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A CASE PRESENTATION ON
END-STAGE RENAL DISEASE SECONDARY TO
DIABETIC NEPRHOPATHY ANEMIA

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

GROUP 2

Abdulmalik, Hanimah
Ashary, Yaharah
Dimaampao, Hanifa
Dimaporo, Hanifa
Junaid, Janisah
Mamosaca, Jenan
Mustapha, Jawia
Noor, Abdul Hamid
Obinay, Paloma
Pangandongan, Sodaiz
Salong, Sittie Nur Jasmerah

Presented to
Danilo E. Ecarma Jr., RN
Faith Syvel L. Evaloraza, RN

April 2022
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TABLE OF CONTENTS
Page
I. TITLE PAGE i
II. TABLE OF CONTENTS ii
III. LIST OF TABLES iii
IV. LIST OF FIGURES iii
V. OBJECTIVES 4
General 4
Specific 4
VI. INTRODUCTION 5-7
VII. NORMAL ANATOMY AND PHYSIOLOGY 8-9
VIII. DEFINITION OF TERMS 10
IX. ASSESSMENT 11
Vital Information 11
Source of Information 11
Chief Complaints 11
Physical Assessment 11
History of Present Illness 12
History of Past Illness 12
Family History 12
Previous Hospitalization 13
Allergies 13
Medication and Drug Study 14-27
X. GENOGRAM 28
XI. GORDON’S FUNCTIONAL HEALTH PATTERNS 29-32
XII. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 33-36
XIII. DIAGNOSTIC TESTS/LABORATORY TEST 37-40
XIV. DIAGNOSIS OF CLIENT’S CASE 41
XV. CONCEPT MAP 42-45
XVI. NURSING CARE PLAN 46-81
XVII. DISCHARGE PLAN 82-100
XVIII. HEALTH TEACHINGS 101-102
XIX. PROGNOSIS 103-104
XX. BIBLIOGRAPHY 105-106

II
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LIST OF TABLES

Page

I. ASSESSMENT 14-27

Medication and Drug Study

II. GORDON’S FUNCTIONAL HEALTH PATTERNS 29-32

III. PHYSICAL ASSESSMENT AND REVIEW OF SYSTEMS 33-36

IV. DIAGNOSTIC TESTS 37-40

V. NURSING CARE PLAN 46-81

LIST OF FIGURES

Page
I.INTRODUCTION 5-7

II.GENOGRAM 28

III.CONCEPT MAP 42-45

III
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OBJECTIVES
General Objectives:

At the end of the one and half-hour case presentation, the presenters will be able to present

complete comprehension and insight about the disease progression and management of a patient

with End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

Specific Objectives

At the end of the one and half-hour case presentation, the presenters will be able to:

1. Define End-Stage Renal Disease and illustrate how it develops;

2. Analyze a comprehensive assessment and identify any abnormalities, particularly in physical

Assessment and family history taking;

3. Identify the risk factors associated with the diseases;

4. Indicate the different signs and symptoms that have been manifested by the patient;

5. Explain the pathophysiology and etiology of the disorder;

6. Recognize relevance of diagnostic test to presenting problem;

7. Formulate efficient nursing care plans based on the actual and potential problems;

8. Propose a health teaching to promote health and prevent occurrence of the disease;

9. Create a discharge plan appropriate for the patient.

10. Develop a prognosis related to the health status of the patient.

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INTRODUCTION

This is a case study of a 77 year-old woman who was diagnosed with End Stage Renal Disease

Secondary to Diabetic Nephropathy Anemia

Diabetes mellitus is a condition in which there is a chronically raised blood glucose

concentration. It is caused by an absolute or relative lack of insulin, i.e., insulin is not being

produced from the pancreas or there is insufficient insulin for the body’s need. Over time, that can

cause serious health problems, such as heart disease, vision loss, and kidney disease.

Diabetic nephropathy (Diabetic Kidney Disease) is the most common cause of death and

disability in diabetes. This is caused by damage to the small blood vessels in the kidneys. It is a

clinical syndrome characterized by persistent albuminuria, a relentless decline in GFR (Glomerular

filtration rate), raised arterial blood pressure and increased relative mortality for cardiovascular

diseases. This follows with a more rapid progression of other secondary complications such as

retinopathy, neuropathy, end stage renal disease, diabetic foot and blood pressure. In early stages

of diabetic nephropathy, there are no particular noticeable signs and symptoms, but in later stages

signs and symptoms may include worsening of blood pressure control, protein in the urine, loss of

appetite, fatigue, confusion or difficulty concentrating, swelling of other body parts, shortness of

breath, drowsiness, weakness. With that, certain diagnostic or blood tests that may be done that

look for specific blood chemistry such as urinary albumin test, BUN blood test, serum creatinine

blood test, and glomerular filtration rate others may include imaging test such as x-rays and

ultrasound.

In addition, in diabetic nephropathy, a kidney that is affected by diabetes can look normal

under an ultrasound but under the microscope the kidney can show damage to the filtering units.

It is the damage in the filtering units’ causes’ protein to leak into the urine, which is an important

marker for diabetic kidney disease. There are five stages of kidney disease. Stage 1 is the mildest

stage and kidney functionality can be restored with treatment. Stage 5 is the most severe form of

kidney failure wherein the kidney is no longer functional that will considered as to End Stage

Renal Disease.
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Stages of Kidney Disease:

Stage GFR Damage and Functionality

Stage 1 90+ Mildest stage; kidney have some damage

but still functioning at a normal level

Stage 2 89-60 Kidneys are damage and have some loss of

functionality

Stage 3 59-30 Kidney has lost up to half of its

functionality; can also lead to problems with

your bones

Stage 4 29-15 Severe kidney damage

Stage 5 <15 Kidney failure; patient need dialysis or

kidney transplant if possible

When a patient has sustained enough kidney damage to require renal replacement therapy

on a permanent basis, the patient has moved into the fifth of final stage of chronic kidney disease

also referred to as End Stage Renal Disease. It is a progressive, irreversible deterioration in renal

function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails,

resulting in uraemia or azotaemia (retention of urea and other nitrogenous waste in the blood). End

stage renal disease is evidence by elevated creatinine and blood urea nitrogen level as well as

electrolyte imbalances. The rate of decline in renal function and progression of chronic renal

failure is related to the underlying disorder, the urinary excretion of protein and the presence of

hypertension. Patient’s body system is affected in ESRD, they exhibit a number of signs and

symptoms. The severity of these signs and symptoms depends in part on the degree of renal

impairment, other underlying conditions, and the patient’s age. Clinical manifestations are

cardiovascular diseases, peripheral neuropathy, complains severe pain and discomfort, neurologic

manifestations such as restless leg syndrome and burning feet in early stage of uremic neuropathy,

integumentary manifestation such as ecchymosis, purpura, gray bronze skin color. Other may also

manifest pitting edema, shortness of breath, constipation, nosebleeds. Patients with ESRD may
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lead to potential complications almost any part of their body such as anemia, bone disease and

metastatic and vascular calcifications, hyperkalemia, pericarditis, fluid in and around the lungs,

and etc. To diagnose end stage renal disease, examinations will be performed such as blood test

for GFR, creatinine and urea, urine test for protein albumin, imaging test such as ultrasound, MRI,

CT Scan and kidney biopsy.

According to the United States Renal Data System, in 2015, there were 124,411 new ESRD

diagnoses, reflecting an increasing burden of kidney failure. The prevalence of the disease has

been rising at a stable number of about 20,000 cases per year. Kidney disease is the ninth leading

cause of death in the United States. In addition, according to the Department of Health, As of

March 3, 2022, the Philippines have a population of more than 112 million. In 2018, the World

Health Organization reported that 3.5 percent of total deaths in the country are due to CKD. The

10th leading cause of mortality in the Philippines in 2020, kidney failure is one of the leading

causes of hospitalization. For the past decade, prevalence of dialysis has increased to

approximately 400 percent. Today, diabetes mellitus and hypertension have taken center stage in

the causation of ESRD which together account for almost 60% of dialysis patients. Recently, the

global burden of disease (GBD) study reported that the average prevalence worldwide is (95% CI)

of CKD stages 3–5 in 14 LMICs (low and low middle income countries) in Asia was 11.2% (9.3–

13.2%). The prevalence of CKD stages 3–5 was varied among subregions and country economic

classification. CKD prevalence was 8.6% (7.2–10.2%) in east Asia, 12.0% (7.7–17.0%) in south-

east Asia, 13.1% (8.7–18.2%) in western Asia, and 13.5% (9.5–18.0%) in south Asia. CKD

prevalence was 9.8% (8.3–11.5%) in upper-middle-income countries and 13.8% (9.9–18.3%) in

lower-middle-income countries. Prevalence of CKD stage 3–5 in LMICs in Asia is comparable to

global prevalence.
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NORMAL ANATOMY AND PHYSIOLOGY

OF THE KIDNEY

The kidneys are a pair of bean-shaped, brownish-red structures located retroperitoneally

(behind and outside the peritoneal cavity) on the posterior wall of the abdomen-from the 12th

thoracic vertebra to the 3rd lumbar vertebra in the adult (see Fig. A). The rounded outer convex

surface of each kidney is called the hilum. Each hilum is penetrated with blood vessels, nerves,

and the ureter (Eaton & Pooler, 2013). The average adult kidney weighs approximately 113 to 170

g (about 4.5 oz) and is 10 to 12 cm long, 6 cm wide, and 2.5 cm thick (Eaton & Pooler, 2013;

Grossman & Porth, 2014). The right kidney is slightly lower than the left due to the location of the

liver.

