CHAPTER I

INTRODUCTION

A. Background of the Story

This study focused on chronic renal failure, specifically end-stage renal disease (ESRD).
Data gathered suggest that the patient is suffering from the disease as manifested by, decrease
muscle tone, elevated blood pressure, darkening of the skin, facial edema, reported decrease of
energy level, frequent fatigue and sleeping problem as well as laboratory results (increased
creatinine and phosphorus levels, deceased hemoglobin, RBC and and platelet level) are clear
manifestation of the disease.

Antonio Paraiso, DOH program manager for the Philippine Network for Organ Sharing,
said close to 23,000 patients were undergoing dialysis treatment in 2013. The figure does not
include those suffering from kidney failure but who are not able to get treatment. In 2004 there
are about 4,000 patients undergoing dialysis treatment. But at the end of 2013, cases increases
close to 23,000 and it is still increasing. About 10- to 15-percent increase per year. According to
Paraiso almost 130 per million-population getting sick of kidney failure each year or one Filipino
develops chronic renal failure every hour, which is about 120 Filipinos per million people per
year.

  The leading cause of kidney failure is diabetes, followed by hypertension and

glomerulonephritis where the part of the kidney that helps filter waste and fluid in the blood is
damaged. Glomerulonephritis used to be the primary cause of kidney failure until it was
overtaken by diabetes and hypertension, which are “both lifestyle diseases.

There are several treatments for ESRD, like Medications (to help with growth, prevent
bone density loss, and/or to treat anemia), Diuretic therapy or medications (to increase urine
output), Specific diet restrictions or modifications, kidney transplantation, and dialysis
(hemodialysis or peritoneal dialysis). Dialysis treatments (both hemodialysis and peritoneal
dialysis) are not cures for ESRD, but will help ESRD patients feel better and live longer.

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 The cost of treating a kidney disease is exorbitant and beyond the reach of ordinary
patients. Renal transplantation is limited due to the expense and the shortage of donors. The best
that can be done is to focus on the prevention of progression of renal diseases.

Disease Condition

Nephrolithiasis (kidney stones) is a disease affecting the urinary tract. Kidney stones are
small deposits that build up in the kidneys, made of calcium, phosphate and other components of
foods. They are a common cause of blood in urine.Kidney stones are common. About 5% of
women and 10% of men will have at least one episode by age 70. Kidney stones affect about 2
out of every 1,000 people. Recurrence is common, and the risk of recurrence is greater if two or
more episodes of kidney stones occur. Kidney stones are common in premature infants. Some
types of stones tend to run in families.

Some types may be associated with other conditions such as bowel disease, ileal bypass
for obesity, or renal tubule defects. A personal or family history of stones is associated with
increased risk of stone formation. Other risk factors include renal tubular acidosis and resultant
nephrocalcinosis. Kidney stone formation may result when the urine becomes overly
concentrated with certain substances. These substances in the urine may complex to form small
crystals and subsequently stones.

Stones may not produce symptoms until they begin to move down the ureter, causing
pain. The pain is severe and often starts in the flank region and moves down to the groin. The
size of the renal stone will dictate the natural history of this condition. If the stone is less the
5mm in diameter, then it will most likely pass on future urination. If the stone is larger than
5mm, urological procedures may be required to remove the stone. Surgical intervention will be
required in any patient whose urinary tract in completely obstructed. This situation represents a
surgical emergency.

Renal failure refers to temporary or permanent damage to the kidneys that result in loss
of normal kidney function. There are two different types of renal failure--acute and chronic.

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Acute renal failure has an abrupt onset and is potentially reversible. Chronic renal failure
progresses slowly over at least three months and can lead to permanent renal failure. 

Chronic kidney disease (CKD) is an umbrella term that describes kidney damage or a
decrease in the glomerular filtration rate (GFR) for three months (Thomas-Hawkins
&Zazworsky, 2005). CKD is associated with decrease quality of life, increase in health
expenditures, and premature death. Untreated CKD can result in end stage renal disease (ESRD)
and necessitate renal replacement therapy (dialysis or kidney transplantation). Risk factors
include cardiovascular disease, diabetes, hypertension, and obesity.

ESRD is when the kidneys stop working well enough for you to live without dialysis or
atransplant.  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.

The medical treatment for ESRD is really costly that most patients don’t have the funds
for the needed treatment. Few patients also can have renal transplantation due to the expense and
a shortage of donors. To prevent ESRD or the progression of renal diseases a healthy lifestyle
should be practice. The people or community should be educated about the causes of ESRD,
prevention, signs and symptoms, and complication of having ESRD.

