Abra Valley Colleges

Bangued, Abra

In Partial Fulfillment of the Requirements

in

NCM 103 (RLE)

A Case Study about

END STAGE RENAL DISEASE

Presented to:
The Nursing Faculty of Abra Valley Colleges
Bangued, Abra

Presented by:
BSN III - Group II
Leslie Mae M. Pimentel - Leader
Creighton A. Bayongan – Asst. Leader
Christian D. Adres
Josephine B. Barber
Jhennyffer L. Barcena
Cristy A. Baris
Arlene A. Bigornia
Shielo M. Bogac
Harold John B. Bunagan
Marife B. Delos Reyes
Harmony Cristie V. Gonzalo
Mediatrix G. Pasiguen
Roxan G. Siwao

October 2010
I. INTRODUCTION

Chronic Renal Failure is usually the result of a gradually progressive loss of renal function, it
occasionally results from a rapidly progressive disease of sudden onset. Few symptoms develop
until after more than 75% of glomerular filtration is lost; then the remaining normal parenchyma
deteriorates progressively, and symptoms worsen as renal function decreases.

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal
physiologic changes in all major organ systems. If the patient can tolerate it, maintenance
dialysis or kidney transplantation can sustain life.

Stages of CRF:
1. Reduced Renal Reserved- GFR of 40-70 mL/min
2. Renal Insufficiency- GFR of 20-40 mL/min
3. Renal Failure – GFR of 10-20 mL/min
4. ESRD- GFR of less than 10 mL/min

Significance of the Study

1. To discuss Chronic Renal Failure its causes, risk factors, complications and surgical
management.
2. To know the Pathophysiology of Chronic Renal Failure
3. To know the anatomy and physiology of the organ/s involved.
4. To be familiar with the medications given to our patient.
5. To effectively use the nursing process in providing holistic care to our patient.
6. To impart knowledge to fellow student nurses to help strengthen their role as health
educators in all health care settings.

Risk factors
 Age  Kidney diseases
 Gender  DM
 Alcoholism  Hypertension
Causes: CRF arises from seven C’s
1. Chronic Glomerular Disease such as AGN and CGN
2. Chronic Infections such as pyelonephritis & TB
3. Congenital Anomalies such polycystic kidney disease
4. Calculi Obstruction
5. Collagen Disease such as SLE
6. Chronic used of Nephritic Drugs such as aminoglycosides
7. Chronic Endocrine Disease such as Diabetes Neuropathy
Signs and Symptoms: Systemic
 Neurologic System:  Gastrointestinal System :
o Listlessness o Metallic taste
o Attention deficit o Ammonia/acetone breath
o Seizure o N/V
o Burning pain o Inflammation
o Irritability o Constipation
o Twitching o Anorexia
o Confusion/ Coma o GI bleeding
o Hiccups.  Integumentary System:
 Pulmonary System: o Dry skin
o Difficulty of breathing o Uremic frost skin
o Insufficient breath sound o Severe itching
o Crakles/Rales o Thin and brittle hair
o Kussmaul’s respiration o Yellow bronze skin
 Cardiovascular System:  Genito-Urinary System:
o Cardiac failure o Anorea
o Hypotension/hypertension o Changes in the urine
o Anemia
appearance/pattern
o Weight gain
o Impotence/Infertility
o Pulse irregularity
o Diluted urine with cast and
o Arrthymia.
crystals.
 Musculoskeletal System :
o Gait abnormality
o Abnormal fracture
o Inability to ambulate
o Muscle cramps/spasms.

Possible Complications
 Anemia
 Bleeding from the stomach or intestines
 Heart and blood vessel complications
o High blood pressure
o Pericarditis
o Stroke
 Increased risk of infections
 Malnutrition
 Seizures
 Weakening of the bones and increased risk of fractures
II. PATIENT’S PROFILE

Hospital #: 914104
Name: Mrs. DOB
Birthdate: March 15, 1972
Age: 38
Birthplace: Mindanao
Address: Kimpal, Lagangilang, Abra
Sex: Female
Civil Status: Married
Religion: UCCP
Nationality: Filipino
Date and Time of Admission: September 14, 2010 @ 9:35 am
Chief Complaint: DOB 1 day PTA
Ward: ICU
Admitting Diagnosis: End Stage Renal Disease (ESRD)
Final Diagnosis: End Stage Renal Disease (ESRD)
Physician: Dr. AT
III. HISTORY OF PAST AND PRESENT ILLNESS