Figure A Figure B

Externally, the kidneys are well protected by the ribs and by the muscles of the abdomen

and back. Internally, fat deposits surround each kidney, providing protection against jarring. The

kidneys and surrounding fat are suspended from the abdominal wall by renal fascia made of

connective tissue which holds the kidney in place (Skorecki, Chertow, Marsden, 2015). The fibrous

connective tissue, blood vessels, and lymphatics surrounding each kidney are known as the renal

capsule. An adrenal gland lies on top of each kidney. The kidneys and adrenals are independent in

function, blood supply, and innervation.

The renal parenchyma is divided into two parts: the cortex and the medulla (see Fig. B).

The medulla, which is approximately 5 cm wide, is the inner portion of the kidney. It contains the

loops of Henle, the vasa recta, and the collecting ducts of the juxtamedullary nephrons. The

collecting ducts from both the juxtamedullary and the cortical neph- rons connect to the renal
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pyramids, which are triangular and are situated with the base facing the concave surface of the

kidney and the point (papilla) facing the hilum, or pelvis. Each kidney contains approximately 8

to 18 pyramids. The pyramids drain into minor calyces, which drain into major calyces that open

directly into the renal pelvis. The tip of each pyramid is called a papilla and projects into the minor

calyx (Eaton & Pooler, 2013). The renal pelvis is the beginning of the collecting system and is

composed of structures that are designed to collect and transport urine. Once the urine leaves the

renal pelvis, the composition or amount of urine does not change.

The cortex, which is approximately 1 cm wide, is located farthest from the center of the

kidney and around the outermost edges. It contains the nephrons (the structural and functional

units of the kidney responsible for urine formation).

Functions of the Kidney:

● Urine formation

● Excretion of waste products

● Regulation of electrolytes

● Regulation of acid-base balance

● Control of water balance

● Control of blood pressure

● Renal clearance

● Regulation of red blood cell production Synthesis of vitamin D to active form

● Secretion of prostaglandins
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DEFINITION OF TERMS

Atrial Gallop. Is an extra heart sound that occurs during late diastole, immediately before the

normal two "lub-dub" heart sounds (S1 and S2).

Azotemia. Is a state of abnormally high nitrogenous waste products in the blood.

Bipedal pitting edema. Occurs when excess fluid builds in the feet and lower legs, causing

swelling; when pressure is applied to the swollen area, a “pit”, or indentation, will remain.

Diabetic nephropathy. A syndrome characterized by the presence of pathological quantities of

urine albumin excretion, diabetic glomerular lesions, and loss of glomerular filtration rate (GFR)

in diabetics.

Ecchymosis. A small bruise caused by blood leaking from broken blood vessels into the tissues of

the skin or mucous membranes.

End stage renal disease (ESRD). Also known as end-stage kidney disease (ESKD), is the final,

permanent stage of chronic kidney disease, where kidney function has declined to the point that

the kidneys can no longer function on their own.

Glomerulus. Tuft capillaries forming part of the nephron through which filtration occurs.

Glomerular Filtration Rate (GFR). Amount of plasma filtered through the glomeruli per unit of

time.

Hyperuricemia. Is an elevated uric acid level in the blood.

Neuropathy. A nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness

in different parts of the body.

Onychomycosis. Is a fungal infection of the fingernails or toenails that causes discoloration,

thickening, and separation from the nail bed.

Purpura. A purple or brownish-red spots on the skin or mucous membranes, caused by the

extravasation of blood.

Renal parenchyma. The functional part of the kidney that includes the cortex and the medulla.

Retinopathy. Is the medical term for disease of the retina.

Senile Osteoporosis. Is bone loss that results from aging.

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ASSESSMENT

A. Vital Information

Name: Mrs. Q

Age: 77 years old

Gender: Female

Civil Status: Widow

Birthdate: September 12, 1945

Address: Zone 10 Bagong Silang, Iligan City

Nationality: Filipino

Religion Affiliation: Roman Catholic

Occupation: Housewife

Date of Admission: April 15, 2023

Time of Admission: 2:30 AM

Admitting Physician: Dr. O (Internal Medicine-Nephrologist)

Admitting Diagnosis: End Stage Renal Disease Secondary to Diabetic/Hypertensive

Nephropathy, Severe Anemia, Moderate Ascites

Final Diagnosis: End Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

B. Source of Information:

Patient’s Chart: 60%

Patient: 20%

Significant Other- 20%

C. Chief Complaints:

Bipedal Edema

D. Physical Assessment:

General Appearance: Awake, alert, coherent, tachypneic

Skin: With skin discoloration (pallor), no lesions, edema on lower legs (both ankles), warm

to touch, good skin turgor

HEENT: Anicteric, pale palpebral conjunctiva

Neck: There are no signs of enlarged or swollen lymph nodes, trachea at midline, and no

venous distension
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Chest/Lungs: Extracapsular extension, with rales sounds, bilateral more on left side, no

retractions noted.

Heart: There is a murmur sound in the S4

Abdomen: Soft, non-tender abdomen, with shifting dullness, abdominal girth= 92.5cm

E. History of the Present Illness

1 month prior to admission, patient noticed swelling on both feet associated with numbness

and weakness of both lower legs. Sought consult to private physician and was advised to

undergo dialysis which the patient refused. No subsequent consults done until 1 day prior

to admission, sought another consultation to a private physician to which labs: Complete

blood count, creatinine, potassium was taken and was subsequently admitted. For blood

transfusion and hemodialysis.

F. History of Past Illness

The patient is positive with the following diseases:

Chronic Kidney Disease stage 3 last March 2023

Hyperuricemia

Hypertension Stage II since 2017

Diabetes Mellitus Type 2 with Nephropathy since 2017

The patient also uses the following medicines:

1. Telmisartein OD

2. Glyxambi OD

3. Vasalat 10mg

4. Lionipres 150mg

5. Ticijerta 5mg

6. Renalog

7. Sodium Bicarb 650mg

8. Clalvin Plus

9. Iberet Folic

10. Rusuvastatin 10mg

G. Family History

Hypertension, Diabetes Mellitus, Kidney Problems

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H. Allergies

No known environmental, drug and food allergies.

I. Previous Hospitalization

March 08, 2023 at Adventist Medical Center due to nose bleeding.

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MEDICATIONS AND DRUG STUDY

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GENOGRAM
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Gordon’s Assessment of Functional Health Patterns

Health Patterns Before Hospitalization During Hospitalization

Health Perception and According to her daughter, the patient According to her daughter, the patient

Health Management knows about her condition because she is is compliant to her medications and

Pattern having a frequent check-up in the clinics. takes it diligently. The patient is

She has an access to help support because currently diagnosed with End stage

her children fully support her medical renal disease secondary to diabetic

treatments. nephropathy anemia. Patient’s

previous food preferences were soda,

meats, fast food, and sweets. During

her stay in the hospital, her diet was

Low Purine and 1 litter limit water

intake.

Nutrition and According to her daughter, the patient is According to her daughter, the patients

Metabolism Pattern fan of eating fast food and processed foods appetite doesn’t improve and partially

because during pandemic and before consumes the food which is a low

hospitalization she stayed at his son’s purine diet that is been prepared for

care/home wherein no one can prepare a her. As for her water intake, she was

healthier food for her because of their limited to take 1 liter per day and she

work. Also, she doesn’t really have a good follows it accordingly.

appetite and drinks not more than 1 liter of

water or 5 glasses of water a day.

Elimination Pattern According to the patient, she is constipated According to the patient, she is still

and having a hard time to defecate/1x a day constipated and having a hard time to

because of hard formed stool “tubol” and defecate but she is relieved whenever

she urinates not that often as she estimates she is given with Dulcolax and

it only 2-3x a day with a total of 250 ml. urinates well.

24 hour I&O as follow;

Day 1 admission (4/16/23)

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Input: 770cc

Output: 400cc, urine clear-yellowish

in color, No BM

Day 2 (4/17/23)

Input: 650cc

Output: 200cc, urine clear yellowish

in color. 1x BM hard formed stool.

Day 3 Discharge (4/18/23)

Input: 450cc

Output: 600cc, urine clear yellowish

in color. 2x BM soft stool.

Activity and Exercise According to her daughter, she doesn’t According to her daughter, the patient

Pattern have any activities even before she was always sleep and sometimes sit in her

hospitalized because she is used to stay at chair for a while whenever she felt

home because of the pandemic. She always some pain in her back because of

lies in bed and watch televisions. prolonged lying down.