Anatomy and Physiology

The kidneys are a pair of bean-shaped organs

that lie on either side of the spine in the lower middle
of the back. Each kidney weighs about 5 ounces and
contains approximately one million filtering units
called nephrons. Each nephron is made of a
glomerulus and a tubule. The glomerulus is a

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miniature filtering or sieving device while the tubule is a tiny tube like structure attached to the
glomerulus.

The kidneys are connected to the urinary bladder by tubes called ureters. Urine is stored
in the urinary bladder until the bladder is emptied by urinating. The bladder is connected to the
outside of the body by another tube like structure called the urethra.

The main function of the kidneys is to remove waste products and excess water from the
blood. The kidneys process about 200 liters of blood every day and produce about 2 liters of
urine. The waste products are generated from normal metabolic processes including the
breakdown of active tissues, ingested foods, and other substances. The kidneys allow
consumption of a variety of foods, drugs, vitamins and supplements, additives, and excess fluids
without worry that toxic by-products will build up to harmful levels. The kidney also plays a
major role in regulating levels of various minerals such as calcium, sodium, and potassium in the
blood.

 As the first step in filtration, blood is delivered into the glomeruli by microscopic leaky
blood vessels called capillaries. Here, blood is filtered of waste products and fluid while
red blood cells, proteins, and large molecules are retained in the capillaries. In addition to
wastes, some useful substances are also filtered out. The filtrate collects in a sac called
Bowman's capsule.

 The tubules are the next step in the filtration process. The tubules are lined with highly
functional cells which process the filtrate, reabsorbing water and chemicals useful to the
body while secreting some additional waste products into the tubule.

The kidneys also produce certain hormones that have important functions in the body,
including the following:

 Active form of vitamin D (calcitriol or 1, 25dihydroxy-vitamin D), which regulates

absorption of calcium and phosphorus from foods, promoting formation of strong bone.

 Erythropoietin (EPO), which stimulates the bone marrow to produce red blood cells.

 Renin, which regulates blood volume and blood pressure

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5
Pathophysiology

Urinary tract stone disease is likely caused by two basic phenomena. The first
phenomenon is supersaturation of the urine by stone-forming constituents, including calcium,
oxalate, and uric acid. Crystals or foreign bodies can act as nidi, upon which ions from the
supersaturated urine form microscopic crystalline structures. The resulting calculi give rise to
symptoms when they become impacted within the ureter as they pass toward the urinary bladder.

The overwhelming majority of renal calculi contain calcium. Uric acid calculi and
crystals of uric acid, with or without other contaminating ions, comprise the bulk of the
remaining minority. Other, less frequent stone types include cystine, ammonium acid urate,
xanthine, dihydroxyadenine, and various rare stones related to precipitation of medications in the
urinary tract. Supersaturation of the urine is likely the underlying cause of uric and cystine
stones, but calcium-based stones (especially calcium oxalate stones) may have a more complex
etiology.

The second phenomenon, which is most likely responsible for calcium oxalate stones, is
deposition of stone material on a renal papillary calcium phosphate nidus, typically a Randall
plaque (which always consists of calcium phosphate). Evan et al proposed this model based on
evidence accumulating from several laboratories.

Calcium phosphate precipitates in the basement membrane of the thin loops of Henle,
erodes into the interstitium, and then accumulates in the subepithelial space of the renal papilla.
The subepithelial deposits, which have long been known as Randall plaques, eventually erode
through the papillary urothelium. Stone matrix, calcium phosphate, and calcium oxalate
gradually deposit on the substrate to create a urinary calculus.

Development of renal colic pain and renal damage

The colicky-type pain known as renal colic usually begins in the upper lateral midback
over the costovertebral angle and occasionally subcostally. It radiates inferiorly and anteriorly
toward the groin. The pain generated by renal colic is primarily caused by the dilation,
stretching, and spasm caused by the acute ureteral obstruction. (When a severe but chronic

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obstruction develops, as in some types of cancer, it is usually painless.)

In the ureter, an increase in proximal peristalsis through activation of intrinsic ureteral

pacemakers may contribute to the perception of pain. Muscle spasm, increased proximal
peristalsis, local inflammation, irritation, and edema at the site of obstruction may contribute to
the development of pain through chemoreceptor activation and stretching of submucosal free
nerve endings.

