009-2015). Insulin is created by the beta cells of the islets of langerhans of the
pancreas and functions by allowing the uptake of glucose which is the primary
energy source of the body into the cells. The signs and symptoms of the disease are
divided into three. Polyuria or increased urination, Polydipsia which is an increased
thirst, and Polyphagia which is increased hunger. There are 2 primary types of
diabetes. Type 1 diabetes mellitus which is also called insulin dependent diabetes
Page | 31

mellitus (IDDM) or juvenile onset diabetes is a condition wherein more than 90% of
of the insulin-producing cells of the pancreas are permanently destroyed. Thus
causing the pancreas to produce little to no insulin. The people who develop type 1
diabetes develop it before the age of 30. There is no known cause for type 1 but
scientists believe it to be an autoimmune disorder caused by a viral infection or a
nutritional factor during childhood or early adulthood. Type 2 diabetes mellitus or
Non insulin dependent diabetes Mellitus (NIDDM) is a condition wherein the
pancreas continues to produce insulin, and sometimes even at higher-than-normal
levels. However, the body develops resistance to the effects of insulin, so there is
not enough insulin to meet the body's needs. It was once known to be rare in
children and adolescents but now it has become more common.

Other types of

diabetes are Prediabetes and Gestational Diabetes Mellitus. Prediabetes is when the
blood glucose level is high but is still within normal parameters, the American
Diabetes Association listed the following criteria for diagnosis of prediabetes:
Impaired Fasting Glucose (IFG), a new category, when fasting plasma glucose is
between 100 and 125 mg/dl or Impaired Glucose Tolerance (IGT) is when 2-hour
sample result of the oral glucose tolerance test is between 140 and 199 mg/dl.
Gestational diabetes happens when the diabetes occurs due to pregnancy but after
pregnancy the diabetes usually resolves on its own. The people who are at risk for
developing diabetes mellitus are the following: race (American Indians, Hispanics),
family history of the disease, obesity, sedentary lifestyle, and diet. Diabetes is
detected and diagnosed through the following screening methods and criteria as
recommended by the American Diabetes Association: fasting plasma glucose of
>126 mg/dl (after no food intake for at least 8 hours), A casual plasma glucose
>200 mg/dl (taken at any time of day without regard to time of last meal) with the
class 3 signs and symptoms, and n oral glucose tolerance test (OGTT) (75 gram
dose) of >200 mg/dl for the two hour sample. The management for Diabetes
Mellitus involves lifestyle modification and the used of medications involving oral
hypoglycemics and insulin. The goal of treatment being the maintenance of blood
sugar within normal range as much as possible. Lifestyle modifications or practices
include: diet, exercise, and education for mild diabetes. If these are ineffective
treatment progresses to oral hypoglycemics such as metformin which lower blood
glucose by promoting its uptake by the cells. Oral hypoglycemics cannot be used
forever so treatment progresses to insulin when these become ineffective of
Page | 32

controlling blood glucose. Insulin replacement therapy involves it being injected into
the skin in a 45 degree angle via subcutaneous route using a special type of
syringe. Insulin currently cannot be taken by mouth because insulin is destroyed in
the stomach. A nasal spray form of insulin was available but has been discontinued.
New forms of insulin, such as forms that can be taken by mouth or applied to the
skin, are being tested. Types of insulin according to the American Diabetes
Association are listed below through the table:
Insulin Type
Rapid acting
Regular/Short acting
Intermediate acting
Long acting

Onset
15 minutes
30 minutes
2-4 hours
Several

Peak
1 hour
2-3 hours
4-12 hours
No peak time;

hours

insulin is

Duration
2 to 4 hours
3-6 hours
12-18 hours
24 hours

delivered at a
steady level
The

complications

of

Diabetes

Mellitus

are

either

macrovascular

or

microvascular in nature. Macrovascluar complications include: Cardiovascluar

diseases like Myocardial Infarction and Cerebrovascular disease. Microvascular
complications include: Diabetic Neuropathy or disease of the nerves, Diabetic
Retinopathy, and Diabetic Nephropathy. Diabetic Nephropathy as described by Dr
Rafay Iqbal (2011) as clinical syndrome characterized by: persistent albuminuria, a
relentless decline in glomerular filtration, a raised arterial blood pressure, and an
increase in cardiovascular morbidity and mortality. There are around 40% of
patients with type 1 diabetes and 20% of those with type 2 diabetes who develop
Diabetic Nephropathy. Diabetic Nephropathy is a common cause of Chronic Kidney
Disease in general practice. Treatment of Diabetic Nephropathy is geared towards
strict glycaemic control in order to prevent further damage to the kidneys. Control
of proteinuria and blood pressure through starting ACE inhibitors ARB, or a nondihydropyridine calcium channel blocker reduces the rate of CKD progression.
Sepsis is a complication of infection which is life threatening in nature. It
mostly occurs in people who are old and those who are immune-compromised
(Healthline Networks Inc, 2005-2015). Sepsis occurs when the body has an infection
and the chemicals released by the body into the blood cause inflammation over the
Page | 33

entire body. This can then lead to septic shock which occurs when the inflammation
causes tiny blood clots to form causing blockage of oxygen to different body organs
and thus organ failure (Healthline Networks Inc, 2005-2015). Sepsis has 3 stages:
sepsis, severe sepsis, and septic shock (Healthline Networks Inc, 2005-2015).
Symptoms of sepsis are: temperature of above 38.5, heart rate of above 90 beats
per minute, respiratory rate higher than 20 breaths per minute, and a having a
diagnosis of infection of some kind. Sepsis is caused by different kinds of infection
bacterial, viral, or fungal but mostly: pneumonia, abdominal infection, bloodstream
infection, and kidney infection (Healthline Networks Inc, 2005-2015). The risks for
developing sepsis include: age, weak immune system, having invasive devices
inserted. Sepsis is diagnosed by blood tests. Sepsis it treated through: IV antibiotics,
vasoactive medications for septic shock in order to increase blood pressure, insulin
to stabilize the blood sugar as increased blood sugar in the blood can increase risk
for infection, corticosteroids to decrease inflammatory response when it is already
harmful to the body and painkillers for comfort and relief from pain. A type of sepsis
which is urosepsis is a complication of a urinary tract infection. Urosepsis is more
common in females than in males, and is more likely to occur in the advanced age
and those with weak immune systems such as diabetes (Cynthia Haines, MD, 2013).
Bacteria that cause urosepsis enter the body through by way of ascension through
the urethra then to the ureters, kidney and to the bloodstream.
B. Nursing Theories
The systems model by Betty Neuman states that the client is a system
made up of five variables which are: psychological, physiological, socioculural,
developmental, and spiritual (Barbara T. Freese, 2008). The model is represented by
circles with a central core. The central core is the basic survival factors or energy
sources of the client which are the five variables of the inidividual as a system. The
core is then surrounded by concentric rings called lines of resistance which are the
defense mechanism such as the immune system of an individual against a stressor
such as a disease. After the lines of resistance, there is the normal line of defense
which is represented by a solid circle surrounding the core and lines of resistance.
This line represents the state in which the client is stable and is used to assess
deviations from the clients usual wellness. The outer part of the circle is called the
flexible line of defense which is then represented by a broken ring. This line
Page | 34

represents a protective buffer for preventing stressors by changing and being

altered rapidly over time to enter the usual wellness state known as the normal line
of defense. As described by Neuman, The flexible line of defense is the clients first
protective mechanism. When all lines are effective, the client system can
reconstitute which means they can remain or return to their period of stability or
wellness but when they fail, disease or death may occur.
Lydia Hall proposed different nursing functions or aspects of nursing which
are represented by three interlocking circles. The circles include the care which
is the body of the client, the core which is the person, and the cure which
pertains to the disease (Ann Mariner Tomey, 2008). Hall states that nurses function
in all these states but to different degrees. With the care the nurse cares for the
patients body using different nursing interventions such as bed bath, back rub or
massage, turning and positioning. With the core the nurse focuses on the
patients psychological state by intervening with health teachings and therapeutic
use of self. With the cure, nursing function is medical and surgical based focusing
The as
Core
on the disease and its management such
giving medications.
Social Sciences

The Care

The Cure

Natural and

Pathological and
biological sciences Medical sciences

Sister Callista Roy formulated the Adaptation Model which focuses on

the adaptation capability of the person. She asserted that the person continually
experiences environmental stimuli which cause a response by the person and
adaptation occurs. The adaptation response can either be an adaptive response or
an ineffective response. Adaptive responses by the person promote integrity and
help the person achieve goals in order to adapt to situations therefore achieving
survival,

growth,

reproduction,

mastery,

and

person

to

environmental

transformations. The ineffective responses fail to achieve or threaten the goals of

Page | 35

adaptation which are mentioned above. The role of the nurse in this model is to
assist the patient by managing the environment so as to assist the patients
adaptation effort which will result in an optimal level of wellness for that patient.
The person as an open living system receives inputs or stimuli from both the
environment and the self. Adaptation occurs when the person responds positively to
environmental changes. This response then promotes the integrity of the person
which leads to his or her health.
Input

Control Processes

Output
Stimuli
Adaptation
Level

Coping
Mechanisms
(Regulator,
Cognator)

Physiological
Function,
Self Concept,
Role function,
Interdependenc
e

Effectors

Adaptive and
Ineffective
repsonses

Feedback
By basing on Virginia Hendersons 14 basic needs and through nursing
research, Faye Glenn Abdellah formulated the typology of 21 nursing
problems (Ann Mariner Tomey, 2008). These are formulated in terms of nursing
centered services which are to be used to determine the needs of the patient. In
the case of our patient which is End stage renal disease secondary to hypertensive
and diabetic nephropathy, by using the 21 nursing problems by Faye Glenn
Abdellah, we are able to identify the areas of the patient with problem: to facilitate
the maintenance of elimination, maintenance of fluid and electrolyte balance are
affected by ESRD, to facilitate maintenance of nutrition for all body cells is affected
by the problem of diabetes mellitus, and to facilitate the supply of oxygen to all
body cells is affected by the problem of hypertension.
The Typology of 21 nursing problems by Faye Glenn Abdellah:
1. To maintain good hygiene and physical comfort
2. To promote optimal activity: exercise, rest, sleep
3. To promote safety through prevention of accident, injury, or other trauma and
through prevention of the spread of infection
4. To maintain good body mechanics and prevent and correct deformity
5. To facilitate the maintenance of a supply of oxygen to all body cells
Page | 36

6. To facilitate the maintenance of nutrition for all body cells

7. To facilitate the maintenance of elimination
8. To facilitate the maintenance of fluid and electrolyte balance
9. To recognize the physiologic responses of the body to disease conditions
pathologic, physiologic, and compensatory
10.To facilitate the maintenance of regulatory mechanisms and functions
11.To facilitate the maintenance of sensory function
12.To identify and accept positive and negative expressions, feelings, and
reactions
13.To identify and accept interrelatedness of emotions and organic illness
14.To

facilitate

the

maintenance

of

effective

verbal

and

nonverbal

communication
15.To promote the development of productive interpersonal relationships
16.To facilitate progress toward achievement and personal spiritual goals
17.To create or maintain a therapeutic environment
18.To facilitate awareness of self as an individual with varying physical,
emotional, and developmental needs
19.To accept the optimum possible goals in the light of limitations, physical and
emotional
20.To use community resources as an aid in resolving problems that arise from
illness
21.To understand the role of social problems as influencing factors in the cause
of illness