According to her, they always encourage

their mom to do some light exercise at

home such as gardening but she still chose

to sleep and watch television instead.

Cognition and Perception According to her daughter, the patient is According to her daughter, since she

Pattern oriented to time, people and the place. But was admitted the patient isn’t oriented

according to her, as far as she can to time, date and sometimes even the

remember the patient became slightly place. She sometimes asks her

disoriented and lack of interest over daughter why they are staying too long

something months ago after her illness got in the hospital and asks for certain

worsen. things all of a sudden. But she can still

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respond to stimuli verbally and

physically.

Sleep and Rest Pattern According to her daughter, the patient is According to her daughter, the patient

not having a hard time to sleep. She sleeps sleeps often and rest after meals. The

10-12 hours a day from 9pm to 7 or 8am in patient is easily awakened by the noise

the morning and a nap during 3pm. The and sleep around 7-8 hours.

patient doesn’t have anything to do at Sometimes her sleep is interrupted due

home thereby she has a good rest and to the medications that she needs to

sleep. take on time, when the nurses check

her vital signs, or when she has

visitors.

Self-Perception and Self- According to her daughter, the patient According to her daughter, the patient

Concept Pattern sometimes expresses what she felt about is aware on what is happening to her

her condition and she accepts it even and her illness. She doesn’t let her

though she acts strong in front of them. She daughter leave the room and don’t

isn’t afraid of going to hospital because she want to be alone as for she sometimes

is used to it and just follows what lies feel afraid.

ahead in her life.

Roles and Relationship The patient has children and has a good The patient has a strong bond with her

Pattern relationship with them. According to her family. The patient’s children were

daughter, she is a loving mother and knows encouraged to be compliant with the

how to adjust when things get harder. nurses and doctors’ orders. Her

Problems with children are also talked out family’s way of speaking to each other

by the whole family and are also relatively was soft and affectionate.

easily resolved. The patient is acquainted

with a few people, friends and loved ones.

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Sexuality and The patient is widowed and a mother of 3 The patient is widowed and a mother

Reproduction Pattern children, as stated she doesn’t engage in of three children. There were no

any sexual activities abnormalities found in the

reproductive area.

Coping and Stress According to her daughter, the patient is According to her daughter, the patient

Tolerance Pattern not vocal when things aren’t good. She always sleep and close her eyes to rest

always says that she is okay but they can and always says that she is doing great

sense it as a child whenever the patient is though they can feel that she is afraid

anxious over something. According to her, and sometimes stress whenever they

the patient is just watching television or go through her dialysis session

sleep to cope with her stress.

Values and Belief Pattern The patient’s faith in God is strong and her According to the patient, her faith in

religion is Roman Catholic. According to God is still strong because she believes

the patient, even before she was not sick, in Him and only the He can cure her

she always attends and goes to church disease.

diligently as for she believes that prayer is

very powerful.
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PEROS (Physical Assessment and Review of Systems)

Areas assessed Subjective findings Objective findings Problems identified

General health • The pt said: • Female • Excess fluid volume
survey “Katong • Weight: 51.7kg related to kidney
wala pa ko • Height: 149 cm dysfunction as
giadmit naa • Awake, and evidenced by
koy ubo” coherent Bipedal pitting
• Occasional Non- Edema and Ascites.
• The SO said: productive cough • Infection related to
“Nanghopon • Skin discoloration compromised
g iyang tiil” (Pallor) physical health
• Ascites secondary to DM as
• Lethargic and evidenced by
restlessness onychomycosis.
• Bipedal pitting • Impaired skin
edema integrity related to
alteration in fluid
• Pale nail beds
volume as
• Onychomycosis
evidenced by
(Fungal nail
presence of bipedal
infection)
pitting edema.
• Tachypnea:26 BPM
• Decrease Cardiac
(During
Output related to
admission:4/15/23)
hypertension as
• GCS: 15 (E4, M6, evidenced by
V5) elevated blood
pressure.
V/S as of March 30, 2023 • Impaired gas
5PM: exchange related to
decreased function
• HR: 66 of lung tissue
• RR: 20 secondary to pleural
• 02: 99% effusion as
• BP: 180/80 evidenced by
• TEMP: 35.9 restlessness,
lethargy, tachypnea
and pallor.
• Ineffective breathing
pattern related to
change in health
status secondary to
pleural effusion as
evidenced by
alteration in
respiratory rate,
depth, and breathe
sounds.
Integumentary • The SO said: • Warm to touch • Impaired skin
system Nibalik man • Good skin turgor integrity related to
mi diri kay • (+) Skin alteration in fluid
after 1 week, discoloration volume as
nang hopong (pallor) evidenced by
iyang tiil” • Bipedal pitting presence of bipedal
edema pitting edema.
• Pale nail bed • Impaired gas
• No Lesions exchange related to
• CRT: <2 secs decreased function
of lung tissue
secondary to pleural
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effusion as
evidenced by pallor.
Neurologic system • The pt said: • Lethargic and • Altered Comfort
“Sa akong restless related to numbness
liog gi bun- • Awake and of body definition:
od man siya coherent Perceived lack of
pero dili • GCS: 15 (E4,M,V5) ease, relief, and
sakit” transcendence in
physical, as
evidenced by
internal jugular
catheter insertion
site on the right
neck.
• Impaired physical
mobility related to
decrease range of
motion as evidenced
by lethargy and
restlessness.
HEENT • The pt said: • No lesions • Disturbed sensory
“Naa koy • Blurred vision perception (visual)
a. Head and
face
samin kay • Pale palpebral related to
naoperahan conjunctiva conjunctivitis as
b. Eyes
c. Ears
man ko og • Pupillary reflex size evidenced by verbal
cataract” on right is 2mm and complaint of
d. Nose
2mm for left. difficulty of seeing
e. Oral cavity
• Wearing graded eye properly, wearing
glasses graded eye glasses
• No nasal discharges and pale palpebral
• Pink lips conjunctiva.
• Edentulism • Impaired dentition
related to deficient
• Yellow teeth
knowledge
regarding dental as
evidenced by
edentulism and
yellow teeth.
Neck • SN: "Wala • Trachea at midline • Altered Comfort
ba kay • No neck vein related to numbness
nafeel na distention of body definition:
sakit da • No lymph Perceived lack of
imoang tiyan adenopathy ease, relief, and
ba or sa • Internal Jugular transcendence in
ulo?" Catheter Insertion physical, as
• The pt said: evidenced by
"Wala ra presence of internal
man Ma'am, jugular catheter
kani lang insertion site on the
naa sa right neck.
akoang liog, • Risk for infection
gi bun-od related to invasive
man siya procedure as
pero dili evidenced by
sakit." presence of internal
jugular catheter
insertion.
Respiratory system • SN: “Ga ubo • X-ray: Minimal • Ineffective airway
ka ma’am” Pleural Effusion clearance related to
• The pt said: • Equal chest fluid collection in
“Oo, mawala expansion the lungs as
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wala raman • (+) Bilateral Rales, evidenced by

ni” more on left adventitious breath
• Occasional non- sounds (e.g Bilateral
productive cough rales, more on left).
• Tachypnea:26 BPM • Impaired Gas
(During Exchange related to
admission:4/15/23) the altered supply of
• 02: 99% oxygen secondary to
Pleural Effusion as
evidenced
by tachypneic and
occasional non-
productive cough.
Cardiovascular • SN: “Dili • (+) Atrial gallop • Decreased Cardiac
system sakit imong (S4) Tissue Perfusion
dughan • No recurrence of related to irregular
ma’am? ” chest pain heart contraction as
• The pt said: • BP: 160/100 evidenced by
“Dili man” (During Presence of
admission:4/15/23) abnormal S4 heart
• HR: 66 sounds upon
auscultation.
• Decrease Cardiac
Output related to
hypertension as
evidenced by
elevated blood
pressure.
Gastrointestinal • SN: “Walay • Soft, non-tender • Excess fluid volume
system sakit sa abdomen related to sodium
imong • (+) Shifting and water retention
tiyan?” dullness as evidenced by
• The pt said: • Abdominal increased abdominal
“Wala man” girth=92.5 cm girth or ascites.
• Ascites

Genitourinary / • SN: • Day 1: April 18, • Imbalance nutrition:

Reproductive “Makapila 2023 Less than body
system ka makaihi (24hrs) requirements related
ma’am?” to Dietary
The pt said: Total intake: restrictions to
“makaisa ra” 650 cc reduce nitrogenous
waste products as
Total output: evidenced by
200 cc limited oral fluid
intake.
• Day 2: • Excess fluid volume
(8AM-2PM) April 19, related to
2023 Compromised
regulatory
Total intake:
mechanism (e.g
300cc End-stage renal
disease) as
Total output: evidenced by
250cc elevated creatinine,
and blood uric acid.
Clinical chemistry test: • Risk for electrolyte
• Blood uric acid: imbalance related to
698.25 renal failure as
evidenced by
• Creatinine: 1045.99
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• Potassium: 3.63 abnormal result of

• Sodium: 132.2 creatinine and Blood
• SGPT/ALT: 29.7 Uric Acid.