The term "renal colic" is actually a misnomer, because this pain tends to remain constant,
whereas intestinal or biliary colic is usually somewhat intermittent and often comes in waves.
The pattern of the pain depends on the individual’s pain threshold and perception and on the
speed and degree of the changes in hydrostatic pressure within the proximal ureter and renal
pelvis. Ureteral peristalsis, stone migration, and tilting or twisting of the stone with subsequent
intermittent obstructions may cause exacerbation or renewal of the renal colic pain.

The severity of the pain depends on the degree and site of the obstruction, not on the size
of the stone. A patient can often point to the site of maximum tenderness, which is likely to be
the site of the ureteral obstruction.

The kidneys have a remarkable ability to adapt to loss of nephron mass. Symptomatic
changes resulting from increased creatinine, urea,and potassium, and alterations in salt and water
balance usually do not become apparent until renal functions decline to less than 25% of normal
when adaptive renal reserves have been exhausted. The intact nephron hypothesis proposes that
loss of nephron mass with progressive kidneydamage cause the surviving nephron to sustain
normal kidney function (Huether and McCance, 2008).

These nephrons are capable of a compensatory hypertrophy and expansion or hyper

function in their rates of filtration, reabsorption, and secretion and can maintain a constant rate of
excretion in the presence of the overall declining GFR.

The intact nephron hypothesis explains adaptive changes in solute and water regulation
that occur with advancing renal failure. Although the urine of an individual with chronic renal
failure may contain abnormal amounts of protein, red blood cells and white blood cells or cast,
the major end products of excretion are similar to those of normally functioning kidneys until

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advanced stages of renal failure when there is a significant reduction of functioning nephrons.
The continued loss of functioning nephrons and the adaptive hyper filtration probably results in
further nephron injury and ultimately results in uremia and end stage renal injury.

The manifestation of chronic renal failure represents the inability of kidney to perform its
normal functions in terms of regulating fluid and electrolyte balance, controlling blood pressure
through fluid volume and renin-angiotensin system, eliminating nitrogenous and other waste
products, governing the red blood cell count through erythropoietin synthesis, and directing
parathyroid and skeletal function through phosphate elimination and activation of vitamin D. The
manifestations of renal failure are determined largely by the extent of renal function that is
present (e.g. renal insufficiency, ESRD), coexisting disease condition, and the type of renal
replacement therapy that the patient is receiving (Port, C., 2002).

Progression of chronic renal failure is thought to be associated with common pathogenic

processes including: glomerular hypertension, hyper filtration, and hypertrophy;
Glomerulosclerosis; and tubulointerstitialinflammation, and fibrosis. The factors that contribute
to the pathogenesis of chronic renal failure are complex and involve the interaction of many
cells, cytokines, and structural alterations. Glomerular hyperfiltration and increased glomerular
capillary permeability lead to proteinuria (Huether and McCance, 2008).

Proteinuria contributes to tubulointerstitial injury by accumulating in the interstitial space

and activating complement proteins and other mediator cells, such as macrophages, that promote
inflammation and progressive fibrosis. Angiotensin II activity is elevated with progressive
nephron injury. Angiotensin II promotes glomerular hypertension and hyper filtration caused by
efferent arteriolar vasoconstriction and also promotes systemic hypertension. The chronically
high intraglomerular pressure increases glomerular capillary permeability contributing to
proteinuria. Angiotensin II also promote the activity of inflammation cells and growth factors
that participate in tubulointerstitial fibrosis and scarring (Huether and McCance, 2008).

In accordance with this definition, the National Kidney Foundation (NKF) developed
guidelines that classify the progression of renal disease into five stages, from kidney disease with
a preserved GFR to end-stage kidney failure. This classification includes treatment strategies for
each progressive level, as follows:

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  Stage 1 – This stage is characterized by kidney damage with a normal GFR (≥ 90
mL/min); the action plan consists of diagnosis and treatment, treatment of comorbid
conditions, slowing of the progressing of kidney disease, and reduction of cardiovascular
disease risks

 Stage 2 – This stage is characterized by kidney damage with a mild decrease in the GFR
(60-90 mL/min); the action plan is estimation of the progression of kidney disease

 Stage 3 – This stage is characterized by a moderately decreased GFR (to 30-59 mL/min);
the action plan consists of evaluation and treatment of complications

 Stage 4 – This stage is characterized by a severe decrease in the GFR (to 15-29 mL/min);
the action plan is preparation for renal replacement therapy

 Stage 5 – This stage is characterized by kidney failure; the action plan is kidney
replacement if the patient is uremic.

