Case Study on Chronic Kidney Disease

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

SPECIFIC OBJECTIVES:The specific objectives of the case study are given below: To assess the patient and find out need of patient according to nursing process.  establish a nurse-client relationship to the client, as well as to the family by rendering a therapeutic nurse-patient relationship;  gather adequate information to be used in the development of the study  present the clients personal data;  illustrate the patient’s family tree and trace significant diseases which may be of relevance to the study  trace the health history of the client and the family by collecting information both of the past and present illnesses;  To provide holistic nursing care to the client to all ages using nursing process.  To manage promptly as necessary to built up comfort.  To provide psychological support to the patient  To apply knowledge from the science, nursing theory and other related courses to plan and implement nursing care.  To provide continuous care till discharge and follow-up care.  Counsel and make aware the patient party about importance of continuity of medicine and psychological support to prevent from worsens.  To provide the discharge teaching to the patient and family member.

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BIOGRAPHIC DATA

1) HEALTH HISTORY A)

DEMOGRAPHIC DATA  NAME:  AGE:  SEX:  ADDRESS:  RELIGION:  EDUCATION  DATE OF ADMISSION:  DATE OF DISCHARGE:  IP NO. :  OCCUPATION:  MARITAL STATUS:  ATTENDING DOCTOR:  INFORMATION SOURCE:  DIAGNOSIS:  BLOOD GROUP:  BED NO:  WARD:

laxman kumar pandit 68yrs male Permanent: nayapati -6, jorpati Hindu iliterate 068/4/6 068/4/17 200821/410159 farmer married Dr. P.K.C patient and his son CKD 5 A +ve 205 nephrology

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

2

C) HISTORY OF PRESENT ILLNESS: According to the patient’s, he come for haemodialysis, due to increased shortness of breath during dialysis he was admitted in the nephrology ward. His general condition is ill looking and oriented with time place and person.

D) HISTORY OF PAST ILLNESS: 

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



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

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

OPERATIONS OR SPECIAL TREATMENT: no any

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

Fig.1 Family Tree

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Table 1 Family Medical history DISEASE

FATHER’S RELATION

MOTHER’S RELATION

Tuberculosis Cancer Heart disease Jaundice Epilepsy Psychological Hypertension

Absent Absent Absent Absent Absent Absent Present

Absent Absent Absent Absent Absent Absent Present

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

4



PERSONAL HISTORY:  Health Habits: Smoker but has left 1-2 months ago, Non alcoholic, Non vegetarian. No food allergy. Maintain personal hygiene Religion belief and worship kuldeuta.  Dietry history: Non vegetarian. Foods like egg-curry, rice, daal etc.



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



ENVIRONMENTAL FACTOR:  Housing Pattern: Well facilitated  Waste disposal: They are practicing collective approach to manage the waste product. Such as temporary container, burning and making compost manure. The people from nagarpalika also come to take waste from there home.  Pollution and noise: his house is near the road , so he is very much affected by the noise of the vehicle and the air pollution caused by the vehicle.

F) DEVELOPMENTAL NEED AND TASK COMPARING WITH NORMAL ADULT CLIENTS Robert Havighurst’s Developmental Tasks

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Developmental Tasks

Description

Passed or Failed

1. Adjusting to decreasing physical strength and health

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

Passed

2. Adjusting to retirement and reduced income

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

Passed

3. Adjusting to death Older adults may of a spouse become caregivers to their spouses. Some older adults have to adjust to the death of their spouses. After they have lived with a spouse for many decades, widowhood

Failed

6

may force older people to adjust to loneliness, moving to a smaller place,and learning about business matters. 4. Establishing an The development of a explicit affiliation large part of the with one's aged group population into old age is historically recent phenomenon to modern cities. Thus, advancements understanding of the aging process may lead to identifying further developmental tasks associated with gains and purposeful lives for adults.

Passed

5. Meeting social and Older people might civil obligations accumulate knowledge about life, and thus may contribute to the development of younger people and the society.

Passed

6. Establishing satisfactory physical living arrangements

Passed

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

Eric Erikson’s Developmental Task Integrity vs. Despair 7

Erikson felt that much of life is preparing for the middle adulthood stage and the last stage recovering from it. Perhaps that is because as older adults we can often look back on our lives with happiness and are contented, feeling fulfilled with a deep sense that life has meaning and we've made contribution to life, a feeling Erikson called integrity. On the other hand, some adults may reach this stage and despair at their experiences and perceived failure. My patient achieved happiness and contentment in his life based on his actions and speeches. He is faithful and devoted to his religion. He is ready to accept death completely and he has shared his experiences to his beloved grandchildren. Even though he accepted death fully but his faith and love for his worshipped God never changed.