Page | 37

V. Journal
TITLE OF THE
ARTICLE
SOURCE

SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

METHOD

High protein diets and renal disease-is there a relationship in

people with type 2 diabetes?
Amber Parry-Strong, Murray Leikis, Jeremy D. Krebs (2013).
The British Journal of Diabetes and Vascular Disease, 13 (56), p. 238-243.
The purpose of this study is to determine if whether a high
protein diet sources can have a positive or negative affect
those with type 2 diabetes mellitus and kidney disease as
one of the management to type 2 diabetes mellitus involves
diet. If it becomes possible that a high protein diet is
applicable to diabetic patients with kidney problem then they
will be able to replace the protein losses due to diabetes
mellitus and kidney disease.
Diabetes is considered to be the leading cause of kidney
disease worldwide. Because type 2 diabetes mellitus impairs
the bodys ability to use glucose properly, it gets from other
sources like protein and fat so a high protein diet and low
carbohydrate diet is one of the dietary recommendations for
the disease. Although this can be applied for ordinary
diabetic patients, there is the problem with its application for
diabetic patients with present or beginning kidney disease.
The current standard recommended by the National Kidney
Foundation for the treatment of diabetes with impaired
kidney function and albuminuria for more than 20 years is a
low protein diet. This is due to the thought of slowing down
the progression of the kidney disease by reducing excretion
of protein. This then suggested that a diet high in protein
might accelerate the progression of kidney disease in
susceptible individuals such as those with type 2 diabetes
mellitus. Although there are only a few studies that tested
the effect of a low protein diet on diabetic nephropathy and a
Cochrane review in 2007 which concluded that a reduction in
protein intake slowed the progression of the disease only
slightly but not significantly statistically.
This study reviewed and evaluated different sources of
literatures regarding the results of previous researches in
Page | 38

RESULTS

CONCLUSION

hopes of gathering enough data. Some of the studies

evaluated involved randomizing a certain number of a group
of people (type 2 diabetics who either had normo,
microalbuminuria or macroalbuminuria) which were divided
into between a control group (had high protein diet) and an
experimental group (low protein group, protein restriction of
0.8 g/kg/day) which were then studied for a certain amount
of time such as six months. The results of these studies
showed a reduction in protein excretion rate but there were
no significant differences in glomerular filtration rate. After
the reviewing and evaluating of different studies, this study
then began evaluating on the effect of dietary protein type
on renal function in type 2 diabetes mellitus which used and
compared the following: the usual based diet, red meat
which was then replaced by chicken by Gross et al. in his
study, plant protein as the low protein diet then replaced by
a lacto vegetarian diet by De Mello et al. in his study using a
four week crossover study in patients with microalbuminuria.
Lastly, this study reviewed on the effect of high protein diet
on renal detoriation. It involved three interventional studies
of high protein diets (30% protein and 40% carbohydrate
versus 15% protein and 55% carbohydrate) in type 2
diabetics. Serum creatinine was then monitored. There were
also other literatures that involved the comparison of high
protein diet and low protein diet among type 2 diabetics.
The results of the comparison of the different dietary protein
types in Gross et al.s study showed that only the chickenbased diet reduced urinary albumin excretion rate than the
low protein and usual based one. However in De Mello et
al.s study, it shows that both the chicken-based diet and
lacto vegetarian diet were able to lower urinary albumin
excretion rate. There was also no reported change in serum
creatinine for the comparison of high protein diet and low
protein diet. The same also goes for the other literatures
that were reviewed in this area.
There is evidence that the restriction of protein benefits the
treatment of existing kidney disease but there is no evidence
that a high protein diet accelerates diabetic nephropathy or
causes renal detoriation in someone who has type 2
diabetes. However the benefit of a low protein diet is difficult
to sustain past six months since not all can completely follow
this regimen. The benefit of substituting other sources of
protein like vegetables and chicken meat may be effective
for long term but it requires more evidence.
Page | 39

IMPLICATION

The implication of this study to our case is that it will be able

to provide knowledge on the dietary benefits of protein to
our patient with ESRD. Protein should not be restricted but
only lowered down to the level of removing animal sources
of protein from the diet except chicken and using plant
sources of protein instead in order to decrease the risk of
damaging the kidney furthermore.

TITLE OF THE
ARTICLE
SOURCE

The Effects of Music as Therapy on the Overall Well-being of

Elderly Patients on Maintenance Hemodialysis
Yen-Ju Lin et al. (2012). Biological Research for Nursing,
14(3), p. 277-285.
The aim of this study is to determine if music as therapy
would decrease the level of anxiety and stress that many
elderly patients experience during hemodialysis sessions and
therefore facilitating adjustment to and acceptance of the
hemodialysis treatment. In this study, the researchers would
then explore the effects of music therapy on the incidence
and severity of adverse reactions during hemodialysis
treatment.
In a survey done by the United States Renal data System in
the year 2010, Taiwan has the highest incidence and
prevalence of Chronic Kidney Disease that requires long term
hemodialysis in the whole world. Furthermore, the patients
that had End Stage Renal Disease who were on hemodialysis,
44.65% are 65 years of age and above (Taiwan Bureau of
National Health Insurance, 2011). Elderly patients who have
End Stage Renal Disease have higher chances of
experiencing comorbidities such as cardiovascular and
autonomic dysfunction which then affects their ability to
cope up with physiological stressors therefore are unable to
main hemodynamic stability during hemodialysis treatment
(Li, Jiang and Xu, 2008). The adverse reactions which the
patients who are undergoing hemodialysis treatment mostly
experience are the following: hypotension (25-50%), muscle
spasm (5-20%), nausea and vomiting (5-15%), headache
(5%), back pain (2-5%), chest pain (2-5%), pruritus (5%)
fever and chills (1%) (M.S. Wu, 2007). Therefore, the
effective management of these adverse reactions are
needed to improve the safety and well being of patients
undergoing
hemodialysis
treatment
(Sulowicz
and
Radziszewski, 2007) in order to improve their adherence to
the treatment. Music as therapy has been studies by
researchers as a complementary treatment in various

SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

Page | 40

METHOD

medical fields. It is had been used by midwives during labor

to decrease stress and anxiety, increase concentration, and
to facilitate a positive experience for the mother and her
relatives (Chang and Chen, 2005).
Design and Setting:
Sought the approval of the ethics committee on human
studies at Cardinal tien hospital, in Taipei, Taiwan. Written
informed consent was then was then obtained from each of
the participating patients.
Participants:
A convenience sample of 88 HD patients were obtained and
were randomly assigned to either the experimental (n=44)
and controlled groups (n=44) by means of coin flip. The age
of the participating patients were 60 years and above of age,
and were known to have ESRD for at least 3 months and on
maintenance hemodialysis three times every week with a
four hour per session and were able to communicate
effectively in Mandarin or Taiwanese.
Instrumentation:
A scale adapted from relevant literature and clinical nursing
management experience known as the Hemodialysis
Adverse Reactions Self-Assessment Scale was used. It
contained 17 common adverse reactions that may occur
during hemodialysis treatment (M. S. WU, 2007). It used a 4
point likert type scale which included: symptom frequency
(1=once or twice, 2=3-5 times, 3=more than 5 times),
severity (1=only mildly ill, 2=moderately ill, 3=seriously ill,
4=extremely ill). Higher scores indicate a higher frequency.
Another scale was also used known as Hemodialysis
Stressor Scale (Chou, 2002). It uses a 32 item scale but the
participants rated the extent of being troubled by the 32
stressors using a 4 point scale: 0=not at all, 1=slightly,
2=moderately, 3= a great deal. The higher the score, the
greater the stress. Biological monitoring systems were used
for the recording of blood pressure, heart rate, respiratory
rate, and oxygen saturation.
Intervention:
1st week- Experimental group patients selected and created
their own music playlists. All of the available selections were
of melodic instrumental music with a tempo of 60-80 beats
per minute.
2nd week- Experimental group listened to the music by using
earphones in their own playlists during every hemodialysis
session for the first 20 minutes of every hour for the first 3
Page | 41

RESULTS

CONCLUSION

hours of hemodialysis. And for the fourth hour, participants

were then asked to listen to music therapy for the last 20
minutes of hemodialysis treatment. Controlled group had no
music therapy at all during hemodialysis.
No statistically significant differences were found among the
control and experiment groups regarding sex, marital status,
religion, annual income, living arrangement, length of time
on hemodialysis and duration of each session, average
frequency and severity of adverse reactions, HSS scores
during hemodialysis, and physiological indices. The
experimental group had a lower mean age of 69.11 7.88
versus 75.55 9.16, p= .001 and the members were more
likely to habitually listen to music (x2 = 19.7, p< .001) that
the control group. Spearmans rank correlation coefficient
was used to analyze the relationships between age and habit
of listening to music and the physiological parameters in all
the participants. There was a negative correlation between
age and diastolic blood pressure(r=.332, p=.002), which
might be caused by the decrease in elasticity and
compliance of arteries that occur with age (M.F. Chen, 2009).
There was no statistically significant correlation between the
habit of listening to music and any of the physiological
parameters or with respect to the sources of stress and the
frequency and severity of adverse reactions during
hemodialysis. After Three sessions or 1 week, the frequency,
severity, and scores on the HSS decreased significantly. The
respiratory rate, temperature decreased and the oxygen
saturation increased. There were no significant changes to
the heart rate and blood pressure. Overall, after 1 week of
music therapy on hemodialysis, the incidence and severity of
adverse reactions and the scores on the HSS decreased to a
significant level compared to the control group. Analysis of
the 32 items on the HSS revealed some of the following
findings of alleviation of stress on the items in which the
music therapy affected: poor/inadequate A-V fistula function,
itching, hypotension, loss of bodily function, limitation of
activity,
sleep
disturbances,
coping
with
family
responsibilities, vacation limitations, and frequency of
hospitalizations.
Physiological indices also showed a
decrease in respiratory rate and increase in oxygen
saturation in the experimental group compared to the control
group.
The study came up with a conclusion that music therapy
when provided during hemodialysis treatment may be an
Page | 42