The patient’s age, degree of renal impairments and any other underlying condition defines
the severity of these symptoms.

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 Family History of HPN Frequent dehydration, High
(non-modifiable factors) Purine diet,
Stone formation Energy drink and Alcohol abuse
inthe kidneys (modifiable factors)

Stone matrix
progression

Multiple urinary
calculus

Frequent Renal
Injury

Further injury to
remaining nephron

Renal function <25% CRF Creatinine and Urea

(ESRD) Increases

Elevated Azotemia Inability to

Angiotensin II synthesize
Erythropoietin

Uremia

HPN Water retention Anemia Pale skin

Pruritus

Edema Weakness, fatigue and

insomnia

Figure 1.Schematic Diagram of Chronic Renal Disease or Failure (CRF).

Figure 1 shows the development of renal disease from chronic or frequent renal injury
caused by kidney stones. Modifiable factor includes the family history of the patient, while the
non-modifiable factors includes frequent dehydration, high purine diet, energy drink and alcohol
abuse, both of which causes further injury to the nephrons that leads to ESRD causing azotemia.
Azotemia is a characteristic of uremia/accumulation of urea and other nitrogenous waste
products. In ESRD, renal function decline to <25% on which lab results shows an increase in
creatinine and urea level.

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 Other signs and symptoms of ESRD includes: elevated angiotensin II activity that goes
with the progression of nephron injury. Angiotensin II, known as a potent vasoconstrictor,
increases blood pressure and sodium reabsorption that causes water retention and edema. As the
kidneys are damage, its ability to synthesize erythropoietin is compromised, causing anemia,
paleness of the skin, weakness, fatigability and insomnia. Accumulation of waste products also
causes pruritus.

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B. Objectives

General Objective:
Application of concepts and theories in the care of client with End Stage Renal Disease
through the utilization of nursing process.

Specific Objectives:
After 10 days of nursing intervention, the nurse will be able to:

1. Assess client condition systematically using Virginia Henderson’s 14 components

and Dillon’s Physical Assessment Tool.

2. Prioritize identified nursing problems using Abraham Maslow’s Hierarchy of

Needs.

3. Formulate comprehensive Nursing Care Plan using the Nursing Intervention

Classification (NIC) and Nursing Outcome Classification (NOC).

4. Implement the Nursing Care Plan utilizing the Virginia Henderson’s Need
Theory.

5. Evaluate the patient improvement and response to the care rendered.

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 C. Significance of the Study

The study will be significant help in the provision of nursing care to a client with ESRD
by assisting and promoting in the performance and management of client’s own activities on a
continuous basis in order to sustain life and health, recover from disease, cope with its effects,
and achieve optimum functioning.

The study will be also beneficial to nurses and other healthcare providers as it would
improve decision making skills among them. Thus, a congruent and collective health-related
planning and section towards client and family immediate health needs, management and
compliance will be effectively promoted.

To the community, this study will provide dissemination of information and awareness of
the disease occurrence, effects, prevalence, condition, approach and management. Health
promotion and disease prevention will then be initiated.

To the graduate students, the study will provide a reference in integrating concepts and
theories in the nursing care process using appropriate Dillon’s Physical Assessment tool,
Maslow’s Hierarchy of Needs, Henderson’s Need Theory, and standardized nursing
terminologies and classification (NIC and NOC). Students will be able to recognize client’s
specific needs, develops quality nursing diagnoses, appropriate nursing interventions and
improve evaluation outcomes.

To the professors, this study can help them provide their students with a systematic
approach and a critical decision making in rendering patient care. Finally, the study will enhance,
support and serve as a guideline to nursing research, education and nursing practice, by
providing relevant data and results that can be utilized as a basis for further study on the
application and impact of Virginia Henderson’s Need Theory in providing nursing care to
patients with ESRD and different medical-surgical conditions. Hence, this will provide the
nursing profession an evidence based practice.

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 CHAPTER II

THEORETICAL BACKGROUND

A. Theoretical Source

Three theories were utilized in the study at hand, namely the Fourteen Fundamental
Needs by Virginia Henderson, Physical Examination by Patricia Dillon and Hierarchy of Needs
by Abraham Maslow.

Virginia Henderson’s Need Theory or The 14 Fundamental Needs described by

Henderson has been very influential in the practice of nursing. In addition to the theory,
Maslow’s Hierarchy of Needs will be utilized primarily in the promotion of the nursing problems
identified.