Physical Assessment Name: Mr.laxman kumar pandit Bed: 205 Age: 68 yrs Status: Married

Ward: nephrology Ward Sex: male

Civil

Vital Signs 8

Axillary T=97 degree F, PR= 90/ min, RR= 22/ min, BP= 150/80 mmHg. General survey Height= 5 ft and 8 inches, weight= 56 kilos,. No signs of distress noted upon assessment, able to smile, cooperate well, responsive to questions, conscious and alert, conversant. Well oriented. Show calmness during the examination. He has no IVF infused, and was asleep at initial assessment. Skin Skin is brown in color, rough, dry and warm. He has good skin turgor. Brownish discolorations that resemble wrinkles are observed on face. Head Skull is round in shape, symmetrical. No masses noted. Facial movement is symmetrical, alopecia. Scalp is clear from dandruff and lice. No scars and wounds noted. Eyes Has symmetrical eyebrows movement, shape and hair distribution. Eyebrows have same color with hair. Eyelashes are evenly distributed and curled outward. Eyelids have no discharges and bilaterally blink. Upper lid covers the small portion of the iris and cornea. Lacrimal duct openings (puncta) are evident at nasal ends of upper and lower lid with no tenderness noted. Palpebral conjunctiva are pinkish in color while the pupils constricted to light, round in shape. He is able to rotate eyes and has coordinated eye movements. Ears Auricle has same color with the skin, has symmetrical shape and located a little bit higher than the eye. Pinnas are symmetrical with no lesions noted. He has wet cerumen noted on both ears when pulled down and back for better visualization. he is able to hear on both ears. Nose Nose has uniform color and symmetrical in shape. Nasal hairs are very evident when light is flashed through the nasal passageways; its color is black. No nasal flaring observed upon respiration. Both nares are patent, air moves freely as client breathes through the nares. Nasal septum is straight and in midline. Nasal mucosa is pinkish in color, has no discharges and no lesions. No tenderness of sinuses noted. Mouth

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Lips are a little brownish in color, dry and has cracks. Tongue is in midline, pinkish in color with thin whitish coating on top. Able to move tongue freely (up & down, side to side). Soft palate is light pink in color while hard palate is lighter in color. Gums are pinkish in color. Plagues are present on his teeth Pharynx Uvula is found well placed in midline of soft palate. Mucosa is pinkish in color. Tonsils are not inflamed. Neck Trachea is in midline. No tenderness of thyroid noted. No enlargement of the neck noted. he is able to flex and extend neck and move it laterally (L and R). Chest and Lungs Breathing pattern is regular. Anteroposterior diameter to transverse diameter is in 1:2. Respiratory excursion is symmetrical (thumb separates to 2-3cm). No tenderness, lump, Presence of breath sound in all area of lungs Heart and Central Vessels Heart sounds are regular. Pulsation of heart is heard in 4 anatomical areas but more audible in apical area upon auscultation. Back and Extremities Peripheral pulses are symmetrical and regular. Nails are long and untrimmed, pinkish in color, and have a capillary refill time of 2 sec. after blanching; and no clubbing of fingernails were noted.. His hands are a little rough. Muscle strength is equal on both sides of the upper and lower extremities. He is able to stand and walk on both feet independently, and his movements are well coordinated. Toes point straight ahead. And he is able to sit up straight. Abdomen His abdomen’s color is same with the rest of the part of the body. His umbilicus is coated with blackish dirt. Neurologic Assessment Cranial Nerves: able to identify aromas by smelling with eyes closed; able to see objects; pupil constricted to light sensation; able to move eyeball downward and laterally; able to blink eyes; able to smile, raise eyebrows, puff cheeks and close eyes; able to respond to questions being heard;) has rough

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and vibrating sound; able to shrug shoulders, elevate and flex arms and legs against resistance; able to protrude tongue and move it side to side.

FINDINGS:     

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

3) DEFINATION, CAUSE AND PATHOPHYSIOLOGY OF CLIENTS DISEASES. Definition: Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss of renal function over a period of months or years in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia. In this condition, the GFR falls below 10% of the normal rate.

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Predisposing Factors Genetics  Heredity Age >40

Causes:

 Glomerular dysfunction  Diabetic nephropathy Decrease insulin  Hypertension Precipitating production/sensitivity  Glomerulonephritis Environment(intrapartal)  Polycystic kidney disease Toxin/Virus  Urinary tract obstruction Obesity  Bladder Decrease Serumtumour Potasium  Urethral obstruction  Hypertensive nephrosclerosis (hardening of the kidney) Elevated Serum Increased Osmolarity due to Glucose

Glucose

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

Polyuria

Polyphagia

Serum Glucose

Stages of chronic kidney disease STAGE 1.

Weight loss

Diabetic neuropathy

2. 3. 4. 5.

Symmetrical loss of sensation

Numbness and paresthesia Wasting of intrinsic muscles

DESCRIPTION GFR ML/MIN Slight kidney damage with More than 90 normal or increased Accelerated Impaired immune Small filtration vessel Diabetic atherosclerosis function disease Mild decrease inretinopathy kidney 60-89 function Hypertension Moderate decrease in 30-59 kidney function Severe decrease in kidney 15-29 Diabetic Infection disease nephropathy Coronary artery Kidney failure Less than 15 or dialysis disease Pathophysiology: End-stage renal failure

Loss of vision

Increase LDL levels

Delayed wound healing

Autonomic neuropathy Impotence Diabetic foot ulceration

Charcot changes in joints

Dry, cracked skin

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Gastroparesis

Neurogenic bladder

4) COMPARISON OF: A) SIGNS AND SYMPTOMS  Neurologic ACCORDING TO BOOK

ACCORDING TO PATIENT 13

      

Weakness and fatigue Confusion Inability to concentrate seizures Restlessness of legs Burning to soles of feet Behavior changes

      

present present absent absent present present present

 integumetry ACCORDING TO BOOK  Dry, flaky skin  Thin, brittle nails  Thinning hair