IMPLICATION

TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

METHOD

effective complementary therapy to improve the overall well

being of the patient. It may be able to increase the
adherence or compliance of the patient to the treatment,
allow the patients to participate in their own healthcare, and
help create a more harmonious relationship between the
patient and health care providers.
The Hemodialysis session is indeed very long for a patient;
usually it lasts for 4 hours. In this huge time span the patient
can have a variety of different feelings. Some may be
detrimental to his or her health. That is why Music therapy
will help the psychological condition of our patient in order to
limit stress which can cause different effects. This can also
increase the compliance of our patient to attend the sessions
more because it is associated with fun and relaxing
memoires.
Managing Anemia of Chronic Kidney Disease
Susan A. Krikorian, MS, PharmD (2009). American Journal of
Lifestyle Medicine, 3 (2) 135-146.
The purpose of this study is to study anemia of chronic
kidney disease, to know the prevalence of CKD and anemia
associated with CKD, the treatment regimens of anemia
associated with CKD, and be able to identify anemia in the
early stages of CKD to prevent cardiovascular complications.
Anemia of Chronic Kidney disease is a hematological
problem which is frequent in nature. It develops early and
when the disease of progresses, it worsens in its prevalence
and severity which affects nearly all of hemodialysis
patients. The World Health Organization defines anemia as
having less than 13g/dl haemoglobin count in men and
postmenopausal women, less than 12g/dl in premenopausal
women. There is an increased risk of morbidity and mortality
associated with anemia of CKD. There are also two current
interventions which are shown to be effective, the use of iron
supplements and erythropoiesis stimulating agents. The
early detection and treatment of anemia of CKD has the
following effects: delays the progression to ESRD, reduce the
morbidity and mortality risk, and improve the quality of life
of patients. The barriers to adequate treatment for anemia of
CKD are: a lack of education and poor understanding of
anemia and its management.
The study first used data from the National Health and
Nutrition Examination Surveys to determine the prevalence
Page | 43

RESULTS

CONCLUSION

IMPLICATION

of Chronic Kidney disease. The method for identifying the

prevalence of anemia of CKD was not established due to the
following reasons: because identifying the true incidence of
anemia is difficult due to the condition being most of the
time undetected, there are varying definitions and criteria for
defining the presence of anemia but the WHO one was used
in this study. The study then continued to review other topics
like anemia and CKD progression, and the treatment
modalities for anemia.
The results of the prevalence of CKD from the data obtained
from NHANES showed an increasing prevalence of CKD in the
United States related to the increasing prevalence of
hypertension and diabetes. The data of the survey shows
that the prevalence of CKD has increased from 10% to 13%
between the years of 1988-1994 and 1999-2004 (It was
estimated to be 20 million to as many as 26 million people)
as documented by Coresh et al. The review on anemia and
CKD progression revealed that as there is declining kidney
function during the progression from CKD stage 1 to 5, the
risk increases dramatically for the development of anemia.
The prevalence of anemia of CKD when using the WHO
criteria was shown to be higher with advanced renal disease
and the 25% of the patients who were at a relatively early
stage of CKD showed to have anemia. The prevalence of
anemia on the stages are as follows: 28% in mild or stage 2
CKD, 87% in severe or stage 4 CKD. The treatment
modalities for anemia such as iron supplementation showed
that oral iron is not as efficient at increasing hemoglobin
production as Intravenous iron. Erythropoiesis stimulating
agent therapy initial studies have shown an improvement in
the quality of life of patients.
This study then concludes that with developing or increasing
stages of CKD, the risk for developing anemia of CKD also
increases. There is also the use of the erythropoietin and
intravenous iron for the treatment of anemia less than 12g/dl
of severe, resistant HF has an improvement on the cardiac
and renal function which then reduces hospitalizations.
Anemia can be seen as not so dangerous but its
complications are indeed a problem. Since the kidney has a
function with erythropoiesis and when the kidney loses this
function due to damage, the result is anemia. Anemia should
be treated as soon as possible because it can cause harmful
effects to the body.

Page | 44

TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM
BACKGROUND

METHOD

Metformin and its use in chronic kidney disease,

cardiovascular disease and cancer
Dr. Ramona-Rita Sultana, Dr. Sam Rice (2015). InnovAiT,
0(0), p. 1-6.
The aim of this study is to be able to identify the effects of
metformin and its function or use in chronic kidney disease,
cardiovascular disease, and cancer.
Metformin is a drug which belongs to the biguanide class.
One of the first members of this class is the drug Phenformin
which was developed in the year 1950s and was noted to
have substantial side effects like lactic acidosis which then
lead to its withdrawal from the US market in 1977. The risk
of this phenformin when compared to metformin is 10 to 20
fold. This then delayed the approval of metformin in the US
until 1994. The levels of phenformin correlate with blood
lactate concentration while metformin does not. The
mechanism of action of metformin is that it inhibits hepatic
gluconeogenesis preventing breaking down of glucose
stores, reduces insulin resistance by increasing the glucose
uptake by red blood cells and increasing intestinal usage of
glucose. It is eliminated through the kidneys, it half life being
of 6 hours although this half life becomes longer when there
is a kidney problem.
Metformin does not cause
nephrotoxicity although when there is already a presence of
kidney failure or kidney injury then there will be a risk for
reduced drug elimination. The creatinine cut off points for
the drug is 1.4 mg/dl in women and 1.5 g/dl in men. The
advantages of metformin include uncommon episodes of
hypoglycaemia. There are also some side effects that occur
in up to 20% of patients taking metformin such as:
abdominal pain, nausea, anorexia, loose stools. These
symptoms usually lessen if metformin us taken with food or
the dose is reduced. Chronic Kidney disease found to be in
23% of type 2 diabetes mellitus patients. Diabetes mellitus is
also known to be a cause of 45% of patients receiving
dialysis due to poor blood sugar control which leads to the
microvascular complication known as diabetic nephropathy
which then leads to chronic kidney disease and End stage
Renal disease.
The study first determines the effects of metformin through
reviewing a study by Hirst, Roberts, Farmer, and Stevens in
2012. The study tested the effect of metformin as
monotherapy compared with placebo. The study then
focuses its review on the different diseases, one of such is
Page | 45

RESULTS

CONCLUSION

IMPLICATION

TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM
BACKGROUND

CKD.
The metformin monotherapy group or control group, the
HbA1C was reduced by 12 mmol/mol (1.12%). When the
metformin was used as an add on medication, there was a
reduction in the HbA1C by 11 mmol/mol (0.95%) more than
the controlled group. With the review of this study on the use
of metformin in CKD, The NICE (2009) advises that the
metformin dose should be reviewed if there is an excess in
serum creatinine greater than 130 mol/l or when the
estimated GFR falls below 45 ml/min/1.73 m2 and it should be
stopped if the creatinine is greater than 150 mol/l or when
the estimated GFR is below 30 ml/min/1.73 m2 . Although
metformin is can still be tolerated at these levels when the
patients CKD is stable and have no other co-morbidities like
liver or respiratory failure.
This study concludes that even with a slight reduction in
HbA1C is beneficial for the prevention of morbidity and
mortality from diabetic complications. That metformin can
still be used in patients with CKD guided that there is
adjustment in the dose rather than stopping it completely
and that the patients have no co-morbidities like liver failure
or respiratory failure.
Metformin may be applicable to our case as our patient has
a CKD with diabetes as one of its causes. The metformin can
be used to lower the blood glucose of our patient alongside
insulin therapy if its not enough.
Of heart and kidney: a complicated love story
Dan Gaita, Adelina Mihaescu, Adalbert Schiller (2014).
European Journal of Preventive Cardiology, 21(7), p. 840-846.
The aim of this study is to have an overview of the current
cardiological and nephrological knowledge on the heart and
kidney interrelationship.
There exists a complex relationship between the
cardiovascular system and the Kidney. In literature, it has
been well established that CKD is an independent risk factor
for cardiovascular disease. The CKD concept has been
introduced by the National Kidney Foundations Kidney
Disease Outcomes Quality Initiative in the year 2002. They
defined it as: having kidney damage with abnormalities in
the urine or blood such as albuminuria, proteinuria,
hematuria, and having results of abnormal pathology tests
and imaging for more than 3 months. The results of the
Page | 46

METHOD

RESULTS

CONCLUSION

IMPLICATION

estimated GFR less than 60 /min/1.73 m2 for more than 3

months.
The study discusses several things about CKD but focuses
more on the prevalence of cardiovascular diseases in the
CKD population. It also discusses on the mortality and
cardiovascular risk among CKD patients, and the treatment
and prevention of having cardiovascular disease among CKD
patients.
The study discussed about the prevalence of having CVD on
CKD patients which showed that the prevalence of having
CVD on those having stage 1-5 non-dialysis CKD patients is
17.9% for men and 20.4% for women. This rises to 40% for
patients starting dialysis treatment and rise up to 85% in
patients having impaired left ventricular function or
structure. It has the same trend with cardiovascular mortality
wherein 40% from the US general population to 50% in non
dialysis CKD patients, it is then 15 times higher in End stage
renal disease patients than that of the general population.
The study also discussed that patients having type 1 or 2
type 2 diabetes mellitus who have any albuminuria or
proteinuria is associated with increased risk in cardiovascular
risk and mortality. The patient with a stage 5 CKD known as
ESRD also has a higher risk of dying to a CVD before starting
renal replacement therapy. The lower the estimated GFR the
higher the progression to CKD then to CVD and death.
Prevention is noted by this study as the most desirable
action for the chance of survival of a patient with CKD to
increase. The management should include lowering the
cardiovascular risk factors and reduction of the target organ
damage such as: cardiovascular, cerebrovascular, peripheral
artery, and residual artery function. Some of these are:
lifestyle changes, exercise, weight reduction, and low salt
diet.
The study concludes that health care providers such as
nephrologists should become more concerned with regards
to lowering the cardiovascular risk rather than the
progression to ESRD while the cardiologists should be aware
what danger kidney disease poses to the cardiovascular
system. The study also shows by the data of the results that
there is an interrelationship between the cardiovascular
system and the kidney as CKD increases the risk for
obtaining cardiovascular diseases.
An implication of this study to ours is that it teaches us to be
mindful of the cardiovascular signs and symptoms that may
Page | 47

happen to our patient since this study points out that CKD
has a risk for developing cardiovascular diseases.
TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

METHOD

Long-Term
Oral
Nutrition
Supplementation
Improves
Outcomes in Malnourished Patients With Chronic Kidney
Disease on Hemodialysis
Siren Sezer, MD et al. (2014). Journal of Parenteral and
Enteral Nutrition, 38(8), p. 960-965.
The aim of this study is to evaluate whether Renal Specific
Oral Nutrition Supplements (RS-ONS) have any effects on
nutrition on various outcomes in maintenance hemodialysis
patients.
Malnutrition is a common problem in patients who have
Chronic Kidney Disease and has an adverse effect on their
prognosis. Some of these patients have a lower than normal
dietary intake and dietary protein intake (due to protein
reduction), and oral nutrition supplements.
Participants:
In 286 Maintenance Hemodialysis patients, 62 were
diagnosed as malnourished with a serum albumin
concentration of less than 4 g/dl and had a loss of greater
than 5% dry weight over the past 3 months. They were
followed up for 6 months between January and July 2011. All
the inpatients were recommended to use the ONS. The study
participants were then divided into: those who agreed to use
the ONS were n=32 (RS-ONS study group or experimental
group), and those who chose to increase their dietary intake
instead n=30 (control group).
Intervention:
One serving which equals to 200 ml of RS-ONS preparation
(Nutrena, Abbott Nutrition, Zwolle, Holland) contained 400
kcal, 14 g protein, 41.3 g carbohydrate, and 19.2 g fat and
had fewer concentrations of sodium, potassium, phosphorus
than the standard ONS. In the experimental group, there
were 24 patients who took 2 daily servings of RS-ONS,
whereas there were t patients who took 3 daily servings for 3
months. During each month, the patients consulted with a
dietician to achieve the target calorie intake of intake of 35
kcal/kg/day. Dietary weight and Intradialytic weight were
measured at every dialysis session and these were recorded.
The body mass index was calculated at the beginning and
end follow up period. The triceps skinfold thickness was also
measured from the arm without atriovenous fistula. The
anthropometric and bioelectrical impedance analysis was
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RESULTS