A. History of Past Illness

Our patient had experience mumps, chicken pox and seasonal cough and colds as
well as fever during her childhood and used to manage these illnesses by home
remedies such as using available health resources by means of using herbal plants that
they believe can treat the said illnesses. According to her she had completed her
childhood immunization. She also claims that she had no known allergies to food and
drugs. But she claims that she is hypertensive since then. Our patient was diagnosed
with CRF and with a stage of ESRD @ metro Vigan. IVP was performed and this
confirms the diagnosis of our patient. According to our patient she’s in and out of the
hospital many times. Due to her condition, our patient had been advised to have an
AV fistula @ Metrovigan on January 10, 2010 at the left hand as an access for her
dialysis.
Few months later it was damaged with unrecalled reason , and her attending
physician suggested that they must have another access for her dialysis then they
inserted a catheter on her intrajugular vein on the left side of her neck, since then
they used it every time she’s undergoing dialysis, her lasts dialysis was on September
07, 2010 @ APH.

B. History of Present Illness

Our patient with her husband went at APH because she experienced DOB. She
was given initial treatment of D5W 1L X KVO regulated @ 10 gtts/min. hooked at
the right metacarpal vein infusing well, and O2 inhalation was hooked via NC at 3-4
Lpm. She was then admitted on September 14, 2010 @ 9:35 am with an admitting
diagnosis of ESRD by Dr. AT. She was forwarded at ICU and stayed there for28 days.

C. Familial History
According to our patient, both his paternal and maternal side had no known
serious diseases such as heart attack, diabetes mellitus, and cancer but claims that her
maternal side had a history of hypertension. They also experienced common illnesses
such as cough and colds, and fever which they treated with herbal medications.

D. Social History
According to our patient she got married when she was 25 and God gave them 3
children, a girl and a twin boy. Farming is the primary source of their food and
income to support their needs. She also claims that she had a good relationship with
her neighbors. She is fund of eating salty foods and often used “bagoong” as sauce in
anything she eats she also says that she loves soft drinks.
IV. NURSING ASSESSMENT (September 23, 2010 @ 8:00 am)

A. Maslow’s Hierarchy of Needs:

1. Physiologic Needs
O2 inhalation was hooked via NC @ 3-4 Lpm. DAT was maintained.
Wasn’t able to pass out urine and stool. She remains silent when asked about her
sexual life.

2. Safety and Security

Our patient feel safe and secured in the presence her husband who is
always there to accompany her in performing activities of daily living such as
toileting, feeding, and hygiene.

3. Love and Belongingness

Aside from her husband our patient, also felt the love rendered by the
health care providers in the hospital. Rapport was established by the staffs and
students nurses in order to obtain accurate information regarding his condition.

4. Self-Esteem
“Sakno ngatan Deng, kastoy met ti kasasaad kon?” as verbalized by the
patient which is an expression of diminishing self-esteem.

5. Self-Actualization
According to our patient, she will be self-actualized if she will be treated
and to see her children finished their studies.

B. Physical Assessment
1. General Survey
 Our patient is a 38 year old, female she appears weak and often complaints
difficulty of breathing. Generalized edema was seen.

Vital Signs:
BP: 130/90 mmHg Temp.: 37.5 °C
PR: 76bpm RR: 42 cpm

2. Cephalocaudal Assessment
Integumentary System:
 Poor skin turgor noted and anasarca.
Head:
 Round in shape.
 Hair is short and brittle with white hair noted
 Evenly distributed.
Eyes:
 Both eyes reveals that pupils are equally round reactive to light
accommodation upon assessment.
 Pale conjunctiva noted.
Ears:
 Able to recognize hear and understand spoken words.
 No lumps or masses and tenderness were noted on both ears upon
palpation.
 (+) discharges noted
Nose:
 Nose is patent upon assessment.
 Upon palpation, no tenderness/masses and pain noted.
 (+) nasal flaring
 O2 inhalation via NC @ 3-4 Lpm.
Mouth and Lips:
 No lesions were found in the mouth but dry mouth is noted.
 (+) plaque noted
 Incomplete set of teeth.
Neck:
 Neck has strength when move from different directions with full ROM
 IJ catheter @ the right side with intact dressing.
Chest:
 (+) adventitious sounds upon auscultation (wheezing)
 Respiratory Rate 42 breathes per minute from the normal range of 16-
20 breaths per minute.
Abdomen:
 (-) scar noted
 (+) abdominal bloating noted.
Genitourinary:
 Never defecated and urinated during our shift
 Upper and Lower extremities:
 With an ongoing IVF of D5W1L @ 600cc level regulated @
30gtts/min @ the right metacarpal vein. Infusing well.
 (+) scars and lesions were noted.
 Warm to touch.