Musculoskeletal • The pt said: • Numbness and • Ineffective tissue

“giadmit weakness of Lower perfusion related to
namo siya leg (During hypervolemia
kay nang Admission: (excess fluid) as
hopong 4/15/23) evidenced by
iyang tiil ug • Bipedal pitting numbness and
gibun-od ” edema weakness of lower
• Senile osteoporosis leg.
(X-ray) • Excess fluid volume
• Strong pulses related to kidney
dysfunction as
evidenced by
Bipedal pitting
Edema.
• Impaired physical
mobility related to
aging process as
evidenced by
decrease range of
motion.
Lymphatic system No swelling on lymph No Problem Identified
nodes
Hematology • The SO said: • Complete blood • Risk for unstable
“Akong count/Hematology: blood glucose level
mama man RBC: 2.63 related to
kay na HCT: 0.24 hyperglycemia as
diagnosed HGB: 79.0 evidenced by HGT
ug diabetes WBC: 5.08 of 79.0
murag 2017 Platelet: 161 • Fatigue related to
paman to, decreased
mao naa hemoglobin and
siyay Differential count:
diminished oxygen-
maintenance Segmenters: 0.61 carrying capacity of
para sa Lymphocytes: 0.22 the blood as
iyaang sugar Stabs: 0 evidenced by
or diabetes.” Monocytes: 0.09 Inability to maintain
Eosinophils: 0.07 the usual level of
Basophils: 0.01 physical activity and
reports fatigue and
lack of energy.
Clinical chemistry test: • Risk for injury
Hemoglucotest related to lethargic
(Hgt): 123 as evidenced by
HBA1C- decreased
Glycosylated hematocrit level.
Hemoglobin: 5.3
HCV: Nonreactive
HBsAg
(qualitative):
Nonreactive
 37

DIAGNOSTIC TESTS

DATE TEST RESULT REFERENCES UNITS INTERPRETATION

AND

TIME

April 15,
●The shadows on a
2023
X-ray ●No evidence of ●Minimal pleural
chest X-ray test
active effusion, left
depend on the degree
parenchymal
of absorbed radiation ●Cardiomegaly
infiltrates.
by the particular
●Atherosclerotic aorta
●Opacity is noted organ based on its
●Senile osteoporosis
in the left lower composition.

hemithorax
●Bony structures
obliterating the
absorb the most
ipsilateral
radiation and appear
hemidiagphragm
white on the film.
and costophrenic

sulcus. ●Hollow structures

containing mostly air,

●Heart is enlarged
such as the lungs,
with inferomedial
normally appear dark.
displacement of
In a normal chest X-
the apex.
ray, the chest cavity is
●Aorta is
outlined on each side
calcified.
by the white bony
●Trachea, right the structures that

hemidiaphragm represent the ribs of

and right the chest wall.
 38

costophrenic ●Inside the chest

sulcus are distinct. cavity, the vertebral

●Decrease density column can be seen

in the visualized down the middle of

osseous structures the chest, splitting it

nearly in equal

halves.

●On each side of the

midline, the dark

appearing lung fields

are seen.

April 15, SARS-CoV-2

2023 Antigen Rapid

Negative Negative
Test
7:05

AM

April 15,

2023
HCV Nonreactive Nonreactive

( hepatitis C

7:05 virus)

AM

HBsAg
Nonreactive Nonreactive

(hepatitis B

surface antigen)

(QUALITATIVE

)
 39

April 15, PROTIME:

2023
Patient 12.8 10.0-13.0 Seconds Normal

Control 13.9 11.0-13.9 Seconds Normal

7:05
Activity 100 85-100 Percentage Normal

AM
INR 1.00 0.9-1.2 Seconds Normal

April 16, Potassium 3.63 3.5-5.3 mmol/L Normal

2023
Sodium 132..2 135-148 mmol/L High

4:31

AM

April 16, Creatinine 1045.99 53-106 umol/L High

2023

SGPT ( Serum 29.7 5-31 U/L Normal

4:31 Glutamic

Pyruvic
AM
Transaminase)

698.25 155-357 umol/L High

Blood uric acid

123 70-110 mg/dL High

Hemoglucotest
 40

April 16, Glycosylated 5.3 4.2-5.6 Percentage Normal

2023 Hemoglobin

2:48

PM

April 16, HEMATOLOG

2023 Y:
2.63 4.7-5.0 M/mm^3 Low

Red Blood Cells

0.24 0.37-0.47 Low

4:31 Hematocrit
79.0 125-160 g/l Low

AM Hemoglobin
5.08 4.0-10.5 x10^3cells/ Normal

White Blood mm^3

Cells

DIFFERENTIAL
0.61 0.35-0.66 Normal
COUNT:

0.22 0.24-0.44 Normal

Segmenters

0 0.05-0.11 Low
Lymphocytes

0.09 0.03-0.06 High

Stabs (Bands)

0.07 0.00-0.03 High

Monocytes

0.01 0.00-0.01 Normal

Eosinophils

Basophils
x10^3/mm
161 150-400 Normal
^3

Platelet Count
 41

DIAGNOSIS OF CLIENT’S CASE

Admission Date: April 15, 2023

Admitting Diagnosis: End Stage Renal Disease Secondary to Diabetic/Hypertensive

Nephropathy, Severe Anemia, Moderate Ascites

Final Diagnosis: End Stage Renal Disease Secondary to Diabetic Nephropathy Anemia
42
43
44
44
45
45
#1 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia 46

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Ineffective airway clearance SHORT TERM: INDEPENDENT: INDEPENDENT: STO Met:

SN: “Ga ubo ka ma’am?” related to decreased energy, Within the end of 6 hours 1. Assess the rate, 1. Tachypnea, shallow After 6 hours nursing

The pt said: “Oo, mawala fatigue, as evidenced by nursing intervention the rhythm, and depth of respirations and intervention the patient was

wala raman ni” tachypnea and, cough patient will be able to: respiration, chest asymmetric chest able to:

without sputum. movement, and use of movement are

• Patient will accessory muscles. frequently present • Patient had

identify/demonstrate because of the demonstrated

behaviors to achieve 2. Assess cough discomfort of moving behaviors to achieve

airway clearance. effectiveness and the chest wall and airway clearance.

• Patient will productivity. fluid in the lung due • Patient had displayed

display/maintain a to a compensatory a patent airway with

patent airway with 3. Auscultate lung fields, response to airway breath sounds

breath sounds noting areas of obstruction. clearing; absence of

OBJECTIVE DATA: clearing; absence of decreased or absent dyspnea, pallor, as

• Total intake: April dyspnea, pallor, as airflow and 2. Coughing is the most evidenced by keeping

18 evidenced by keeping adventitious breath effective way to a patent airway.

650 cc a patent airway. remove secretions.

 47

Total output: April sounds: crackles,

19 wheezes, or rales. 3. Decreased airflow

200 cc occurs in areas with

LONG TERM: 4. Observe if there is consolidated fluid. LTO Met:

• X-ray: Minimal Within the end of 12 hours sputum. Bronchial breath After 12 hours nursing

Pleural Effusion nursing intervention the sounds can also occur intervention the patient was

• (+) Bilateral rales, patient will be able to: 5. Assess the patient’s in these consolidated able to:

more on left • Shows sign of relief hydration status. areas. Crackles, • Shows sign of relief

• Occasional non- • Clear breath sounds rhonchi, and wheezes • Clear breath sounds

productive cough • No signs of tachypnea 6. Elevate the head of are heard on • No signs of tachypnea

• Lethargic & • No signs of pallor the bed and change inspiration, expiration • No signs of pallor

restlessness • No episodes of non- position frequently. due to fluid • No episodes of non-

• Bipedal pitting edema productive cough accumulation, thick productive cough

• (+) Skin 7. Teach and assist the secretions, and airway

Discolorations patient with proper spasms and

(Pallor) deep-breathing obstruction.

exercises.
• Tachypnea
Demonstrate proper
 48

V/S taken as follow: splinting of the chest 4. Changes in sputum

BP- 160/80 and effective characteristics may

T- 36 coughing while in an indicate infection.

RR- 26 (During Admission) upright position.

HR- 64 5. Airway clearance is

O2- 95 8. Maintain adequate hindered by

hydration by forcing inadequate hydration

fluids to atleast and the thickening of

1000mL/day. secretions.

9. Encourage 6. Doing so would lower

ambulation. the diaphragm and

promote chest

10. Monitor serial chest x- expansion, aeration of

rays, ABGs, and pulse lung segments,

oximetry readings. mobilization, and

expectoration of

secretions.
 49

7. Helps to facilitate the

maximum expansion

COLLABORATIVE: of the lungs and

11. Administer smaller airways and

medications, as indicated. improve the

productivity of cough.

8. Fluids, especially

warm liquids, aid in

the mobilization and

expectoration of

secretions. Fluids help

maintain hydration

and increase ciliary

action to remove

secretions and reduce

viscosity.
 50

9. Helps mobilize

secretions and reduces

atelectasis.