CONCLUSION

IMPLICATION

TITLE OF THE
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SOURCE
SIGNIFICANCE OF
THE PROBLEM

performed within 30 minutes after dialysis treatment. Some

clinical biochemical measurements were also obtained which
are: serum concentrations of hemoglobin, creatinine, intact
parathyroid hormone, low density lipoprotein and high
density lipoprotein, triglycerides, serum albumin, C-reactive
protein, transferrin saturation levels.
The patients
malnutrition and inflammation score was created using the 7
components
of
the
conventional
subjective
global
assessment.
The mean (SD) age of the RS-ONS group or experimental
group was 62.0 (11.3) years (55.2% female), and 57.2 (12.3)
years (female) in the control group. There were no significant
differences in terms of age, sex, duration, of Hemodialysis,
and basal urea reduction ratio. The findings of the study
revealed that the mean (SD) levels of serum albumin were
significantly increased RS-ONS group from 3.5 g/dl to 3.7 g/dl
at 6 months. (p=.028) and did not change in the control
group. Anthropometric findings revealed that dietary weight
in the RS-ONS group had a significant increase and a
decrease in the control group at 6 months. The BMI of the 2
groups were same at baseline (p=.355) however the control
group exhibited a significant decrease from their baseline to
6 months (P< .001) while the BMI for the RS-ONS group
remained stable. The malnutrition and inflammation scores
were also similar for both groups at the baseline level
(p=.682) but there was an increase in the control group at 6
months (p=.006) whereas the RS-ONS group remained
stable all throughout.
The study concludes that the findings indicate that
consuming Renal Specific Oral Nutrition Supplements (RSONS) improves the nutrition and inflammatory status of
patients with CKD.
Renal Specific Oral Nutrition Supplements may be applicable
to our patient even though she is not having any
malnutrition since it has the ability to improve or maintain
the nutritional status and prevent malnutrition from even
happening and improvement of the inflammatory status.
Aspirin Resistance in Patients Undergoing Hemodialysis and
Effect of Hemodialysis on Aspirin Resistance
Hale Unal Aksu, M.D. (2015). Clinical and Applied
Thromobis/Hemostasis., 21(1), p. 82-86.
The purpose of this study was the evaluation of aspirin
resistance in patients who are undergoing hemodialysis and
Page | 49

BACKGROUND

METHOD

to assess the effect of hemodialysis on the Multiplate test.

Aspirin is known to be the most widely used antiplatelet drug
worldwide. Its mechanism of action is that it inhibits the
platelet cyclooxygenase 1 enyzme which then prevents the
production of thromboxane A2 which is a potent
vasoconstrictor and platelet activator from arachidonic acid.
It is used primarily and secondarily in the prevention
thromboembolic vascular events. However, the phenomenon
known as Aspirin resistance may occur wherein patients that
take aspirin might exhibit variable responses to in vitro tests
for platelet aggregation and might experience recurrent
thromboembolic vascular events. Aspirin resistance is known
to be associated with an increased risk for cardiovascular,
cerebrovascular events. It is a multifactorial phenomenon
wherein there are a lot of possible causes which of some are:
polymorphism, factors related to compliance and absorption
of aspirin, inadequate dosage, drug interactions, reduced
bioavailability, and increased platelet turnover.
Participants:
54 patients undergoing hemodialysis were studied (19
[35.2%] were female, 35 [64.8% were male), mean age of
56.79 12.74. The 54 patients were drawn from a
population of 150 from 2 hemodialysis centers, the patients
had been on regular aspirin therapy for at least 7 days. The
patients were undergoing dialysis sessions of 3 times a week
for 4 hours with polysulfone low flux dialyzers.
Anticoagulation was performed with an intravenous bolus of
2000 units heparin followed by 1000 units/h infusion over 3
hours.
Ethical Process:
Approved by the local ethics committee, all participants were
given written informed consent before participating.
Intervention:
Aspirin resistance was assessed using different methods.
Multiplate analyzer (Dynabyte, Medical, Munich, Germany)
was used to perform whole blood aggregation. It is an
impedance aggregometer, based on the principle that
activated platelets expose receptors on their surface which
allows them to attach to artificial surfaces. There were whole
blood samples taken and drawn into test tubes containing
anticoagulant as hirudin 25 mcg/ml. From each patient, there
were 2 blood samples drawn and collected after 1 hour of
aspirin ingestion and at the end of the hemodialysis session.
Analysis was performed within 2 hours of sampling. The
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RESULTS

CONCLUSION

IMPLICATION

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SOURCE
SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

aggregation agonist used was arachidonic acid. The

aggregation measured by the device is quantified as area
under the curve, aggregation degree, and aggregation
velocity. The platelet aggregation results were presented as
Aggregation unit x minutes, values over 300 were accepted
as Aspirin resistance.
The results of the study are as follows: platelet aggregation
values of the study population measured by the multiplate
test were 363.01 225.69 AU x minute before hemodialysis.
After hemodialysis, it was 375.33 254.05 AU (P=.350). A
strong correlation was found between the values before and
after hemodialysis (R=.755, P=<.0001). Aspirin resistance
was detected in 28 (51.9%) patients before hemodialysis but
in 27 (50%) patients after hemodialysis (P=<.0001). The
aspirin resistance status in 9 (16.6%) patients after
hemodialysis was changed. The aspirin resistance status also
emerged in 4 patients after hemodialysis who did not have
this status before.
The study concluded that the exact cause of aspirin
resistance in patients undergoing hemodialysis is unknown
although there is a complex platelet dysfunction with
patients with uremia. The prevalence of aspirin resistance to
patients undergoing hemodialysis seems higher than in most
studied populations, showing that the AR statuses of a
number of significant patients undergoing hemodialysis
treatment change after a session.
Aspirin is can prevent vascular problems from occurring and
since our patient is known to have ESRD or CKD she is at risk
for developing these problems. It is important to be able to
find out whether there is the presence of aspirin resistance.
Fragmented care and Whole-person illness, Decision making
for people with Chronic End Stage Kidney Disease
Dawn Allen et al. (2014). Chronic Illness, 0(0), p. 1-12.
The study aims to understand how patients with multi
morbid, chronic illness who are receiving care in institutions
designed for treatment of acute illness experience and
participate in health related decisions.
Patients with End Stage Renal Disease have complex care
demands because comorbidity is common in them, meaning
they can still acquire other illnesses due to them being
already weakened by their current disease. An example
provided by this study is that patients with heart disease and
diabetes receive care from three different specialists, in
Page | 51

METHOD

RESULTS

separate clinical settings, with different and distinct clinical

guidelines. The decision making when it comes ESRD is one
that entails fragmented care. It involves the following: choice
of treatment modality, end of life decision making, advance
care planning and advance directives.
Design and Setting:
The overall design and orientation of this study was guided
by ethnography which is the study of human behaviour on
the context in which it is embedded. It is characterized by
certain key features such as: beliefs and practices of
everyday life, gaining an insider perspective on these beliefs
and practices, interpretation of these beliefs and practices as
shaped by and dependent on the context in which they
occur.
Ethical Process:
The study was approved by the Ethical Review Board and
consulted and collaborated with a Nephrologist and Nurse
Practitioner.
Participants:
Six co-morbid ESRD patients through purposive sampling
were identified who had different ages, illness histories, and
experience with hemodialysis. This then provided a rich
range of care related communication and decision making
from both within and beyond the hemodialysis unit.
Intervention:
In a period of 12 months, there was a conduction of biweekly observations and a total of 25 interviews with the
patients regarding their hospital care experiences and
decision making process. Multiple care perspectives were
provided by 19 interviews with 11 health professionals. It
helped the study understand the larger hospital context and
the health care delivery system. Data analysis occurred with
concurrence with and again after data collection.
The study showed how patients with complex chronic
disease engage in health related decision making, how these
decision making are embedded into the structure and
delivery of care, and a collaborative approach that
corresponds to the patients own goals and values. The
decision making of co-morbid patients is often about striking
a balanced between a present known quality of life and an
uncertain one in the future. The decision making for this
population group of ESRD hemodialysis patients is often
about running the risk that decision involving sacrifices to
their current quality of life will not entail a benefit in ones
Page | 52

CONCLUSION

IMPLICATION

TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

METHOD

future quality of life.

The study concludes that patients decision making was an
ongoing process of weaving their illness and their life into an
integrated whole. The patients desire to pursuit wholeness
out of all the fragmentation of the health care they receive.
Patient advocacy should be part of the process of health care
institutions on becoming whole in which they will develop
and integrated response not only to the disease but to the
interrelated needs of the people with disease.
Patients need to be able to decide for themselves on the
health care that they will receive and health care providers
should be able to explain to them well the different
treatments that they need. Patients should also be treated as
a whole in order for them to have a quality of life.

Lipids, Waist Circumference, and Body Mass Index in

Hemodialysis patients
Maribor Slovenia (2011). The Journal of International Medical
Research, 39, p. 1063-1074.
The study aims to investigate the association between
abdominal obesity which is defined by waist circumference
and body mass index; and blood lipids which include: total
cholesterol, HDL, LDL, triglycerides, lipoproteins.
The problems of obesity and being overweight have both
posed a global clinical problem with the former being a
strong risk factor for the development of diseases such as
diabetes mellitus, cardiovascular diseases, cancer, and
Chronic kidney disease. Patients having maintenance
hemodialysis seem to have a lower body mass index
compared with age and sex matched controls in the general
population. Kalantar-Zadeh et al. entailed that there is
increased mortality in patients undergoing hemodialysis who
have had weight loss while those who had weight gain had
survival advantages. The relationship of weight loss and a
reduction in adipose tissue are associated with the imminent
release and significant increase in circulating lipophilic
hydrocarbons, reduced skeletal oxidative metabolism which
then leads to reduced antioxidant defense.
Participants:
This study gathered its participants from the department of
dialysis clinic for internal medicine at the University Medical
centre Maribor in Slovenia between the months between
October and December 2003. The patients with acute
Page | 53