V. ANATOMY AND PHYSIOLOGY

Kidneys
The kidneys balance the urinary excretion of substances against the accumulation within
the body through ingestion or production. Consequently, they are major controller of fluid and
electrolyte homeostasis. The kidneys also have several non-excretory metabolic and endocrine
functions, including blood pressure regulation, erythropoietin production, insulin degradation,
prostaglandin synthesis, calcium and phosphorus regulation and Vitamin D metabolism.
The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on
either side of the ventral column. They lie between the 12th thoracic and third lumbar vertebrae.
The left kidney is usually positioned slightly higher than the right. Adult kidneys are average
approximately 11 cm in length, 5 to 7.5 cm in width, and 2.5 cm in thickness. The kidney has a
characteristic curved shape, with a convex distal edge and a concave medial boundary.
Functions of the Urinary System
The major functions of the urinary systems are performed by the kidneys and the
kidneys play the following essentials roles in controlling the composition and volume of
body fluids:
1. Excretion.
 The kidneys are the major excretory organs of the body. They remove waste
products, many of which are toxic, from the blood.
Most waste products are metabolic by products of cells and substances
absorbed from the intestine. The skin, liver, lungs, and intestines eliminate some
of these waste products, but they cannot compensate if the kidneys fail to
function.

2. Blood volume control

The kidneys play an essential role in controlling blood volume by regulating
the volume of water removed from the blood to produce urine.

3. Ion concentration regulation.

The kidneys help regulate the concentration of the major ions in the body
fluids.

4. pH regulation.
The kidneys help regulate the pH of the body fluids. Buffers in the blood and
the respiratory system also play important roles in the regulation of pH

5. Red blood cell concentration

The kidneys participate in the regulation of red blood cell production and
therefore, in controlling the concentration of red blood cells in the blood.

6. Vitamin D synthesis
The kidneys along with the skin and the liver, participate in the synthesis of
vitamin

Ureters, Urinary Bladder and Urethra

The ureters are small tubes that carry urine from the renal pelvis of the kidney to the
posterior inferior portion of the urinary bladder. The urinary bladder is a hollow muscular
container that lies in the pelvic cavity just posterior to the pubic symphysis. It functions to store
urine, and its size depends on the quantity of urine present. The urinary bladder can hold from a
few milliliters to a maximum of about 1000 mL of urine. When the urinary bladder reaches a
volume of a few hundred mL, a reflex is activated, which causes the smooth muscle of the
urinary bladder to contract and most of the urine flows out of the urinary bladder through
urethra. The urethra is a tube that exits the urinary bladder inferiorly and anteriorly. The triangle-
shaped portion of the urinary bladder located between the opening of the ureters and the opening
of the urethra is called trigone. The urethra carries urine from the urinary bladder to the outside
of the body.

Renal Blood flow and Glomerular Filtration

The kidney receive 20% to 25% of the cardiac output under resting conditions, averaging
more than 1 L of arterial blood per minute. The renal arteries branch from the abdominal aorta at
the level of he second lumbar vertebra, enter the kidney, and progressively branch into lobar
arteries. Blood flows from the interlobular arteries through the afferent arteriole, the glomerular
capillaries, the efferent arteriole and the peritubular capillaries. Some of the peritubular
capillaries carry a small amount of blood to the renal medulla in the vasa recta before entering
the venous drainage. The blood leaves the kidney in venous system closely corresponding to the
arterial system: interlobular veins, arcuate veins, interlobar veins, and the renal vein. The renal
circulation then empties into the inferior vena cava.
Physiology Characteristics of Urine
Urine is a watery solution of nitrogenous waste an inorganic salts that are removed from
the plasma and eliminated by the kidneys. It is 5% water and 5% dissolved solids and gases. The
amount of these dissolved substances is indicated by it specific gravity. The specific gravity of
pure water, used as a standard is 1.000. Because of the dissolved materials it contains, urine has a
specific gravity that normally varies from 1.010 to 1.040. When the kidneys are diseased, they
lose the ability to concentrate urine, and the specific gravity no longer varies as it does when the
kidneys function normally.