10. Follows progress and

effects and extent of

pneumonia. A

therapeutic regimen

may facilitate

necessary alterations

in therapy. Oxygen

saturation should be

maintained at 90% or

greater. Imbalances in

PaCO2 and PaO2 may

indicate respiratory

fatigue.
 51

COLLABORATIVE:

11. Mucolytics,

Expectorants ,

Bronchodilators,

Analgesics; are

medicines that helps

to liquefy respiratory

secretions/ improve

cough effort by

reducing discomfort.

#2 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Impaired Gas Exchange SHORT TERM: INDEPENDENT: INDEPENDENT: STO MET:

• The SO said: “Gi related to the altered Within the end of 30 1. Assess respiratory rate, 1. Rapid and shallow

ubo mana siya pero supply of oxygen minutes to 1 hour nursing depth, and effort, including breathing patterns and
 52

dili on and off ug secondary to pleural intervention the patient will the use of accessory hypoventilation affect gas After of 30 minutes to 1

walay sipon bitaw.” effusion as evidenced be able to: muscles, nasal flaring, and exchange (Gosselink & hour nursing intervention

by occasional non- • Patient maintains abnormal breathing Stam, 2005). Increased the patient was able to:

productive cough and clear lung fields and patterns. respiratory rate, use of • Patient had

tachypneic. remains free of signs accessory muscles, nasal maintained clear

of respiratory 2. Observe for signs and flaring, abdominal lung fields and

distress. symptoms of pulmonary breathing, and a look of remains free of

• Patient verbalizes infarction: bronchial breath panic in the patient’s eyes signs of respiratory

understanding of sounds, may be seen with hypoxia. distress.

oxygen and other consolidation, cough, fever, • Patient verbalized

therapeutic hemoptysis, pleural 2. Increased dead space and understanding of

interventions. effusion, pleuritic pain, and reflex bronchoconstriction oxygen and other

OBJECTIVE DATA: pleural friction rub. in areas adjacent to the therapeutic

• Occasional non- infarct result in hypoxia interventions.

productive cough. 3. Monitor for alteration in (ventilation without

• Restlessness LONG TERM: BP and HR. perfusion).

• Tachypnea

LTO MET:
 53

• HGB: 79 Within the end of 12 hours 4. Monitor for signs of 3. BP, HR, and respiratory After of 12 hours nursing

• CHEST X-RAY nursing intervention the hypercapnia. rate all increase with initial intervention the patient was

RESULT: Minimal patient will be able to: hypoxia and hypercapnia. able to:

Pleural Effusion, • Patient manifests 5. Monitor the effects of • Patient had

Left Cardiomegaly resolution or absence position changes on 4. Signs of hypercapnia manifested

(04/15/2023) of symptoms of oxygenation (ABGs, include headaches, resolution or

respiratory distress; venous oxygen saturation dizziness, lethargy, reduced absence of

V/S taken as follow: RR-20, O2-97 [SvO2], and pulse ability to follow symptoms of

BP- 160/70 • Shows sign of relief oximetry. instructions, disorientation, respiratory distress;

T- 36.2 • Maintain normal and coma. RR-20, O2-97

RR- 26 (During range of HGB levels. 6. Check on Hgb levels. • Shows sign of relief

Admission) 5. Putting the most • Maintained normal

HR- 60 7. Assess the patient’s ability compromised lung areas in range of HGB

O2- 97 to cough out secretions. the dependent position levels.

Take note of the quantity, (where perfusion is

color, and consistency of greatest) potentiates

the sputum. ventilation and perfusion

imbalances.
 54

8. Position patient with head

of the bed elevated, in a 6. Low levels reduce the

semi-Fowler’s position uptake of oxygen at the

(head of the bed at 45 alveolar-capillary

degrees when supine) as membrane and oxygen

tolerated. delivery to the tissues.

9. Encourage or assist with

ambulation as per the 7. Retained secretions weaken

physician’s order. gas exchange.

10. Help patient deep breathe 8. Upright or semi-Fowler’s

and perform controlled position allows increased

coughing. thoracic capacity, total

descent of the diaphragm,

COLLABORATIVE: and increased lung

11. Administer medications as expansion preventing the

prescribed. abdominal contents from

crowding.
 55

9. Ambulation facilitates lung

expansion, secretion

clearance and stimulates

deep breathing.

10. This technique can help

increase sputum clearance

and decrease cough

spasms. Controlled

coughing uses the

diaphragmatic muscles,

making the cough more

forceful and effective.

COLLABORATIVE:

11. The type depends on the

etiological factors of the

 56

problem

(e.g., antibiotics for pneumonia,

bronchodilators for

COPD, anticoagulants,

thrombolytics for

pulmonary embolus, analgesics

for thoracic pain).

 57

#3 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION

SUBJECTIVE DATA: Excessive fluid volume SHORT TERM: INDEPENDENT INDEPENDENT STO MET:

SN: “Makapila ka makaihi related to kidney Within the end of 4 hours 1. Monitor intake and 1. Monitoring sources of intake After of 4 hours of nursing

ma’am?” dysfunction as evidenced of nursing intervention: output. (oral, IV) and comparing to intervention:

The pt said: “makaisa ra” by bipedal pitting edema. • The patient will be 2. Monitor vital signs. the patient’s output (if a • The patient was able to

able to display 3. Monitor lab values. urinary catheter is inserted) display normal fluid

normal fluid 4. Review dietary will help prevent fluid volume as evidenced by

volume as restrictions. overload. balanced intake and

evidenced by 5. Elevate edematous 2. Increased heart rate, blood output.

balanced intake and extremities, and pressure, and respiratory rate

output. handle with care. can indicate an increase in

OBJECTIVE DATA: fluid volume.

• Day 1: April 18, COLLABORATIVE 3. With excess fluid volume,

2023 electrolytes may be diluted

(24hrs) 6. Enforce fluid causing low sodium

Total intake: LONG TERM: restrictions and (hyponatremia). Serum LTO MET:
 58

650 cc Within the end of 2 days of educate on the osmolality will be decreased After of 12 hours of nursing

Total output: nursing intervention: importance. with overhydration. intervention:

200 cc • The patient will be 7. Take diuretics as Hematocrit will also decrease • The patient verbalized

• Day 2: able to verbalize prescribed. with an excess of circulating understanding of the

(8AM-2PM) April 19, understanding of 8. Review dietary blood volume. BUN importance of fluid

2023 the importance of restrictions. measures kidney function restrictions.

Total intake: fluid restrictions. and will decrease with too • The patient displayed no

300cc • The patient will be much fluid. signs of bipedal pitting

Total output: able to display no 4. Patients may be on a low or edema.

250cc signs of bipedal restricted sodium diet.

pitting edema. Monitor for appropriate

meals, provide salt

• Creatinine: 1045.99 substitutes and educate on

• Blood Uric Acid: diet changes such as reading

698.25 food labels, restricting fast or

frozen foods and eliminating

table salt.
 59

5. Elevation increases venous

return to the heart and, in

turn, decreases edema.

Edematous skin is more

susceptible to injury.

COLLABORATIVE

6. If a fluid restriction is

ordered, the nurse should

educate the patient and their

family on the reason for

better adherence. Fluid

restrictions prevent the

patient from taking in too

much extra fluid.

7. Diuretics aid in the excretion

of excess body fluids.

 60

8. Patients may be on a low or

restricted sodium diet.

Monitor for appropriate

meals, provide salt

substitutes and educate on

diet changes such as reading

food labels, restricting fast or

frozen foods and eliminating

table salt.
 61

#4 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION

SUBJECTIVE DATA: Impaired skin integrity SHORT TERM: INDEPENDENT INDEPENDENT STO MET:

• The pt said: related to impaired Within the end of 4 hours 1. Promote early and 1. To promote circulation and After of 4 hours of nursing

“giadmit namo siya circulation as evidenced by of nursing intervention; ongoing mobility. prevent excessive tissue intervention;

kay nang hopong numbness and weakness of • The patient will be Assist with or pressure. • The patient was able to

iyang tiil ug gibun- lower leg. able to verbalize encourage position 2. To enhance venous return verbalized relief of

od ” relief of numbness changes, active or and reduce edema formation. numbness and weakness

• SN: “Ma’am wala and weakness on passive and 3. Poor skin turgor, decreased on lower leg.

ray sakit sa imoa lower leg. assistive exercises. sensations (nerve damage),

like sa ulo or sa 2. Recommend and poor circulation (lack of LTO MET:

imoang tiil?” LONG TERM elevation of lower blood flow assessed via After of 12 hours of nursing

The pt said: “wala Within the end of 12 hours extremities when palpation of pulse sites as intervention:

raman kaning naa of nursing intervention: sitting. well as observed by purplish • The patient was able to

sa akoang liog lang • The patient will be 3. Assess skin turgor, or ruddy discoloration of maintain intact skin

murag gibun-od.” able to maintain sensation, and lower legs) increase the risk integrity.

intact skin integrity. circulation. of tissue damage.