RESULTS

CONCLUSION

inflammation or cancer were not included. There were a total

of 72 hemodialysis patients who were asked to participate in
this study. 32 (44%) were females, and 40 (56%) were male.
Ethical Process:
The study was approved by the National Medical Ethics
Committee of the republic of Slovenia. A written informed
consent was given to each participant.
Intervention:
The anthropometric measurements such as body weight and
height, waist and arm circumference were recorded. The
body mass Index was calculated using the standard formula
and the patients were then divided into 3 groups. The
underweight who had a BMI of <20kg/m, overweight who
had a BMI of 26-29 kg/m, and the obese with a BMI of >30
kg/m. Then all the patients were analyzed in tertiles
according to their BMI. First tertile for females was BMI of
<20.7 kg/m, for males it was BMI of >21.5 kg/m. The third
tertile for females was BMI of >25 kg/m, for males was BMI
of >25.2 kg/m. The patients were also divided into tertiles
according to their WAC. The first tertile for females was
<84cm, for males it was <89cm. The third tertile for females
was >96cm and for males it was >102.7cm.
All of the data are presented as mean SD in which the
statistical analysis was carried out using the SPSS statistical
package version 12.0 for windows. The results show that the
mean SD BMI was 24.0 5.7 kg/ m and ranged from 16.8
to 43.4 kg/ m. There were 7 (9.7%) of patients who were
underweight, 50 (55.6%) who had a normal BMI, 15 (20.8%)
who were overweight, and 10 (13.9%) were obese. A finding
of 62.5% in abdominal obesity was found in the hemodialysis
patients. No correlations between BMI and lipid status were
found in females. However in males, there was a correlation
between BMI and triglyceride levels (r=0.362, P=0.022). The
males in the third BMI tertile in comparison to those in the
first tertile had significantly lower concentrations of HDL
(P=0.03). Abdominal obesity which is a WAC of greater than
or equal to 94 cm was found in 21 (52.5%) of males. The
WAC also correlated with the levels of triglycerides. The
males in the highest WAC tertile in comparison to those in
the lowest were significantly lower in HDL Cholesterol levels
(P=0.004) and having higher triglyceride levels (P=0.047).
The study then concluded that CKD generates an
atherogenic lipid profile that is characterized by high
triglycerides, low HDL, and an accumulation of small dense
Page | 54

IMPLICATION

TITLE OF THE
ARTICLE
SOURCE
SIGNIFICANCE OF
THE PROBLEM

BACKGROUND

LDL particles. This may in turn lead to Atherosclerosis of CKD

which is characterized by more advanced and heavily
calcified plaques which extend to both of the intima and
media layers of the wall of the artery. Patients with CKD have
impaired maturation of HDL because of decreased plasma
lecithin cholesterol acyltransferase activity. It is therefore
concluded that in the general population, there is a sex
difference associated with lipid status which could be
associated with hormonal status and inherited distribution of
fat tissue. This study also indicated that the results show
that there was an association between abdominal obesity,
BMI, and lipid status in hemodialysis patients due to
hypertriglyceridaemia being found out in abdominally obese
and high BMI hemodialysis patients but there were negative
correlations that exist between HDL and WAC in both male
and female patients.
The implication of this study is that it shows the importance
of proper weight management among patients with CKD
since there is a relationship between their BMI and WAC with
that of their blood lipids. High level of blood lipids like LDL
and triglycerides can cause cardiovascular problems and
more likely to happen in CKD patients. It is therefore
important that the patient to adhere to a strict and balanced
diet.
Palliative Dialysis in End-Stage Renal Disease
Disha D. Trivedi, MD (2011). American Journal of Hospice and
Palliative Medicine, 28(8), p. 539-542.
The aim of this article is to conduct a review of the current
medicare policy regarding hospice benefits and creating a
new palliative dialysis category that would allow patients to
receive treatments on a less regular schedule without
affecting the quality statistics of the dialysis center.
End Stage Renal Disease is a long and slow to progress type
of disease that takes many years to end a patients life. The
patients who are undergoing dialysis treatment and are
approaching to the end of life are having a difficult choice
whether to stop dialysis and enter hospice care or continue
dialysis and forego the benefits of both hospice and palliative
care. The problem lies with some patients who only like to
continue dialysis on a PRN basis just for symptom
management but are denied of this due to the current
Medicare payment system of needing to go to dialysis first in
Page | 55

METHOD

RESULTS

CONCLUSION

IMPLICATION

order to receive hospice benefits.

This article only does a review on the effects of the current
Medicare payment system policy due to approximately three
quarters of US patients undergoing dialysis treatments have
Medicare as their primary insurance. This article reviewed a
previous study which was conducted at Caritas Medical
Centre in Hong Kong wherein symptom prevalence and
intensity overlapped considerably in both groups of patients
and symptom burden was considerable. Another study that
this article reviewed is one that took place in the United
Kingdom wherein symptom data was collected from all
palliative CKD stage 4-5 patients from 2 renal units referred
to a new renal palliative care service for a period over 10
months from April 2005 January 2006. Another study in the
Northern Alberta Renal Program was reviewed to evaluate
end of life care preferences.
The results of the study in Hong Kong showed that palliative
care needs were common to common to patients regardless
whether they are undergoing dialysis treatment. The results
of the study in the United Kingdom showed that the total
number of symptoms each patient experience ranged from
1-14. The mean was 6.8 and the median was 7. The Northern
Alberta Renal Program study showed that the preferences of
the patients were to alleviating pain and suffering. Only an
18% of the patients preferred dialysis for extension of lives.
It is concluded by this article that it is appropriate to
consider the inclusion of dialysis as a part of palliative care
in patients with ESRD due to providing better symptom relief
therefore improving the patients quality of life. However, the
patients would only need to go to dialysis treatment when
the intensity of symptoms becomes too severe and not be
forced to have treatment when they do not want to. It would
therefore need a Medicare policy change to allow routine
palliative dialysis.
The patient should be allowed to choose the care that she
will receive. Palliative care is usually done for diseases which
can only be managed but not cured. It usually involves
symptom relief. It is still important for the patient to receive
this kind of care because the patient needs to be able to
have a quality of life even when nearing death. Dialysis for
ESRD patients can reduce the symptoms which causes them
discomfort such as edema.

Page | 56

Page | 57

VI. Pathophysiology

LEGEND:
S: Signs and
symptoms
L: Laboratory
results

Predisposing
factors:

Precipitating
factors:

Non-modifiable
factors
-

Age (68 yo)

Gender
(Female)

Hypertension
Diabetes
Mellitus
History of stroke

Modifiable factors
-

Diet
Insulin resistance /
Decreased production
of insulin

Systemic
Vasoconstriction
Increased peripheral
resistance to blood
flow

Diminished
intracellular reaction
Glucose cannot enter
target cells

L: CBG
T: Apidra
and lantus

Glucose accumulate in
bloodstream
Kidneys filter excess
glucose and water

Cell starvation

S: Polydipsia,
Polyuria,
Polyphagia

Page | 58

Dysfunction of Auto
regulatory response
Increased arterial
dilatation
Increased intra
glomerular pressure
Messangial
hypertrophy

Decreased tubular
secretion of H+

Increased
concentration of H+

RAAS activation

Renin released in
blood
A A1 A2

L: Metabolic
Acidosis
T: Sodium

Sodium and water

retention

S: edema
L: low Hct

Increase contractility
of heart to distribute
blood
Hypertension
Decreased cardiac
output
Decreased renal
perfusion

Decreased vitamin
D sysnthesis

L: Low Ionized
calcium

Decreased secretion
of erythropoeitin

Decreased RBC
production

S: Anemia, pallor,
fatigue
L: Low RBC, Low
Hgb

L: Increased
Creatinine
T: Hemodialysis

Impaired Renal
Function

Unable to filter
blood toxins
Creation of
vascular
access/hemodialysi
Entrance of
microorganisms in
the system

Infection/Sepsis

Page | 59

VII. Nursing Plan of Care

A. Nursing Theory
Nursing Process type of Conceptual framework

Assessment

Diagnosis and
Planning

Stressors

Client System:
-Physiological
-Psychological
-Sociocultural
-Developmental
-Spiritual

Typology of 21
Nursing
Problems:
-To facilitate
maintenance of
elimination
-To facilitate
maintenance of
fluid and
electrolyte
balance

Intervention

Evaluation

Care
Nursing
Intervention
s
Core
Holistic
patient
centered
Interventions

Stimuli
caused by
Health Care
Provider

Adapt
Ineffectiv
e
Cure
Response
Medical
and the systems model by
This conceptual framework is based on
4 theories:
Collaborativ
Stressors
Betty Neuman, Typology of 21 nursing problems
by Faye Glenn Abdellah, The Care,
eInterventio
ns model by Sister Callista
Core, Cure model by Lydia Hall, and the Adaptation
Roy. The
Feedback
conceptual framework also is likened to the nursing process wherein each of the
different theories are applied to the steps of the nursing process in order to be able
to come up with a nursing plan of care. First is with Assessment of the client system
as a whole. The client system is protected by different lines called lines of resistance
which serve as the defense mechanism of the client against stressors such as
disease. When these lines are broken, the nurse then assesses the patient as a
whole in order to proceed to the next step which is Diagnosis. Using the typology of
21 nursing problems by Faye Glenn Abdellah, problems are identified and a plan of
care is established. The third step which is the Intervention involves using Lydia
Halls model by dividing each of the different interventions to be done to the client.
Using Sister Callista Roys Adaptation Model, the Interventions done to the client are
the stimuli which facilitates the client to either adapt or be unable to adapt to the
interventions done and cause no improvement in health. If the client is able to
Page | 60

adapt then the patient will be able to have a feedback of improvement in health
status.
In our Case, we can use this conceptual framework to be able to make a plan
of care that will be able to be organized in a manner that will be able to show
progression in terms of interventions.

B. Nursing Diagnoses
High Priority:
1. Ineffective Cardio-Renal Tissue Perfusion
2. Acute pain
3. Hyperthermia
Moderate Priority;
4. Fluid Volume Excess
5. Imbalanced Nutrition
Low Priority:
6. Activity Intolerance
7. Risk for Altered Physical mobility
The following problems were identified as the nursing diagnoses for the case
of this patient which is arranged according to priority. Ineffective Cardio-Renal tissue
perfusion as the priority nursing diagnosis by using the ABCs (Airway, Breathing,
Circulation) for prioritization. Ineffective Cardio-Renal tissue perfusion falls under
the circulation part. Compared to the other diagnoses, Ineffective Cardio-Renal
tissue perfusion needs the most attention and immediate care because a lack of
perfusion especially to major organs like the heart and the brain can lead to death if
not treated immediately. In our case, Ineffective tissue perfusion is observed in all
three of the diseases which are ESRD, Hypertension, and Diabetes Mellitus. An
ineffective tissue perfusion to an organ, which in our case is the kidney, causes it at
first to use compensatory mechanisms like the Renin Angiotensin Aldosterone
System which has an effect of increasing blood flow to the kidney but this
compensatory mechanism doesnt last forever and over time the kidneys will be
Page | 61

damaged. Diabetes Mellitus can also cause ineffective tissue perfusion by making
the blood more viscous due to abnormally high concentrations of glucose as well as
hypertension caused by hyperlipidemia because of the impeding of blood flow to
organs. In our case there is also the presence of a low hemoglobin level; a low
hemoglobin level suggests a decrease in the capacity of the blood to carry oxygen
therefore causing an ineffective perfusion of oxygen to the target tissue. Acute pain
was second because of it was caused by the ineffective tissue perfusion of oxygen
therefore solving the ineffective tissue perfusion will also solve the pain the patient
is experiencing. Hyperthermia is 3rd because it is causes a discomfort for the patient
that should be resolved. It was chosen as a problem because of the event that
happened when the patient was at the dialysis and rushed to the ER being noted of
having a body temperature of 38.6 degrees Celsius. A nursing diagnosis of Fluid
volume excess was made because of the patients diagnosis of ESRD which
suggests the presence of fluid and waste retention in the body. This diagnosis would
become first or second in the high priority if there would be a presence of
pulmonary edema due to fluid volume excess but there was none noted. There
would be an imbalance in nutrition A nursing diagnosis of Activity intolerance was
made because of being anemic having an ineffective tissue perfusion to her body
causes the patient to feel tired an unable to resume the normal activities that she
does. The problem of activity intolerance and below would only be of low priority
because these problems can be solved anytime and is not life threatening in nature.
There would also be a risk for altered physical ability because during hospitalization,
the patient is always in complete bed rest. The patients needs complete assistance
from significant others. There is also the presence of anemia which causes the
patient to become tired and not be able to move for long periods leading to mobility
alteration. This diagnosis would be last because it is only and there is no presence
of the problem yet.