ACCORDING TO PATIENT  present  present  absent

 cardiovascular    

ACCORDING TO BOOK Hypertension Pitting edema Periorbital edema

ACCORDING TO PATIENT  present  present  present

 pulmonary ACCORDING TO BOOK  Shortness of breath  tachypnea  Kussmaul- type respiration

ACCORDING TO PATIENT  present  present  present

 G.I ACCORDING TO BOOK  Metallic taste  Anorexia, nausea  Vomiting, constipation/ diarrhea

ACCORDING TO PATIENT  Absent  Absent  present

 Hematologic ACCORDING TO BOOK  Anemia

ACCORDING TO PATIENT  present

 Reproductive

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ACCORDING TO BOOK  amenorrhea  infertility  Testicular atrophy

ACCORDING TO PATIENT  Absent  Absent  absent

 Musculoskeletal ACCORDING TO BOOK  Muscle cramps  Loss of muscle strength  Bone pain  Bone fracture

ACCORDING TO PATIENT  Present  Present  Present  absent

B) INVESTIGATION ACCORDING TO BOOK Laboratory test:

ACCORDING TO PATIENT Blood urea: 119.0 mg/dl Creatinine:9.1 Na+:139.o K+:5.2 meq/r 15

USG biopsy KUB film

Serum albumin:2.8gm/dl Hb:9.6gm% Glucose f:120 mg/dl Glucose pp : 141mg/dl Done but report was not available Done but report was not available Not done

It is an ultrasound-based diagnostic medical imaging technique used to visualize muscles, tendons, and many internal organs, to capture their size, structure and any pathological lesions with real time tomographic images.

Normal Size in cm: Left Kidney Right Kidney 10.8 +- Length 9.7 +0.8 0.7 4.2 + Width 4.3 +-0.5 0.5 4.8 +Thick 3.9 +0.5 0.5 1.5 C. Thick 1.5

C) COMPARISON OF MEDICAL MANAGEMENT The goal of management is to maintain kidney function and homeostasis for as long as possible. Because of the great deterioration of renal function, the duration of management may vary from months to years. Nothing can be done to prevent or delay the fatal outcome. ACCORDING TO BOOK  Control of urinary volume: fluids

ACCORDING TO PATIENT  My patient was prescribed to drink 16

are forced since kidney has lessened ability to concentrate solids. more fluids about 2litres is needed to excrete waste. Sometimes frusemide may be required to increase urine production.  Control of nausea and vomiting: anorexia, nausea and vomiting tend to develop when the cretinine clearance falls below 5ml/min. so reduction in protein is required to improve nausea. Blood: 0.8-1.4 mg/dL is the normal. Due to impaired kidney function, creatinine in the blood elevates.  Antiseizure agents  Antihypertensive agents: hypertension is managed by intravascular volume control and a variety of anti- hypertensive agents.  Control of hyperkalaemia will be treated with I/V glucose and insulin in a ratio of 3 gm Glucose to 1 unit soluble insulin.  Control of anemia: blood transfusion are frequently required.  Accurate record of input and output chart should be maintained

 Other therapy: dialysis It is usually initiated when the patient cannot maintain a

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

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

 Since my patient didn’t develop any kind of seizure. So antiseizure agents were not used.  Tab nifedipine 10 mg,tds was given to my patient to control hypertension. 

 Since my patient didn’t develop anemia so bllod transfusion was not done.  Input and output chart was maintained.  4/6 : 200ml total input and 200ml was total output  4/7: 350ml was total input and 250 mi was total output  4/8: 500ml total input and 350ml total output  4/9: 530ml was total intake and 150 ml was total output  4/10: 450ml total input and 300ml total output  4/11: 400 ml total input and 300 ml total output  My patient is undergoing regular dialysis, 2-3 times in a week

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reasonable lifestyle with conservative treatment.

COMPARISON OF SURGICAL MANAGEMENT ACCORDING TO BOOK  Kidney transplantation: it involves transplanting a kidney from a living donor to a recipient who has ESRD. The success rate increases if kidney transplantation from a living donor is performed before dialysis is initiated.

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

D) COMPARISON OF NURSING MANAGE MENT The patient with chronic renal failure requires astute nursing care to avoid the complications of reduced renal failure and the stresses and anxieties of dealing with a life threatening illness. ACCORDING TO BOOK  Nursing care is directed toward assessing

ACCORDING TO PATIENT As a nurse I assessed the fluid status of my patient 18

fluid status and identifying potential source of imbalance  Implement a dietary program to ensure proper nutritional intake within the limits of the treatment regimen.  Promote positive feelings by encouraging increased self care  Provide explanations and information to the patient and family concerning ESRD, treatment options and potential complications  Nurse must be familiar with various drugs and their side effects  Provide emotional support to the patient and his family because of the numerous changes experienced.

by monitoring input and output record closely. My patient was prescribed to have fluid less than 500ml/day and was on renal diet. As a nurse I closely observe the dietary pattern of my patient I encouraged my patient to perform his activity of daily living by himself and promoted the positive feelings. As a nurse I provided explanation to the patient and his family members about his treatment options and potential complications. As a nurse I provided information to my patient regarding various drugs used in it. I provided my patient and his family emotional support so that anxiety and tension is relieved to some extent.