Virginia Henderson’s Need Theory

Virginia Henderson viewed the patient as an individual who requires help toward
achieving independence and completeness or wholeness of mind and body. She envisioned the
practice of nursing as independent from the practice of physician and acknowledges her
interpretation of the nurse’s function as a synthesis of many influences. Her work was based on
(1) that Thorndike, an American psychologist, (2) her student experience with Henry House
Visiting Nurse Agency, (3) her experience in rehabilitation nursing and (4) Orlando’s
conceptualization of deliberate nursing action (Henderson, 1964; Orlando, 1961).

Henderson emphasized the art of nursing and identified 14 proposed basic needs on
which nursing care is based. These 14 components are used by nurses to assess client’s
individual needs and show a holistic approach to nursing that covers the physiological,
psychological, spiritual and social needs.

Physiological Components

1. Breathe normally.
2. Eat and drink adequately.

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 3. Eliminates body waste.
4. Move and maintain desirable postures.
5. Sleep and rest.
6. Select suitable clothes, dress and undress.
7. Maintain body temperature within normal range by adjusting clothing and
modifying environment.
8. Keep the body clean and well groomed and protect the integument.
9. Avoid dangers in the environment and avoid injuring others.

Psychological Aspects of Communicating and Learning

10. Communicate with others in expressing emotions, need, fears, or opinions.

14. Learn, discover, or satisfy the curiosity that leads to normal development and
health and use the available health facilities.

Spiritual and Moral

11. Worship according to one’s faith.

Sociologically Oriented to Occupation and Recreation

12. Work in such a way that there is sense of accomplishment.

13. Play or participate in various forms of recreation.

The role and functions of professional nursing vary with the situations. If the total health
care team comprises a pie graph in health care situation, in some situations no role exists for
certain health care workers. Although there is always role from family and patient, the pie
wedges for team members vary in size according to (1) the problem of the patient, (2) the
patient’s self-help ability, and (3) the help resources. Central to nursing that seeks towards
independence is empathetic understanding and unlimited knowledge. She described the nurse’s
role as substitutive (doing for the person), supplementary (helping the person), complementary
(working with the person), with the goal of helping the person become as independent as
possible.

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 Head-to-toe physical assessment is a process that entails the use of one’s senses to collect
objectives data. Cognitive, psychomotor, interpersonal, affective, and ethico-legal skills are
required in performing an accurate, thorough physical assessment.

Like the health history, the main objective the head-to-toe examination is not only to
identify actual or potential health problems but also to discover patient’s strengths. Data from
physical assessment can be used to validate the health history data, findings from the head-to-toe
assessment would be essential in formulating nursing diagnoses and in developing a plan of care
for the patient.

In addition, the head-to-toe physical examination may either be complete of focused. A

complete physical assessment compromises a general survey, measures of vital signs, assessment
of height and weight, and physical examination of the entire structures, organs, and body system.
It is performed when examining a patient for the first time and when there is need to establish a
baseline.

On the other hand, a focused physical assessment zeroes in on the acute problem. Only
parts of the body related to the identified problem are being assessed. It is usually performed
when the patient’s condition is unstable as a follow-up to a complete assessment.

The most important tools in conducting a head-to-toe physical assessment are one’s
senses. The eyes are used to inspect, looking for both physical changes and nonverbal clues from
the patient. The ears are used to listen, hearing both sounds produced by various body structures
and also what the patient is saying. The nose will be used to detect any unusual odors that may
indicate an underlying problem. Lastly, the hands will be used to feel for physical changes and
also to convey a sense of caring for the patient.

Along with the senses, a variety of equipment is used to perform the head-to-toe physical
examination to enhance one’s assessment abilities.

Physical examination provides another perspective- it allows one to see the patient
objectively through one’s senses. The objectives data gathered complete patient’s health profile
(Dillon, 2013).

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 Maslow's hierarchy of needs is a theory in psychology proposed by Abraham
Maslow in his 1943 paper "A Theory of Human Motivation" in Psychological Review. Maslow
subsequently extended the idea to include his observations of humans' innate curiosity. His
theories parallel many other theories of human developmental psychology, some of which focus
on describing the stages of growth in humans. Maslow used the terms "physiological", "safety",
"belongingness" and "love", "esteem", "self-actualization", and "self-transcendence" to describe
the pattern that human motivations generally move through.