Urine formation
The chief function of the kidneys is to produce urine. Each part of the nephrons performs a
special function. There are three important processes by which urine is formed. They are glomerular
filtration, tubular reabsorption and tubular secretion.

The Path of the Formation of Urine

Blood enters the Efferent arterioles

Passes through the Glomeruli

 To Bowman’s capsule

Now it becomes filtrate (blood minus RBC’s and plasma protein protein

Continues through the proximal convulated tubule

To the loop of Henle

To the distal convulated tubule

To the collecting tubule (at this about 99% of the filtrate has been reabsorbed)

Approximately 1 ml of urine is formed per minute and goes to the renal pelvis

To the ureter

To the bladder

To the urethra

To the urinary meatus

VI. PATHOPHYSIOLOGY

Predisposing factors Precipitating factors

- Age (54) - Lifestyle
- Gender (Male) - Diet (salty foods)
- -

Renal Malfunction

Nephrons are permanently destroyed

Kidneys become unable to respond to excessive or decreased salt and fluid intake

Synthesis of erythropoietin diminishes, and the kidneys are unable to excrete end products of
metabolism

Number of substances that are normally excreted accumulate in the body, including nitrogenous waste,
electrolytes, and uremic toxins

Signs and Symptoms

Musculoskeletal System Pulmonary System

 Gait abnormality  DOB
 Inability to  Insufficient breath
ambulate sound
 Loss of muscle  Kussmaul’s
strength respiration

Integumentary System Cardiovascular System
 Dry Skin  Hypertension
 Uremic frost skin  Anemia
 Severe itching  Weight gain
 Thin and brittle hair  Pulse irregularity
 Yellow bronze skin  Arrhythmia
 

Genitourinary System Gastrointestinal System

 Changes in urine  Ammonia breath
pattern  Anorexia

Neurologic System
 Leastlessness
 Attention deficit
 Irritability

Management
 Dialysis
 Medications
- Paracetamol 300mg IV qq 4˚
- Hydrocortisone 100mg IV qq 6˚
- Ranitidine 50mg IV qq 12˚
- Furosemide 20mg IV OD
- Calcium Carbonate 1 tab TID
- Sodium Bicarbonate 1 tab TID
- Salbutamol nebule 2.5cc qq 4˚
-

Untreated
 Complications may occur
 Anemia
 Bleeding from the stomach or
intestine
 Heart and blood vessel
complications:
- High blood pressure
- Pericardidits
- Stroke
 Increased risk in infections
 Malnutrition
 Seizures
 Weaking of the bones and increase
risk of fractures
 Possibly death
VII. DIAGNOSTICS EXAMS
A. Ideal
 Urinalysis
This test detects ion concentration of the urine. Small amounts of protein or
ketoacidosis tend to elevate results of the specific gravity. Specific gravity is an
expression of the weight of a substance relative to the weight of an equal volume of
water. Water has a specific gravity of one. The specific gravity of your urine is
measured by using a urinometer. Knowing the specific gravity of your urine is very
important because the number indicates whether you are hydrated or dehydrated. If
the specific gravity of your urine is under 1.007, you are hydrated. If your urine is
above 1.010, you are dehydrated.
 Renal Scan
A Renal Scan is used to help diagnosis kidney disease and certain problems
with the rest of the urinary tract. It is primarily used to evaluate the function and size
of the kidneys.
 Complete Blood Count
A complete blood count (CBC), also known as full blood count (FBC) or full
blood exam (FBE) or blood panel, is a test panel requested by a doctor or other medical
professional that gives information about the cells in a patient's blood. A scientist or lab
technician performs the requested testing and provides the requesting medical
professional with the results of the CBC. Blood studies show elevated blood urea
nitrogen, serum creatinine, and potassium levels; decreased arterial pH and bicarbonate;
and low hemoglobin (Hb) level and hematocrit (HCT).
 Urine Culture
 A urine culture is a diagnostic laboratory test performed to detect the presence
of bacteria in the urine (bacteriuria). There are several different methods for
collection of a urine sample. The most common is the midstream clean-catch
technique. Hands should be washed before beginning. For females, the external
genitalia (sex organs) are washed two or three times with a cleansing agent and rinsed
with water. In males, the external head of the penis is similarly cleansed and rinsed.
The patient is then instructed to begin to urinate, and the urine is collected midstream
into a sterile container. In infants, a urinary collection bag (plastic bag with an
adhesive seal on one end) is attached over the labia in girls or a boy's penis to collect
the specimen.
 Intravenous Pyelogram (IVP)
An intravenous pyelogram (also known as IVP, pyelography, intravenous
urogram or IVU) is a radiological procedure used to visualize abnormalities of
the urinary system, including the kidneys, ureters, and bladder.
An injection of x-ray contrast media is given to a patient via a needle
or cannula into the vein, typically in the arm. The contrast is excreted or removed from
the bloodstream via the kidneys, and the contrast media becomes visible on x-rays
almost immediately after injection. X-rays are taken at specific time intervals to
capture the contrast as it travels through the different parts of the urinary system. This
gives a comprehensive view of the patient's anatomy and some information on the
functioning of the renal system.
 Renal function Test
Renal function test are used to determine effectiveness of the kidney’s
excretory functioning, to evaluate the severity of kidney’s disease and to follow the
patient’s progress.
 ABG Analysis
Blood is taken from an artery in wrist, arm or groin. The blood is tested for the
amount of gases in it, such as oxygen, acids and carbon dioxide as well as the pH of
the blood that provides a means of assessing the adequacy of ventilation and
oxygenation.
 B. Actual