5) DRUGS CARD OF MEDICINES My patient has used the following drug: Tab nifedipine 10mg, tds  Tab lasix 40mg, od  Tab pantop 40 mg  Diclofenac gel 19

 Tab domel 1 tab  Tab haloperidol 1. Tab nifedipine

Therapeutic class: antianginal, antihypertensive, calcium channel blocker Action :antihypertensive agent that inhibits calcium ion movement across cell membranes, depressing contraction of cardiac and vascular smooth muscles Therapeutic effect: decreases blood pressure Indication: chronic stable angina, hypertension Contra- indication: severe hypotension Side effects: peripheral edema, headache, dizziness, (occasional): nausea, muscle cramps and pain, dyspnea, cough (rare): hypotension, rash, constipation, sexual difficulties Nursing management: administer on an empty stomach Do not crush or chew sustained release dosage forms

2. Furosemide

Novosimide; PMS-Furosimide Classification: Loop diuretics Indications:

Edema

d/t

heart

failure,

hepatic

impairment

or renal disease. Hypertension. Action: Inhibits the reabsorption of sodium and

chloride from

the loop of Henle and distal renal tubule. Increases

renal

excretion of water, sodium, chloride, magnesium, potassium, and calcium. Effectiveness persists in impaired renal function. Decreased blood pressure. Dosage: 1 tablet, 200 mg Contraindication: Hypersensitivity; Cross-sensitivity with thiazides and sulfonamides may occur; Hepatic coma or anuria; Some liquid products may contain alcohol, avoid in patients with alcohol intolerance. Precautions: Severe liver disease; electrolyte depression Side effects: CNS – blurred vision, dizziness, head ache, vertigo 20

EENT – hearing loss, tinnitus CV – hypotension GI – anorexia, constipation, diarrhea, dry mouth, nausea, vomiting GU – excessive urination Derm – photosensitivity, rash F and E – dehydration Nursing Responsibilities: 1. Assess fluid status. Notify physician or other health care professional if thirst, dry mouth, hypotension, or oliguria occurs. 2. Monitor blood pressure and pulse before and during administration. 3. Monitor blood glucose closely; may cause increased blood glucose level. 4. Caution patient to change positions slowly to minimize orthostatic hypotension. 5. Advise patient to contact health care professional immediately if muscle weakness, cramps, nausea, dizziness and numbness occurs. 6. Caution older patients or their caregivers about increased risk for falls.

3. tab pantop

Generic name: pantoprazole Functional class: proton pump inhibitor Action: it inhibits the secretion of hcl in the stomach by specific action on the proton pumps of the patietal cells. Dose and routes: Adult: 40 mg/day (PO) In pathological hypersecretory conditions: adult I/V 80 mg over 12 hours Indication: Peptic ulcer,zollinger ellison syndrome, NSAIDS associated peptic ulcer Contraindication: lactation, hypersensitivity to drug Side effects: CNS: headache, insomnia, mental depression, confusion GI system: diarrhea, abdominal pain, constipation INTEG: rash, peripheral edema Muscular system: myalgia( pain in the muscles) 21

4. diclofenac gel therapeutic class: NSAID, antipyretic, non narcotic analgesic action: NSAID that inhibits prostaglandin synthesis reducing the intensity of pain therapeutic effect: produces analgesic and anti-inflammatory effects indication: osteoarthritis, rheumatoid arthritis, pain, primary dysmennorrhea contra indication: hypersensitivity to aspirin, diclofenac side effects: headache, abdominal cramps, constipation, diarrhea, nausea

5. Domperidone

Motilium (1 tab, 100 mg) Classification:

Anti-emetic

and

anti-vertigo

Mode of Action: Domperidone is a dopamine-receptor blocking agent. Its action on the dopaminereceptors in the chemo-emetic trigger zone produces an anti-emetic effect. Interactions: 

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



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



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



Since MOTILIUM has gastro-kinetic effects, it could influence the absorption of concomitant orally administered medicines, particularly those with sustained release or enteric coated formulations.



As MOTILIUM interferes with serum prolactin levels, it may interfere with other hypoprolactinaemic agents and with some diagnostic tests.



Antacids and anti-secretory agents lower the oral bioavailability of domperidone. They should be taken after meals and not before meals, i.e. they should not be taken simultaneously with MOTILIUM.

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

Reduced

gastric

acidity

impairs

the

absorption

of

domperidone.

Oral bioavailability is decreased by prior administration of cimetidine or sodium bicarbonate Side Effects: 

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



Abdominal cramps have been reported.



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



Where the blood brain barrier is not fully developed (mainly in young babies) or is impaired, the possible occurrence of neurological side-effects cannot be totally excluded

Nursing Responsibilities: 1. Assess for extra-pyramidal effects such as jerking and tongue protrusion. 2. Check for hypotension.