Page | 62

C. Nursing Care Plans

ASSESSMENT

Subjective:
Namamanas
yung
kanang braso
ko,
as verbalized by
the patient.
Objective:
-BP: 140/80
-PR: 94 bpm
-T: 36.7c
-Weight:
Before dialysis:
100.46kg
After dialysis:
100kg
-Edema at right
upper arm
-Bipedal edema
-Ascites
-Poor skin turgor

NURSING
DIAGNOSI
S
Fluid
Volume
Excess
related to
decreased
glomerular
filtration
rate,
sodium and
water
retention.

BACKGROUND
KNOWLEDGE

GOALS AND
OBJECTIVES

Renal disorder
impairs
glomerular
filtration that
resulted to fluid
overload. With
fluid volume
excess,
hydrostatic
pressure is
higher than the
usual pushing
excess fluids
into the
interstitial
spaces. Since
fluids are not
reabsorbed at
the venous
end, fluid
volume
overloads the
lymph system
and stays in the

Short Term:
At the end of
nursing
interventions
during the 8hour shift, the
client will be
able to:
-demonstrate
behaviors to
monitor fluid
status and
decrease
recurrence of
fluid excess.
-verbalize
understanding
of dietary
measures/
fluid
restriction.
Long Term:
Upon
discharge, the

NURSING
INTERVENTIONS
AND RATIONALES
Independent:
-Monitor weigh daily, I
& O balance, skin
turgor and presence of
edema.
- Elevate upper
extremities to the
level of the heart to
reduce edema.
-Change position
every two hours to
prevent pressure
ulcers.
-Promote early
mobility to prevent
stasis.
-Frequent oral care,
chewing hard candy to
reduce discomforts of
fluid restrictions.
Dependent:
-Hook to IV fluid as
ordered and set
appropriate rate of

EVALUATION

Goal Met.
The client
was able to:
demonstrat
ed
behaviors to
monitor
fluid status
and
decrease
recurrence
of fluid
excess.
-verbalized
understandi
ng of
dietary
measures/
fluid
restriction.

Page | 63

-Intake > Output

-Low hematocrit

interstitial
spaces leading
the patient to
have edema,
weight gain,
pulmonary
congestion and
HPN at the
same time due
to decrease
GFR, nephron
hypertrophied
leading to
decrease ability
of the kidney to
concentrate
urine and
impaired
excretion of
fluid thus
leading to
oliguria/anuria.

client will be
able to:
-maintain
ideal body
weight and
fluid balance
without
excess fluid.

infusion to prevent
valleys in fluid level.
Collaborative:
-Hemodialysis
-Renal diet and DM
diet (dietitian).

Page | 64

ASSESSMENT

Subjective:
Simula nung
nahospital ako,
hindi na ko
masyado
makakilos
ng mag-isa
lang, as
verbalized by
the
patient.
Objective:
-BP: 140/80
-PR: 94 bpm
-Weak looking
-Pale
-Low Hgb and

NURSING
DIAGNOSI
S
Activity
intoleranc
e related to
fatigue,
anemia,
and
retention of
waste

BACKGROUND
KNOWLEDGE

GOALS AND
OBJECTIVES

Most activity
intolerance is
related to
generalized
weakness and
debilitation
secondary to
acute or
chronic illness
and disease.
This is
especially
apparent in
elderly patients
with a history
of orthopedic,
cardiopulmonar
y, diabetic, or
pulmonaryrelated
problems. The

Short Term:
At the end of
nursing
interventions
during the 8hour shift, the
client will be
able to:
-perform
activities that
she can
tolerate.
-participate in
selected selfcare activities
-report
increase
sense of wellbeing.
Long Term:
Upon

NURSING
INTERVENTIONS
AND RATIONALES
Independent:
-Identify factors that
contributes to
weakness
(transferring from bed
to wheel chair,
hemodialysis)
-Perform active ROM
to have a good body
circulation.
-Promote
independence un selfcare activities as
tolerated.
-Encourage
alternating activity
with rest.
-Promote adequate
rest periods to regain
strength after
hemodialysis.

EVALUATION

Goal Met. At the end of

nursing interventions
during the 8-hour shift, the
client will be able to:
-performed activities that
she can tolerate.
-participated in selected
self-care activities
-reported increased sense
of well-being.

Page | 65

RBC count

ASSESSMENT

NURSING
DIAGNOSIS

aging process
itself causes
reduction in
muscle
strength and
function, which
can impair the
ability to
maintain
activity.

discharge, the
client will be
able to:
-demonstrate
increase
tolerance to
activities of
daily living.

BACKGROUND
KNOWLEDGE

GOALS AND
OBJECTIVES

NURSING
INTERVENTIONS AND
RATIONALES

EVALUATION

Page | 66

Subjective:
sumasakit dibdib
ko, parang
pinipiga, as
verbalized by the
patient.
Objective:
-BP: 140/80
-PR: 148bpm
-T: 36.3c
-Restless
-Weight: 100kg
-Diaphoretic
-CK-MB = 47.5
IU/L
-With Pain scale of
7 out 10.

Acute pain
related to
tissue
ischemia
secondary to
arterial
occlusion.

Arterial occlusion
causes to
impede sufficient
blood supply,
thus leading to
deprivation and
decreased supply
of oxygen
needed by the
cardiac muscles.
Decrease of
oxygen causes
tissue death
leading to
ischemia. Tissue
death produces
lactic acid and
promotes
inadequate
pumping load of
the heart.

Short Term:
At the end of
nursing
interventions
during the 8hour shift, the
client will be
able to:
-Demonstrate
relief of pain as
evidenced by
stable vital
signs, absence
of muscle
tension and
restlessness.
-Report anginal
episodes
decreased in
frequency,
duration, and
severity
Long Term:
Upon
discharge, the
client will be
able to:
-manage
activities as not
to arise chest
pain and other

Independent:
-Provide
adequate
resting periods.Reduces
myocardial
oxygen
demand to minimize risk
of tissue injury.
-Place
in
a
calm
environment.
Mental/emotional stress
increases
myocardial
workload.
-Encourage
deep
breathing exercises
- Observe for associated
symptoms:
dyspnea,
nausea and vomiting,
dizziness, palpitations.
Decreased
cardiac
output
stimulates
sympathetic
and
parasympathetic
nervous system, causing
a variety of vague
sensations that patient
may not identify as
related
to
anginal
episode.
-Elevate head part of
the bed if patient is
short of breath. This
promotes gas exchange

Goal partially
met. The
client was
able to:
-reduce pain
from a scale
of 7 out of 10
to 2 out of
10. And
eventually
did not have
episodes of
chest pain.
-maintain
stable vital
signs as
follows: HR:
100-105 bpm
T: 36.8c

Page | 67

factors such as
stress, both
mental and
emotional.

to decrease hypoxia.
-Provide light meals.
Have the patient rested
for 1 hour after meals.
Dependent:
-Hook to oxygen support
per nasal cannula.
Increases oxygen
available for myocardial
uptake and reversal of
ischemia.
Collaborative:
-12-lead ECG as to
determine unusualities
in the rhythm of the
heart. Ischemia during
anginal attack may
cause transient ST
segment depression or
elevation and T wave
inversion. Serial tracings
verify ischemic changes,
which may disappear
when patient is painfree. They also provide a
baseline against which
to compare later pattern
changes. Impression:
ATRIAL FIBRILLATION; RAPID
Page | 68

VENTRICULAR RESPONSE.

-Amiodarone drip.
Amiodarone is used to
treat arrhythmias.

ASSESSMENT

NURSING
DIAGNOSIS

BACKGROUND
KNOWLEDGE

GOALS AND
OBJECTIVES

Subjective:
sumasakit ang
dibdib ko
verbalized by the
patient.

Ineffective
cardiorenal
tissue
perfusion
related to
decreased
haemoglobin
concentratio
n in blood.

Having and
Ineffective tissue
perfusion means
that there is a
decrease or
failure in the
oxygen delivered
by the blood to
the tissues at the
capillary level.

Short Term:
At the end of
nursing
interventions
during the 8hour shift, the
client will be
able to:
Demonstrates
adequate tissue
perfusion as
evidenced by
palpable
peripheral
pulses, warm

Objective:
Pain Scale: 7/10
BP-140/90
Hemoglobin98g/l
CK-MB- 47.5 IU/L
Restless
Diaphoretic

NURSING
INTERVENTIONS AND
RATIONALES
Independent:
-assess for untoward
signs and symptoms
that affect multiple
systems.
-note for baseline data:
Vital signs, Arterial
blood gas, Complete
blood count.
-encourage quiet and
restful environment.
-caution client to avoid
activities that increase
cardiac work load.
-encourage early
ambulation when

EVALUATIO
N

ASSESSMEN
T

Goal Met: the

client was
able to:
-verbalized
understandin
g of the
condition.
demonstrate
d behaviour
changes to
improve
circulation.
-identified
changes in
lifestyle that
Page | 69

ASSESSMENT

Subjective
Nurse, parang

NURSING
DIAGNOSIS
Hyperther
mia related

BACKGROUN
D
KNOWLEDGE
Hyperthermia
or commonly

and dry skin,

possible
are needed
adequate
-elevate head of bed at
to increase
urinary output,
night.
tissue
and the
-encourage using
perfusion.
absence of
relaxation technique.
respiratory
distress
Dependent:
-administer medications
as ordered:
Verbalizes
1. Erythropoietin 4,000
knowledge of
units subcutaneously for
treatment
post hemodialysis for
regimen,
treatment of anemia of
including
CKD,
increasing
the
appropriate
number of RBCs that
exercise and
carry oxygenated blood.
medications
and their
Collaborative;
actions and
1. Collaborate with the
possible side
Respiratory
therapists
effects
regarding
oxygen
saturation
of
the
Identifies
patient.
changes in
lifestyle that
are needed to
increase tissue
perfusion.
GOALS AND
NURSING
EVALUATION
OBJECTIVES
INTERVENTIONS AND
RATIONALE
Short Term
Independent
Goal Met. The client was able to:
After 1 hour of
1. Monitor vital signs.
Page | 70

mainit ung
nanay ko as
verbalized by the
relative of the
patient.
Objective
Temperatu
re: 38.6C
RR:
26cycle
per minute
Hot,
flushed
skin
Increased
respiratory
rate
Diaphores
is
Warm to
touch

to bacterial
infection.
Definition:
Body
temperature
elevated
above
normal
range

known as
fever is
present when
the body
temperature is
higher than
37C which
can be
measured
orally, but
37.7C if
measured per
rectum. It
occurs when
the body is
invaded by
some bacteria,
viruses, or
parasites.
Sometimes the
occurrence of
fever may also
be due to noninfectious
factors like
injury, heat
stroke or
dehydration.

appropriate
nursing
intervention the
patients
temperature will
decrease to
37.5oC.
Long Term
After 4 hours of
appropriate
nursing
intervention the
patients vital
signs will return
to normal range;
with a
temperature of
36.5-37.5oC,
pulse rate of 60100bpm and
respiratory rate
of 12-20 cycles
per min.