 62

• The patient will 4. Monitor fluid 4. This detects the presence of • The patient verbalized

OBJECTIVE DATA: able to verbalize intake and dehydration or overhydration plan of care to maintain

• Numbness and plan of care to hydration of the that affect circulation and uncompromised skin

weakness of Lower maintain skin and mucous tissue integrity at the cellular integrity.

leg (During uncompromised membranes. level.

Admission: skin integrity. 5. Inspect dependent 5. Edematous tissues are more

4/15/23) areas for edema. prone to breakdown.

• Bipedal pitting Elevate legs as Elevation promotes venous

edema indicated. return, limiting venous stasis

• Strong pulses 6. Assist with and edema formation. As

• (+) Skin procedures such as kidney function declines

discoloration dialysis. further, sodium retention and

(pallor) extracellular volume

• Pale nail beds COLLABORATIVE: expansion lead to peripheral

7. Administer edema. Despite moderate or

diuretics. severe reductions in GFR,

tubulointerstitial renal

diseases may manifest first as

 63

polyuria and volume

depletion, which can result in

dehydration (Arora &

Batuman, 2023).

6. Dialysis removes waste and

excess fluid from patients

with kidney failure.

7. Diuretics rid the body of

excess sodium and water in

the body. This can relieve

high blood pressure, anemia,

and shortness of breath.

 64

#5 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION

SUBJECTIVE DATA: Decrease Cardiac Output SHORT TERM: INDEPENDENT INDEPENDENT STO MET:

SN: “Dili sakit imong related to hypertension as Within the end of 4 hours 1. Closely monitor 1. In patients with decreased After of 4 hours of nursing

dughan ma’am?” evidenced by elevated of nursing intervention; fluid intake, cardiac output, poorly intervention the patient was able

The pt said: “Dili man” blood pressure. • The patient will including IV lines. functioning ventricles may to:

show adequate Maintain fluid not tolerate increased fluid • The client showed

cardiac output as restriction if volumes. adequate cardiac output as

evidenced by blood ordered. 2. The new onset of a gallop evidenced by blood

pressure, heart rate, 2. Auscultate heart rhythm, tachycardia, and fine pressure, heart rate, and

and rhythm within sounds for gallops crackles in lung bases can rhythm within normal

normal limits. (S3, S4); auscultate indicate the onset of heart limits.

breath sounds. failure. If the patient

OBJECTIVE DATA: LONG TERM: develops pulmonary edema,

there will be coarse crackles LTO MET:

 65

• (+) Atrial gallop Within the end of 12 hours 3. Check for any on inspiration and severe After of 12 hours of nursing

(S4) of nursing intervention: alterations in level dyspnea. S4 occurs with intervention:

• No recurrence of • The patient will of consciousness. reduced compliance of the • The patient was able to

chest pain able to remain free 4. Assess oxygen left ventricle, which impairs remain free of side effects

• BP: 180/80 of side effects from saturation with diastolic filling. from the medications used

• HR: 66 the medications pulse oximetry both 3. Alterations in cardiac output, to achieve adequate

used to achieve at rest and during either acutely or chronically, cardiac output.

adequate cardiac and after can lead to changes in

output. ambulation. cerebral blood flow (Meng et

5. Monitor heart al., 2015). Decreased

rhythm. cerebral perfusion and

hypoxia are reflected in

COLLABORATIVE irritability, restlessness, and

difficulty concentrating.

6. Administer Older patients are

prescribed particularly susceptible to

medications as reduced cerebral perfusion.

ordered.
 66

7. Implement a 4. An alteration in oxygen

rehabilitation plan saturation is one of the

for activity (PT earliest signs of reduced

and/or cardiac cardiac output. Hypoxemia is

rehab). common, especially with

activity. Administer

supplemental oxygen as

needed.

5. Decreased cardiac output can

result in cardiac arrhythmias.

A common cardiac

arrhythmia seen in these

patients is atrial fibrillation.

COLLABORATIVE

6. Various medications may be

ordered for patients with

 67

decreased cardiac output (i.e.

ACE, ARBs, etc.). These will

help to improve heart

function and decrease

patient’s symptoms and

cardiac workload.

7. These types of programs can

improve patient’s quality of

life and decrease mortality.

 68

#6 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Imbalanced nutrition: Less SHORT TERM: INDEPENDENT: INDEPENDENT: STO MET:

• SN: “Unsa iyaang than body requirements Within the end of 5 hours 1. Assess and document 1. This aids in After of 5 hours nursing

ginaka-on sa una related to dietary restrictions nursing intervention the dietary intake. identifying intervention the patient was

Ma’am?” to reduce nitrogenous waste patient will be able to: deficiencies and able to:

The SO said: “Sauna products as evidenced by • The client will 2. Provide frequent, dietary needs. General • The client had

hilig jud siya ug mga limited oral fluid intake. maintain/regain the small feedings. physical condition, maintained the weight

pagkaon sa fastfood weight as indicated by uremic symptoms as indicated by the

like processed foods the individual 3. Give the client or (nausea, anorexia), individual situation,

pero sa karon na situation, free of family caregiver a list and multiple dietary free of edema.

hospital siya na limit edema. of permitted foods or restrictions affect food • The client had

na niya iyaang gina- • The client will fluids and encourage intake. demonstrated

kaon ug iyaang gina- demonstrate involvement in menu behaviors, lifestyle

inom.” behaviors, lifestyle choices. 2. This minimizes changes, such as food

anorexia and nausea changes.

 69

changes, such as food 4. Encourage of complex associated with a

changes. carbohydrates intake uremic state and/or

OBJECTIVE DATA: to meet caloric needs diminished peristalsis.

• Day 1: April 18, 2023 and essential amino

(24hrs) acids. Avoid 3. This provides the

Total intake: concentrated sugar client with a measure

650 cc sources. of control within LTO MET:

Total output: dietary restrictions. After of 12 hours nursing

200 cc LONG TERM: 5. Maintain proper Food from home may intervention the patient was

• Day 2: Within the end of 12 hours electrolyte balance by enhance appetite. able to:

(8AM-2PM) April 19, 2023 nursing intervention the strictly monitoring Dietary changes are an • Displayed normal

Total intake: patient will be able to: levels. important facet of AKI level of blood glucose

300cc • Display normal level treatment. test

Total output: of blood glucose test 6. Restrict potassium, • Maintained

250cc • Maintain satisfactory sodium, and 4. Carbohydrates meet satisfactory weight,

• Blood uric acid: weight, height, & phosphorus intake as energy needs and limit height, & body build

698.25 body build indicated. tissue catabolism,

• Creatinine: 1045.99 preventing keto acid

 70

• Patient have 7. Monitor or maintain formation from protein • Patient had understand

V/S taken as follow: understand the dietary serum glucose levels and fat oxidation. the dietary

BP- 160/70 restrictions/intake between 140 t0 180 Carbohydrate restrictions/intake

T- 36.2 mg/dL. intolerance mimicking

RR- 20 DM may occur in

HR- 60 COLLABORATIVE: severe renal failure.

O2- 97 8. Administer

medications as 5. Medications and a

indicated. decrease in GFR can

cause electrolyte

9. Consult with the imbalances and may

dietitian support team. further cause renal

injury. Urine

electrolyte findings

can also serve as

valuable indicators of

functioning renal

tubules.
 71

6. Restriction of these

electrolytes may be

needed to prevent

further renal damage,

especially if dialysis is

not part of treatment,

and during the

recovery phase of

ARF.

7. Clients are at

increased risk of both

hyper- and

hypoglycemia. Insulin

resistance is highly

prevalent among

clients with AKI and

 72

is associated with

increased mortality

risk.

COLLABORATIVE:

8. Calcium carbonate:

This restores normal

serum levels to

improve cardiac and

neuromuscular

function,

blood clotting, and

bone metabolism. Low

serum calcium is often

corrected as phosphate

absorption is

decreased in the GI
 73

system.

9. This determines

individual calorie and

nutrient needs within

the restrictions and

identifies the most

effective route and

product (oral

supplements, enteral

or parenteral

nutrition).
 74

#7 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT NURSING DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION

SUBJECTIVE DATA: Fatigue related to SHORT TERM: INDEPENDENT: INDEPENDENT: STO MET:

decreased hemoglobin and Within the end of 4 hours 1. Assess laboratory 1. Monitoring complete blood After of 4 hours of nursing

diminished oxygen- of nursing intervention; values. counts helps determine the intervention;

carrying capacity of the • The patient will be 2. Encourage sleep progression of the patient’s • The patient was able to

blood as evidenced by able to and rest. condition and the maintain/regain energy

Inability to maintain the maintain/regain 3. Assess temperature, effectiveness of and ability to maintain

usual level of physical energy and ability respiratory, and interventions. physical activity.

activity and reports fatigue to maintain urinary system 2. Adequate sleep is an

OBJECTIVE DATA: and lack of energy. physical activity. changes as the essential modulator of LTO MET:

• Lethargic and disease progresses. immune responses. A lack of After of 12 hours of nursing

restlessness LONG TERM: 4. Perform sleep can weaken immunity intervention:

• Complete blood Within the end of 12 hours handwashing, and and increased susceptibility • The patient was able to

count/Hematology: of nursing intervention: medical or surgical to infection. have normal results of

RBC: 2.63 asepsis during 3. This provides information CBC.

