Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Short Background: Chronic kidney disease (CKD) occurs when one suffers from gradual and usually permanent loss of kidney function over time. With loss of kidney function, there is an accumulation of water; waste; and toxic substances, in the body, that are normally excreted by the kidney. Glomerular Filtration Rate (GFR), the measure of the kidney's function, determines the severity or stage of the disease (whereas Stage 5 CKD is considered Renal Failure due to gradual loss of GFR, GFR < 15: needs dialysis). CKD often develops from 1Diabetes (stenosis/ischemic), 2Hypertension (microvascular damage), 3Glomerulonephritis (post-infection), or 4Nephrotoxicity (medications).

Assessment
Subjective: Patient is not able to verbalize.

Nursing Diagnosis
Ineffective Breathing Pattern r/t impending pulmonary congestion d/t impaired GFR and fluid retention or respiratory muscle weakness d/t physical stress.

Scientific Explanation of the Problem

Impaired GFR results into fluid overload. With fluid volume excess, venous pressure is more likely to cause both circulatory and pulmonary congestion. The patient may possibly manifests fatigue, dyspnea, tachypnea, muscle weakness (including diaphragm), or sputum production that are related to pulmonary congestion. Physical stress also impacts pulmonary functioning. Diabetic, there is a possibility that sugar crystallization has occurred and leads to renal artery stenosis or a microvascular complication due to viscosity.

Planning
Goal: Establish Spontaneous, nonLabored Breathing Short Term: After 4 hours of nursing interventions, patient will be able to reduce labored and difficult breathing and establish a respiratory rate of less than 30cpm. Long Term: After 5 days of nursing interventions, patient will be able to demonstrate nonlabored and spontaneous breathing.

Interventions
Collaborative: 1. Administer humid Oxygen (8-10Lpm) as ordered. 2. Assist in Manual Ventilation via ET Tube.

Rationale

Evaluation

1. To help patient get adequate oxygen despite of DOB. 2. To assist patient on respiration and to ensure adequate tidal volume.

Objective:
> Deep, fast, noisy breathing > RR 33cpm > Crackles heard on inspiration > SaO2 99% > BP 140/100mmhg > PR 80bpm > T 37.0 C > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > Increased respiratory secretions.

Independent: 1. Monitor and record vital signs. 2. Assess for lung sounds.

1. To check and reassess vital function changes (Respiration). 2. To identify extent of fluid accumulation in the respiratory system. 3. To facilitate gravitational expansion of the lungs to decrease inspiratory effort. 4. To avoid stressors and let patient regain strength by manipulation of environment. 5. To facilitate airway clearance and reduce effort from DOB.

3. Position on moderate high back rest.

4. Maintain calm and nonstimulating environment.

5. Suction secretions PRN.

CELESTINO, JOHN CHRISTOPHER S. WUP SN13 senior block 04

Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Priority Problem: (Priority 1) Ineffective Breathing Pattern

Assessment
Subjective: Patient is not able to verbalize.

Nursing Diagnosis
Fluid Volume Excess R/T decrease Glomerular filtration Rate and sodium retention.

Scientific Explanation of the Problem

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces, causes venous return, leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hypertrophied leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria. With associated DM, there is a possibility that sugar crystallization has occurred and leads to renal artery stenosis or a microvascular complication due to viscosity of blood.

Planning
Goal: Reduce Fluid Volume Excess, output more than input. Short Term: After 4 hours of nursing interventions, patient will be able to avoid recurrence of fluid excess Long Term: After 5 days of nursing intervention the patient will manifest stabilize fluid volume, I & O, normal VS, stable weight, and free from signs of edema.

Interventions
Collaborative: 1. Administer loop diuretics (Furosemide/Lasix) as ordered. 2. Assist in specimen extraction for serum analysis (Serum Electrolytes/ RBS or FBS) and urine analysis (BUN/Crea). 3. CBG Test as ordered. Independent: 1. Monitor and record vital signs 2. Auscultate breath sounds 3. Record occurrence of dyspnea

Rationale
Collaborative: 1. Diuretics reduce fluid volume by helping kidney excrete urine and sodium. 2. To prepare patient for possible lab orders.. 3. To determine the efficacy of DM regimen. Independent: 1. To check and reassess vital function changes (Circulation). 2. To determine extent of fluid excess. 3. To check possible respiratory complications (pulmonary congestion). 4.

Evaluation

Objective:
> Anuria > BP 140/100mahg > RR 27cpm > PR 80bpm > T 37.0 C > Peripheral Edema > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > Increased respiratory secretions. > CBG 126mg/dL

4. Review lab data like BUN, Creatinine, Serum electrolyte.

To monitor kidney function and fluid retention (electrolyte compensation).

5. To determine fluid retention and kidney function (GFR). 6. Increasing weight may indicate fluid retention. 7. To allow patient cope with stressors naturally.

5. Record I&O accurately and calculate fluid volume balance

6. Weigh client 7. Encourage quiet, restful atmosphere. Main Problem: (Priority 2) Fluid Volume Excess CELESTINO, JOHN CHRISTOPHER S. WUP SN13 senior block 04

Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Manifestation Problem: (Priority 3) Risk for Impaired Skin Integrity

CELESTINO, JOHN CHRISTOPHER S. WUP SN13 senior block 04

Patients Diagnosis: CHRONIC KIDNEY DISEASE probably secondary to DM Nephropathy

Assessment
Subjective: Patient is not able to verbalize.

Nursing Diagnosis
Risk for Impaired Skin Integrity r/t edema and prolonged bed rest d/t

Scientific Explanation of the Problem

Due to fluid retention, fluid accumulates and fluid shifts from intracellular compartment to extracellular compartment causing escape of fluid to the tissues (edema). With associated complications of anemia, skin nutrition would be crucial and may have easily broken off. DM could cause high blood sugar levels and leads to viscosity of blood that also impairs nutrition of skin or reduction of blood cells to capillaries.

Planning
Goal: Prevent Risks on Developing Skin Breakdown. Short Term: After 4 hours of nursing interventions, patient will be able to remove potential threats that may lead to poor skin integrity. Long Term: After 5 days of nursing interventions, patient will be able to identify and avoid factors that lead to skin breakdown.

Interventions
Collaborative: 1. Ferrous Sulfate (Iron supplement) as ordered. 2. Update Lab Findings for CBC (RBC, Hgb, Hct). 3. CBG T.I.D. as ordered.

Rationale

Evaluation

Objective:
> Peripheral Edema > Prolonged bed rest > Pallor > Hgb > Diaphoretic, cold clammy skin > Unresponsive; may be due to fatigue/weakness. > CBG 126mg/dL

1. To help body regulate RBC in the absence/lacking of hormone erythropoietin. 2. To evaluate efficacy of treatment/prophylaxis for anemia regimen. 3. To determine hyperglycemia that makes blood viscous and induces the risk for infection.

Independent: 1. Assess skin appearance (color, texture, temperature). 2. Turn patient side to side every 2 hours if possible.

1. To determine edema or erythema that indicates possible bed sore. 2. To make pressure equal when lying to avoid unilateral skin tissue blood insufficiency. 3. To avoid skin irritation from crease. 4. To avoid risk for skin injury and infection.

3. Maintain crease-free bed linen. 4. Maintain a clean, therapeutic environment.

CELESTINO, JOHN CHRISTOPHER S. WUP SN13 senior block 04