URINALYSIS (September 15, 2010)

LAB TEST RESULT NORMAL VALUE SIGNIFICANCE
COLOR Straw , light yellow Amber straw significant
TRANSPARENCY Slightly turbid Clear significant
ALBUMIN +++ Negative significant
PUS CELLS 1-2/hpf 0-1hpf significant
RBC 1-3/hpf Negative significant
BACTERIA ++ Negative significant
EPITHELIAL + Negative Significant
CELLS

Interpretation:
Laboratory results revealed that there is the presence of albumin in the blood which
indicates that the glomerulus cannot filter large molecules such as that of albumin. It also
revealed that there is bacterial infection as evidenced by the presence of bacteria, pus cells and
red cells in the urine.

HEMATOLOGY (September 15, 2010)

RESULT NORMAL VALUES SIGNIFICANCE
WBC 7.4 103/mm3 4.0-11.0 Non-significant
RBC 2.23 L 10 6/mm3 3.80-5.80 Significant
HGB 6.8 L g/dL 12.0-17.0 Significant
HCT 18.3 L % 36.0-52.0 Significant
PLT 241 10 3/ mm3 150-450 Non-significant
PCT .179 % .100-.500 Non-significant
MCV 82 um3 80-97 Non-significant
MCH 30.3 pg 26.5-33.5 Non-significant
MCHC 36.9H g/dL 31.5-35.0 Significant
RDW 17.7H % 10.0-15.0 Significant
MPV 7.4 u m3 6.5-11.0 Non-significant
PDW 174% 100-180 Non-significant

Interpretation:
HCT and HGB were all below the normal level, thus indicating renal malfunction
and thereby, causing anemia (Decreased erythropoietin synthesis 2˚ to renal malfunction).

VIII. MANAGEMENT
A. Ideal Management
1. Medical
 Erythropoietin agonists - for management of anaemia associated with chronic
renal failure
 Phosphate binders - for management of hyperphosphatemia in chronic renal
failure
 Calcium supplements - for hypocalcaemia associated with chronic renal
failure
 Calcitriol and other Vitamin D supplements - for hypocalcaemia and
hyperparathyroidism associated with chronic renal failure
 Sodium bicarbonate - for acid-base disturbance
 Loop Diuretics with fluid restrictions as needed
  Use of ACE inhibitors - in patients both with and without proteinuria, has
been shown to slow the progression of renal failure
2. Surgical
 Dialysis
It refers to the diffusion of solute molecules through a semipermeable
membrane, passing from the side of higher concentration to that of lower
concentration. The purpose of dialysis is to maintain the life and well-being of the
patient. It is a substitute for some kidney excretory functions but does not replace
the kidney’s endocrine and metabolic functions.
Types:
1. Hemodialysis
In hemodialysis, the patient's blood is then pumped through the
blood compartment of a dialyzer, exposing it to a partially permeable
membrane. The dialyzer is composed of thousands of tiny synthetic
hollow fibers. The fiber wall acts as the semipermeable membrane.
Blood flows through the fibers, dialysis solution flows around the
outside the fibers, and water and wastes move between these two
solutions. The cleansed blood is then returned via the circuit back to
the body. Ultrafiltration occurs by increasing the hydrostatic pressure
across the dialyzer membrane. This usually is done by applying a
negative pressure to the dialysate compartment of the dialyzer. This
pressure gradient causes water and dissolved solutes to move from
blood to dialysate, and allows the removal of several litres of excess
fluid during a typical 3 to 5 hour treatment.
2. Peritoneal Dialysis
In peritoneal dialysis, a sterile solution containing glucose is run
through a tube into the peritoneal cavity, the abdominal body cavity
around the intestine, where the peritoneal membrane acts as a
semipermeable membrane.