HCT: 0.24 procedures or care about the presence of

 75

HGT: 79.0 • The patient will be as appropriate. infection caused by

WBC: 5.08 able to have normal Instruct the client progressive chronic disease

Platelet: 161 results of CBC. and family and its deteriorating effect on

• Differential count: members in all systems. The innate

Segmenters: 0.61 handwashing immune system is ubiquitous

Lymphocytes: 0.22 technique, and and the most evolutionary

Stabs: 0 proper disposal of conserved arm of the

Monocytes: 0.09 tissues and used immune system. It includes

Eosinophils: 0.07 articles. defense mechanisms that

Basophils: 0.01 5. Teach the client to generate rapid, nonspecific

avoid contact with inflammatory responses to

persons with upper signals from pattern-

respiratory recognition receptors (Syed-

infections. Ahmed & Narayanan, 2019).

4. Perform handwashing, and

COLLABORATIVE: medical or surgical asepsis

during procedures or care as

appropriate. Instruct the

 76

6. Discuss with client and family members in

ordering provider handwashing technique, and

the potential need proper disposal of tissues and

for physical therapy used articles.

and/or a cardiac 5. This prevents the

rehab program as transmission of infectious

appropriate. agents that may lead to

7. Develop activity pneumonia. During the

plan. COVID-19 pandemic, data

suggest a two-times increase

in mortality from COVID-19

in the presence of CKD.

Despite screening and

isolation of affected clients,

outbreaks cannot always be

prevented because some

infected individuals can have

long incubation periods or be

 77

asymptomatic carriers

(Kalantar-Zadeh et al., 2021).

COLLABORATIVE:

6. This will further help the

patient to regain strength and

improve endurance and

decrease fatigue.

7. This will allow the nurse and

patient to have a plan that

will gradually increase the

patient’s activity level and

strength.
 78

#8 Priority Nursing Care Plan for End-Stage Renal Disease Secondary to Diabetic Nephropathy Anemia

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE DATA: Risk for unstable blood SHORT TERM: INDEPENDENT: INDEPENDENT: STO MET:

• The SO said: “Akong glucose level related to Within the end of 4 hours of 1. Assess for signs of 1. Hyperglycemia results After 4 hours of

mama man kay na hyperglycemia as evidenced nursing intervention hyperglycemia. when there is an nursing intervention

diagnosed ug by HGT of 123. the patient will be able to: inadequate amount of the patient was able to:

diabetes murag 2017 • The client will 2. Assess medications insulin to glucose. Excess • The client had

paman to, mao naa acknowledge factors taken regularly. glucose in the blood acknowledged factors

siyay maintenance that will lead to creates an osmotic effect that will lead to

para sa iyaang sugar hyperglycemia. 3. Assess feet for that results in increased hyperglycemia.

or diabetes.” temperature, pulses, thirst (polydipsia), hunger

color, and sensation. (polyphagia), and

increased urination

4. Assess blood glucose (polyuria).

LONG TERM: level before meals LTO MET:

Within the end of 2 days of and at bedtime. 2. A lot of drugs can cause After of 2 days of nursing

nursing intervention the fluctuations in blood intervention the patient was

patient will be able to: glucose as a side able to:

 79

• Maintain glucose in a 5. Assess eating effect. Beta-blockers, • Maintained glucose

OBJECTIVE DATA: satisfactory range patterns. corticosteroids, in a satisfactory

• HGT: 123 • The patient have thiazide diuretics, estrogen, range.

• HGB: 79 understand the diet 6. Assess the patient’s isoniazid, lithium, • The patient had

restrictions and its current knowledge and phenytoin can cause understand the diet

prescribed diet and understanding hyperglycemia. restrictions and its

about the prescribed prescribed diet

diet. 3. This is to monitor

peripheral perfusion and

7. Assess the pattern neuropathy.

of physical activity

4. Blood glucose should be

COLLABORATIVE: between 140 to 180

8. Administer mg/dL. Non-intensive care

medications as patients should be

physician’s order. maintained at pre-meal

levels <140 mg/dL.

 80

5. Non-adherence to dietary

guidelines for a specific

clinical condition can

result in fluctuations in

blood glucose.

6. An individualized diet plan

is recommended.

7. Physical activity helps

lower blood glucose levels.

Regular exercise is a core

part of diabetes

management and reduces

risk for cardiovascular

complications.

COLLABORATIVE:
 81

8. Diabetic medications helps

manage diabetic patient at

risk for unstable blood

glucose level.
 82

DISCHARGE PLAN

Name of Client: Mrs. Q Age: 42 years old

Gender: Female Religion: Roman Catholic

Admitting Diagnosis: End Stage Renal Disease Secondary to Diabetic/Hypertensive

Nephropathy, Severe Anemia, Moderate Ascites

Hospital: AMCI

Attending Physician: Dr. Q

Room/Ward Number: 251-1

A. OBJECTIVES

At the end of an hour of health education the client will be able to:

1. To encourage adequate information, comprehend the cause, prognosis, and course of

treatment for the illness.

2. Change their lifestyle to avoid and reduce further issues.

3. Encourage family involvement and self-care as part of client treatment.

 83

B. METHODS

1. Medications:

Name of Drug Dosage/ Route Curative Side Effects Instructions

Preparation/ Effects/

Frequency/ Indications

Duration

Generic Name: 40mg, PO, 1 PO Treatment of • Headache Advise patient

tablet for 14 gastroesophageal • Nausea to avoid foods

PANTOPRAZOLE days reflux disease • Vomiting that may cause

associated with a • Diarrhea an increase in

Brand Name: history of erosive • Dizziness GI Irritation.

esophagitis.

PANTROPAZ Instruct

patient to

Classification: report

bothersome or
 84

PROTON PUMP prolonged side

INHIBITORS effects,

including

headache or GI

effects

(diarrhea,

flatulence, and

belching,

abdominal

pain).

Generic Name: 2 tabs, three PO Used as nutrition • Increased Instruct the

times a day therapy or calcium levels patient to take

ALPHA taken orally dietary • Nausea with meals to

KETOANALOGUE supplements in • Vomiting allow proper

 85

+ ESSENTIAL until stocks patients with • Diarrhea absorption of

AMINO ACIDS consumed. chronic kidney • Abdominal amino acids.

failure. Pain

Frequently

Brand Name: assess for

serum calcium

RENALOG levels.

Classification: Take drug as

prescribed.

NUTRITIONAL

FORMULA

Generic Name: PO Used to • Nausea Calcium

1 tablet, two prevent/treat • Vomiting supplements

times a day calcium and • Diarrhea are best taken

taken orally • Epigastric with meals to

 86

CALCIUM + vitamin pain ensure optimal

VITAMIN D3 + deficiency • Anorexia absorption.

MINERALS

Monitor for

Brand Name: adverse

effects.

CALCIUM PLUS

Drink a full

Classification: glass of water

with each dose.

CALCIUM

SUPPLEMENT

Generic Name: 1 PO Used to treat or • Diarrhea Advise patient

tablet, prevent vitamin • Upset to never take

MULTI taken deficiency due to stomach more than the

VITAMINS + IRON orally • Constipation recommended

 87

poor diet, certain • Change in dose of a

illnesses. color of multivitamin.

Brand Name: stool

Vomiting Avoid taking

IBERET FA any other

multivitamin

Classification: product within

2 hours before

MULTIVITAMINS or after taking

WITH MINERALS the medication.

Taken after

food to reduce

gastrointestinal

side effects.
 88

Advise

patients that

they may

experience

discolored

stools.

Generic Name: 1 tab PO Used together • Headache Obtain dietary

10mg, with a proper • Diarrhea history,

ROSUVASTATIN taken diet to lower bad • Dyspepsia especially fat

orally cholesterol • Nausea consumption.

(LDL) and Myalgia

 89

Brand Name: before triglycerides Assess

bedtime. (fats) in the baseline lab

RUSTOR blood, and to results: serum

increase your cholesterol,

Classification: good cholesterol triglycerides,

(HDL) hepatic

STATINS function tests.

Monitor serum

cholesterol,

triglycerides

for therapeutic

response.

Monitor daily

pattern of
 90

bowel activity,

stool

consistency.

Generic Name: 1 tablet, PO Used to treat • Headache Monitor blood

10mg, hypertension, • Dizziness pressure and

AMLODIPINE taken angina pectoris • Fatigue pulse rate

BESILATE orally. and vasospastic • Nausea before giving

angina. the medication.

Brand Name: Ensure to

observe the

VASALAT following

rights of the

Classification: patient.
 91

CALCIUM Taken after

CHANNEL dinner.