Maslow's hierarchy of needs is often portrayed in the shape of a pyramid with the largest,
most fundamental levels of needs at the bottom and the need for self-actualization at the
top. While the pyramid has become the de facto way to represent the hierarchy, Maslow himself
never used a pyramid to describe these levels in any of his writings on the subject.

The most fundamental and basic four layers of the pyramid contain what Maslow called
"deficiency needs" or "d-needs": esteem, friendship and love, security, and physical needs. If
these "deficiency needs" are not met – with the exception of the most fundamental
(physiological) need – there may not be a
physical indication, but the individual will
feel anxious and tense. Maslow's theory
suggests that the most basic level of needs
must be met before the individual will
strongly desire (or focus motivation upon)
the secondary or higher level needs. Maslow
also coined the term "metamotivation" to
describe the motivation of people who go
beyond the scope of the basic needs and
strive for constant betterment.

The human mind and brain are

complex and have parallel processes running at the same time, thus many different motivations
from various levels of Maslow's hierarchy can occur at the same time. Maslow spoke clearly
about these levels and their satisfaction in terms such as "relative," "general," and "primarily."
Instead of stating that the individual focuses on a certain need at any given time, Maslow stated

17
that a certain need "dominates" the human organism. Thus Maslow acknowledged the likelihood
that the different levels of motivation could occur at any time in the human mind, but he focused
on identifying the basic types of motivation and the order in which they should be met.

Every person is capable and has the desire to move up the hierarchy toward a level of
self-actualization. Unfortunately, progress is often disrupted by failure to meet lower level needs.
Life experiences, including divorce and loss of job may cause an individual to fluctuate between
levels of the hierarchy.

Maslow noted only one in a hundred people become fully self-actualized because our
society rewards motivation primarily based on esteem, love and other social needs.

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Theoretical Framework

Henderson’s 14 Components as Applied to Maslow’s Hierarchy of Needs

Since there is much similarity, Henderson’s 14 components can be applied or

compared to Maslow’s Hierarchy of Needs. Components 1 to 9 are under Maslow’s
Physiological Needs, whereas the 9th component is under the Safety Needs. The 10th and 11th
components are under the Love and Belongingness category and the 12th, 13th and 14th
components are under the Self Esteem Needs.

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B. Conceptual Framework

ASSESSMENT

 Assess patient using Dillon’s physical health assessment tool, 14

Components of Virginia Henderson’s Need Theory, Barthel Index of
ADL, Fatigue Severity Scale and Insomnia Severity Index.
 Problem identification and prioritization using Maslow’s Hierarchy of
Needs.

PLANNING

 Develops expected outcome utilizing NOC.

 Select nursing intervention based from NIC.

IMPLEMENTATION

 Implement Nursing care plan.

 Document client response through the 10-day progress note.

EVALUATION

 Appraisal of nursing interventions and goals: Structures, Process and

Outcome

Figure 2.The Nursing Process Flowchart

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Nursing Process Flow Chart

The common thread uniting different types of nurses who work in varied areas is the
nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-
focused care. The nursing process flow chart as shown in figure 2 describes the four systematic
processes in the care of a patient.

The first part of the Nursing Process is the Assessment phase, a systematic, dynamic way
to collect and analyze data and uses different assessment tools. The theory of Virginia
Henderson is utilize to assess the condition that validates the existence of a requirement for
nursing a patient, the absence of the ability to maintain continuously that amount and quality of
self-care which is therapeutic in sustaining life and health, in recovering from disease or injury,
or in coping with their effects. In addition, a complete health history must be accomplished in
order to identify problems and prioritize using the Maslow’s hierarchy of needs.

After a comprehensive assessment, the next step is the Planning phase. Based on the
assessment done and identified problems, the nurse sets measurable and achievable short- and
long-range goals for the patient. To achieve the desired goals the Nursing Standard Language,
which are the Nursing Outcome Classification (NOC) and the Nursing Intervention
Classification (NIC), will be utilized to identify the suited nursing intervention and desired
outcomes.

The third phase is the Implementation Phase; there will be10 consecutive days to
implement the nursing care plan, performing the determined interventions that were selected to
help meet the goals/outcomes that were established. Delegated tasks and the monitoring of them
are included here as well. Proper documentation of the progress and improvement must be
observed throughout the period.

The last phase is the Evaluation Phase, once all nursing intervention actions have taken
place; the nurse completes an evaluation to determine of the goals for patient wellness has been
met. Both the patient’s status and the effectiveness of the nursing care must be continuously
evaluated.