6. Haloperidol

Therapeutic class: antipsychotic Action: an antipsychotics agent that competitively block postsynaptic dopamine receptors Therapeutic effect: produces tranquilizing effect Indication: treatment of psychotic disorders Contra indication: CNS depression, hepatic disease Side effects: blured vision, constipation, dry mouth, peripheral edema, difficulty urinating, decreased thirst, dizziness, drowsiness Nursing consideration: 

take with food or milk



donot mix liquid formulation with coffee or tea



use a sunscreen during sun exposure to prevent burns

7. inj. Novapid 4 units Func class: antidiabetic Chem.. class: exogenous unmodified insulin

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

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Uses: DM type 1 and 2 Doses and routes: Adult: subcut dosage individualized, give within 15 min before or 20 min after starting a meal Side effects: EENT: blurred vision, dry mouth INTEG: flushing, swelling, redness META: hypoglycemia SYST: anaphylaxis Contraindication: hypersensitivity to protamine Precaution: pregnancy Nursing Interventions: 1. Assess for symptoms of hypoglycemia such as: anxiety, restlessness, tingling in hands, feet, lips or tongue, chills, cold sweat, confusion, pale skin, difficulty in concentration, drowsiness, excessive hunger, head ache, irritability, nightmares or trouble sleeping, nausea,. 2. Assess for symptoms of hyperglycemia: confusion, drowsiness, flushed and dry skin, rapid deep breathing, polyuria, loss of appetite, nausea & vomiting, unusual thirst. 3. Monitor body weight periodically. Changes in weight may necessitate changes in insulin dose. 4. Monitor blood glucose every 6 hours during therapy. 6.

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

7.

Rotate site of infection.

8.

Instruct patient on proper techniques for administration.

9.

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

6) SUMMARY OF CLIENT DAILY PROGRESS REPORT IN HOSPITAL

DATE

TIME

04/O8/068

2am

TEMPERATUR PULSE E 98 degree F 80/m

RESPIR ATION 20/m

BP

SUMMARY

200/80mm Pt’s g/c is seems of hg satisfactory, vital signs monitored with rise in 24

6pm

04/09/068

04/10/068

04/11/068

97.6 degree F

88/m

28/m

210/80 mm of hg

blood pressure. Prescribed medicine carried out. Input and output chart maintained. Paln for haemodialysis tomorrow. No any complain from the patient side.

12:30p 98 degree F m

82/m

24/m

210/100 mm of hg

1:20p m

98 degree F

90/m

20/m

210/100 mm of hg

2pm

98 degree F

100/m

22/m

6pm

101.6 degree F

110/m

24/m

200/90 mm of hg 210/80 mm of hg

10am

97 degree f

90/m

20/m

210/90 mm of hg

2pm

97 degree f

88/m

20/m

210/90 Pt’s general condition is mm of hg satisfactory. Vital signs are taken with rise in blood pressure. prescribed medicine carried out. Normal bowel and bladder habit. Patient complain is dry and itching over skin of

pt’s g/c seems satisfactory. Vital signs are taken and recorded with rise in blood pressure. haemodialysis done. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side. Pt’s g/c is satisfactory. Vital signs are taken and recorded with rise in blood pressure and temperature. Tab paracetamol and cold compresses given to the patient.All prescribed medication was carried out. Patient is on normal diet.

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04/12/068

10 am

97 degree f

92/ min

20/min

2pm

98 degree f

88/min

20/min

04/13/068

10am

98 degree f

80/min

22/min

04/14/068

10 am

97 degree f

80/ min

20/min

2pm

98 degree f

76/min

20/min

10am

98 degree f

78/min

22/min

04/15/068

hands and legs. So he is in dermatology consultation. Dermatology department prescribed him coconut oilto apply in itching and dry areas three times a day. 180/80 pt’s g/c seems satisfactory. mm of hg Vital signs are taken and recorded with rise in blood pressure. haemodialysis done through left femoral vein. Put the sand bag pressure at the femoral site for 2 hours. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side. 180/70 mm of hg 150/90 Patient general condition mm of hg seems satisfactory. Vital signs taken with rise in blood pressure. Prescribed medicine carried out. Normal bladder habit but bowel habit is disturbed.no any such complain from patient side 140/80 Patient general condition seems mm of hg satisfactory. Patient general condition seems satisfactory. Vital signs taken with rise in blood pressure. Prescribed medicine carried out. Normal bowel and bladder habit. No any itching on the patient’s skin 170/70 mm of hg 190/80 pt’s g/c seems satisfactory. mm of hg Vital signs are taken and recorded with rise in blood pressure. haemodialysis done through left femoral vein.dialysis three times a 26

week that is on Sunday,Wednesday and Friday. Patient in normal diet. Prescribed medication carried out. No any specific complain from patient side. 04/16/068

04/17/068

10 am

97 degree f

80/ min

20/min

2pm

98 degree f

88/min

20/min

10am

98 degree f

90/min

22/min

190/70 mm of hg 180/60 mm of hg

180/70 mm of hg

Pt’s g/c is improved. Vital signs taken with rise in blood pressure. All prescribed medication was carried out. . Discharge on o4/17/068. Patient general condition seems fair. Vital signs are taken and recorded with rise in blood pressure.prescribed medicine carried out,normal bowel and bladder habit.dialysis three times a week. That is on Sunday, Wednesday and Friday. Follow up on medical out patient department on Monday or Thursday.

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

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

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 Group therapy: I gave many examples of other people having the same disease condition and also introduced him with some of them so that he can realize that many others have and share problems which are very similar to their own problems and that they are not alone in their suffering.  Relaxation training: I encouraged my patient for performing yoga and meditation as relaxation produces physiological effect that are opposite to those anxiety, that is slow heart rate, increased peripheral blood flow.  Psychological therapy: I encourage my patient to express his feelings and attitude, and communicate with the care takers as well as the family members. Because of this his psychological depression can be reduced and he feels better. 