 Continuous Renal Replacement Therapy (CRRT)

CRRT is a mode of renal replacement therapy for hemodynamically
unstable, fluid overloaded patients and patients with sepsis and septic shock in
management of acute renal failure especially in the intensive care unit setting.
 The popularity of ‘slow continuous therapies’ for the treatment of critically ill
patients with renal failure is increasing. The techniques which are most
commonly used are slow continuous hemodialysis and hemodiafiltration.
Slow continuous hemofiltration and slow continuous ultrafiltration also are
commonly used. Management in initial hours to counter the derangements in
critically ill patients is the most vital thing in the therapy. CRRT initiated for
ARF in critically ill patients should serve as a renal ‘replacement’ therapy
mimicking as artificial kidney support. It should enhance recovery of the
native kidneys with prevention of hyperkalemia, hyper/hyponatremia,
acidosis/alkalosis and rapid correction of pulmonary/peripheral edema by
gradual and consistent removal of extra fluid retained in the body.

 Kidney transplant
Kidney transplantation or renal transplantation is the organ transplant of
a kidney into a patient with end-stage renal disease. Kidney transplantation is
typically classified as deceased-donor (formerly known as cadaveric) or
living-donor transplantation depending on the source of the donor organ.
Living-donor renal transplants are further characterized as genetically related
(living-related) or non-related (living-unrelated) transplants, depending on
whether a biological relationship exists between the donor and recipient.

 Arteriovenous Fistula
An AV fistula requires advance planning because a fistula takes a while
after surgery to develop (in rare cases, as long as 24 months). But a properly
formed fistula is less likely than other kinds of vascular accesses to form clots
or become infected. Also, fistulas tend to last many years, longer than any
other kind of vascular access. A surgeon creates an AV fistula by connecting
an artery directly to a vein, usually in the forearm. Connecting the artery to the
vein causes more blood flow into the vein. As a result, the vein grows larger
and stronger, making repeated insertions for hemodialysis treatment easier.
 For the surgery, you will be given a local anesthetic. In most cases, the
procedure can be performed on an outpatient basis.
These fistulas require up to 6 weeks to mature before they can be used,
which makes this approach inappropriate for immediate hemodialysis.
Peritoneal dialysis or large venous access catheters may be used while the
fistula is maturing. External arteriovenous shunts are rarely used.

B. Actual
1. Medical Management
 D5W1L x 8° @ 30gtts/min @ the right metacarpal vein
 O2 inhalation was hooked via NC @ 3-4 Lpm
 Meds.
 Ranitidine HCl 50 mg IV qˉ 8°
 Hydrocortisone 50 mg qˉ 8°
 Salbutamol nebule 2.5cc qˉ 4°
 Furosemide 25 mg IV OD
 Paracetamol 300 mg IV PRN
 Calcium Carbonate 1 tab TID
 Sodium Bicarbonate 1 tab TID

2. Nursing Management
 Recognize the patient for risk of recurrence for infection
 Monitored Intake &output
 Monitored V/S every hour to serve as baseline data
 Encouraged to avoid high protein, sodium and potassium rich foods to prevent
further complications.
 Instructed to do deep breathing relaxation to promote generalized relaxation
 Positioned in semi-fowlers to promote comfort.
 Administered medications as ordered.
XI. HEALTH TEACHINGS

 Encouraged patient to do deep breathing to facilitate lung expansion.

 Instructed patient to have enough rest to gain strength.
 Instructed to avoid rich in protein, sodium and potassium foods to prevent further
complication and may slow the progress of renal failure.
 Instructed to eat nutritious foods (high in calorie diet) to strengthen the immune
system.
 Advised to drink limited amounts only when thirsty.
 Advised to eat food before drinking fluids to alleviate dry mouth.
 Advised to use hard candy, chewing gum to moisten mouth.
 Emphasized the importance of proper hygiene to promote comfort.
 Reinforced SO and patient the importance of treatment because lack of cooperation
may lead to failure of therapy.
 Advised patient not to see things complicatedly regarding her condition but rather
take it as a challenge to strengthen her faith in God.