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D. Definition of Terms

Nursing Outcomes Classification (NOC) is a classification system which

describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate
the effects of nursing care as a part of the nursing process

Nursing Interventions Classification (NIC) is a comprehensive, research-based, standardized

classification of interventions that nurses perform. It is useful for clinical documentation,
communication of care across settings, integration of data across systems and settings,
effectiveness research, productivity measurement, competency evaluation, reimbursement, and
curricular design. The Classification includes the interventions that nurses do on behalf of
patients, both independent and collaborative interventions, both direct and indirect care.

Imbalance Nutrition Less than Body Requirements- the state in which an individual
experiences an intake of nutrients insufficient to meet metabolic needs.

Totally adequate: Refers to the indicators with complete quantity of nutrient intake with the scale
of (5).

Substantially adequate: Refers to the indicators with significant number of nutrient intake with a
scale of (4).

Moderate adequate: Refers to the indicators that with average amount of nutrient intake with a
scale of (3).

Slightly adequate: Refers to the indicators that having minimal nutrient insufficiency with a scale
of (2).

Excess Fluid Volume- a state where an individual experiencing or at risk of excess intracellular
or interstitial fluid.

Not compromised: Refers to the indicators that are observed normal at all times, manifested,
demonstrated or maintained with score of (5).

Mildly compromised: Refers to the indicators that are observed normal most of the time,
manifested, demonstrated or maintained with score of (4).

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Moderately compromised: Refers to the indicators that are observed normal some of the time,
manifested, demonstrated or maintained with score of (3).

Substantially compromised: Refers to the indicators that are observed normal occasionally,
manifested, demonstrated or maintained with score of (2).

Severely compromised: Refers to the indicators that are almost never observed normal,
manifested, demonstrated or maintained with score of (1).

Impaired Physical Mobility- limitation in independent, purposeful physical movement of the

body or of one or more extremities.

Not compromised: Refers to the indicators that are observed normal at all times, manifested,
demonstrated or maintained with score of (5).

Mildly compromised: Refers to the indicators that are observed normal most of the time,
manifested, demonstrated or maintained with score of (4).

Moderately compromised: Refers to the indicators that are observed normal some of the time,
manifested, demonstrated or maintained with score of (3).

Substantially compromised: Refers to the indicators that are observed normal occasionally,
manifested, demonstrated or maintained with score of (2).

Severely compromised: Refers to the indicators that are almost never observed normal,
manifested, demonstrated or maintained with score of (1).

Fatigue- an overwhelming sustained sense of exhaustion and decreased capacity for physical and
mental work at usual level.

Not compromised: Refers to the indicators that are observed normal at all times, manifested,
demonstrated or maintained with score of (5).

Mildly compromised: Refers to the indicators that are observed normal most of the time,
manifested, demonstrated or maintained with score of (4).

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Moderately compromised: Refers to the indicators that are observed normal some of the time,
manifested, demonstrated or maintained with score of (3).

Substantially compromised: Refers to the indicators that are observed normal occasionally,
manifested, demonstrated or maintained with score of (2).

Severely compromised: Refers to the indicators that are almost never observed normal,
manifested, demonstrated or maintained with score of (1).

Disturbed Sleep Pattern- disruption of sleep time causes discomfort or interferes with desired
lifestyle.

Consistently demonstrated: Refers to the indicators that are observed normal at all times,
manifested, demonstrated or maintained with score of (5).

Often demonstrated: Refers to the indicators that are observed normal most of the time,
manifested, demonstrated or maintained with score of (4).

Sometimes demonstrated: Refers to the indicators that are observed normal some of the time,
manifested, demonstrated or maintained with score of (3).

Rarely demonstrated: Refers to the indicators that are observed normal occasionally, manifested,
demonstrated or maintained with score of (2).

Never demonstrated: Refers to the indicators that are almost never observed normal, manifested,
demonstrated or maintained with score of (1).

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 CHAPTER III

THE NURSING PROCESS

A. Assessment Phase

1. Biographical Data

Name: Mr. TM

Age: 48 years

Birth date: March 15, 1969

Sex: Male

Religion: Roman Catholic

Civil Status: Married

Educational Attainment: College Graduate

Occupation:Businessman

Ethnic Group: Cebuano

Address: Calarian , Zamboanga City

Diagnosis: Chronic Kidney Disease (CKD) Stage 5 secondary to Obstructive

Urophaty, Nephrolithiasis

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2. Clinical History

A. Past Health History

Prior to his present condition, patient has an active lifestyle. From childhood to his
adulthood, he enjoys sports, loves to play basketball and other sports and push himself to the
limits.