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



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

APPLICATION OF NURSING THEORIES Virginia Henderson’s Independent Theory: In 1955, Henderson formulated unique function of nursing, she purposed 14 components of Basic nursing care. The components are as follows:  Breathe normally.  Eat and drink adequately  Eliminate body wastes  Move and maintain desirable postures. 28

 Sleep and rest  Select suitable clothes- dress and undress  Maintain body temperature within normal range by adjusting clothing and modifying the environment.  Keep the body clean and well groomed and protect the integument.  Avoid danger in the environment and avoid injuring others.  Communicate with others in expressing emotions, needs, fear or opinion.  Worship according to one’s faith.  Play or participate in various forms of recreation.  Learn, discover or satisfy the curiosity that leads to normal developmental and health and use of the available facilities.

APPLICATION OF THEORY ON MY PATIENT  Breath normally:- I encourage my patient to do deep breathing and coughing exercise. This helps to promote lung expansion and gases extent and also help to loosen and bring out secretion.  Eat and drink adequately:- I encourage my patient to eat and drink adequately according to body needs and the patient food habit was well maintained.he was prescribed to have fluid less than 500ml/day 29

 Eliminate body waste:- My patient bowel and bladder habit was normal so his eliminate body waste pattern was well maintained.  Move and maintain desirable posture:- I helped my patient to move and maintain the desirable position  Sleep and rest: I encouraged patient to take a adequate rest and sleep according to body need and disease condition for a positive health.  Select suitable clothe and dress:- Suitable clothe was selected.  Body cleanliness:- I encourage my patient to keep her body clean.  Avoid danger in the environment and avoid injuring others: sometimes my patient shows aggressive behavior so antipsychotics drugs were prescribed to my patient to avoid danger in the environment and also to avoid injuring others.  Communicate with others in expressing emotions, needs, fear or opinion:- As my patient was able to communicate, his communication pattern was maintaining.  Worship according to one’s faith  Play or participate in various forms of recreation:- This component help me inspire my patient to write new poems, story and jokes.

9) NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATIO N

RATIONAL

EVALUATI ON

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

Excess fluid volume related to fluid

Patient will maintai n fluid

-assess weight, lung sounds and extremities for presence of

-weight, lung sounds and extremities was assessed for

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

My goal was fully met as patient is 30

swelling” objective data: patient’s face and hand was swelling

accumulatio n between dialysis treatments.

volume status within establis hed paramet ers.

edema

presence of edema. -input and output was monitored.

-monitor intake and output. Some patient continue to urinate small amounts, but it is inadequate to clear all waste products. -monitor -laboratory data laboratory data: was monitored blood urea,nitrogen,ser um creatinine,sodiu m,potassium,cal cium,hb,etc

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

free of peripheral edema.

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

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

-fluid restrictions between treatment was maintained. -the need for restricting sodium intake was teached.

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

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATIO N

RATIONAL

EVALUATI ON

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

Risk for skin integrity related to alterations in skin turgor

Patient will maintai n an intact skin

-inspect skin for changes in colour,turgor,va scularity,note redness -monitor fluid intake and

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

-indicates areas of poor circulation/breakdo wn that may lead to infection. -detects presence of dehydration or

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

objective data:

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patient’s hand and face was swelling

(edema)

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATIO N

RATIONAL

EVALUATI ON

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

Risk for injury related to infection

Patient will be free of infectio n

-assess skin , nothing redness,swelling ,local warmth,tendern ess -avoid

-nothing redness,local warmth,tenderne ss and skin was assessed

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

-Aseptic

-prevents

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

objective data:

hydration of skin and mucous membranes -inspect dependent areas for edema. Elevate legs as indicated.

skin and mucous overhydration that membranes was affect circulation monitored. and tissue integrity at the cellular level. -dependent areas -edematous tissues for edema was are prone to inspected and breakdown. legs was Elevation promotes elevated as venous return, indicated. limiting venous stasis,edema - provide formation. soothing skin -soothing skin -lotions and care. Restrict care was ointment may be use of soaps. provided and desired to relieve Apply ointments creams, dry,cracked skin. or creams. ointments was -keep linens dry, applied. wrinkles free -linens were -reduces dermal kept dry and irritation and risk of -investigate wrinkles free. skin breakdown. reports of - reports of -although dialysis itching itching was has largely investigated eliminated skin problems associated with uremic frost,itching can occur because the skin is an excretory route for waste - suggest products. wearing loose - loose fitting -prevents direct fitting cotton cotton garments dermal irritation garments were suggested and promotes to wear. evaporation of moisture on the skin.

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patient’s neck was red.

contamination of assess site. Use aseptic technique and masks when applying/changi ng dressings and when starting/complet ing dialysis process. -monitor temperature, note presence of fever,chills

technique and masks were applied when changing dressings and when starting/complet ing dialysis process.

introduction of organisms that can cause infection.

-signs of infection/sepsis requiring prompt medical intervention. -culture the -blood samples site/obtain blood were obtained samples as indicated -administer -Medicines were medicines as administer as indicated indicated.