Vital signs
provide more
accurate
indication of core
temperature.
2. Provide tepid
sponge bath. Do not
use alcohol.
TSB helps in
lowering the
body
temperature and
alcohol cools the
skin too rapidly,
causing
shivering.
Shivering
increases
metabolic rate
and body
temperature
3. Remove excess
clothing and covers.
These decrease
warmth and
increase
evaporative
cooling.
4. Promote a wellventilated area to
patient.

report and show

manifestations that fever
is relieved or controlled
through verbatim,
temperature of 36.8C per
axilla, respiratory rate of
12- 18 breaths per
minute, pulse rate of 6075 beats per minute,
stable blood pressure,
absence of muscular
rigidity/ chills and profuse
diaphoresis after 4 hours
of nursing care

Page | 71

To promote clear
flow of air in the
patients area.
One way of
promoting heat
loss.
5. Maintain bed rest.
Reduce
metabolic
demands/
oxygen
consumption
6. Educate and advise
support system
(relative) to do TSB
when patient feels hot.
- Luke warm water only.
- Make sure that
armpits and groins
were included in doing
TSB.
Teaching the
Support system
the right way to
do TSB will help
in knowing what
to do in case the
patients
temperature
increases
9. Monitored VS and

Page | 72

recheck.

To know the
effectiveness of
nursing
interventions
done and to
know the
progress of
patients
condition.
Dependent
10. Provide antipyretic
medications as
indicated.
These drugs
inhibit the
prostaglandin
that serve as
mediators of pain
and fever.

ASSESSMEN
T
Subjective:
Hindi ko na
nagagawa
ang mga
Gawain ko
dati kasi

NURSING
DIAGNOSIS
Risk for
Altered
Physical
Mobility
related to

BACKGROUND
KNOWLEDGE
Impaired
Physical
mobility is the
limitation in
independent,
purposeful

GOALS AND
OBJECTIVES
Goal:
The patient
will participate
in ADLs and
desired
activities.

NURSING INTERVENTIONS
AND RATIONALES
Independent:
1. Assess the patients condition
for factors that contributes to
immobility.
Rationale: These conditions can
cause physiological and

EVALUATIO
N
Goal met:
patient was
able to:
Participate in
ADLs and
Page | 73

madali ako
mapagod
kaya
nakahiga
nalang ako
palagi as
verbalized by
the patient.
Objective:
-The patient is
on complete
bed rest and
cannot stand
on own.
-Patient now
needs
complete
assistance
from his
significant
other.
-Muscle
strength:
1.Right upper
extremity
Grade 4
(active motion
with some
resistance)
2. Left upper
extremity

restriction in
physical
activity and
activity
intolerance

physical
movement in
the body or of
one or more
extremities.
(Marilynn E.
Doenges et. Al.
(2006). Nurses
Pocket Guide,
11th Edition, p.
457-461)

Objectives:
Verbalize
understanding
of situation
and individual
treatment
regimen and
safety
measures.
Demonstrate
behaviours/tec
hniques to
that enable
resumption of
activities.
Maintain
position of
function and
skin integrity
as evidenced
by absence of
decubitus and
contractures.
Maintain or
increase
strength and

psychological problems that can

seriously impact well being.
2. Monitor and record client's
ability to tolerate activity and
use all four extremities; note
pulse rate, blood pressure,
dyspnea, and skin color before
and after activity.
Rationale: Baseline data.
3. Make a bed rest / activity
schedule if necessary to provide
a continuous period and
nighttime sleep uninterrupted.
Rationale: There should be a
schedule for periods of rest and
periods of activity and there
should be no activity at night
time for the patient to have
adequate rest at night.
4. Change positions frequently
with sufficient amount of
personnel. Demonstrate / aids
removal techniques and the use
of mobility assistance.
Rationale: Eliminates stress on
the nurse and improves
circulation for the patient.
Proper moving techniques also
prevent skin tearing or abrasion.
5. Assist with range of motion
exercises.

desired
activities.

Page | 74

Grade 5
(active motion
without
resistance)
3. Right lower
extremity
Grade 4
(active motion
with some
resistance)
4. Left lower
extremity
Grade 4
(active motion
with some
resistance)
-Full range of
motion on all
joints.

function

Rationale: Maintains or improves

joint function, muscle strength,
and stamina.
6. Encourage the patient to
maintain an upright posture and
sitting height, standing, and
walking. Position with pillows.
Rationale: To maximize joint
function and maintain mobility.
Increases stability.
7. Provide a safe environment,
such as raising the chair, using
the toilet railings, wheelchair
use.
Rationale: Prevent Injury.
Dependent:
1. Give medications such as
clopidogrel for preventing clot
formations due to immobility
which lead to embolus as
ordered.
Rationale: To reduce the risk of
cardiovascular problems due to
immobility.
Collaborative:
1. Consult with physical
therapist for further evaluation,
strength training, gait training,
and development of a mobility
plan.
Rationale: Techniques such as
Page | 75

gait training, strength training,

and exercise to improve balance
and coordination can be very
helpful for rehabilitating clients
(Tempkin, Tempkin, Goodman,
1997).

ASSESSME
NT

NURSING
DIAGNOSI
S

Subjective
Data:

Altered
Nutrition:
Less than
body
Requirem
ent r/t
catabolic
state,
anorexia
and
malnutritio
n
secondary
to renal
failure

nawawalan
ako ng
ganakumain
as
verbalized
by the
patient
Objective
Data:
Anorexia
Anemia
Fatigue

BACKGROU
ND
KNOWLEDG
E
Due
restricted
foods and
prescribed
dietary
regimen, an
individual
experiencing
renal
problem
cannot
maintain
ideal body
weight and
sufficient
nutrition. At
the same

GOALS
AND
OBJECTIVE
S
Patient will
demonstrat
e
behaviors,
lifestyle
change to
regain and
maintain
an
appropriate
weight.
Support
adjustment
to lifestyle
changes.

NURSING INTERVENTIONS AND

RATIONALES

Establish rapport
To gain patients trust
Assess general appearance and monitor
vital signs.
To establish baseline data.
Identify patient at risk for malnutrition.
To assess contributing factors.
Ascertain understanding of individual
nutritional needs.
To determine what information to
provide the patient.
Assess weight, age, body build, strength,
rest level.
To provide comparative baseline.
Assist in developing individualized regimen.
To control underlying factors.
Provide diet modification as indicated.

EVALUATIO
N

Goal met:
patient was
able to:
Short
term:
Adhere to
food and
prescribed
dietary
regimen
Long term:
Maintain
ideal body
Page | 76

Weakness
Reported
inadequate
food intake
less than
recommend
ed daily
allowance

time patients
may
experience
anemia due
to decrease
erythropoieti
c factor that
cause
decrease in
production of
RBC causing
anemia and
fatigue

To establish a nutritional plans.

Avoid high in sodium-rich food.
To prevent further increase in sodium
level.
Promote relaxing environment.
To enhance intake.
Provide oral care.
To prevent further spread of dental
caries.
Limit fluid intake as ordered.
To prevent water retention.
Encourage to do Passive range of motion
exercise.
To have proper circulation of blood.
Encourage early ambulation.
To prevent muscle atrophy.
Regulate Intravenous line as Ordered.
To maintain hydration status.
Administer Medications as ordered.
To prompt treatment.

weight

Page | 77

VIII. MEDICAL PLAN OF CARE

A. ESRD
Healthy kidneys clean the blood by filtering out extra water and wastes. They
also make hormones that keep your bones strong and blood healthy. When both of
your kidneys fail, your body holds fluid. Your blood pressure rises. Harmful wastes
build up in your body. Your body doesn't make enough red blood cells. When this
happens, you need treatment to replace the work of your failed kidneys.
ESRD is when the kidneys stop working well enough for you to live without
dialysis or a transplant. This kind of kidney failure is permanent. It cannot be fixed.
Most cases of ESRD are caused by diabetes or high blood pressure. Some problems
you are born with, some reactions to medicines, and some injuries can also cause
ESRD. If you have ESRD, you will need dialysis or a kidney transplant to live.
Treatments for ESRD are the following:

Our

Haemodialysis
Peritoneal dialysis
Kidney transplant
patient

is

undergoing

Hemodialysis

as

her

mode

of

treatment.

Hemodialysis
Date: January 21, 2015, Setting: Hemodialysis unit, Duration: 5 hours, BFR: 250ml/
minute, Site/Access: Left AVG, Dialyzer: Reuse, Dialysis bath: Bicarb, target
ultrafiltration: 2kgs The objective of hemodialysis is to extract toxic nitrogenous
substances from the blood and to remove excess water. In hemodialyis, the blood is
diverted from patient to a machine (dialyzer), where toxins are filtered out and
removed and the blood is returned to the patient. (Brunner and Suddarth, 2010).
Pre-Hemodialysis Care
-

Assess the patient (monitor vital sign and record)

Patency of the shunt
Weigh the patient
Do not administer antibiotics and anti-hypertensive drugs
Check creatinine level
Administer heparin as ordered

Post-Hemodialysis Care
Page | 78

Re-assess the patient (Vital Sign)

Re-weigh the patient
Administer erythropoietin as ordered

B. SEPSIS
Sepsis is a potentially life-threatening complication of an infection. Sepsis
occurs when chemicals released into the bloodstream to fight the infection
trigger inflammatory responses throughout the body. This inflammation can
trigger a cascade of changes that can damage multiple organ systems, causing
them to fail.
If sepsis progresses to septic shock, blood pressure drops dramatically, which
may lead to death.
According to mayoclinic, to be diagnosed with sepsis, you must exhibit at least
two of the following symptoms:

Body temperature above 101 F (38.3 C) or below 96.8 F (36 C)

Heart rate higher than 90 beats a minute

Respiratory rate higher than 20 breaths a minute

Probable or confirmed infection

Diagnosing sepsis can be difficult because its signs and symptoms can be caused by
other disorders. Doctors often order a battery of tests to try to pinpoint the
underlying infection.

Blood tests

Evidence of infection
Clotting problems
Abnormal liver or kidney function

Page | 79

 Impaired oxygen availability

Electrolyte imbalances

Urine. If your doctor suspects that you have a urinary tract infection, he or
she may want your urine checked for signs of bacteria.

Wound secretions. If you have a wound that appears infected, testing a

sample of the wound's secretions can help show what type of antibiotic might
work best.