He smoke cigarettes occasionally but does not use any form of illegal drugs. But
according to him he drinks emperador lights and beer occasionally with his friends. He loves
“papaitan” and “kilawin” as their pulutan. He usually includes “bulad” (dried fish) and
“ginamos” (brined fish or shrimp) for breakfast. During weekdays he usually plays basketball
with his friends, accompanied by excessive sweating and increased thirst. He developed a habit
of replenishing his dehydrated body by “sting” or “cobra” (energy drink). He usually takes
medicines whenever he is having fever, flu and body aches.

In March 2012, he had frequent body weakness, flank pain and edema on both
extremities. In April 2012, his condition worsens and thus seeks medical management. He was
admitted at Zamboanga Doctors’ Hospital, series of laboratory test were made only to find out
that he have Chronic Kidney Disease secondary to nephrolithiasis as the KUB ultrasound reveals
and an elevated blood creatine levels. His attending Nephrologist in Zamboanga Doctors’
Hospital advised him to undergone an emergency dialysis but he refused. After a week of
admission he decided to discharge against medical advice and seek for second opinion to another
Nephrologist in town. His new attending nephrologist advised him to undergone CT scan of his
both kidneys, the CT scan reveals his both kidneys have stones. His attending Nephrologist
referred him to a Urology Surgeon at Western Mindanao Medical Center. The surgeon advised
him to undergo a surgical procedure to removes the stones in his kidneys. After the surgery and a
series of medications his blood creatinine level lowers, ranging 315mg/dl. After 3 weeks of
confinement he was discharged from the hospital. According to him after he recovers from the
surgery he never return to smoking and alcohol drinking. In the late April 2014 while he was
attending a fiesta he noticed that his lower extremities were edematous. He consulted his
attending Nephrologist and a series of laboratory test was taken, as far as he remembers was the
result of his blood creatinine level at that time which was at 380mg/dl. No advised for dialysis

26
from the nephrologist but he was given medications, one of those is ketoanalouge plus amino
acid. But after three months of taking the medicines prescribed his condition was not getting
better. He experienced difficulty of breathing, severe body weakness and edema on both lower
extremities. July 2014 he was admitted at Ciudad Medical Zamboanga, series of laboratory test
were taken. Increase creatinine and urea and decrease in amount of hemoglobin levels in his
blood found out. He was diagnosed of Chronic Kidney Disease stage 5. This time he agreed to
undergo an emergency dialysis. After a night of admission he was scheduled to have an
intrajugular catheter insertion, a surgical procedure that served as his temporary hemodialysis
access. During his emergency hemodialysis procedure two units of PRBC was transfused to him
to replace the low levels of hemoglobin in his blood. After a month of having a hemodialysis
anarterovenous fistula was made in his left arm that was used as his permanent hemodialysis
access.

B. History of Present Illness

The client is diagnosed with Chronic Kidney Disease (CKD) Stage 5 secondary to
Obstructive Urophaty, Nephrolithiasis. Because of his condition he is now experiencing
imbalanced nutrition, fluid volume excess, impaired physical mobility, fatigue and disturbed
sleep pattern.

The client is on dialysis for almost three years now, since then he has lost weight.
Before his dialysis prescription was once in a week but because of recurrence edema and
difficulty of breathing his attending nephrologist changed it to twice in a week, every Tuesday
and Friday.

His blood pressure during dialysis is high most of the time, it ranges from 140 to
160mmhg for systolic and 80 to 110mmhg for diastolic. He has blood pressure medication
maintenance. His gain weight from his dry weight is 2 to 3.5 kg every treatment.

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 C. Family Health History

Some of the patient’s details on his family’s health history.

Father Mother
84 y.o. 84 y.o.
HPN A&W
decesead

Sister 1 Sister 2 Sister 3 Sister 4 Brother 3 Patient Brother 2

59 y.o. 57 y.o. 54 y.o. 52 y.o. 50 y.o. 48y.o. 45 y.o.
HPN A&W A&W HPN A&W Nephrolitiasis, A&W
CKD, HPN

Legend:
A&W: alive and well
HPN: hypertension
CKD: chronic kidney disease

Figure 3. Genogram

Figure 3 shows both of his father has hypertension and died at the age of 84 years, his
mother is still alive and well at the age 84 years. He has four sisters and two brothers. His sixth
among the seven siblings, his eldest and fourth sister has hypertension. All of his siblings is alive
and well.

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