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

of infection

-Prompt treatment of infection may save access, prevent sepsis

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATIO N

RATIONAL

EVALUATI ON

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

Situational low self esteem related to chronic kidney failure requiring

Patient will mainati n positive body image

- monitor patients response to illness and treatments

-patients response to illness and treatments were monitored.

-allow patient to grieve over his

-patient was allowed to

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

My goal was fully met as patient verbalizes acceptance of treatment

objective data: patient looks

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depressed

machine dependency

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

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

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

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

-monitor for excessive concerns about losses,depressio n

-excessive concerns about losses, depression was monitored

recovery -demonstrate empathy and validates the patients feeling

regimen as part of lifestyle

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

ASSESSMENT

DIAGNOSIS

GOAL

PLANNING

IMPLEMENTATIO N

RATIONAL

EVALUATI ON

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

Disturbed thought processes related to accumulatio n of toxins

Patient will mainati n optimal level of mentati on

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

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

-uremic syndrome’s effect can begin with minor confusion, irritability -minimizes environmental stimuli and reduces

My goal was fully met as patient

objective data: patient looks

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

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

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

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

-promote adequate rest and sleep -prepare for dialysis

confusion -provides clues to aid in recognition of reality

-confrontation potentiates defensive reaction and may lead to pt mistrust and heightened denial of reality -may aid in reducing confusion and increases possibility that communications will be understood -sleep deprivation may further impair cognitive abilities -marked deterioration of thought processes may indicate worsening of azothemia & g/c,requiring prompt intervention to regain homeostasis

DISCHARGE TEACHING:Categories

Plan 

Medication

Instruct

patient

to

Rationale take

prescribed

-Compliance to appropriate

medications regularly and comply with

medication and treatment

the treatment regimen prescribed by the

prevents further complications

physician.

and resistance to antibiotics and promote continuous recovery of



Teach patient regarding the names of the

drug,

its

dosage,

time

of

optimal health. -The patient has the right to know

35



administration, its contraindication and

his drug’s therapeutic effects as

side effects.

well as its adverse effects. He

Inform patient and significant others not to take drugs not prescribed by the



physician. Instruct the patient to check for the expiration date of the drug before taking it.

also has the right to gain awareness about why is it given to him. -Drug interactions may occur which may be fatal to patient’s current situation. -Checking for the expiration date of the drug before administering it





Do not administer any other drug with

ensures it potency and safety. It

same action without the physician’s

also prevents any unwanted

prescription. Educate the patient and the significant

reactions like hypersensitivity. -Non-prescription drug may have

others about the expected responses of

antagonistic or synergistic effects

drug to the body, side effects, adverse

if taken with other drugs.

effects that may possibly seen into the 

patient. Instruct the significant others to report any remarkable adverse reactions or

-To be geared up of enough information that may lead to immediate medical responses.

any appearance of side effects noted. -For immediate remedial action response and to prevent any  Explain to patient the significance of

Exercise

and

circulation and prevent arterial and

stretching. If unable to mobilize alone,

venous stasis thus lessens platelet

instruct the watcher to give assistance

coagulation to aged people. Older

all the time. Encourage to use crutches

people have weakened blood

or any device for support. Stretching

vessel walls which can cause any

upper extremities also promote healthy

alteration in blood flow.

living. Also instruct patient to perform

Also exercise prevents atrophy of

passive range of motion.

the muscles.

Teach patient to wait for 1 to 2 hours

-Older people has slower digestion

after

rate, thus they need to conserve

regular



complicated reactions. -Exercises promote proper blood

exercise

eating

like

before

physical activities.

walking

performing

any

more oxygen which will be necessary for digestion of food. Activities must be limited to

36

decrease oxygen demand by organs and tissues other than the digestive system. Instruct the patient to practice deep breathing exercise.

-Deep breathing exercises promote thoracic expansion which allows air to enter the respiratory tract and provide oxygen to the alveoli to avoid atelectasis or lung collapse due to increase fluid pressure in

Treatment



Instruct patient to comply with his

the pleural space. -Maintenance meds should not be

medication treatment like the continuous

forgotten to achieve highest

use of beta blocker Metoprolol for

therapeutic effect.

control of hypertension and Insulin for diabetes mellitus. 

Instruct client to seek medical help if any

-These unusualties may be

unusualties are felt such as tingling

indicative of worsening condition.

sensation or paresthesia, fatigue and body malaise, dizziness, headaches, irritability, tremors, diaphoresis, etc. 

As part of long-time treatment, advise

-Medical alert bracelet provides

patient to wear medical alert bracelet all

basic information about the client in

the time and wherever he goes. It

case of accidents.

contains the patient’s name, disease condition, address and contact person. 

Advise to have a family member take your blood pressure to check if you’re

-Monitor of blood pressure is

maintaining a stable blood pressure.

significant for evaluating the medication’s effectiveness.



Since the client has his own glucose

-Glucose monitoring is a big factor

monitor, tell client to continue monitoring

in the management of diabetes

blood glucose level, and immediately

mellitus.

seek Hygiene



for

medical

help

if

level

is

abnormally high. Instruct patient to practice foot care to

-Proper foot care prevents injury to

prevent ulceration and formation of

feet and toes.

gangrenous

tissues

to

the

lower

37

extremities. - Check and carefully wash your feet every day. -Do not wear shoes that are too small or socks that do not fit right inside your shoes. -Soak your feet in warm soapy water for 10 minutes before cutting your nails. Trim your toenails straight across to prevent ingrown toenails. You may also file down your toenails. Do not cut your nails into the corners or close to the skin. You should not dig under or around the nail. 