Respiratory secretions. If you are coughing up mucus (sputum), it may be

tested to determine what type of germ is causing the infection.

Page | 80

Drug

Classification and
Action

Erythropoeitin

Anti anemic

4,000 units
subcutaneously for
post hemodialysis.

-Kidneys are
responsible for the
RBC production and
they can detect low
levels of oxygen in
the blood. Renal
disease decreases
the functionality of
the kidneys to
produce
erythropoietin, a
hormone that
stimulates bone
marrow to begin
RBC production.
Eprex contains
synthetic
erythropoietin that
alternatively
stimulates bone
marrow to produce
mature RBCs in the
bloodstream.

Apidra
5 units
subcutaneous, for
CBG >200

(insulin glulisine
[rDNA origin]
injection) is a rapidacting human
insulin analog

Indication
for the
Patient
Treatment of
anemia from
renal failure
disease

8 units
subcutaneous
Daily (PM)

(insulin glulisine
[rDNA origin]
injection) long
acting insulin
-It lowers the blood

Remarks

-Take
seizure
precautions
.

Doses
given on
1-21-15
Given of 2
doses
after
hemodialy
sis.

-Provide
safety and
seizure
precautions
.
-Encourage
patient to
eat ironrich foods.
-Inform
patient of
the
adverse
effects of
the drug.

Type 2
diabetes

- Insulin glulisine
binds to the insulin
receptor (IR), a
heterotetrameric
protein consisting
of two extracellular
alpha units and two
transmembrane
beta units.

Lantus

Nursing
Care

-Monitor
CBG before
and after
giving the
drug.
-Rotation of
sites

Type 2
diabetes

-Monitor
CBG before
and after
giving the
drug.

Given on
1-19, 6am
and 1-21,
10pm.
Given SQ
for CBG.
>200.
Check the
CBG
before
and after
giving
insulin.
Rotate
the site
were the
insulin is
administe
red.
Initially
started on
Page
| 81
1-20
to 122. Given
daily SQ 6
pm.

Name of
fluid and
incorporat
ed drug
D5W 500 +
amiodarone

Classification and
Action

Indication

Nursing
Care

Remarks

Class III
antiarrhythmic

To treat lifethreatening,
recurrent
ventricular
fibrillation and
hemodynamic
ally
unstable
ventricular
tachycardia

- Monitor
vital signs
and oxygen
level often
during and
after giving
amiodarone.
Keep
emergency
equipment
and drugs
nearby.

Started on
1-21 to 1-23
to run for 18
hours for
treatment of
Atrial
Fibrillation

-Acts on cardiac cell

membranes,
prolonging
repolarization and
the refractory period
and raising
ventricular
fibrillation threshold.
Drug relaxes
vascular smooth
muscles,
mainly in coronary
circulation, and
improves myocardial
blood flow. It relaxes
peripheral vascular
smooth muscles,
decreasing
peripheral vascular
resistance
and myocardial
oxygen
consumption.

D5W 500 +
levophed
Dose 4
Concentrati
on 16

Cardiac Stimulant
-At more than 4
mcg/min, directly
stimulates
alpha-adrenergic
receptors and
inhibits
adenylcyclase, which

ECG result was

Supra
Ventricular
Tachyarrythmi
a

To treat acute
hypotension

-Monitor
continuous
ECG; check
for
increased
PR and QRS
intervals,
arrhythmias,
and heart
rate below
60
beats/min
because
amiodarone
toxicity
may cause
or worsen
arrhythmias.
-Check
blood
pressure
every 15
minutes

Started on
1-19 upto 122
0.5 mcg/kg

-If blanching
occurs along
vein,
Page | 82

inhibits
cAMP production.
Inhibition of cAMP
contricts arteries
and veins and
increases
peripheral vascular
resistance and
systolic
blood pressure. At
less than 2 mcg/min,
norepinephrine
directly stimulates
betaadrenergic
receptors in the
myocardium
and increases
adenylcyclase
activity, producing
positive inotropic
and chronotropic
effects.

IX.

change
infusion site
and notify
prescriber at
once.
-Monitor
continuous
ECG during
therapy

INSTRUCTIONAL DESIGN

Setting:

OLLH Industrial BLDG 5th floor

Duration:

45 minutes

Target:

Nurses

Facilitator: Don and Nikki

Instructional Scenario: A ward Nurse explaining to the relatives how to care to a
bedridden DM patient.
Page | 83

Description:
Learning

Content

Teaching

outcomes

outline

learning

Time frame

Materials

Student/

teacher activ

strategies
The goal of

This program

this program

include a

is to enhance

comprehensiv

the

e discussion

knowledge,

on:

skills and
attitude of

Discussion

nurses in

1.Perception

taking care of

of nurses

DM patients.

about

3 minutes

LCD projector

The
teacher/facili
tor will
encourage th
nurses to sha
their
knowledge/
perception o
experiences
about diabet

diabetes.
The specific
objectives of
this programs
are the ff:
Diagram

5 minutes

- To

LCD
projector/laptop/pow

Differentiate

2.Definition of

er point

Type 1, Type

type 1 and

presentation

2, diabetes.

type 2
diabetes.
Lecture

10 minutes

-To describe

LCD

the

projector/laptop/pow

complications

3.Complicatio

er point

of diabetes

n of diabetes

presentation

and identify

and its care.

steps to care.

Picture

The trainer w
Provide a
discussion

5 minutes

presentation
- To Gain

The trainer w
: provide a
concise
discussion
about diabet
and its two
types using a
diagram.

LCD
Page | 84

insight on

4.Healthy

projector/laptop/pow

healthy

eating habits

er point

eating

and physical

presentation

strategies

activity of DM

diabetes and

patients.

physical
activity of DM
patients for
them to

Lecture

10 minutes

successfully
manage their
disease.
- To define

LCD
5.Diabetes

projector/laptop/pow

management.

er point

diabetes

about 3 majo
complication
diabetes and
the steps to
care for it.

The trainer w
provide a slid
show of
pictures
showing food
and exercise
that is
important for
managing a
diabetes
patient.

presentation

management
and some
basic
strategies to
Return
demonstratio
n

help patients
take
medications

The trainer w
Provide a set
diabetes
managemen
and strategie
how to take o
inject insulin

10 minutes

safely.
- To
demonstrate
a skill in
taking
glucose
meter.

6.skills in DM
care

Glucometer

The trainer w
Demonstrate
how to use a
glucometer.

Page | 85

Page | 86

X. Clinical Experiences
Our learning throughout the one and half month of training in Lourdes
hospital has been helped by an unerring optimism in the value of nursing, and an
appreciation that each and every daily interaction augments our experience. We are
also exposed to many intellectual academic and practical concepts simultaneously
within the our assigned area in turn we developed multi-tasking skills emotionally,
mentally and physically as we adjust to the pace of clinical areas, peer driven life
and the setting in our home.
Our experience has been exhilarating in its own way, it has also become an
eye opener to the realities of life as a nurse. We are thankful to the things that we
learned, we are confident that this experience will allow us to succeed to be a better
nurses, and we look forward to the challenges and rewards of an engaging
fellowship.
Our 30 day experience of training in the Our Lady of Lourdes hospital is
indeed a very memorable and learning experience. It was a 30 day duty with
different shifts changing from 6 am to 2 pm, 2pm to 10 pm, and 10pm to 6am. We
went to duty five days a week. The setting of the Our lady of Lourdes hospital is a
bit above average since it has caters a large bed capacity and the facilities are well
made for patients, and some are even being renovated for the continuous
improvement of the hospital. My first and 2 nd week of duty began with an orientation
to the facilities and the routines of the unit. It was hard at first to cope up but
through hard work it is possible. The staffs were friendly and nice; they were helpful
and teaching as well. The patients are usually kind and compliant to the care given
to them.
The impact of this case to us as a nurse is that enhances further my
knowledge on the disease itself and how it is managed. As a person, it allows me to
correlate with my patient and understand how the disease affects them as a person.
The lessons or realizations that we got from taking care of this patient is that
I should do everything that I can to be of help to the patient and to try to take care
of the patient as a whole by interacting with them and taking care of them through
the different nursing interventions.

Page | 87

XI.

Bibliography

Books:
Alligood, M.R. (2014). Nursing Theorists and their work (8th ed.). St. Loius, MO:
Mosby Inc.
Ann Mariner Tomey and Martha Raille Alligood (2008). Nursing Theorists and Their
Work (6th ed.). Mosby Inc.
Jones, B. and Bartlett, J. (2011). Nurses Drug Handbook (10th ed). Tall Pine Drive,
Canada: Malloy Inc.
Smeltzer, S., et al. (2010). Brunner and Suddarths textbook of Medical-Surgical
Nursing (12th ed.). Walnut Street, Philadelpia: Lippincott Williams & Wilkins.
Turkoski, B., et al. (2006). Drug Information Handbook for Nursing (6th ed). Canada:
Lexi-Comp Inc.
Journals:
Amber Parry-Strong, Murray Leikis, Jeremy D. Krebs (2013). High protein diets and
renal disease-is there a relationship in people with type 2 diabetes? The British
Journal of Diabetes and Vascular Disease, 13 (5-6), p. 238-243.
Dan Gaita, Adelina Mihaescu, Adalbert Schiller (2014). Of heart and kidney: a
complicated love story. European Journal of Preventive Cardiology, 21(7), p. 840846.
Dawn Allen et al. (2014). Fragmented care and Whole-person illness, Decision
making for people with Chronic End Stage Kidney Disease. Chronic Illness, 0(0), p.
1-12.
Disha D. Trivedi, MD (2011). Palliative Dialysis in End-Stage Renal Disease.
American Journal of Hospice and Palliative Medicine, 28(8), p. 539-542.
Dr. Jayne Haynes (2011). What is CKD? InnovAiT, 2(2), p. 92-99.
Dr. Jayne Haynes (2009). Chronic Kidney Disease. InnovAiT, 4(1), p. 37-40.
Dr Rafay Iqbal (2011). Diabetic Nephropathy. InnovAiT. 4(12), p. 706-711.

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Dr. Ramona-Rita Sultana, Dr. Sam Rice (2015). Metformin and its use in chronic
kidney disease, cardiovascular disease and cancer. InnovAiT, 0(0), p. 1-6.
Hale Unal Aksu, M.D. (2015). Aspirin Resistance in Patients Undergoing
Hemodialysis and Effect of Hemodialysis on Aspirin Resistance. Clinical and Applied
Thromobis/Hemostasis, 21(1), p. 82-86.
Maribor Slovenia (2011). Lipids, Waist Circumference, and Body Mass Index in
Hemodialysis patients. The Journal of International Medical Research, 39, p. 10631074.
Siren Sezer, MD et al. (2014). Long-Term Oral Nutrition Supplementation Improves
Outcomes in Malnourished Patients With Chronic Kidney Disease on Hemodialysis.
Journal of Parenteral and Enteral Nutrition, 38(8), p. 960-965.
Susan A. Krikorian, MS, PharmD (2009). Managing Anemia of Chronic Kidney
Disease. American Journal of Lifestyle Medicine, 3 (2) 135-146.
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