BLOCKERS

Generic Name: 1 tablet, PO Indicated for • Low blood Check for

5mg taken the treatment of sugar doctor’s order

LINAGLIPTIN orally type II diabetes • Myalgia before giving

in addition to • Sore throat the medication.

diet and exercise. • Stuffy nose

• Cough Monitor blood

Brand Name: glucose levels

periodically.

TRAJENTA

Monitor
 92

patient for

Classification: signs and

symptoms of

DIPEPTIDYL hypoglycemia.

PEPTIDASE

INHIBITORS Taken after

breakfast.

Generic Name: 1 tab, PO Treatment of • Dry mouth Monitor BP

twice a hypertension. • Chest pain before and

CLONIDINE HCI day, taken • Constipation after giving the

orally • Vomiting medication.

• Drowsiness
Brand Name: Rash Instruct patient

to report chest
 93

CLONIPRESS pain, dizziness

with position

changes,

Classification: excessive

drowsiness and

CENTRALLY tell patient to

ACTING ALPHA- rise slowly to

AGONIST avoid

HYPOTENSICE hypotensive

AGENTS effects.

Dosage is

usually

adjusted to the

patients’ blood

pressure and
 94

can cause

hypotension,

bradycardia

and sedation

Generic Name: 1 tab, 650 PO Used to relieve • Headache Tablets must be

mg, thrice heartburn and • Nausea taken with a full

SODIUM a day acid indigestion. • Vomiting glass of water.

BICARBONATE taken • Loss of

orally appetite

Classification: • Weakness Monitor for

Irritability adverse effect

ALKALINIZING such as GI

AGENTS effects, serum &

electrolyte

imbalances.
 95

Assess for

evidence of

excessive

chloride loss.
 96

2. Exercise/Activity and Home Environment

Types of Activity that should be allowed:

Type of Activity that should be allowed /to be continued

➢ Walking, light exercises for 15-25 minutes

➢ Getting Vitamin D from the sun by walking from 6AM-7:30AM

➢ Deep breathing exercises

Types of Activity that should not be allowed:

➢ Based on her age, she should avoid strenuous activity such as running

➢ Lifting heavy objects

Restrictions:

a. Avoid food and drinks that is rich in salt and carbohydrates such as

➢ Brown rice

➢ Canned foods

➢ Dairy products

➢ Sodas

➢ Oily foods

➢ Sweets

Home Environmental Hazards:

a. Make sure that the floors don’t have uneven surfaces to avoid accidents

b. Have a good lighting

c. Make sure to have a good air ventilation in the house

 97

3. Treatments/Therapies (e.g., Chest physiotherapy, warm compress, steam inhalation,

hydrotherapy, nebulization, etc)

a. Hemodialysis

4. Health teaching/ Education

a. Encourage to strictly follow the scheduled hemodialysis

b. Avoid food that is rich in sodium

c. Be cautious of the fluid intake per day

d. Have enough rest when possible

5. OPD Visit

Clinic Appointment Schedule: N/A

Follow-up Diagnostic or Laboratory Exam: Secure schedule for hemodialysis

Referrals: N/A

6. Diet

➢ Low Purine

3- Day Sample Menu

Day 1 Day 2 Day 3

Breakfast Breakfast Breakfast

2 scrambled eggs 2 slices of French toast 1 cup of corn flakes

1 slice of toast bread 2 sunny side up eggs 1 scrambled egg

Coffee or tea (8oz) Coffee (8oz) Coffee/tea (8oz)

 98

Lunch Lunch Lunch

½ cup of white rice ½ cup of white rice 2 slices of white bread

Low sodium Tuna or Steamed chicken (palm Low sodium Tuna

steamed fish (palm size) size)

1 sunny side up egg

1 apple Chicken broth (less salt)

1 apple juice

1 glass of water 1 apple

1 glass of grape juice

Dinner Dinner Dinner

Oven-Baked chicken ½ cup of white rice Oven-Baked chicken

½ cup mashed potato Grilled Fish (3oz) ½ cup mashed potato

1 glass of milk 1 glass of milk 1 glass of milk

a. Diet Restrictions:

➢ Red meat, seafood, and alcohol.

 99

1. Spiritual Care and Psychological or Sexual Needs (Give special consideration to

religious and cultural practices)

Spiritual and Psychological Needs

(/) Spiritual Counseling

( ) Grief Work

( ) Anger Management

( ) Confession

( ) Family Therapy

( ) Reconciliation of Conflicted Relationships

(/) Supportive Counseling

( ) Join Church Organizations/Activities

(/) Prayer

( ) Meditation, Reflection, and Spiritual Devotion

( ) Religious Rituals

( ) Religious/Spiritual Materials

Sexual Needs

( ) Marriage Counseling

( ) Sex Therapy

( ) Sexual Violence

( ) Referral to Appropriate Agencies

 100

C. DISCHARGE DETAILS

a. Date and Time of Discharge:

➢ April 18, 2023

b. Mode of Transportation:

➢ Own vehicle

c. General Condition upon Discharge:

➢ The patient is coherent, alert, conscious and oriented.

 101

HEALTH TEACHING PLAN

Patient teaching is a critical component of care for patients. The patient should also be

encouraged to change lifestyle and control the environmental trigger factors.

Before

Follow a Healthy Diet

- Teach the patient to eat plenty high-fiber foods that are packed with nutrients but low in

sugar/artificial ingredients

Exercise and Try Physical Therapy

- Exercising regularly is one of the simplest ways to manage diabetes symptoms, help maintain

a healthy weight, control blood sugar and high blood pressure symptoms, increase strength,

and improve range of motion in addition to all the other benefits of exercise

Reduce Exposure to Toxins and Quit Smoking

- Teach the patient to quit smoking as quickly as possible, since s/he is more likely, than diabetic

nonsmokers, to develop nerve damage and even have a heart attack or stroke

Manage Stress

- Stress makes inflammation worse and raises the risk for diabetic complications. Exercising,

meditating or practicing healing prayer, spending more time doing hobbies or being in nature,

and being around family and friends are all natural stress relievers that should be considered.

During
 102

Manage Blood Sugar Levels

- Maintaining blood sugar consistently within a healthy range is the most important thing to

prevent permanent damage to the nerves, blood vessels, eyes, skin and other body parts before

complications develop.

Protect Skin and Feet

- Teach the patient to wash skin and feet/toenails carefully daily, especially in skin folds where

bacteria and moisture can build up and cause infections.

After the hemodialysis the patient needs to:

- Take care of fistula or graft, if they have one. Wash fistula or graft with soap and warm

water every day and before each dialysis treatment. Don't scratch or pick at the area. Don't

let anyone use that arm to take blood or measure blood pressure.

- Keep the catheter protected, if they have one. This is important to help prevent infection.

A doctor or nurse will cover the catheter with a bandage and change it at each dialysis

session. Do not try to remove or change your bandages at home.

- If you have a clear waterproof bandage that sticks to the skin around your catheter site, you

can take a shower or bath with it on. But do not put the area underwater. If you have a

gauze bandage that is not waterproof, do not get it wet at all.

- Weigh yourself every day. When your kidneys don't work, fluid collects in your body. Let

your doctor or nurse know if you gain more weight than usual between dialysis treatments.

- Follow a special diet. You will need to limit the amounts of fluids you drink. You might

also need to avoid foods with a lot of sodium, potassium, and phosphorus. These are

minerals that can build up in your body if you have kidney problems.
 103

PROGNOSIS

Criteria Poor Good

A. Onset of illness ✓

B. Duration of illness ✓

C. Attitude and willingness to take ✓

medication
D. Precipitating factor ✓

E. Family support ✓

a) Onset of Illness - The onset of illness is poor since the patient has end-stage renal disease. This

means that kidney function has declined to the point that the kidneys can no longer function on

their own.

b) Duration of Illness – The duration of illness is poor because the patient still has bipedal pitting

edema and is on permanent, ongoing hemodialysis.

c) Attitude & Willingness to take medication - Attitude and willingness to take medication is

good because the patient was willing to take the medication as prescribed.

d) Precipitating Factors - The precipitating factor is poor, even though the patient is aware of her

current health status and has a willingness to change her lifestyle; her existing Diabetes Mellitus

Type 2 and her uncontrolled hypertension is making her health status little by little deteriorated

such as these two existing diseases or health problems had already progressed or developed into

End-Stage Renal Disease.

e) Family Support - With regards to the patient's support system, there was a positive response.

Despite the financial problems of the family, they still supported the patient.
 104

Overall, the prognosis is poor, because even though the patient and her family are willing

to cooperate and participate regarding the care that was given to her; we cannot still deny the fact

that her condition or her current health status and her present diagnosis is not that good, which

making her health status little by little deteriorated. End-stage renal disease is a progressive

disorder, and timely renal replacement therapy is necessary to prevent death. The disorder is

associated with numerous hospitalizations, increased healthcare costs, and metabolic changes. The

mortality rates for patients with end-stage renal disease are significantly higher than those without

the disease. Even with timely dialysis, the death rates vary from 20% to 50% over 24 months. In

addition, her Diabetes Mellitus Type 2 is making her current health condition worst.
 105

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