Emphasize the importance of bathing

-Proper bathing eliminates

everyday. Wash genitals with mild soap.

proliferation of germs and bacteria in the body. Mild soap does not irritate the skin and the genitals.

 

Instruct client to maintain good oral

-Tooth brushing prevents build up

hygiene.

of plaques and cavities.

Instruct to wear clean clothes and

-Dirty or improperly washed

underwear.

underwear may become a sanctuary for microbial growth. Microbes may enter the genitals and might worsen the client’s

Out-Patient Referral

 Encourage patient to undergo physical therapy sessions.

UTI/Cystitis. -A Physical Therapist is a source of information to understand agerelated changes and offer assistance for regaining lost abilities or develop new ones. Physical therapy can be applied to the client’s condition: arthritis, urinary and fecal incontinence,

38

amputation, and cardiac and pulmonary disorders. It can : a). increase, restore or maintain range of motion, physical strength, flexibility, coordination, balance and endurance b.) aids adaptations to make the home accessible and safe teach positioning, transfers, and walking skills c.) promote maximum function and independence within an individual's capability d.) increase overall fitness through exercise programs e.) prevent further decline in functional abilities through education, energy conservation techniques, joint protection, and use of assistive devices to promote independence f.) improve sensation, joint proprioception g.) reduce pain  Advise to have check-ups after discharge.

-Serves as an evaluation process to note if condition has progressed to better or worse.

 Advise to have regular laboratory exams

-To assess for renal function.

for creatinine, albumin, sodium, potassium and calcium.  Encourage to undergo ABG Test every Diet

month or once every 2 months.  Instruct client to avoid simple sugars.

-Simple sugars easily break down

Take energy from complex carbohydrates

and enter the blood stream.

like unpolished rice, bread and

Complex carbohydrates can

vegetables.

sustain the body’s energy requirement for a longer time

39

because they are not broken down easily.  Encourage patient to eat fibrous foods

-A diet rich in fiber relieves

like fruits and vegetables. But do not eat

constipation. It adds bulk to the

too much as it can irritate the GI tract and

excreta and facilities expulsion.

causes bleeding. Other examples of sources of fiber are: whole grains, cereals and legumes.  Limit intake of purine rich foods such as

-Accumulation of uric acid in the

liver, beef kidneys, brains and meat

joints causes arthritis. Uric acid is

extracts. Encourage to eat in moderate

the by product of purine break

amount: asparagus, cauliflower, spinach,

down in the liver. Because of renal

mushrooms, green peas, dried peas and

malfunction, uric acid is retained in

beans.

the blood stream and is shunted to connective tissues.

WHAT I LEARNED FROM THIS CASE STUDY:Case study is the comprehensive study of one selected patient and comparative study with books. During my case study, I learned the following things. i. About the disease:I got opportunity to read and gain comprehensive knowledge through various books, literatures, teachers, doctors, ward staffs, colleagues and via. Secondary internet. I also obtained a comprehensive knowledge on the disease its treatment and management. ii. About the patient:My patient was a open book to learn for me, as I got an opportunity in learning through involving patients care, treatment, diversional therapy and teaching not only from patient but also from his family member. I learned personal quality of patient and use the information in treating her. I also taught the families, socio cultural, economical, religious and traditional beliefs of the patient which influence her health. iii. About nursing care:I applied holistic approach while giving nursing care to the patient. I followed the theorie of Henderson in providing nursing care and I gained more knowledge and skill. iv. About documentation.

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

Heredity Glomerular dysfunction Diabetic nephropathy Hypertension Glomerulonephritis Polycystic kidney disease Urinary tract obstruction Bladder tumour Urethral obstruction Hypertensive nephrosclerosis (hardening of the kidney) are some of the causes of chronic kidney disease The clinical features of ESRD are: weakness and fatigue, confusion, seizures, burning soles of feet, thin, brittle nails, hypertension,periorbital oedema,etc

It can be investigate through laboratory test such as cbc, urinalysis, blood urea ,ultrasonography, kub film etc. During my case study, I provided health education, applied different diversional measures, treatment, investigation, diet, personnel hygiene etc. I feel great pleasure whenever patient and his family get treatment satisfaction and getting better. His general condition was improved so he was discharged. 41

13) REFERENCES  Nursing care plan, Marilynn E. Doengs, Mary. Francesmoorhoose, Alice C. Geissles. Murs 6th edition  Rai lalita “nursing concept theories and principles”; 1st edition  Helth learning materials centre Tu, institute of medicine, maharajgunj, ktm, textbook of adult helath nursing  Mosby’s nursing drug reference,2007  Phipps Monahan and sands marek neighbors”medical surgical nursing health and illness perspectives” 7th edition, page 1260 to 1271  A Lippincott manual ”the Washington manual of medical therapeutics”,33rd edition, page 430 to 433  http://www.emedicinehealth.com/chronic_kidney_disease/page2_em.htm  http://www.ehttp://www.emedicinehealth.com/chronic_kidney_disease/page4_em.htmmedicineh ealth.com/chronic_kidney_disease/article_em.htm  http://en.wikipedia.org/wiki/Chronic_kidney_disease

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